361: FC1

PAPPA2 P.ALA1034VAL KNOCK-IN MOUSE MODEL RECAPITULATES HOMOZYGOUS HUMAN PAPPA2 MUTATION ASSOCIATED WITH SHORT STATURE
Andrew Dauber, MD; Melissa Andrew, BS/BA; Lihong Liao, MD; Vivian Hwa, PhD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Objectives: Pregnancy-associated plasma protein A2 (PAPP-A2), a metalloproteinase, is a key regulator of circulating IGF-1 bioavailability. IGF-I circulates in ternary complex with IGF binding protein IGFBP-3 or IGFBP-5 and acid labile subunit, and the cleavage of IGFBP-5 and IGFBP-3 by PAPP-A2 is hypothesized to free the IGF-I for bioactivities. This critical role of PAPPA2 was recently supported by our report of the first homozygous loss-of-function PAPPA2 mutations identified in patients with post-natal growth failure and markedly low free IGF-I despite significantly elevated total serum IGF-I levels. Interestingly, one of the two mutations was a missense mutation, p.Ala1033Val, located downstream of the peptidase domain. We demonstrated that this recombinant mutant protein, when compared to wild-type PAPPA2 in over-expressed HEK293 reconstituted systems, was functionally inactive, as it could not proteolyze either recombinant IGFBP-3 or IGFBP-5 proteins. To further validate the biological significance of this missense mutation, we sought to create a mouse model of our patient's homozygous missense mutation.

Methods: We successfully generated an in vivo knock-in (KI), Pappa2 p.Ala1034Val, mouse model (B6D2F1/J), employing CRISPR/CAS9 methodology. We then phenotyped the mice and measured total and free IGF-1 as well as intact IGFBP-3 in mouse serum via ELISA.

Results: Preliminary post-natal growth profiles of the homozygous KI (n=10) at 16 days of age, indicated weights were 17.7% ± 3.0% less than wild-type mice (n=8), P<0. 0001, and remained lower than wild-type mice at 48 days (weight were 21.6%±0.05% lower). Serum samples collected were evaluated for total Igf-I, free Igf-I and intact Igfbp-3. Wild-type mice had total Igf-I of 30.6±3.3 ng/ml, Igf-I of 1.5±0.6 ng/ml and intact Igfbp-3 of 328.3±81ng/ml, whereas the KI mice had significantly higher total Igf-I of 52.0±2 ng/ml, undetectable free Igf-I and higher intact Igfbp-3, 710±48 ng/ml.

Conclusions: In summary, our KI mouse model recapitulates the features of reduced IGF-I bioavailability and impaired post-natal growth profiles observed in our patients. Further investigations are in progress to confirm these results, and to determine if treatment of KI mice with recombinant PAPPA2 can rescue the impaired growth phenotype.

109: FC2

GENETIC SCREENING OF PATIENTS WITH CONGENITAL GH DEFICIENCY IN THE GENESIS OBSERVATIONAL PROGRAM: MUTATION FREQUENCY, PHENOTYPE AND GROWTH OUTCOMES
Roland W Pfäffle, MD; Jürgen Klammt, PhD; Heike M Pfäffle, MTA, University of Leipzig, Leipzig, Germany; Serge Amselem, MD, Hôpital d'Enfants Armand-Trousseau , Paris, France; Marie Legendre, PhD, Hôpital Trousseau , Paris, France; Marie-Laure Sobrier, PhD, Inserm US013 , Paris, France; Christopher J Child, PhD; Christine Jones, PhD; Alan G Zimmermann, PhD, Eli Lilly and Company, Indianapolis, IN, United States; Werner F Blum, MD, University of Giessen, Giessen, Germany

Objectives: Congenital GH deficiency (GHD) may be caused by mutations in genes involved in pituitary development, GH synthesis or secretion. Defects in GH1 & GHRHR commonly cause isolated GHD (IGHD). Defects in genes for transcription factors (GLI2, HESX1, LHX3, LHX4, SOX3, PROP1, POU1F1) that shape the developing pituitary & specify hormone-producing cells, cause multiple pituitary hormone deficiencies (MPHD). Using GeNeSIS DNA Analysis Sub-study data, we investigated mutation frequency, & variability in phenotype & final height (FH) gain in GH-treated patients with & without mutations.

Methods: SSCP, dHPLC & direct sequencing analyses were performed based on a candidate gene approach in patients with IGHD or MPHD. DNA variants were classified as pathogenic according to American College of Medical Genetics and Genomics standards. FH was defined by at least 1 of: closed epiphyses, height velocity 14 years-girls/>16 years-boys.

Results: The frequency of detected mutations is shown in the table. Baseline features (mean±SD & p=0.005 unless specified) significantly different between those with mutation(s) (N=92) & those without (N=825) included age (y) 5.7±4.2 vs 7.3±4.7; height standard deviation score (SDS) -4.1±2.2 vs -2.9±1.5; height minus target height SDS -4.0±2.0 vs -2.4±1.6; height velocity SDS -2.3±2.0 vs -1.5±1.9, p=0.02; median peak stimulated GH 1.1 vs 3.8 µg/L; IGF-I SDS -5.9±3.5 vs -3.4±3.3. In those who reached FH, features significantly different between those with mutation(s) (N=24) & those without (N=191) were baseline age (y) 7.4±4.3 vs 9.4±4.2, p=0.03; height SDS -4.1±2.3 vs -2.9±1.2; height minus target height SDS -4.1±2.1 vs -2.3±1.5; median peak stimulated GH 1.0 vs 4.7 µg/L; GH therapy duration (y) 10.7±4.4 vs 7.7±4.0; & FH SDS gain 3.4±1.4 vs 2.0±1.4.

Conclusions: Children with congenital GHD should be considered for DNA testing in genes involved in pituitary development, GH synthesis & secretion. Patients who had mutations were younger & had more severe GHD than those without. FH gains after GH therapy were greater in those with mutations, possibly because of earlier start of GH treatment. DNA analysis may aid decision making regarding the clinical course of hypopituitarism & outcomes of GH treatment.

398: FC3

MECHANISMS OF FIBROBLAST GROWTH FACTOR 21 (FGF21) MEDIATED GROWTH HORMONE RESISTANCE IN HUMAN GROWTH PLATE IN CHRONIC CHILDHOOD CONDITIONS.
Jayna N Mistry, MRes; Gerard Ruiz-Babot, PhD, Queen Mary University of London, London, United Kingdom; Farasat Zaman, PhD, Karolinska Institutet, Stockholm, Sweden; Lars Sävendahl, MD, PhD, Karolinska University Hospital, Stockholm, Sweden; Leonardo Guasti, PhD; Leo Dunkel, MD, PhD, Queen Mary University of London, London, United Kingdom

Objectives: FGF21 is an essential hormone regulating metabolic processes to the adaptation to fasting; inducing gluconeogenesis, fatty acid oxidation and ketogenesis. Undernutrition and chronic inflammation have been suggested to elevate FGF21 levels, developing Growth Hormone (GH) resistance and subsequent attenuation of longitudinal growth and growth plate chondrogenesis in both mice and humans through unknown mechanisms.

We propose that chronic exposure to a high FGF21 environment promotes GH resistance by a direct action on human chondrocytes. The objective of this study is to identify the mechanistic interplay of FGF21 in GH-Receptor (GHR) signalling and GH resistance.

Methods: Hek-293 stable lines expressing human GHR were generated and examined for FGF21 and receptor complex (FGFR1/ β-KLOTHO) expression. Immunohistochemistry on human growth plate was studied to identify the localisation of FGF21 and co-receptors within growth plate zonation. Stable lines and/or human growth plate explants were evaluated for GHR half-life and the activation of key GHR signalling mediators; STAT5, negative feedback regulator SOCS2 and IGF-1 in the presence or absence of rhGH and rhFGF21. For the validation of clinical significance FGF21 and IGF-1 levels were measured serially in peripubertal Crohn’s patients.

Results: Expression of FGF21 receptor complex; FGFR1 iiiC/β-KLOTHO and the molecular integrity of GHR signalling was confirmed in stable lines. In the human growth plate FGF21 and co-receptors were localised within the proliferative and pre-hypertrophic zones. Chronic exposure to FGF21 significantly reduced GHR half-life and GH induced STAT5 phosphorylation, whilst the expression of SOCS2 was increased. Ex vivo studies on human growth plate explants verified our in vitro findings, whereby elevated FGF21 was seen to increase SOCS2 expression and supress IGF-1 expression. A negative association (p<0.005) of FGF21 with IGF-1 levels was found in peripubertal patients diagnosed with Crohn’s disease.

Conclusions: Chronic FGF21 exposure inhibits key GHR signaling mediators, playing a central role in GH resistance secondary to chronic childhood conditions.

682: FC4

REGULATION OF GROWTH PLATE CHONDROCYTE DIFFERENTIATION BY SPECIFIC MICRORNAS
Youn Hee Jee, MD; Jinhee Wang, PhD; Melissa Jennings, Post-bac, NICHD/NIH, Bethesda, MD, United States; Ola Nilsson, Professor, Karolinska Institutet and University Hospital, Stockholm, Sweden; Julian C. Lui, PhD; Jeffrey Baron, MD, NICHD/NIH, Bethesda, MD, United States

Objectives: Growth plate (GP) chondrogenesis is the fundamental process that drives linear growth in children and consequently, defects in chondrogenesis cause short stature. In GP, chondrocytes undergo sequential differentiation to form the resting (RZ), proliferative (PZ), and hypertrophic zones (HZ). The important role of microRNAs in the GP was revealed by cartilage-specific ablation of dicer, an enzyme essential for biogenesis of microRNAs. Here, we sought to identify specific microRNAs that regulate differentiation of PZ chondrocytes to HZ chondrocytes.

Methods: Individual GP zones were collected by microdissection from 4-day-old rat proximal tibias. Using Nanostring and RNAseq, we identified microRNAs that were downregulated in HZ vs PZ (>2 fold and FDR<0.05 by Nanostring). To prioritize these microRNAs for subsequent study, we identified microRNAs that were 1) predicted to regulate multiple genes that are differentially expressed in PZ vs HZ, and 2) predicted to target critical regulatory genes in the GP, and 3) highly expressed in GP chondrocytes compared to osteoblasts. For the four highest prioritized microRNAs, inhibitors were transfected into primary rat GP chondrocytes for evaluation of cell proliferation (3H-thymidine labeling) and changes in expression (real-time RT-PCR) of genes that are upregulated in the PZ to HZ transition.

Results: Four microRNAs (mir-369-3p, mir-374-5p, mir-379-5p, mir-503-5p) that were downregulated in HZ vs PZ were selected based on the prioritization analysis. When inhibitors for these microRNAs were transfected into chondrocytes, proliferation decreased (38, 26, 46, 49%, respectively, P<0.001) vs control (scrambled microRNA). The inhibitors for three of microRNAs (mir-374-5p, mir-379-5p, mir-503-5p) also increased expression of genes physiologically upregulated in HZ: Ihh(7.6, 6.9, 8.0-fold increase respectively, P<0.01), Bmp2(7.6, 5.4, 5.6-fold, P=0.008, 0.06, 0.047), Bmp6(3.5, 2.9, 3.2-fold, P=0.008, 0.06, 0.047), and Col10a1(5.3, 4.5, 4.4-fold, P=0.015, 0.051, 0.04). 

Conclusions: Our findings suggest that mir-374-5p, mir-379-5p, and mir-503-5p are downregulated in the PZ to HZ transition, thereby contributing to the inhibition of proliferation and stimulation of hypertrophic differentiation, which are important steps in endochondral bone formation at the GP.

329: FC5

RESPONSE TO RECOMBINANT HUMAN INSULIN-LIKE GROWTH FACTOR-1 AFTER TWO YEARS OF THERAPY IN TWO PATIENTS WITH PAPP-A2 DEFICIENCY
Maria T Muñoz-Calvo, MD, Hospital Infantil Universitario Niño Jesús/Universidad Autónoma de Madrid, Madrid, Spain; Vicente Barrios, PhD, Hospital Infantil Universitario Niño Jesús, CIBEROBN, Madrid, Spain; Jesus Pozo, MD, Hospital Infantil Universitario Niño Jesús/Universidad Autónoma de Madrid, Madrid, Spain; Gabriel Á. Martos-Moreno, MD; PhD., Hospital Infantil Universitario Niño Jesús. UAM. , Madrid, Spain; Federico Hawkins, MD; PhD, Hospital 12 de Octubre/Universidad Complutense, Madrid, Spain; Julie A Chowen, PhD, Hospital Infantil Universitario Niño Jesús, CIBEROBN, Madrid, Spain; Luis A Perez-Jurado, MD, Universidad Pompeu Fabra, Barcelona, Spain; Claus Oxvig, PhD, Aarhus University, Aarhus, Denmark; Jan Frystyk, MD, Aarhus University Hospital, Aarhus, Denmark; Jesús Argente, MD, PhD, Hospital Infantil Universitario Niño Jesús. UAM, Madrid, Spain

Objectives: PAPP-A2 is a metalloproteinase that specifically cleaves IGFBP3 and IGFBP5. We have recently described the first mutations in the PAPP-A2 gene that cause postnatal growth failure in humans and specific skeletal features, due to the resulting decrease in IGF-1 bioavailability.

The objectives are: 1. To determine auxological, hormonal and metabolic parameters after administration of rhIGF-1 to two patients with complete lack of PAPP-A2 activity. 2. To assess the safety of this treatment after two years.

Methods: The study included two prepubertal siblings, a 10.5-year-old female (patient 1) and a 6-year-old boy (patient 2), born to non-consanguineous Spanish parents. Both patients exhibited very high serum levels of IGF-I, IGF-II, ALS, IGFBP3 and IGFBP5, as well as a similar phenotype and short stature due to a homozygous loss-of-function frameshift mutation in the exon 3 of the PAPP-A2 gene (p.D643fs25*) and undetectable PAPP-A2 activity. Both siblings were treated with rhIGF-1 (Mecasermin, Increlex®; Ipsen), with progressive doses (40, 80, 100 y 120 µg/kg), twice daily for 2 years. After 6 months of treatment with rhIGF-I, patient 1 entered puberty (Tanner II). In an attempt to improve her final height, she receives Triptorelin (3.75 mg/28 days).

Results: Treatment with rhIGF-1 accelerated growth velocity, clearly improving height SDS according to age and sex in both patients at 6 mo, 12 mo and 24 mo of therapy (Table). Acutely, rhIGF-I administration increased bioactive IGF-I 60-120 minutes later. Twelve hours after treatment, serum bioactive IGF-I, total IGF-I and IGFBP-3 levels were similar to their pretreatment levels (Table). At 1 yr of treatment, fasting hyperinsulinemia was normalized (patient 1: 11 μU/mL; patient 2: 8 μU/mL) with normal glycemia and glycosylated hemoglobin before and during treatment. Treatment with rhIGF-1 produced an increase in total body mineral conent (DXA) (patient 1: 23% and patient 2: 30%) after 2 years) and increased the percentage of lean body mass in both patients. Neither patient experienced episodes of hypoglycemia or hyperglycemia or any other previously described secondary effect of rhIGF-I.

Conclusions: Treatment with rhIGF-I in children with PAPP-A2 deficiency improves growth after two years, with no apparent adverse effects.

521: FC6

IDENTIFICATION OF SMCHD1 MUTATIONS IN A SEVERE FORM OF KALLMANN SYNDROME (KS) WITH ABSENCE OF THE NOSE (ARHINIA) ATTESTS TO THE POWER OF EXTREME PHENOTYPES IN HUMAN REPRODUCTIVE GENE DISCOVERY
Natalie D Shaw, MD, National Institute of Environmental Health Sciences, Durham, NC, United States; Harrison Brand, PhD, Massachusetts General Hospital, Boston, MA, United States; Zachary A Kupchinsky, PhD, DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC, United States; Hemant Bengani, PhD, Institute of Genetics and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; Lacey Plummer, BS/BA, Reproductive Endocrine Unit of the Department of Medicine, Massachusetts General Hospital , Boston, MA, United States; Takako I Jones, PhD, University of Massachusetts, Worcester, MA, United States; Serkan Erdin, PhD, Massachusetts General Hospital, Boston, MA, United States; Kathleen A Williamson, MD, Institution of Genetics and Molecular Medicine, University of Endinburgh Western General Hospital, Edinburgh, United Kingdom; Joe Rainger, PhD, Institute of Genetics and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; Alexei Stortchevoi, PhD, Massachusetts General Hospital, Boston, MA, United States; Kaitlin Samocha, PhD, Broad Institute of MIT and Harvard, Cambridge, MA, United States; Benjamin B Currall, PhD, Massachusetts General Hospital, Boston, MA, United States; Donncha S Dunican, MD, Institute of Genetics and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; Ryan L Collins, PhD, Massachusetts General Hospital, Boston, MA, United States; Jason R Willer, PhD, Duke University Medical Center, Durham, NC, United States; Angela Lek, PhD, Harvard Medical School, Boston, MA, United States; Monkol Lek, PhD, Broad Institute of MIT and Harvard, Cambridge, MA, United States; Malik Nassan, MD, Mayo Clinic, Rochester, MN, United States; Shahrin Pereira, BS/BA; Tammy Kammin, MS/MA, Brigham and Women's Hospital, Boston, MA, United States; Diane Lucente, MS/MA; Alexandra Silva, BS/BA; Catarina M Seabra, BS/BA; Colby Chiang, PhD; Yu An, PhD, Massachusetts General Hospital, Boston, MA, United States; Morad Ansari, PhD, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; Jacqueline K Rainger, PhD, Institue of Genetics and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; Shelagh Joss, PhD, South Glasgow University Hospitals, Glasgow, United Kingdom; Jill Clayton Smith, MD, Institute of Human Development, Manchester Centre for Genomic Medicine, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester, United Kingdom; Margaret F Lippincott, MD; Syliva S Singh, MD; Nirav Patel, BS/BA; Jenny W Jing, BS/BA, Massachusetts General Hospital, Boston, MA, United States; Jennifer R Law, MD, University of North Carolina, Chapel Hill, NC, United States; Nalton Ferraro, MD, Boston Children's Hospital, Boston, MA, United States; Alain Verloes, MD, Robert Debre Hospital, Paris, France; Anita Rauch, MD, Univeristy of Zurich, Schlieren-Zurich , Switzerland; Katharina Steindl, MD; Markus Zweier, MD, University of Zurich, Schlieren-Zurich, Switzerland; Ianina Scheer, MD, Children's Hospital, Zurich, Switzerland; Daisuke Sato, MD, Hokkaido University Graduate School of Medicine, Sapporo, Japan; Nobuhiko Okamoto, MD, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan; Christiana Jacobsen, MD, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States; Jeanine Tryggestad, MD, Universtiy of Oklahoma Health Sciences Center, Oklahoma City, OK, United States; Steven D. Chernausek, MD, University of Oklahoma Health Science Center, Oklahoma City, OK, United States; Lisa A Schimmenti, MD, Mayo Clinic, Rochester, MN, United States; Benjamin Brasseur, MD, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States; Claudia Cesaretti, MD, Fondazione IRCCS Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy; Jose E Garcia-Ortiz, MD, Instituto Mexicano del Seguro Social, Guadalajara, Mexico; Tatiana Pineda Buitrago, MS/MA, Universitario de San Jose, Bogota, Colombia; Orlando Perez Silva, MD, de Medicina de Colombia, Bogota, Colombia; Jodi D Hoffman, MD, Tufts Medical Center, Boston, MA, United States; Wolfgang Muhlbauer, MD, ATOS Klinik , Munich , Germany; Klaus W Ruprecht, MD, University Hospital of the Saarland, Homburg, Germany; Bart L Loeys, MD, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; Masato Shino, MD, Gunma University Graduate School of Medicine, Gunma , Japan; Angela M Kaindl, MD, Charite- University Medicine Berlin and Berlin Institute of Health, Berlin, Germany; Ravikumar Balasubramanian, MD; Janet E Hall, MD; Stephanie B Seminara, MD, Massachusetts General Hospital, Boston, MA, United States; Daniel Macarthur, PhD, Broad Institute of MIT and Harvard, Cambridge, MA, United States; Steven A Moore, MD, University of Iowa Carver College of Medicine, Iowa City, IA, United States; Koh-Ichiro Yoshiura, MD, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; James F Gusella, MD, Massachusetts General Hospital, Boston, MA, United States; Joseph A Marsh, PhD, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; John M Graham, Jr, MD, Cedars Sinai Medical Center, Los Angeles, CA, United States; Angela E Lin, MD, Massachusetts General Hospital, Boston, MA, United States; Nicholas Katsanis, PhD, DUKE UNIVERSITY MEDICAL CENTER, Durham, NC, United States; Peter L Jones, PhD, University of Nevada, Reno, NV, United States; William F Crowley, Jr, MD, Massachusetts General Hospital, Boston, MA, United States; Erica E Davis, PhD, DUKE UNIVERSITY MEDICAL CENTER, Durham, NC, United States; David R Fitzpatrick, MD, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; Michael E Talkowski, PhD, Massachusetts General Hospital, Boston, MA, United States; Chie-Hee Cho, MD, University Hospital of Bern, Bern, Switzerland; Cynthia C Morton, MD, Broad Institute of MIT and Harvard, Cambridge, MA, United States; Richard R Meehan, PhD; Veronica Van Heyningen, MD, Institute of Genetics and Molecular Medicine, University of Edinburgh Western General Hospital, Edinburgh, United Kingdom; Eric C Liao, MD, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States

Objectives: The study of patients with extreme clinical phenotypes is an efficient strategy for gene discovery. Harnessing the phenotypic depth and size of our cohort of subjects with hypogonadotropic hypogonadism (HH), we applied this approach to a group of KS subjects with a completely absent external nose (arhinia).

Methods: Through an international consortium, we expanded our arhinia cohort to 41 cases, performed whole-exome sequencing (WES) and defined the full reproductive phenotypic spectrum.

Results: Rare mutation burden testing in WES data from cases vs ExAC controls identified 1 gene, SMCHD1, exceeding genome-wide significance. 86% of cases had a rare, heterozygous missense variant in SMCHD1, which encodes an epigenetic repressor that causes a rare form of muscular dystrophy. SMCHD1 is expressed in the human olfactory epithelium, a tissue highly relevant to arhinia and GnRH ontogeny. Cases did not harbor rare sequence variants (RSVs) in any genes associated with KS.

Reproductive function was assessed in 22M and 10F; 97% had HH, cryptorchidism, microphallus, or 1o amenorrhea. Three patients had apulsatile LH profiles, consistent with GnRH deficiency, and physiologic GnRH administration induced ovulation in a female while a male (with eutopic testes) had an exaggerated FSH response and modest T rise, suggesting coexistent testicular resistance. Neuroimaging revealed absent olfactory structures. In 3 multiplex families, an SMCHD1 RSV segregated with arhinia or sub-phenotypes (anosmia) but not with KS, indicating that HH is incompletely penetrant or variably expressed, compatible with oligogenicity.

Smchd1 suppression in zebrafish produced aberrant facial cartilage and a much shorter GnRH-immunopositive terminal nerve. RNAseq of blood cells from arhinia patients vs unaffected family revealed altered expression of craniofacial but not KS genes. 

Conclusions: 1) SMCHD1 alterations cause a broad spectrum of phenotypes that are incompletely penetrant and variably expressed, suggesting  pleiotropy, oligogenicity, or environmental modifiers

2) Epigenetic modification by SMCHD1 appears to play a role in reproductive developmental biology, and

3) KS patients with phenotypic extremes provide critical genetic insights into human reproductive function.

539: FC7

METABOLOMIC PROFILE OF SEVERE VERSUS ATTENUATED MUCOPOLYSACCHARIDOSIS TYPE I
Lynda E Polgreen, MD; Patricia I Dickson, MD; Jennifer K Yee, MD; Kent D Taylor, PhD, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, United States; David Elashoff, PhD, UCLA, Los Angeles, CA, United States; Ellen Fung, PhD, Children's Hospital Oakland Research Institute, Oakland, CA, United States; Bradley S. Miller, MD, PhD; Weston P Miller, MD; Paul J Orchard, MD; Troy C Lund, PhD, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States

Objectives: Mucopolysaccharidosis type I (MPSI) is a lysosomal storage disease caused by a mutation in the IDUA gene that results in progressive multi-system disease. MPSI can be separated into two phenotypes: MPSIH (for MPSI Hurler), which is the most severe phenotype and treated with hematopoietic cell transplantation, and MPSIA (for MPSI attenuated), a “milder” clinical phenotype that is treated with enzyme replacement therapy alone. Both treatments are most effective if initiated prior to the onset of clinical signs of disease. As the era of newborn screening for MPSI begins, so does the promise of early diagnosis and treatment. However, current diagnostics cannot predict which of the two profoundly different MPSI phenotypes will manifest, and thus cannot adequately guide treatments. Thus we aimed to identify a biochemical signature that distinguishes MPSIH from MPSIA.

Methods: Metabolomics analysis was performed on 25 samples from treated patients with MPS I (17 MPSIH; 8 MPSIA). Welch’s two-sample t-test was used to identify metabolites that differed significantly between groups and an estimate of the false discovery rate (q-value) was calculated. Random forest analysis ranked metabolites for their ability to separate groups. Finally a sparse partial least squares discriminant analysis was performed to determine the combination of metabolites that would best predict MPSIH.

Results: 125 metabolites were different and generally increased in treated MPSIH versus MPSIA (p<0.05); 14 of those metabolites also had a q-value<0.05. Random forest analysis identified methionine sulfone, 1-palmitoyl-2-linoleoyl-GPI (16:0/18:2), N-acetylhistidine, 1-methylimidazoleacetate, and cysteine to be the 5 most discriminative metabolites. A single principal component based on two metabolites (1-palmitoyl-2-linoleoyl-GPI and methionine sulfone) achieved 100% discrimination of the two disease types in our sample set.

Conclusions: We have identified 14 plasma metabolites that effectively distinguish MPSIH from MPSIA after adjustment for multiple comparisons. Of these, the combination of two biomarkers distinguished MPHIH from MPSIA in our cohort of treated MPSI patients. These findings establish a starting point for evaluating a biomarker-based diagnostic tool to predict phenotype in newborns diagnosed with MPSI.

1407: FC8

MIRAGE SYNDROME: ADDITIONAL CASES WITH SAMD9 MUTATIONS, CLINICAL AND BIOLOGICAL CHARACTERIZATION
Florence Roucher-Boulez, MD; Delphine Mallet-Motak, PhD, Hospices Civils de Lyon Université Lyon 1, Lyon, France; Dulanjalee Kariyawasam, MD, Hopital Necker - Enfants Malades. Université Paris Descartes, Paris, France; Graziella Pinto, MD, Hopital Necker - Enfants Malades. Université Paris Descartes, Paris, France; Marion Gerard, MD, CHU de Caen, Caen, France; Virginie Ribault, MD, Centre Hospitalier Universitaire, Caen, France; Christel Chalouhi , MD, Hopital Necker - Enfants Malades. Université Paris Descartes, Paris, France; Julien Thevenon, MD, CHU Dijon, Université de Bourgogne, Dijon, France; Raja Brauner, MD, Fondation Rothchild, Paris, France; Patricia Bretones, MD, Hospices Civils de Lyon Université Lyon 1, Lyon, France; Pierre Simon Jouk , MD, CHU de Grenoble site Nord , Grenoble, France; Veronique Tardy-Guidollet , MD, Hospices Civils de Lyon Université Lyon 1, Lyon, France; Candace Ben Signor, MD, CHU Dijon, Université de Bourgogne, Dijon, France; Yves Morel, MD, Hospices civils de Lyon, Université Lyon 1, Lyon, France

Objectives: The new MIRAGE (Myelodysplasia, Infection, Restriction of growth, Adrenal hypoplasia, Genital phenotypes, and Enteropathy) syndrome, described in 2015, is due to de novo heterozygotes mutations in SAMD9 gene. Our objective was to screen the patients of our cohort with intrauterine growth restriction, adrenal insufficiency and / or disorder of sex differentiation (DSD) and to characterize the adrenal and DSD phenotype.

Methods: SAMD9 Sanger sequencing for 20 patients (20 families)

Results: Mutations were found for 8 patients. 3 had the previous described mutations by Narumi et al: p.Arg459Gln, p.Glu974Lys. The other mutations were: p.Arg685Gln, p.Thr778Ile, p.Arg982His (2 patients), p.Ser1074Ile.  Those mutations have never been reported in databases. They all had MIRAGE syndrome with additional or missing symptoms. All patients had intrauterine growth restriction (IUGR) and born pre-termed. They had recurrent invasive infections. All the patients had a 46,XY DSD but with a variable degree of masculinisation. Nevertheless only one was reared as a boy. No mullerien residue has been detected but AMH was always low when available. Gonads were ectopic and testosterone low in most cases. Adrenal insufficiency was revealed rapidly at birth associated with high ACTH and low steroids, except D4 androstenedione and 11-desoxycortisol which could be normal or high, suggesting an impairment of CYP450 type II involved in the steroidogenesis.  Additionally, 2 had hypoplastic kidney, 6 had respiratory distress. 1 died in utero, 4 died before 3 months of life, 2 at 1 year old but interestingly one patient is still alive and actually 14 years old.  This patient has a particular phenotype without adrenal insufficiency but with thrombocytopenia and necrotizing enterocolitis at birth.

Conclusions: As MIRAGE syndrome may be incomplete, sequencing of SAMD9 gene should be done with the association of IUGR, adrenal insufficiency and/or 46, XY DSD and polymalformative syndrome. Those additional and future cases, with hormonal assays (steroids, AMH, gonadotrophins), are very interesting for a better understanding of the role of this gene on adrenal and gonadal development.

1318: FC9

SHOULD 45,X/46,XY BOYS WITHOUT DSD BE EVALUATED? RETROSPECTIVE LONGITUDINAL STUDY OF GROWTH, PUBERTY AND PHENOTYPIC FEATURES OF 34 PATIENTS.
Laurence Dumeige, MBBS, University of Paris, Robert Debré Hospital, Paris, France; Livie Chatelais, MD, University Hospital of Angers, Angers, France; Claire Bouvattier, MD, University of Paris, Bicêtre Hospital, Le Kremlin Bicêtre, France; Marc De Kerdanet, MD, University Hospital of Rennes, Rennes, France; Blandine Esteva, MD, University of Paris, Armand Trousseau Hospital, Paris, France; Dinane Samara-Boustani, MD, University of Paris, Necker-Enfants Malades Hospital, Paris, France; Delphine Zenaty, MD, University of Paris, Robert Debré Hospital, Paris, France; Marc Nicolino, MD, University Hospital of Lyon, Paris, France; Sabine Baron, MD, University Hospital of Nantes, Nantes, France; Chantal Metz, MD, Brest Regional Medical Center, Brest, France; Catherine Naud-Sandreau, MD, Bretagne Sud Medical Center, Lorient, France; Clémentine Dupuis, MD, University Hospital of Grenoble, Grenoble, France; Jean-Claude Carel, MD, University of Paris, Robert Debré Hospital, Paris, France; Régis Coutant, MD, University Hospital of Angers, Angers, France; Laetitia Martinerie, MD, University of Paris, Robert Debré Hospital, Paris, France

Objectives: Few studies of patients with a 45,X/46,XY mosaicism, have considered those with normal male phenotype, while they represent ~90% of the patients born with this karyotype. The purpose of this study was to evaluate the clinical outcome of 45,X/46,XY boys born with normal or minor abnormalities of external genitalia (unilateral cryptorchidism or glandular hypospadias), in terms of growth, puberty and other phenotypic characteristics.

Methods: We present a retrospective longitudinal study of 34 patients followed between 1982 and 2016 in 13 French reference centers for pediatric endocrinology.

Results: Twenty patients had a prenatal diagnosis whereas 14 patients had a postnatal diagnosis, mainly for short stature. Most patients had stunted growth, decreasing during puberty with a mean adult height of 156 +/- 6 cm, i.e. -2.3DS with correction for target height. Seventy percent of patients presented with Turner syndrome features including 5 patients with cardiac anomalies (comprising 2 bicuspid aortic valves and 1 aortic dilation) and 3 patients with renal malformations. Nineteen patients had minor abnormalities of external genitalia, and one patient developed a testicular embryonic carcinoma, underlining evidence of some level of gonadal dysgenesis in these patients. Puberty occurred spontaneously in most cases but 56% of patients evaluated at the end of puberty presented signs of declined Sertoli testicular function (increased level of FSH and low level of inhibin B).

Conclusions: Despite a clear selection bias, this study emphasizes the need to follow, up to adulthood, 45,X/46,XY patients born with a normal male phenotype, which present similar prognosis to those born with a difference in sex development. Screening for cardiac and renal malformations, and regular testicular examination appear to be indicated in all these patients, as well as monitoring of growth and testicular function during puberty. Currently, most of these patients are diagnosed in adulthood with infertility and azoospermia, which is consistent with our observations of decreased testicular function at the end of the puberty. Early management may lead to fertility preservation strategies in these patients.

1130: FC10

CLINICAL AND MOLECULAR ANALYSIS OF PUBERTAL CONTROL IN A COHORT OF SILVER-RUSSELL AND TEMPLE SYNDROMES PATIENTS
Ana Canton, PhD, INSERM UMR S938, UPMC Paris 6, Sorbonne Universities, Paris, France; Madeleine D Harbison, MD, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Walid Abi Habib, PhD, INSERM UMR S938, UPMC Paris 6, Sorbonne Universities, Paris, France; Jennifer Salem, MD, The MAGIC Foundation, Chicago, IL, United States; Annick Blaise, PhD, INSERM UMR S938, UPMC Paris 6, Sorbonne Universities, Paris, France; Sophie Geoffron, MD; Eloise Giabicani, MD, Armand Trousseau Hospital, APHP, Paris, France; Alexander A L Jorge, PhD, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Frédéric Brioude, MD, Hopital Trousseau, Paris, France; Iréne Netchine, Professor, INSERM UMR S938, UPMC Paris 6, Sorbonne Universities, Paris, France

Objectives: Epigenetic marks have been related to pubertal timing. Central precocious puberty (CPP) can be caused by MKRN3 mutations, and the loci DLK1-GTL2, MKRN3-MAGEL2 and KCNK9 have shown parent-of-origin-specific associations for age at menarche. Silver-Russell syndrome (SRS) and Temple syndrome (TS) are imprinting disorders (ID) with an overlap in clinical features, in which early puberty is frequent. Some patients with ID can present with multilocus methylation defects. The aim of this study is to analyse the pubertal timing in a cohort of SRS and TS, and to look for a correlation with the methylation status of DLK1-GTL2, MKRN3-MAGEL2 and KCNK9 imprinted loci.

Methods: We retrospectively analysed 153 SRS (119 11p15 loss of methylation (LOM) and 34 mUPD7) and 19 TS (14 DLK1/GTL2 LOM and 5 mUPD14) patients collecting clinical data, sexual steroids levels and baseline IGF-1 levels (prepubertal period without rhGH). We performed Allele-Specific Methylated Multiplex Real-Time Quantitative PCR with leukocyte DNA from all patients, analysing separately the methylation index (MI) of DLK1-GTL2, MKRN3-MAGEL2 and KCNK9 loci. For comparison, patients were grouped as 11p15 LOM, mUPD7 and chr14 anomalies.

Results: The mean ages of CP onset in boys were 10.4y in 11p15 LOM; 9.4y in mUPD7; and 9.6y in chr14 anomalies (p=0.01). In girls, they were respectively 9.8y; 8.2y; and 7.6y (p=0.0002). The frequencies of CCP were 71% in chr14, 50% in chr7 and 15% in 11p15 anomalies (p<0.0001). 11p15 LOM group presented the highest baseline IGF-1 (mean 1.0 SDS; p=0.03). We found hypomethylation in DLK1 locus in three 11p15 LOM patients; one of them had a history of CPP. For all patients, there were no differences between MI from patients with or without CPP for the three loci (MKRN3 p=0.3; KCNK9 p=0.8; DLK1 p=0.7).

Conclusions: Central precocious puberty is common among TS patients, as well as among SRS patients, particularly among those with mUPD7. The age of CP onset may be earlier in mUPD7 and TS children than in general population. There were no leukocytes methylation defects in the loci MKRN3-MAGEL2 and KCNK9 related to CPP in the cohort of SRS and TS, while one 11p15 LOM patient with CPP also had DLK1 LOM.

358: FC11

BONE MINERAL DENSITY AFTER CESSATION OF GH TREATMENT IN YOUNG ADULTS BORN SGA: A 5-YEAR LONGITUDINAL STUDY
Carolina CJ Smeets, MD; Manouk Van Der Steen, PhD; Judith S Renes, PhD, Erasmus Medical Centre, Rotterdam, Netherlands; Anita CS Hokken-Koelega, MD, PhD, Erasmus Medical Center / Dutch Growth Research Foundation, Rotterdam, Netherlands

Objectives: Short children born small for gestational age (SGA) have a bone mineral density (BMD) below average. Growth hormone (GH) treatment improves height and BMD in short SGA children. Longitudinal data on BMD in adults born SGA, after GH cessation, are lacking. The objective of this study was to determine BMD in young adults born SGA until 5 years after GH cessation.

Methods: In 173 GH-treated adults born SGA (SGA-GH), BMD of total body (BMDTB) and bone mineral apparent density of lumbar spine (BMADLS) were measured longitudinally at adult height (GH-stop), and 6 months, 2 years and 5 years thereafter. At 5 years after GH-stop (mean age 21 years), data were compared with 45 untreated short SGA adults (SGA-S), 59 SGA adults with spontaneous catch-up (SGA-CU), and 81 adults born appropriate for gestational age (AGA).

Results: At GH-stop (mean age 16.4yrs), estimated mean (SE) BMDTB SDS was -0.40 (0.1) in males and -0.51 (0.1) in females followed by a trend towards a decrease of BMDTB in males to -0.59 (0.1) at 5yrs after GH-stop (p=0.06), while it remained stable in females (-0.57 (0.1), p=0.33). At GH-stop, BMADLS SDS was -0.01 (0.1) in males and -0.29 (0.1) in females, followed by a decrease in males and females to -0.38 and -0.55 at 5 years after GH-stop, resp. (p<0.001). At 5 years after GH-stop, BMDTB and BMADLS in SGA-GH were similar compared to SGA-S, SGA-CU and AGA.

Conclusions: After cessation of GH treatment, there is a gradual decline of BMADLS, but at the age of 21 years, BMDTB and BMADLS are similar as in untreated short SGA adults.

251: FC12

ESTABLISHMENT OF A HUMAN GROWTH PLATE MODEL WITH IPS CELL-DERIVED CARTILAGE
Takeshi Kimura, MD, Osaka University, Osaka, Japan; Akihiro Yamashita, PhD, Center for iPS cell Research and Application, Kyoto University, Kyoto, Japan; Keiichi Ozono, MD, PhD, Osaka University Graduate School of Medicine, Osaka, Japan; Noriyuki Tsumaki, MD, Center for iPS cell Research and Application, Kyoto University, Kyoto, Japan

Objectives: Endochondral ossification (EO) in growth plate cartilage (GPC) plays a crucial role in the determination of the length and shape of long bones. Many skeletal dysplasias cause growth plate dysfunction, resulting in short stature. While biology of GPC in mice is well studied, little is known about the process of EO in humans. We previously reported that human iPS cell-derived cartilage (hiPSC-Cart), when implanted into the subcutaneous spaces of SCID mice for one year, formed skeletal tissue which is composed of epiphyseal cartilage- and diaphyseal bone-like tissues containing GPC-like structure. The aim of the present study is to investigate whether this human iPS cell-derived GPC (hiPSC-GPC) could model the abnormalities of GPC of FGFR3-related diseases.

Methods: We used 4 hiPSC lines derived from healthy control and patients with FGFR3-related diseases (thanatopholic dysplasia, achondroplasia and hypochondroplasia). hiPSC-Carts were transplanted into the subcutaneous space of SCID mice of various ages, and their ossification was analyzed with X-ray images over time and EO process was evaluated histologically.

Results: Histological analysis showed that control hiPSC-GPC had a zonal arrangement similar to GPC and is associated with bone formation, and each zone expressed marker gene such as indian hedgehog or type X collagen. The EO process in hiPSC-GPC was accelerated when hiPSC-Carts were transplanted in younger mice. When transplanted into 4 weeks-old mice, GPC-like structures were formed 4 weeks later. Cells in cartilage expressed human vimentin, but cells in bone-like structure did not. These results suggest that EO of hiPSC-GPC depends on interaction between the donor cells and host. We observed specific patterns in the hiPSC-GPC generated from patient-specific hiPSC. The patient-specific hiPSC-GPC showed shorter hypertrophic zone and smaller hypertrophic cells than those in control samples. In addition, these changes correlated with the severity of the diseases. By using patient specific hiPSC-GPC as a model, we are searching for candidates that will be useful for the treatment of patients with FGFR3–related diseases.

Conclusions: We have established an in vivo hiPSC-GPC model. The model should contribute to the investigation of human growth plate biology and pathology.

667: FC13

SYMPTOMATIC VITAMIN D DEFICIENT RICKETS IN MANITOBA - JUST THE TIP OF THE ICEBERG
Maria-Elena Lautatzis, MD; Atul Sharma , MD, FRCPC, University of Manitoba , Winnipeg , MB, Canada; Celia Rodd, MD, FRCPC, University of Manitoba, Winnipeg, MB, Canada

Objectives: Despite preventative strategies, vitamin D deficient rickets remains a current problem. A recent study in the province of Quebec found a sharp increase, culminating in an annual incidence of 7.9 per 100,000 live births; this was three-times an earlier national survey. Importantly, the true incidence of nutritional rickets is likely underestimated by surveys based on clinical symptoms.The primary objective of this study is to determine the annual incidence of rickets in Manitoba using multiple datasets, including comprehensive laboratory reports of 25-hydroxyvitamin D (25(OH)D) levels. Secondarily, we are interested in the clinical phenotypes at presentation.

 

Methods: This is a retrospective chart review to determine cases of rickets in our catchment area (Manitoba, NW Ontario and W. Nunavut) from 2003 – 2015. Data sources included endocrine and hospital charts using ICD-9 and -10 codes, hospital radiology reports, and reviews of all laboratory 25(OH)D tests from 2011-2015. For the laboratory assessment, 25(OH)D <30 nmol/L paired with an elevated PTH or alkaline phosphatase prompted a chart review in children <7y of age. We excluded children who were premature or who had other forms of rickets.

Results: We identified 123 cases; 13% presented with hypocalcemic seizures, 17% with bony deformities, and 70% were incidental findings. This gave an annual incidence of 35.3 per 100,000 infants and 15.8 per 100,000 children aged 1-7y. No increase in incidence was noted over the study time. Most children were from northern or rural locales; about 50% were of self-declared First Nations' heritage. The majority of children were from families with high material deprivation using area-based socio-economic measures.  

Conclusions: Our rates of rickets are much higher than previously reported, in part due to our ability to evaluate comprehensive laboratory data. Nutritional vitamin D deficient rickets remains a problem in our catchment area, especially within certain high-risk groups. Strong preventative strategies are essential. Besides providing supplements of a convenient infant vitamin D formulation in drop form at birth for all infants, other methods are clearly needed to improve childhood and maternal vitamin D status.

475: FC14

KRN23 EFFECTS ON PHOSPHATE AND VITAMIN D METABOLISM IN CHILDREN <5 YEARS OLD WITH X-LINKED HYPOPHOSPHATEMIA (XLH)
Thomas Carpenter, MD, Yale University, New Haven, CT, United States; Erik Imel, MD, Indiana University School of Medicine, Indianapolis, IN, United States; Gary S Gottesman, MD, Shriners Hospital for Children, St Louis, MO, United States; Javier San Martin, MD; Meng Mao, PhD; Alison Skrinar, PhD, Ultragenyx Pharmaceutical Inc., Novato, CA, United States; Michael P Whyte, MD, Shriners Hospital for Children, and Washington University School of Medicine, St Louis, MO, United States

Objectives: In pediatric XLH, renal phosphate (Pi) wasting due to increased circulating fibroblast growth factor 23 (FGF23) leads to hypophosphatemia, rickets, and skeletal deformities. KRN23, an investigational human monoclonal antibody, binds FGF23 and inhibits its action. Interim results of our Phase 2 study of KRN23 in XLH children (ages 5-12 yrs) showed improvements in serum Pi and rickets. In a new Phase 2 trial we evaluate the efficacy and safety of KRN23 in younger children with XLH.

Methods: In an ongoing, open-label, multicenter trial, children 1-4 yrs old with XLH received KRN23 at an initial dose of 0.8 mg/kg subcutaneously every 2 weeks. We evaluated safety, serum Pi, alkaline phosphatase (ALP), 1,25(OH)2D, and KRN23 levels. We report here baseline (BL) data for the first 10 children enrolled, and up to 4 weeks of treatment data for the first 5 children.

Results: At BL (N=10), the mean age was 3.0 yrs and 70% were boys. The median standing height percentile was 9.1%.  Complications of XLH included gait disturbance (60%), tibial torsion (60%), knee deformity (40%), and misshapen skull (40%). Significant radiographic evidence of rickets was present despite all subjects having received prior conventional therapy for a mean of 19.2 months. All had low serum Pi levels (mean (SE) = 0.83 (0.025) mmol/L) (normal: 1.03 - 1.97) and ALP was elevated in 8 of 10 children. Mean serum Pi level increased during KRN23 treatment by +0.41 (0.030) mmol/L at Week 1, and by +0.36 (0.070) mmol/L at Week 4. Normal serum Pi levels were achieved in 100% and 80% of children at Weeks 1 and 4, respectively. Mean (SE) serum 1,25(OH)2D levels increased from 118 (17) pmol/L at BL to 256 (38) pmol/L at Week 1 (normal: 60-220). Serum KRN23 concentrations at Weeks 1 and 4 resembled values observed in the Phase 2 study in older children. All adverse events (AEs) were mild, and except for upper respiratory tract infections (n=2); all other AEs occurred in 1 subject each. No serious AEs were reported.

Conclusions: Initial results in 1-4 yr-old children with XLH suggest that pharmacodynamic responses to KRN23 are similar to those of older children. The ongoing study will evaluate changes in rickets severity and growth.

1437: FC15

INHALED BETA-AGONISTS AND BONE MASS IN CHILDREN AND ADOLESCENTS
Alexis J Feuer, MD, Weill Cornell Medicine, New York, NY, United States; Ashley Thai, MS/MA, Columbia University, New York, NY, United States; Ishita Kharode, MD, Weill Cornell Medicine, New York, NY, United States; Maria Vogiatzi, MD, Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: Mounting evidence indicates the sympathetic nervous system (SNS) plays a critical role in bone remodeling. Murine studies reveal activation of the SNS leads to bone loss through norepinephrine stimulated beta (β)-adrenergic signaling and epidemiologic data in humans show use of beta-blockers is associated with higher bone mineral density (BMD) and reduced fractures. Stimulant medications, which increase β-adrenergic signaling, are also associated with lower bone mass and reduced turnover in children. While systemic β-agonist modulation of the SNS yields skeletal effects, the role of inhaled β-agonists on bone is unclear. Inhaled β-agonists are widely used to treat acute and chronic symptoms of asthma. Existing literature on inhaled β-agonists reveals conflicting results in adults and the pediatric data is sparse. As childhood is a critical period for bone accrual, it is important to assess effects of inhaled β-agonists on bone mass in this population. This study investigates associations between inhaled β-agonist use and bone mass in pediatric subjects.

Methods: Cross-sectional analysis of data from the 2005–2010 National Health and Nutrition Examination Study (NHANES). 6489 participants ages 8–20 years (mean 13.58±3.58) were analyzed. Outcome measures were total femur, femoral neck and lumbar spine bone mineral content (BMC) and density (BMD) assessed via dual-energy X-ray absorptiometry (DXA).
 

Results: 303 of 6489 subjects used inhaled β-agonists and 81 subjects used combination inhaled β-agonist and corticosteroid (ICS). After multivariable adjustment, there were no significant differences in BMD or BMC in the β-agonist-treated group versus controls at any anatomic site. Combination β-agonist/ICS users had significantly lower total femur BMC than non-users (33.93+0.17 vs 31.79+1.07, p=0.05). No other significant differences were noted.

Conclusions: Pediatric subjects using inhaled β-agonists had similar DXA measurements compared to non-users. Use of combination β-agonist/ICS was associated with significantly lower total femur BMC. This suggests that skeletal effects of inhaled β-agonists may be trivial. Additional studies in children using combination β-agonist/ICS are needed to assess skeletal effects compared to ICS use alone.

567: FC16

MAPPING THE STEROID METABOLOME IN INBORN STEROIDOGENIC DISORDERS: PERFORMANCE OF A NOVEL COMPUTATIONAL APPROACH IN COMPARISON TO CONVENTIONAL GC-MS ANALYSIS.
Elizabeth S Baranowski, MBChB, University of Birmingham, Birmingham, N/A, United Kingdom; Kerstin Bunte, PhD, University of Groningen, Groningen, Netherlands; Cedric HL Shackleton, Professor; Angela E Taylor, PhD; Beverley A Hughes, BS/BA, University of Birmingham, Birmingham, United Kingdom; Michael Biehl, Professor, University of Groningen, Groningen, Netherlands; Peter Tino, Professor, University of Birmingham, Birmingham, United Kingdom; Tulay Guran, MD, Marmara University, Istanbul, Turkey; Wiebke Arlt, Professor, University of Birmingham, Birmingham, United Kingdom

Objectives: We developed and applied a novel computational tool to analyse gas chromatography-mass spectrometry (GC-MS) steroid metabolite profiling data that functions irrespective of age and sample type variation and assessed its performance in comparison to established GC-MS analysis utilising steroid substrate/product ratios.

Methods: We collected urine (nappy, spot and 24hr) from 829 healthy controls (<1m: n=85; 1-3m: n=89; 3m-1y: n=131; 1-4yr: n=96; 4-10y: n=44; 10-16y: n=24; 16-30y: n=90; 30-50y: n=146; >50y: n=90) and 118 patients with genetically confirmed inborn steroidogenic disorders including CAH due to mutations in 21-hydroxylase, 11β-hydroxylase, 17-hydroxylase deficiency, P450 oxidoreductase and 3β-HSD2, and 46,XY DSD due to mutations in 5α-reductase type 2, 17β-HSD3, and cytochrome b5. We undertook GC-MS analysis for identification and quantitation of 34 individual steroid metabolites, calculated age-specific medians, 5th/95th centiles and 22 defined steroid ratios conventionally used for diagnosis of these disorders. We then analysed the steroid profiling results employing our newly developed machine learning approach, Angle Learning Vector Quantization (ALVQ). Using vectors created from ratios of metabolites, the model develops prototypes as typical representative fingerprints of a category and an adaptive dissimilarity measure based on angles between vectors. Healthy control projections were visualised to assess for age correlation.

Results: Our data showed a high degree of variation in both individual steroid metabolites and the conventionally defined diagnostic steroid ratios over life when looking at centile data, with substantial overlap between distinct disease groups. By contrast, ALVQ correctly categorised healthy control and patient data by distance to projected prototype with 100% sensitivity and 97% specificity, and compensated for missing values and heterogeneity regards age/sex/units/method of collection.

Conclusions: The newly developed machine learning-based method provides higher sensitivity and profoundly better specificity in diagnosing inborn steroidogenic disorders than currently applied conventional biochemical analysis, with highly promising potential for implementation in routine clinical practice.

940: FC17

MOLECULAR STUDY OF RAS/MAPK PATHWAY GENES IN PATIENTS WITH CRYPTORCHIDISM
Fernando A Rodríguez, PhD; Carla Vallejos, TM; Nancy Unanue, MD; María I Hernández, MD, School of Medicine, University of Chile, Santiago, Chile; Soledad Célis, MD, San Borja – Arriarán Clinical Hospital, Santiago, Chile; Rubén Martín-Arenas, PhD; María Palomares Bralo, PhD; Karen E Heath, PhD, La Paz University Hospital, Madrid, Spain; María T López, MD, San Borja - Arriarán Clinical Hospital, Santiago, Chile; Fernando Cassorla, MD, School of Medicine, University of Chile, Santiago, Chile

Objectives: Cryptorchidism is a frequent finding in patients with RASopathies, which are caused by derangements in Ras/MAPK genes. Our aim was to determine whether patients with only one feature of this condition, such as cryptorchidism, exhibit alterations (mutations or copy number variations) in some genes of the Ras/MAPK pathway.

Methods: Two hundred and forty three patients with cryptorchidism were recruited and classified into three study groups, according to their height and presence of a phenotype suggestive of RASopathy. Genomic DNA was extracted for molecular analysis of PTPN11, SOS1, KRAS, NRAS, HRAS, RAF1, BRAF, MAP2K1 and MAP2K2 genes. Molecular analysis involves: i) screening of mutations through High Resolution Melting (HRM) followed by sequencing and ii) determination of gene copy number variation by comparative genomic hybridization and SNPs array.

Results: A total of 193 patients had isolated cryptorchidism (G1), 19 had cryptorchidism, short stature and no other RASopathie feature (G2), and 31 had cryptorchidism, short stature and a phenotype suggestive of RASopathy (G3). Molecular analysis of G1 showed one synonymous substitution (BRAF_p.Q456Q) in two patients; five missense substitutions (SOS1_ p.R497Q, BRAF_ p.W619C, BRAF_ p.F595L, NRAS_ p.T50I and MAP2K2_ p.Y134C) in six patients, and a ~175 Kb microduplication including RAF1 in two patients. Group 2 analyses did not show any molecular alteration. Finally, G3 analysis showed five missense substitutions (PTPN11_p.E139D, PTPN11_p.F285L, PTPN11_p.T468M, SOS1_ p.R552G and HRAS_p.G12S), which have been previously reported in RASopathie patients. Analysis of the synonymous substitution BRAF_ p.Q456Q with software ESEfinder2.0 predicts that it might alter mRNA editing. On the other hand, the missense substitutions found in G1 patients have been associated with Noonan and Cranio-facio-cutaneous syndromes. Finally, a RAF1 microduplication similar to that found in our patients was described in a patient with testicular aplasia.

Conclusions: We report the first molecular study of RASopathies in a cohort of patients with isolated cryptorchidism. Our results suggest that some patients with isolated cryptorchidism may harbour Ras/MAPK pathway gene alterations. (Fondecyt1140450)

838: FC18

ANDROGEN INSENSITIVITY DUE TO INCREASED METHYLATION IN THE ANDROGEN RECEPTOR PROMOTER
Nadine C Hornig, PhD; Pascal Rodens, Medical Student, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany; Hans Udo Schweikert, Prof., University Bonn, Bonn, Germany; Olaf Hiort, ; Ralf Werner, Dr., University Luebeck, Luebeck, Germany; Susanne Gonzalves, MD, Diakonissen-Stiftungs-Krankenhaus, Speyer, Germany; Anne Katrin Eckstein, MD, Praxisklinik Kronshagen, Kronshagen, Germany; Ole Ammerpohl, Prof.; Paul-Martin Holterhus, , Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Kiel, Germany

Objectives: Androgen insensitivity syndrome (AIS) is a common cause of 46,XY differences in sex development. Although classically defined as the inability of the androgen receptor (AR) to respond to androgens only 40% of clinically diagnosed AIS cases reveal a partial or complete loss of function mutation in the AR-gene. This leaves a considerable amount of AIS patients without a clear diagnosis and underlines the need of factors outside the AR for proper androgen action.

Objective: To investigate, if changes in AR-transcription can explain AIS in the absence of an AR-gene mutation.

Methods: Analysis of AR function (APOD-assay) and AR mRNA levels in AR-gene mutation negative cultured genital skin fibroblasts (GF) from individuals with the clinical diagnosis AIS as well as bisulfite-sequencing of the AR-promoter in these GF. In order to define AIS on a functional basis we previously established an assay measuring the transcriptional activity of the AR to induce its target gene Apolipoprotein D (APOD) in GF. The APOD-assay clearly distinguishes AR-activity in GF of male controls from GF of individuals with a mutation in the AR gene (p<0.0001).

Results: Applying this assay to GF from clinically diagnosed AIS individuals but no mutation in the AR gene we saw a reduced AR function in about one-third of the cases (n=23). This subgroup can be defined as functional AIS in the absence of an AR-gene mutation (AIS type II). Analyzing AR mRNA levels in these 23 GF revealed a reduced AR mRNA expression in 8 cases compared to age and tissue matched controls. Methylation analysis of the AR-promoter in these cases showed a significantly increased methylation at specific, so far not described sites in 5 cases.

Conclusions: Using the APOD-assay we were previously able to validate the clinical diagnosis AIS on functional grounds (AIS type II). In search for co-regulators of androgen action in AIS type II we identified a region in the AR promoter necessary for proper AR expression. We postulate that high methylation of this promoter region leads to a reduced AR- transcription and thereby androgen insensitivity in the absence of a mutation in the AR gene.

586: FC19

12 MONTH SURGICAL OUTCOMES FOLLOWING GENITOPLASTY IN CHILDREN WITH MODERATE-TO-SEVERE GENITAL ATYPIA
Kerlly J Bernabé, MPH, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, United States; Natalie J Nokoff, MD, Children's Hospital Colorado, Aurora, CO, United States; Denise Galan, CPNP; Diane Felsen, PhD, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, United States; Christopher E Aston, PhD, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States; Paul Austin, MD, St. Louis Children's Hospital, St. Louis, MO, United States; Laurence Baskin, MD, University of California, San Francisco Medical Center, San Francisco, CA, United States; Yee-Ming Chan, MD, PhD, Boston Children's Hospital / Harvard Medical School, Boston, MA, United States; Earl Cheng Cheng, MD, Lurie Children’s Hospital of Chicago, Chicago, IL, United States; David Diamond, MD, Boston Children’s Hospital, Boston, MA, United States; Allyson Fried, CPNP, RN, MSN, BSN , Women and Children's Hospital of Buffalo, Buffalo, NY, United States; Lynette Gonzalez, CRC, University of California, San Francisco Medical Center, San Francisco, CA, United States; Saul Greenfield, MD, Women and Children's Hospital of Buffalo, Buffalo, NY, United States; Thomas Kolon, MD, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Bradley Kroop, MD, Cook Children's Medical Center, Fort Worth, TX, United States; Yegappan Lakshmanan, MD, Children's Hospital of Michigan, Detroit, MI, United States; Sabrina Meyer, CPNP, Women and Children’s Hospital of Buffalo, Buffalo, NY, United States; Theresa Meyer, CPN, Lurie Children’s Hospital of Chicago, Chicago, IL, United States; Alexandria Mullins, PhD; Larry L Mullins, PhD, Oklahoma State University, Stillwater, OK, United States; Blake Palmer, MD, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States; Alethea Paradis, MTS, St. Louis Children's Hospital, St. Louis, MO, United States; Pramod Reddy, MD, Cincinatti Children's Hospital Medical Center, Cincinatti, OH, United States; Kristy J Scott-Reyes, BS/BA, Cook Children's Medical Center, Fort Worth, TX, United States; Marion Schulte, MHSA, RN, Cincinatti Children's Hospital Medical Center, Cincinatti, OH, United States; Jonathan M Swartz, MD, Boston Children’s Hospital , Boston, MA, United States; Elizabeth Yerkes, MD, Lurie Children’s Hospital of Chicago, Chicago, IL, United States; Cortney Wolfe-Christensen, PhD; Amy Wisniewski, PhD, Cook Children's Medical Center, Fort Worth, TX, United States; Dix Poppas, MD, New York Presbyterian Hospital / Weill Cornell Medicine, New York, NY, United States

Objectives: There are few prospective studies on short and long-term outcomes following genitoplasty among children with atypical genitalia. Historically, studies report suboptimal outcomes. We report complication rates and cosmetic outcomes as rated by surgeons and parents within one year of a child born with atypical genitalia receiving genitoplasty.

Methods: This 10-site, prospective, observational study included children: 2 years of age or younger, with Prader 3-5 or Quigley 3-6 external genitalia, no prior genitoplasty and no other malformations other than urogenital at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests were used to evaluate differences in mean cosmesis ratings. We examined 12-month outcomes for planned 1-stage repairs on girls, planned 1-stage repairs on boys, and planned 2-stage repairs on boys.

Results: Fifty-four percent (15) of children had congenital adrenal hyperplasia, 32% (9) had an unknown diagnosis, 10% (3) had gonadal dysgenesis and 1 patient had partial androgen insensitivity syndrome. Among children who had feminizing genitoplasty (16), vaginoplasty was performed in all, clitoroplasty in 56% (9), external genitoplasty in 75% (12), urethroplasty in 25% (4), perineoplasty in 25% (4) and total urogenital sinus mobilization in 1. Two girls (13%) developed complications: vaginal stenosis and a vaginal mucosal polyp. Twelve children had masculinizing genitoplasty; complications occurred in 25% (1/4) of boys with a planned 1-stage genitoplasty and 50% (4/8) of boys with a planned 2-stage genitoplasty: glans dehiscence, urethral dehiscence, distal fistula, other fistula and urinary tract infection. Cosmesis scores significantly improved from pre-op to 6-month post-op and were similar between 6- and 12-month visits for all raters (Table). There were no significant differences between 6- and 12-month ratings, with all scores "good" or "satisfied."

Conclusions: Parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. Boys who received planned 2-stage genitoplasty procedures had the highest complication rates.

355: FC20

ANTENATALLY DETERMINED SESQUIZYGOSITY IN GENDER DISCORDANT MONOCHORIONIC DIAMNIOTIC TWINS (46,XX/46,XY):- POSTNATAL CLINICAL AND GONADAL PHENOTYPE.
Louise S Conwell, PhD, Lady Cilento Children's Hospital, Children's Health Queensland; Children's Health Queensland Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia; Gayle E Phillips, MBBS, Department of Health, Queensland Government, Lady Cilento Children's Hospital and Royal Brisbane and Women's Hospital; Faculty of Medicine, University of Queensland, Brisbane, Australia; Adayapalam Nandini, PhD, Pathology Queensland, Brisbane, Australia; Peter A Borzi, MBBS, Lady Cilento Children's Hospital, Children's Health Queensland; Children's Health Queensland Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia; Michael T Gabbett, MBBS, Royal Brisbane and Women's Hospital; School of Medicine, University of Queensland, Brisbane, Australia

Objectives: Sesquizygosis is an exceptional intermediate between mono- and dizygotic twinning.

A spontaneously conceived twin pregnancy had monochorionic, diamniotic placentation from the 6 week ultrasound (US) (confirmed postnatally). From 14 weeks gestation, US showed phenotypic gender discordance in otherwise structurally normal twins with male (twin A) and female (twin B) phenotypes.

FISH / SNP karyotyping on mid-trimester amniotic fluid showed twin A 50:50 XX/XY and twin B 90:10 XX/XY. Similar ratios were later confirmed in cord tissue.

Genotyping indicated (i) maternally identical, sharing half their paternal genome, hence three-quarter identical or sesquizygotic twins (ii) parthenogenetic activation of the haploid oocyte as the initial step in the aetiology.

Objective:-Describe the postnatal clinical and gonadal phenotype.

Methods: Postnatal clinical and US assessments; FSH, AMH, Inhibin B levels; gonad biopsies with histopathology, immunohistochemistry and cytogenetics.

Results: Postnatal assessments confirmed twin A to be phenotypically male and twin B female with accordant gender of rearing.

The female had granulosa cell compromise suggested by FSH, AMH, Inhibin B at age 4.5 and 16 months. Bilateral intra-abdominal gonad biopsies at age 16 months showed dysgenesis with ovarian type stroma, abnormal primordial follicles and no seminiferous tubules. There were islands of cells, some cystic, with partly cribriform architecture, the largest consistent with gonadoblastoma. On immunohistochemistry, these islands of cells were positive for OCT-4, c-KIT, PLAP and Inhibin B. Ki-67 (proliferation marker) was positive in 2-10% of these cells. Cytogenetics (FISH) identified XY in 2.8-8.5% of cells, but confined to those islands of cells. The gonads were removed (no invasive germ cell tumour).

The male had robust Sertoli cell markers at age 4.5mths. Bilateral intra-scrotal gonad biopsies at 25 months showed normal testes for age (OCT-4, c-KIT negative). Cytogenetics (FISH): 50% and 40% of cells XY in the gonads.

Conclusions: This adds to the one prior report1 in which postnatal genotyping suggested sesquizygotic twins, 46,XX/46,XY but with phenotypic differences and no immunohistochemistry reported.

1Souter VL et al. Hum Genet (2007) 121:179-185

1575: FC21

NOVEL METABOLIC PHENOTYPE FROM ACAD 10 DEFICIENCY IN MICE
Yan Wang, PhD; Zhengwei Gong, PhD; Emir Tas, MD; Kai Su, MS/MA; Ting Wang, PhD; Wei Chen, PhD; Jerry Vockley, MD; Eric Goetzman, PhD, University of Pittsburgh, Pittsburgh, PA, United States; Radhika Muzumdar, MD, Childrens Hospital of Pittsburgh of UPMC/University of Pittsburgh, Pittsburgh, PA, United States

Objectives: Acyl-CoA Dehydrogenase Family Member 10 (ACAD10) has conserved acyl-CoA dehydrogenases domain, which catalyzes α, β-dehydrogenation reactions, including the first step in mitochondrial fatty acid oxidation (FAO), and intermediary reactions in amino acids catabolism. ACAD10 gene polymorphisms associated with obesity and type 2 diabetes in Pima Indians that could be linked to impaired fatty acid oxidation. 

We investigated the function of ACAD10 in glucose homeostasis using Acad10-/- (KO) mouse model. 

Methods: Glucose homeostasis and insulin sensitivity were analyzed by glucose and insulin tolerance tests (GTT, ITT) in Acad10-/- mice and compared to wild type littermate (WT) controls. Gluconeogenesis was evaluated by pyruvate tolerance test (PTT). Unbiased RNA-Seq and Ingenuity Pathway Analysis (IPA) approaches were performed to identify differentially expressed genes in the liver of KO and WT female mice (n=4 each) using Illumina NextSeq 500. 

Results: Acad10-/- mice demonstrate profound fasting hypoglycemia (50-89 mg/d L, p<0.03) compared to WT.  However, unlike FAO defects, fasting hypoglycemia is associated with increased ketogenesis.  Gluconeogenesis was robust on PTT (P<0.03) in Acad10-/- mice compared to WT. RNA-Seq data and Ingenuity pathway analysis showed i) higher PEPCK expression (key gluconeogenic enzyme); ii) upregulation of PPAR-α signaling; iii) increased FGF21 expression and iv) higher expression of genes involved in bile acid synthesis and signaling such as cyp4a11, cyp7a1 and FXR. All gene changes were validated by RT-PCR. In particular, RT-PCR showed a 10 fold higher expression of Fgf21 in ACAD 10 -/- mice.

Conclusions: ACAD10 deficiency induces fasting hypoglycemia along with increased gluconeogenesis and ketogenesis. Significant changes in FGF21 and bile acid pathway contribute to the phenotype and indicate a novel metabolic pathway.   

374: FC22

IMPACT OF METRELEPTIN ON HEPATOMEGALY IN PEDIATRIC PATIENTS WITH GENERALIZED LIPODYSTROPHY
Elif A. Oral, MD, Brehm Center for Diabetes, Ann Arbor, MI, United States; Elaine Chiquette, PharmD, Aegerion Pharmaceuticals, Cambridge, MA, United States; James H. Lewis, MD, Georgetown University Hospital, Washington, DC, United States; Alison Long, Md, PhD; Taylor C Salinardi, PhD, Aegerion Pharmaceuticals, Cambridge, MA, United States; Rebecca Brown, MD, National Institutes of Health, Bethesda, MD, United States

Objectives: Generalized lipodystrophy (GL) is a rare disease, inherited or acquired, progressive and often life-threatening. The underlying pathogenesis is the irreversible, widespread loss of adipose tissue, leading to low leptin levels and storage of excess calories as triglycerides (TG) in ectopic locations such as the liver. The goal of this study was to examine the effect of leptin replacement (metreleptin, ML) on liver volume (LV) and key metabolic parameters in pediatric patients with GL.

Methods: This is a post hoc analysis of an open-label, prospective study of ML in GL conducted at NIH. LV by MRI, was assessed for all available pediatric patients enrolled from 2000–2008. Normal LV was estimated as 2.5 MN, respectively. Triglycerides, hemoglobin A1c (A1c), AST, and ALT were measured at baseline and after ML treatment.

Results: Baseline and follow-up liver volumetric measurements were obtained in 13 patients (age < 18 years, mean 14 ± 3) with GL. The majority were female (69%), 69% had congenital GL, 85% had diabetes, and 77% had hypertriglyceridemia. At baseline, all had enlarged liver with a mean ± SD LV of 3459 ± 1178 mL, ranging from 1.2–6 times normal. For patients assessed within a year after initiating ML (n=13, mean treatment duration of 9.4 ± 3.2 months), LV decreased by 25.2 ± 15.4%. Patients (n=9) with longer exposure (46.2 ± 26.9 months) appeared to have a larger decrease in LV relative to baseline of 34.3 ± 18.1%. Treatment with ML for 1 year resulted in significant reductions in A1c [n=11, –2.2 ± 1.4%], AST [n=11, –56.3 ± 75.3 U/L], ALT [n=11, –90.5 ± 128.6 U/L], and TG [n=9, –43.1 ± 30.8 mg/dL]. ML was generally well tolerated; gastrointestinal disorders including abdominal pain and pancreatitis were the most commonly reported adverse events.The 2 patients with pancreatitis also reported it in their past medical history.

Conclusions: Moderate to severe hepatomegaly, usually due to hepatic TG accumulation, is a common feature in pediatric patients with GL. In addition to its metabolic effects, this post hoc analysis provides additional evidence that ML may have a significant and sustained effect in reducing LV in pediatric patients with GL.

1048: FC23

PREVALENCE OF “PREDIABETES” RANGE HEMOGLOBIN A1C IN NORMAL WEIGHT YOUTH FROM THE HEALTHY STUDY
Christine L Chan, MD, University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, United States; Kimberly L Drews, PhD, George Washington University, Washington, DC, United States; John B Buse, MD/PhD, University of North Carolina School of Medicine, Chapel Hill, NC, United States; Philip S Zeitler, MD, PhD, University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, United States; Megan M Kelsey, MD, University of Colorado/Children's Hospital Colorado, Aurora, CO, United States

Objectives: Hemoglobin A1c (HbA1c) cutpoints set in adults to diagnose prediabetes and diabetes have been extrapolated to youth. However, little is known about normal variation of HbA1c in youth, particularly during the time of physiologic pubertal insulin resistance. This study is a secondary analysis from the HEALTHY Study to evaluate HbA1c variation in normal weight 6th and 8th graders.

Methods: Study population – Normal weight girls (n=2849) and boys (n=2367) aged 11-15 years from HEALTHY, a randomized trial to assess school-based intervention on diabetes risk factors in 6th-8th graders. Descriptive statistics were performed to assess the normal distribution of HbA1c in the whole cohort and by race/ethnicity. Puberty staging was performed by self-assessment.

Results: In 6th and 8th graders, respectively, mean (SD) age (years) was 11.3+0.6 and 13.7+0.6; BMI %ile 50.8+23.9% and 54.2+23.3, and HbA1c (%) 5.11+0.29 and 5.11+0.31. The majority were pubertal (88% and 99.8% of 6th and 8th graders, respectively). There was significant racial/ethnic variability in the cohort (51.3% Hispanic, 18.9% Black, 20.1% White and 9.6% other).  Just under 2% of this normal weight cohort had an HbA1c 5.7%-6.0%. In both boys and girls, HbA1c was significantly higher in Blacks than in Hispanics (p<0.0001) and Whites (p<0.0001).

Conclusions: A small, but clinically meaningful, proportion of normal weight youth have an HbA1c in the prediabetes range, based on adult criteria; thus, caution needs to be taken in interpreting HbA1c when used as a screening tool for diabetes in otherwise healthy youth, particularly in Black youth. Further research is needed to better understand the potential impact of pubertal insulin resistance on glycemic variability in healthy youth.

467: FC24

PREDICTIVE UTILITY OF 10-SNPS GENETIC RISK SCORE FOR PEDIATRIC-ONSET TYPE 2 DIABETES.
America L Miranda Lora, PhD; Mario Molina-Díaz, MD, Hospital Infantil de México Federico Gómez, México, Mexico; Miguel Cruz, PhD, Centro Médico Nacional sXXI, Instituto Mexicano del Seguro Social, México, Mexico; Miguel Klunder Klunder, PhD, Hospital Infantil de México Federico Gómez, México, Mexico

Objectives: To evaluate whether a genetic risk score (GRS) could improve pediatric-onset T2D risk prediction in Mexicans. 

Methods: We performed a case-control study. A total of 97 individuals with pediatric-onset T2D and 84 controls less than 19 years without T2D (population controls) were included. We obtained information about family history of T2D, demographic, anthropometric, biochemical, lifestyle information and fitness score. We also genotyped 10 single nucleotide polymorphisms (SNPs) previously associated with T2D in Mexican children and adolescents  (ADORA1/rs903361, CADM2/rs13078807, GNPDA2/rs10938397, POC5/rs2112347, VEGFA/rs6905288, RPS10/rs206936, GLIS3/rs7034200, LINGO/rs10968576, FTO/rs9939609 and SLC16A11/rs13342232). Allele frequencies and genotype distributions were analyzed. The genetic risk score (GRS) was constructed by summing the 10 risk alleles. A logistic regression analysis, adjusted for age, sex and maternal history of diabetes and Z score of body mass index (Z-BMI) was performed to evaluate the probability of presenting T2D in a first model. A second model was evaluated by adding the GRS. The areas under the curve (AUC) were calculated to assess the discriminatory ability of each model.

Results: The Z-BMI was found to be an independent environmental factor associated with pediatric-onset T2D (OR=1.7; p=0.004), as well as maternal history of T2D (OR=6.4; p<0.001). We didn´t observe association with another environment factors. The patients with T2D have higher risk alleles in relation to controls. The GRS showed also a significant association (OR=1.2; p=0.008). The AUC of the full model, which combined, age, sex, Z-BMI, maternal history of diabetes and GRS was significantly bigger than the model without this last variable (0.71 vs 0.78 respectively, p=0.020) (Figure 1).

Conclusions: A GRS based on these 10-SNPs is associated with pediatric-onset T2D in Mexicans. The GRS in conjunction with non-genetic risk factors significantly improves the prediction of pediatric-onset T2D.

980: FC25

TRENDS IN GLYCEMIC MEDICATIONS AND CONTROL IN YOUTHS WITH TYPE 2 DIABETES (T2D): THE SEARCH FOR DIABETES IN YOUTH STUDY
R. Ravi Shankar, MD; Cathy Anne Pinto, PhD; Tongtong Wang, PhD, Merck and Co., Inc., Upper Gwynnedd, PA, United States; Jeanette M Stafford, MS/MA; Ralph B D'Agostino, PhD, Wake Forest University, Winston-Salem, NC, United States; Jean M Lawrence, ScD, Kaiser Permanente, Pasadena, CA, United States; Grace Kim, MD; Catherine Pihoker, MD, Seattle Children's Hospital, Seattle, WA, United States; Dana Dabelea, MD,PhD, University of Colorado Denver, Aurora, CO, United States

Objectives: To assess temporal changes in pharmacologic treatment of T2D youths.

Methods: Using data from the US SEARCH for Diabetes in Youth Study, we conducted 1) a cross-sectional comparison of medication use for 646 incident T2D cases (age 15.4 [±2.7] years, 62% female, 18.9% Non-Hispanic white) who completed a SEARCH baseline visit in two periods (2002-2005 vs. 2008 and 2012), and 2) a longitudinal analysis for a subset of 322 participants who also had a follow up visit on average after 7.1±2.1 years. For the cross-sectional analyses, data are presented as 2002-2005 vs. 2008 and 2012.

Results: The majority of incident cases in each period received metformin (64.9% vs. 70.4% and/or insulin (38.1% vs. 38.4%), while fewer were treated with sulfonylurea (5.6% to 3.6%), with non-significant changes over time.  There was a significant reduction in thiazolidinedione (TZD) use (5.0% vs. 2.0%, p<0.05). 

At baseline, participants on metformin monotherapy had a lower unadjusted A1C (6.4±1.4%) compared to those on insulin monotherapy (8.4±2.2%, p<0.0001) or insulin plus an oral diabetes medication (ODM) (7.7±2.2%, p<0.0001).  Among participants on metformin monotherapy at baseline (n=138), only 29.7% reported metformin monotherapy at follow up, with the remainder either adding (19.6%) or switching (8.0% to insulin, another ODM (15.9%), or not on any medication (26.8%).  Of those receiving insulin (±ODM) at baseline (n=129), 76% were continuing on insulin (±ODM) at follow up.

Overall, 35% of the 322 patients in the longitudinal follow up analyses were at an A1C goals of <7.0% at the follow up visit: 44.1% of patients on metformin monotherapy at baseline, 20.6% of those on insulin (±ODM) at baseline, and 64.5% of those with no reported medication use at baseline had an A1C <7.0% at the follow up visit.

Conclusions: Despite the growing number of medications available for T2D adults, youths with T2D are still largely being treated with metformin and/or insulin, which are the only medications approved for pediatric use in the US, with a recent decline in TZD use as seen in adults. A majority of the youths with T2D receiving treatment for an average of 7 years were not at the A1A-recommended A1C goal.

1597: FC26

EVALUATION OF THE EFFECTIVENESS OF A PEDIATRIC ENDOCRINOLOGY EDUCATION PROGRAM FOR HAITI (PEEP-H): A PRELIMINARY REPORT
Renault Louis, MD, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti; Daphné Cloutier, MD; Marie-Ève Robinson, MD, McGill University Health Centre, Montréal, QC, Canada; Dearthlie Benardeau, MD; Clorène Cadet, MD, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti; Renée Alcée, MD; Steeven Joseph, MD, NPH Haiti Saint Damien Pediatric Hospital, Port-au-Prince, Haiti; Guy Van Vliet, MD, Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC, Canada; Julia Von Oettingen, MD, McGill University Health Centre, Montréal, QC, Haiti

Objectives: To evaluate the effectiveness of a pediatric endocrinology education program in a low-resource setting on its participants' knowledge and skills in general pediatric endocrinology.

Methods: The Pediatric Endocrinology Education Program for Haiti (PEEP-H), supported by the Pediatric Endocrine Society (PES) and the European Society for Pediatric Endocrinology (ESPE), was developed with the objective to establish pediatric endocrinology training in Haiti. A two-year curriculum is taught during bi-monthly onsite training visits by a rotating body of francophone pediatric endocrinologists. Monthly teleconferences, e-learning and a remote consultation platform supplement the training. Using a prospective cohort study design, we collected participants’ demographic information, and evaluated the impact of PEEP-H by means of pre/post training examinations, and quantitative and qualitative evaluation.

Results: Six onsite visits were held for 52 trainees between March 2016 and February 2017. Residents were in their first, second and third year of training or were pediatricians in 17, 48, 29 and 7%, respectively. Ninety percent had completed medical school in Haiti and only 7% had previously participated in a pediatric endocrinology rotation. More than 60% evaluated their knowledge in 8 different areas of pediatric endocrinology as insufficient or fair: On a scale of 1 (insufficient) to 5 (excellent), the mean rating was 1.8±0.8. Mean examination scores ranged between 37-45% before and 62-65% after onsite training, with mean percentage increments ranging from 17 to 28%. Forty Haitian trainees and 14 pediatric endocrinologists from three different countries registered on the consultation platform. Thirteen cases were discussed, and 157 messages were exchanged. Trainees positively evaluated training and consultation interactions.

Conclusions: Pediatric residents in Haiti subjectively and objectively have insufficient pediatric endocrine knowledge. Knowledge level improves following PEEP-H training, and trainees see benefit in the training modules offered. While interim results are encouraging, long-term evaluation is needed to assess the program’s value and potential as a subspecialty training model for additional specialties and other resource-limited settings.

262: FC27

EARLY LIFE STRESS INDUCES TYPE 2 DIABETES AT ADULTHOOD IN MALE MICE
Hanna Ilchmann, MS/MA; Maiwenn Olier, PhD; Corinne Lencina, research technician; Sandrine Ellero-Simatos, PhD; Michèle Nankap, MS/MA; Ambre Riba, PhD; Caroline Sommer, research technician; Hervé Guillou, PhD; Laurence Guzylack-Piriou, PhD; Vassilia Théodorou, PhD; Sandrine Ménard, PhD, INRA, Toulouse, France

Objectives: The incidence of metabolic disorders is increasing worldwide. Besides diet and life style habits, epidemiological studies highlighted an association between post-traumatic stress and metabolic disorders. Based on the concept of Developmental Origins of Health and Diseases our study aimed to investigate whether early life stress can trigger metabolic disorders and associated key features i.e. low-grade inflammation and microbiota dysbiosis.

Methods: Maternal separation (MS) is an established model of early life stress in rodent. C3H/HeN mice pups were separated from their dam and the rest of the litter 3 hours per day during 10 days starting at post-natal day 2 (PND2). All experiments were carried out in male offspring aged of PND350 on standard diet. Metabolic state was evaluated by oral glucose tolerance test (OGTT) and intraperitoneal insulin tolerance test (ITT). Cellular immune response was analyzed by primary cell culture of spleen, lamina propria and mesenteric lymph nodes. Plasmatic and fecal Ig concentrations were measured by ELISA. Fecal microbiota composition was analyzed by GUt Low-Density Array (GULDA).

Results: MS had no effect on body weight in male mice but increased fasted blood glycemia. Furthermore, MS induced glucose intolerance, measurable during OGTT. Blood glucose was higher at 15 min and 30 min in MS mice after oral administration of glucose. During ITT, blood glucose in MS mice diminished slower resulting in an increase of the area under the curve (blood glucose mg/dL/30min). MS did not affect cellular immune response. However, MS decreased IgG concentrations in plasma and feces without modification of IgA concentrations. Finally, MS induced fecal dysbiosis favoring pathobionts (Bacteroides vulgatus, Enterobacteriaceae, Escherichia coli, Enterococcus spp).

Conclusions: We demonstrated for the first time that early life stress induces glucose intolerance associated with a loss of insulin sensitivity in mice non-genetically predisposed to metabolic disorders and fed with standard diet. Interestingly, glucose intolerance is not associated with local or systemic low-grade inflammation but is associated with a decrease of humoral (IgG) response. Furthermore, MS induces a fecal dysbiosis favoring pathobionts.

860: FC28

SEXUAL DIMORPHISM OF SIZE: ONTOGENY AND LIFE HISTORY
Alina German, MD, Bnei Zion medical Center, Haifa, Israel; Ze'Ev Hochberg, MD, PhD, Technion-Israel Institute of Technology, Haifa, Israel

Objectives: Sexual dimorphism in size (stature and weight) is the outcome of boys and girls responding differently to environmental cues, but may also have fitness advantage. It results from the sex-specific interaction between size-related survival and size–related obstetric complications and fertility. Our Hypotheses were:  1. Living standard and health affect size dimorphism; 2. Variations in size dimorphism are due to differential responding by boys and girls to environmental cues; 3. Size dimorphism will be greatest where population average height and weight are greatest.

Methods:  1. We characterized size dimorphism in the CDC2000 database from age 0-20. 2. We correlated 161 countries’ a-gross domestic product (GDP per capita), b-life expectancy (LE), c-population average size with adult M/F ratio in height and weight per country. 3. We correlated M/F ratio in 44 present-day preindustrial societies with average size, LE, total population and density.

Results:   1. Size dimorphism appears and disappears at minipuberty and then is gradually established when the boys enter puberty. (Figure) 2. Stature and weight M/F ratio correlate with the LE (r=.572**, =.262*, resp.) and average M (r=.519**, =.523**) and F height (r=.183*, p=0.019, r=.299**), but not with the GDP. 3. In 44 preindustrial societies, size dimorphism correlates positively with average M (r= .410*) but not F height, and weight dimorphism correlates with the total population (r=-.534*). Density and LE at birth and age 15 did not correlate with size dimorphism. *p<.001**p<.0001.

Conclusions:  1. Minipuberty is associated with adult-type size dimorphism.2. Size dimorphism is established during puberty. 3. In industrial, but not in preindustrial societies, health, but not living standards, positively correlates with size dimorphism. 4. Female’s growth is more resilient to negative health effects. 5. Size dimorphism is greatest where human size is largest (hyperallometry).

1139: FC29

A STUDY OF THE INCIDENCE OF PERMANENT CONGENITAL HYPOTHYROIDISM BASED ON REEVALUATIONS IN THE NIIGATA PREFECTURE JAPAN
Keisuke Nagasaki, MD, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan; Hiromi Nyuuzuki, MD; Sunao Sasaki, MD; Yohei Ogawa, MD, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan

Objectives: More than 30 years have passed since screening for congenital hypothyroidism (CH) was started in Japan, but the true incidence rate of CH in Japan is not yet apparent. Periodic reevaluation at appropriate times is necessary for patients with positive neonatal mass screening in order to determine the true frequency of CH since transient CH or transient hyperthyroxinemia are included among positive results. We investigated the incidence of permanent CH based on reevaluation and definitive diagnoses for CH mass screening-positive patients in Niigata Prefecture, Japan.

Methods: Between April 2002 and March 2006, 106,114 newborns were screened for CH in Niigata Prefecture. A blood TSH cutoff level of 8 mU/L was established. 116 newborns were considered positive for CH and 104 (90%) of those patients were referred to our institution and evaluated. To determine the true incidence of CH, we conducted a retrospective study based on the use of levothyroxine Na (LT4) therapy, the situation at first visit, reevaluation at two to three years of age and definitive diagnosis at five years old or later.

Results: Among the 104 patients, 72 (69%) were started on oral levothyroxine therapy for CH at their first visit. Of the remaining 32 patients, nine were started on LT4 therapy by the age of one due to the continuation of slightly high levels of serum TSH. Therefore, 81 patients (78%) had received LT4 treatment by the age of two. Of these, 51 patients were reevaluated at two to three years of age to assess whether they continued to need levothyroxine. Fourteen patients were able to discontinue LT4 therapy at reevaluation. Five patients have moved away during this period. At the age of five, 62 patients (60%) were receiving LT4 treatment, and of these 56 patients had received definitive diagnoses. Eighteen patients were able to discontinue LT4 therapy, and 44 patients were to continued LT4 therapy.

Conclusions: The incidence of permanent CH in Niigata, Japan was from 1:2,000 to 1:2,500. About half of the patients who received LT4 therapy had transient CH or transient hyperthyroxinemia.

469: FC30

SECULAR CHANGES OF ADULT HEIGHTS IN THE NORDIC COUNTRIES
Anton Holmgren, MD, University of Gothenburg/Halland Hospital Halmstad, Gothenburg/Halmstad, Sweden; A. Stefan Aronson, MD, PhD, Halland Hospital Halmstad, Halmstad, Sweden; Aimon Niklasson, MD,PhD; Kerstin Albertsson-Wikland, MD,PhD, Sahlgrenska Academy; University of Gothenburg, Gothenburg, Sweden

Objectives: To investigate if the secular trend with taller adult heights is still ongoing by comparing data regarding mean adult heights for both sexes from a new Swedish growth cohort with previous data from Sweden and the other Nordic countries.

Methods: The results of mean adult heights for females and males from the new Swedish longitudinal growth birth cohort GrowUpGothenburg1990 (n 1901) was analysed and compared with data from the GrowUpGothenburg1974 birth cohort (present national growth reference) and the former Swedish national growth reference of individuals born 1956. The results were also compared with information of mean adult heights from previous and present growth references in the other Nordic countries. No corrections have been done for different definitions of adult height or different selections of individuals in the studies.

Results: Adult height was greater in the GrowUp1990 cohort (mean 168.3/181.7 cm, females/males), than in the previous Swedish cohort, born 16 years earlier, with increased adult heights of 4/10 mm for females/males (p=0.023/p<0.001). All three Swedish neighbour countries; Denmark, Finland and Norway have presented nex growth references based on cross-sectional datasets within the last 6 years, also showing continous secular trends regarding adult heights for both females and males (Figure; left females, right males). The Swedish females and males were the tallest, with the exception of Danish females (18 mm taller than the Swedish females); females were 11 mm taller in Sweden compared to Norway and Finland (Figure, left). The Swedish males were 13, 7 and 10 mm taller than the males in Denmark, Norway and Finland, respectively (Figure, right).

Conclusions: The Nordic countries, having among the tallest populations of the world, are still showing continuous positive secular trends regarding adult heights for both females and males, demonstrating the need of regularly updated national growth references.

516: FC31

DIFFERENTIAL EFFECTS OF LOW-WEIGHT, AMENORRHEA AND EXERCISE ON BONE MICROARCHITECTURE AND STRENGTH ESTIMATES AT WEIGHT BEARING AND NON-WEIGHT BEARING SITES IN ADOLESCENT GIRLS AND YOUNG ADULTS
Nurgun Kandemir, MD, Hacettepe University, Ankara, Turkey; Karen J Campoverde Reyes, MD; Vibha Singhal, MD; Meghan Slattery, NP; Kathryn Ackerman, MD; Shreya Tulsiani, BS/BA; Hang Lee, PhD; Karen K Miller, MD; Kamryn T Eddy, PhD; Anne Klibanski, MD; Madhusmita Misra, MD, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States

Objectives: Bone microarchitecture is impaired in low weight amenorrheic girls with anorexia nervosa (AN) compared to controls, and normal-weight oligo-amenorrheic athletes (AA) compared with eumenorrheic athletes (EA) and non-athletes (NA). However, data directly comparing the differential effects of low-weight, amenorrhea, and athletic activity on bone structure are lacking. Our objective was to evaluate effects of low-weight, oligo-amenorrhea, and weight bearing exercise on cortical and trabecular microarchitecture and strength estimates in females with AN, AA, EA and NA at the non-weight bearing radius and weight bearing tibia.

Methods: 267 females 14-25 yo were included:61 AN, 106 AA, 43 EA and 57 NA. All participants underwent HRpQCT of the distal radius and tibia.

Results: Groups did not differ for age and height. AN had lower BMI than other groups. Distal radius: On extended cortical analysis (ECA), AN had lower total volumetric BMD (vBMD), cortical area (CA) and thickness (CT), and cortical total and bone volume (CTV and CBV) than NA. On individual trabecula segmentation (ITS), AN had lower total trabecular (trab.) bone volume fraction (BV/TV), plate (P), axial and rod (R) BV/TV and R-P junction density than EA. AN and AA had comparably lower trab. plate number density, and P-P junction density than EA. On finite element analysis (FEA), AN had lower stiffness and failure load than EA and NA. Distal tibia: On ECA, AN had lower total vBMD, lower CA, CT, CTV and CBV than EA and NA. Cortical porosity was higher in AN than EA and NA. Both AN and AA had lower cortical vBMD than NA. EA had higher cortical and endocortical perimeter than AN and NA. On ITS, AN had lower trab. vBMD, trab. number and plate BV/TV, and higher trab. separation than AA and EA. EA had higher trab. vBMD than NA. On FEA, AN had lower stiffness and failure load than AA, EA and NA.

Conclusions: Athletic activity has a favorable effect on cortical structure of weight bearing bone. Amenorrhea is detrimental to the trabecular compartment of non-weight bearing bone, and cortical density of weight bearing bone (despite weight bearing activity). Low weight and amenorrhea have a strong negative effect on cortical and trabecular morphology and strength at weight bearing and non-weight bearing sites

1779: FC32

APPLICATION OF 18F-NAF PET/CT IMAGING IN FIBROUS DYSPLASIA
Georgios Z Papadakis, MD, Institute of Computer Science, Crete, Greece; Georgios C Manikis, MS/MA, Institute of Computer Science , Crete, Greece; Apostolos H Karantanas, MD, University of Crete School of Medicine, Crete, Greece; Kostas Marias, PhD, Institute of Computer Science , Crete, Greece; Michael T Collins, MD; Alison M Boyce, MD, National Institutes of Health, Bethesda, MD, United States

Objectives: Fibrous dysplasia (FD) is a mosaic disease in which bone is replaced with fibro-osseous tissue, leading to fractures, disability, & pain. Clinical evaluation is challenging, because there are no surrogate markers to assess disease burden, & no methods to quantify FD lesion activity. 18F-NaF is a radiopharmaceutical which can target skeletal processes in FD. This study investigates application of 18F-NaF PET/CT in evaluating FD disease burden & activity.

Methods: 16 subjects had 18F-NaF PET/CT scans (mean 26y, 6-57). PET scans were obtained on dedicated scanners, 58-70 min after injecting 18F-NaF 2.7-3.3 mCi. Low dose, non-diagnostic CTs were performed for co-registration & to correct attenuation. 18F-NaF activity was quantified with MIM Vista (v6.5.9). A volume of interest encompassing the skeleton was drawn, & SUVmax (max standardized uptake value) threshold was customized. Areas of unrelated 18F-NaF activity were manually excluded. The following parameters were obtained: SUVmax, SUVmean, & entire skeleton indices of total volume (TV) of 18F-NaF avid FD lesions, & total activity (TA) determined as the summation of activity of each FD lesion, calculated as the product of lesion volume and its SUVmean. Spearman’s rank & Mann Whitney tests determined associations between 18F-NaF parameters & clinical endpoints, including fractures, orthopedic & craniofacial procedures, ambulation, & pain.

Results: Lifetime & mean fractures per year were strongly correlated with TA & TV of FD involving the total body less head (rs=0.8729, ps=0.8296, p<0.01)(rs=0.8721, ps=0.8108, p<0.01). Strong associations were similarly found with lifetime & mean orthopedic surgeries/year (rs=0.8803, ps=0.9055, p<0.01)(rs=0.8774, ps=0.8948, p<0.01). TA & TV of total body less head FD distinguished subjects with impaired ambulation & pain (p<0.05). Skull FD TA & TV were strongly associated with lifetime & mean craniofacial surgeries/year (rs=0.8314, ps=0.8548, p<0.01)(rs=0.8348, ps=0.86, p<0.01).

Conclusions: 18F-NaF PET/CT imaging is of prognostic value in assessing FD. This hybrid (functional/anatomical) technique holds great potential for clinical evaluation & as a surrogate endpoint for trials.

1440: FC33

POOR CORRELATION BETWEEN DISCREPANCY OF BONE MINERAL DENSITY Z-SCORES BY DUAL-ENERGY X-RAY ABSORPTIOMETRY AND VERTEBRAL FRACTURES IN CHILDREN
Tasma Harindhanavudhi, MD, University of Minnesota, Minneapolis, MN, United States; Anna Petryk*, MD, *Current affiliation: Alexion Pharmaceuticals, New Haven, CT, United States; Richard Jones, MD, University of Minnesota, Minneapolis, MN, United States; Amanda R Wallin, MD, Karolinska Institutet, Stockholm, Sweden; Sara Van Nortwick, MD, University of Minnesota, Minneapolis, MN, United States; Bradley S. Miller, MD, PhD, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States; Tara Holm, MD; Kyriakie Sarafoglu, MD, University of Minnesota, Minneapolis, MN, United States

Objectives: Dual-energy X-ray absorptiometry (DXA) remains the most common mode of bone mineral density (BMD) evaluation in adults and children. In adults, the presence of a disproportionately BMD Z-score (>1 SD difference) between adjacent lumbar vertebrae could be an indicator of a vertebral fracture and, therefore, warrant further evaluation of the lateral vertebral morphology. However, in children, the skeleton is still growing and reshaping, introducing developmental aspects as a confounding variable.  The study’s objective was to correlate the results of a lumbar spine DXA with lateral lumbar spine morphology to elucidate the clinical significance of discrepancies between individual vertebral BMD Z-scores.

Methods: A retrospective chart review identified 360 DXA scans performed between 9/01/2014 and 5/01/2016 in patients <18 years of age. DXA scans were cross-referenced against all lumbar spine x-ray and vertebral fracture analysis (VFA) database within the 6 months preceding or following the date of a DXA scan.

Results: Out of 360 DXA scans, 52 (14.4%) had both a DXA scan, and either lumbar spine x-ray or DX VFA. Thirty of 52 patients (58%) had a vertebral BMD L1-L4 Z-score >1 SD difference between adjacent vertebrae. None of the patients who had vertebral BMD L1-L4 Z-score >1 SD difference between adjacent vertebrae had lumbar fracture. The most common vertebra with the highest BMD Z-score was L1 (63%), followed by L3 (33%), L2 (3%) and L4 (7%).

Conclusions: We concluded that the correlation between the finding of discrepancy >1 SD difference between adjacent vertebral BMD Z-scores by DXA scan and vertebral fracture was low and likely represented developmental variants in children. Therefore, it does not appear justified to recommend further imaging based solely on the results of a DXA scan without clinically meaningful indications. Due to these variations, it may be more appropriate to use L2-L4 average rather than L1-L4 average for reporting BMD Z-scores in children. VFA may be useful in some cases in children, although the quality of the image is inferior compared to the radiograph, particularly in younger patients.

514: FC34

THE RELATIONSHIP BETWEEN ADIPOSITY AND BONE DENSITY IN U.S. CHILDREN AND ADOLESCENTS
Cecilia Gállego Suárez, MD; Joyce M Lee, MD; Achamyeleh Gebremariam, MS/MA; Kanakadurga Singer, MD, University of Michigan, Ann Arbor, MI, United States

Objectives: The effects of excess adiposity on bone health are not completely understood. Since childhood and adolescence are critical stages for skeletal mineralization, it is important to understand how body composition during this period may influence bone mineralization and may affect bone health. The objective of this study was to examine associations between percent body fat and total fat mass (in kg) on total, pelvic and lumbar bone mineral density (BMD) in a nationally representative sample of U.S. children and adolescents, and to examine gender and race/ethnicity interactions in these associations. We hypothesized that higher percent body fat would be associated with lower BMD across all regions.

Methods: We used data from National Health and Nutrition Examination Survey (NHANES) 1999-2006. A total of 8,348 participants 8-18 years of age had whole body DXA scans performed. We conducted linear regressions to examine the relationship between percent body fat and total fat mass (in kg) with outcome variables of total, pelvic and lumbar BMD, controlling for lean body mass and assessing for gender and race/ethnicity interactions.

Results: The average age was 13 years, and 17% and 18.8% of subjects had overweight and obesity, respectively. A higher proportion of African American and Hispanic children were overweight or obese compared with White children. Total BMD decreased with increasing percent body fat and total fat mass (kg) in both genders and all races (figure 1). Pelvic BMD showed a positive trend with increasing percent body fat in both males and females, and with increasing total fat mass (kg) only in females. For pelvic BMD, relationships were mixed for the different races (figure 2). Lumbar BMD decreased with increasing percent body fat in both genders and all races (figure 3).

Conclusions: We found significant interactions by gender and race/ethnicity in the relationship of adiposity with total, pelvic and lumbar BMD; finding decreases in total and lumbar BMD with increasing percent body fat and total fat mass (kg), but less consistent patterns for pelvic BMD. Our findings emphasize the need for further investigations to understand the impact of adiposity on bone health outcomes since childhood.

1773: FC35

CLINICAL AND STRUCTURAL IMPACT OF MUTATIONS AFFECTING THE PLS3 GENE IN PATIENTS WITH BMND18
Ting Chen, MD, University of Soochow, Suzhou, China; Chenxi Zhang, BS/BA, Medical College of Soochow University, Soochow University, Suzhou, China; Haiying Wu, MD; Rongrong Xie, pediatrician, University of Soochow, Suzhou, China; Fengyun Wang, MD, Children's Hospital of Soochow University, Soochow University, Suzhou, China; Xiuli Chen, pediatrician, University of Soochow,Children's hospital of Soochow university, Suzhou, China; Hui Sun, pediatrician, University of Soochow, Suzhou, China; Fei Xiao, PhD, Medical College of Soochow University, Soochow University, Suzhou, China; Linqi Chen, Pediatrician, University of Soochow,Children's hospital of Soochow university, Suzhou , China

Objectives: Bone Mineral Density Quantitative Trait Locus 18 (BMND18) is a recently described X-linked disease with early-onset osteoporosis and osteoporotic fractures. This rare hereditary disorder is caused by loss-of-function mutation in the gene encoding the plastin 3 (PLS3), which is a protein involved in actin bundle formation in the cytoskeleton. The aim of this study is to report a case of BMND18 with a novel mutaion in PLS3. Moreover, we construct the structure of PLS3 and find the impact of all the reported mutations on the conformation and function of PLS3.

Methods: We clarified the patient's genetic sequence through focused-exome sequencing analysis and verified the results via Sanger sequencing. We constructed the stucture of PLS3 through homology modeling.

Results: We identified a novel nonsense mutation in the PLS3 gene (c.745 G>T) causing truncation of a highly conserved amino acid residue (p.E249X) of plastin 3 in a boy with early-onset osteoporosis and osteoporotic fractures (Fig 1.). This unique mutation affects the integrity of the Actin-binding Domain 1(ABD1) and Actin-binding Domain 2(ABD2) fragments of PLS3, and thereby hinders PLS3 from cross-linking actin filaments into higher-order assemblies like bundles.

This led us to study the molecular impact of all the mutations previously detected in patients on the structure and function of PLS3 protein. By homology modeling, we constructed models of wild type and mutants of PLS3 (Fig 2.). Structural analysis of these models showed that the structural integrity is essential for the function of PLS3. More importantly, residues p.239-267, which connect CH1 and CH2 domains of ABD1 fragment, are highly conserved among species (Fig 3.) and sensitive to the conformation (Fig 2.). Mutations in this critical region will impair the integral conformation of PLS3, and thus affect its function.

Conclusions: In summary, we analyzed the impact of mutations affecting the PLS3 gene using a bioinformatics approach, which provides a mechanistic view of their pathogenic effect.

305: FC36

CARNOSINE AS AN ADJUVANT THERAPY IN PEDIATRIC PATIENTS WITH DIABETIC NEPHROPATHY: A RANDOMIZED PLACEBO-CONTROLLED TRIAL
Nancy S Elbarbary, MD; Eman Abdel Rahman Ismail, MD, Ain Shams University , Cairo, Egypt; Abdel Rahman El-Naggar, MD; Mahitab Hany Hamouda, resident , Modern technology and Information University, Cairo, Egypt; Manal El- Hamamsy, MD, Ain Shams University , Cairo, Egypt

Objectives: Oxidative stress is a significant contributor to the pathogenesis of diabetic nephropathy. Carnosine is a natural radical oxygen species scavenger. The aim of this study is to  investigate the effect of carnosine as an adjuvant therapy on urinary albumin excretion (UAE), the tubular damage marker alpha 1-microglobulin (A1M), and oxidative stress in pediatric patients with type 1 diabetes and nephropathy.

Methods: This randomized placebo-controlled clinical trial included 90 patients with diabetic nephropathy, despite oral angiotensin-converting enzyme inhibitors (ACE-Is), who were randomly assigned to receive either 12 weeks of carnosine 1g/day (n = 45), or matching placebo (n = 45). Both groups were followed-up with assessment of hemoglobin A1c (HbA1c), UAE, A1M, total antioxidant capacity (TAC) and malondialdhyde (MDA).

Results: Baseline clinical and laboratory parameters were consistent between carnosine and placebo groups (p>0.05). After 12 weeks, carnosine treatment resulted in significant decrease of HbA1c, UAE, A1M, MDA levels while TAC levels were increased compared with baseline levels or placebo group (p<0.001). No adverse reactions due to carnosine supplementation were reported. Baseline TAC was inversely correlated to HbA1c and A1M among the carnosine group (p<0.05).

Conclusions: Oral supplementation with L-Carnosine for 12 weeks resulted in a significant improvement of oxidative stress, glycemic control and renal function. Thus, carnosine can be a safe and effective strategy for treatment of  pediatric patients with diabetic nephropathy.

981: FC37

CONTINUOUS SUBCUTANEOUS INSULIN INFUSION COMPARED TO MULTIPLE DAILY INJECTION REGIMENS IN CHILDREN AND YOUNG PEOPLE AT DIAGNOSIS OF TYPE I DIABETES: A PRAGMATIC RANDOMISED CONTROLLED TRIAL AND ECONOMIC EVALUATION (SCIPI TRIAL)
Joanne Blair, MD, Alder Hey Children's Hospital, Liverpool, United Kingdom; Andrew Mckay, MS/MA, Liverpool University, Liverpool, United Kingdom; Colin Ridyard, PhD, Bangor University, Bangor , United Kingdom; Keith Thornborough, RN, Alder Hey Children's Hospital, Liverpool, United Kingdom; Emma Bedson, PhD, Liverpool University, Liverpool, United Kingdom; Matthew Peak, PhD; Mohammed Didi, MRCPCH, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Francesca Annan, MS/MA, University College London Hospital, London, United Kingdom; Gregory John, PhD, School of Medicine, Cardiff University, Cardiff, United Kingdom; Dyfrig Hughes, PhD, Bangor University, Bangor, United Kingdom; Carrol Gamble, PhD, Liverpool University, Liverpool, United Kingdom

Objectives: To compare glycaemic control (primary outcome), quality of life (QoL), safety and cost effectiveness of treatment with continuous subcutaneous insulin infusions (CSII) with multiple daily injections (MDI) in pediatric patients newly diagnosed with type I diabetes.

Methods: Patients age 7months-15years were randomised to CSII or MDI on a 1:1 ratio, stratified by age and treatment center. All patients had structured education. Randomised treatment started within 14 days of diagnosis. Resource use and clinical data (HbA1c, height, weight, insulin dose, adverse events) were collected at randomisation, 3,6 9 and 12 months. QoL was assessed by the Pediatric QoL Inventory, diabetes module, at 6 and 12 months. The Health Utilities Index was completed at all study visits.

Partial remission was defined as Insulin Dose Adjusted A1c <9.

Results: 293 patients age 9.8yrs (0.7 - 16) from 15 British diabetes clinics were randomised (CSII:149, MDI:144). Baseline characteristics did not differ between treatment arms (Table 1). Completeness of primary outcome data was 97%

At 12 months, there was no difference in HbA1c: CSII mean (95th CI): 60.9(58.5,63.3), MDI: 58.5 (56.1,60.9), % of patients with HbA1c in target (<48mmol/mol): CSII 15.4, MDI 20.4 relative risk (RR) 0.75 (0.46,1.25), partial remission rates (%): CSII: 24.4, MDI: 32.8, RR 0.74 (0.45,1.24). Reported insulin dose was higher in the CSII arm: CSII - MDI 0.1unit/kg/day (0.0,0.2) p=0.01. Parents, but not patients, reported superior QoL during CSII treatment: PedsQL score CSII-MDI 4.1 (0.6,7.6) p=0.02.

The incidence of severe hypoglycaemia (CSII:6/144, MDI: 2/149) and diabetic ketoacidosis (CSII: 2/144, MDI 0/149) were low. 68 adverse events (14 serious) were reported in the CSII arm, and 24 (8 serious) in the MDI arm.

CSII was more expensive: £1,863 (1,620, 2,137), with no additional Quality Adjusted Life Year gains [-0.006 (-0.031,0.0180)].

Conclusions: No clinical benefit of CSII over  MDI was identified. CSII is not cost effective in patients representative of the study population. The generalisability of our data beyond 12 months is uncertain.

588: FC38

ANTI CD4 AND ANTI CD8 ANTIBODY CO-THERAPY INDUCES REMISSION OF DIABETES IN NEW ONSET NOD MICE VIA LOCALIZED INDUCTION OF T CELL EGRESS FROM THE PANCREAS
Mark Henin, MD; Matthew Clark, PhD; Roland Tisch, PhD, University of North Carolina, Chapel Hill, NC, United States

Objectives: Previous studies have shown that anti-CD4/anti-CD8 antibody treatment produced indefinite diabetes remission in new onset non-obese diabetic mice. Histologic studies of the mice reveal reduced T cell pancreatic islet infiltration. How the antibodies induce pancreatic T cell egress is unknown.  A recently completed study showed that IFN-γ injections caused diabetes recurrence in mice with anti-CD4/anti-CD8 induced remission. It is hypothesized that anti-CD4/anti-CD8 antibody treatment decreases T cell secretion of IFN-γ and IL-2, blunting the local inflammatory response, ultimately facilitating T cell egress.

Methods: Female NOD mice with confirmed new onset diabetes (BG > 250 x2 days) were injected intraperitoneally with rat anti-mouse CD4 and CD8 or rat anti-mouse 2A3 control antibody once daily for two days. Treatment doses were serially diluted from 160 to 0.625μg/mL. Seventy two hours after antibody injection, mice were sacrificed for analyses of sera and organ T cell content. Single-cell suspensions were prepared from tissues. Leukocytes were removed from islets via an enzyme-free dissociation buffer with cytokine levels measured via ELISA and T cell counts calculated via flow cytometry.

Results: Diabetes was reversed in 79% (n= 24) of anti-CD4/anti-CD8 treated NOD mice but persisted in the control group. Both IFN-γ and IL-2 levels and total pancreatic T cell counts decreased exponentially with increasing concentrations of anti-CD4/anti-CD8 antibody while no change was seen in the control group. There was no decrease in splenic T cell counts of the treatment or control groups.

Conclusions: The results are consistent with previous studies showing anti-CD4/anti-CD8 antibody treatment reversing diabetes in new onset NOD mice. Furthermore, anti-CD4/anti-CD8 treatment causes a dose dependent decrease in concentrations of IFN-γ and IL-2 with an exponential decrease of T cell counts in the pancreas. Normal splenic T cell counts indicate the effects are localized and not due to systemic immunosuppression. Studies examining the FOXO1 pathway, via RT-PCR, are underway. It is theorized that FOXO1 moves into the nucleus of unstimulated T cells, causing downregulation of CD69, an early T cell activation cofactor, and upregulation of S1P, a membrane protein thought to promote T cell egress from tissue.

1165: FC39

THE RISK OF PROGRESSION TO TYPE 1 DIABETES (T1D) IN INDIVIDUALS OF DIVERSE AGES WITH MULTIPLE AUTOANTIBODIES
Laura M Jacobsen, MD, University of Florida, Gainesville, FL, United States; Carmella Evans-Molina, MD; Linda A Dimeglio, MD, Indiana University School of Medicine, Indianapolis, IN, United States; Robin Goland, MD, Columbia University, New York, NY, United States; Darrell M Wilson, MD, Stanford University, Stanford, CA, United States; Mark Atkinson, PhD, University of Florida, Gainesville, FL, United States; Tandy Aye, MD, Stanford University, Stanford, CA, United States; William Russell, MD, Vanderbilt University, Nashville, TN, United States; John Wentworth, MD, Royal Melbourne Hospital, Melbourne, Australia; Susan Geyer, PhD; David Boulware, MS/MA, University of South Florida, Tampa, FL, United States; Jay Sosenko, MD, University of Miami, Miami, FL, United States

Objectives: Young children with multiple autoantibodies (≥2 Abs) are at high risk for the development of type 1 diabetes (T1D) with reported 5 and 10-year risks of 0.44 and 0.70. However, the risk in individuals of diverse ages with multiple Abs has not been studied in depth.

Methods: We examined the impact of age, the Diabetes Prevention Trial Risk Score (DPTRS), and types of Abs upon the risk of T1D in TrialNet Pathway to Prevention (PTP) participants with ≥2 Abs (IAA, GADA, IA-2A, ICA, ZnT8), a cohort with a wide age range [n=1896; mean±SD age: 13.5±10.7 years (range 1-45 years); ZnT8A measured in 1119]. Findings are shown for the full cohort, since they were similar with or without ZnT8A.

Results: Based on the hazard ratio (HR) from a Cox regression analysis, there was 4.5% (95% CI: 3.3%, 5.6%) less risk for T1D per year increase in age (p<0.001). In the analysis of the DPTRS (based upon age, BMI, log fasting C-peptide, glucose and C-peptide sums from 30 to 120 minutes during 2-hr OGTTs), among PTP participants with normal glucose levels, the cumulative incidence for T1D was higher for values ≥6.5 than values <6.5 (p<0.001), both among individuals with 2 Abs [5-year risks: 49% (n=184) vs. 12% (n=429)] and >2 Abs [(5-year risks: 57% (n=397) vs. 21% (n=368)]. In the Ab analysis, adjusting for Ab number, those with GADA as one of the ≥2 Abs had less risk than the others [HR: 0.337 (0.281, 0.505); p<0.001]. In contrast, those with IA-2A as one of the ≥2 Abs were at higher risk [HR: 1.78 (1.33, 2.38); p<0.001]. 10-year risks for 2 Abs with DPTRS values <6.5 (n=429), or ≥2 Abs with GADA in the absence of IA-2A (n=556), were approximately 20% and 40% respectively.

Conclusions: In summary, the risk for T1D in a diversely aged population with ≥2 Abs becomes quite low as individuals age. A lower risk is also evident among those with normal glucose levels and DPTRS values <6.5, and among those with GADA as one of the ≥2 Abs in the absence of IA-2A. In conclusion, the findings suggest that a considerable proportion of diversely aged individuals with ≥2 Abs appear unlikely to progress to T1D.

486: FC40

DOMINANT TNFA AND IMPAIRED IL-2 CYTOKINE EXPRESSION PROFILES OF CD4+ MEMORY T CELLS FROM CHILDREN WITH TYPE 1 DIABETES ARE PROMOTED BY IL-7
Julia Seyfarth, MD, Heinrich Heine University Duesseldorf, Duesseldorf, Germany; Rosa Sherfat, MD, Medstar Georgetown University Hospital, Washington, DC, United States; Hans-Jürgen Laws, MD, Heinrich Heine University Duesseldorf, Duesseldorf, Germany; Beate Karges, Professor, RWTH Aachen University, Aachen, Germany; Ertan Mayatepek, MD, University Children's Hospital , Düsseldorf, Germany; Thomas Meissner, MD, University Children's Hospital Duesseldorf, Duesseldorf, Germany; Marc Jacobsen, Professor, Heinrich Heine University Duesseldorf, Duesseldorf, Germany

Objectives: Aberrantly activated CD4+ T memory cells play a central role in the development of type-1-diabetes. Interleukin-7 (IL-7) promotes generation of autoimmune memory T cells and increased IL-7 availability is associated with type-1-diabetes susceptibility. T-cell mediated immune pathology at onset of disease is well defined, but characteristics of long-term symptomatic disease stages remain largely elusive. In the present study memory CD4+ T-cell activation and cytokine expression as well as sensitivity to IL-7 in vitro were compared between patients with type-1-diabetes at clinical onset (n=25), long-term symptomatic disease (median duration 4.5 years, n=19), and matched healthy controls (n=21). 

Methods: Sample collection was performed in the framework of the pediatric diabetes biomaterial bank in German Center for Diabetes Research. The effect of IL-7 co-stimulation on T-cell activation dependent cytokine expression and differences between the study groups were assessed by intracellular cytokine staining and flow cytometric analysis of donors PBMC.

Results: T-cell responses of type-1-diabetes patients were characterized by higher frequencies of cytokine and activation marker expressing CD4+ memory T cells as compared to healthy controls. Notably, qualitative differences of cytokine profiles characterized by significantly increased TNFα and decreased IL-2 expressing T-cell proportions were solely detected in long-term type-1-diabetes patients. IL-7 mediated T-cell co-stimulation induced quantitative and qualitative cytokine expression differences highly similar to type-1-diabetes specific profiles. In addition, CD4+ memory T cells from children with long-term type-1-diabetes were more sensitive to in vitro IL-7 co-stimulation. Global transcriptome analysis revealed IL-7 induced expression differences of CD4+ T cells including increased IL-2R expression and effects on subsequent T-cell receptor activation.

Conclusions: Our results indicate that long-term symptomatic type-1-diabetes patients differ in memory T-cell cytokine profiles and IL-7 co-stimulation. Regulation of IL-2 expression and sensitivity are affected with possible consequences for the course of disease and severity at long-term type-1-diabetes stages.

808: FC42

WHAT ARE THE PERSPECTIVES AMONG TRANSGENDER YOUTH AND THEIR PARENTS REGARDING FUTURE FERTILITY? INSIGHTS FROM THE FERTILITY AND REPRODUCTIVE HEALTH SURVEY OF TRANSGENDER YOUTH (FROST) STUDY
Lyne N. Chiniara, MD; Christine Viner, MD; Herbert J. Bonifacio, MD, MSc, MPH, MA; Mark R. Palmert , MD, PhD, Hospital for Sick Children/University of Toronto, Toronto, ON, Canada

Objectives: Fertility is an important topic for patients, families, and care providers when considering medical and/or surgical treatment for gender dysphoria (GD). The aim of this study was to investigate the perspectives of youth with GD and their parents concerning fertility and future parenthood.

Methods: A prospective, questionnaire-based study among transgender youth and their parents designed to collect baseline demographic information, knowledge of potential effects of treatments on fertility, current and perceived future life priorities, and preferences regarding future fertility/parenting options.

Results: A total of 61 youth (82% female bodied youth (FBY), 18% male bodied youth (MBY), 70% between ages 16-18 years, 26% between 13-15 years) and 56 parents participated. 47 youth identified as male, 10 as female, and 4 as non-binary. The top three current life priorities for youth were: (1) Being in good health, (2) Have lots of friends and (3) Do well in school/work. The least important priority was Having children. This was ranked last by 58% of FBY and 64% of MBY. Perceived life priorities in 10 years were ranked similarly. Parents’ rankings paralleled the youth responses in terms of their top three current priorities for their child. Similarly, parents ranked having children as the lowest current life priority but ranked it a much higher priority for the FBY but not MBY youth in 10 years.

The majority of youth (68% FBY, 73% MBY) want to be a parent in the future. However, most do not envision having a biological child. A large majority (72% FBY, 82% MBY) were open to adoption with smaller numbers open to surrogacy and fewer still considering sperm or egg donation.

All youth knew treatment with cross-sex hormones could alter future fertility but only 6% of FBY and no MBY would delay start of hormone blockers or cross-sex hormones to pursue potential treatments to preserve fertility.

Conclusions: Fertility is a low current and future life priority for transgender youth. Fertility is also a low current priority for parents, although parents of FBY view it as a higher future life priority. The majority of youth wish to become parents but are open to alternative strategies for building a family. Further studies are needed to assess if youths’ life priorities change over time.

708: FC43

BODY COMPOSITION OF YOUNG ADULT TRANSWOMEN WHO STARTED GENDER REASSIGNMENT IN ADOLESCENCE
Daniel T Klink, MD, ZNA Queen Paola Children's Hospital, Antwerp, Belgium; Maartje Klaver, MD; Niek Van Regteren, MD; Chung-Wen Mak, MD; Martin Den Heijer, MD; Joost Rotteveel, MD, VU Medical Center, Amsterdam, Netherlands

Objectives: Sex steroids influence body composition. During gender reassignment (GR) natal adolescent boys with gender dysphoria (GD)  (transwomen) are treated with gonadotropin-releasing hormone analogs (GnRHa) and estrogens. Currently, effects of this treatment regime on body composition in adulthood are not known. Our objective is to study body composition and body mass index (BMI) during GR and at the age of 22 in young adult transwomen who commenced treatment in adolescence

Methods: In a longitudinal observational study at a tertiary referral center, young adults diagnosed with GD (DSM IV-TR) who started GR in puberty and had undergone gonadectomy between June 1998 and April 2016 were included. After a median duration of GnRHa monotherapy of 1.4 years 17-B-estradiol was added for median duration  of 5.9 years. GnRHa was discontinued after gonadectomy. In 26 subjects BMI, waist circumference (W), hip circumference (H) and body fat percentage (BFP), as determined by dual-energy X-ray absorptiometry, was measured at start GnRHa, start estrogens and at age 22.

Results: During GnRHa monotherapy BMI increased from 19.5 to 21.0 kg/m2 (p<0.01), whereas BMI standard deviation score (SDS) calculated for both natal and desired sex remained stable (n=26). Total BFP (n=24) increased with +6% (Cl95%0;12) (p=0.01), percentage gynoid fat increased with +8% (Cl95%2;13) (p=0.01) whereas the percentage android fat increased with +4% (Cl95%0;11) (p=0.01). W-SDS and WHR-SDS did not change. 

When estrogens were added till the age of 22, BMI increased to 21.5 kg/m2 (p<0.01) but SDS  did not change. Total BFP increased with +3% (Cl95%-2;12) (p=0.03), and percentage gynoid and android fat with +3% (Cl95%-2;9) (p=0.01) and +1% (Cl95%-5;17) (p=0.20), respectively. W-SDS and WHR-SDS did not change.

Conclusions: GR in adolescence was not associated with unfavorable weight increase in young adulthood. During GR total BFP, gynoid fat  and android fat increased in transwomen. This increase was most pronounced during GnRHa monotherapy coinciding with a higher increase in gynoid fat than in android fat. These changes may reflect a more feminized phenotype of body fat distribution.

162: FC44

MENTAL HEALTH CONCERNS AND INSURANCE DENIALS AMONG TRANSGENDER ADOLESCENTS
Leena Nahata, MD, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States; Gwendolyn P. Quinn, PhD, Moffitt Cancer Center, Morsani College of Medicine, University of South Florida, Tampa, FL, United States; Nicole M. Caltabellotta, BS/BA, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States; Amy C. Tishelman, PhD, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States

Objectives: Transgender youth are at high risk for mental health concerns. Based on treatment guidelines, puberty blockers and gender-affirming hormone therapy should be considered to alleviate distress due to discordance between an individual’s assigned sex and gender identity. The goal of this study was to examine the: 1) prevalence of mental health diagnoses, self-injurious behaviors, and school victimization, and 2) rates of insurance coverage for hormone therapy, among a cohort of transgender adolescents at a large pediatric gender program, to understand access to recommended therapy.

Methods: An IRB-approved retrospective medical record review (2014-2016) was conducted of patients with ICD 9/10 codes for gender dysphoria referred to pediatric endocrinology within a large multidisciplinary gender program. Researchers extracted: demographics, age, assigned sex, identified gender, insurance provider/coverage, mental health diagnoses, self-injurious behavior, and school victimization.

Results: Seventy-nine records (51 transgender males, 28 transgender females) met inclusion criteria (median age: 15 years, range: 9-18). Seventy-three subjects (92.4%) were diagnosed with one or more of the following conditions: depression, anxiety, post-traumatic stress disorder, eating disorders, autism spectrum disorder, and bipolar disorder. Fifty-nine (74.7%) reported suicidal ideation, 49 (55.7%) exhibited self-injurious behavior, and 24 (30.4%) had one or more suicide attempts. Forty-six (58.2%) subjects reported school victimization. Of the 27 patients prescribed gonadotropin-releasing hormone analogues, only 8 (29.6%) received insurance coverage.

Conclusions: Transgender youth face significant barriers in accessing appropriate hormone therapy. Given the high rates of mental health concerns, self-injurious behavior, and school victimization among this vulnerable population, healthcare professionals must work alongside policy makers towards insurance coverage reform.

1427: FC45

EVALUATING ACCESS TO PRESCRIBED MEDICATIONS AND ASSOCIATED PSYCHIATRIC COMORBIDITIES IN TRANSGENDER YOUTH
Kristin Dayton, MD; Lindsay Thompson, MD; Rebeccah Mercado, MS/MA; Janet Silverstein, MD; Amanda Hicks, PhD; Jeffrey Ferrell, BS/BA; Corey Gallet De St Aurin, BS/BA, University of Florida, Gainesville, FL, United States

Objectives: To determine if transgender and gender noncomforming youth attending a multidisciplinary clinic are able to access prescribed medications, including pubertal blockers.

Transgender youth have unique healthcare needs. It is recommended by multiple professional societies (WPATH, Endocrine Society, PES) that transgender children be offered treatment with pubertal blockers once they reach Tanner stage 2 of puberty. However, these medications may be prohibitively expensive if not covered by insurance. The risks of not obtaining and starting these medications in a timely fashion include continued pubertal progression and development of secondary sexual characteristics opposite those of the child’s affirmed gender. This may lead to a future need for increased surgical intervention as well as increased psychological distress for the patient.

Methods: In this retrospective chart review study, 19 patient charts were analyzed over the treatment period from January 1 – August 15, 2016 for prescriptions for pubertal blockers (GnRH analog (GNRHa) therapy) and whether or not these medications were approved by insurance and initiated during this time period.

Results: GnRHa were prescribed in over half of the patient charts reviewed. Of note, patients 12 and younger were not prescribed these medications, likely due to being assessed as prepubertal during their visits with our clinic and therefore not qualifying for this therapy. In patients aged 13-17, 60% of those prescribed GnRHa therapy were able to obtain and start the medication, while in patients aged 18 and over only 40% of those prescribed the medication were able to start therapy. In assessing psychiatric comorbidities, 60% of those patients treated with GnRHa displayed psychiatric comorbidities, while 71% of those not treated with GnRHa were diagnosed with psychiatric disorders.

Conclusions: Patients in our transgender clinic have difficulty obtaining prescribed therapy with GnRHa. Additionally, there are high rates of psychiatric comorbidities in our patient population, as has been previously described in transgender youth. The rate of psychiatric disorders was slightly higher in patients not treated with GnRHa, though this would need to be repeated in a larger population to determine if this difference is statistically significant.

809: FC46

ANG1-7 EXERTS ANTI-OBESITY EFFECT THROUGH PROLIFERATION OF BAT
Hidechika Morimoto, MD; Jun Mori, MD; Yusuke Tsuma, MD; Shota Fukuhara, MD; Keiichi Shigehara, MD; Kazuki Kodo, MD; Hisakazu Nakajima, MD; Hajime Hosoi, MD, Kyoto prefectural university of medicine, Kyoto, Japan

Objectives: Background, Aims and Objectives: Angiotensin II (Ang II) is converted to Angiotensin1-7 (Ang1-7) by ACE2. Ang1-7 binds to Mas receptor, a specific receptor of Ang1-7, and exerts a counteracting effect of Ang II, such as improvement in either fatty acid or glucose metabolism. On the other hand, in recent years, brown adipose tissue (BAT), which is essential for energy consumption, has attracted attention from the viewpoint of treating obesity. Here, we studied the role of BAT on anti-obesity effect of Ang1-7.

Methods: Method: Four-week-old C57BL/6J male mice were fed normal chow or High-Fat-diet (HFD) for 8 weeks. Ang1-7 (0.5 mg/kg per day) was administered subcutaneously via implanted micro-osmotic pump during last 4 weeks.

Results: Result: In HFD-fed mice, Ang1-7 treatment decreased body weight with no alteration of food intake and increased O2 consumption. Glucose tolerance test and insulin tolerance test showed Ang1-7 treatment ameliorated insulin resistance in HFD-fed mice. Either subcutaneous or visceral white adipose tissue (WAT) in HFD-fed mice was decreased with administration of Ang1-7, concomitant with the smaller size of adipocyte in WAT. On the other hand, the volume of BAT was increased and lipid droplets in BAT became smaller by Ang1-7 treatment, accompanied with amelioration of insulin signaling and increase UCP1 expression. Furthermore, protein levels of PRDM16 and phosphorylation of AMPKα were upregulated in BAT with administration of Ang1-7.

Conclusions: Conclusion: We identified that Ang1-7 promotes differentiation and proliferation of brown adipocytes leading to the increase of energy expenditure. Furthermore, we demonstrated that Ang1-7 ameliorate insulin signaling in BAT. These findings suggest that Ang 1-7 can be a new therapeutic tool for obesity.

722: FC47

USE OF ELEVATED HOMA-IR AND BLOOD PRESSURE VALUES IN DECIDING IN WHICH OBESE CHILDREN SHOULD OGTT BE PERFORMED
Rade Vukovic, PhD; Tatjana Milenkovic, PhD; Katarina Mitrovic, PhD; Sladjana Todorovic, MD; Ljiljana Plavsic, MD, Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Belgrade, Serbia; Ivan Soldatovic, PhD, School of Medicine, University of Belgrade, Belgrade, Serbia

Objectives: The prevalence of impaired glucose tolerance (IGT) in obese children is rising with the pandemic of obesity. Having in mind the high numbers of the obese children, it is important to identify those at risk for IGT/T2DM, in which OGTT should be performed. Current ADA recommendations are that OGTT should be performed in obese children with any of the following: family history of T2DM, ethnic predisposition, acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome. However this approach results in high number of false positives and sensitivity in detecting obese children with IGT has not been thoroughly evaluated. Objective was to evaluate the sensitivity and number needed to screen (NNS) using findings of basal insulin resistance or elevated blood pressure in identification of obese children with IGT, and to compare the results with sensitivity and NNS of current ADA criteria.

Methods: Data regarding basal values of glucose, insulin, blood pressure and OGTT results were collected from the medical records of 290 obese (BMI≥95th percentile) children and adolescents with normal fasting glucose. The screen was considered positive if subjects had either HOMA-IR>3 or blood pressure ≥130/85 mmHg. Second screening was performed for comparison purposes using the ADA criteria.

Results: Of the total of 290 obese children with normal fasting glucose levels, 22 (7.6%) had IGT and one (0.3%) had T2DM according to the OGTT 120 min. glucose levels. ADA criteria identified 240 children as at risk for IGT, amongst which 21 had abnormal 120 min. glucose values. There were 2 missed children with IGT (8.7%) and NNS was 11.4. Identifying children in whom OGTT should be performed on the basis of either insulin resistance or hypertension resulted in identification of 223 subjects, of whom 23 had abnormal 120 min. glucose values. None of the subjects with IGT were missed using this approach, and NNS was 9.7.

Conclusions: Performing OGTT in children who have either HOMA-IR>3 or blood pressure ≥130/85 mmHg has higher sensitivity and lower NNS than when using current ADA guidelines. We suggest considering OGTT in children with either basal insulin resistance or high blood pressure.

1077: FC48

THE RS626283 VARIANT IN THE MBOAT7 GENE CONFERS AN INCREASED RISK OF NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD) AND INSULIN RESISTANCE TO CAUCASIAN YOUTHS
Giuseppina Rosaria Umano, MD, Yale School of Medicine, New Haven, CT, United States; Anna Di Sessa, MD; Sonia Caprio, MD, Yale University, New Haven, CT, United States; Naga Chalasani, MD, Indiana University, Indianapolis, IN, United States; Wanqing Liu, MD, Purdue University, West Lafayette, IN, United States; Tiebing Liang, MD, Indiana University, Indianapolis, IN, United States; Mary Savoye, RD; Bridget Pierpont, MS/MA; Mariana Mata, MS/MA; Nicola Santoro, MD, Yale University, New Haven, CT, United States

Objectives: Non Alcoholic Fatty Liver Disease (NAFLD) is a leading cause of liver damage in U.S. The disease occurrence is influenced by genetic and environmental factors. Recently, the rs626283 polymorphism in the MBOAT7 gene has been found to be associated with Alcoholic Liver Disease and NAFLD in adults. In this study we sought to evaluate the association between the rs626283 variant and NAFLD in a pediatric multiethnic cohort.

Methods: 467 obese youths (190 Caucasians, 126 African Americans, and 151 Hispanics) were enrolled (mean age 13.6+/-3.6 years; mean BMI 31.18+/-6.7 Kg/m2). All of them underwent a MRI to measure intra-hepatic fat content (HFF%), an oral glucose tolerance test (OGTT) to assess glucose metabolism and insulin sensitivity and the genotyping of the rs626283 polymorphism in the MBOAT7 gene by Sequenom Massarray.

Results: The genotype frequencies were in Hardy-Weinberg equilibrium in all the ethnic groups. The three ethnic groups did not differ for age, gender and BMI. Caucasian youths homozygous for the minor allele (CC) showed significantly higher HFF% (p=0.034) compared to heterozygous (CG) and major allele carriers (GG). Moreover, Caucasian youths homozygous for the C allele presented the features of insulin resistance: higher fasting glucose (p=0.045), higher fasting insulin (p=0.023), higher HbA1c (p=0.016), lower degree of whole body insulin sensitivity (p=0.007), and a trend towards an impairment of insulin secretion determined by calculating the disposition index (DI) (p=0.056). In contrast, there was no difference in HFF% among the genotypes in African Americans and Hispanics (p>0.05).

Conclusions: The rs626283 variant in the MBOAT7 gene is associated with NAFLD and alterations of glucose metabolism in obese Caucasian youths. Further studies are needed to confirm this finding and to clarify the mechanisms by which this gene variant might predispose to pediatric NAFLD and insulin resistance.

102: FC49

STRUCTURAL AND FUNCTIONAL ABNORMALITIES IN THE HYPOTHALAMUS OF OBESE CHILDREN
Leticia Esposito Sewaybricker, PhD, State University of Campinas, Campinas, Brazil; Ellen A Schur, MS/MA; Susan J Melhorn, PhD, University of Washington, Seattle, WA, United States; Brunno M Campos, PhD, State University of Campinas, Campinas, Brazil; Mary K Askren, PhD, University of Washington, Seattle, WA, United States; Guilherme A S Nogueira, MS/MA; Mariana P Zambon, PhD; Maria Angela RGM Antonio, PhD; Fernando Cendes, PhD; Licio A Velloso, PhD; Gil Guerra-Junior, PhD, State University of Campinas, Campinas, Brazil

Objectives: Recent findings from experimental models suggests that an inflammatory response in the hypothalamus may contribute to obesity pathogenesis by disrupting key neurons involved in the regulation of caloric intake and energy expenditure. In obese adult humans, neuroimaging studies have shown a defective hypothalamic response to nutrients as well as have provided evidence for the existence of structural changes in the Medial Basal Hypothalamus (MBH) characterized by gliosis. Therefore, hypothalamic abnormalities, as assessed by different approaches, are present in the hypothalamus of obese adults and experimental animals. However, no previous studies have evaluated such abnormalities among obese children. So, the aim was to study, structurally and functionally, the hypothalamus of children and adolescents with obesity.

Methods: Twelve obese and 11 lean aged between 9 and 17 years agreed to participate and underwent fasting blood draws, body composition analysis by DXA, and brain magnetic resonance imaging (MRI) scans: quantitative MRI to measure T2 relaxation time to investigate hypothalamic tissue characteristics and functional MRI to verify hypothalamic response after oral glucose ingestion.

Results: Obese subjects had longer T2 relaxation times in the MBH when compared to lean group (P<.001), consistent with gliosis. Moreover, there was a highly significant group*region interaction (P=.0016), demonstrating that signs of gliosis were specific to the MBH as compared to control brain regions. Longer T2 relaxation times were correlated with higher visceral body fat percentage (r=0.591, P=.04) and android fat percentage (r=0.676, P=.009), but not fasting insulin concentrations (r=0.125, P=0.6). In functional studies, the hypothalamus of obese children presented an impaired response to oral glucose ingestion, with lower mean signal change (P<.001) and a lower general connectivity with brain gray matter (P=.013).  Finally, we found a negative correlation between MBH T2 relaxation and the mean hypothalamic BOLD signal change following glucose intake (r = -0.46, P=.041).

Conclusions: This is the first study demonstrating that the hypothalamus can be functionally and structurally affected in childhood obesity.

763: FC50

STEROID METABOLOMIC SIGNATURE OF INSULIN RESISTANCE IN CHILDHOOD OBESITY
Aneta M Gawlik, , Medical University of Silesia, Katowice, Poland; Michael Shmoish, PhD, Technion-Israel Institute of Technology, Haifa, Israel; Michaela F Hartmann, PhD, Justus Liebig University, Giessen, Germany; Ewa Malecka-Tendera, PhD, Medical University of Silesia, Katowice, Poland; Stefan A Wudy, PhD, Justus Liebig University, Giessen, Germany; Ze'Ev Hochberg, MD, PhD, Technion-Israel Institute of Technology, Haifa, Israel

Objectives: Based on urinary steroidal GC-MS, we previously defined a novel concept of disease-specific “steroid metabolomic signature” and reclassified childhood obesity into 5 groups with distinctive signatures (JCEM 2016, 101:4329).

Here, we determined the steroidal signature of insulin resistance (IR) in obese children.

Methods: Urinary samples of 87 children (44 girls) age 8.5-18.0 yrs with obesity (BMI >97%) were quantified for 31 steroid metabolites by GC-MS. IR defined by HOMA IR>95% or fasting glucose/insulin ratio (FIGR)>0.3 was diagnosed in 50 (57.5%) and 20 (23%) of examined patients, respectively (all with IRFIGR had HOMA IR>95%). The steroidal fingerprints of IRFIGR were compared to obese children with non-IRFIGR. The steroidal signature of IRFIGR was created from the product of IR [-] non-IR for each of the 31 steroids (Fig1).

Results: IR and non-IRFIGR children had comparable mean age (13.7±1.9 and 14.6±2.4 yrs resp., p>0.05) and z-score BMI (2.7±0.5 and 2.7±0.5, resp., p>0.05). IRFIGR was more common in boys (60%). The steroidal signature of IRFIGR (Fig 1) was characterized by high adrenal androgens, glucocorticoids and mineralocorticoid metabolites, higher 5α-reductase [An/Et] (p=0.007) and 21OHase [THE+THF+αTHF)/PT] activity (p=0.006) and lower 11β-HSD-I [(THF+αTHF)/THE] activity (p=0.01).

Conclusions: 1. The steroidal metabolomic signature of IR in obese children is characterized by enhanced secretion of steroids from all three adrenal pathways 2. As only the fasciculate and reticularis are stimulated by ACTH, these findings suggest that the adrenal per se is target to IR effect. 3. Obese children with IR and the new signature may benefit from amelioration of their hyperadrenalism. 4. We reveal a vicious cycle, whereby glucocorticoids induce IR, which further stimulates steroidogenesis.

690: FC51

ABILITY OF ANTI-THYROID PEROXIDASE AND ANTI-THYROGLOBULIN ANTIBODIES ALONE AND IN COMBINATION TO PREDICT SUBSEQUENT HYPOTHYROIDISM IN NEWLY DIAGNOSED TYPE 1 DIABETES PATIENTS
Bhavana Narala, MD, Medical College of Wisconsin , Milwaukee , WI, United States; Evelyn Kuhn, PhD, Children's Hospital of Wisconsin , Milwaukee, WI, United States; David Wyatt, MD, Medical College of Wisconsin , Milwaukee, WI, United States; Peter Wolfgram, MD, Medical College of Wisconsin, Milwaukee, WI, United States

Objectives: Background: Lack of consensus remains between the American Diabetes Association (ADA) and the International Society of Pediatric and Adolescent diabetes (ISPAD) guidelines regarding whether both anti-thyroid peroxidase (aTPO) and anti-thyroglobulin (aTG) antibodies are required to assess newly diagnosed pediatric type 1 diabetes (T1D) patients’ risk of developing auto-immune hypothyroidism.

Objective: To determine the ability of aTPO alone to assess risk for subsequent hypothyroidism in recently diagnosed T1D patients in Wisconsin.

Methods: Data was extracted from EPIC, and included patients who had aTPO and/or aTG (Quest Diagnostics) obtained at diagnosis with T1D between 2013-16. Use of levothyroxine (LT4) was used to define hypothyroidism. Sensitivity and specificity of aTPO and aTG were calculated, and compared using the McNemar test (2-sided).

Results: Of 879 patients diagnosed with T1D since 2013, 874 had aTPO and 683 had aTG results. aTPO was positive in 19% and aTG in 13 % of patients. In 677 patients with both antibodies, aTPO was positive in 21% and aTG in 13%; 33 (5%) started on LT4 during this time. aTPO had greater sensitivity (p=0.039) than aTG, however, aTG had greater specificity than aTPO (p=0.008). Use of aTG and aTPO combined (either positive) did not have greater sensitivity than TPO alone, and had lower specificity than either aTG or aTPO alone (p<0.001). The combination of aTG and aTPO (both positive) provided the highest specificity (p<0.001), but lowest sensitivity. For likelihood ratios (LR), the best +LR was seen with combined aTG and aTPO both being positive; while the best –LR was seen with aTPO alone or combination of either positive.

Conclusions: Addition of aTG to aTPO alone did not improve, and potentially worsened, sensitivity and -LRs, while the combination of both positive maximized specificity and +LR. Given ADA and ISPAD recommendations that clinically euthyroid T1D patients with negative antibodies be screened for hypothyroidism every 1-2 years, the specificity gained by addition of aTG becomes less clinically meaningful. As a result, use of aTPO alone is clinically effective and could reduce cost, however, further study is needed to see if TSH alone may obviate the need for antibodies.

166: FC52

QUALITY IMPROVEMENT IN THE PERIOPERATIVE MEDICAL MANAGEMENT OF PEDIATRIC THYROIDECTOMY
Kristina Cossen, MD; Kanika Shanker, MD; Kurt Heiss, MD; Matthew Santore, MD, Emory University, Atlanta, GA, United States; Briana Patterson, MD, Emory University School of Medicine, Atlanta, GA, United States

Objectives: The aim of this quality improvement project is to assess intuitional variability in perioperative medical management of pediatric thyroidectomy and to institute protocols to standardize practice and enhance quality of care.

Methods: A retrospective cross-sectional assessment was conducted to review the perioperative medical management of total thyroidectomy patients seen between January 2010 through October 2014 at two campuses of a pediatric tertiary care hospital system in Atlanta, GA. Baseline data was extracted from 107 patients. Indications for thyroidectomy included Graves disease (n=66), thyroid cancer (n=20), and other thyroid conditions (n=21). After the baseline data was evaluated, we implemented standardized inpatient order sets, a written care pathway, and conducted education sessions with endocrinologists and surgeons. From September 2015 through January 2017, we collected post-intervention data on 30 patients (Graves disease (n=18), thyroid cancer (n=10), and other thyroid conditions (n=2)) to evaluate improvement in a practice bundle: prescribing preoperative iodine in Graves disease, measuring serum parathyroid hormone (PTH) and calcium levels at 6 hours post operation, and ordering universal postoperative prophylactic calcium carbonate. Feedback is being provided to both campuses.

Results: Rates of prescribing iodine in Graves disease showed a trend toward improvement (71.2% at baseline, 83.3% after the initiative, p=0.3). Rates of postoperative monitoring of PTH rose from 10.2% to 73.3% (p <0.01), and serum calcium monitoring rose from 37.3% to 90% (p <0.01). Postoperative prophylactic calcium carbonate utilization improved from 30.8% to 90% (p <0.01).

Conclusions: After the implementation of the quality initiative, we observed statistically significant improvement in 3 domains: PTH and calcium levels and prophylactic calcium carbonate. One barrier to universal implantation was the presence of multiple endocrine and surgical groups and 2 hospital sites. We plan additional PDSA cycles to improve our care pathway and increase utilization of the order sets, with the end goal to better standardize care and decrease transient postoperative hypocalcemia.

279: FC53

URINARY STEROIDOMICS FOR THE MANAGEMENT OF CHILDREN WITH CONGENITAL ADRENAL HYPERPLASIA
Clemens Kamrath, MD; Lisa Wettstaedt, Medical Student, Justus Liebig University Giessen, Giessen, Germany; Michaela F Hartmann, PhD; Stefan A Wudy, PhD, Justus Liebig University, Giessen, Germany

Objectives: Treatment of children with classic congenital adrenal hyperplasia (CAH) with glucocorticoids is a difficult balance of hypercortisolism and hyperandrogenism. Biochemical monitoring of treatment is not well defined. Normal growth is an important objective of treatment.

Methods: We retrospectively analysed 123 24-hr urinary steroid hormone metabolite profiles determined by gas chromatography-mass spectrometry with their corresponding one-year height velocity (HV) z-scores of 63 children aged 7.2 ± 1.6 years with classic CAH due to 21-hydroxylase deficiency treated with hydrocortisone and fludrocortisone.  

Results: Multivariate linear mixed effects model analyses revealed positive influence of z-scores of summed daily excretions of all urinary androgen metabolites (B= 0.97 ± 0.20, t-value = 4.97, P < 0.0001) and negative influence of daily excretion of the cortisol metabolite tetrahydrocortisol  (B= -1.75 ± 0.79, t-value = -2.20, P = 0.03) on HV z-scores.

ROC analysis revealed that adrenal androgen excess, defined as HV > 1.5 z, was best determined by a z-score of the sum of the daily excretion rates of all urinary androgen metabolites of > 0.644 (accuracy 70.7%, sensitivity 81.6 %, specificity 53.2%, positive prediction values (PPV) 73.8%, negative prediction values (NPV) 64.1%, positive likelihood ratio 1.7), whereas 24-hr excretion of tetrahydrocortisol  > 1.750 µg/ m2 BSA/ d in conjunction with suppressed daily excretion of urinary androgen metabolites < 0.163 z indicated cortisol excess and overtreatment, defined as HV < -1.5 z (accuracy  89.4 %, sensitivity 37.5 %, specificity 97.2%, PPV 66.7%, NPV 91.2%, positive likelihood ratio 13.4).

Conclusions: Urinary steroid metabolomics distinguishes patients with adequate metabolic control from those who were over treated or revealed an insufficient adrenal suppression. Therefore, urinary steroid metabolomics is an appropriate method for the monitoring of management of children with CAH.

802: FC54

PREVENTION OF DIABETES KETOACIDOSIS BY IMPLEMENTATION OF INTENSIVE SICK DAY RULES
Grace Nelson, MD; Ramin Alemzadeh, MD; Amit Lahoti, MD, University of Tennessee Health Science Center, Memphis, TN, United States

Objectives: Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes due to suboptimal insulin administration and hydration commonly observed in patients with uncontrolled type 1 diabetes mellitus (T1DM) leading to hospitalization. In order to prevent DKA-related hospital admissions, a new intensive in-home sick-day protocol was initiated and its efficacy was evaluated over a period of one year.

Methods: New sick day rules were implemented in January 2016 and all clinic T1DM patients were educated about them during their clinic visits or hospitalizations. A laminated copy of the sick day rules was also given to patients for reference. Retrospective data over 12 month periods for 2015 and 2016 were collected with the 2015 data serving as control and 2016 as post-intervention study data. We collected demographic, clinic and hospital admission data on known diabetes clinic patients with T1DM admitted to our hospital with DKA.

Results: The DKA-related admissions declined from 21.9 to 18.4 per 100 patients/year from 2015 to 2016, consistent with 16% reduction. The mean age, gender and HbA1c were not statistically different for the patient cohorts between the two years. While the number of admissions for patients with 3 or more admissions per year was similar (7.5 and 7.8/100 patients/year in 2015 and 2016, respectively), the number of DKA admissions for patients with <3 admissions/year declined from 14.4 to 10.6/100 patients per year, a 26% decrease (p=0.045).

Conclusions: Educating patients on intensive sick day rules was associated with a 16% decrease in DKA admissions per 100 known T1DM patients.  A significant decrease was seen in patients admitted <3 times per year. Further research is needed to identify interventions to reduce admissions for patients admitted more frequently.

340: FC55

HYDROCORTISONE GRANULES WITH TASTE MASKING ARE WELL ABSORBED AND TOLERATED IN NEONATES, INFANTS & CHILDREN WITH ADRENAL INSUFFICIENCY
Uta Neumann, MD, Charite-Universitätsmedizin Berlin, Berlin, Germany; Martin J Whitaker, Prof., Diurnal Limited, Cardiff, United Kingdom; Susanna Wiegand, MD; Heiko Krude, Prof., Charité University medicine Berlin, Berlin, Germany; John Porter, PhD; Madhu Davies, MB; Dena Digweed, BSc, Diurnal Limited, Cardiff, United Kingdom; Richard J Ross, MD, University of Sheffield, Sheffield, United Kingdom; Oliver Blankenstein, PhD, Charité – Universitätsmedizin Berlin, Berlin, Germany

Objectives: There is no licensed dose appropriate formulation of hydrocortisone for pre-school children with adrenal insufficiency (AI) and they rely on compounded adult medication.

To evaluate the absorption, palatability and safety of Infacort, an immediate-release, multi-particulate formulation of hydrocortisone with taste masking.

Methods: Setting: Single investigator site with satellite sites attended by a “flying” doctor from the investigator site.

Design: Open-label, single-dose study in three consecutive cohorts of children (n=24) with adrenal insufficiency; Cohort 1, aged 2-6 years (n=12); Cohort 2, infants 1 month to 2 years (n=6); Cohort 3, neonates 1 to 28 days (n=6). Fasted children were given a single dose of Infacort dose as dry granules administered directly from capsule or spoon followed by a drink. The primary endpoint was serum cortisol concentration 60 min after Infacort administration. Secondary endpoints were palatability assessed by parents and (where possible) children, and adverse events (AEs).

Results: All children showed an increase in cortisol above baseline after administration of Infacort (p<0.0001), with geometric mean ± SD cortisol concentration at 60 min of 575.8 ± 299.5 nmol/L. There were no difficulties with administration of Infacort and 95.5% of parents/carers reported they preferred Infacort over their child’s current medication. 6 children completed an age- appropriate palatability questionnaire with 80% responses were very good or neutral and 20% were bad or very bad. No serious or severe treatment-emergent AEs were reported.

Conclusions: Infacort is well tolerated, easy to administer to neonates, infants and children and shows a good absorption with cortisol levels at 60 min after administration being similar to physiological cortisol levels reported in healthy children.

363: FC56

NOVEL DOMINANT-NEGATIVE GH RECEPTOR MUTATIONS EXPANDS THE SPECTRUM OF GHI AND IGF-I DEFICIENCY
Kanimozhi Vairamani, PhD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Lina Merjaneh, MD, Seattle Children's Hospital, Seattle, WA, United States; Paula Casano-Sancho, MD, Sant Joan de Déu Hospital, Barcelona, Spain; Merve E Sanli, MD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Alessia David, MD, Imperial College London, London, United Kingdom; Louise A Metherell, PhD; Martin O Savage, MD, William Harvey Research Institute, London, United Kingdom; Jaime Sánchez Del Pozo, MD, Hospital Doce de Octubre. UCM, Madrid, Spain; Philippe Backeljauw, MD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Ron G Rosenfeld, MD, Oregon Health & Science University, Portland, OR, United States; Javier Aisenberg, MD, Hackensack University Medical Center, Hacksensack, NJ, United States; Andrew Dauber, MD; Vivian Hwa, PhD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Objectives: Autosomal recessive mutations in the growth hormone receptor (GHR) are the most common causes of primary growth hormone insensitivity (GHI) syndrome. We evaluated the functional effects of novel heterozygous GHR variants (located in the intracellular domain) identified in three unrelated children with non-classical GHI phenotypes (normal or elevated GHBP, low serum IGF-I, low-normal IGFBP-3, significant but less severe growth failure than classical GHI), and report therapeutic responses to rhIGF-I and/or rhGH therapy.

Methods: Sanger sequencing of the GHR gene or whole exome sequencing analysis was performed. Two of the GHR variants, c.964dupG and c.920_921ins14, were re-generated by site-specific mutagenesis and analyzed in HEK293 reconstitution studies (expression, GH-induced STAT5B phosphorylation and luciferase reporter assays).  Patients were treated with rhGH, rhIGF-I, rhIGF-I/IGFBP-3 or combination rhIGF-I+rhGH

Results: All three variants identified (c.964dupG, c.920_921ins14, and c.945+2T>C) are predicted to result in frameshift and early protein termination. In vitro functional analysis of variants c.964dupG and c.920_921ins14 demonstrated expression comparable to wild-type GHR, but an inability to activate GH-induced STAT5B signaling. When co-expressed with wild-type GHR, these variants significantly blunted GH signaling responses of wild-type GHR, similar to our previously described, dominant-negative GHR c.899dupC. We show that a combination therapy of rhGH and rhIGF-I optimally improved linear growth to within normal range for the patient carrying the dominant-negative GHR c.899dupC mutation.

Conclusions: Dominant-negative GHR mutations, all located in the intracellular GHR domain, are causal of the mild GHI, IGF-I deficiency, and significant growth failure observed in our patients. A combined therapy of rhGH plus rhIGF-I appears to be an effective treatment option, with some response seen in patients receiving rhIGF-I or rhGH alone. The possibility of heterozygous mutations in the GHR intracellular domain should be considered in patients presenting with low IGF-I concentrations and growth phenotypes less severe than seen in classical GHI syndrome.

1289: FC57

TRANSCON CNP, A SUSTAINED-RELEASE PRODRUG OF C-TYPE NATRIURETIC PEPTIDE, EXERTS POSITIVE EFFECTS ON BONE IN YOUNG CYNOMOLGUS MONKEYS AND IN A MOUSE MODEL OF ACHONDROPLASIA
Kennett Sprogoe, PhD; Vibeke Mil Breinholt, PhD; Rasmussen Caroline, PhD; Per H Mygind, PhD; Oliver Keil, PhD; Susanne Adermann, PhD; Ulrich Hersel, PhD, Ascendis Pharma, Heidelberg, Germany; Nabil Kaci, PhD; Cornille Maxence, PhD, Inserm U1163-Institut Imagine, Paris, France; Lars H Andersen, PhD, Ascendis Pharma, Hellerup, Denmark; Laurence Legeai-Mallet, PhD, Inserm U1163-Institut Imagine, Paris, France

Objectives: No FDA-approved treatment option exists for achondroplasia (ACH), the most common form of dwarfism. C-Type Natriuretic Peptide (CNP) has shown promising efficacy in both animal models and human subjects with ACH. TransCon CNP is a prodrug designed specifically to release free CNP at a slow rate resulting in a hemodynamically safe and efficacious drug levels following weekly dosing. The aim of these nonclinical studies was to compare the efficacy of the long-acting TransCon CNP to a daily administered CNP in normal and diseased animal models.

Methods: TransCon CNP was administered to newborn ACH mice harboring the Fgfr3Y367C/+mutation (5.6 mg/kg/day) and to young, healthy cynomolgus monkeys (N=4) (up to 100 µg/kg/week). Body, tail, and selected bones were measured by radiography/µCT and/or with a caliper. H&E and Collagen X staining were performed on the growth plate in order to address effects on the bone architecture. Cardiovascular tolerability was studied by telemetry in both mice and monkeys.

Results: The administration of TransCon CNP to ACH mice resulted in positive effects on axial and appendicular bones and in an increased diameter of foramen magnum. Collagen type X and H&E staining showed an improvement of the growth plate architecture, including an increased size of the epiphysis and secondary ossification centers, compared to Fgfr3Y367C/+ mice treated with vehicle. In young, healthy cynomolgus monkeys, TransCon CNP induced a dose-responsive effect on tibia growth, with increases up to 70% relative to the growth rate for control animals, without observed hypotension or increased heart rate. In cynomolgus monkeys TransCon CNP exhibited a T½ of 80-120 hours.

Conclusions: TransCon CNP exerted growth promoting effects on bone in both healthy animals and in a disease model of ACH resulting in improvement of the ACH phenotype. Additionally, TransCon CNP increased the diameter of the foramen magnum in ACH mice. In contrast to daily CNP, no apparent risk of hypotension was observed for TransCon CNP. These data supports further development of TransCon CNP as a potential therapy for ACH providing safe and efficacious CNP levels, with weekly administration.

568: FC58

3-YEAR UPDATE OF THE PHASE 2A AND LONG-TERM SAFETY STUDIES (VERTICAL AND VISTA) OF SOMAVARATAN (VRS-317), A LONG-ACTING RHGH FOR THE TREATMENT OF PEDIATRIC GROWTH HORMONE DEFICIENCY
Bradley S. Miller, MD, PhD, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States; Wayne V. Moore, MD, PhD, Children’s Mercy Hospital and University of Missouri-Kansas City, Kansas City, MO, United States; Patricia Y. Fechner, MD, Seattle Children's Hospital and University of Washington, Seattle, WA, United States; Huong Jil Nguyen, MD, Sierra Medical Research, Clovis, CA, United States; Quentin L. Van Meter, MD, Van Meter Pediatric Endocrinology, P.C., Atlanta, GA, United States; John S. Fuqua, MD, Riley Hospital for Children,Indiana University School of Medicine, Indianapolis, IN, United States; David Ng, PhD, ResearchPoint Global, Inc., Austin, TX, United States; Eric Humphriss, MBA; R. W. Charlton, MD, Versartis, Inc, Menlo Park, CA, United States; George M. Bright, MD, Versartis, Inc., Menlo Park, CA, United States

Objectives: Recombinant human growth hormone (rhGH) is the standard of care for pediatric growth hormone deficiency (GHD). Requirement for daily rhGH injections represents a treatment burden that can compromise adherence and efficacy in these patients. Somavaratan, a novel, long-acting rhGH fusion protein under development for pediatric and adult GHD, showed significant improvements in height velocity (HV) and IGF-I in a multicenter, randomized phase 1b/2a study in prepubertal children with GHD. We present preliminary efficacy and safety results of somavaratan in subjects receiving 3 years of treatment.

Methods: In the phase 2a VERTICAL study, 64 subjects were randomized to receive 5.0 mg/kg/month (weekly vs. twice monthly vs. monthly dosing) for 6 months; 60 elected to continue treatment in the VISTA long-term safety study. As initial IGF-I response supported a dose increase, all subjects transitioned to somavaratan 3.5 mg/kg twice monthly by the second treatment year. Data cutoff was December 8, 2016.

Results: Of 48 subjects (24 male, 24 female) in the third year of somavaratan treatment, mean baseline age (±SD) was 7.6±2.4 years. Mean IGF-I standard deviation score (SDS) increased from -1.8±0.8 at baseline to 1.0±1.6 (n=45) at peak (3–8 days postinjection) and -0.5±1.0 (n=47) at trough (end-of-dosing cycle). In years 1, 2, and 3, mean HV remained consistent at 8.4±2.0, 8.3±1.6, and 7.8±1.6 cm/year, respectively, and height (HT) SDS showed continued increases from -2.6±0.6 at baseline to -2.1±0.6, -1.6±0.7, and -1.2±0.8. Mean bone age delay (years) was -1.48±0.81 at baseline (n=48), -1.34±0.89 (year 1, n=48), -1.09±1.02 (year 2, n=47), and -0.66±0.82 (year 3, n=25). Treatment-related adverse events were mild and transient.

Conclusions: At 3 years of somavaratan treatment, IGF-I, HV, HT SDS, and bone age showed continued improvement in prepubertal children with GHD. Increasing the somavaratan dose to 3.5 mg/kg twice monthly yielded consistent growth rates, with overall year 3 growth consistent with that of daily rhGH treatment reported in US registries. The somavaratan 3.5 mg/kg twice-monthly dose is being evaluated in treatment-naïve GHD children in an ongoing phase 3 trial.

1252: FC59

PHENOTYPICAL FEATURES OF PATIENTS WITH A MOLECULAR DEFECT OF THE IGF-1 RECEPTOR AND THE GROWTH RESPONSE TO GROWTH HORMONE TREATMENT.
Marie JE Walenkamp, MD, VU University Medical Center, Amsterdam, Netherlands; Jasmijn ML Robers, BS/BA; Jan M Wit, Professor, Leiden University Medical Center, Leiden, Netherlands; Gladys RJ Zandwijken, MD, Dutch Growth Research Foundation, Rotterdam, Netherlands; Wilma Oostdijk, MD; Sarina G Kant, MD, Leiden University Medical Center, Leiden, Netherlands; Monique Losekoot, PhD, Leiden University Medical Centre, Leiden, Netherlands

Objectives: To describe the phenotype and response to rhGH treatment of patients with an IGF-I receptor (IGF1R) defect and to develop a clinical score to select patients for genetic testing.

Methods: Between 2005-2016 41 patients were identified with an IGF1R defect. The 32 patients from whom clinical data were available were divided into 4 groups, based on in silico analysis and clinical data: group 1 (n=19): pathogenic mutations; group 2 (n=7): terminal deletions; group 3 (n=4): non-pathogenic variants; group 4 (n=2): digenic disorders (IGF1R + another defect). For groups 1 and 2 we analysed the 3-year height SDS and IGF-I SDS response to GH treatment in comparison to GH-treated children born small for gestational age (SGA).

Results: In total, 22 pathogenic mutations, 6 non-pathogenic variants, 9 deletions and 2 digenic defects were identified. The included patients (n=32) had a mean height SDS of -3.0 (range -5.5 to -1.7), birth weight (BW) SDS of -2.1 (range -3.7 to -0.4), and birth length (BL) SDS of -2.6 (-5.0 to -1.0). Head circumference (HC) was lower at presentation than at birth (-2.6 vs -1.6, p=0.02). Mean serum IGF-1 was 1.1 SDS (range -1.3 to 3.2, p<0.001). Fourteen out of 19 reported feeding problems. A scoring system with 100% sensitivity in our cohort and in reported patients was developed, based on a positive score on ≥3 of the following criteria: BW and/or BL< 0 SDS; height 0 SDS. Of the 20 rhGH-treated patients (13 mutations; 7 terminal deletions), average height gain in group 1 was 0.5, 0.7 and 1.0 SDS during the first 3 years and 0.8, 1.1 and 1.3 SDS in group 2, while children born SGA gained 0.9, 1.5 and 1.8 SDS. Mean maximum IGF-I levels on treatment were 3.5 SDS (range 1.2-6.0 SDS).

Conclusions: We present the largest cohort of patients with an IGF1R defect so far and confirm that the phenotype is characterized by SGA in most cases, short stature, microcephaly, serum IGF-I >0 SDS and feeding problems, which we converted into a simple clinical score to select patients for IGF1R analysis. The growth response to GH treatment is clinically significant but lower than observed in SGA patients on a similar dose, in spite of increased serum IGF-I levels.

601: FC60

BONE MINERAL DENSITY IN YOUNG ADULTS WITH PRADER-WILLI SYNDROME: RESULTS OF A 2-YEAR RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, CROSS-OVER TRIAL
Stephany H Donze, MD; Renske J Kuppens, MD, PhD, Erasmus Medical Center / Dutch Growth Research Foundation, Rotterdam, Netherlands; Nienke E Bakker, MD, PhD; Elbrich PE Siemensma, MD, PhD, Erasmus Medical Center, Rotterdam, Netherlands; Anita CS Hokken-Koelega, MD, PhD, Erasmus Medical Center / Dutch Growth Research Foundation, Rotterdam, Netherlands

Objectives: Adults with Prader-Willi syndrome (PWS) are at risk to develop osteoporosis. Growth hormone (GH) treatment has beneficial effects on bone mineral density (BMD) in children with PWS. Cessation of GH treatment at attainment of adult height (AH) might deteriorate BMD in patients with PWS, while continuation might be beneficial. The objective was to investigate the effects of GH versus placebo on BMD in young adults with PWS who were GH-treated during childhood and had attained AH.

Methods: Two-year, randomized, double blind, placebo-controlled crossover GH study in 27 young adults with genetically confirmed PWS who were treated with GH during childhood for at least 2 years and had attained AH. Patients were stratified according to gender and BMI (below/above 25 kg/m2) and then randomly and blindly assigned to 1 year of subcutaneous injections once daily at bedtime of either 0.67 mg/m2/day GH (Genotropin®, 5 mg/ml, Pfizer) or 1 year of identical appearing placebo, after which they crossed-over to the alternative treatment for another year.

Results: At AH, BMDTotalBodySDS was significantly lower compared to healthy peers (p=0.002), while BMADLumbarSpineSDS was similar (p=0.75). Both were significantly lower in patients with a deletion than in those with an mUPD (p=0.036 and p=0.035, resp.). Compared with GH, placebo did not significantly deteriorate BMDTBSDS and BMADLSSDS (p=0.71 and p=0.14, resp.). In patients who did not receive sex steroid replacement therapy (SSRT) BMDTBSDS decreased from -0.48 SDS at AH to -0.7 SDS after 2 years (p=0.036), and BMADLSSDS from 0.25 to -0.21 SDS (p=0.019). In patients who received SSRT, BMDTBSDS significantly increased from -1.03 to -0.76 SDS (p=0.01).

Conclusions: This two-year cross-over GH trial in young adults with PWS who were treated with GH during childhood and had attained AH shows that, compared to GH, 1 year of placebo does not deteriorate BMDTBSDS and BMADLSSDS. BMD in patients who received SSRT during the RCT improved significantly compared to patients who did not. GH is not able to prevent a decline in BMD when patients need SSRT. This indicates that SSRT should be considered when BMD starts to decline due to incomplete pubertal development in PWS.

205: FC61

THE ROLE OF SOLUBLE LIPID TRANSPORT PROTEINS IN MODULATING LIVER RECEPTOR HOMOLOG-1 (LRH-1) MEDIATED GENE EXPRESSION
Mireille El Bejjani, MD, Emory University , Atlanta, GA, United States; Suzanne G. Mays, MS/MA; Matthew C. Tillman, BS/BA; Eric A. Ortlund, PhD, Emory University, Atlanta, GA, United States

Objectives: LRH-1 is a nuclear receptor that binds phosphatidylcholines (PCs) and regulates multiple metabolic pathways including hepatic glucose sensing and metabolism; however, mechanisms through which insoluble PCs access LRH-1 in the nucleus are unclear. We aim to test the role of lipid transport proteins in shuttling PCs from cytoplasmic membranes into the nucleus to regulate LRH-1 activity.

Methods: We identified four lipid transport proteins that bind PCs and localize to the nucleus: PCTP, PITPα, STARD7 and STARD10. We tested their effect on LRH-1 transactivation by a series of siRNA-mediated knockdown and transient overexpression experiments in human liver cell lines. The effects of knockdown and overexpression were measured by qRT-PCR against a panel of known LRH-1 target genes and by luciferase reporter assays. We subsequently explored mechanisms through which these candidate lipid transport proteins modulate LRH-1 transactivation. This was done by pulldown and split luciferase experiments to test for direct interactions. We also introduced mutations in the pocket of the transport proteins to prevent PC binding or nuclear localization and measured the effect on LRH-1 target genes by qRT-PCR.

Results: The knockdown of PCTP as well as its inhibition using the synthetic agonist A1 both resulted in decreased LRH-1 transactivation by luciferase reporter assays. Knockdown of PITPα, STARD7 and STARD10 by siRNA resulted in decreased level of expression of SHP, a known target of LRH-1. Overexpression of PCTP led to a lower expression levels of some LRH-1 target genes. The split luciferase experiment did not capture a direct interaction between LRH-1 and any of the transport proteins indicating that the interactions may be transient or that transport proteins have an indirect effect on LRH-1 transactivation.

Conclusions: Alteration of lipid transport proteins expression has an impact on LRH-1 transactivation. This effect does not appear to be mediated by a stable direct interaction between LRH-1 and the transport proteins, but rather through an indirect pathway. Understanding the regulatory pathways governing LRH-1 activity is key to developing novel therapeutic approaches to prevent metabolic disease progression.

727: FC62

BARIATRIC SURGERY DURING THE TRANSITION PHASE IN PRADER-WILLI SYNDROME: LONG-TERM OUTCOME AFTER BILIOPANCREATIC DIVERSION
Antonino Crino', MD; Danilo Fintini, MD; Alessio Convertino, MD; Sarah Bocchini, MD, Bambino Gesù Hospital, Research Institute, Palidoro (Roma), Italy; Graziano Grugni, MD, Italian Auxological Institute, Piancavallo (Verbania), Italy

Objectives: Improvement in weight control remains the most important goal of any treatment program in Prader-Willi syndrome (PWS). To date, bariatric surgery experience in PWS is limited, and different procedures have been used with varying success. Malabsorptive procedures, such as biliopancreatic diversion (BPD), are not always recommended for PWS due to safety lack of data and involves long-term complications.

Methods: We report 10 severely obese patients (6 males) with genetically confirmed PWS (7 del15, 3 UPD15), who underwent Scopinaro’s BPD after inability to control food intake with the classical approaches. Surgery was performed on patients aged 18,8±2,9 yrs (mean±SD) (range: 15,4-24,3 yrs) and the BMI (kg/m2) was ≥40 in all cases (49,3±6,4). At baseline, severe co-morbidities were present, such as obstructive sleep apnea (OSAS), type 2 diabetes mellitus (T2DM), hypertension, metabolic syndrome and/or steatohepatitis.

Results: No perioperative complications were observed. After a follow-up period of 13,7±7,4 yrs (range: 4.1-27 yrs; mean age at follow-up: 32.5±6.8 yrs) the maximum weight loss% (MWL%) was 30,7±10 (10,1-52,6). Following BPD, BMI decreased in 6 patients, stable in 3 subjects and increased in 1 individual. The mean BMI at the last visit was 40,5±8.8 (28,9-51,6). After BPD, appetite was reduced in 7 cases; 6 subjects had hypocromic anemia and diarrhea; OSAS were present in 5 patients and osteoporosis/osteopenia in all individuals. T2DM disappeared and behavioural problems improved in some cases. One patient suddenly died at the age of 37.3 yrs.  After surgery all patients received medical therapy to prevent nutritional deficiency.

Conclusions: The long-term outcome of BPD in our PWS seems to be favorable, with a significant reduction of weight excess in the majority of subjects. Thus, BPD seems to be a good option in the presence of severe comorbility and in selected PWS patients, with co-operating families, when other classical approaches have failed. Due to the presence of specific side effects of the procedure, however, a careful long-term multidisciplinary follow-up is always necessary.

1241: FC63

TREATMENT OF TWO POMC DEFICIENT PATIENTS WITH THE MELANOCORTIN-4 RECEPTOR AGONIST SETMELANOTIDE LED TO SUCCESSFUL WEIGHT LOSS
Peter Kühnen, MD, Charité Universitätsmedizin Berlin, Berlin, Germany; Karine Clément, Professor, Assistance-Publique Hôpitaux de Paris, Paris, France; Keith Gottesdiener, MD, Rhythm pharmaceuticals, Boston, MA, United States; Barbara Wolters, MD, Charité Universitätsmedizin Berlin, Berlin, Germany; Fred Fiedorek, MD; Lex Van Der Ploeg, MD, Rhythm pharmaceuticals, Boston, MA, United States; Oliver Blankenstein, PhD, Charité – Universitätsmedizin Berlin, Berlin, Germany; Susanna Wiegand, MD, Charité University medicine Berlin, Berlin, Germany; Annette Grüters, Professor, Charité Universitätsmedizin Berlin, Berlin, Germany; Heiko Krude, Prof., Charité University medicine Berlin, Berlin, Germany

Objectives: The rare condition of POMC deficiency is characterized by monogenic obesity due to early onset hyperphagia, red hair and ACTH insufficiency. We have recently described the first results of an investigator initiated phase 2 study in which two POMC deficient patients were treated with the Melanoocortin-4 receptor (MC4R) agonist setmelanotide (Kühnen et al., NEJM, 2016).

Methods: The Phase 2, non-randomized, open label pilot study with the new MC4R agonist setmelanotide was conducted in two POMC deficient adult patients (EudraCT No. 2014-002392-28; clinicaltrials.gov identifier No. NCT02507492). Setmelanotide was injected with a single dose which gradually escalated from 0.5 to 1,5mg subcutaneously once per day. We now describe the follow-up results of the initially included two POMC deficient patients after a treatment period of over 24 months.

Results: Following over 24 months treatment for each patient, reductions in the body weight of 65.6 kg (42.3 % of the initial body weight) for patient 1 and 40.5 kg (27 % of the initial body weight) for patient 2 were achieved. So far, we observe no severe adverse events related setmelanotide treatment, Due to the activation of the melanocortin-1 receptor (MC1R) in the skin, the treatment was accompanied by an increased tanning of the skin and a hair color change. Moreover, pre-existing hyperinsulinemia normalized during the study in parallel with the weight loss observed, which was based on a reduction in severe hyperphagia and accompanying increases in energy expenditure. Cardiovascular parameters significantly improved in each patient.

Conclusions: We present long term (> 24 months) setmelanotide treatment induced physiological results observed in two POMC deficient patients. The initiation of the treatment led to severe reduction of body weight caused by setmelanotide replacement of the defective MSH signal in the MC4 signaling pathway in these patients. The results point to a potential neuropeptide replacement therapy with this MC4R agonist, that can include other indications in which MSH deficiency might lead to the occurrence of severe hyperphagia as observed in LEPR deficient patients and potentially other MC4 pathway deficiency genetic disorders.

354: FC64

ADJUSTING FOR PUBERTAL STATUS REDUCES PREVALENCE OF OBESITY
O. Yaw Addo, PhD, Rollins School of Public Health Emory, Atlanta, GA, United States; Bradley S. Miller, MD, PhD, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States

Objectives: Pubertal stage has been shown to distort body composition indicators of children based upon existing reference standards using calendar age. For instance, tall children are more likely to have higher body mass index, BMI and be misclassified as obese. This concept has been consistently observed in apparently healthy cohorts of children in Europe, United States, and elsewhere. We examined growth pattern differences Tanner-stage-age normed vs chronologic age BMI z scores for US children transitioning through puberty ages 8-18y and Tanner 2-5 and quantified maturation-chronologic age differences when estimating prevalence of obesity or overweight in US youths.

Methods: We performed secondary data analyses of anthropometry and Tanner staging data of 3206 US children ages 8 – 19 years from the National Health and Nutrition Examination Survey (NHANES III) (n=1606, 53% male, 72% Non-Hispanic White (NHW), 9% Mexican American (MA) and 19% Non-Hispanic Black (NHB). The semi-parametric LMS in GAMLSS technique of growth modeling was utilized to generate specialized age-conditioned growth functions within each Tanner stage. Overweight/obesity status were then defined based on resultant Tanner-stage-age and BMI-age z-scores.

Results: Highly variable patterns of prevalence of obesity and overweight (derived from BMI z-score-for chronologic age) were observed when results were examined by tanner stages by ethnicity and sex. For example, NHW (35%) and MA (33%) females had higher prevalence of overweight at early puberty relative to NHB (24%) females, yet at late-puberty NHB (46%) females had the highest prevalence (NHW 28%, MA 38%). A similar pattern was observed for obesity prevalence and for males. Adjusting for Tanner stage significantly reduced the prevalence of overweight (males: from 27 – 38% to 16 – 22%; females: 25-36% to 15-19%; similar reduction magnitudes with obesity) across ethnicities and sex.

Conclusions: Differences in timing of puberty between ethnic groups can affect the estimated prevalence of overweight/obesity. Adjustment for pubertal development reduces the prevalence of overweight/obesity. This adjustment may be important when interpreting prevalence data and interventions aimed at reducing the public health impact of obesity.

493: FC65

IDENTIFICATION OF RARE GENETIC VARIANTS IN PATIENTS WITH NON-SYNDROMIC EARLY-ONSET OBESITY USING A POOLED DNA SEQUENCING APPROACH
Gabriel Á. Martos-Moreno, MD; PhD., Hospital Infantil Universitario Niño Jesús. UAM. , Madrid, Spain; Clara Serra-Juhé, PhD; Francesc Bou, PhD; Benjamín Rodríguez-Santiago, PhD; Raquel Flores, PhD; Luis A Pérez-Jurado, MD, PhD, Universitat Pompeu Fabra, Barcelona, Spain; Jesús Argente, MD, PhD, Hospital Infantil Universitario Niño Jesús. UAM, Madrid, Spain

Objectives: Studies trying to elucidate the pathophysiology of obesity consistently describe a highly heterogeneous disorder both at a clinical and molecular level, with high heritability. At least 10 genes, mostly with recessive inheritance, have been reported to cause monogenic severe obesity, and there are few more candidates with strong effect identified in association studies. The aim of this study was to establish the contribution of rare sequence variants (RSVs) in candidate genes to severe early-onset obesity (BMI > +3SDS, onset < 3years).

Methods: Using a pooled DNA sequencing approach we screened 15 candidate genes for obesity in a cohort of 480 patients and 480 controls: 1) genes with reported alterations in patients with obesity (LEP, LEPR, MC3R, MC4R, PCSK1, NTRK2 and SIM1) and 2) genes strongly associated to obesity by GWAS (BDNF, FTO, NEGR1, GHSR, ADRB3, PPARG, PCSK2, PCSK1 and TMEM18A) We focused on RSVs found in single or few individuals per cohort.

Results: Seven of the 15 genes (BDNF, FTO, MC3R, MC4R, NEGR1, PPARG and SIM1) were differentially represented between patients and controls; we identified 30 RSVs in the mentioned subset of genes in 35 patients and 5 in 6 controls (p<0.0001). The difference of probably pathogenic RSVs (15 in 17 patients vs. 1 in 1 control) was also significant (p=0.0001); all were single allele changes and none of the individuals carried more than one variant.

Conclusions: Our data reveal a higher burden of probably pathogenic heterozygous RSVs in several candidate genes in patients with severe early-onset obesity compared to controls. Our results reinforce the role of the melanocortin pathway (including MC3R, MC4R and SIM1) and bring to light other genes with highly penetrant obesogenic single allele RSVs like PPARG (regulator of adipocyte differentiation) and BDNF (regulator of stress response and appetite).

897: FC66

DIABETES MELLITUS IN THE LONG-TERM FOLLOW-UP OF NON-PANCREATECTOMISED PATIENTS WITH PERSISTENT HYPERINSULINAEMIC HYPOGLYCAEMIA OF INFANCY DUE TO LOSS-OF-FUNCTION MUTATIONS IN THE ABCC8 GENE: A NEW FORM OF MONOGENIC DIABETES?
María Clemente, PhD, Hospital Vall d´Hebron/ Autonomous University, Barcelona, Spain; Ariadna Campos, PhD, Hospital Vall d´Hebron, Barcelona, Spain; Diego Yeste, PhD, Hospital Vall d´Hebron/ Autonomous University. CIBERER, Barcelona, Spain; María Caimari, PhD, Hospital Universitario Son Espases, Palma de Mallorca, Spain; Rosa Martínez-Salazar, PhD, BioCruces Health Research Institute, Cruces University Hospital, CIBERDEM, CIBERER, Barakaldo, Spain; Antonio Carrascosa, PhD, Hospital Vall Hebron, Barcelona, Spain

Objectives: Mutations in the ABCC8 gene are the most common cause of congenital hyperinsulinism (CHI). Diabetes has been observed in the evolution of several non-pancreatectomized patients.

To observe the evolution of glucose metabolism in non-pancreatectomised patients with CHI due to mutations in the ABCC8 gene.

Methods: Twenty-three patients with CHI and mutations in the ABCC8 gene followed up over the last 45 years.

Nineteen patients were non-responders to diazoxide; 2 patients were subtotally pancreatectomised and 4 totally pancreatectomised.

Continuous glucose monitoring (CGM) was performed periodically from 2003 in non-pancreatectomized patients. Oral glucose tolerance test (OGTT) was performed from the age of 5 years if hyperglycaemias were detected by CGM (glucose excursions>180 mg/dL). Diabetes was diagnosed according to ADA criteria. Normal CGM was defined as all glucose values< 140 mg/dL.

Results: Follow-up of 15 (8 girls) non-pancreatectomised patients (1 non-pancretectomised patient died from pulmonary hypoplasia and follow-up of other is not available). Current age: 17.04±9.03 years (2.8-42). 

Eight patients presented normal CGM; current age: 11.0 ± 4.8 (16.2-2.9) years. Genetic study: 3 homozygous/compound heterozygous, 5 heterozygous. Four responded to diazoxide and only the youngest remains on this treatment.

Seven patients presented hyperglycaemias during evolution: 2 developed diabetes (previously published); 1 patient previously published as glucose-intolerant developed diabetes at the age of 26 years (hyperglycaemia and HbA1c 6.7%); one patient (patient 6) developed diabetes at the age of 6.5 years (first diabetic OGTT) and was insulinised at the age of 12; three patients presented hyperglycaemias by CGM from 13 to 1 years of age, one of whom had a diabetic OGTT (patient 4) with HbA1c of 6.1% and the other two have their OGTT pending (patients 6 and 9). Anti-GAD, -IA2 and –ICA antibodies were negative in all seven.  

Conclusions: - A significant proportion (7 of 15) of patients with CHI due to mutations in the ABCC8 gene who were medically treated developed hyperglycaemias and 4 of the 7 diabetes mellitus.

- No relationship appeared to exist between diabetes occurrence and ABCC8.

- Responders to diazoxide did not present hyperglycaemias after treatment withdrawal.

249: FC67

SULPHONYLUREAS ARE A HIGHLY EFFECTIVE AND SAFE LONG-TERM TREATMENT FOR NEONATAL DIABETES DUE TO KCNJ11 MUTATIONS: THE FIRST 10-YEAR FOLLOW-UP STUDY OF A LARGE INTERNATIONAL COHORT.
Pamela Bowman, MBBS, University of Exeter, Exeter, United Kingdom; Asta Sulen, BS/BA, University of Bergen, Bergen, Norway; Fabrizio Barbetti, MD, University of Rome Tor Vergata, Rome, Italy; Jacques Beltrand, MD, Faculte de médecine Paris Descartes, Hôpital Universitaire Necker Enfants Malades, Paris, France; Michel Polak, Professor, INSERM U1016, Cochin Institute and INSERM U1163, Imagine Institute, Paris Descartes University, Sorbonne Paris Cité, Necker Children's University Hospital, Paris, France; Dario Iafusco, MD, Bambino Gesu Children's Hospital, University of TorVegata, Rome, Italy; Pernille Svalastoga, MD, University of Bergen, Bergen, Norway; Torild Skrivarhaug, MD, University of Oslo, Oslo, Norway; Iwar Klimes, MD, Slovak Academy of Sciences, Bratislava, Slovakia; Ethel Codner, MD, University of Chile, Santiago, Chile; Ellen Tessmann, MD, University of Tennessee, Knoxville, TN, United States; Maciej T Malecki, MD, University Hospital, Jagiellonian University Medical College, Krakow, Poland; Andrew T Hattersley, MD, University of Exeter, Exeter, United Kingdom; Pal R Njolstad, MD, University of Bergen, Bergen, Norway

Objectives: Mutations in KCNJ11 cause permanent neonatal diabetes (PNDM) due to activation of the pancreatic KATP channel. 90% of patients can transfer from insulin to sulphonylurea therapy (SU) improving glycaemic control at 1 year. “SU failure”, where SU no longer maintains good glycaemic control, is seen in ≈50% of people with Type 2 diabetes after 5 years of treatment. No previous studies have assessed long-term efficacy and safety of SU in KCNJ11 PNDM. We report the first 10-year follow-up of a large international cohort of patients with SU-treated KCNJ11 PNDM.

Methods: We followed up all patients diagnosed with KCNJ11 PNDM in laboratories in Exeter, Bergen, Rome, Paris and Poland and who successfully transferred from insulin to oral SU prior to 2007. Primary outcomes were sulfonylurea efficacy and metabolic control. Secondary outcomes were side effects, hypoglycaemia and complications. OGTT and IVGTT were done in six patients.

Results: Long-term data were available for 81/91 eligible patients (89%).  Median follow-up duration was 10.2 years. 75/81(93%) remained on SU alone at most recent follow-up: 6/81(7%) were on SU and daily insulin. Excellent glycaemic control was maintained long-term (fig. 1): in patients on SU alone, median(IQR) HbA1c pre-transfer to SU, at 1-year and at 10-years was 8.0(7.2-9.2)%, 5.9(5.5-6.4)% and 6.3(5.9-7.2)%. Median SU dose fell over the period of follow-up (1 year dose 0.28 mg/kg/day and 10 year dose 0.23 mg/kg/day, p=0.01). There were no reported episodes of severe hypoglycaemia. Side-effects (diarrhoea/nausea/reduced appetite/abdominal pain) were reported in 10/81(12%); these were transient and no patients discontinued SU as a result. Microvascular complications were reported in 7/81(9%) patients; there were no macrovascular complications. Patients with complications were older at age of transfer to SU than those without complications (age at transfer 20.5 v 4.1 years, p=0.0005). OGTT and IVGTT revealed good insulin response to glucose and maintained incretin effect after ten years.

Conclusions: SUs are a safe, highly effective treatment for KCNJ11 PNDM, maintaining excellent glycaemic control over 10 years despite the dose of SU being reduced. In contrast to Type 2 diabetes “SU failure” is not seen with prolonged treatment in KCNJ11 PNDM.

1203: FC68

PSEUDOACROMEGALY AND INSULIN RESISTANCE, A RARE DISORDER OF DOWNSTREAM INSULIN SIGNALING
Stephen I Stone, MD; Jennifer A Wambach, MD; Francis S Cole, MD; Daniel J Wegner, MS/MA; Fumihiko Urano, MD PhD, Washington University School of Medicine, St. Louis, MO, United States

Objectives: We report a case of a 12 year old female presenting to pediatric diabetes clinic with extremely tall stature, acanthosis nigricans, severe hirsutism, obesity, and acromegaloid features. Due to her unique presentation, we were concerned that she has an insulin resistance syndrome. However, most insulin resistance syndromes are associated with short stature.

Methods: The subject and her first-degree relatives underwent extensive metabolic phenotyping in addition to whole exome sequencing. 

Results: The subject’s IGF-1 was normal, however she was noted to have extremely elevated insulin (2446 uIU/mL) postprandially. She had biochemical hyperandrogenism with elevated free testosterone (16 pg/mL), and a relative leptin deficiency (19.0 ng/mL). The subject’s bone age was 14 years, giving her a predicted adult height of 1.83m (+3.23 SDS). Two hour oral glucose tolerance testing indicated an undetectable growth hormone at 90 minutes, however her insulin was elevated to 799 uIU/mL at 60 minutes.

Whole exome sequencing identified no variants in insulin, insulin receptor, or the IGF-1 receptor. However it did identify 2 variants in genes critical to the FGF-21 signaling pathway. Fibroblast growth factor 21 (FGF-21) is a recently discovered peptide that has gained attention for its important effects on insulin sensitivity, growth hormone, and fertility. The mutated genes were Fibroblast Growth Factor Receptor 1 (FGFR1) and beta Klotho (KLB). FGFR1 and KLB are transmembrane co-factors that bind FGF-21. These variants (p.V102I and p.S9Y) were inherited in trans from each parent. They are extremely rare, and are predicted to be damaging by the majority of in-silico variant prediction programs. The subject’s FGF-21 level was elevated (391.3 pg/mL) compared to her father (104.3 pg/mL) and mother (225.2 pg/mL). Mutant and wild type FGFR1 and KLB were transfected into various cell lines in order to assay downstream insulin signaling.

Conclusions: We hypothesize that, together, the FGFR1 and KLB mutations act in a dominant and synergistic manner, resulting in this subject’s severe insulin resistance, tall stature, and hirsutism. If true, this would represent a novel category of insulin resistance syndromes related to FGF-21.

975: FC69

ADIPOCYTE GAMMA-SECRETASE INHIBITION ALTERS INFLAMMATORY CYTOKINE PRODUCTION
David Sparling, MD, PhD; Nile Mccullough, BS/BA, University of Oklahoma, Oklahoma City, OK, United States

Objectives: Adipose tissue-immune system interactions likely play a significant role in the pathophysiology of obesity and Type 2 diabetes mellitus. Expanding research suggests that adipocytes themselves may regulate inflammatory cascades. The gamma-secretase enzyme complex has an emerging role in regulation of both adipose insulin signaling as well as the immune system. Pathways regulated by gamma-secretase in a variety of cell types have also been implicated in obesity phenotypes. Previous data has suggested that adipocyte-specific blockade of gamma-secretase leads to decreased macrophage recruitment and/or activation in adipose tissue. We therefore hypothesized that the gamma-secretase enzyme complex is required for adipocyte-mediated inflammatory signaling.

Methods: To explore this hypothesis in a controlled in vitro system, we examined the effect of gamma-secretase inhibition on fully differentiated 3T3-L1 adipocytes following exposure to lipopolysaccharide (LPS). We utilized qRT-PCR to follow changes in gene expression of a variety of inflammatory cytokines and immunoreceptors previously identified in adipocytes, including TNF-a, IL-6, MCP1, CD44, and TREM2. Cytokine secretion was also determined by ELISA.

Results: While baseline transcription of TNFa, IL6, and CD44 were not significantly affected by g-secretase inhibition, MCP1 and TREM2 mRNA levels were significantly downregulated after overnight exposure to a g-secretase inhibitor (decreased 66% and 77%, respectively, p<0.01, n=6). Exposure to increasing amounts of LPS (range 0 to 10 ng/mL) for 6 hours led to an expected increase in IL6 and MCP1 secretion, which could be significantly attenuated by pre-treatment with a g-secretase inhibitor. MCP1 secretion was decreased 1.5 fold (p<0.05, n=6/condition); surprisingly, IL-6 secretion was decreased 2.2 fold (p<0.01, n=6/condition) despite the lack of change in IL6 transcription.

Conclusions: This data suggests that the gamma-secretase enzyme complex plays a variety of roles in both the production and secretion of inflammatory cytokines in adipocytes. This may open new avenues of research into pathways regulating adipose inflammation, insulin resistance, and Type 2 diabetes mellitus.

1451: FC70

THE PREVALENCE OF ABNORMAL LIPIDS AND PREDIABETES IS SIGNIFICANTLY INCREASED IN YOUTH WITH DOWN SYNDROME COMPARED TO TYPICALLY-DEVELOPING PEERS
Sheela N. Magge, MD; Rachel Walega, MS/MA, Children's National Health System, 111 Michigan Ave NW, DC, United States; Claire I. Cochrane, BS/BA; Babette S. Zemel, PhD, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Andrea Kelly, MD, The Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: Down syndrome (DS) is associated with increased obesity. Although previously thought to be protected from atherosclerosis, our group previously documented a more atherogenic lipid profile in DS youth compared to controls. However, the prevalence of abnormal glucose tolerance (AGT) and actual dyslipidemia in DS youth compared to controls is not known.  We aimed to compare the prevalence of prediabetes and dyslipidemia in youth with DS compared to typically-developing controls, using current clinical thresholds.

Methods: DS and typically-developing youth (age 10-20y) of comparable age, sex, race, ethnicity, and BMI%ile were enrolled at two large children’s hospitals. Fasting lipids and oral glucose tolerance tests were performed. Lipid abnormalities were defined using NHLBI guidelines for children 10-19 years. Impaired glucose tolerance (IGT), impaired fasting glucose (IFG), and overall AGT(IGT and/or IFG) prevalence were measured in both groups, limited to those with BMI≥85%ile on the CDC BMI chart. Unpaired t-test and/or Wilcoxon rank sum tests were used as appropriate to compare continuous variables, and Fisher’s exact test was used for categorical variables.

Results: 144 DS youth (age 14.6±3.3y, 56%F, 20% African American(AA)) were compared to 87 controls(age 14.9±3.1y, 59%F, 27%AA) of similar BMI (27.0 ±7.9 DS vs 27.2 ± 7.8 controls, p=0.9). Compared to controls, DS youth had increased prevalence of total cholesterol ≥170mg/dl (50.7% vs 23%, p<0.0001), triglycerides(TG) ≥ 90mg/dl (49.3% vs 33.3%, p=0.02), TG≥130 mg/dl(26.4% vs 11.5%, p=0.007), LDL-C ≥110 mg/dl (45.5% vs 19.5%, p<0.0001), and non-HDL-C ≥120mg/dl (58.3% vs 27.6%, p<0.0001). Among those with BMI ≥85%ile (DS n= 72, control n= 51), youth with DS had greater prevalence of AGT (26.4% vs 9.8%, p=0.036) and IFG(14.3% vs 3.6%, p= 0.049). There was no difference in prevalence of HDL≤40 mg/dl or IGT.

Conclusions: Contrary to prior dogma, DS youth had significantly higher prevalences of abnormal lipid and glucose levels compared to typically developing controls, and should be carefully screened by clinicians. Future studies are needed to determine if these abnormalities in cardiometabolic risk during youth are predictive of later ischemic heart disease and type 2 diabetes.

347: FC71

BORDERLINE NEONATAL TSH LEVELS AND EDUCATIONAL AND DEVELOPMENT OUTCOMES: A POPULATION-BASED RECORD-LINKAGE STUDY
Michelle M Jack, PhD, Royal North Shore Hospital, Northern Clinical School, University of Sydney, St Leonards, Australia; Samantha Lain, PhD; Jason Bentley, PhD, University of Sydney, Sydney, Australia; Veronica Wiley, PhD, The Children's Hospital at Westmead, Sydney, Australia; Christine Roberts, PhD, Kolling Research Institute, Sydney, Australia; Bridget Wilcken, MD, The Children's Hospital at Westmead, Sydney, Australia; Natasha Nassar, PhD, University of Sydney, Sydney, Australia

Objectives: Newborn screening has almost eliminated intellectual disability in children with Congenital hypothyroidism however, clinical uncertainty remains about infants with TSH concentrations lower than the newborn screening cutoffs. We assessed the association between neonatal TSH concentrations and educational and developmental outcomes.

Methods: A population-based record-linkage study of all liveborn infants undergoing newborn screening from 1994 to 2008 in New South Wales, Australia. Developmental and educational outcomes were linked to individual records by the NSW Centre for Health Record Linkage. The primary educational outcome was the proportion of students with National Assessment Program Literacy and Numeracy results lower than the national minimum standard in reading or numeracy and the primary developmental outcome was the proportion of children assessed at high risk by the Australian Early Development Census at age 4–6 years. The proportions of infants with each outcome were calculated per percentile (0–100) of TSH concentration. Multivariable logistic regression was used to account for potential confounding by maternal and fetal variables known to affect neonatal TSH concentrations or neurodevelopmental outcomes.


 

Results: 503,706 infants had a newborn TSH result that linked to a developmental or educational outcome. As newborn TSH levels increase, from the 75-80th centile, the risk of having a poor neurodevelopmental outcome increased until the 99.95thcentile. Infants with a newborn TSH >99.95th centile, likely to have diagnosed and treated CH, had similar results to infants with a TSH <75th centile. Infants with a newborn TSH result between 99.5th-99.9th centile were more likely to have special needs (adjusted odds ratio (aOR) 1.68, 95% confidence interval (95%CI) 1.23-2.30), poor numeracy performance (aOR 1.57, 95%CI 1.29-1.90) and poor development (aOR 1.52, 95%CI 1.20-1.93).

Conclusions: We found an association between neonatal TSH concentrations lower than the present newborn screening thresholds and poor educational and developmental outcomes. This association needs further investigation to assess whether assessment and treatment of these infants might improve their long-term cognitive outcomes.

1591: FC72

DETERMINATION OF CALCITONIN REFERENCE RANGES FROM HEALTHY INFANTS, CHILDREN AND ADOLESCENTS – AN IMPORTANT TOOL FOR THE EARLY DIAGNOSIS OF MEDULLARY THYROID CANCER
Felix Eckelt, doctoral candidate; Mandy Vogel, PhD; Mandy Geserick, PhD; Toralf Kirsten, PhD; Yoon Ju Bae, PhD; Michael Schaab, PhD; Antje Koerner, MD; Andreas Hiemisch, PsyD; Joachim Thiery, MD; Roland Pfaeffle, MD; Wieland Kiess, MD, University of Leipzig, Leipzig, Germany; Friedhelm Raue, MD, University of Heidelberg, Leipzig, Germany; Juergen Kratzsch, PhD, University of Leipzig, Leipzig, Germany

Objectives: The aim of our study was to establish age-dependent reference ranges for calcitonin (CLCT) in serum of healthy infants, children and adolescents to enable the diagnosis of medullary thyroid cancer (MTC), to monitor MTC follow-up and to validate CLCT reference data in pediatric cohorts with thyroid diseases, asthma and multiple endocrine neoplasia type 2 (MEN2).

Methods: 3196 serum samples of children in the age range of 1 month and 17.9 years were collected. Reference ranges were established between the 2.5th and the 97.5th percentile. CLCT concentrations of children with thyroid diseases (n=138), asthma (n=163) and MEN2 (n=49) were measured for comparison. All sera were quantified by the Cobas® Calcitonin ECLIA (Roche). The LMS-method was used to set up reference ranges.

Results: CLCT levels of healthy children demonstrated a dynamic course during childhood. For both gender the highest levels were detected in the first months of life. A decline was observed until the age of 3 years as well as a second minor decline during puberty. CLCT levels of boys were significantly higher compared to girls (p<0.01). 3.7% of patients with thyroid disease and 4.9% of patients with asthma had increased CLCT levels. From the MEN2 cohort every RET-protooncogene carrier (n=10) revealed a detectable CLCT value. After thyroidectomy 78.9% of MEN2 patients had undetectable levels whereas 11.1% were suspicious of micrometastasis or relapse.

Conclusions: This is the first study to establish CLCT reference ranges for pediatric uses by the highly sensitive and precise ECLIA technology. The data suggests different regulation of this hormone within the first years of life. Cut-offs from the 97.5th percentile of infants were clearly higher than the respective cut-offs of adults which are frequently used for reference in pediatrics. Probably due to the higher thyroid volume boys revealed significantly higher CLCT values than girls. Thyroid disease and asthma that were investigated to be influencing factors for hypercalcitoninemia in adults, appear to have only a minor effect on CLCT level in pediatric patients. The ECLIA method was found to be a suitable tool to monitor CLCT in children with MEN2, also without stimulation by calcium or pentagastrin.

168: FC73

EPIDEMIOLOGY OF CHILDHOOD HYPERTHYROIDISM IN FRANCE: A NATIONWIDE POPULATION-BASED STUDY
Marie Simon, MD; Rigou Annabel, MS/MA; Le Moal Joëlle, MD; Zeghnoun Abdelkrim, PhD; Le Tertre Alain, PhD; De Crouy-Chanel Perrine, MS/MA, Santé publique France, Paris, France; Florentia Kaguelidou, PhD; Juliane Léger, MD, University of Paris, Robert Debré Hospital, Paris, France

Objectives: Hyperthyroidism affects all age groups, but only limited epidemiological data are available for children. We therefore investigated the epidemiology of hyperthyroidism in children and adolescents in a nationwide study in France.

Methods: We used antithyroid drug reimbursement recorded in the French National Health Insurance database in 2015 as an indicator of childhood hyperthyroidism (patients aged 6 months up to < 18 years). We estimated incidence rates (IRs) and 95% confidence intervals with a non-linear model based on a Poisson distribution. We also performed a spatial analysis of the case distribution in France.

Results: We identified 670 cases of hyperthyroidism in children during the year 2015, with no evidence of month to month variation. Twenty patients (3%) had an associated autoimmune or genetic disease, type 1 diabetes and Down syndrome being the most frequent. The annual IR for 2015 was 4.58/100,000 person-years (95% CI 3.00-6.99/100,000). The IR increased with age in both sex from approximatively 5 years. This increase was particularly marked from eight years onwards in girls and 10 years onwards in boys. The increase was more pronounced in girls, and there was a female preponderance in all age groups (female to male sex-ratio 3.27:1). The observed interaction between age and sex revealed that the effect of being female increased with age: girls were 3.2 times more likely to be affected than boys in the [10-14 years] age group, and 5.7 times more likely to be affected in the [15-17 years] age group. About 10 % of the patients were affected very early (below the age of five years), with a sex ratio of 1:1.43. No conclusions could be drawn concerning a possible spatial pattern.

Conclusions: These original findings provide further insight into the IR of this condition and the impact of the sex of the patient during childhood and adolescence. They also reveal a higher IR than expected from data for other countries in Northern Europe, consistent with a possible increase in IR.

1064: FC74

THE PARIS-IMAGINE “HYPOTHYSEQ NGS PANEL” IS NOW FUNCTIONAL AND BRINGS VALUABLE INFORMATION ON THE GENETICS IN A LARGE COHORT OF CHILDREN WITH CONGENITAL HYPOTHYROIDISM
Athanasia Stoupa, MD, INSERM U1163, Imagine Institute, Paris Descartes University, Sorbonne Paris Cité, Necker Children's University Hospital, Paris, France; Manelle Gueriouz, BS/BA, IMAGINE Institute Affiliate, Paris, France; Dulanjalee Karyiawasam, MD, PhD, AP-HP, Paris, France; Sylvain Hanein, PhD, IMAGINE Institute Affiliate, Paris, France; Christine Bole-Feysot, PhD, INSERM U1163, Imagine Institute, Paris Descartes University, Sorbonne Paris Cité, Necker Children's University Hospital, Paris, France; Johnny Deladoey, Professor, University of Montreal, Montreal, QC, Canada; Gabor Szinnai, MD, PhD, University of Basel, Basel, Switzerland; Michel Polak, Professor, INSERM U1016, Cochin Institute and INSERM U1163, Imagine Institute, Paris Descartes University, Sorbonne Paris Cité, Necker Children's University Hospital, Paris, France; Aurore Carre, PhD, Paris Descartes University, Sorbonne Paris Cité, Paris, France

Objectives: Congenital hypothyroidism (CH) is mainly due to thyroid dysgenesis (TD) (65%) and dyshormonogenesis (DH) (35%). Genes implicated in DH are well known while causative mutations in TD account for less than 5% of all cases. Our aims were 1)to develop a custom targeted NGS strategy for the molecular diagnosis in CH of various causes and 2)to assess the possible molecular implication of candidate genes.

Methods: The HypothySeq NGS panel has been designed for different thyroid disorders. We included 78 genes: i)23 known genes; causative genes for DH and TD, for defects in thyroid hormone, transport proteins, inborn errors of thyroid hormone membrane transport, metabolism or action and ii)55 candidate genes, arising from invalidated animal models (n=27) or from human pathologies or experimental biology (n=28). We performed targeted NGS using SureSelectXT Target Enrichment Reagent Kit. We have tested a cohort of 226 TD patients, 17 DH patients and 6 positive controls.

Results: In TD patients, we found 10 variants in known causative genes at the heterozygous state (6 mutations in PAX8, 3 in NKX2-1 and 1 in TSHR) considered pathogenic. No mutation was found in HHEX and FOXE1 genes. In patients considered DH, 12 mutations were identified in 8 patients (2 heterozygous mutations in PAX8, 1 homozygous mutation in TG and 1 in DUOX2, 2 composite heterozygous mutations in TPO, in NIS and 2 in TG). Interestingly, we found three coding heterozygous mutations in TBX1, 3 for SALL1, 1 for NTN1: 3 mutations may be pathogenic being in functional domains and in silico prediction. Surprisingly, we found several mutated candidate genes in the same patient and sometimes with a heterozygous variant of DH causative genes.

Conclusions: We designed and validated a targeted NGS panel for diagnosis of congenital thyroid disorders. The HypothySeq panel allowed the molecular diagnosis of 4,4% of TD patients and 47% of DH patients with causative genes. The analysis of results on candidate genes in TD patients will allow us to establish genotype-phenotype correlations. This first screening step of thyroid disorders improves molecular diagnosis for patients at a lower cost.

Supported in part by a PHRC, ClinicalTrials.gov NCT01916018, Sandoz, Merck Serono

1466: FC75

MUTATIONS IN IRS4 ARE ASSOCIATED WITH CENTRAL HYPOTHYROIDISM
Charlotte A. Heinen, MD; Emmely M. De Vries, PhD, Academic Medical Center, Amsterdam, Netherlands; Erica L.T Van Den Akker, MD, Erasmus MC, Rotterdam, Netherlands; Boudewijn Bakker, MD, Reinier de Graaf Hospital, Delft, Netherlands; Gera Hoorweg-Nijman, MD, St. Antonius Hospital, Nieuwegein, Netherlands; Ferdinand Roelfsema, MD, Leiden University Medical Center, Leiden, Netherlands; Raoul C. Hennekam, MD; Anita Boelen, MD; Eric Fliers, MD; A.S. Paul Van Trotsenburg, MD, Academic Medical Center, Amsterdam, Netherlands

Objectives: Congenital central hypothyroidism (CeH) may occur isolated, or in combination with other pituitary hormone deficiencies. Although a fourth causative gene for CeH was recently reported (TBL1X), the etiology of isolated CeH remains unsolved in many cases.

Methods: Using whole exome sequencing in two unrelated sets of brothers with idiopathic isolated CeH, we identified frameshift mutations in the insulin receptor substrate 4 (IRS4) gene. The IRS-family acts as an interface between tyrosine kinase receptors, including the leptin receptor, and multiple intracellular signalling pathways. Sanger sequencing of this gene in unrelated cases of idiopathic isolated CeH revealed two additional frameshift mutations in three families. We performed clinical and biochemical characterization of the probands and relatives with a mutation identified by family screening. In additional experiments, we investigated IRS4 mRNA expression in post-mortem human hypothalamus and pituitary tissue, and measured serum thyroid hormones, and Trh and Tshb mRNA expression in respectively hypothalamus and pituitary of Irs4 knockout mice.

Results: Family screening detected mutations in 10 relatives (one male). All male mutation carriers (n=8) had CeH with plasma free thyroxine (FT4) concentrations below the reference interval in combination with thyrotropin concentrations within the reference interval. Female carriers had FT4 concentrations in the lower half of the reference interval. MRI of the hypothalamus and pituitary in 11 mutation carriers showed no structural abnormalities. 24-hour TSH secretion profiles were tested  in two adult male patients and showed decreased basal, pulsatile and total secretion of TSH. IRS4 mRNA was expressed in the several human hypothalamic nuclei, including the paraventricular nucleus, and the pituitary gland. Tshb mRNA expression in pituitaries of female Irs4 knockout mice was clearly decreased while plasma T4 was unaltered.

Conclusions: Mutations in IRS4 are associated with familial isolated CeH in men. As IRS4 is responsible for mediating signalling by tyrosine kinase receptors, including the leptin receptor, we hypothesize that the CeH in these men is caused by impaired leptin signalling in hypophysiotropic TRH neurons.

1280: FC76

IDENTIFICATION OF GENETIC VARIANTS IN A LARGE COHORT OF PATIENTS WITH CONGENITAL HYPOTHALAMO-PITUITARY DISORDERS
Louise C Gregory, PhD, UCL Great Ormond Street Institute of Child Health , London, United Kingdom; Mark J Mccabe, PhD; Kyriaki S Alatzoglou, PhD; James P Turton, PhD; Emma A Webb, PhD; Hywel Williams, PhD, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Carles Gaston-Massuet, PhD, Barts & The London Medical School,Queen Mary University of London, London, United Kingdom; Daniel Kelberman, PhD; Mehul Dattani, Professor, UCL Great Ormond Street Institute of Child Health, London, United Kingdom

Objectives: Congenital hypothalamo-pituitary (HP) disorders, including congenital hypopituitarism (CH) and hypogonadotrophic hypogonadism (HH), are frequently associated with midline brain/craniofacial abnormalities. Phenotypic severity ranges from fatality, to holoprosencephaly (HPE), septo-optic dysplasia (SOD), and isolated CH or hormone deficiencies [GH deficiency (GHD), HH].

Methods: Our CH patient cohort (n=1,839 samples) has been screened for mutations in known causative genes specific to their phenotype. Those with unique complex phenotypes are undergoing whole exome sequencing (WES). Control databases are consulted for any identified variants. Expression studies of novel genes are performed on human embryonic tissue from the HP region and related tissues, followed by functional studies to show significance of variants.

Results: HESX1 mutations were identified in <1% (7/724) and SOX3 in 2% (7/354) of CH patients, including SOD. SOX2 and OTX2 accounted for 22% and 7% respectively of those with severe eye phenotypes (13/59, 4/59). Variants in Kallmann syndrome (KS) genes were identified in SOD patients; these included PROKR2 (2%), FGF8 (<1%) and KAL1 (<1%) variants. In isolated CH patients, mutations in PROP1 were present in 7% (18/253), POU1F1 in 9% (12/139), LHX3/LHX4 in 6% (7/110) and GLI2 in 3% (3/106). GH1 or GHRHR mutations were identified in 10% of IGHD patients (51/413). In HH/KS patients, 5% (4/84) had mutations in KS genes; KAL1 (2), FGFR1 (2). In HPE patients, 5/64 (8%) had an SHH (4) or FGF8 (1) mutation. Screening is ongoing for all of these genes in CH patients. A total of 52 pedigrees with familial or unique phenotypes had WES, with 33 novel variants identified in 81 patients so far.

Conclusions: To date, we have identified mutations in 175/1,839 (10%) CH patients; the genetic cause remains unknown in the majority. Given the phenotypic variability, Sanger sequencing is not an optimal strategy; targeted sequencing using microarrays or next generation sequencing may identify more variants. Epigenetic factors may also need consideration. Phenotypic characterization and functional studies are essential to validate any novel variant.

663: FC77

OXYTOCIN IN CHILDHOOD-ONSET CRANIOPHARYGIOMA - FIRST EXPERIENCES WITH NEUROPSYCHOLOGICAL EFFECTS OF OXYTOCIN ADMINISTRATION
Hermann L. Müller, MD; Hoffmann Anika, MD; Daubenbüschel Anna, MD; Boekhoff Svenja, Physician's Assistant; Tjaden Kerstin, PhD, Medical Campus University Oldenburg, Oldenburg, Germany; Özyurt Jale, PsyD, Carl von Ossietzky University, Oldenburg, Germany

Objectives: Quality of survival after childhood craniopharyngioma (CP) is frequently impaired by hypothalamic involvement (HI) and sequelae such as obesity and neuropsychological deficits. Oxytocin (OXY) is produced in the hypothalamus, secreted by posterior pituitary gland, and plays a major role in regulation of behavior and body composition.

Methods: In a cross-sectional study, OXY saliva concentrations were analyzed in 34 CP and in 73 healthy controls. OXY was measured in saliva before and after standardized breakfast and associations with gender, body mass index (BMI), HI, diabetes insipidus, and irradiation were analyzed. Furthermore in a pilot study, emotion recognition abilities were analyzed with regard to OXY concentrations in saliva and urine before and after nasal administration of 24 IU OXY in 10 CP patients with hypothalamic lesions (4 grade I: limited to anterior hypothalamic areas; 6 grade II: involving mammillary bodies and posterior hypothalamic areas). Perception and identification of emotional expressions were tested using the Geneva Multimodal Emotion Portrayals (GEMEP) corpus. Current mental state was assessed by Multidimensional Mood Questionnaire.

Results: In cross-sectional analyses, CP with preoperative HI showed similar OXY levels compared to CP without HI and controls. However, CP with grade I surgical hypothalamic lesions presented with lower levels (p=0.017) of OXY under fasting condition compared to CP with grade II surgical lesion and CP without hypothalamic lesions (grade 0). CP patients’ changes in OXY levels before and after breakfast correlated (p=0.02) with their BMI. In a pilot trial, nasal administration of OXY was well tolerated and resulted in increased OXY concentrations in saliva and urine. After OXY administration, CP with postsurgical grade I hypothalamic lesions showed improvements in emotional identifications compared to CP with grade 2 hypothalamic lesions. CP patients improved assignment to negative emotions.

Conclusions: CP patients continue to secrete OXY, especially when anterior hypothalamic areas are not involved, but OXY shows less variation due to nutrition. OXY might have positive effects on emotion perception in CP with specific lesions of anterior hypothalamic areas.

879: FC78

A NOVEL DENOVO FORKHEAD BOX A2 (FOXA2) MUTATION LEADS TO CONGENITAL HYPERINSULINISM, CRANIOFACIAL DYSMORPHIC FEATURES AND CONGENITAL HYPOPITUITARISM
Dinesh Giri, FRCPCH, University of Liverpool & Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Maria Lillina Vignola, MSc; Angelica Gualtieri, MSc; Valeria Scagliotti, MSc, Queen Mary University of London, London, United Kingdom; Mohammed Didi, MRCPCH, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Carles Gaston-Massuet, PhD, Barts & The London Medical School,Queen Mary University of London, London, United Kingdom; Senthil Senniappan, PhD, University of Liverpool & Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom

Objectives: FOXA2, located at the at the cytogenetic location 20p11.21, has been shown to play a role in the pancreatic β-cell development. FOXA2 knockout mouse has been shown to exhibit severe hyperinsulinaemia. Genes at 20p11.21 have been implicated to have a potential role in the pituitary development.We show for the first time that a de novo mutation in the developmanetal transcription factor FOXA2 (formerly HNF3B) is associated with congenital hyperinsulinism (CHI) combined with hypopituitarism in humans.

Methods: A female baby born to non-consanguineous Caucasian parents at 42 weeks gestation with a birth weight of 4.185Kg (+1.72SDS) was noted to have high glucose requirement and a hypoglycaemia screen confirmed CHI. She also developed TSH,ACTH and GH deficiencies. Genetic analysis was negative for ABCC8, KCNJ11HNF4A or GCK mutations. MRI brain showed a hypoplastic anterior pituitary, absent posterior pituitary, thin pituitary stalk and corpus callosum.18F-DOPA PET-CT suggested diffuse pancreatic lesion. She has solitary median maxillary incisor, congenital nasal pyriform aperture stenosis, pulmonary stenosis, choroidal coloboma and hepatic portal bridging fibrosis.

Results: Whole exome trio sequencing identified a novel de novo heterozygous mutation in FOXA2 (c.505T>C, p.(S169P) in the child. The identified variant is highly conserved, not present in control databases and predicted to be deleterious to the protein function. We have demonstrated strong expression of FOXA2 mRNA in the pituitary of mouse embryos by in situ hybridisation. Expression profiling on human embryos by immunohistochemistry, showed strong expression in the neural tube, third ventricle, diencephalon and in the pancreas. Transient transfection of HEK293T cells with Wt(Wild type) hFOXA2 or mutant hFOXA2 showed an impairment in transcriptional reporter activity by the mutant hFOXA2. Furhter biochemical analyses demonstrated that the c.505T>C, p.(S169P) variant is pathogenic resulting in  lower expression levels  when compared with Wt hFOXA2

Conclusions: We describe, for the first time, the expression of FOXA2 in human pituitary and pancreatic development and the disruptive effect of the mutation on the protein function thereby demonstrating FOXA2 as a novel candidate gene in humans with pituitary and pancreatic β-cell disorders.

1474: FC79

MOLECULAR ANALYSIS OF BRAZILIAN PATIENTS WITH COMBINED PITUITARY HORMONE DEFICIENCY (CPHD) AND ORTHOTOPIC POSTERIOR PITUITARY LOBE (OPP) REVEALS 8 DIFFERENT PROP1 ALTERATIONS WITH THREE NOVEL MUTATIONS
Joao LO Madeira, MD; Mirian Y Nishi, PhD; Marilena Nakaguma, MD; Anna F Bennedetti, BS/BA; Isabela P Biscotto, MD, University of Sao Paulo, Medical School, São Paulo, Brazil; Thamiris Fernandes, MD, Faculdade de Medicina da Universidade Federal do Espírito Santo, Vitoria, Brazil; Thiago Pequeno, MD; Thalita Figueiredo, PhD, State University of Paraiba, Campina Grande, Brazil; Marcela M França, PhD, University of Sao Paulo, Medical School, São Paulo, Brazil; Fernanda A Correa, PhD, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Aline P Otto, PhD; Milena Abrão, MS/MA, University of Sao Paulo, Medical School, São Paulo, Brazil; Mirta Miras, PhD, Hospital de Niños de Córdoba, Córdoba, Argentina; Silvana Santos, PhD, State University of Paraiba, Campina Grande, Brazil; Alexander A L Jorge, PhD, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Everlayny F Costalonga, PhD, Faculdade de Medicina da Universidade Federal do Espírito Santo, Vitoria, Brazil; Berenice B Mendonça, PhD, University of Sao Paulo, Medical School, São Paulo, Brazil; Ivo J P Arnhold, PhD; Luciani R Carvalho, PhD, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

Objectives: Mutations in PROP1, HESX1 and LHX3 are associated to CPHD and OPP. We aimed to identify mutations in PROP1, HESX1 and LHX3 in a large cohort of patients with CPHD and OPP (43 Brazilian, 2 Argentinian).

Methods: We studied 30 index patients with CPHD and OPP (7 familial and 23 sporadic) as well as 15 relatives. All index-patients presented GH deficiency, 28 had TSH deficiency, 25 had LH/FSH deficiency, and only 21 had ACTH deficiency. PROP1 was sequenced by the Sanger method in all except one sporadic case studied by a candidate gene panel. Multiplex-ligation-dependent probe amplification (MLPA) was applied to 2 familial cases in whom PROP1 failed to amplify by PCR. In the 13 patients without PROP1 mutations, HESX1 and LHX3 were sequenced by the Sanger method and one case was studied by whole-exome sequencing (WES).

Results: Sanger sequencing identified mutations in PROP1 in 13 index cases, with two novel mutations in compound heterozygous state in 2 index cases: c.1A>G and c.342+1G>C, respectively associated with c.263T>C (p.Phe88Ser) and c.218G>A (p.Arg73His). Mutation c.1A>G affects the initiation codon and abolishes the translation of the protein, while c.342+1G>C affects splicing of exon 2. The mutations already described c.150delA (p.Arg53Aspfs*112), c.263T>C (p.Phe88Ser) and c.301_302delAG (p.Leu102Cysfs*8) were found in homozygous state in 11 index cases. The candidate gene panel identified the novel mutation c.109+1G>A in PROP1 in compound heterozygous state with c.301_302delAG (p.Leu102Cysfs*8) in 1 sporadic case. MLPA confirmed complete PROP1 deletion in two families. The homozygous HESX1 mutation c.68T>C (p.Ile26Thr) was identified by WES in one sporadic case born to consanguineous parents. No LHX3 mutation was detected. All mutations found in our cohort were classified as pathogenic according to the American College of Medical Genetics guideline.

Conclusions: PROP1 mutations, including three novel mutations described herein, were detected in 53% (16/30) of this cohort with CPHD and OPP, with 7/7 of familial cases and 9/23 of sporadic cases harboring PROP1 mutations. The high prevalence and diversity of PROP1 mutations is probably associated to the ethnic background of this cohort.

1791: FC80

DIABETES INSIPIDUS AFTER MODERATE-SEVERE TRAUMATIC BRAIN INJURY IN CHILDREN
Deepti R Deshpande, MBBS, University of Arizona, Tucson, AZ, United States; Cindy Chin, MD, University of Arizona, College of Medicine , Tucson, AZ, United States; Mark Borgstrom, PhD; Sydney Rice, MD, University of Arizona, Tucson, AZ, United States

Objectives: Traumatic brain injuries (TBI) are a major cause of death and disability in children. There are limited pediatric data on the incidence and course of diabetes insipidus in the immediate period after TBI. In this study, we investigated the incidence of diabetes insipidus and assessed the relationship between diabetes insipidus and mortality after moderate to severe traumatic brain injuries in children.

Methods: Children less than 18 years of age who were hospitalized between January 2005 to April 2011 in a U.S. academic hospital with a Level 1 Trauma Center were screened for inclusion in this retrospective chart review. Children were identified using ICD-9 codes for traumatic brain injuries. Those with a Glasgow Coma Scale (GCS) score of ≤ 12 assessed in the emergency department were included and classified as having moderate to severe brain trauma. Diabetes insipidus was defined during hospitalization as a serum Na ≥ 146 mmol/L with increased serum osmolality > 300 mOsm/kg and polyuria > 2 L/ m2/ day as well as at least any 1 of the following: urine osmolality < 300 mOsm/kg, diabetes insipidus diagnosed in the medical chart, or vasopressin administration during hospitalization.

Results: A total of 156 children were identified with moderate to severe traumatic brain injury during the study period. 18 children (11.5%) were diagnosed with diabetes insipidus during hospitalization. Overall mortality was 14% (22/156). Mortality in children who developed diabetes insipidus was 83% (15/18), while mortality in children without diabetes insipidus was 5% (7/138), (p<0.001).

Conclusions: Development of diabetes insipidus is relatively common after moderate-severe traumatic brain injury in children. The occurrence of diabetes insipidus is an ominous sign associated with high mortality. Further prospective studies are warranted in better clarifying the natural history of diabetes insipidus after traumatic brain injuries in children and effects of treatment in improving survival. 

297: FC81

CARDIOVASCULAR AUTONOMIC DYSFUNCTION PREDICTS INCREASING ALBUMIN EXCRETION IN TYPE 1 DIABETES
David L Lu, MBBChir, National University Health System, Singapore, Singapore; David B Dunger, PhD; Loredana Marcovecchio, PhD, University of Cambridge, Cambridge, United Kingdom

Objectives: To determine the potential role of autonomic dysfunction in the development of renal complications of type 1 diabetes in the pediatric population

Methods: In this prospective study, 199 children and adolescents (47% female; median [IQR] age: 14.16 [11.02 – 17.02] years) in the Oxford Regional Prospective Study underwent assessment of autonomic function ~5 years after diagnosis, and were subsequently followed with longitudinal assessments of HbA1c and urine albumin-creatinine ratio (ACR) over 8.59 ± 3.39 years. Autonomic function was assessed with 4 standardized tests of cardiovascular reflexes: (i) heart rate response (HRR) to Valsalva Maneuver, (ii) HRR to deep breathing, (iii) HRR to standing, and (iv) blood pressure (BP) response to standing. Linear mixed models were used to assess the association between autonomic parameters and future rates of change in ACR.

Results: Independent of HbA1c, the rate of change in ACR over time was significantly influenced by: (i) HRR to Valsalva Maneuver: for every SD increase in HRR, ACR increased by 2.16% [95% CI: 0.08 – 4.28] per year, and (ii) diastolic BP response to standing (2.55% [95% CI: 0.37 – 4.77] per year per SD increase). There was also a strong trend for the effect of HRR to standing (-2.07% [95% CI: -4.11 – 0.01] per year per SD increase, p=0.051). A lower HRR to standing in our cohort was associated with a higher minimum heart rate after standing (p<0.01), instead of a diminished maximum heart rate (p=0.75), indicating persistence of the known initial cardioacceleratory response.

Conclusions: In this cohort of young people with type 1 diabetes, future increases in urine ACR were predicted by enhanced cardiovascular reflexes at baseline, including HRR to Valsalva Maneuver and diastolic BP response to standing. This pattern of autonomic dysfunction implicates sympathetic overactivity in the pathogenesis of diabetic nephropathy.

292: FC82

EFFICACY AND SAFETY OF SWITCHING FROM INSULIN DETEMIR TO INSULIN DEGLUDEC WITH MEALTIME INSULIN ASPART IN PEDIATRIC PATIENTS WITH TYPE 1 DIABETES. AN OBSERVATIONAL PROSPECTIVE STUDY
Nancy S Elbarbary, MD, Ain Shams University , Cairo, Egypt

Objectives: Insulin degludec (IDeg; Tresiba®) is a novel basal insulin with an ultra-long, flat and stable action profile. The aim of the current study is to assess the long-term efficacy and safety of insulin degludec(IDeg) as a part of a basal–bolus therapy among children and adolescents affected by type 1 diabetes (T1DM) previously on insulin detemir(IDet).

Methods: In the present study, 43 T1DM patients (11.8±1.3 years of age, duration 4.6±1.9 years) started on IDeg once daily as basal insulin after at least 1 year on IDet twice daily. The primary end-points were the changes in glycated hemoglobin (HbA1c) from baseline at 6 months. The secondary end-points were changes in insulin dose (basal and bolus), frequency of hypoglycemia and occurrence of adverse events.

Results: Both HbA1c and fasting plasma glucose (FPG) levels decreased significantly from 8.2±0.3%  and 139±4.2 mg/dL at baseline to 7.7±0.2% and 119±3.6 mg/dL at 6 months after starting IDeg (P<0.001 for both). The daily basal insulin dose was significantly reduced from 0.67±0.04 U/kg/day at baseline to 0.55±0.02 U/kg/day at the end of the study period (P<0.05), which corresponded to 79.2% of the baseline value. Moreover, mealtime insulin aspart (0.64±0.15 vs 0.48±0.13 U/kg/day, P< 0.02) were significantly reduced.The frequency of both overall and nocturnal hypoglycemia decreased significantly from 4.9±0.7 times/month to 2.4±0.3 times/month at 6 months after starting IDeg(P<0.05). However, no severe hypoglycemia occurred during the study period. Rates of hyperglycemia with ketosis were significantly lower for IDeg vs. IDet(P<0.05). Both treatments were well tolerated with comparable rates of adverse events.

Conclusions: In our cohort, switching from  IDet treatment to IDeg was safe and seemed to improve metabolic control expressed by HbA1c and FPG levels with the added benefit of a reduced basal and bolus insulin dose while reducing the frequency of hypoglycemia episodes in young people with T1DM.

179: FC83

CAN AN ELECTRONIC CLINICAL TOOL IMPROVE COMMUNICATION AROUND EXERCISE IN YOUTH WITH TYPE 1 DIABETES?
Connor A Mitrovich, BS/BA, Seattle Children's Research Institute, Seattle, WA, United States; Alissa J Roberts, MD, University of Washington, Seattle, WA, United States; Joyce Yi-Frazier, PhD, Seattle Children's Hospital, Seattle, WA, United States; Craig E Taplin, MBBS, University of Washington, Seattle, WA, United States

Objectives: Exercise is a risk factor for dysglycemia, especially hypoglycemia, in youth with type 1 diabetes (T1D). Previous work has shown that many youth with T1D do not exercise safely, especially with regard to the risk of post-exercise hypoglycemia. Many also report a desire for more education during diabetes clinic visits on how to manage insulin and fuel intake around exercise. We created an electronic clinical tool to survey management of T1D during and after exercise with generation of a report for providers to use with patients. The objective was to assess its feasibility and effectiveness in the clinic setting.

Methods: We recruited 50 T1D youth, ages 10-18 (mean 14.8 ± 2.4) years. 60% used an insulin pump. Subjects completed the T1D Report of Exercise Practices (T1D-REPS) on an electronic tablet prior to a clinic visit. Participant responses were flagged if contrary to ISPAD exercise guidelines and a report of behaviors with personalized recommendations was produced for providers prior to seeing the patient in clinic. Post-clinic assessment surveys were completed.

Results: A mean of 4 (± 0.9) responses per patient flagged as potentially unsafe. 91% of providers reported it took < 10 minutes to review and discuss the report with patients; 62% of youth reported their providers used the report to discuss exercise in the clinic visit. Responses were rated on a 5-point scale (1 = not at all; 5 = very much so). Providers rated the tool’s utility highly in facilitating  education regarding exercise guidelines at that clinic visit (mean rating 4.2 ± 0.8); 91% of providers rated the tool ≥4 . When asked whether its use altered management plans around exercise, 58% of youth rated the tool ≥4 . When asked if such a tool should be used routinely in diabetes clinic, 64% of provider responses and 62% of patient responses were ≥4.

Conclusions: This electronic tool identified frequent and multiple deficits in exercise safety in youth with T1D, and improved education in the clinic visit regarding exercise. Both providers and patients reported the tool frequently prompted specific behavior recommendations, and a majority felt it feasible and desirable to include in routine outpatient diabetes care.

370: FC84

PERSISTENT ELEVATIONS IN BETA CELL DEATH AMONG INDIVIDUALS WITH LONGSTANDING TYPE 1 DIABETES
Emily K Sims, MD; Sarah Tersey, PhD; Jennifer Nelson, BS/BA; Raghavendra G Mirmira, MD-PhD; Carmella Evans Molina, MD-PhD, Indiana University School of Medicine, Indianapolis, IN, United States

Objectives: Because beta cells contain increased unmethylated preproinsulin (INS) DNA compared to other cell populations, DNA release by dying beta cells leads to increased circulating levels of unmethylated INS DNA.  Consistent with the classic paradigm of large-scale beta cell destruction early in the course of Type 1 Diabetes (T1D), this novel biomarker is elevated before and at the time of T1D onset.  However, recent studies have identified persistence of beta cells years after T1D diagnosis.  It is unclear whether these persistent beta cells continue to undergo destruction, or whether circulating INS DNA levels are linked to persistent endogenous C-peptide secretion in later stages of T1D.

Methods: We assayed fasting and stimulated banked sera from subjects enrolled in the T1D Exchange registry (n=90, median age: 33.5 yrs, median T1D duration: 9 yrs), determined to be either Cpep (-) or (+) based on mixed-meal tolerance testing (MMTT). Results were compared to adult nondiabetic controls (n=12). Levels of unmethylated and methylated INS DNA were analyzed by droplet digital PCR using a dual fluorescent probe-based multiplex assay detecting methylation or unmethylation at bp -69 of the INS gene.

Results: Fasting and stimulated circulating unmethylated INS DNA levels were increased among both Cpep (-) and Cpep (+) subjects with longstanding T1D compared to non-diabetic controls (p<0.01). Circulating fasting INS DNA concentrations were negatively associated with age and T1D duration (p=0.04).  Consistent with prior reports, unmethylated INS DNA values correlated with methylated INS DNA values, which were also elevated among T1D subjects (p<0.001).  Although fasting INS DNA concentrations correlated with stimulated concentrations, there was wide variation in the effects of meal-stimulation on DNA levels, with fasting values in the highest quartiles decreasing with stimulation (p<0.001).

Conclusions: These results confirm ongoing beta cell death in individuals with longstanding T1D, even in the absence of detectable C-peptide production, suggesting that therapies targeting beta cell survival could be beneficial among patients with longstanding T1D. Future studies in longitudinal samples will better elucidate the natural history of beta cell death after T1D diagnosis.

66: FC85

GLUCOSE CONTROL IN ADOLESCENTS WITH T1D DURING THE MEDTRONIC HYBRID CLOSED-LOOP PIVOTAL TRIAL
Jennifer Sherr, MD, PhD, Yale University School of Medicine, New Haven, CT, United States; Stuart A Weinzimer, MD, Yale University, New Haven, CT, United States; Robert H Slover, MD, University of Colorado Denver, Aurora, CO, United States; Bruce A Buckingham, MD, Stanford University, Stanford, CA, United States; Amy B Criego, MD, MS, Park Nicollet Clinic Pediatric Endocrinology, Minneapolis, MN, United States; Stacey M Anderson, MD, PhD, University of Virginia, Charlottesville, VA, United States; Timothy S Bailey, MD, AMCR Institute, Escondido, CA, United States; Bruce W Bode, MD, Atlanta Diabetes Associates, Atlanta, GA, United States; Ronald L Brazg, MD, Rainier Clinical Research Center, Renton, WA, United States; Satish K Garg, MD, University of Colorado Denver, Aurora, CO, United States; Jacob Ilany, MD, Sheba Medical Center, Tel Hashomer, Israel; John Shin, PhD; Scott W Lee, MD; Toni Cordero, PhD; Francine R Kaufman, MD, Medtronic, Northridge, CA, United States

Objectives: The MiniMed® 670G hybrid closed-loop (HCL) insulin delivery system was evaluated in a 3-month in-home pivotal trial, in adolescents (14-21 years, n=30) and adults (22-75 years, n=94) with T1D.  For adolescents, a 0.6% reduction in glycated hemoglobin (A1c) levels (7.7% to 7.1%, p<0.001) and increased time in target range of 71-180mg/dL (60.4% to 67.2%, p< 0.001) was observed. To further quantify HCL impact on glycemic control, an exploratory analysis was conducted in adolescents aged14-17 years (n=20) and 18-21 years (n=10), during the 24-hour, night (10pm-7am) and early morning (3am-6am) periods. 

Methods: Participants wore the system (MiniMed 670G insulin pump, Guardian® Sensor 3 glucose sensor and Guardian Link 3 transmitter) in Manual Mode for a baseline 2-week run-in phase followed by a 3-month study phase with HCL control enabled (Auto Mode), during which HCL was utilized 75.8% of the time. Distribution of sensor glucose (SG) values during the aforementioned time periods was compared between the run-in and study phases.

Results: The table shows the mean±SD percent of SG values for each time period. Both age groups had increased time in target range and reductions in hypo- and hyperglycemia. The greatest percent of time in target for both groups was in the early morning, a period when the HCL algorithm functioned, for the most part, with minimal subject-delivered meal boluses and physical activity. During the early morning, the HCL algorithm-determined insulin delivery (at 5-minute intervals) led to insulin suspension 28.4±8.4% and 31.5±17.8% of the time, for the younger and older cohorts. Mean A1c decreased in both cohorts (14-17 year olds: 7.8±0.7% to 7.2±0.5%; 18-21 year olds: 7.4±1.0% to 6.8±0.6%). There were no severe hypoglycemic or diabetic ketoacidosis events during the entire study.

Conclusions: Both adolescent groups experienced improved glycemia (increased time in target, reduced A1c, reduced exposure to hypoglycemia) during the study phase, compared to baseline. Findings from the MiniMed 670G HCL system pivotal trial suggest that the automated and dynamic delivery of basal insulin every 5 minutes might improve T1D outcomes for the difficult to manage adolescent group.

665: FC86

RESTORATION OF STEM CELL DERIVED BETA-CELL FUNCTION FROM PERMANENT NEONATAL DIABETES PATIENT BY CRISPR/CAS9
Shuangyu Ma, BS/BA; Ryan Viola, Lab Manager, Columbia University, New York, NY, United States; Valentino Cherubini, MD, Salesi Hospital, Ancona, Italy; Fabrizio Barbetti, MD, University of Rome Tor Vergata, Rome, Italy; Dieter Egli, PhD, Columbia University, New York, NY, United States

Objectives: Permanent Neonatal Diabetes Mellitus (PNDM) can be caused by heterozygous, gain-of-proteotoxic function mutations of the insulin (INS) gene or -rarely- by recessive, loss-of-function INS mutations.  Currently, insulin injection is the only treatment available for these patients. With this study we wanted to verify the feasibility of restoring pancreatic beta-cell function by mutation correction in induced pluripotent stem cells (iPSC) from a patient with PNDM due to a homozygous INS mutation.

Methods: iPSCs were generated by reprogramming somatic cells from a skin biopsy of the patient. We corrected the mutation (INS p.0? c.331C>A) in patient iPSCs with CRISPR/Cas9-mediated ssDNA replacement.

Results: Using differentiation to stem cell derived beta cells (sc-beta cells), we confirmed the absence of insulin production in sc-beta cells expressing MAFA, Nkx6.1, and synaptophysin. Upon iPSC gene correction by CRISPR/Cas9 and differentiation to sc-beta cells, we found that insulin production and stimulated secretion was restored to levels comparable to IPSc from INS wildtype cells. The functional testing of gene-corrected sc-beta cells in mice is ongoing.

Conclusions: Our study provides proof of principle for the generation of genetically corrected sc-beta cells for patients with PNDM. Because of the lack of auto-immunity, insulin dependent diabetes caused by single gene mutations should be amenable to cell therapy.

511: FC87

A NOVEL SYNDROME OF HYPERINSULINAEMIC HYPOGLYCEMIA AND POLYCYSTIC KIDNEYS DUE TO A PROMOTOR MUTATION IN PMM2
Oscar Rubio R Cabezas, MD, Hospital Infantil Universitario Niño Jesús, MADRID, Spain; Sarah Flanagan, PhD, University of Exeter Medical School, Exeter, United Kingdom; Horia Stanescu, PhD, UNIVERSITY COLLEGE LONDON, LONDON, United Kingdom; Hi-Pkd Consortium, PhD, MULTIPLE COLLABORATIONS, MULTIPLE, United Kingdom; Robert Kleta, MD; Detlef Bockenhauer, MD, UNIVERSITY COLLEGE LONDON, LONDON, United Kingdom; Sian Ellard, Prof., University of Exeter Medical School, Exeter, United Kingdom; Khalid Hussain, MD, SIDRA MEDICAL AND RESEARCH CENTER, DOHA, Qatar

Objectives: Background: Hyperinsulinaemic hypoglycemia (HH) occurs due to the dysregulation of insulin secretion from the pancreatic beta cell and leads to hypoglycemia. Polycystic kidney disease (PKD) is characterized by multiple cysts in the kidneys and is either autosomal recessive or dominant. No previous association has been reported between HH and PKD.

Methods: We identified 18 children from 12 families with the combination of HH and PKD. Homozygosity mapping, non-parametric linkage analysis, whole genome sequencing, and in-vitro studies were undertaken to understand the molecular basis of this association

Results: Homozygosity and linkage data in a consanguineous family with 3 affected members revealed a homozygous 2.5Mb region on chromosome 16p13.2. Whole genome sequencing in this and 4 other informative families confirmed this to a single significant locus of 2.3Mb that includes 14 genes. No mutation were found in the coding regions of these 14 genes but a PMM2 promoter variant (c.-167G>T) in all patients. This variant was either homozygous or in trans with PMM2 coding variants, including mutations previously reported in patients with congenital disorder of glycosylation (CGD) type 1a. Patients had no other features of GCD type 1a and the transferrin isoelectric focusing was normal. In vitro studies in patient cells revealed decreased transcription activity of the mutant promoter. Electrophoretic mobility shift assay demonstrated impaired binding of the transcription factor ZNF143. In silico analysis revealed the importance of ZNF143 for the structural confirmation of a chromatin loop including PMM2 to enable tissue-specific transcription.

Conclusions: We report a novel disorder of HH and PKD due to promoter variant in PMM2 that appears to exert a critical tissue-specific effect on transcription, leading to an organ-specific phenotype.

925: FC88

MODELING CONGENITAL HYPERINSULINISM IN PATIENT STEM CELL DERIVED BETA-LIKE CELLS
Väinö Lithovius, Bachelor of Medicine; Jonna Saarimäki-Vire, PhD; Diego Balboa, MS/MA; Jarkko Ustinov, MS/MA; Timo Otonkoski, MD/PhD/Prof., University of Helsinki, Helsinki, Finland

Objectives: Mutations in the genes encoding the potassium-sensitive ATP (K-ATP) channel of the pancreatic beta cell are the most common cause of congenital hyperinsulinism (CHI). In Finland, the most common single cause is the ABCC8 mutation V187D which leads to a trafficking defect of the SUR1 protein, causing a drug resistant, severe form of the disease. Our objective was to recapitulate the CHI phenotype with patient induced pluripotent stem cell (iPSC)-derived beta-like cells, to enable future studies in testing novel pharmaceuticals and PET tracers for improved management and diagnostics of CHI.

Methods: iPSCs were derived from a patient with severe, diazoxide unresponsive diffuse CHI caused by homozygous ABCC8-V187D. iPSCs from a healthy donor were used as a control. The cells were differentiated towards beta-cell fate, using a 7-stage, 30-day protocol which yielded islet-like clusters containing 20-40% insulin-positive monohormonal beta-like cells. These were studied in vitro or transplanted to immunocompromised NSG mice.

Results: Insulin secretion was studied in vitro by static 30-min sequential exposure to glucose and pharmaceuticals acting on K-ATP channels.  Mutant beta-like cells failed to shut down secretion when exposed to diazoxide as compared to healthy control cells (fold change 1.00±0.19 vs. 0.44±0.11; mean ± 95% CI; p=0.0005) and did not increase secretion in response to tolbutamide (fold change 0.91±0.25 vs. 1.56±0.31, p<0.0001, n=5). Four months post transplantation the mice were subjected to an insulin tolerance test. The CHI-mice had lower fasting blood glucose (5.2±2.1 vs. 8.4±2.7 mmol/l, p=0.09) and higher human C-peptide (704±328 vs. 155±67 pmol/l, p<0.01). Most importantly, human C-peptide secretion was not inhibited by insulin-induced hypoglycemia in the CHI-mice (reduction at 40 min after insulin administration 17.6±23.3% n=6 vs. 67.8±11.8 % n=6, p<0.01). Quantitative immunohistochemical analysis of the grafts is ongoing to assert differences in endocrine cell populations and the rates of apoptosis and proliferation.

Conclusions: In conclusion, we have successfully recapitulated the CHI phenotype in beta-like cells derived from patient-iPSC and created a humanized mouse model for CHI.

1782: FC89

EFFECT OF EXENDIN-(9-39) ON GLUCOSE AND INSULIN RESPONSES TO A MIXED MEAL AND A PROTEIN LOAD IN CHILDREN WITH HYPERINSULINISM
Darko Stefanovski, PhD, University of Pennsylvania, Philadelphia, PA, United States; Mary E Vajravelu, MD, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; Diva D De Leon Crutchlow, MD, Perelman School of Medicine at the University of Pennsylvania/The Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: Congenital hyperinsulinism due to inactivating mutations of the KATP channels (KATPHI) is frequently unresponsive to available medical therapy. We have strong preclinical and clinical data supporting a novel therapeutic approach employing exendin-9-39 (Ex9). Our objectives were to: 1) examine the effect of Ex9 on glucose and insulin responses to a mixed meal (MMTT) and  a protein load (OPTT) in children with KATPHI; 2) apply a novel model of insulin secretion to analyze these responses. 

Methods: Eight children with KATPHI (3-15 yrs) underwent 2 experiments on 2 separate days; on each day, subjects received either vehicle or Ex9 (0.1mg/kg/hr) intravenously during a MMTT and an OPTT (1 gm/kg protein). Blood glucose (BG), insulin (Ins), and C-peptide were measured at multiple time points. The applied mathematical model relies on C-peptide and insulin plasma levels to resolve relevant indices of whole-body insulin kinetics.

Results: Area under the curve (AUC) BG for the MMTT was significantly elevated by 28% with the administration of Ex9 (26259±3204 vs 33469±3204 mg*min/dL, P≤0.0001). AUC BG for the OPTT was significantly greater during Ex9 compared to vehicle (12612±1414 vs 18504±1323 mg*min/dL, P=0.002). AUC insulin secretion rate (ISR) was not significantly different during Ex9 compared to vehicle infusion for the MMTT (P=.5) or the OPTT (P=.3). Fractional clearance rate of insulin (FCR) was not affected by Ex9 treatment during the MMTT (P=.9) or OPTT (P=.9). While the fraction of insulin that survives First Pass Hepatic Extraction of Insulin (FPHEI) estimated from the MMTT data did not show any difference during treatment with Ex9 (P=.3), FPHEI estimated from OPTT data show statistical trend for 60% increase (47±12 vs 75±16 %, P=.08). FPHEI during treatment with Ex9 was significantly different between the MMTT and the OPTT (P=0.002). During the MMTT there was a significant reduction in insulin sensitivity (SI) by 30% in Ex9 vs vehicle (13.3±5.5 vs 9.3±1.7 10^-4.(mu/l)^-1.min^-1, P=0.015). 

Conclusions: Based on our results, it appears that Ex9 exerts its effect by decreasing the hepatic extraction of insulin but only during OPTT. Furthermore, the significant reduction of SI with Ex9 during MMTT suggest that its effects are extra-pancreatic.

534: FC90

RISK FACTORS FOR PERINATAL STRESS-INDUCED HYPERINSULINISM.
Courtney L Reynolds, MPH; Lisa Truong, CPNP; Larry Rodriguez, RN; Jonathon Nedrelow, MD; Paul Thornton, MD, Cook Children's Medical Center, Fort Worth, TX, United States

Objectives: Hyperinsulinism (HI) is a disorder that may result in severe hypoglycemia, which may lead to seizures, brain damage, and increased morbidity. Most of the current literature on hyperinsulinism focuses on forms caused by genetic disorders; however, a more common form of hyperinsulinism is perinatal stress-induced hyperinsulinism (PSHI). PSHI presents itself in the neonatal period in association with risk factors such as birth asphyxia, intrauterine growth retardation, hypertension, maternal toxemia, meconium and prematurity.  Recent recommendations from the Pediatric Endocrine Society (PES) suggest that more patients should be screened for hypoglycemia that the previous AAP guidelines

Aim: To evaluatet the PSHI patient population and to determine the risk factors associated with PSHI

Methods: A retrospective chart review was conducted of all PSHI patients from January 1, 2004 to February 1, 2017 at Cook Children’s Medical Center. Data was abstracted from the patients’ electronic medical record, recorded, and stored in a password-secured REDCap database. Data was exported to SPSS and analyzed using basic descriptive statistics.

Results: There are currently 71 PSHI patients who have been evaluated of whom 61% are male, 76% Caucasian race and 32% of Hispanic ethnicity. 64% were delivered by C-section at a mean gestation 35.6 weeks (range 24.7 to 41) with mean birth weigh 2177 (452 to 4762g).  Of these 44% were SGA.  Hypoglycemia was diagnosed by day 3 in 87% but the median day of diagnosis of hyperinsulinism was day 13.  24% of the mothers had pregnancy induced hypertension and 8% had preeclampsia.  21% reported meconium being present during delivery.   All 71 patients responded to diazoxide.  Currently 54 patients are >2 years old and having prospective neurological outcome data collected. 

Conclusions: Currently, this report is the largest descriptive analysis of PSHI patients in the current literature. Infants with maternal or fetal risk factors for PSHI should be screened at birth and treated to determine if early diagnosis and treatment can improve long term neurological outcome.  This paper supports the PES recommendation that infants of mothers with Pregnancy induced hypertension and meconium should be screened.  Further analysis of long-term neurological outcome of our cohort is underway.

789: FC91

A MIRAGE SYNDROME PATIENT WITHOUT HEMATOLOGICAL PHENOTYPES: INACTIVATION OF A GERMLINE ACTIVATING SAMD9 MUTATION BY A SOMATICALLY ACQUIRED NONSENSE MUTATION IN HEMATOPOIETIC CELLS.
Hirohito Shima, MD, National Research Institute for Child Health and Development, Tokyo, Japan; Yumiko Nomura, MD; Kazuhiko Sugimoto, MD; Akira Satoh, MD, Hirosaki National Hospital, Hirosaki, Japan; Tsutomu Ogata, Professor, Hamamatsu University School of Medicine, Hamamatsu, Japan; Maki Fukami, PhD; Satoshi Narumi, MD, National Research Institute for Child Health and Development, Tokyo, Japan

Objectives: MIRAGE syndrome is a newly-recognized form of syndromic adrenal hypoplasia. Germline heterozygous SAMD9 mutations, which are usually observed as de novo mutations, cause the syndrome. Mutant SAMD9 proteins have augmented growth-restricting capacity in vitro. We report a MIRAGE syndrome patient that had one germline and one somatic SAMD9 mutations on a same allele. Significance of the somatic mutation (“adaptation by inactivation”) is discussed.

Methods: A 10-year-old girl was born at gestational age 33 weeks with a birth weight 1,058 g (- 3.3 SD). She was diagnosed as having adrenal hypoplasia based on hormone measurements and adrenal ultrasonography. She was treated with hydrocortisone and fludrocortisone. She had female-type external genitalia despite 46, XY karyotype. She had short limbs and joint contracture in her wrists and ankles. The growth was stunted with height 81 cm (-8.7 SD) at age 10 years. Chronic diarrhea, recurrent respiratory infection and severe intellectual disability were observed, but no significant hematologic abnormalities were noted throughout the course. We extracted genomic DNA samples from her lymphocytes and hair follicles. SAMD9 was analyzed with next-generation sequencing and/or Sanger sequencing. Pathogenicity of the detected germline SAMD9 mutation (p.Ala722Glu) was verified in vitro.

Results: Analysis of the lymphocytic DNA showed two heterozygous mutations on one allele (p.[Arg685*; Ala722Glu]). The p.Arg685* mutation was not detected in hair follicles, suggesting that the p.Arg685* mutation was somatically acquired. Parents of the patient did not carry the two mutations. Expression of the p.Ala722Glu-SAMD9 protein caused strong growth-restriction in HEK293 cells.

Conclusions: We identified a MIRAGE syndrome patient who had a germline SAMD9 mutation with growth-restricting capacity, and had an additional somatic inactivating mutation on the same allele. Somatic inactivation of the deleterious SAMD9 allele likely caused expansion of the clone with two mutations (“adaptation by inactivation”), and was possibly associated with the absence of hematologic abnormalities.

509: FC92

HIGH DHEAS AT AGE 7 ARE ASSOCIATED TO HIGHER GLYCEMIA DURING PUBERTY BUT NOT METABOLIC SYNDROME
Ana Pereira, PhD; Camila Corvalan, PhD; Paulina M Merino, MD, University of Chile, Santiago, Chile; German Iñiguez, PhD, University of Chile/Faculty of Medicine, Santiago, Chile; Veronica Mericq, MD, University of Chile , Santiago, Chile

Objectives: Premature adrenarche (PA) has been recently identified as a risk factor for metabolic diseases. This risk may depend on ethnic background,birthweight and infancy weight gain. In a longitudinal cohort (Growth and Obesity Cohort,GOCS  n=969 both sexes) children with high DHEAS (HD=biochemical adrenarche) at 7 y,were fatter and more centrally obese than their counterparts (ND) (AJCN,2013).Aim:To determine whether HD at age ~7yr in girls determines a higher prevalence of metabolic Syndrome or its components during puberty.

Methods: Girls from the GOCS cohort with anthropometry since birth (2003).From 2006, a clinical evaluation and a complete metabolic profile at  Tanner B2/B4.HD defined by DHEAS (RIA, μg/dl) >75th percentile (girls>42.0 µgr/dl).Metabolic syndrome accordingly to IDF 2007. Statistics: Generalized linear models and survival analysis were used to assess the relation between HD and anthropometric and metabolic profile at B2(n=401) and B4(n=357).Adjusting by infancy weight change(>0.67),mother´s age at menarche,maternal height and education.

Results: Girls who displayed HD,at tanner B2 were taller,had higher BMI and were younger (8.8 (CI 95%CI;7.9-9.3)vs.9.3(95%CI;9.1-9.6)than girls with normal DHEAS (ND).None of the girls met the blood pressure criteria. No differences were observed in the risk of metabolic syndrome or its components (Summarized in Table).However, glycemia > 100 mg/dl was present in higher percent of HD girls at Tanner II and Tanner IV. *p<0.05**p>0.005

 Tanner II  Tanner IV  
  ND HD NDHD    
 Metab.Synd.   n(%) 2 (0.7)3(3.8) 2(0.8) 2(2.6)    
 WC > 90thperc.27(8.6)11(12.9)34(11)11(13.2) 
TG> 150 mg/dl34(12)12(15)40(16.6)16(20.7)
HDL<40 mg/dl57(20.0)19(23.8)36(14.4)10(12.5)      
Glycemia>100mg/dl  4(1.4)5(6.3)*4(1.7)7(9.1)**
BMI>2SDS37(12.2)20(20.4)*32(12.5)18(18)
mean glycemia mg/dl88.3 ±7.189.9±7.8*86 ±6.687 ±8.7*     
Conclusions: HD conferred a risk of higher glycemia and the rest of the components of metabolic syndrome appeared to ameliorate with advanced pubertal stage. Follow-up of this cohort is necessary to address prospectively the interrelationships of HD, early growth ,adiposity, sex steroids and markers of metabolic risk (Fondecyt 1140447 & 1120326, WCRF:2010/245).

1757: FC93

ALTERED STEROID AND DRUG METABOLISM BY A P450 OXIDOREDUCTASE VARIANT FOUND IN APPARENTLY NORMAL POPULATION
Florence Roucher-Boulez, MD, Hospices Civils de Lyon Université Lyon 1, Lyon, France; Shaheena Parween, PhD, University Children’s Hospital, University of Bern, Bern, Switzerland; Yves Morel, MD, Hospices civils de Lyon, Université Lyon 1, Lyon, France; Amit V. Pandey, PhD, University Children's Hospital Bern,, Bern, Switzerland

Objectives: A broad spectrum of human diseases, including abnormalities in steroidogenesis, is caused by mutations in the NADPH P450 oxidoreductase (POR). POR transfers electrons from NADPH to several small molecules, non-P450 redox partners and microsomal cytochrome P450 proteins (CYPs). Our aim was to check if POR variations from non-clinical samples, by seeking 1000 genomes database, can be disruptive. Y607C variant (rs72557954, NM_000941.2:c. 1820A>G) has been reported in population studies and prevalent in south Asians, but was predicted to be likely pathogenic. We performed detailed enzymatic and biochemical characterizations of Y607C variant to study its effect on different substrate and redox partners.

Methods: We analysed the ability of POR wild type (WT) and Y607C variant to reduce ferricyanide, MTT, cytochrome c and drug, and steroid metabolizing CYP450. POR WT and Y607C were expressed and produced as recombinant proteins while CYP19A1 and CYP3A4 were produced as His-tagged recombinant proteins and purified by affinity chromatography. The effect of mutation on cofactor (FAD/FMN) binding and activity under varying substrate and cofactor conditions was performed.

Results: We found varied effects of Y607C mutation on reduction activity of different substrates. As compared to WT, Y607C variant showed 66% cytochrome c and 91 % ferricyanide reduction activity but had only 13 % MTT reduction activity. Y607C did not affect POR flavin content but NADPH binding was severely affected. With varying NADPH concentration, Y607C showed ~95% decrease in supporting CYP19A1 and CYP3A4 activity. This mutation was later identified in patients with POR deficiency.

Conclusions: Identification of severe effects of this mutation on both drug and steroid metabolizing CYP450s indicates that likely pathogenic mutations may be found in apparently normal (non-clinical) population. Their combination as compound heterozygotes or homozygous may lead to severe impact on both steroid and drug metabolism by modification of its redox partners activities. Variations in POR need to be evaluated individually. Most importantly, advanced identification of disease causing variants in POR will help in understanding the POR deficiency in patients if the same mutations are later identified.

426: FC94

BIOAVAILABILITY OF ORAL HYDROCORTISONE CORRECTED FOR BINDING PROTEINS AND MEASURED BY LC-MS/MS USING SERUM CORTISOL AND SALIVARY CORTISONE
Richard J Ross, MD, University of Sheffield, Sheffield, United Kingdom; Trevor N Johnson, PhD, Simcyp, Sheffield, United Kingdom; Martin J Whitaker, PhD, Diurnal Ltd, Sheffield, United Kingdom; Brian Keevil, MD, University Hospital of South Manchester, Manchester, United Kingdom

Objectives: The assessment of absolute bioavailability of oral hydrocortisone is complicated by its saturable binding in the therapeutic range to cortisol binding globulin (CBG). Ninety percent of serum cortisol circulates bound to CBG, 5% to generic binding proteins, such as albumin and α-1 glycoprotein, and only 5% is unbound or ‘free’(1). CBG has high affinity for cortisol but lower capacity whereas albumin has a lower affinity and higher capacity(2). An increase in the free fraction results in an increase in clearance with dose and therefore less than dose proportional increases in Cmax and AUC(3). Derendorf reported absolute bioavailability to be 0.96 (CI 0.82 to 1.09) using a radioimmunoassay to measure cortisol in serum (3); however immunoassays give variable results and LC-MS/MS is now becoming the gold standard method for measuring steroids. We have measured absolute bioavailability of hydrocortisone using serum cortisol and salivary cortisone measured by LC-MS/MS.

Methods: 14 healthy male dexamethasone suppressed volunteers were administered 20mg hydrocortisone either intravenously or orally by tablet. Samples of serum and saliva were taken and measured for cortisol and cortisone by LC-MS/MS. Serum cortisol was corrected for saturable binding using published data (2) and PK parameters derived using the program WinNonlin.

Results: The mean (95% CI) bioavailabilities of oral hydrocortisone calculated from serum cortisol, corrected serum cortisol and salivary cortisone were 1.00 (0.89-1.14); 0.89 (0.75-1.05); and 0.93 (0.83-1.05), respectively.

Conclusions: The data confirm that after oral administration hydrocortisone is completely absorbed(3). The data derived from serum cortisol corrected for protein binding and that from salivary cortisone are similar supporting the concept that salivary cortisone reflects serum free cortisol levels and that salivary cortisone can be used as a non-invasive method for measuring the pharmacokinetics of hydrocortisone.

Refs: 1. Lewis JG, et al. Clin Chim Acta 2005; 359:189-194. 2. Lentjes & Romijn. J Clin Endocrinol Metab 1999; 84:682-687. 3. Derendorf et al. Journal of Clinical Pharmacology 1991; 31:473-476

Acknowledgements: Funded by MRCUK-G1100236, EUFP7-201444, EUFP7-281654.

Conflicts: Martin Whitaker and Richard Ross are Directors of Diurnal PLC.

888: FC95

SIMULTANEOUS PROFILING OF 17 STEROID HORMONES USING LIQUID CHROMATOGRAPHY TANDEM MASS SPECTROMETRY IN NEWBORN AND EARLY INFANCY
Ece Öge Enver, MD; Pinar Vatansever, PhD, Marmara University, Faculty of Medicine, istanbul, Turkey; Omer Guran, MD; Leyla Bilgin, Assoc Professor, Health Sciences University, Umraniye Training and Research Hospital, istanbul, Turkey; Perran Boran, professor; Serap Turan, Professor; Goncagul Haklar, professor; Abdullah Bereket, Professor; Tulay Guran, Assoc Professor, Marmara University, Faculty of Medicine, Istanbul, Turkey

Objectives: Many of the steroidogenic disorders present in newborn or early infancy with ambiguous genitalia and/or salt-wasting.Quantification of endogenous hormonal steroids and their precursors is essential for the diagnosis. Rapid changes in steroid hormone concentrations due to fetal adrenal zone involution, low-concentration analytes and assay interference by endogenous or placental steroids are main diagnostic challenges of this critical life period. Analysis of serum steroids by liquid chromatography tandem mass spectrometry (LC-MS/MS) can provide rapid, highly specific, and sensitive simultaneous analysis of multiple steroid analytes. 

Methods: We employed LC-MS/MS to measure a panel of 17 steroids of 300 healthy full-term newborns and babies (150 males, 150 females) grouped in five age groups (3-7th, 8-14th, 15-28th, 29-90th, 91-180th days). Nonparametric statistical approaches were used to generate the mean, 2.5th-97.5th percentile distributions for age groups. 17OH-Progesterone+21-deoxycortisol)/cortisol, 11-deoxycortisol/cortisol, 17OH-pregnenolone/cortisol, cortisol/cortisone and testosterone/dihydrotestosterone (only in boys) ratios were calculated as biomarkers of specific enzyme deficiencies.

Results: Reference intervals of 17 steroids measured simultaneously by LC-MS/MS were established.17-hydroxylated C21-glucocorticoids , non-17-hydroxylated C21-mineralocorticoid precursors (pregnenolone and progesterone) and C19-androgens (dehydroepiandrosterone, dehydroepiandrosterone-sulphate, Δ4-androstenedione) showed most significant age-related changes from 3 to 180 days of life.However C21-mineralocorticoids (aldosterone, corticosterone, 11-deoxycorticosterone) remained constant during the first 6 months of life.Biomarkers of 21-α-hydroxylase, 11-β-hydroxylase, 3-β-hydroxylase activities were in favor of cortisol increase.

Conclusions: Implementation of LC-MS/MS based steroid panel will provide shortly correct diagnosis.Therefore, the establishment of age-related reference intervals for newborn babies and early infancy in this study will allow rapid, noninvasive, accurate diagnosis and differential diagnosis, guide sex assignment, genetic counseling, predicting prognoses and prevent the potential life-threatening outcomes of impaired steroidogenesis.

444: FC96

LOW VITAMIN D RECEPTOR (VDR) IMPACTS PEDIATRIC ADRENOCORTICAL TUMOR BEHAVIOR WHILE VDR ACTIVATION REPRESSES WNT/ß-CATENIN SIGNALING AND ADRENOCORTICAL CELL PROLIFERATION
Ana C Bueno, PhD, Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil; Leticia F Leal, PhD, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil; Debora C Gomes, PhD, Federal University of Uberlandia, Uberlandia, Brazil; Ana P Montaldi, PhD, Ribeirao Preto Medical School, Ribeirao Preto , Brazil; Silvia R Brandalise, PhD; Maria J Masterallo, PhD; Izilda A Cardinalli, PhD; Jose A Yunes, PhD, Boldrini Children’s Center, Campinas, Brazil; Luiz G Tone, PhD; Carlos A Scrideli, PhD; Ayrton C Moreira, PhD; Carlos AF Molina, PhD; Fernando F Ramalho, PhD; Silvio Tucci, PhD; Leandra NZ Ramalho, PhD; Margaret De Castro, PhD; Sonir R Antonini, PhD, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil

Objectives: We investigated the role of the vitamin D receptor (VDR) in adrenal development and pediatric adrenocortical tumorigenesis, and its interaction with Wnt/β-catenin pathway and adrenocortical cell proliferation.

Methods: Clinicopathological features, VDR (qPCR and immunohistochemistry) and cyclin D1 (CCND1; qPCR) expression were evaluated in 74 pediatric ACTs and 44 fetal/pediatric normal adrenals. In vitro, we evaluated in NCI-H295 cells the effects of VDR activation by 1α,25-dihydroxyvitamin D3 (VitD3, 10-7M) or inhibition (siRNA) on the expression of Wnt/β-catenin components and cell cycle progression-governing complexes (qPCR, immunoblotting and immunofluorescence), cell cycle (flow cytometry) and viability (MTS). We also evaluated the effect of TCF/β-catenin blockage (PNU-74654, 10-4M) over VDR expression.

Results: We demonstrate important nuclear VDR immunostaining in normal human adrenal cortex since midgestation, and its protein and mRNA underexpression in pediatric ACTs. In these tumors, VDR expression correlated negatively with Wnt/β-catenin components expression AXIN1 and MYC, positively with WNT4 and DKK3, and especially with cell cycle regulator CCND1, which was associated with poor patient outcome. In vitro, VitD3 treatment directly inhibited β-catenin/CTNNB1 expression, nuclear accumulation, and reduced the expression of its targets CCND1, MYC and GLI1. Moreover, the expression of CDK4, CDK2, CCNE1, and MDM2 was also declined. Concomitant cell cycle impairment with G0/G1 accumulation was observed. In line, VDR knockdown elicited opposite results, with upregulation of β-catenin expression and abrogation of the inhibitory effect VitD3 over Wnt/β-catenin pathway. Decline of cells in G0/G1 phase, but increase in sub-G1/apoptotic was also observed. The inhibition of TCF/β-catenin importantly increased VDR expression and nuclear accumulation.

Conclusions: VDR plays an important role in normal adrenal differentiation and maintenance, which is lost in pediatric ACTs. VDR underexpression associates with tumor progression and poor prognosis. VitD3/VDR activation represses Wnt/β-catenin signaling and adrenocortical cell proliferation. VDR activation may emerge as an adjuvant therapy for patients with ACT.

1419: FC97

WOULD MOLECULAR TESTING IDENTIFY CASES OF CONGENITAL ADRENAL HYPERPLASIA MISSED BY NEWBORN SCREENING?
Cindy P Lorentz, MS, CGC, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States; Christopher N Greene, PhD; Zachary Detwiler, PhD, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States; Aida Ltief, MD, The Mayo Clinic College of Medicine, Rochester, MN, United States; Jennifer Kyllo, MD, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; Mark Mccann, BS/BA, Minnesota Department of Health, St. Paul, MN, United States; James Hodges, PhD, University of Minnesota, Minneapolis, MN, United States; Carla D Cuthbert, PhD; Suzanne K Cordovado, PhD, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States; Kyriakie Sarafoglou, MD, University of Minnesota, Masonic Children's Hospital, Minneapolis, MN, United States

Objectives: To prepare for the first prospective trial in the USA using a molecular assay as a 2nd tier newborn screening (NBS) test for congenital adrenal hyperplasia (CAH), our objectives were: 1) to characterize the CYP21A2  mutation spectrum in a large cohort of Minnesota CAH patients; 2) to evaluate whether a mass screening assay developed by the Centers for Disease Control (CDC) was accurate and reproducible in identifying mutations causing CAH disease from dried blood spots; 3) to examine the genotypes and phenotypes of the probands and their original NBS result.

Methods: Blood specimens from probands and their parents were spotted on to filter paper to approximate NBS dried blood spot specimens. Genotyping was done by the CDC using a CDC-developed rapid high-throughput assay. Medical charts were reviewed to identify phenotypes and original NBS results.

Results: Gene sequencing results of 97 families with 109 CAH affected children identified the 12 common mutations found in diagnostic panels as well as large 30kb deletions, large gene conversions, and 10 other CYP21A2 mutations, including nine rare and one novel. The CDC assay showed 100% accuracy and reproducibility on 900 dried blood spot samples tested. CAH subtypes of probands (n=109) were 61 salt-wasting (SW); 28 simple-virilizing (SV); 20 non-classic (NC). The original NBS for CAH results (n=82) identified 61 affected newborns (51 SW, 10 SV) and missed 21 (7 SW, 14 SV); 27 probands were excluded from NBS analysis (17 NC-CAH, 1 adopted, 9 with no NBS results available). There were 3 CYP21A2 mutations (H62L-P453S, L307V and G424S) found only in the missed NBS cases.

Conclusions: A high fraction (26%) of CAH-affected newborns are missed by the current NBS method, an immunoassay measuring 17-hydroxyprogesterone (17OHP), a metabolite elevated due to the enzymatic block, from blood samples taken at 24-36 hours of life. This suggests that some newborns with CAH have a delayed rise in 17OHP that is not captured by early NBS sampling but would be by molecular assay as it is not time dependent. 

848: FC98

MUTATION IN SAMD9 EXTENDS THE GENETIC AND CLINICAL SPECTRUM OF TRIPLE A SYNDROME
Angela Huebner, PhD, Technische Universität Dresden, Dresden, Germany; Klaus Mohnike, , Otto-von Guericke Universität Magdeburg, Magdeburg, Germany; Satoshi Narumi, MD, National Research Institute for Child Health and Development, Tokyo, Japan; Dana Landgraf, Research Technician; Felix Reschke, MD; Ramona Jühlen, PhD; Katrin Koehler, PhD, Technische Universität Dresden, Dresden, Germany

Objectives: Triple A syndrome is a rare autosomal recessive disorder characterized by adrenal failure, alacrima, achalasia and a variety of neurological features. It is caused by mutations in the AAAS gene. We recently described two triple A-like disorders caused by mutations in GMPPA and TRAPPC11 being responsible for 4 % of AAAS mutation-negative cases. However, about 26 % of patients with suspected triple A syndrome are still genetically undiagnosed. This study aims to summarize genotypes and phenotypes of triple A syndrome including a novel case caused by SAMD9 mutation.

Methods: Clinical and genetic analyses of more than 300 patients with suspected triple A syndrome.

Results: In classic triple A syndrome due to AAAS mutations adrenal insufficiency occurs in 77.1 %, achalasia in 85.1 % and alacrima in 89.7 % of all patients. Most patients (72.8%) display neurological impairment, most frequently distal muscular weakness, hyperreflexia, nasal speech and autonomic dysfunction. Recently a new form of syndromic adrenal hypoplasia termed MIRAGE syndrome (Myelodysplasia, Infection, Restriction of growth, Adrenal hypoplasia, Genital phenotypes and Enteropathy) caused by germline de novo heterozygous SAMD9 mutations was described. SAMD9 has a role in growth factor signal transduction and is involved in endosome fusion. We identified a novel heterozygous SAMD9 mutation (c.2306A>G, p.Asp769Gly) in a girl with adrenal insufficiency, dysautonomia, diarrhea, proteinuria and delay in intellectual, motor and speech development. Hypolacrima and achalasia extended the MIRAGE phenotype in this patient. She died at age 12 years from multiorgan failure due to severe infection. Family segregation analysis confirmed the de novo status of this mutation.

Conclusions: There are at least three novel disorders who display overlapping features with classic triple A syndrome. Protein products of the mutated genes are involved in different cellular pathways. Clinicians should be aware of this genetic heterogeneity in terms of genetic and clinical counselling. Mutation analysis in SAMD9 and the presence of MIRAGE syndrome should be taken into consideration in patients with adrenal insufficiency, achalasia, alacrima and lack of mutations in AAAS, GMPPA and TRAPPC11.

431: FC99

SERUM CORTISOL AND SALIVARY CORTISONE AND FREQUENCY OF SAMPLING TO ESTIMATE CORTISOL EXPOSURE
Richard J Ross, MD; Robert F Harrison, MD; Miguel Debono, PhD, University of Sheffield, Sheffield, United Kingdom; Martin J Whitaker, PhD, Diurnal Ltd, Sheffield, United Kingdom; Brian G Keevil, MD, University Hospital of South Manchester, Sheffield, United Kingdom; John Newell-Price, MD, University of Sheffield, Sheffield, United Kingdom

Objectives: Measuring cortisol exposure is important as excess is associated with increased mortality. Salivary cortisone provides a non-invasive method. To validate the relationship between serum cortisol and salivary cortisone and examine measurement frequency required to estimate cortisol exposure.

Methods: Serum cortisol and salivary cortisone measured by LC-MS/MS in 2 cohorts hourly over 24hrs: Cohort 1, 14 volunteers; Cohort 2, 8 volunteers, 12 patients with adrenal adenomas (6 non-functioning, 6 functioning). The relationship was analysed in Cohort 1 using linear mixed effects model and the resulting fixed effects component applied predictively to Cohort 2. The relationship between estimated AUC (eAUC) and absolute AUC (AUC24) was investigated by deriving the standard deviation of the per subject percentage error (SDPE, similar to coefficient of variation) for the use of 1 to 3 equi-spaced sampling points in 24 hours.

Results: The fixed effects model: log10 serum F = 1.24+0.89 log10 salE best described the relationship between serum cortisol and salivary cortisone in cohort 1 and gave similar results when applied to cohort 2: model predictions r=0.93 and 0.91 p<0.001, respectively. For a single measurement of serum cortisol used to derive eAUC the mean SDPE of the different time points for cohort 1 and 2 respectively was: 20% (range 7.4% - 39%) & 27% (range 16% - 56%); highest at 07:00h and lowest at 01:00h; for 2 samples at 12hrs 14% (range 8.7% - 23%) & 16% (range 9.8% - 23%); for 3 samples at 8hrs 10% (range 5.2 - 14%) & 12% (range 6.4% - 15%). A sensitivity analysis using 3 samples but shifting each sample time by 1 to 2 hours either side of nominal showed the mean deviation from the on time value was within 5.5%.

Summary: salivary cortisone as a measure of serum cortisol is confirmed in patient population. A single cortisol sample is a poor measure of AUC24 especially in the morning, but 3 x 8 hourly gives an eAUC within 5-15% of the AUC24 and samples taken up to two hours off nominal time a variation of only 5.5%.

Conclusions: Three ~8 hourly salivary cortisone samples provide a non-invasive method for estimating cortisol exposure. EUFP7-281654

Conflicts: MJW & RJR Directors of Diurnal Plc

1072: FC100

17OH-PREGNENOLONE SEEMS A MAJOR DRIVE OF ANDROGEN EXCESS IN PATIENTS WITH 11ß-HYDROXYLASE DEFICIENCY
Melek Yildiz, MD, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey; Serap Turan, Professor, Marmara University, Faculty of Medicine, Istanbul, Turkey; Teoman Akcay, Assoc Professor, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey; Zeynep Atay, Assoc Professor, Marmara University, Faculty of Medicine, Istanbul, Turkey; Hasan Onal, Assoc Professor, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey; Tugba Baris, PhD, Health Sciences University, Haseki Diagnostic Center, Istanbul, Turkey; Goncagul Haklar, Professor, Marmara University, Istanbul, Turkey; Abdullah Bereket, Professor, Marmara University, Faculty of Medicine, Istanbul, Turkey; Tulay Guran, MD, Marmara University, Istanbul, Turkey

Objectives: Biallelic mutations in the CYP11B1 gene causes 11β-hydroxylase deficiency (11β-OHD) which is a rare form of congenital adrenal hyperplasia (CAH) with reported prevalence of 1 in 100.000 live births. However, a higher frequency of 11OHD in Turkey is estimated most likely due to the higher rate of consanguineous marriages.Our aim was characterization of clinical features and liquid chromatography tandem mass spectrometry (LC-MS/MS)-based steroid metabolome analysis of 11β-OHD.This would give us a further understanding of pathways leading to accumulation of steroid metabolites with mineralocorticoid and androgen function besides an opportunity to make a better differential diagnosis with far more common 21-hydroxylase deficiency and 3β-hydroxysteroid dehydrogenase deficiency.

Methods: A clinical questionnaire was used to describe previously unreported patients with genetically confirmed 11β-OHD. We employed LC-MS/MS to measure a panel of 17 plasma steroids in patients (n=25;13F,12M) and healthy controls aged 0-18 yrs (n=160;76F,84M).

Results: There were 2 missense, 2 nonsense, 2 frameshift homozygous mutations of the CYP11B1 gene, 2 of them being novel. Affected patients were severely virilized, 4 of them had salt-wasting and other 6 had hypertension at presentation. All patients had significantly advanced bone age, 4 were treated for precocious puberty, one was given letrozol for severely advanced bone age, 3 boys had adrenal rest tumors. Seven patients were initially misdiagnosed with 21-hydroxylase deficiency and one girl with 3β-hydroxysteroid dehydrogenase deficiency. Four patients were treated with mineralocorticoids before definitive diagnosis. 17OH-Pregnenolone/cortisol and 17OH-progesteron/cortisol ratios were significantly higher in patients than in controls (p<0.0001). However significantly elevated 11-deoxycortisol/cortisol ratios as well as high 11-deoxycorticosterone and corticosterone concentrations established the diagnosis.

Conclusions: Deep clinical phenotyping together with LC-MS/MS-based steroid metabolome analysis will guide accurate diagnosis and treatment, and predicting prognosis in CAH.Excessive androgen biosynthesis seems to be regulated mainly by 17OH-Pregnenolone accumulated upstream of 11β-hydroxylase.

1317: FC101

UNDERSTANDING WOLFRAM SYNDROME: GENETICS, FUNCTIONALITY & ALLELIC VARIATIONS
Melissa Riachi, MS/MA; Mark Kristiansen, PhD, University College London Great Ormond Street Institute of Child Health, London, United Kingdom; Sebahat Yilmaz, Associate Prof; Zehra Aycan, Prof; Erdal Kurnaz, MD, Dr Sami Ulus Training and Research Children's Hospital, Istanbul , Turkey; Nanna Dahl Rendtorff, PhD; Lisbeth Tranebjaerg, Prof, University Hospital / University of Copenhagen, Copenhagen, Denmark; Robert Kleta, Prof, University College London Faculty of Medical Sciences, London, United Kingdom; Detlef Bockenhauer, Prof, University College London, Faculty of Medical Sciences, London, United Kingdom; Maria Bitner - Glindzicz, Prof, University College London Great Ormond Street Institute of Child Health, London, United Kingdom; Khalid Hussain, Division chief, Sidra Medical and Research Center, Doha, Qatar

Objectives: Wolfram syndrome (WS) , also known as (DIDMOAD), is a progressive neurodegenerative disease characterized by diabetes insipidus, diabetes mellitus, optic atrophy and sensorineural deafness. The heterogeneity of this syndrome entails its wide spectrum of symptoms which can include abnormal sexual development, urinary tract complications, neurological and psychiatric abnormalities. This phenotypic spectrum of Wolfram Syndrome type 1 (WS1) is caused by mutations in the WFS1 gene, which encodes for Wolframin, a protein essential for the mediation of the endoplasmic reticulum stress response. There are currently two types of WS that are mainly differentiated by their genetic cause. Despite their many overlapping clinical features, Wolfram type 2 (WS2) is distinguished by its lack of diabetes insipidus and is caused by mutations in the CISD2 gene.

Aims: To understand the genetic and functional mechanisms behind recessive and dominant WS and WS – like syndromes in a cohort of 12 patients.

Methods: Results: WS1 was identified in 42% of the cohort. Protein expression was performed, and decreased and/or absent levels of Wolframin were detected in the patients compared to healthy age matched controls. Heterozygosity in WFS1 was previously detected by Eiberg H et al. (2006) and Rendtorff ND et al. (2011) in 17 % of the cohort. Protein expression is still being analyzed using the fibroblasts of these patients with dominant Wolfram. Moreover, WS2 was detected in 9 % of the cohort and Western Blotting revealed decreased levels of the CISD2 protein.

As for the remaining 32% of the patients with a WS-like phenotype, compound heterozygosity in WFS1 is still being examined and WFS1 and CISD2 homozygosity has been ruled out. Also, potentially new candidate genes are being explored through whole exome sequencing analyses.

Conclusions: So far this study has identified novel and rare autosomal recessive mutations in the Wolfram genes. These genetic findings were combined with the respective protein expression analyses which in turn showed altered levels of protein.

Also, protein expression analyses in dominant Wolfram has neither been previously examined nor reported in the literature.

1297: FC102

UNCOVERING A NEW MECHANISM IN THE PIGMENTARY HYPERTRICHOSIS AND NON-AUTOIMMUNE DIABETES MELLITUS (PHID) SYNDROME INVOLVING THE 3'UTR.
Melissa Riachi, MS/MA, University College London Great Ormond Street Institute of Child Health, London, United Kingdom; Feyza Darendeliler, Prof; Firdevs Bas, Prof, Istanbul Faculty of Medicine, Istanbul, Turkey; Khalid Hussain, Division chief, Sidra Medical and Research Center, Doha, Qatar

Objectives: Background: H syndrome, formerly known as histiocytosis – lymphadenopathy plus syndrome, is a cluster of autosomal recessive auto - inflammatory disorders characterized by histiocytosis and prominent cutaneous presentations. Pigmentary hypertrichosis and non-autoimmune immune insulin dependent diabetes mellitus (PHID) is one of the rare H syndrome diseases mainly characterized by hyperpigmentation, hypertrichosis, sensorineural hearing loss, cardiac complications, developmental delay and diabetes mellitus. Mutations in the coding regions of the SLC29A3 gene that encodes for an equilibrative nucleoside transporter (ENT3), have been reported to cause the phenotypic spectrum of the H syndrome. Disease causing mutations in the untranslated regions of the SLC29A3 gene have not been previously described in the literature. The importance of the untranslated region (UTR) of the mRNA in the post transcriptional regulation of gene expression makes it a ‘hotspot’ for pathologies, as mutations in this region can be very consequential.

Objectives: To determine whether a novel 3’UTR mutation in the SLC29A3 gene is disease causing in two Turkish patients that presented with a PHID phenotype.

Methods: The mutation was identified by a targeted gene approach using Sanger Sequencing. In order to understand the functionality of this 3’UTR mutation, mRNA expression studies were performed by using the quantitative real time Polymerase Chain Reaction (rtPCR) method. Also, protein expression analyses were performed by Western Blots on the fibroblasts cultured from the patients’ skin biopsies

Results: The rtPCR results showed a decrease in the patients’ SLC29A3 expression levels compared to seven controls matched for passage numbers and RNA extraction methods. Also, the Western Blots showed a decrease in the expression of the ENT3 protein in the patients compared to six controls.

Conclusions: The mRNA and protein expression analyses proved that the novel 3’UTR mutation in the SLC29A3 gene is indeed disease causing, highlighting a new pathological mechanism for the PHID syndrome. The involvement of the 3’UTR has not been previously establilshed in any of the H syndrome disease cluster.

624: FC103

PROGRESSION OF DIABETES MELLITUS IN WOLFRAM SYNDROME
Bess A Marshall, MD; Neil H White, MD; Tamara Hershey, PhD, Washington University in St. Louis, St. Louis, MO, United States

Objectives: Wolfram Syndrome is a rare multisystem degenerative disease caused by mutations in the WFS1 gene. Features include neurodegeneration, diabetes insipidus, diabetes mellitus, optic atrophy, loss of vision, hearing loss, bladder dysfunction, and other endocrinopathies. Detailed natural history information is needed to improve patient care and to design intervention trials.

Methods: Thirty-seven persons with Wolfram, (age 5-30, average age 16.0±0.5 years, 14 male) have participated in a seven-year natural history study collecting detailed phenotypic data. In 30 subjects, C-peptide was obtained 30 min after ingestion of a standard mixed meal after an overnight fast (Boost, Nestle; 6 ml/kg, max 360 ml; 240 ml = 240 kcal, 41 g carbohydrate, 4 g fat, 10 g protein). Subjects with fasting glucose over 250 mg/dl (13.9 mmol/L) were not given Boost but C-peptide was collected. Subjects on insulin were instructed to continue their usual insulin dosing.

Results: Three subjects (7.2 to 15.8 years) did not have diabetes mellitus and their 30 min C peptide did not change over three annual visits (year 1: 8.0±2.3, year 2:7.2±4.0, and year 3 8.5± 3.4 ng/ml, data shown as mean±SEM). The other 27 subjects had an average age of onset of diabetes of 5.6±0.5 years (range 2.2-13.9 years) and an average duration of diabetes of 10.7±0.5 years (range 1-27 years). Their stimulated C peptide declined with the duration of their diabetes. C-peptide in ng/ml at 30 min after Boost or with glucose >250 mg/dl: at 1 year, 1.8±0 (n=2), year: 2: 1.0±0.1 (n=3), year 3: 1.2±0.2 (n=7), year 4: 1.2±0.3 (n=7), year 5 0.7±0.2 (n=8), year 6: 0.7±0.1 (n=8), year 7: 0.7±0.2 (n=6), year 8: 0.4±0.1 (n=9), year 9: 0.7 ±0.3 (n=8), year 10: 0.4±0.1 (n=7), year 11: 0.6±0.3 (n=6), and years 12-23: 0.2 or 0.3 ±0.1 (n=4, 5, 6, 6, 9, 5, 4, 1, 0, 1, 2, 2 for years 12-23, respectively), years 24-27: less than 0.2, all single subjects.

Conclusions: In conclusion, C-peptide stimulated by mixed meal challenge or by fasting hyperglycemia in subjects with Wolfram Syndrome falls with duration of diabetes mellitus over approximately 10 years after diagnosis, with the largest decline occurring in the first 5 years after diagnosis.

972: FC104

A REVIEW OF GENOTYPE-PHENOTYPE PRESENTATIONS IN PATIENTS WITH PSEUDOHYPOALDOSTERONISM TYPE 1 FOLLOWING THE IDENTIFICATION OF NOVEL MUTATIONS
Jaya Sujatha Gopal-Kothandapani, MRCPCH, University of Sheffield, Sheffield, United Kingdom; Arpan Doshi, Medical Student, Sheffield Medical School, Sheffield, United Kingdom; Christian Martin, MRCP, Nottingham University Hospital, Nottingham, United Kingdom; Talat Mushtaq, MD, The Leeds Teaching Hospitals, Leeds, United Kingdom; Indraneel Banerjee, MD, Central Manchester University Hospitals, Manchester, United Kingdom; Raja Padidela, MD, Royal Manchester Children’s Hospital, Manchester, United Kingdom; Renuka Ramakrishnan , MRCPCH, Alder Hey Children's Hospital, Liverpool, United Kingdom; Catherine Owen, PhD; Timothy Cheetham, MD, Royal Victoria Infirmary, Newcastle, United Kingdom; Kath Smith, MSc; Paul Dimitri, PhD, Sheffield Childrens Hospital, Sheffield, United Kingdom

Objectives: Background: There is limited data available in the literature on the genotype-phenotype correlation and the management of patients with Type I pseudohypoaldosteronism (PHA1), a rare condition characterised by hyponatremia, hyperkalemia and metabolic acidosis.   

Objective: Our aim is to study the clinical presentation and management in relation to the underlying genetic abnormality of patients with PHA1.

Methods: A Questionnaire-based, cross-sectional survey, of all the paediatric consultants in the United Kingdom was undertaken through the British Society of Paediatric Endocrinology and Diabetes (BSPED) in January 2015. The questionnaire collected information on patients with genetically confirmed PHA1: Number of PHA1 patients, Demographics (including ethnicity), Clinical features of PHA1 (vomiting, weight loss, dehydration, drowsiness, seizures), Investigations – Biochemistry, imaging, genetic analysis, Management at presentation,  Duration, clinical course and other complications. 

Results: A total of 17 patients with PHA1 were identified from 6 tertiary paediatric endocrine centres. Genetic confirmation of the diagnoses was made in 12 patients (9 males and 3 females). Out of 12 patients, 4 had autosomal dominant renal type PHA (PHA1a), including one novel mutation. Eight had autosomal recessive multi-system type PHA (PHA1b), of which 2 are novel mutations in the SCNN1A and 1 novel mutation in SCNN1B. Detailed phenotypic information was collected and analysed from this cohort. Depending on the type and location of mutation, a clear difference in clinical phenotype was difficult to distinguish in our patient cohort (table) in line with the exisiting evidence.

Conclusions: Conclusion: PHA being a rare condition there is limited genotypic and descriptive phenotypic data available in the current literature. Within our cohort and review of the literature, there appears to be no obvious genotype –phenotype correlation for both PHA1a and 1b. We recommend establishing a national database incorporating detailed genotypic and phenotypic data for such rare life-threatening conditions. This may enable identification of genetic subgroups that would have the potential to develop personalised patient care.

1573: FC105

PANCREATIC INSULINOMAS IN CHILDHOOD: CLINICAL, MORPHOLOGICAL AND GENETIC CHARACTERISTICS OF 16 CHILDREN.
Maria Melikyan, PhD, Endocrine research center, Moscow, Russian Federation; Sergey Makarov, MD, Russian Children's Clinical Hospital, Moscow, Russian Federation; Larisa Gurevich, PhD, M. F. Vladimirsky regional clinical institute, Moscow, Russian Federation; Youriy Sokolov, PhD, paediatric municipal clinical hospital, Moscow, Russian Federation; Henrik t Christesen, PhD, Odense University Hospital, Odense, Denmark

Objectives: Insulinomas are extremely rare tumors in children. An early clinical and genetic diagnosis is very important for the appropriate mediacal assessment. There are only few reports of malignant insulinomas in children. 

We ame to investigate clinical features, biochemical, genetic and histopathological characteristics of 16 children with pancreatic insulinomas. 

Methods: Insulinomas were dignosed biochemically and by imaging and verified histopathologically. Detailed clinical and biochemical examination was performed in all children. Sequencing of the MEN1 gene was performed in 15 patients using the bidirectional direct sequencing and MLPA deletion analysis. Follow up (mean age 15,3 y) included screening for signs of MEN1, neurodevelopmental examination and screening for the metastasis in case of malignant cases. 

Results: Sixteen children (8 boys and 8 girls) aged 8-16 years were diagnosed to have primary pancreatic insulinoma. Seizures and weight gain were the most common symptoms of hyperinsulinaemic hypoglycemia (68,7% and 57,2% respectively). Six children (37,5%) had hypoglycemic coma before the diagnosis was established. Ten patients (62,5%) were erroneously diagnosed with epilepsy and treated with anticonvulsants. Seven out of fifteen children (46,6%) were found to have mutations in MEN1 gene, multiple pancreatic tumors were found in five of them. The mean tumor size was 2,8 cm. There was no predominance in tumore localisation within the pancreas. Histopathological studies revealed G2 differentiation stage (ENETs grade) in seven of sixteen cases (43,7%). Distant metastases were seen during follow up in two patients. Neurologic examination revealed hypoglycemic brain damage in four out of 15 patients. 

Conclusions: Late diagnosis of insulinoma is typical, probably to unspecific symptoms and the disease rareness, what may lead to neurodevelopmental impairment. MEN1 syndrome should be suspected in all cases of paediatric insulinomas. 

295: FC106

PATERNALLY INHERITED DLK1 DELETION AS A NOVEL CAUSE OF FAMILIAL CENTRAL PRECOCIOUS PUBERTY
Andrew Dauber, MD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Marina Cunha-Silva, MD; Delanie Macedo, MD; Vinicius Brito, MD, Universidade de São Paulo, São Paulo, Brazil; Ana Paula Abreu, MD, Brigham and Women's Hospital , Boston, MA, United States; Stephanie Roberts, MD, Boston Children's Hospital, Boston, MA, United States; Luciana Montenegro , PhD, Universidade de São Paulo, São Paulo, Brazil; Melissa Andrew, BS/BA, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Andrew Kriby, BS/BA, Massachusetts General Hospital, Boston, MA, United States; Matthew Weirauch, PhD; Guillaume Labilloy, MS/MA, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States; Danielle Bessa, MD, Universidade de São Paulo, São Paulo, Brazil; Rona Carroll, PhD, Brigham and Women's Hospital , Boston, MA, United States; Dakota Jacobs, MS/MA; Patrick Chappell , PhD, College of Veterinary Medicine, Oregon State University, Corvallis, OR, United States; Berenice B Mendonca , PhD, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; David Haig, PhD, Harvard University, Cambridge, MA, United States; Ursula Kaiser, MD, Brigham and Women's Hospital , Boston, MA, United States; Ana Claudia Latronico, MD, Universidade de São Paulo, São Paulo, Brazil

Objectives: We sought to identify the genetic etiology of CPP in a three-generation family with familial CPP.

Methods: We studied a three-generation family in which two sets of sisters and their paternal grandmother were affected by CPP. We performed whole exome sequencing, followed by linakge analysis and whole genome sequencing in selected family members. Serum levels of DLK1 were measured via ELISA. Expression of DLK1 was measured in mouse hypothalamus and in kisspeptin-secreting neuronal cell lines in vitro.

Results: CPP first manifested with thelarche in all four girls (age of onset 4.6-5.9 years). CPP was confirmed based on elevated baseline and GnRH-stimulated LH levels. Brain MRIs were normal. The fathers of the affected girls were brothers and had normally timed puberty. This pattern of inheritance suggested an imprinted disorder. Whole exome sequencing was performed in the 5 affected individuals and an unaffected sister but no candidate variants were identified, including no mutations in MKRN3. Linkage analysis identified 5 regions of maximal linkage. One of these regions (chr14q32) harbored a cluster of imprinted genes; defects in this region are known to cause Temple Syndrome, a complex developmental syndrome, which includes CPP. Additionally, prior GWAS studies have identified a SNP in this region that affects timing of menarche when paternally inherited. Whole genome sequencing identified a complex defect in the paternally expressed imprinted gene DLK1 (~14 Kb deletion and 269 bp duplication). The deletion included the 5'UTR and the first exon of DLK1, including the translational start site. Only family members who inherited the defect from their father had precocious puberty, consistent with the known imprinting of DLK1. The patients did not demonstrate additional features of Temple syndrome except for increased fat mass. Serum DLK1 levels were found to be undetectable in all affected individuals when compared to healthy controls. Furthermore, we demonstrated that Dlk1 was expressed in mouse mediobasal hypothalamus and in kisspeptin neuron-derived cell lines, supporting a link between DLK1 and the regulation of pubertal timing.

Conclusions: We identified the first genomic defect in DLK1 causing nonsyndromic familial CPP. Loss of DLK1 expression is the likely cause of CPP in Temple syndrome.

228: FC107

DELETION OF THE URIDINE DIPHOSPATE GLUCURONYLTRANSFERASE UGT2B17 GENE IS ASSOCIATED WITH DELAYED PUBARCHE IN HEALTHY BOYS
Annette Mouritsen, MD, PhD; Alexander S Busch, MD; Lise Aksglaede, MD, PhD; Ewa Rajpert-De Meyts, PhD, Rigshospitalet, Copenhagen , Denmark; Anders Juul, PhD, Rigshospitalet, Denmark, Copenhagen, Denmark

Objectives: Urinary excretion of testosterone (T) as water-soluble conjugate depends on the sulfation and glucuronidation capacity. One of the essential glucuronidases is encoded by the UGT2B17 gene. We previously reported that homozygous deletion of UGT2B17 in boys was associated with lower urinary excretion of T. The objective was to study whether boys with less glucuronidation capacity may have altered androgen action affecting pubarche, representing an androgen-dependent pubertal event.

Methods: A cross sectional study of 668 healthy Danish boys aged 6.1 to 21.9 years. 65 of the boys where followed every 6 months in a longitudinal study. UGT2B17 copy number variation (CNV) genotyping was performed using quantitative PCR. Reproductive hormone levels were measured.

Results: In the cross-sectional study, 59 of the 668 boys (8.8%) presented with a homozygous deletion of the UGT2B17 (del/del). These boys experienced pubarche at a mean age of 12.73 years (12.00–13.46), which was later compared to a mean age of 12.40 years (12.11–12.68) in boys heterozygous for UGT2B17 (del/ins)  and a mean age of 12.06 years (11.79–12.33) in boys with the wildtype genotype (ins/ins), even after correction for BMI z-score (p = 0.029). The effect accounted for 0.34 years delay per allele (95% CI: 0.03–0.64). A comparable trend was observed in genital development and testicular volume but did not reach statistical significance. No significant differences were observed in circulating levels of FSH, E2, LH, T, SHBG, DHEAS or androstenedione between genotype groups after correction for age.

Conclusions: CNV of UGT2B17 is a genetic factor contributing to the timing of male pubarche.

154: FC108

EXTREME HYPERANDROGENISM WORSENS METABOLIC BUT NOT DERMATOLOGIC FINDINGS WITHIN OBESE ADOLESCENTS WITH POLYCYSTIC OVARIAN SYNDROME
Melanie Cree-Green, MD,PhD; Michelle Torres, MD, PhD; Laura Pyle, PhD, University of Colorado/Children's Hospital Colorado, Aurora, CO, United States; Ann Scherzinger, PhD, University of Colorado, Aurora, CO, United States; Megan M Kelsey, MD; Kristen J Nadeau, MD, MS, University of Colorado/Children's Hospital Colorado, Aurora, CO, United States

Objectives: Hyperandrogenism and polycystic ovarian syndrome (PCOS) are associated with an increased risk of cardiometabolic disease in adolescents, yet it is unclear if androgen concentrations per se relate to the risk of disease.

Methods: Overweight or obese control girls without PCOS (OC, N=34) and with PCOS per NIH criteria (PCOS, N=78) were included. Anthropometric data and personal and family history were assessed. Hirsutism and acne were evaluated as dermatologic hyperandrogenism. Exercise and activity was quantified by questionnaire, and hepatic fat % and body fat % were assessed by MRI and DEXA, respectively. Fasting measurements included: glucose, insulin, leptin, adiponectin, A1c, lipids, c-reactive protein, hepatic transamininases, estradiol, progesterone, total testosterone, free testosterone (FT) and sex-hormone binding globulin (SHBG). Free androgen index (FAI) and HOMA-IR were calculated.

Results: OC and PCOS groups had a median age of 15 years, BMI%ile of 98, were equally sedentary and had a similar family history of type 2 diabetes. The PCOS group had severe acne and hirsutism and higher androgens, as expected (FAI 9.9±6.3 vs 3.2±2.1, p<0.0001; FT 8.9±4.9 ng/mL vs 3.7±2.1, p <0.001). Cardiometabolic risk was worse in PCOS vs. OC, including: fasting insulin (28±17 uIU/mL vs 19±7; p=0.005), HOMA-IR (5.5±1.8 vs. 3.9±1.2; p=0.002), ALT (38±16 U/L vs 32±12; p=0.023), LDL (98±31 mg/dL vs 80±20; p=0.007), and visceral fat (80.0 ± 27 cm2 vs 63.8 ± 24; p=0.006). Within PCOS, higher FT concentrations directly related to higher insulin, C-peptide concentrations and thus HOMA-IR. When the PCOS cohort was divided by a FT above or below 10 ng/mL, those with FT >10 had higher HOMA-IR (p=0.003), serum triglycerides (p=0.002) and hepatic fat percent (p=0.017).

Conclusions: Compared to OC, PCOS have higher androgens and worse metabolic and dermatologic findings. Within the PCOS group, girls with higher FT have worse metabolic markers, but physical attributes including BMI and adiposity, acne and hirsutism are similar. Our results suggest that obese PCOS adolescents with very high FT have a greater risk for metabolic disease and may require more frequent screening for serum lipids, hepatic steatosis and development of type 2 diabetes.

1697: FC109

DISCOVERY OF MUTATIONS IN MULTIPLE GENES CONTROLLING GNRH NEURONAL MIGRATION AND DEVELOPMENT IN PATIENTS WITH SELF-LIMITED DELAYED PUBERTY
Sasha R Howard, MBBS, Queen Mary University of London, London, United Kingdom; Valentina Andre, PhD, University of Milan, Milan, Italy; Leo Guasti, PhD; Claudia P Cabrera, PhD; Michael R Barnes, PhD, Queen Mary University of London, London, United Kingdom; Anna Cariboni, PhD, University of Milan, Milan, Italy; Leo Dunkel, MD, PhD, Queen Mary University of London, London, United Kingdom

Objectives: Abnormal pubertal timing affects >4% of adolescents and is associated with adverse health outcomes. Up to 80% of variation in the timing of pubertal onset is genetically determined. Self-limited delayed puberty (DP) segregates in an autosomal dominant pattern, but in the majority the neuroendocrine pathophysiology and genetic regulation remain unclear. Mis-regulation of the embryonic migration of GnRH neurons has been implicated in the pathogenesis of DP (Howard et al 2016).We aim to identify new candidates for the genetic basis of DP using expression data on genes up- or down-regulated during GnRH neuronal migration.

Methods: We performed whole exome sequencing (WES) in 115 members of 18 families from our self-limited DP patient cohort, and filtered the data for genes with rare, predicted deleterious variants that segregated with trait within families. These data were firstly examined for overlap with gene expression data from microarray analysis of GnRH:GFP primary rat neurons at E14, E17 and E20. Secondly the data were compared to a microarray analysis of genes differentially expressed in GN11 (immature and migratory) and GT1-7 (mature and non-migratory) immortalised GnRH neurons.

Results: After WES, 1765 genes contained rare, predicted deleterious variants that segregated with trait. Microarray analysis identified 677 genes with significant (fold change > 2) up- or down-regulation during the time period of embryonic GnRH neuronal migration, and 102 differently expressed between GN11 and GT1-7 cells.  48 genes identified as significantly up- or down-regulated between GnRH:GFP primary rat neurons at E14 and at E20, and 15 genes reaching statistical significance for differential expression between GN11 and GT1-7 cells, were also identified as potentially pathogenic in self-limited DP patients. These include the G-protein coupled receptor LGR4 and the neuronal growth regulator NEGR1.

Conclusions: This analysis has yielded several interesting new rare, potentially pathogenic variants in genes implicated in GnRH neuronal migration and development in 7 families from our cohort. Whilst these candidates need to be functionally validated, these data provides further evidence for the importance of GnRH neuronal migration in the timing of puberty onset.

1212: FC110

USE OF TESTOSTERONE GEL COMPARED TO INTRAMUSCULAR FORMULATION FOR PUBERTY INDUCTION IN MALES WITH CONSTITUTIONAL DELAY OF GROWTH AND PUBERTY
Danilo Fintini, MD, Bambino Gesù Children's Hospital, Rome, Italy; Laura Chioma, MD; Giulia Papucci, MD, Bambino Gesù Children’s Hospital, Rome, Italy; Marco Cappa, MD, Bambino Gesù Children's Hospital, Rome, Italy

Objectives: Delayed puberty may include hypo- or hypergonadotropic hypogonadism, and constitutional delay of growth and puberty (CDGP) that represents the most common cause (up to 65%) of delayed puberty in boys. CDGP can be considered an extreme of the normal spectrum of pubertal timing, it remains a diagnosis of exclusion and can only be confirmed when puberty occurs spontaneously. CDGP treatment include expectant observation or therapy with intramuscular low-dose of testosterone (IMTT) while there are no data available regarding its use of transdermal testosterone gel (TTG). The aim of our observational study was to analyze the use of TTG for pubertal induction compared to IMTT in males with CDGP.

Methods: 75 adolescent boys with CDGP were recruited Endocrinology Unit of Bambino Gesù Pediatric Hospital between 2010 and 2016, divided into three homogeneous groups: Group 1 (N=25) treated with 50 mg i.m. enanthate testosterone (IMTT) every 4 weeks for three months; Group 2 (N=26) treated with 10 mg daily 1% testosterone transdermal gel (TTG) for three months, and Group 3 (N=22) only observed as control group (CNT). All the subjects were observed at baseline and after 6 months.

Results: The Height Velocity (HV) were statistically higher after 6 months in both IMTT and TTG groups compared to CNT, while in the CNT group showed significant increase of the testicular volume compared to IMTT and TTG groups. No other differences were recorded between IMTT and TTG group.

Conclusions: To our knowledge this is the first study that investigate the role of TTG on treatment of pubertal activation on CDGP population compared to conventional treatment. Despite the small sample size, our preliminary data confirm the efficacy of short-term Testosterone gel treatment to induce the growth spurt with a rapid improvement on HV such as to approach to pubertal values.

2908: FC111

BIG FAT SECRET: DISRUPTION OF T CELL HOMEOSTASIS BY CYCLIN DEPENDENT KINASE 5 ACTIVITY IS CRITICAL IN THE PATHOGENESIS OF INFLAMMATION-INDUCED OBESITY
Priyanka Bakhtiani, MD, UH Rainbow Babies and Children's Hospital/ Case Western University, Cleveland, OH, United States; Tej Pareek, PhD, UH Rainbow Babies and Children's Hospital, Cleveland, OH, United States; Sumana Narasimhan, MD, Cleveland Clinic Children's Hospital , Cleveland, OH, United States; Hsi-Ju Wei, PhD, Case Western Reserve University, Cleveland, OH, United States; John Letterio, MD, UH Rainbow Babies and Children's Hospital, Cleveland, OH, United States

Objectives: A decline in regulatory T cells (Tregs) and an increase in pro-inflammatory T cells in adipose tissue (AT) characterize the low-grade chronic inflammation of obesity and insulin resistance. Signal transducer and activator of transcription 3 (STAT3) is a critical mediator in this process; however, other regulators of this inflammatory cascade remain unclear. Cyclin-dependent kinase 5 (CDK5), primarily a neuronal kinase, was recently reported as necessary for STAT3 phosphorylation.  With this pilot project, we aimed to investigate the T cell-specific function of CDK5 in age- and diet-induced obesity.

Methods: Male and female mice with T cell lineage-restricted deletion of the Cdk5 gene (Cdk5TKO) and their Wild Type (Cdk5WT) littermates fed standard chow diet were compared at 1 year of age.

4 week old Cdk5TKO and Cdk5WT mice were fed high-fat diet (45kcal % fat, HFD) or low-fat control diet (10kcal% fat, LFD) for 16 weeks.

The effects of HFD on the metabolic phenotype were observed by serial measurements of body weight and food intake, histopathology, MRI with IDEAL imaging, and intraperitoneal glucose tolerance test (GTT).

To identify the pathogenic role of CDK5 in HFD-mediated alteration of T cell repertoire, T cells isolated from spleen and AT were analyzed by flow cytometry.

Results: We noted that Cdk5TKO mice were resistant to age-induced obesity and visceral adiposity at 1 year of age.

Cdk5TKO mice also remained lean on HFD, gaining significantly less weight than Cdk5WT mice. MRI showed that Cdk5TKO mice were protected against visceral and hepatic adiposity. GTT revealed better glucose tolerance in Cdk5TKO mice. The percentage of Tregs was significantly higher in AT (but not spleen) of Cdk5TKO mice on HFD. The proportion of CD8 T cells, Th1 cells, Th17 cells, and effector-memory T cells trended lower in Cdk5TKO mice fed HFD.

In the LFD group, no difference was noted between Cdk5TKO and Cdk5WT mice.

Conclusions: 1) The pathogenesis and complications of inflammation-induced obesity (propagated by aging and HFD) depend on the impaired T cell homeostasis resulting from constitutive activation of CDK5 in T cell lineage.

2) T cell-specific CDK5 activity may be targeted for treatment of obesity and insulin resistance.

2857: FC112

HISTONE PHOSPHORYLATION BY THE KINASE OF TRANSIENT RECEPTOR POTENTIAL MELASTATIN 6 (TRPM6) ATTENUATES ADJACENT ARGININE METHYLATION IN DISORDERED PEDIATRIC MINERAL METABOLISM
Nora Renthal, PhD, Boston Children's Hosptial, Boston, MA, United States; Grigory Krapivinsky, PhD; David E Clapham, PhD, Boston Children's Hospital, Boston, MA, United States

Objectives: Melastatin-related Transient Receptor Potential 6 (TRPM6) is a cation channel kinase, “chanzyme," highly expressed in intestinal mucosa and kidney. TRPM6 and its sister chanzyme, TRPM7, are the only known examples of single polypeptides containing both an ion channel pore and a serine/threonine kinase. Deletion of either gene in mice is embryonically lethal. Human mutations in TRPM6  cause Familial Hypomagnesemia with Secondary Hypocalcemia (HSH), a rare autosomal recessive disease, characterized by severe hypomagnesemia with hypomagnesemic parathyroid failure. Affected individuals suffer neurologic symptoms of hypomagnesemic hypocalcemia, beginning in infancy, including tetany, refractory seizures, and death. Our study aimed to uncover the function of the TRPM6 kinase, its phosphorylation targets, the roll of these targets in the cell, and the interdependance of the TRPM6 channel and TRPM6 kinase.

Methods: This study employed techniques such as protein immunoprecipitation, western blotting, tandem affinity purification and mass spectrometry, CRISPR-Cas9 tag and mutation incorporation, immunofluorescence microscopy, autoradiography, and qPCR.

Results: Our laboratory has uncovered a signaling pathway mediated by TRPM6, whereby its C-terminal kinase is cleaved from the channel in a cell type-specific, channel-dependent fashion, and remains active. The cleaved kinase translocates to the nucleus where it phosphorylates specific histone serine and threonine (S/T) residues. TRPM6 cleaved kinases (M6CKs) bind subunits of the PRMT5 molecular complex responsible for the methylation of histone arginine residues, an important epigenetic modification. Histone phosphorylation by M6CK results in a dramatic decrease in methylation of arginines adjacent to M6CK-phosphorylated amino acids. Knockout of TRPM6 or inactivation of its kinase results in global changes in histone S/T phosphorylation and changes the transcription of hundreds of genes.

Conclusions: M6CK associates with the PRMT5 molecular complex to provide site-specific histone phosphorylation, which regulates transcription by attenuating the effect of local arginine methylation. These investigations provide a better understanding of cation-directed intracellular signaling and shed light on the pathophysiology of patients with HSH.

2910: FC113

INFLUENCE OF GROWTH HORMONE THERAPY IN THE OCCURRENCE OF SECOND NEOPLASM IN SURVIVORS OF CHILDHOOD CANCER.
Cecile Thomas-Teinturier, MD, AP-HP Hopitaux Paris-Sud Site Bicêtre, Le Kremlin-Bicêtre, France; Isabelle Oliver-Petit, MD, Hôpital Purpan, Toulouse, France; Helene Pacquement, MD, Institut Curie, Paris, France; Odile Oberlin, MD, Institut Gustave Roussy, Villejuif, France; Martine Munzer, MD, American Memorial hospital, Reims, France; Florent De Vathaire, PhD, Institut Gustave Roussy, Villejuif, France

Objectives: Growth hormone (GH) deficiency is a common endocrine late effect of cranial irradiation for childhood cancer and needs GH treatment to achieve normal adult height. But concerns have been raised that GH treatment might lead to an increased risk of secondary neoplasms (SN).

To study the role of GH therapy in the risk of occurrence of SN, we used the database from the retrospective French cohort of 5-year survivors of childhood cancer treated before 1986, in which radiation dose-volumes to each organ had been estimated. 80% of survivors sent back a questionnaire. SN and GH therapy were validated.

Methods: Analysis of SN incidence was done using time-dependent Cox regression model. Then, we undertook a cohort-nested case-control study on 45 case patients with secondary meningioma and 173 controls matched for radiation dose distributions to meninges, sex, age at first cancer and duration of follow-up.

Results: Among 2852 survivors born after 1958, median age at cancer 4 years, with a median follow-up of 26 years, 196 received GH therapy. 376 survivors had a SN, including 40 who had received GH therapy: 17 meningioma (11 in females), 9 brain cancer, 14 non brain cancer.

In a multivariate analysis, adjusting for age at diagnosis, gender, neurofibromatosis, brain tumor as first cancer, chemotherapy and radiation dose, GH treatment did not significantly increase the risk of secondary non brain cancer (RR=0.86, 95%CI:0.48-1.55, p=0.6), secondary brain cancer except meningioma (RR=0.69, 95%CI:0.27-1.77, p=0.4) or secondary meningioma (RR=2.01, 95%CI:0.93-4.34, p=0.07).

The case-control study confirmed a slight but non-significant excess risk of meningioma (OR=1.94, 95%CI: 0.82-4.6, p=0.2), greater in females (OR=4.26, 95%CI: 0.95-19.04, p=0.06).

Conclusions: Our study confirms the safety of GH use in survivors of childhood cancer with no significant influence in the occurrence of SN. The non-significant slight excess risk of meningioma, in particular in women does not justify a restriction on the use of GH therapy for GH deficient patients but life-long MRI follow-up of all survivors, especially women, who received brain radiation. Study on other confounding factors in women, such as oestrogen use is still ongoing.

2938: FC114

IMPROVING OUTCOMES IN ADOLESCENTS WITH POORLY CONTROLLED TYPE 1 DIABETES
Catherine Stanger, PhD; Amy Hughes Lansing, PhD; Emily Scherer, PhD; Alan Budney, PhD, Geisel School of Medicine, Hanover, NH, United States; Ann S Christiano, APRN; Samuel J Casella, MD, Children's Hospital at Dartmouth, Lebanon, NH, United States

Objectives: We conducted a randomized controlled trial to assess the efficacy of a web-delivered multi-component intervention to improve blood glucose control in adolescents with poorly controlled type 1 diabetes mellitus.  We targeted self-monitoring of blood glucose levels (SMBG), working memory, and parental supervision. 

Methods: Adolescents (N=61) with poorly controlled T1DM were randomized to usual care or to a 25-week/15 session web-delivered intervention (WebRx).  The intervention included behavioral economic incentives for teens and parents, motivational and cognitive behavioral therapy and working memory training for the adolescent, and parent training.  Outcome measures,  including frequency of SMBG, visual spatial working memory, family conflict and HbA1c were assessed at baseline, at the end of the intervention period and 6 months thereafter (12 months after entering the study).  

Results: Retention was very high, with 28 of 30 families completing more than 12 of 15 online counseling sessions and 25 of 30 teens completing at least 20 of the 25 working memory sessions.  Adolescents who participated in WebRx had higher rates of SMBG at 6 months (5.51 vs 3.97, p<0.01) and at 12 months (4.75 vs 3.76, p<0.05).   Parental monitoring was also higher in the intervention at 6 months (3.78 vs 2.28, p<0.01), but was not statistically different at 12 months.  The teens who participated in WebRx achieved higher scores of working memory both at 6 months (62.1 vs 48.77, p<0.05) and at 12 months (70.96 vs 52.82, p<0.01).   The experimental group had lower HgbA1c (8.57 vs 9.10, p <0.05) at the end of the intervention and this effect persisted at 12 months (8.73 vs 9.29, p<0.05).  We also observed decreased family conflict and improved inhibition in the WebRx group.

Conclusions: This innovative, web-delivered intervention improved targeted behaviors as well as glycemic control in teenagers with poorly controlled type 1 diabetes.  The beneficial effects were evident at the end of the intervention and were still demonstrable 6 months after the end of the active behavioral treatment.  Because the intervention can be completed online, it may be particularly helpful for patients who have limited access to diabetes centers.

2901: FC115

RAPID MULTISTEROID MASS SPECTROMETRY (MS) PROFILING COMBINED WITH SIMULTANEOUS GONADAL PEPTIDE MEASUREMENT ALLOWED FOR IMMEDIATE DIAGNOSIS OF MAJOR DISORDERS OF SEX DEVELOPPEMENT (DSD) AND EARLY GENDER ASSIGNMENT IN A COHORT OF 92 NEONATES
Fatma Chebbi, MD; Marie-Christine Temple, MD, CHU COCHIN, PARIS, France; Cyril Amouroux, MD, CHRU Montpellier, MONTPELLIER, France; Françoise Paris, MD,PhD, CHRU de Montpellier, MONTPELLIER, France; Laetitia Martinerie, MD, University of Paris, Robert Debré Hospital, Paris, France; Karine Braun, MD; Hélène Bony, MD, CHU Amiens, AMIENS, France; Jean-Claude Carel, MD, University of Paris, Robert Debré Hospital, Paris, France; Najiba Lahlou, MD,PhD, University Paris Descartes, Paris, France

Objectives: As DSD constitute a heterogeneous group, our diagnostic strategies were based on assessment of both adrenal and gonadal secretion. Molecular diagnosis is limited by accessibility, delay and the small number of genes known to cause DSD. Multisteroid MS offers higher specificity, sensitivity and quicker results in smaller volume than immunoassays.

Methods: We developed a rapid liquid chromatography-tandem MS assay for simultaneous quantification of 10 steroids, targeting, in combination with gonadal peptides, the DSD underlying etiologies. Cortisol, 11-Deoxycortisol, Corticosterone, Deoxycorticosterone, Testosterone, Dihydrotestosterone, Androstenedione, Dehydroepiandrosterone, 17-hydroxyprogesterone and Progesterone were quantified by triple-quadrupole MS Quattro Premier (Waters, StQuentin-en-Y, Fr). On the same samples AMH and inhibinB were simultaneously assayed using ultrasensitive ELISA (AnshLabs, Houston, Tx). All results were obtained within 5 hours.

Patients: Over the last 3 years, 92 neonates with DSD detected at birth were investigated in the first week of life and retrospectively classified after karyotyping as XX and XY DSD.

Results: Among 43 neonates with XX DSD, were diagnosed or suspected within one day: three 21-hydroxylase blockades, two 11ß-hydroxylase blockades, 1 case of ovotestis, and 15 cases of isolated clitoris hypertrophy related to transient persistence of adrenal fetal zone.

Among 49 neonates with XY DSD, were diagnosed or suspected within one day : one 3ß-dehydrogenase defect, 2 cases of 5a-reductase defect, 2 cases of androgen insensitivity, 1 case of SF1 defect, 1 case of SOX9 defect and 5 cases of AMH defect responsible for Mullerian duct persistence.

In all cases the biological diagnosis was confirmed later on by molecular biology, showing several not yet reported mutations. All other patients from the cohort were free from any endocrine or genetic abnormality.

Conclusions: The applied strategy for evaluating at the same time both adrenal and gonadal functions allowed for fast and reliable diagnosis and therapy of acute situations such as congenital adrenal hyperplasia, and helped to swiftly assign the appropriate gender in all DSD cases.

626: P1-100

IDENTIFICATION OF A FOUNDER EFFECT OF THE STAR P.Q258* NONSENSE MUTATION IN KOREAN PATIENTS WITH CONGENITAL LIPOID ADRENAL HYPERPLASIA
Eungu Kang, MD; Yoon-Myung Kim, MD; Gu-Hwan Kim, PhD; Beom Hee Lee, MD; Han-Wook Yoo, MD; Jin-Ho Choi, MD, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic Of

Objectives: Congenital lipoid adrenal hyperplasia (CLAH) is the most severe form of congenital adrenal hyperplasia, caused by defects in the steroidogenic acute regulatory protein (STAR) or, rarely, the cholesterol side-chain cleavage enzyme (P450scc). The most common STAR gene mutation is c.772C>T (p.Q258*), which was identified in 65 to 90% of Japanese and Korean patients with CLAH, suggesting a founder effect. This study aimed to investigate the phenotypic and mutation spectrum of STAR defects and identify a founder effect of the p.Q258* mutation in Korean patients with CLAH.

Methods: For 45 patients from 42 independent pedigrees, haplotype analysis was performed in 10 unrelated trio families, including patients with the p.Q258* mutation whose DNA samples were available, using 1,972 single nucleotide polymorphism (SNP) and six short tandem repeat (STR) markers. An Illumina Infinium® Human Omni2.5-8 v1.3 performed the SNP genotyping.

Results: Among 84 alleles from 42 unrelated families, mutation p.Q258* was found in 74 alleles (88.1%) from 41 families. A shared haplotype was identified in 17 of 20 alleles from 10 patients (size, 198 kb). The age of the founder mutation was estimated as 4,875 years (95% credible set: 3,575–7,925 years) assuming an intergenerational time interval of 25 years.

Conclusions: A haplotype analysis showed that the 198-kb region was shared by most individuals with CLAH, indicating the existence of a founder effect. The STAR p.Q258* mutation is the most common in Korean patients with CLAH, suggesting a founder effect. The age of the mutation corresponded with the date when the Korean people settled in the Korean peninsula. The high prevalence of p.Q258* in Japan and China also suggests a founder effect in Asian countries.

1366: P1-101

GONADAL FUNCTION IN ADULT MALE PATIENTS WITH CONGENITAL ADRENAL HYPERPLASIA
Manon Engels, MS/MA, Radboud University Medical Centre, Nijmegen, Netherlands; Henrik Falhammar, PhD, Karolinska University Hospital, Stockholm, Sweden; Emma Webb, PhD, University of Birmingham, Birmingham, United Kingdom; Anna Nordenstrom, , Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; Fred Sweep, PhD; Paul Span, PhD; Teun van Herwaarden, PhD, Radboud University Medical Centre, Nijmegen, Netherlands; Julia Rohayem, PhD, Universitätsklinikum Münster, Münster, Germany; Claire Bouvattier, PhD, Bicêtre Hospital, Paris Sud University, Paris, France; Birgit Koehler, PhD, Charité, CVK, Berlin, Germany; Barbara Kortmann, PhD, Radboud University Medical Centre, Nijmegen, Netherlands; Wiebke Arlt, Professor, University of Birmingham, Birmingham, United Kingdom; Nel Roeleveld, PhD, Radboud Universitair Medisch Centrum, Nijmegen, Netherlands; Nike Stikkelbroeck, PhD, Radboud University Medical Centre, Nijmegen , Netherlands; Nicole Reisch, PhD, Klinikum der Universität München, München, Germany; Hedi Claahsen - Van Der Grinten, PhD, Amalia Children's hospital, Radboudumc Nijmegen, Nijmegen, Netherlands

Objectives: Reported fertility problems in men with congenital adrenal hyperplasia (CAH) range from normal to severely impaired. Previous studies are most often based on data from a single center. Mechanisms for fertility impairment include primary, secondary and tertiary gonadal dysfunction or psychosexual problems. Primary gonadal dysfunction may be due to benign testicular adrenal rest tumors (TART). In addition, central gonadal dysfunction may be caused by the suppressive effects of elevated adrenal androgens or their metabolites on the HPG axis. Aim of the study is to determine gonadal function in male CAH patients in the European DSD life cohort.

Methods: The DSD LIFE database contains data of 1161 patients with different forms of disorders of sex development (DSD) including 121 male CAH patients from 14 European centers. Indirect markers of gonadal function were collected including hormone concentrations, serum analysis (n=43-90) and ultrasound testes (n=67). Patient characteristics, biochemical parameters and treatment  in patients with and without gonadal dysfunction were evaluated.

Results: 121 male CAH patientswere available for the study. In 118 patients, median age 28 (range 15-68) years, gonadal function could be  evaluated, 3 were excluded due to longstanding testosterone treatment. 2 patients had 11β-hydroxylase deficiency, 116 patients suffered from 21-hydroxylase deficiency (genotype 0=23 pts, A=36 patients, B=32 pts, C=3 pts, no mutation=22 pts).  Low testosterone concentrations (according to range variable lower than reference range) were reported in 19/97 (19.6%), low LH in 12/90  (13.3%), low FSH in 9/90 (10%), and low inhibin B in 8/43 patients (18.6%). Pathologic semen parameters (according to WHO 2010) were observed, considering low sperm count (15/39 patients), decreased motility (13/37 patients), abnormal morphology (4/28 patients). TARTs were present in 27 of 67 patients (in 2 patients unilaterally). 26 patients had fathered a total of 43 children.

Conclusions: Gonadal function in male CAH patients can be compromised with a high prevalence of TART. Further analyses are necessary to compare TART and non TART patients and to determine other contributing pathogenetic factors.

226: P1-102

ADRENOCORTICAL CARCINOMA IN CHILDREN: A CLINICO-PATHOLOGIC ANALYSIS OF 41 PATIENTS AT MAYO CLINIC FROM 1950-2016
Nidhi Gupta, MD; Michael Rivera, MD; Paul Novotny, MS/MA; Vilmarie Rodriguez, MD; Irina Bancos, MD; Aida Lteif, Associate Professor, Mayo Clinic College of Medicine, Rochester, MN, United States

Objectives: Adrenocortical carcinoma (ACC) is an aggressive rare childhood cancer. No definite histopathological criterion exists to differentiate pediatric ACC from adrenocortical adenoma. The aim of this study was to describe the clinico-pathologic data of children with ACC and identify prognostic factors. Performance of Weiss score, modified Weiss score and Wieneke-index was evaluated.

Methods: Retrospective chart review of patients with histologically proven ACC from 1950-2016 at the Mayo Clinic was done (age at onset of symptoms ≤ 21y). Archived pathology slides were reviewed.

Results: Forty-one patients met inclusion criteria. Median age at onset of symptoms was 15.7y (range, 0.2-21y). Female-male ratio was 3.6:1. Mixed symptomatology with >1 hormonal abnormality was the most common presentation (54%, n=22) followed by virilization alone (17%, n=7). Sixty-seven percent of patients (26/39) underwent total adrenalectomy and 56% (23/41) received adjuvant therapy. Patients aged <4y had smaller median tumor diameter and lower median tumor weight as compared to those >12y (tumor diameter: 6.4cm vs. 10.8cm; tumor weight: 80 grams vs. 435 grams). Metastatic disease was reported in 63% of patients (n=26). Most common sites of metastases were liver (74%, n=20) and lungs (67%, n=18). The majority of patients (63%, n=26) were classified as Stage IV (T1-4N0-1M1) by ENSAT system. Recurrent disease was reported in 24% patients (n=10). At a median follow-up of 1.8y (range 0.1-37y), 46% of patients (13/29; SE 0.095) remained alive. The 2-year and 5-year survival rates were 34.8% (SE 0.092) and 26.5% (SE 0.087) respectively. In a multivariate analysis, age at onset of symptoms and disease stage were independently associated with overall survival. The Wieneke scoring system (≥ 4) was most accurate in predicting death or recurrence of ACC (sensitivity 100%, specificity 83.3%, Fisher’s Exact Test p=0.0014).

Conclusions: Younger age at onset of symptoms (<4y) and less advanced stage of disease (Stage I or II) are favorable prognostic factors for survival in children with ACC. The Wieneke scoring system was most closely associated with patient outcomes. This is the largest single institution report on pediatric ACC.

250: P1-103

PROS AND CONS OF SALIVARY 17 HYDROXY PROGESTERONE IN CONGENITAL ADRENAL HYPERPLASIA CHILDREN, AN EGYPTIAN EXPERIENCE
Ahmed Hassan, MD, Tanta University, Tanta, Egypt; Mona Hafez, MD, Cairo University, Cairo, Egypt; Adel Erfan, MD, Tanta University, Tanta, Egypt; Fatma El-Mougy, MD, Cairo University, Cairo, Egypt

Objectives:

Methods: Results: Female patients were 20 cases (66.7%) and male patients were 10 (33.3%). Unexpalined sibling death were found in 26.7% of paients. There was  significant positive correlation between serum and salivary 17 OHP in cases( P 0.001) but there was non significant positive corralation in control (P 0.731). All salivary samples (100%) obtained at diagnosis were insuffient and those patients were excluded from the study, while only 10% of salivary samples at follow up were insufficient and their patients were excluded from the study. Duration of salivary samples in infants aged less than 2 years were significantly longer than salivary sampling in children aged more than 2 years(P <0.05).                           

Conclusions: CAH in Egypt has unbalanced male female ratio which indicate underdiagnosis of this condition in male cases and highlights the importance of neonatal screening in Egypt. Salivary 17OHP is a reliable method for assessment of CAH patients and as effective as serum 17OHP that should be used in follow up, not in diagnosis of CAH. Difficulties during sampling might limit the use of salivary 17OHP in infancy. More training of medical personnel is required before recommendation of wide use of salivary 17OHP in Egypt.

270: P1-104

ADRENOMEDULLARY FUNCTION DECREASES AFTER BIRTH IN CLASSICAL CONGENITAL ADRENAL HYPERPLASIA AND PREDISPOSES TO ACUTE ILLNESS
Jonathan F Weber, MD, Children's Hospital of Los Angeles, Los Angeles, CA, United States; Christina M Koppin, BS/BA; Sanjay Chand, BS/BA; Monica Serrano-Gonzalez, MD; Mitchell E Geffner, MD; Mimi S Kim, MD, Children's Hospital Los Angeles, Los Angeles, CA, United States

Objectives: Youth with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD) exhibit abnormal morphology and function of the adrenal medulla. We have shown decreased epinephrine (Epi) levels in newborns and young infants with CAH, indicating that impaired adrenomedullary function may occur during fetal development and be present from birth. Little is known about adrenomedullary function in older infants and toddlers with CAH when they are at high risk for illness-related morbidity and mortality. Our objective was to quantify catecholamine levels in very young children with CAH and to correlate adrenomedullary function with frequency of acute illness.

Methods: We studied 34 newborns, infants and toddlers with CAH due to biochemically confirmed 21OHD, and 28 age-matched unaffected controls. Plasma catecholamine [Epi and norepinephrine (NE); pg/mL] levels and NE:Epi were determined at newborn, 1-yr, 2-yr, and 3-yr visits. We also quantified the frequency of acute illness for 22 CAH newborns/young infants compared to 17 controls. Data are presented as mean ± SD, or median (IQR).

Results: Epi levels were lower in CAH newborns and young infants [80 (40-104)] vs. controls [127 (77-173.5); p< 0.05], with a decrease in Epi between birth and 1 year in CAH [newborn 81 (45.5-102.5), 1-yr 40 (40-80.7); p< 0.05]. Epi levels remained similar at 2 and 3 year in CAH toddlers. NE:Epi at birth was higher in CAH [12.3 (7.8-16.9)] vs. controls [6.7 (5.4-9.3); p< 0.01] and increased over the 1st year in CAH [newborn 11.5 (8.3-15), 1-yr 23.8 (17-26); p< 0.05], reflecting either the decline in Epi and/or overcompensation by the sympathetic nervous system for impaired adrenomedullary function. CAH infants had more illness in the 1st year (CAH 2.0 ± 2.8, controls 0.4 ± 1; p< 0.05) and 2nd year (CAH 1.2 ± 1.4, controls 0.2 ± 0.4; p< 0.01). CAH infants with lower Epi (<100) had a higher frequency of illness (1.4 ± 1.7) in the 1st year of life compared to those with Epi ≥100 (0.3 ± 1; p<0.05).

Conclusions: Epi levels are lower in newborns and young infants with CAH, and decline further over the first year of life, when CAH youth are prone to acute illnesses. CAH infants with lower Epi may be at even higher risk for more frequent illness.

580: P1-105

DISSOLUTION AND COMPATIBILITY OF HYDROCORTISONE GRANULES FOLLOWING EXPOSURE TO COMMON PAEDIATRIC ADMINISTRATION FLUIDS AND FOOD MATRICES
Sandra Klein, PhD; Erik Wollmer, Dipl.Pharm., University of Greifswald, Greifswald, Germany; Greg Neal, Eng.D., Diurnal Limited , Cardiff, United Kingdom; Daniel Margetson, PhD; Martin J Whitaker, Prof.; John Porter, PhD, Diurnal Limited, Cardiff, United Kingdom

Objectives: The objective of the present work was to study the biorelevant dissolution and compatibility properties of hydrocortisone granules (Infacort® development formulation Diurnal Ltd.) following exposure to typical administration fluids including breast milk, artificial milk, whole milk, water, apple-, orange- and tomato juice and semi-solid dosing vehicles such as apple sauce and yoghurt.

Methods: Dosing conditions were assessed for a representative patient collective, ranging from neonates to school children. Hydrocortisone doses applied in the in vitro experiments were in the dose range of 0.5 to 5 mg. Test media and volumes were adapted to simulate gastric contents of children of different ages immediately after administering a single dose of hydrocortisone together with an age appropriate volume of the different fluids (50-200 ml), or immediately after mixing and administering a single dose with a dosing vehicle (1 teaspoon) followed by some water intake. Dissolution experiments were performed at 37 °C with the Mini-Paddle apparatus. The total duration of the dissolution experiments was 120 or 240 min to screen both dissolution and compatibility with the different media. Samples were taken at predetermined time points and analyzed by HPLC.

Results: In all dosing scenarios simulating initial gastric conditions after administering age-related hydrocortisone doses to children of different age groups, in vitro drug release was fast and complete, i.e. > 75 or 80 % of the dose was released in within 30 min. This was despite the dosing matrices differing significantly in pH and other physicochemical parameters. Moreover, in all experiments no drug precipitation or degradation could be observed over the entire test duration.

Conclusions: Results from the present study confirm the compatibility and chemical stability of hydrocortisone granules with commonly used dosing matrices over a 120 or 240 min time period, respectively. Results from the biorelevant in vitro dissolution experiments suggest that in vivo dissolution and bioavailability of the granules will not be affected by the composition of the co-administered fluids and vehicles studied.

Acknowledgements

Dr. Anja Lange, Hospital for Pediatrics, University of Greifswald, is gratefully acknowledged for her support.

1335: P1-106

CLINICAL AND GENETIC CHARACTERIZATION OF A COHORT OF PATIENTS WITH ALGROVE SYNDROME (AS)
Erdal Kurnaz, MD, Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, Ankara, Turkey; Paolo Duminuco, MD, IRCCS Istituto Auxologico Italiano, Milan , Italy; Zehra Aycan, professor, Dr. Sami Ulus Research and Training Hospital of Women’s and Children’s Health and Diseases, , Ankara, Turkey; Senay Savas Erdeve, Assoc. Professor, Ankara Children's Hematology Oncology Education and Research Hospital, Ankara, Turkey; Nursel Muratoglu Sahin, MD, Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, Ankara, Turkey; Melisah Keskin, MD, Dr. Sami Ulus Obstetricsand Gynecology and Pediatrics Training and Research Hospital, Ankara, Turkey; Elvan Bayramoglu, MD, Dr. Sami Ulus Research and Training Hospital of Women’s and Children’s Health and Disease, Ankara, Turkey; Marco Bonomi, MD; Semra Çetinkaya, MD, Dr. Sami Ulus Obstetricsand Gynecology and Pediatrics Training and Research Hospital, Ankara, Turkey

Objectives: Allgrovesyndrome, AS (also calledTriple-A syndrome, OMIM #231550) is a rare autosomal recessive disorder characterized by adrenocorticotropic hormone resistant adrenal insufficiency, alacrima, achalasia, neurological and dermatological abnormalities. Mutations in the AAAS gene on chromosome 12q13 encoding the nuclear pore protein ALADIN have been reported in these patients

Methods: Over the period 2006 and 2016, we evaluated five patients with the clinical diagnosis of triple A syndrome, based on the presence of at leat two symptoms, usually adrenal insufficiency and alacrimia.

Results: Patients underwent genetic analysis revealing homozygous mutations in the AAAS gene in all of them. One novel mutations was detected: homozygous deletion of 10bp (c. 1262_1272del, p.Q421NfsX126) in the exon 14 of the AAAS gene that causes a frameshift with introduction of an aberrant stop codon after 126 amino acids. This genetic variants, due to significant alterations in the protein structure,are highly probable pathogenetic. A precise genotype–phenotype correlation was impossible to be established.

Conclusions: Based on our experience, we recommend that in the presence of alacrima and at least one more symptom of AS, molecular analysis should be performed. Our cases share many clinical features with AS and underlines the variability in this syndrome and the need for thorough investigations following a multidisciplinary approach.

1288: P1-107

MANAGEMENT OF CUSHING SYNDROME IN CHILDREN WITH MCCUNE-ALBRIGHT SYNDROME IS A CHALLENGING TASK.
Nadezhda Makazan, MD, Endocrinology Research Centre, Moscow, Russian Federation; Elizaveta M Orlova, PhD, Institute of Paediatric Endocrinology, Endocrinology Research Center, Moscow, Russian Federation; Natalya Zubkova, PhD; Maria Kareva, PhD, Endocrinology Research Centre, Moscow, Russian Federation; Valentina Peterkova, MD-PhD, Institute of Pediatric Endocrinology, Moscow, Russian Federation

Objectives: McCune-Albright syndrome (MAS) is a rare genetic disorder caused by somatic mutations of GNAS with mosaic distribution of  activated Gas subunit in various tissues. Clinical features include café-au-lait spots, hyperfunctioning endocrinopathies and fibrous dysplasia. Cushing syndrome (CS) is a rare life-threatening manifestation of MAS associated with bilateral adrenal hyperplasia. In most of cases, bilateral adrenalectomy is required but in selected cases spontaneous remission was described. 

Methods: We present three cases of Cushing syndrome in children with MAS and describe different treatment approaches.

Results: All the patients with MAS manifested with CS in neonatal period. ACTH-independent hypercortisolism was diagnosed based on clinical features and laboratory findings. Abdominal CT identified bilateral adrenal hyperplasia in all cases. Patients (P) 1 and 2 were admitted because of severe recurrent pneumonia since birth. They have “moon face”, growth retardation and café-au-lait spots since birth and were diagnosed with CS at 4th and 5th months old respectively. Adrenalectomy was performed just after diagnosing because of the severity of symptoms. P1 underwent unilateral adrenalectomy of the larger gland with complete remission during next seven years of follow up, she did not develop adrenal insufficiency. In P2 bilateral adrenalectomy was performed following by substitutive therapy with hydrocortisone and fludrocortisone. P3 had milder clinical phenotype than patients 1 and 2 and was diagnosed with CS at the age of two, but clinical features of CS (“moon face”, growth retardation, bone delay and obesity) and café-au-lait spots were presented since birth. Treatment with steroid synthesis inhibitor (ketoconazole) during a year was not effective. Unilateral adrenalectomy of the larger gland was performed at the age of three but the remission hadn’t been achieved, so the second adrenal was removed six months after. There were no cases of adrenal crisis after surgical treatment.

Conclusions: Treatment approach to CS in MAS is challenging. Unilateral adrenalectomy sometimes could be effective but in others bilateral adrenalectomy is necessary. We need more experience to create clinical recommendations and to determine factors that could be predictable for unilateral adrenalectomy success.

706: P1-108

METFORMIN FOR RAPIDLY MATURING GIRLS WITH CENTRAL ADIPOSITY: NORMALIZATION OF ACCELERATED BONE MATURATION RELATES TO LIVER FAT
Rita Malpique, PhD, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Francis De Zegher, PhD, University of Leuven, Leuven, Belgium; Cristina García Beltrán, MS/MA, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Abel Lopez-Bermejo, PhD, Hospital Dr. Josep Trueta and Girona Institute for Biomedical Research, Girona, Spain; Lourdes Ibáñez, PhD, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain

Objectives: Girls with a history of prenatal growth restraint and postnatal weight catch-up tend to develop an excess of visceral and hepatic fat. Such central adiposity may be accompanied by an upregulated adrenarche with precocious pubarche (PP), and by a rapidly progressive puberty leading to early menarche and relatively short stature. A pilot study suggested that metformin treatment for 4 yr can reduce central adiposity in low-birthweight (LBW) girls with PP, and normalize pubertal milestones and adult height. We studied the relationships among metformin treatment, bone maturation and body composition in LBW-PP girls of this pilot study.

Methods: Longitudinal hand X-rays (0-4 yr, analysed by BoneXpert) were available from 34 randomized non-obese LBW-PP girls (89% of original cohort; N=17 untreated, N=17 metformin-treated; mean age at start 8 yr) along with body composition (0-4 yr, by DXA), hepatic fat and abdominally subcutaneous and visceral fat (post-treatment, by MRI).

Results: At start, bone age was ahead of chronological age. The tempo of bone aging was accelerated in untreated girls (≈ 16% faster vs chronological aging) and normal in metformin-treated girls (≈ 20% slower vs untreated girls). Metformin-treated girls gained more height per bone-age year. Metformin treatment was accompanied by lower gains of fat, particularly of visceral and hepatic fat. The tempo of bone maturation associated most closely (R=0.55; P<0.001) with hepatic fat.

Conclusions: Metformin treatment in rapidly maturing LBW-PP girls with central adiposity was found to normalize the accelerated bone maturation; this normalization was accompanied by less central fat, and it related most closely to hepatic fat.

585: P1-109

EFFECT OF MEGESTROL ACETATE ON ADRENAL FUNCTION WHEN USED AS AN APPETITE STIMULANT AMONG CHILDREN.
Anoop Mohamed Iqbal, MD, Mayo Clinic College of Medicine, Rochester, MN, United States; Seema Kumar, Associate Professor, Mayo Clinic, Rochester, MN, Rochester, MN, United States; Aida Lteif, Associate Professor, Mayo Clinic College of Medicine, Rochester, MN, United States

Objectives: Background: Adrenal insufficiency has been reported as an adverse effect of treatment with megestrol acetate in few case reports and few case series. In adults, hyperglycemia and features of Cushing syndrome have been described.  The effect of cortisol synthesis on body mass index (BMI) has not been well described in children.

Objectives: To evaluate the effect of megestrol acetate on BMI and to describe its adverse events when used as an appetite stimulant in children.  

Methods: Patients and methods: The study included patients < 21 years of age, who were treated with megestrol acetate at Mayo Clinic between 1996 and 2014. These individuals had to have documentation of weight and height at initiation and at discontinuation of the therapy. 

Results: Results: 73 patients were treated with megestrol acetate (Mean age: 10.07 ± 4.84 years Male: 63%;). Mean length of treatment was 3.91 ± 3.54 months. Mean starting dose of Megestrol acetate was 7.8 ± 4.44 mg/kg/day. Mean BMI z score before and after the treatment were statistically different (Before: -0.76 ± 1.52; After: -0.07 ± 1.40;( p <0.001)).  After adjusting for age and gender, we found that the change in BMI z-scores were positively related to the dose (β:0.1 kg/m2; p=0.008) and duration(β: 0.07 kg/m2; p=0.03) of treatment. 11 patients (15%) had a cortisol level checked while on Megestrol.   Additional 3 patients had cortisol level measured at completion of treatment. Cortisol was low in all 11 patients, at least once during the treatment period. Suppression was seen as early as 25 days post initiation of megestrol acetate treatment. In 9 patients cortisol levels had normalized when checked 12 days to 6 months after discontinuation of the megestrol acetate therapy.  One patient had hyperglycemia but this was around the time of death. Mild hyponatremia was noted (131-134 mg/dL) in 2 patients who did not have a cortisol level checked.

Conclusions: Conclusions: Megestrol acetate causes adrenal suppression at the standard treatment dose.  Electrolyte abnormalities are uncommon.  Megestrol is effective in improving BMI z score. We recommend that cortisol level be measured in all patients treated with megestrol acetate in the first 4 weeks of initiating therapy.

1013: P1-110

ASSESSMENT OF HEALTH-RELATED QUALITY OF LIFE IN EGYPTIAN CHILDREN AND ADOLESCENTS WITH CONGENITAL ADRENAL HYPERPLASIA.
Noha Musa, MD; Lubna Fawaz, MD; Noha Asem, MD; Shaza Basyony, MS/MA, Cairo University, Cairo, Egypt

Objectives:    To assess health-related quality of life (HRQOL) in Egyptian children and adolescents with congenital adrenal hyperplasia (CAH) and to study different factors affecting QOL in CAH.

Methods: This cross-sectional study included 200 children and adolescents with CAH due to 21hydroxlase deficicency (21OHD) regularly attending Diabetes, Endocrine and Metabolism Pediatric Unit (DEMPU) at Cairo University Children's hospital. Enrolled patients were evaluated regarding age, sex of rearing (initial and final), family history, clinical type (salt wasting, simple virilizing or late onset), timing of genitoplasty, number of hospital admissions in the last year, compliance to treatment, regularity of follow up, presence of complications (hirsutism, precocious puberty, hypertension, complicatons related to genitoplasy) as well as hormonal control. HRQOL was assessed using WHOQOL-BREF questionnaire with four domains analysed independently including physical, psychological, social and environmental domains with higher scores indicating better QOL.

Results: The study included 140 females and 60 males wth a mean age of 6.6 + 4.5 yrs. Eighty-eight percent of them were salt wasting CAH. Older children and adolescents had significantly lower QOL scores (r=-0.151, p=0.033). Total QOL score correlated significantly with degree of virilzation (Prader score) in females (r=-0.314, p=0.041), frequency of hospitalization (r=-0.272, p=0.000) and level of androstenedione (r=-0.274, p=0.007). Psychological domain was affected by age (r=-0.157, p=0.026) and timing of genitoplasty (r=-0.326, p=0.001) while social domain was affected by age (r=-0.277, p<0.001) and pubertal stage (r=-0.195, p=0.006). Females had lower scores at psychological domain (p<0.001), whereas males showed lower scores at physical domain (p=0.003). Salt losing CAH patents had lowest QOL scores at physical domain (p=0.003).  Patients on regular follow up scored higher at the environmental domain (p=0.037) and those with good hormonal control had higher total QOL scores (p=0.032).

Conclusions: HRQOL was relatively more affected in CAH patients with older age, poor hormonal control, more frequent hospital admissions and those who developed complications.

1661: P1-111

MUTATION SPECTRUM OF ABCD1 IN 20 VIETNAMESE PATIENTS WITH X-LINKED ADRENOLEUKODYSTROPHY
Khanh N Nguyen, MD; Dung Chi Vu, MD; Ha T Nguyen, MD; Thao P Bui, MD; Ngoc T.B Can, MD; Dat P Nguyen, A/Prof; Hai T Le, MD, The National Children's Hospital, Hanoi, Viet Nam; Vu Anh Hoang, MD, University of Medicine and Pharmacy at Ho Chi Minh, Ho Chi Minh, Viet Nam; Shimozawa Nobuyuki, MD, Gifu University, Gifu, Japan

Objectives: X-linked adrenoleukodystrophy (X-ALD) is caused by a defect in the gene ABCD1, which maps to Xq28 and codes for a peroxisomal membrane protein that is a member of the ATP-binding cassette transporter superfamily. This disease characterized by progressive neurologic dysfunction, occasionally associated with adrenal insufficiency.We identified mutations of gene ABCD1 in Vietnamese patients with X-ALD.

Methods: Genomic DNA from 20 Vietnamese patients from 18 unrelated families was extracted using standard procedures from the peripheral blood leukocytes. Mutation analysis of ABCD1 was performed using Polymerase chain reaction (PCR) and DNA direct sequencing.

Results: We identified 17 different mutations of ABCD1 in 20 patients including missense mutations (11/17), deletion (4/17), frameshift mutation (1/17) and splice site mutation (1/17). Of which, six novel mutations including c.1202G>T (p.Arg401Trp); c.1208T>A (p.Met403Lys); IVS8+28-551bp del; c.1668G>C (p.Q556H); c.292_296delTCGGC (p.S98RfsX95); and the extent of deletion included between IVS1+505 and IVS2+1501, containing whole the exon 2 (4243bp), plus insertion of 79bp from BAP31 and 8bp from unknown origin in this deleted region were identified in six unrelated patients. Eleven reported mutations including c.796G>A (p.Gly266Arg); c.1628C>T (p.Pro543Leu); c.1553G>A (p.Arg518Gln); c.1552 C>T (p.Arg518Trp); c.854G>C (p.R285P); c.1825G>A (p.E609K); c.1415_1416delAG (p.Q472RfsX83) and c.46-53del insG, c.1553G>A (p.Arg518Gln), c.1946-1947insA (p.Asp649fsX733), c.1978C>T(p.Arg660Trp) were identified in 14 patients from 11 families.

Conclusions: Mutation analysis of ABCD1 helped confirmation of diagnosis of X-ALD, genetic counselling and prenatal diagnosis.

134: P1-112

COULD WE BE OVER DIAGNOSING CENTRAL ADRENAL INSUFFICIENCY IN PRADER-WILLI SYNDROME?
Kathryn Obrynba, MD, Nationwide Children's Hospital/The Ohio State University, Columbus, OH, United States; David Repaske, MD, PhD, University of Virginia Children's Hospital/University of Virginia, Charlottesville, VA, United States; Jason Buckner, MD, Nationwide Children's Hospital/The Ohio State University, Columbus, OH, United States; Kathryn Anglin, RN, MSN, Nationwide Children's Hospital, Columbus, OH, United States; Loyal Coshway, MD, Toledo Children's Hospital/University of Toledo, Toledo, OH, United States; Rachel Cazeau, MD, Florida Hospital, Orlando, FL, United States; Rolando Lozano, MD, Central Ohio Pediatric Endocrinology and Diabetes Services, Columbus, OH, United States; Manmohan Kamboj, MD; Amy Pyle-Eilola, PhD, Nationwide Children's Hospital/The Ohio State University, Columbus, OH, United States

Objectives: To examine the function of the hypothalamic adrenal axis and presence of central adrenal insufficiency (CAI) in patients with Prader-Willi Syndrome (PWS), and to determine the correlation of the low dose ACTH stimulation test (LDAST) compared to the overnight metyrapone test (OMT) when used sequentially in the same patient.

Methods: Subjects with PWS (n=21), age 3-53 yo, 10 male, 11 female were admitted to the hospital for overnight testing. Subjects did not have recent oral glucocorticoid use or known diagnosis of CAI. LDAST (1 mcg/m2, maximum 1 mcg) was performed followed by OMT. OMT was performed by adminstering a single dose of metyrapone (30 mg/kg, maximum 1 g) orally at 2400h. Serum was collected for cortisol, 11-deoxycortisol (11-DOC), and ACTH the following morning at 0800h. Peak cortisol results >15.5 mcg/dL following LDAST and 0800 11-DOC  results >7 mcg/dL following OMT were classified as adrenal sufficiency. Peak cortisol result indicating adrenal sufficiency on LDAST was chosen based on institutional accepted normal values for a specific cortisol assay. OMT was used as the standard test for comparison.

Results: All patients (n=21) had 0800 11-DOC values >7 mcg/dL following OMT, indicating adrenal sufficiency. 6/21 (29%) failed LDAST based on peak cortisol < 15.5 mcg/dL. Using the traditionally accepted cut-off for stimulated cortisol of 18.1, 13/21 (62%) failed LDAST. There was no apparent relationship between those who passed and those who failed LDAST in age, gender, or body mass index. No patient displayed signs or symptoms of adrenal insufficiency.

Conclusions: Our results indicate poor agreement between LDAST and OMT results in patients with PWS. We found no evidence of CAI in our PWS population based on 0800 11-DOC values following OMT, yet 29-62% of our PWS popluation demonstrating a normal response to OMT failed LDAST. This data suggests that LDAST may have a high false positive rate in diagnosing CAI patients with PWS which may lead to over diagnosis.

1760: P1-113

CLINICAL AND MOLECULAR CHARACTERIZATION OF PATIENTS WITH CONGENITAL LIPOID ADRENAL HYPERPLASIA IN SOUTHEAST ASIA
Taninee Sahakitrungruang, MD; Patra Yeetong, PhD; Pattaranatcha Charnwichai, MS/MA, Chulalongkorn University , Bangkok, Thailand; Somchit Jaruratanasirikul, MD, Prince of Songkla University, Bangkok, Thailand; Kah Yin Loke, MD, National University Health System, Singapore, Singapore; Pirunyar Nakavachara, MD, Mahidol University, Bangkok, Thailand; Chawkaew Kongkanka, MD, Queen Sirikit National Institute of Child Health, Bangkok, Thailand; Vorasak Shotelersuk, MD, Chulalongkorn University , Bangkok, Thailand

Objectives: Mutations in Steroidogenic Acute Regulatory protein (StAR) cause congenital lipoid adrenal hyperplasia (lipoid CAH), characterized by absent steroidogenesis, potentially lethal salt loss, 46,XY sex reversal and massively enlarged adrenals engorged with cholesterol esters. Nonclassic lipoid CAH is a recently recognized disorder caused by StAR mutations that retain partial function. We aim to delineate the clinical, hormonal, and molecular characterization of StAR mutations in patients with lipoid CAH.

Methods: The entire coding regions of the StAR gene were assessed by polymerase chain reaction and sequencing analysis. Novel StAR missense mutations were re-created in expression vectors and StAR activity was measured as pregnenolone production in COS-7 cells. A minigene assay was used to determine the effects of the splicing mutation.

Results: There were 10 patients of lipoid CAH had mutations in the StAR gene with 5 novel mutations (p.P230L>WfsX, IVS6-1G>A, IVS3+(2-3)insT, p.W147R, p.Q264R).  Eight patients had classic lipoid CAH presenting with adrenal crisis during early infancy (range of onset 3-11 months of age). Two siblings had nonclassic phenotypes with later onset adrenal insufficiency without disordered sex development.  Adrenal enlargement by imaging was demonstrated in only 3 cases of classic lipoid CAH. The in vitro activities of W147R, and Q264R were 3.9%, and 1.6% of wild-type activity. The IVS6-1G>A mutation caused intron retention in the StAR gene.

Conclusions: StAR mutations may not be rare in Southeast Asian population. There is a broad clinical spectrum of StAR mutations varying from early onset adrenal insufficiency to late onset of glucocorticoid deficiency with only mild defects in mineralocorticoid and sex steroid synthesis.  Adrenal gland enlargement is not pathognomonic for lipoid CAH.

713: P1-114

SERUM FREE CORTISOL IS SUPERIOR TO TOTAL CORTISOL IN ASSESSING THE ADRENAL AXIS DURING GLUCAGON STIMULATION TEST IN CHILDREN AND ADOLESCENTS
Anita Schachter Davidov, MD; Eyal Ori, MD; Anat Segev Becker, MD; Naomi Weintrob, MD, Pediatric Endocrinology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel/Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel

Objectives: Total cortisol (TC) response is routinely measured during glucagon stimulation test for growth hormone reserve in order to assess the adrenal axis. We recently published norms for serum free cortisol (sFC) response in children and adolescents during ACTH stimulation test. We extended this research to assess whether sFC is superior to TC in assessing the adrenal axis during glucagon test and could predict growth hormone (GH) response to glucagon stimulation.

Methods:  Infants and children referred for evaluation of GH reserve underwent glucagon testing. Baseline and stimulated serum TC, sFC, GH and glucose levels were measured before and every 30 minutes for 180 minutes after IM administration of Glucagon (30 mcg per kg, max of 1 mg). Serum TC and GH were determined by chemiluminescence and sFC was measured by the same method following equilibrium dialysis. The cutoff value was set at >20 mcg/dl for TC and >0.9 mcg/dl for sFC.

Results: The study group consisted of 103 subjects (62 girls), median age 3.9 years (range, 0.5-14). The mean basal and peak TC levels were 13.3 ± 6.7 mcg/dl and 29.6 ± 8.8 mcg/dl, respectively. The mean basal and peak sFC levels were 0.7 ± 0.8 mcg/dl and 1.7 ± 1.1 mcg/dl, respectively. There was a positive correlation between TC and sFC levels at all time-points. Girls had higher TC levels than boys at all time-points (P=.05), but there were no significant differences in sFC. There was a negative correlation between peak TC and age (r=-0.3, P=.007), but not between peak sFC and age. Of particular significance is the observation that 5 of the patients showing subnormal TC had a normal sFC response based on the previously published norms. We did not find a correlation between sFC and GH reserve.

Conclusions: sFC may spare the need for further evaluation of the adrenal axis in children undergoing glucagon stimulation test. The finding that TC is age and gender dependent while sFC is not may suggest that the sFC is superior to TC measurement in the pediatric population.

1195: P1-115

PRESENTING CHARACTERISTICS OF CHILDREN WITH CONGENITAL ADRENAL HYPERPLASIA IN SRI LANKA : A GENDER BASED ANALYSIS
Sumudu N Seneviratne, PhD; Udara S Hewa Gamage, MBBS; Ashangi M Weerasinghe, MBBS; Piyumi S Wickramarachchi, MBBS; Shamya De Silva, MD, University of Colombo, Colombo, Sri Lanka

Objectives: To describe and compare clinical and biochemical characteristics at initial presentation in male and female children with congenital adrenal hyperplasia (CAH) from Sri Lanka, in the absence of newborn screening.

Methods: This retrospective study was carried out in all consenting patients with CAH followed up at a tertiary care paediatric endocrinology clinic in Colombo, Sri Lanka in 2016. Data was collected on to a structured data collection sheet, from past clinical records. The characteristics of male and female patients were compared using Chi square for discrete variables and student t-test for continuous variables.

Results: Thirty nine participants aged between 1.5-17.5 years were included, of which 29 (74%) were salt wasters. Parental consanguinity was seen in 9 (23 %), while 6 (15 %) had a previously diagnosed sibling. A majority (77%) had hyper-pigmentation, while more than 50% had features of salt wasting (vomiting, dehydration) at presentation. All girls except one, had virilised genitalia. Hyponatremia (Na less than 125 mmol/l) was present in 12 (30%) and hyperkalaemia ( K more than 5.5 mmol/l ) in 27 (69%).

Majority was genetically female 30 (77%), and amongst one was being reared as a male due to severe virilisation. Males were more compromised at presentation, with higher numbers having dehydration (89 % of males vs 43% of females, p = 0.016) and vomiting (89% of males vs 27% of males, p = 0.001). Two (22%) males and 4 (13%) females presented in a hypotensive/ collapsed state. Mean serum Na at presentation was 120 mmol/l in males and 125 mmol/l in females.

Conclusions: Majority of children with CAH had evidence of salt wasting at presentation, with male children being more compromised.  The discrepancy in distribution among the two genders suggests that male children with CAH may have succumbed to the illness at a young age, without proper diagnosis.  Addition of CAH screening to the newborn screening program in Sri Lanka may help to detect those affected earlier, before salt wasting crisis occurs.

498: P1-116

LYMPHOPENIA AND INFECTION RISK IN PEDIATRIC CUSHING SYNDROME
Christina Tatsi, MD; Rebecca Boden, Student; Meg Keil, PhD; Charalampos Lysikatos, MD; Elena Belyavskaya, MD; Constantine A Stratakis, MD; Maya B Lodish, MD, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD, United States

Objectives: Pharmacologic doses of glucocorticoids are commonly used for immunosuppression, leading to higher risk for infections, related in part to lymphopenia. Adult patients with endogenous hypercortisolemia have been reported to have an abnormal cellular immune system and high risk for infections. Similar data have not been described in the pediatric population with endogenous Cushing Syndrome (CS).

Methods: We identified 195 pediatric patients (mean age at diagnosis: 12.5 years, range: 2.7-18, 88 males) with endogenous CS due to various causes (Cushing Disease: 152, ACTH-independent CS: 38, Ectopic CS: 5). A group of 66 children (mean age: 12.5 years, range: 2.9-17.9, 29 males) with documented normal cortisol levels was defined as the control group. We collected WBC with differential, urine cortisol, serum cortisol and ACTH levels at the time of diagnosis and at the follow up visits. We noted the presence of infection (including common bacterial, viral, and fungal infections, and opportunistic infections) at the time of their presentation.

Results: The lymphocyte count of the patients with CS was significantly lower than that of controls (2.2±0.8 vs 2.6±0.8 K/mcL, P=0.002). In addition, the lymphocyte count was negatively associated with the parameters of Cushing’s severity, including serum morning and midnight cortisol, morning ACTH (for the patients with Cushing Disease) and urinary free cortisol levels (P<0.01). For the patients who were followed after cure (n=126), the lymphocyte count improved significantly after resolution of hypercortisolemia from 2.1±0.8 to 2.9±1.0 K/mcL (P<0.001). The percentage of patients who were lymphopenic decreased from 7% at diagnosis to 2.4% after cure (Table 1). Infections were identified in 34 patients (17.5%) at the time of diagnosis. The presence of infection correlated with the serum morning cortisol (P=0.005), midnight cortisol (P=0.003) and urinary free cortisol (P=0.006) levels.

Conclusions: Children with endogenous CS have significant derangements of their lymphocyte count, which correlates with the severity of their disease and normalizes after the resolution of the hypercortisolemia. This has significant implications for the infection risk and the dysregulation of the immune system in children with iatrogenic CS.

1526: P1-117

SPECTRUM OF CONGENITAL ADRENAL HYPERPLASIA AT THE NORTH PEDIATRIC REFERRAL CENTRE OF VIETNAM
Dung Chi Vu, MD; Thao P Bui, MD; Khanh N Nguyen, MD; Dat P Nguyen, A/Prof; Hai T Le, MD; Ngoc T.B Can, MD; Mai T.T Do, MD; Huong T Bui, BSN; Ha T Nguyen, MD, The National Children's Hospital, Hanoi, Viet Nam

Objectives: Our aim is to analyze spectrum of all congenital adrenal hyperplasia (CAH) patients from 1999-2016 at the National Children's Hospital (NCH), Hanoi, Vietnam - an 1200 bed tertiary referral centre sevicing approximately 30 million people from northern provinces of Vietnam.

Methods: This is cases series study including clinical and biochemical characteristic analysis. Phenotype classification using criteria of Pang S. 1993 for cases with 21-hydroxylase deficiency (21-OHD). Virilisation severity was evaluated using Prader grading, puberty stages were evaluated using Tanner criteria. Bone age was obtained for children > 3 years and conpared with Atlat of Greulich and Pyle. Serum electrolyte using automated Beckman Coulter AU2700/AU 680 system, serum 17-OHP levels before and after stimulation by ACTH were measured by ELISA using DRG kits, and Elx808 reader system. Urinary steroid profile was analysed by GC/MS. Rare forms of CAH were confirmed by mutation analysis.

Results: At the start of 1999 there were 90 children with CAH managed at NCH. By Dec 2016 this increased to 848 including 441 (52%) male patients and 407 (48%) female patients. Age at diagnosis was 3 hours to 31 years. Number of cases with 21-OHD, 11ß-hydroxylase deficiency and 3ß-hydroxysteroid dehydrogenase deficiency was 833 (98.2%); 12 (1.4%) and 3 (0.4%), respectively. 829 of 833 patients with 21-OHD were classical phenotype and 4 of 833 cases were non classical phenotype. Among cases with 21-OHD classical phenotype, 74% were salt wasting and 26% were simple virilisation. Total number of cases representing a more than nine fold increase over 16 years. Most children (85%) were diagnosed at less then 12 months of age (55% at less than 1 month of age); 74% of all children were younger than 10 years. Formal mortality figures were low (11 known deaths).

Conclusions: The caseload of CAH at NCH has increased since 1999 and additional capacity is needed for patients care. Newborn screening would enable more accurate estimation of CAH incidence, reduce infant mortality and minimize trauma to affected infants and their families.

1470: P1-118

BILATERAL ADRENAL CALCIFICATIONS IN WOLMAN DISEASE
Amir Babiker, FRCPCH, CCT (UK); Albandri Al Hamza, MBBS; Fahad Al Juraibah, MD; Mohamed Al Dubayee, MD; Majid Al Fadhel, MD, King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia

Objectives: Background:

Wolman disease (WD) is a severe rare inherited disorder due to mutation in Lysosomal Acid Lipase gene, localized to 10q24-q25. To our knowledge, approximately only 50 patients were reported worldwide. We present a 2-month-old child with the disease and extensive adrenal calcifications.

Methods: Case Report

A 2 months old girl who is an outcome of full-term uneventful pregnancy and delivery, presented with recurrent vomiting, jaundice and anemia. Examination showed distended tense abdomen, marked hepatosplenomegaly and ascites. Abdominal girth was 43 cm. She had a sister previously diagnosed as Hemophagocytic Lymphohistiocytosis (HLH) who died at 3 months of age. A provisional diagnosis of HLH was suggested and the patient treated accordingly for 2 days. Investigations showed pancytopenia, high ferritin, hyperbilirubinemia, elevated liver enzymes, and high triglycerides. The ascites compressed her lungs and therefore we obtained a chest X-ray showing striking yet classic bilateral adrenal calcifications. Based on clinical and radiological presentations, we considered WD as a working diagnosis. We, therefore, started Sebelipase alpha (Recombinant form of LAL). However, a confirmatory genetic diagnosis is still awaited.

Results: Discussion

In WD, lipids accumulate in different tissues such as liver, spleen and adrenal glands. WD and HLH may share common features of deranged lipid profile and abnormal LFT. However, the classic bilateral adrenal calcification with clear demarcation of the glands is unique for WD. The underlying mechanism of adrenal calcification is not understood.

Since the patient may rapidly develop multi-organ failure, and/or may require invasive procedures such as liver biopsy, the adrenal reserve needs to be verified and a replacement started accordingly. In addition, stress doses may need to be considered during the critical course of the illness. An early use of the recently became available Enzyme replacement therapy (ERT) should be prioritized.

Conclusions: WD is very rare and may mimic the presentation of HLH. However, the combination of impaired liver function, hyperlipidemia, pancytopenia and classic adrenal calcifications may favor the diagnosis of WD and support an early start of ERT.

1338: P1-119

FAMILIAL GLUCOCORTICOID DEFICIENCY TYPE 2: A NEW MUTATION IN THE MRAP GENE P. K30DEL
Aysun Bideci, MD, Gazi University Medicine Faculty, Ankara, Turkey; Esra Doger, MD, Gazi University, Faculty of Medicine, Ankara, Turkey; Emine Demet Akbas, MD; Aylin Kilinc Ugurlu, MD, Gazi University Medicine Faculty, Ankara, Turkey; Tulay Guran, MD, Marmara University, Istanbul, Turkey; Orhun Camurdan, MD, Gazi University Medicine Faculty, Ankara, Turkey; Peyami Cinaz, Professor, Gazi University, Medical School, Ankara, Turkey

Objectives: Familial glucocorticoid deficiency is an autosomal recessive disorder characterized by isolated glucocorticoid deficiency. Type 1 due to MC2R gene mutation and type 2 due to MRAP gene mutation.

Methods: Case 1

The fifteen years old male who was admitted due to short stature have a history of term, 2000 gr, twin spouse and renal transplantation 1 month ago due to Cronic Renal Failure. Her parents were first degree cousin and a 21-day sister death before him. In physical examination bone age was 11 years, weight of him was 32,5 kg (<3p), his height  was 139,1 cm (<3p), Boy SDS: -3,7sd, testis volume 10 ml. in his growth hormone stimulation tests peak response was 7.2 so growth hormone therapy initiated. Primary adrenal insufficiency was diagnosed when ACTH :1250 pg / ml and cortisol : 2.78 μg / dl due to the darkening of the skin pigmentation during the first year of treatment with growth hormone and prednisolone 5 mg / day. The tests for etiology were normal. Despite hydrocortisone treatment at 15 mg / m 2 / day, ACTH was 5560 pg / mL and cortisol was 2.34 μg / dL in the second month.

Case 2 :

At the age of 5 years, TSH elevation was detected in the external center and the patient's medical history was inapplicable. Mother and father were first-degree cousins in the family history. Physical examination weight: 15,8 kg (10-25p), height: 104,9 cm (10-25p), bone age was  4 years and 6 months, testis volume 2 ml, penis size 8 cm. On follow-up, skin thickening was observed in ACTH: 1294 pg / ml, cortisol: 6, 1 μg / dl. The family story was re-questioned and the patient learned that the first case was uncle of him.

Results: In a genetic analysis of cases with familial glucocorticoid deficiency, a new mutation in the MRAP1 gene, p.K30del mutation, was detected.

Conclusions: MRAP (MC2 receptor accessory protein) is associated with its travel to the plasma membrane of the MC2 receptor. MC2 receptor function is impaired in MRAP gene mutations. Previously, MRAP mutations have been reported to account for 20% of all familial glucocorticoid deficiency cases. It is shared because of a new mutation identified in the MRAP gene.

1762: P1-120

SHORT STATURE AND HYPERAGONADISM WITH RESOLUTION OF HYPERCORTISONISM AND HYPERTHYROIDISM IN SEVER MCCUNE ALBRIGHT SYNDROME
Ying T Chang, MD, Penn State University, Hershey, PA, United States

Objectives: To demonstrate a case of severe McCune Albright syndrome with remission of hypercortisonism and hyperthyroidism while growth failure, hypergonadism,  polyostosis fibrous dysplasia and pauciductal cholestasis remain at 9 y of age.

Methods: Case report

Results: An African American male was diagnosed with McCune Albright syndrome at age 2 mo due to R201H mutation of GnAs1. He had multiple large cafe-au-laid spots, growth failure, hyperthyroidism, hypercortisonism, hypergonadism, polyostotic fibrous dysplasia, severe pauciductal cholestasis, nephrocalcinosis,  hypertension, developmental delay, and bilateral hip rotations. 

 His initial serum cortisol was 38 mcg/dl and post-dexamethason cortisol was 28.4 mcg/dl. He was treated with metyraponsince at age 3 mo, peak dose 450 mg/m2/day during the first 4 y, but not increase thereafter.  The dose was 57 mg, t.i.d at age 9 y. A 24-h urine free cortisol was 30.8 mcg/24h (1-30 for age 5-9 y) after withholding metyrapone for 5 days, and was 11.2 mcg/24 h after withholding for 10 days. 

At age 1.7 mo, TSH

At age 5 y, testicles were 2.7x1.3 cm and penile length was 4.3 cm. At age 9 y 2 mo, testis were 3.7 x 1.7 cm.  The bone age (BA) was 6 y 6 mo while chronological age (CA) was 3 y 8 mo. BA was 11 y 6 mo when CA was 7 y 8 m.  Testosterone was 52 ng/dl (was 41 ng/dl at 2 y of age).  GnRH stimulation test was prepubertal.  Alpha-FP and hCG were normal.  Because of his severe liver disease, ketoconazole was not used.

He has been very short since infancy.  Ht Z = -4.2 at 2 y 8 mo.  At 8 y 9 mo, ht z =-3.7.  Wt 19.1 kg, z =-3.2.  His peak GH was 10 ng/ml after stimulation at age 2 y 2mo, and was 30 ng/ml at age 7 y 8 mo.

Conclusions: Hypercortisonism and hyperthyroidism in severe McCune Albright syndrome may resolve years later.  Treatment with GnRH analog or aromatase inhibitor or tamoxifen for hypergonadism in this case is debatable due to severe fibrous dysplasia and uncertain effectiveness.

625: P1-121

A CASE OF MIRAGE SYNDROME WITH A NOVEL HETEROZYGOUS MUTATION IN THE SAMD9 GENE
Go Hun Seo, MD; Yoon-Myung Kim, MD; Gu-Hwan Kim, PhD; Jin-Ho Choi, MD; Han-Wook Yoo, MD, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic Of

Objectives: MIRAGE (Myelodysplasia, Infection, Restriction of growth, Adrenal hypoplasia, Genital phenotypes, and Enteropathy) syndrome is a new form of syndromic adrenal hypoplasia caused by heterozygous mutations in the SAMD9 gene. This study described a case of MIRAGE syndrome in Korea.

Methods: A patient presented with intrauterine growth retardation (IUGR) and adrenal insufficiency was included. He was born at 31st weeks of gestation with a birth weight of 882 g (<3rd percentile). Diagnostic exome sequencing was performed using genomic DNA from peripheral blood leukocytes. Exome was captured using Trusight One Panel (Illumina) and sequenced on the NextSeq platform (Illumina). The mean depth of coverage was 114× and approximately 98% of targeted bases were read more than 10×. Reads were aligned to the hg19 human reference genome.

Results: The patient’s birth length and head circumference were 35 cm (<3rd percentile) and 24 cm (<3rd percentile), respectively. There was no family history of adrenal insufficiency. He had highly pigmented skin, bilateral cryptorchidism, and a micropenis. At three days of age, acute adrenal insufficiency was evident by hypotension, hyponatremia, hyperkalemia. His plasma ACTH level was 4,670 pg/mL with 217 ng/mL/h of plasma renin activity. An abdominal ultrasonogram did not visualize any adrenal structure, and both testes were found in his abdominal cavity. Replacement of hydrocortisone, fludrocortisone, and sodium were initiated. However, he was died of recurrent infection and septic shock at the age of 4 months. Diagnostic exome sequencing identified a novel heterozygous variant of c.2944C>T (p.R982C) in exon 3 in the SAMD9 gene. This variant was not found in normative databases including 1000genomes browser, NHLBI ESP Exome Variant Server, and genome Aggregation Database, and predicted to be damaging by in silico prediction programs including PolyPhen-2, Sorting Intolerant From Tolerant, and MutationTaster. The variant was validated by Sanger sequencing using custom-designed primers.

Conclusions: We describe a case of MIRAGE syndrome presented with severe adrenal insufficiency, IUGR) and recurrent infection.

1304: P1-122

ALDOSTERONE SYNTHASE DEFICIENCY : A NEW MUTATION
Esra Doger, MD; Aylin Kilinc Ugurlu, MD; Alp Kazancioglu, MD; Emine Demet Akbas, MD, Gazi University Medicine Faculty, Ankara, Turkey; Tulay Guran, MD, Marmara University, Istanbul, Turkey; Aysun Bideci, MD; Orhun Camurdan, MD, Gazi University Medicine Faculty, Ankara, Turkey; Peyami Cinaz, Professor, Gazi University, Medical School, Ankara, Turkey

Objectives: Aldosteron synthase deficiency is a rare disease with  autosomal recessive inheritance which is confronted with findings of growth retardation, hypotension, hyponatremia, hyperkalemia in infant. The aldosteron synthase is a cytochrome P450 enzyme which located in the inner mitochondrial membrane of cells in zona glomerulosa, and catalyses the last steps of aldosterone synthase pathway (11 beta hydoxylation, 18-hydroxylation, 18-oxidation).

Methods: A 1-month-old boy of cousin marriage was examined for failure to thrive and poor weight gain. In physical examination his weight was 4200 gr (90-97p),  height was 50 cm (25-50 p), a pulse rate of 100 / min, blood pressure: 90 / pulse, thyroid stage 0, testis volumes 2 ml /2 ml , no scrotal hyperpigmentation was detected. Laboratory findings were hyponatremia, hyperkalemia, high plasma renin and low aldosterone levels. Serum analysis by Liquid chromatography–mass spectrometry(LC-MS) showed that  synthesis of corticosterone, 11 deoxycorticosterone was elevated. The patient was therefore suspected to have aldosterone synthase deficiency.

Results: Genetic analysis revealed a c1015- 1029del15bp homozygous mutation in the CYP11B2 gene. Fludrocortisone and oral salt treatment was initiated.

Conclusions: Aldosteron synthase deficiency is a rare disease in childhood. A new mutation was detected in our patient so is shared.

671: P1-123

CYP11A1 MUTATIONS RESULT VARIOUS CLINICAL PHENOTYPES
Ayla Güven, MD, Göztepe Education and Research Hospital, ISTANBUL, Turkey; Federica Buonocore, MD; John Achermann, MD, University College London, London, United Kingdom; Tulay Guran, Assoc Professor, Marmara University, Faculty of Medicine, Istanbul, Turkey

Objectives:  Cytocrome P450 side-chain cleavage enzyme (CYP11A1) is the first enzyme and catalyzes the rate-limiting step of steroidogenesis. CYP11A1 deficiency is associated with adrenal insufficiency (AI), and commonly a disorder of sex development (DSD) in 46, XY individivulas. Our objectives was to define the clinical presentation of our patients with CYP11A1 mutations, one of whom had a novel CYP11A1 mutation.

Methods: Four patients were presented. Case 2 has been reared as a girl and she has a novel CYP11A1 mutataion. Case 3 and 4 are siblings. Clinical findings are given in Table.

Results:
 Case1Case2Case3Case4
Age at diagnosis, year1.240.085.162.64
KaryotypeXXXY, t(4;9)(p16.6?;p13.3)XYXY
Birth weight, gr/gestational weeks3600/391750/332200/392800/39
Parents1.cousin1.cousinSame regionSame region
PresentationAdrenal CrisisAdrenal crisisNo symptomAdrenal crisis
Height, cm (SD)72 (-1.83)44(-6.05)105 (-1.1)95 (0.96)
Weight, kg (SD)8000 (-2.65)1675 (-4.67)18.6 (-0.1)11.5 (-1.5)
External genitaliaLabial synechiaeNormal femaleNormal maleNormal male
Basal cortisol, mcg/dL<18.157.69.2
Stimulated cortisol, mcg/dL<18.037.89.4
ACTH, pg/mL259>1250>1250>1250
Progesterone, ng/mL1.40.03<0.1<0.1
DHEAS, mcg/dL4.216.4148.530.7
17-OH Progesterone,ng/mL0.70.560.340.33
1.4 Andrestenedion, ng/mL0.181.20.330.33
Testosterone, ng/mL0.30.02<0.13<0.13
Aldosterone, ng/mL<1331.30.16
Renin, pg/mL; PRA ng/mL/hr>500>520 19.43 ng/ml/hr
CYP11A1 mutationp.R451Wp.W152Xp.R451Wp.R451W
Conclusions: These cases demonstrate That CYP11A1 deficiency can be seen in newborn period or in early childhood as a classical or nonclassical forms. Normal genital appearance can be found in 46, XY patients in nonclasical form and this does not exclude life-threatening AI risk.

314: P1-124

HYPERTHYROTROPINEMIA : A PRESENTATION OF SECONDARY ADRENAL INSUFFICIENCY
Rohan K Henry , MD; Monika Chaudhari, MD, Nationwide Children's Hospital, The Ohio State University College of Medicine , Columbus, OH, United States

Objectives: To present a case of hyperthyrotopinemia in the setting of newly diagnosed secondary adrenal insufficiency (AI) that resolved with glucocorticoid replacement therapy.

Methods: Case Report

Results: A 10- year and 7- month old Caucasian male presented with a history of TSH elevations, 13.1 and 9.8 (0.32-5mlU/mL), one week apart. There was a longstanding vague history of tiredness unassociated with other symptoms of thyroid dysfunction. Of significance, he had three episodes of culture negative shock each requiring Intensive care management with pressors. At the time of the last episode of septic shock (five years prior); serum cortisol was 27.5 mcg/dL at 4:30 am (hydrocortisone was not administered prior to this lab draw). To evaluate fatigue, testing indicated TSH 11.47 (0.6-4.5mlU/mL), free T4 0.9 (0.7-2.1 mg/dL) with negative anti- thyroid peroxidase and anti- thyroglobulin antibodies. Random cortisol level at 11 am <0.9 mcg/dL and ACTH 16 (0-50 pg/mL), with normal sodium and potassium levels. Peak cortisol level after sequential low (1 mcg) and high (250 mcgs) dose cosyntropin stimulation tests was 1.7 mcg/dL and 2.7 mcg/dL, respectively. 21-hydroxylase antibodies, renin, aldosterone, LH, FSH as well as pituitary dual MRI were all normal. Immunological work up to exclude an immune-deficient state as a contributor to the septic shock episodes was unremarkable. Hydrocortisone therapy was initiated, 10 mg/m2/day.Two and four weeks later, the TSH normalized with level of 4.22 and 3.25 respectively. There was marked increase in baseline energy levels, physical activity and exercise tolerance.

Conclusions: As in primary AI, hyperthyrotopinemia may exist at presentation in ACTH deficiency. This should be suspected when a history of poor exercise tolerance, cardiovascular instability suggested by episodes of shock, exists. As in primary AI, TSH normalization will occur with glucocorticoid replacement hence, practitioners should delay treating initial hyperthyrotropinemia.

208: P1-125

UNUSUAL CAUSE OF CUSHING SYNDROME
Janani Ravi, DNB; Cindy Ho, MBBS; Kah Yin Loke, MD, National University Health System, Singapore, Singapore

Objectives: A primary hepatic tumor / adrenal rest tumor producing hypercortisolism has not been previously reported in the pediatric age group. We report a novel case of paediatric Cushing syndrome due to adrenal rest cells in the liver.

Methods: Retrospective case report and review of the literature

Results: Cushing syndrome comprises symptoms secondary to high levels of circulating serum cortisol. It is a rare entity in pediatric age group. The most common cause of Cushing syndrome is iatrogenic, secondary to exogenous steroid use. However endogenous Cushing syndrome secondary to adrenal tumours or an ectopic ACTH producing tumour is uncommon. The usual diagnostic features of childhood hypercortisolism include weight gain, growth retardation, fatigue, hypertension, easy bruisability and hirsutism.

We report on an extremely interesting case of a 13-year old boy who was first referred for a hepatocellular carcinoma but found to have endogenous Cushing syndrome possibly secondary to an adrenal rest tumour of the liver. We reviewed the literature on hypercortisolism due to ectopic adrenals and adrest rest tumours.

Conclusions: This is a novel case which highlights a rare cause of paediatric Cushing syndrome masquerading as a hepatocellular carcinoma.

Medical therapy for Cushing syndrome in the pediatric age group has not been widely used, but it has a role in children with surgically inoperable Cushing syndrome who present with symptoms of hypertension and depression.

1200: P1-126

TWO SIBLINGS WITH FAMILIAL GLUCOCORTICOID DEFICIENCY: A CASE SERIES
Yuezhen Lin, MD, Baylor College of Medicine, Houston, TX, United States

Objectives: to describe a case series of two siblings with familial glucocorticoid deficiency (FGD)

Methods: case series

Results: Case 1: 3-month-old boy presented with septic shock. Exam was remarkable for significant hyperpigmentation. Lab evaluation revealed low cortisol and markedly elevated ACTH however normal serum electrolytes, aldosterone and renin activity. At 15 months of age, the diagnosis of FGD was confirmed by homozygous mutation for a 409C>T change (p Arg137Trp) in MC2R gene.  He was treated with hydrocortisone (HC) since initial presentation. He is now 10 and doing well.

Case 2: Patient is case 1’s sister and 6 years older. Since birth, increased pigmentation was noted when compared to other members of the family. At one year of age, she was admitted to a hospital (out of country) for pneumonia and shock. She was discharged with prednisone 5mg daily with a diagnosis of “adrenal hypoplasia” (record unavailable). At 2.5 years of age when she was first referred to our endocrine clinic, she had continued to be on prednisone for adrenal insufficiency. She was switched to HC and never required mineralocorticoid replacement as there was no evidence of mineralocorticoid deficiency. The diagnosis of FGD was not uncovered until she was 7 after FGD was confirmed in her baby brother (case 1). Although she did not have genetic testing, we assumed that she has the same mutation as parents are both from a relatively small town with a population of approximately 2000 people. She is now 16 and also doing well.

Conclusions: FGD is a rare autosomal recessive disorder characterized by primary hypocortisolism and normal mineralocorticoid production. To date FGD has been associated with mutations in the following genes: MC2R, MRAP, STAR, MCM4, and NNT.  This case series serves as a reminder to have a high index of suspicion for FGD as a rare cause of primary AI especially when lack of evidence of mineralocorticoid deficiency. Prompt initiation of steroids along with a thorough diagnostic evaluation is important to avoid unnecessary lifelong mineralocorticoid replacement and recurrent illness secondary to life threatening adrenal insufficiency in patients with FGD.

473: P1-127

VIRILIZING ADRENOCORTICAL CARCINOMA IN A TWO YEAR OLD FEMALE
Anamaria M Manea, MD; Stephen H Lafranchi, MD, Oregon Health & Science University, Portland, OR, United States

Objectives: We present a case of virilizing adrenocortical carcinoma (ACC) in a 2 year old female. Pediatric ACC is extremely rare and not well characterized. The incidence is 0.2-0.3/million among patients <20 years of age. Virilization is the most common presentation in younger children.

Methods: 2 year old female was admitted to pediatric oncology service for an abdominal mass suspicious for Wilms’ tumor. Abdominal distension has progressed for the past year, but child was never taken by her parents for an evaluation, until she was placed in foster care. A primary care provider found a diffusely enlarged abdomen, UTI, and an abdominal mass on ultrasound (19.8x14.8x12.2cm). She developed pubic hair and adult body odor at 12 months of age. ROS was positive for profuse sweating, increased thirst, occasional abdominal discomfort. On exam weight is 20 kg (>99th%), height is >97th%. Blood pressure was elevated (131/90, >99th%), and antihypertensives were started after admission. She had Tanner stage 3 pubic hair and stage 1 breasts, clitoromegaly (length 1.5cm, width 0.75cm), hirsutism, no Cushingoid features.

Results: Computer tomography showed a dominant heterogeneous encapsulated mass at the left superior kidney pole (15.5x11x16.5cm), 2 possible metastasis. Echocardiography showed left ventricular hypertrophy secondary to HTN. Laboratory results were compatible with a testosterone producing adrenal tumor (see table), and tumor biopsy disclosed the adrenocortical carcinoma. GeneTrails® Solid Tumor Panel showed a mutation of potential clinical significance (KDR p.G873E), not previously described in ACC. Considering the tumor extension surgery was postponed. Combination chemotherapy with Mitotane was started per protocol ARAR0332. Since Mitotane produces adrenal necrosis, hydrocortisone and fludrocortisone were initiated. Child tolerated 3 chemotherapy cycles, the tumor size decreased (13.8x10x14.6cm), biopsy of the presumable pulmonary metastasis were negative. Child is scheduled for surgical tumor excision.

Conclusions: As our patient illustrates, pediatric ACC has a female preponderance, commonly presenting <4 years of age, with survival rates 50-80% in this age group. Early diagnosis and treatment of ACC are essential. Complete tumor resection is required for cure.

1793: P1-128

PSEUDOHYPOALDOSTERONISM TYPE 1: A CHALLENGING DIAGNOSIS
Dr Shaila Bhattacharyya Shamanur, MD DCH DM, Manipal Hospitals, Bangalore, India; Kirti V Prabhu, DNB Pediatrics, Manipal Hospital , Bangalore, Bangalore, India

Objectives: To understand the presentation of Primary Pseudohypoaldosteronism type 1(PHA1) and differentiate it from Congenital Adrenal Hyperplasia (CAH)

Methods: Case Report: 5 day old female baby,first by birth order born of 2nd degree consanguineous marriage,brought with not feeding well and lethargy for 1 day.The baby was born full term normal delivery with birth weight of 2.5 kg(5th percentile) and normal APGAR.There were no perinatal problems and family history unremarkable.Baby was exclusively breast feed and had a weight loss of 17% from birth.Pulse was 89/min,respiratory rate 68/min,mean arterial blood pressure 52 mmHg,hypothermia with cold peripheries,prolonged capillary refill with acidotic breathing and distress.Tone was poor,anterior fontanelle sunken and skin turgor decreased.She had normal external female genitalia,no hyperpigmentation,no signs of virilisation.Investigations showed hyponatremia(118),hyperkalemia(8) and metabolic acidosis(pH 7.22,bicarbonate 7).Sepsis work up was normal.BUN(49.50) and creatinine(0.7) were elevated.Metabolic work up and TMS/GCMS was normal.A provisional diagnosis of adrenal insufficiency was considered and relevant hormonal assays were sent which revealed a normal 17-hydroxyprogestenone (1.67ng/ml), thyroid (7.20) and cortisol (1721 nmol/L) level.Renal ultrasonography was normal.Baby was treated with calcium gluconate,soda bicarbonate,glucose insulin infusion,potassium binding resins,3% saline but continued to have recurrent persistent hyperkalemia and hyponatremia,hence suspected to have PHA.Repeat 17-OHP and Cortisol were normal with increased Aldosterone levels(1544pg/ml) favouring PHA.Treatment was continued with high oral sodium supplements,K+ binding resins and started on oral Fludrocortisone

Results: Recurrent hyponatremia and hyperkalemia with metabolic acidosis with normal 17-OHP & Cortisol and elevated Aldosterone suggest PHA. The genetic testing revealed a homozygous insertion of 2 nucleotides at 744 and 745 positions(c.744_745insTG;p. Arg249*) in the Exon 3 of the SCNN1A gene which confirmed diagnosis

Conclusions: Hyperkalemia, hyponatremia and weight loss should be evaluated for adrenocortical function.  It is important to differentiate PHA1 from CAH as the former does not respond to corticosteroids

620: P1-129

ALDOSTERONE SYNTHASE DEFICIENCY IN TWO UNRELATED LEBANESE CHILDREN
Chiraz Ghaddhab, MD, University of Montreal/Ste-Justine Hospital, Montreal, QC, Canada; Cameron P Capper, PhD, University of Michigan, Ann Arbor, MI, United States; Wissam Fayad, MD, Balamand University/St-Georges Hospital, Beyrouth, Lebanon; Patricia Olivier, MD; Guy Van Vliet, MD, University of Montreal/Ste-Justine Hospital, Montreal, QC, Canada; Richard J Auchus, MD, University of Michigan, Ann Arbor, MI, United States; Johnny Deladoëy, MD, University of Montreal/Ste-Justine Hospital, Montreal, QC, Canada

Objectives: To report two unrelated Lebanese children with aldosterone synthase deficiency, one of whom has a novel mutation in CYP11B2.

Methods: Patient 1 was born to first cousin parents, weighing 3.680 kg and was referred at 9 days weighing 3.230 kg, looking wasted and dehydrated. The external genitalia were normal. Serum sodium was 128 mEq/L and potassium 8.9 mEq/L. Urine sodium was 91 mEq/L. Serum cortisol was 513.9 nmol/L, DHEAS 11.3 µmol/L and testosterone 3.9 nmol/L. 21 hydroxylase deficiency was suspected. Treatment was started with hydrocortisone (20 mg/m2.day), fludrocortisone (0.05, then 0.1 mg/day) and NaCl (4 mEq/kg.day). Upon receipt of the normal serum androstenedione (8.1 nmol/L) and 17 OH progesterone (7.2 nmol/L), the diagnosis was revised to primary adrenal insufficiency, until the results of exome sequencing were obtained. Patient 2 is a girl born to unrelated Lebanese parents. She was born at term, weighing 3.100 kg, and had normal female external genitalia. She was initially breast fed, but failed to thrive, prompting a switch to exclusive formula feeding at one month of age. At three months, she was admitted weighing 3.400 kg and looked malnourished and slghtly dehydrated. Serum sodium was 122 mEq/L, potassium 6.6 mEq/L. Urine sodium was 36 mEq/L. Serum 17 OH progesterone was 2.2 nmol/L, cortisol 392 nmol/L nmol/L and renin > 30.000 mU/L. A diagnosis of aldosterone synthase deficiency was made. Under treatment with fludrocortisone 0.05 mg bid, plasma renin normalized.

Results: Exome sequencing of patient 1 revelaled a novel homozygous mutation in CYP11B2 (Asn201Asp, Polyphen score 0.589, possibly damaging). The functional effects of this mutation is being tested in vitro. This established the diagnosis or aldosterone synthase deficiency and allowed hydrocortisone to be gradually discontinued. At 2 years of age, low dose ACTH stimulation evoked a rise in serum cortisol from 357 to 473 nmol/L. In patient 2, molecular confirmation of the diagnosis is pending.

Conclusions: a) Causes other than 21 hydroxylase deficiency should be kept in mind in salt wasting newborns; b) Exome sequencing is a powerful technique for establishing the correct diagnosis in atypical presentations and led to simplifying treatment in patient 1.

2927: P1-130

AN AUDIT OF ACUTE ILLNESS AND ITS MANAGEMENT IN CAH: VARIATIONS BETWEEN HOSPITALS
Georgina L Chrisp, BA(Hons), The University of Notre Dame Australia, Sydney, Australia; Ann M Maguire, PhD, The Children's Hospital at Westmead, Sydney, Australia; Maria Quartararo, PhD, The University of Notre Dame Australia , Sydney, Australia; Henrik Falhammar, PhD, Karolinska University Hospital, Stockholm, Sweden; Bruce R King, PhD, John Hunter Children's Hospital, Newcastle, Australia; Shihab Hameed, PhD, Sydney Children's Hospital, Sydney, Australia; Craig Munns, PhD, The Children’s Hospital at Westmead, Sydney, Australia; David Torpy, PhD, Royal Adelaide Hospital, Adelaide, Australia; R. Louise Rushworth, PhD, The University of Notre Dame, Australia, Sydney, Australia

Objectives: This study assessed the incidence of acute adrenal insufficiency (AI), adrenal crisis (AC), and the utilisation of stress management strategies in patients with Congenital adrenal hyperplasia (CAH) who were treated at the three referral paediatric hospitals in NSW, Australia between 2000 and 2015.

Methods: The records of all hospital attendances (admission or emergency only) for children with a diagnosis of CAH who had at least one admission to a referral hospital between 2000 and 2015 were audited. All admissions for each patient over the time period of the study were examined for the underlying diagnosis, use of stress dosing (including IM hydrocortisone), precipitating illnesses and outcomes. Chi square tests were used to assess the significance of categorical variables and t tests were used to assess differences in the distribution of continuous variables between groups.

Results: There were 588 records of hospital attendance for children with CAH, with 409 (69.9%) attendances for an acute medical condition or injury. Of these, 344 attendances were for children who were receiving glucocorticoid therapy. The median age was 3.0 (IQR: 1-8) years and 189 (54.9%) were for males. A principal diagnosis of CAH or an AC was identified in 77 attendances (22.4%) and there were 29 ACs recorded (8.4%). Fifty-one (14.8%) of the attendances had a principal diagnosis of gastroenteritis and another 85 (24.7%) had a principal diagnosis of infection. Stress dosing prior to presentation was documented in 207 (60.2%) of the treatment episodes. IM hydrocortisone use was documented in 72 (20.9%). Use of stress dosing (oral or IM) and IM hydrocortisone differed significantly by hospital (both p<0.01). Documented stress dosing ranged from 42.4% to 70.9% and IM hydrocortisone from 8.3% to 24.0% between the hospitals. No in-hospital deaths were recorded. 

Conclusions: Among CAH patients on replacement therapy with an acute health condition presenting to hospital, a diagnosis of AC was recorded in 8.4%. Stress dosing was documented in 60% of patients overall but this varied significantly by hospital, as did the use of IM hydrocortisone. Variations in the use of stress dosing among patients treated in specialist centres are important and merit further investigation.

2864: P1-131

INCIDENCE AND RATE OF ADRENAL INSUFFICIENCY AND STRESS DOSING IN A LARGE COHORT WITH CONGENITAL ADRENAL HYPERPLASIA
Diala El-Maouche, MD; Courtney Hargreaves, BS/BA; Ninet Sinaii, PhD, National Institutes of Health, Bethesda, MD, United States; Ashwini Mallappa, MD, National Institutes of Health Clinical Center, Bethesda, MD, United States; Deborah P Merke, MD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health and National Institutes of Health Clinical Center , Bethesda, MD, United States

Objectives: Patients with congenital adrenal hyperplasia (CAH) are at risk for adrenal crisis which may lead to increased hospitalization rate and excess mortality. As a preventative measure, education regarding stress dosing is routinely enforced at each visit for our CAH patients.  In this study, we sought to characterize the rates and causes of stress dosing and related conseqeunces in a cohort of patients with CAH.

Methods: Retrospective longitudinal study of a cohort of CAH pediatric patients (followed every 6 months) and adults (followed annually) over 10 years at the National Institutes of Health (NIH) Clinical Center.

Results: The cohort consisted of 156 patients, 60% male. Patients were followed for an average of 10 years. Pediatric patients had the highest rate of illness episodes and stress dosing in the 0-4 year old age group as compared to 4-18 year old age group (2.5 ± 3.0 vs. 1.5 ± 2.3 illness episodes/year, p< 0.0001; 5.0 + 10.2 vs. 2.2 + 3.8 stress dose days/year, p< 0.0001). Among adults, an increase in stress dosing and illness episodes was seen in patients age 55 or older (1.9 ± 2.3 vs. 0.7 ± 1.7  illness episodes/year, p=0.01; 2.6 + 3.5 vs.  0.7 + 1.9 stress dose days/year, p=0.006). For pediatric patients only, females reported higher rates of illnesses and stress dosing than males (1.9 2.9 vs. 1.4+ 2 days/year, p<0.0001).  The main factors requiring stress dosing in both adult and pediatric patients were gastro-intestinal, upper respiratory and febrile illnesses. Thirteen patients had documented episodes of hypoglycemia (age range: 1.1 to 5.2 years) including 2 with hypoglycemic seizures, usually precipitated by fever and decreased oral intake.  For the pediatric group only, age was negatively correlated with rate of yearly hospitalizations and ER visits (p<.0001).

Conclusions: In this cohort of patients with CAH receiving repeated adrenal insufficiency education, stress dosing was mostly according to our teaching protocol, but hospitalizations and hypoglycemic events still occurred.  Special attention should be given to the youngest and eldest age groups in this population, who may be more susceptible to illnesses. Further preventative measures should be undertaken in an attempt to minimize morbidity and mortality in patients with adrenal insufficiency.

2898: P1-132

AUTOIMMUNE POLYGLANDULAR SYNDROME TYPE 1: A CASE REPORT
Garima Chawla , MD, Sir GangaRam Hospital , New Delhi, India; Archana Arya, DO, Sir Ganga Ram Hospital, New Delhi., New Delhi, India

Objectives: APS type 1also known as APCED : Autoimmune Polyendocrinopathy – Candidiasis – Ectodermal dystrophy is an autosomal recessive disorder with mutations in a particular autoimmune regulator gene (AIRE gene) on chromosome 21q22.3 and presents with a classical Whitaker’s triad of Chronic mucocutaneous candidiasis , Hypoparathyroidism and Addison’s disease.

Methods: Case Report:

4y8month old, male presented to pediatric casualty with complaints of seizures, fever, neck stiffness. He had a past history of an episode of tetanic spasms 1month prior to this. Se Calcium remained low normal despite Calcium supplements. Work up revealed low se. calcium , ionized Ca, low PTH, high phosphorus and a normal 25(OH) Vitamin D3 level. Diagnosis of Hypoparathyroidism was made. Initially stabilised in hospital with i.v. Ca gluconate, i.v. MgSO4 & Rocaltrol. He was discharged on calcium supplements & Calcitriol and was advised a low phosphorus diet. On follow up he showed normal growth  & was maintaining normal values of Calcium, ionic calcium, phosphorus, PTH & Vit d.  Dose of rocaltrol & calcium were being titrated.

At  7yr of age, on follow up visit, oral candidiasis mostly at angles of mouth and on tongue, dental enamel defects and blackish discolouration of the nails were noticed. Possibility of Autoimmune polyglandular endocrinopathy type 1 was considered and sample was sent for AIRE gene study.

Results: Gene sequencing revealed two heterozygous mutations in the AIRE gene c.1A>G in exon1 and c.274C>T in exon2, confirming the diagnosis of Autoimmune polyendocrinopathy type1 . Carrier testing in parents and checking for mutation in sibling was done.

Sibling tested positive for the same mutation. He was a 1y7m old male with past history of repeated episodes of oral candidiasis treated with oral fluconazole. Biochemical parameters were within normal range except for Vit D deficiency (12ng/ml). The child is having no complaints on follow up.

Conclusions: Genetic testing forms an integral part of diagnosis and management of APS. Mutation may co-exist in other family members thereby necessitating the screening of family members to enable timely diagnosis.

Annual testing recommended to look for evolving Autoimmune endocrine and non-endocrine organ involvement.

2921: P1-133

SEVERE ADRENAL INSUFFICIENCY AND REVERSIBLE DILATED CARDIOMYOPATHY IN A NEWBORN DUE TO STAR PROMOTOR DELETION
Anil Piya, MD, Memorial Health University Medical Center/Mercer University School of Medicine, Savannah, GA, United States; Himangshu S Bose, PhD, Mercer University School of Medicine, Savannah, GA, United States

Objectives: The steroid synthesis starts with cholesterol, the only substrate to initiate the synthesis of steroid prednenolone. Cholesterol cannot be transported into the mitochondria by itself. Steroidogenic acute regulatory protein(StAR), which acts at the outer mitochondrial membrane that helps in the transport of cholesterol from the outer to inner mitochondrial membrane. Mutations in the StAR protein result in most fatal form of congential adrenal hyperplasia called lipoid congenital adrenal hyperplasia(CAH). StAR protein consists of seven exons and distal promotor 35 bp upstream of the start codon. Biochemical analysis in nonsteroidogenic COS-1 cells showed that the first two exons are not essential to initiate pregnenolone synthesis. Our patient presented with ambigious genitalia, severe adrenal crisis and dilated cardiomyopathy within two weeks after birth. Laboratory analysis revealed diminished steroidogensis in all the pathways and elevated ACTH level. Echocardiogram revealed dilated cardiomyopathy and 35% ejection fraction. 

Methods: Sequence analysis of the StAR. Mitochondrial protein import analysis.

Results: Sequence analysis of the StAR, including the exon intron boundries, showed complete deletion of exon 1 as well as more than 50 nucleotides upstream of StAR promotor. Mitochondrial protein import analysis of the mutant StAR protein lacking exon 1 showed the absence of import and no signal sequence cleavage following import. 

Conclusions: Cardiomyopathy resolved dramatically after glucocorticoid and mineralocorticoid therapy. Thus, cardiomyopathy and impending heart failure can be reversed by early diagnosis and treatment of CAH. Moreover, full-length StAR gene is essential to initiate pregnenolone synthesis in human.

2855: P1-134

STRESS-INDUCED CUSHING (SIC) SYNDROME: PROPOSAL TO RENAME PSEUDO-CUSHING SYNDROME EXEMPLIFIED BY PRESENTATION OF A PATIENT WITH PEDIATRIC GLYCOGEN STORAGE DISEASE
Margaret A Stefater, MD/PhD; Nina S Ma, MD; Joseph I Wolfsdorf, MD, Boston Children's Hospital, Boston, MA, United States; Joseph A Majzoub, MD, Harvard Medical School, Boston, MA, United States

Objectives: Cushing syndrome (CS) is one of the most challenging endocrine disorders to diagnose, particularly in children, and it is difficult to distinguish classical CS from non-classical cases that share similar clinical manifestations such as growth failure, obesity, and cushingoid features.  The presence of increased cortisol secretion without classical causes such as neoplastic pituitary or adrenal disease is typically referred to as pseudo-CS.  However, the term pseudo-CS may be misleading as it implies that abnormally high cortisol secretion does not have pathological consequences. 

Methods: We present an infant with a physical exam and laboratory evaluation consistent with CS.

Results: The patient had moon facies, growth failure and obesity (Figure), and laboratory evaluation consistent with CS: an elevated midnight cortisol and lack of suppression to low dose dexamethasone (Table). During the evaluation, he was found to have liver disease and hypoglycemia; genetic testing revealed a diagnosis of glycogen storage disease type IXa.  The child’s cushingoid appearance, poor linear growth, obesity and dexamethasone suppression test improved (Figure, Table) after instituting treatment to prevent recurrent hypoglycemia.

Conclusions: We suspect this child’s CS-like presentation was caused by hypothalamic-pituitary-adrenal activation induced by chronic hypoglycemia, and we suggest that excessive cortisol secretion may be a response to physiologic stress such as the recurrent hypoglycemia observed in this child.  Further, the elevated cortisol in pseudo-CS may cause poor growth and excessive weight gain.  This case highlights that pseudo-CS can have serious adverse effects, and emphasizes that growth in children is a particularly sensitive assay for glucocorticoid exposure.  We speculate that other types of chronic stress may also lead to CS-like features, and that relief of the underlying stressor may ameliorate phenotypic symptoms such as poor growth and obesity.  Consequently, we propose that pseudo-CS be renamed stress-induced Cushing (SIC) syndrome, to emphasize that elevated cortisol secretion in the diseases associated with SIC can be detrimental, and that SIC is a subtype of CS and not a benign entity to be ruled out.

1829: P1-135

CHALLENGES IN CHOOSING SOCIAL SEX IN THE LATE DIAGNOSIS OF CONGENITAL ADRENAL HYPERPLASIA
Tathiana L Teixeira, MD, Hospital das Clínicas de São Paulo - FMUSP, São Paulo, Brazil; Selma RC San Martin, MD, University of Sao Paulo, Sao Paulo, Brazil; Nathalia L Brigatti, MD; Wendy J Céspedes, MD, Hospital das Clínicas de São Paulo - FMUSP, Sao Paulo, Brazil; Marianna R Ferreira, MD; Nathalia FV Duarte, MD; Leandra Steinmetz, MD, University of Sao Paulo, Sao Paulo, Brazil; Ruth R Franco, MD, Hospital das Clínicas de São Paulo - FMUSP, Sao Paulo, Brazil; Louise Cominato, MD, University of Sao Paulo, Sao Paulo, Brazil; Hamilton CM Filho, MD, Hospital das Clínicas de São Paulo - FMUSP, Sao Paulo, Brazil; Durval Damiani, PhD, University of Sao Paulo, Sao Paulo, Brazil

Objectives: To identify issues related to sexual definition and reassignment in patients with congenital adrenal hyperplasia (CAH).

Methods: Retrospective review of medical records.

Results: RKMI, 4 years and 8 months, hispanic, from Marília-SP, born with bilateral cryptorchia. The patient had a 5.5 cm falus with no palpable gonads, and was being raised as male since then. Ultrasound of abdomen and inguinal canal did not show presence of gonads, only Mullerian derivatives. Adrenal glands with no alterations. Baseline total testosterone was 290 ng/dL. Dehydroepiandrosterone sulfate (DHEA-S) 2321 ng/ml. 17α-Hydroxyprogesterone (17α-OHP) 393 ng/ml. Plasma renin 1215.5 pg/ml. Karyotype 46, XX. Diagnosis of congenital salt-wasting adrenal hyperplasia after test results was signed. In a meeting with a multiprofessional team and the parents of the child, the team decided jointly by the surgical exeresis of Mullerian remains and maintaining male social sex. Promptly initiated treatment for CAH with glucocorticoids and mineralocorticoids. At age 10 the patient opted for surgical testicular prosthesis bilaterally. Patient develops progressive increase of gonadotropins (LH and FSH) when, at age eleven (bone age of thirteen), was chosen to introduce testosterone monthly for the development of secondary male sexual characters with consequent penile enlargement. Patient maintains option in the masculine social sex with the passing of his adolescence, and in the 20 years old was performed another surgery for placement of penial expanders. Currently patient has sexual relations with erections and ejaculations present. He is still satisfied with his sexual performance, but with a final height of 148.5 cm.

Conclusions: The precise diagnosis in cases of HAC is important to avoid situations of risk to the patient's life as in cases of salt-losing form, however, the definition of social sex is a fundamental part of the treatment as well, and causes great impact on the family. It is essential to understand that the definition of social sex rests with the multiprofessional team and family, taking into accounts the convictions and interests, cultural and emotional aspects of the family.

151: P1-200

BONE MICROSTRUCTURE DETERMINED BY HIGH-RESOLUTION PERIPHERAL QUANTITATIVE COMPUTED TOMOGRAPHY (HR-PQCT) IN PRE-PUBERTAL GROWTH HORMONE DEFICIENT MALES
Tamar G Baer, MD; Sanchita Agarwal, MS/MA; Fernando Rosete, RT; Sharon E Oberfield, MD; Kyle Nishiyama, PhD; Patricia Vuguin, MD, Columbia University Medical Center, New York, NY, United States

Objectives: Growth Hormone affects bone density, though there are limited studies in prepubertal children assessing the impact of growth hormone deficiency (GHD) on bone microstructure. Our objective is to characterize bone microarchitecture by high resolution peripheral quantitative computed tomography (HR-pQCT), a novel imaging modality, in prepubertal boys with GHD, prior to therapeutic intervention.

Methods: To date, scanning by HR-pQCT with isotropic voxel size of 61µm was performed at the distal radius (7%) and tibia (4.5%) in 15 prepubertal boys, age 5-10 years, n=12 controls (height Z score-0.3±0.31) and n=3 GHD (height Z score -2.52±0.59) (Table 1). Volumetric bone mineral density (vBMD), microstructure, and geometry were evaluated (Table 2). Statistical analysis was done using descriptive measures of mean and standard error, and correlation analysis was applied to control data.

Results: Correlation analysis in control subjects showed that older age was associated with decreased trabecular vBMD (Tb.vBMD) (p=0.05) and with increased cortical vBMD (Ct.vBMD) (p <0.05). Higher BMI%ile was associated with decreased trabecular inhomogeneity (Tb.1/N.SD) (p<0.01) and decreased trabecular separation (Tb.Sp) (p=0.06).

Preliminary results comparing GHD to controls:

Bone Mineral Density: At the radius, cortical vBMD (Ct.vBMD) was 9% higher in GHD compared to controls.

Bone Microstructure: At the radius, trabecular bone volume fraction (BV/TV) was 16.2% lower while trabecular separation (Tb.Sp) was 11% larger in GHD compared to controls. At the tibia, the cortical bone was 66.6% less porous (Ct.Po) and 15% thinner (Ct.Th) in GHD compared to controls.

Bone Geometry: At the radius, total area (Tt. Ar) was 25.5% smaller in GHD compared to controls. At the tibia, total area was 6.9% smaller in GHD compared to controls.

Conclusions: The preliminary findings of our ongoing study demonstrate that age and BMI related differences in vBMD and microarchitecture within controls may vary by bone compartments. Differences in vBMD, microarchitecture, and geometry in GHD boys possibly suggest an important role of growth hormone in prepubertal bone health, though significance was not calculated due to disparity in group size at this early point in recruitment.

1528: P1-201

TRANSDERMAL 17-ß ESTRADIOL INCREASES BONE DENSITY AT THE LUMBAR SPINE AND FEMORAL NECK IN OLIGO-AMENORRHEIC ATHLETES
Kathryn Ackerman, MD; Vibha Singhal, MD, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Charumathi Baskaran, MBBS, Massachusetts General Hospital, Brookline, MA, United States; Meghan Slattery, NP, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Karen Joanie Campoverde Reyes, MD, Massachusetts General Hospital, Boston, MA, United States; Shreya Tulsiani, BS/BA, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Alexander Toth, BS/BA, Massachusetts General Hospital, Boston, MA, United States; Hang Lee, PhD; Anne Klibanski, MD; Madhusmita Misra, MD, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States

Objectives: Normal-weight oligo-amenorrheic athletes are at risk for low bone mineral density (BMD) at sites of predominantly trabecular bone. However, data are lacking regarding the impact of estrogen administration on BMD in this population.  Our objective was to determine the impact of estrogen administration via a transdermal versus oral route on BMD in normal-weight oligo-amenorrheic athletes engaged in weight-bearing activity of the lower extremities.

Methods: 121 oligo-amenorrheic athletes 14-25 years old were randomized to receive either (i) the 100 mcg 17- β estradiol transdermal patch applied continuously with cyclic oral micronized progesterone (200 mg for 12 days of each month) (PATCH group), or (ii) the 30 mcg ethinyl estradiol oral pill with 0.15 mg desogestrel daily with a week of placebo pills every month (PILL group), or (iii) no estrogen/progesterone (NONE). All participants received calcium and vitamin D supplementation. BMD was assessed at the lumbar spine, femoral neck and whole body using dual energy x-ray absorptiometry at baseline, 6 and 12 months. An intention to treat population based analysis set included all randomized study participants in the longitudinal linear mixed effects model to determine whether the transdermal patch performed better than the oral pill or no estrogen in improving BMD. We adjusted for age, height, race and ethnicity in all analyses.

Results: The randomization groups did not differ significantly for age, BMI or BMD Z-scores at baseline. Mean age was 19.9±2.6 years, and BMI 20.7±2.3 kg/m2. Compared with the other two groups by means of linear contrasts of the time x treatment interaction, the PATCH group demonstrated significant increases over the study duration in lumbar spine and femoral neck mean BMD Z-scores compared to the PILL (p=0.0161 and p=0.0287 respectively) and NONE (p=0.0139 and p=0.0244 respectively) groups after controlling for covariates. Groups did not differ for changes in total hip and whole body BMD Z-scores over the study duration.

Conclusions: These data demonstate the efficacy of transdermal 17-β estradiol in increasing BMD measures at predominantly trabecular sites in adolescent and young adult oligo-amenorrheic athletes.

441: P1-202

LOW BONE MASS GAIN FROM ADOLESCENCE TO EMERGING ADULTHOOD IS ASSOCIATED WITH OBESITY, INSULIN RESISTANCE AND CARDIOMETABOLIC PROFILE AT AGE 16
Raquel Burrows, MD; Paulina Correa-Burrows, PhD; Carmen Gloria Güichapani, MSc(c), University of Chile, Santiago de Chile, Chile; Estela Blanco, MS/MA; Sheila Gahagan , MS/MA, University of California San Diego, San Diego, CA, United States

Objectives: Despite that obesity has been associated with lower fracture risk, evidence show that peripheral fat may also have a deleterious effect on bone mass (BM). Increased peripheral and bone marrow fat and insulin resistance (IR) alter osteoblast differentiation and function and increase osteoclastic activity. We studied BM gain from adolescence to emerging adulthood and its association with anthropometric and cardiometabolic (CM) profile at 16y.

Methods: Observational, prospective study in n=325 22 year-olds (51% males) from an infancy cohort. BMI, waist circumference (WC), arterial blood pressure (BP), bone mineral density (BMD=gr/m2) by DXA, triglycerides (TG), HDL, glucose, and insulin were measured at 16y and 22y. BMIz, HOMA-IR, SPISE Index (SI=600 × HDL0.185/(TG0.2 × BMI1.338)) and TG/HDL were estimated. HOMA-IR values ≥2.6 were considered IR. BM gain was estimated as the percentage difference between BMD at 22y and 16y. To assess quality of gain, BM gain distribution was divided into tertiles: low (? ≤3.4%), intermediate (? 3.5%-9.1%) and high (? ≥9.2%). Regression models examined the associations of anthropometric and CM biomarkers in adolescence with the risk for low BM gain controlling for sex, physical activity, diet and obesity at 5y and 10y.

Results: There was a significant association (P<0.01) of BM gain with anthropometric and CM biomarkers at 16y. Participants with low BM gain had significantly higher values of BMIz, WC, TG, insulin and HOMA-IR and lower valued of SPISE compared to participants in the middle and highest BM gain tertile. Participants with low BM gain showed a significantly higher prevalence of obesity (21.4%) abdominal obesity (49.1%) and IR (22.5%) compared to participants with highest BM gain (8.3%, 23.2% and 9.3% respectively). As BMIz, WC, BP, TG, TG/HDL, insulin and HOMA increased, the odds of having BM gain in the lowest tertile increased. Conversely, as SPISE increased, the risk of low BM gain decreased.

Conclusions: BM gain from adolescence to early adulthood was associated with better 16y nutritional status, insulin sensitivity and CM profile. Increased BMIz, WC, BP, TG, insulin and HOMA and lower SPISE were associated with lower BM gain. Funding: NHLBI-HL088530,CONICYT-PAI7914003.

1105: P1-203

NATIONAL VITAMIN D INTOXICATION OUTBREAK AMONG INFANTS DUE TO A MANUFACTURING ERROR OF VITAMIN D3 DROPLETS: CHALLENGES FOR MANAGEMENT
Henrik t Christesen, PhD, Odense University Hospital, Odense, Denmark; Soeren Boegevig, MD, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark; Anders J Schou, PhD, Odense University Hospital, Odense, Denmark; Ida M Schmidt, PhD, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Fie J Vojdeman, PhD, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark; Konstantinos Kamperis, MD, Aarhus University Hospital Skejby, Odense, Denmark; Christina Brot, PhD, The Danish Health Authorities, Copenhagen, Denmark; Lotte C Hoegberg, PhD, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark

Objectives: Danish Health Authorities (DHA) recommends vitamin D supplementation for children <2y with 10 µg (400 IU)/day. This dose is considered safe and less than recommended in a recent global guideline, why vitamin D intoxication should not be expected.

Methods: Patient evaluation, national warnings, national surveys.

Results: An infant presented with hypercalcemia and unmeasurable high s-25OHD levels despite vitamin D3 supplementation strictly as recommended. Suspicion was raised on the vitamin D3 droplet product used. Laboratory analysis showed that the specific vitamin D3 product contained 150 µg/droplet instead of the intended 2 µg/droplet. Infants dosed as recommended therefore received 750 µg (30,000 IU) daily. The product was immediately withdrawn after actions from The Danish Poison Information Center and Danish Health Authorities (DHA). A total of 340 bottles were already sold from March 2016. Nine days after withdrawal of the product the DHA had identified 150 children <2 years at risk of intoxication. Of those, 87 children had already been diagnosed with s-25OHD >150 nmol/L. Serum ionized calcium >1.35 mmol/L was detected in 76 infants, and 18 infants had severe hypercalcemia with ionized calcium of >1.49 mmol/L. A few patients had severe symptoms and extremely high concentrations of s-25OHD and calcitriol. We developed an urgent national tracing, diagnosis and treatment algorithm for vitamin D intoxication. Warnings and public emergency announcements were issued from the DHA and a strategy for keeping the media attention to the matter was made to ensure identification and management of all exposed infants. Treatment of this exceptional vitamin D intoxication outbreak included the - in infants - unprecedented use of calcitonin in the acute phase and repeat biphosponate infusion over months on top of standard treatment. Despite, severe nephrocalcinosis was seen.

Conclusions: Delay in clinical diagnosis and errors in distribution of important information regarding triage and treatment were numerous. The outbreak gave occasion to an acutely made national management guideline on vitamin D3 intoxication in infants. The intoxication outbreak illustrates the legislation challenges by categorization of potentially toxic substances as food supplements instead of registered pharmaceuticals.

767: P1-204

BONE DENSITOMETRIC PARAMETERS AND BODY COMPOSITION IN PRETERM AND TERM INFANTS AT FORTY WEEKS OF GESTATIONAL AGE
Paola Diana, MD; Sara Notarnicola, MD, University of Genova, Giannina Gaslini Institute, Genova, Italy; Cristina Traggiai, MD, Giannina Gaslini Institute, Genova, Italy; Annalisa Calcagno, MD, University of Genova, Giannina Gaslini Institute, Genova, Italy; Luca A. Ramenghi, MD; Mohamad Maghnie, MD, Giannina Gaslini Institute, Genova, Italy; Natascia Di Iorgi, MD, University of Genova, Giannina Gaslini Insitutite, Genova, Italy

Objectives: Limited data are available on body composition of preterm and term infants.  The aim of this study was to assess bone, fat (FM) and free fat (FFM) mass in preterm and term infants at 40th wks of gestational age (GA).

Methods: We analyzed 62 infants, n=54 preterm (23 M, 31F) born at the mean GA of 31.0±2.5 wks and n=8 born at term (4M, 4F) at a mean GA of 39.7±1.0 wks. A dual energy x-ray absorptiometry (DXA, LUNAR Prodigy, Infant software) was obtained at the mean GA of 40.9 ± 1.7 in both groups for bone mineral content (BMC, g), mineral density (BMD, gr/cm2), FM (gr,%) and FFM (gr). We considered the total body less head (TBLH) for body composition and the trunk (based on a designed ROI) for spine data.

Results: Preterm were significantly lighter (1545.7±484.4 vs. 3465±260.1 gr, p<0.0001) and shorter than born at term infants (41.4±5.1 vs 50.7±1.7 cm, p<0.0001) at the time of birth, but comparable for weight and length at 40.9 weeks of GA; they displayed more FM (20.5±5.1% vs. 16.7±6.3%, p 0.04) and similar FFM than those born at term. A significantly lower BMD(0.196±0.043 vs. 0.275±0.011 gr/cm2, p<0.0001), BMC(25.0±5.7 vs. 48.2±6.8 gr, p<0.0001) at the TBLH and lower BMD (0.183±0.042 vs. 0.252±0.020, p<0.0001), BMC (13.0±3.7 vs. 26.1±4.4, p<0.0001) at the spine was found in preterm compared to born at term neonates. All bone parameters were related to birth weight (r’s  range=0.09-0.25, all p's <0.07) and GA (r’s range=0.16-0.49, all p's <0.004) in preterm infants. However, multiple regression analysis showed that in preterm infants FFM was a direct predictor (β 4.339e-5, p 0.0035) and %FM an indirect predictor (β-0.002, p 0.0069) of TBLH BMD (adj.R2 =0.601, p <0.0001), after adjustment for GA and birth weight; also after correction for length (β 0.008, p 0.0075), the model confirmed %FM as a strong indirect predictor (β -0.003, p 0.0002) of TBLH BMD (p<0.0001, adj. R2 0,649).

Conclusions: Our data demonstrate that preterm infants exhibit early recovery in weight and length, but deficient in bone mass compared to full-term infants; already at the corrected term age FFM seems to be more important than birth weight or prematurity for bone mass development, while fat mass might have a negative impact. 

949: P1-205

TRABECULAR BONE SCORE (TBS) OF CHILDREN AND ADOLESCENTS 4 TO 19 YEARS OLD IN MEXICO CITY
Miguel Angel Guagnelli, MD, Hospital Infantil de Mexico, Mexico City, Mexico; Regina Ambrosi, MS/MA; Desiree Lopez-Gonzalez, MD, MSC, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico; Renaud Winzenrieth, PhD, Medimaps SASU, Merignac, France; Luis Del Rio, PhD, CETIR Medical Center, Barcelona, Spain; Patricia Clark, PhD, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico

Objectives: Trabecular Bone Score (TBS) is a texture-based tool analyzing DXA images in order to assess bone microarchitecture in the lumbar region. In pediatric population, definition of normative values has remained elusive due to the disparities of results in normal population, probably linked to uncontrolled factors which impact bone microarchitecture and the nonlinear behavior of bone growth.

Our objective was to evaluate TBS in healthy Mexican children and adolescents using chronological age or bone age (BA) taking into account skeletal maturation and puberty onset as confounding variables.

Methods: DXA acquisitions from 269 boys and 296 girls aged 5 to 20 years were included. Bone age was evaluated according to Greulich and Pyle method. Pseudo volumetric BMD (3D BMD) was calculated based on cylindrical model proposed by Kroeger et al. (Bone Mineral, 1992). TBS assessment was evaluated using a custom version of TBS (Med-Imaps SASU, France) that includes a soft tissue correction for pediatric subjects.

Loess method for local regression was used to show the means of the population on different ages using SPSS v23. The LMS statistical method proposed by Cole and Green (Stat Med, 1992) was used to construct aBMD, vBMD and TBS age-related curves using LMSchartmaker 2.0.

Results: When chronological age was used, girls’ curve showed decreasing phase delineating a “U” shape similar to previous reports. However, when evaluated with bone age, both graphs show constant TBS until 9 years in girls and 12 years in boys, both in accordance to the age of puberty, the onset of which is different between genres, a well-known phenomenon.

Conclusions: Bone age, better related to puberty onset than chronological age, may be more useful to interpret TBS and may allow to have normative data for children. This preliminary data need to be reproduced by other groups in healthy children and adolescents as well as in groups with different pathologies affecting this population. 

88: P1-206

PRIMARY OVARIAN INSUFFICIENCY IN ADOLESCENTS AND YOUNG ADULTS
Rula V Kanj, MD; Nana Ama Ofei-Tenkorang, BS/BA; Mekibib Altaye, PhD; Catherine M Gordon, MD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Objectives: Primary ovarian insufficiency (POI) affects up to 1/1000 women under age 30, and in most cases, the cause is idiopathic (or unexplained). We sought to identify clinical features of POI in adolescents and young women and gather information on the initial presentation, evaluation, and treatment plan.

Methods: IRB-approved retrospective chart review of female patients ages 11-26 with initial presentation of POI at pediatric tertiary care center, 1/1/2009 to 12/31/15. Patients were included if they had confirmed diagnosis of POI that was not secondary to cytotoxic agents. Patients either met strict criteria for POI (two serum FSH >40 IU/mL), modified criteria (one FSH >40), or had outside diagnosis. Data collected included referral reason, symptoms, laboratory & imaging results, bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), receipt of estrogen therapy, and data from follow-up visits. Descriptive statistics were generated.

Results: 331 charts were reviewed, 71 had confirmed diagnosis of POI, and 50 had sufficient data for inclusion (Figure 1). Among the 50, 21 (42%) had Turner syndrome, 18 (36%) remained idiopathic, and 11 (22%) had another condition (e.g., autoimmune polyglandular syndrome, galactosemia, chromosomal disorder). During evaluation, 36 patients (72%) were karyotyped; in 14 (28%), 21-hydroxylase antibodies were measured; 32 (64%) underwent DXA of lumbar spine (LS). On initial LS DXA, 10 of 32 (31%) had low BMD (Z-score ≤-2.0) and 9 of 32 (28%) had slightly low BMD (-1.0 to -1.9). All 19 patients with borderline/low BMD started estrogen within 2 years of presentation, with 17 of 19 started within 6 months. 8 of 50 patients (16%) had history of fracture. Of these, at presentation, 4 (50%) had low BMD, and 2 (25%) were slightly low. In follow-up, only 2 patients (4%) saw a psychologist or social worker for emotional support.

Conclusions: POI is a model of pure hypogonadism and estrogen deficiency with many cases due to idiopathic causes. On initial presentation, many young patients have a low BMD and few are seen for psychological counseling and support. Due to the infertility aspect, the diagnosis causes emotional distress. Management of psychological well-being should be included as a component of multidisciplinary care.

1538: P1-207

CALCIUM-PHOSPHORUS METABOLISM AND BONE MINERAL DENSITY OF PEDIATRIC CELIAC DISEASE.
Rosaura Leis Trabazo, PhD, Hospital Clínico Universitario y Universidad de Santiago de Compostela. CiberObn. IDIS. , Santiago de Compostela, Spain; Rebeca Saborido Fiaño, MD; Nazareth Martinón Torres, PhD; Marta Lendoiro Fuentes, MD; Rocío Vázquez Cobela, PhD; Vanesa Crujeiras Martínez, MD, Universidad Santiago de Compostela, Santiago de Compostela, Spain

Objectives: To analyze bone mineral density (BMD) and calcium-phosphorus metabolism of pediatric celiac disease patients at the moment of diagnosis.

Methods: A cross-sectional study was performed in the Pediatric Nutrition Unit of a tertiary hospital. We reviewed data regarding presenting symptoms, age of diagnosis and anthropometric measures.

Bone alkaline phosphatase, N-terminal Propeptide Type I (PINP), β-CrossLaps, PTH and 25-hydroxyvitamin D were measured.

BMD of total body, lumbar spine and femur (trochanter and neck) was measured in celiac patient older than 2 years of age, using dual-energy x-ray absorptiometry (DXA). DXA were performed using a total-body scanner (LUNARenCORE®).

Results: Seventy five celiac children (49 females) with median age of 5.5 ± 3.7 years (range 0.91-14 years) were studied during the first 3 months after the diagnosis.

Sixty-two children (82.6%) were found to have vitamin D levels ≤ 30ng/mL and twenty three children (30%) had levels ≤ 20ng/ml. All patients had normal level of PTH.

A significant negative correlation between PINP levels and total body BMD (r = -0.425, p 0.03) and trochanter BMD (r= -0,368, p 0.012) were demonstrated.

DXA measurements were analyzed of 61 children older than 2 years.  Seven children (11.5%) had a low BMD for chronological age at the level of lumbar spine (Z-scores ≤ -2.0).

Patients that presented malabsorption symptoms (diarrhea, growth failure and/or iron deficiency) had significantly lower values of lumbar spine, trochanter and total body BMD than patients who did not have these symptoms (p 0.017, p 0.015 and p 0.015, respectively).

Conclusions: A high percentage of celiac patients at the moment of diagnosis have hypovitaminosis D, without hyperparathyroidism.

Low BMD (Z-scores ≤ -2.0) affects up to 11% of celiac patients older than 2 years old.  

Celiac children that present symptoms of malabsorption are more likely to have low lumbar spine, femoral and total body BMD.

Low BMD is associated with a high rate of bone remodeling (high PINP). In adult studies it was shown that these are independent predictors of relative risk of fractures. Therefore, in children, it could be a risk factor of accelerated loss of BMD.

 

128: P1-208

VITAMIN D DEFICIENCY IS PREVALENT IN SHORT STATURE CHILDREN WITH UNDERLYING ILLNESS
Jun Mori, MD; Hidechika Morimoto, MD; Yusuke Tsuma, MD; Shota Fukuhara, MD; Hisakazu Nakajima, MD; Hajime Hosoi, MD, Kyoto prefectural university of medicine, Kyoto, Japan

Objectives: Background: Vitamin D (VitD) is essential for calcium phosphate homeostasis and bone health. In recent years, numerous clinical research papers have shown that VitD deficiency is becoming a global issue.

Objective and hypotheses: The aim of this study is to realize an adequate screening of VitD deficiency by reviewing cases in detail.

Methods: Method: Medical records from 7 children diagnosed with VitD deficiency within one year were reviewed. Serum 25(OH) VitD less than 20ng/dl (50nmol/l) is considered to be VitD deficient, according to the guideline of the Japanese Society for Pediatric Endocrinology.

Results: Results: The mean age of diagnosis was 18 ± 4.1 months (1-31 months). The mean and standard deviatiojn of Ca, iP, ALP and 25(OH)VitD were 10.3 ± 0.3mg/dl, 5.2 ± 0.2mg/dl, 1334 ± 242IU/l and 13.4 ± 2.3ng/dl, respectively. Six of the patients had growth retardation at diagnosis (height below -2 SD below mean) and had imaging findings of rickets by X-ray. All patients have underlying illness and the detail breakdown is the following: 1, egg allergy; 2, low birth weight infant; 2, systemic bone disease; 1, Bartter syndrome; 1, cutis marmorata telangiectatica congenital.

 

Conclusions: Conclusion: Careful checkup for VitD deficiency is needed for short stature children with any underlying illness, such as low birth weight infant, systemic bone disease, food allergy and so on. However, treatment should be deliberated to avoid overtreatment to avoid overtreatment.

207: P1-209

PUTATIVE EXTRA-GONADAL EFFECTS OF HCG STIMULATION TEST ON CALCIUM HOMEOSTASIS
Li J Mortensen, MD, Rigshospitalet, Copenhagen, Denmark; Poul Jannik Bjerrum, MD, PhD, Holbæk Sygehus, Holbæk, Denmark; Beate Lanske, PhD, HSDM, Harvard School of Dental Medicine, Boston, MA, United States; Anders Juul, PhD, Rigshospitalet, Denmark, Copenhagen, Denmark; Niels Jørgensen, MD, PhD; Martin Blomberg Jensen, MD, DMSc, Rigshospitalet, Copenhagen , Denmark

Objectives: Sex steroids and gonadotropins have been suggested to influence calcium homeostasis. hCG stimulation tests are used  in boys and men to evaluate the presence or absence of functional Leydig cells. We aimed to investigate the possible link between calcium homeostasis and reproductive hormones in normal and hemicastrated men undergoing hCG stimulation test.

Methods: 300 healthy young men were included and delivered semen samples, and blood samples were drawn. Men with previous testicular cancer (treated with unilateral orchiectomy, n=49) were included. Blood samples were analyzed for 25-hydroxyvitamin D, PTH, albumin, calcium, LH, FSH, SHBG, testosterone and estradiol in sera from the 300 men, and in samples before (t=0) and after (t=72 hrs) an hCG injection (Pregnyl, 5000 IU).

Results: Serum calcium (albumin corrected) levels were inversely associated with SHBG (β-10.4 p=0.051) and testosterone/estradiol (β-0.054 p=0.025) levels in normal men. Serum calcium (albumin corrected) levels were inversely associated with circulating inhibin B (β-123 p=0.035), inhibin B/FSH (β-20 p=0.008), and positively associated with free testosterone (β204 p=0.039), free androgen index (β33 p=0.0002) and testosterone/LH (β.7 p=0.029) at baseline in the 49 hemicastrated men. Eighteen of forty-nine men experienced an average increase in calcium of 6.5% 72 hours after hCG injection, while 30 men had an average decrease of 7%. Men with a decrease in calcium had higher baseline estradiol (74 pmol/L vs 47 pmol/L p=0.006). Importantly, five men had a dramatic decrease of 17-44% in serum calcium (albumin corrected), they all developed transient hypocalcemia, had a lower increase in total and free testosterone after hCG injection (5.4 nmol/L p=0.053 and 154 pmol/L p=0.055 lower), and their BMI was higher (32.6kg/m2 [29.1-36.1] vs 25.9 kg/m2[24.6-27.2] p=0.0012) compared to men who did not develop hypocalcemia.

Conclusions: We show here that sex steroids and calcium homeostasis are associated in young 19 year old men. A subset of patients who developed hCG-induced hypocalcemia were characterized by diminished Leydig cell function and higher BMI. Further studies on the potential acute effects of hCG on calcium metabolism are needed to clarify the possible mechanism of action and reproducibility in a prospective cohort.

242: P1-210

DETECTION OF SOMATIC ACTIVATING GNAS MUTATIONS IN PERIPHERAL BLOOD LEUCOCYTES BY NEXT GENERATION SEQUENCING IN ISOLATED MONOSTOTIC FIBROUS DYSPLASIA AND IN ISOLATED AUTONOMOUS OVARIAN CYST
Hironori Shibata, MD, Keio University School of Medicine, Tokyo, Japan; Satoshi Narumi, MD, National Research Institute for Child Health and Development, Tokyo, Japan; Tomohiro Ishii, MD; Yoshiaki Sakamoto, MD, Keio University School of Medicine, Tokyo, Japan; Koji Muroya, MD; Yumi Asakura, MD; Masanori Adachi, MD, Kanagawa Children's Medical Center, Yokohama, Japan; Goro Sasaki, MD, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan; Takumi Shibazaki, MD; Yosuke Hara, MD, Shinshu University School of Medicine, Matsumoto, Japan; Gen Nishimura, MD, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan; Tomonobu Hasegawa, MD, Keio University School of Medicine, Tokyo, Japan

Objectives: McCune-Albright syndrome (MAS) caused by somatic activating GNAS mutations is characterized clinically by the classic triad of fibrous dysplasia, café-au-lait skin spots, and GnRH-independent precocious puberty due to autonomous ovarian cyst (AOC). Monostotic fibrous dysplasia (MFD) and AOC can also occur in isolation. We reported that next generation sequencing (NGS) detected somatic activating GNAS mutations sensitively from peripheral blood leucocytes (PBL) samples in MAS (PLoS One 2013; 8: e60525). On the other hand, there are no reports on detection of somatic activating GNAS mutations in PBL samples by NGS in isolated MFD or in isolated AOC. In a previous report, somatic activating GNAS mutations were found in 21 (52.5%) of 40 bone samples from patients with isolated MFD by direct sequencing (Hum Pathol 2012; 43: 1234) and in 13 (33.3%) of 39 ovarian samples from patients with isolated AOC by nested PCR and restriction enzyme digestion (J Clin Enocrinol Metab 2004; 89: 2107).

The objective of this study was to determine detection probabilities of somatic activating GNAS mutations in PBL samples by NGS in patients with isolated MFD and in patients with isolated AOC.

Methods: The study included 8 patients with isolated MFD and 8 patients with isolated AOC. We performed both NGS and combinatory method of peptide nucleic acids probe with NGS (PNA-NGS) using PBL samples from all patients.

Results: Detection probabilities of somatic activating GNAS mutations in patients with isolated MFD were 12.5% by NGS and 62.5% by PNA-NGS (Table.1). Those in patients with isolated AOC were 12.5% by NGS and 62.5% by PNA-NGS. The distribution of NGS measured mutation abundance in isolated MFD and isolated AOC were statistically significantly lower than that in MAS in our previous study (P=0.01, Wilcoxon rank sum test).

Conclusions: The combinatory method of PNA-NGS can detect somatic activating GNAS mutations sensitively from PBL samples in patients with isolated MFD and in patients with isolated AOC. Our data indicate that ratio of mutant to wildtype alleles in PBL are lower in isolated MFD and isolated AOC than in MAS.

1449: P1-211

TARGETED NEXT GENERATION SEQUENCING IN GENETIC DIAGNOSTICS OF OSTEOGENESIS IMPERFECTA
Darja Smigoc Schweiger, PhD; Sara Bertok, MD; Marusa Debeljak, PhD; Jernej Kovac, PhD; Tine Tesovnik, BS/BA; Tadej Battelino, PhD; Katarina Trebusak Podkrajsek, PhD, University Children's Hospital Ljubljana, Ljubljana, Slovenia

Objectives: Osteogenesis imperfecta (OI) is a hereditary disease characterized by increased bone fragility and additional non skeletal findings. In most affected individuals OI is caused by dominant mutations in COL1A1 or COL1A2. Recessive forms of OI are caused by mutations in other genes affecting collagen synthesis. Molecular genetic testing can increase the sensitivity of clinical diagnosis. The exact diagnosis is relevant since it might have an impact on the treatment and is also important for family planning and genetic counselling. The aim of our study was to assess the utilisation of targeted next generation sequencing (NGS) for a select group of genes in diagnostic settings for OI.

Methods: The study population comprised 15 individuals with OI phenotype (3 males, 12 females) aged between 1 month and 18 years who were evaluated at the tertiary paediatric outpatient clinic. Fourteen patients had clinically mild OI and one patient had clinically severe OI. NGS had been performed as the initial diagnostic methodology in all patients. We performed targeted NGS with TruSightOne Sequencing Panel on the  MiSeq  platform (Illumina, USA) followed by interpretation of variants in the OI associated genes (ALPL, BMP1, COL1A1, COL1A2, CRTAP, FKBP10, IFITM5, LEPRE1, LRP5, PLOD2, PPIB, SERPINF1, SERPINH1, SP7) and subsequent Sanger sequencing confirmation.

Results: We detected ten different mutations in genes COL1A1 and COL1A2 in ten patients (66% success rate). Pathogenic mutation COL1A2, NM_000089.3:c.1704_1705insAAA (p.Gly568_Lys569ins Lys) found in patient with a severe OI phenotype was not previously reported. Among patients with mild OI two novel pathogenic variants, namely COL1A1, NM_000088.3:c.1853delC (p.Ala618ValfsTer148) and COL1A1, NM_000088.3:c.740C>T (p.Pro247Leu) were identified.

Conclusions: Presented subject group had mutations in genes commonly associated with OI. However each subject had his own private mutation. NGS enabled fast and precise molecular diagnosis by identifying causal mutations in several genes related to OI simultaneously.

1400: P1-212

A NOVEL MUTATION IN FIBROBLAST GROWTH FACTOR 23 IDENTIFIED IN A PATIENT WITH HYPOPHOSPHATEMIC RICKETS PREVENTS PROTEOLYTIC CLEAVAGE.
Hiroyuki Tanaka, MD; Mayuko Tamura, MD; Chie Takahashi, MD, The University of Tokyo, Tokyo, Japan; Mirai Muto, MD, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan; Yuka Kinoshita, PhD; Nobuaki Ito, PhD; Akira Oka, Professor; Sachiko Kitanaka, Associate Professor, The University of Tokyo, Tokyo, Japan

Objectives: Background: Fibroblast growth factor 23 (FGF23) plays a key role in regulation of phosphorus metabolism. Biologically active intact FGF23 is cleaved between Arg179 and Ser180, and this processing inactivates its function. The subtilisin-like proprotein convertase (SPC) proteolytic processes recognize Arg176 to Arg179 cleavage site (RXXR motif). Mutations of FGF23 at Arg176 and Arg179, the key residues for the cleavage, have been known to cause autosomal dominant hypophosphatemic rickets (ADHR). However, no mutation other than these residues has been reported.

Case: A 13-year-old boy visited our institution complaining of bilateral knee joint pain. His height was normal and there was no physical finding. Radiography of his bone revealed rickets, and blood examination showed a high level of ALP, low level of phosphorus (1.9 mg/dL), normal levels of calcium, and intact PTH, and undetectable level of FGF23. He also presented iron-deficient anemia.

Methods: We performed genetic analysis of FGF23, PHEX, DMP1, and SLC34A3 genes with informed consent and the approval of the Ethics Committee. For revealing the effect of a novel mutation of FGF23, we conducted Western blotting of overexpressed proteins, comparing with wild-type and other mutations located at the cleavage site (R176Q, R179Q) and our case (S180I). FGF23 cDNA expression plasmid were transiently transfected into UMR106 cells and the protein extracts from the extracellular fluid were analyzed by Western blotting using an antibody that recognizes the C-terminal regions of FGF23.

Results: The genetic analysis revealed a novel heterozygous missense mutation Ser180Ile in FGF23. No pathogenic mutation in PHEX, DMP1, SLC34A3 was found. Western blot analysis revealed that, whereas wild-type FGF23 protein showed two bands of the full-length protein (32kDa) and the processed (12kDa), S180I showed only one band of 32kDa, which was the same pattern to the both of R176Q and R179Q.

Conclusions: We report a novel FGF23 mutation, S180I detected in a hypophosphatemic rickets patient with iron-deficient anemia. S180I showed prevention of proteolytic cleavage in vitro. This is the first study to demonstrate that the mutation of FGF23 other than SPC cleavage site leads to protease resistance.

1125: P1-213

THE MECHANISM OF CNES UPSTREAM AND DOWNSREAM OF SHOX REGULATING SHOX
Min Zhu, MD; Shijie Xin, MD; Xuejiao Xu, MD; Huiying Mao, MD; Ke Xu, MD; Feng Xiong, MD, Children’s Hospital of Chongqing Medical University, Chongqing, China

Objectives:

To establish U2OS cell line with conserved noncoding DNA elements (CNEs) knocked out is to study the activity of CNE9 and CNE10 of short stature homeobox-containing gene (SHOX) by the functional deletion strategy ; To study the relationship of CNEs of SHOX gene and SHOXpromoter2(SHOXp2),and analyze the regulatory mechanisms of CNES.

Methods:

1. We established U2OS cell line with CNE9 and CNE10 knocked out by the usage of CRISPR/Cas9 technique; Sanger sequencing verified positive cell lines; Western-blot tested the protein expression of SHOX gene.

2. To construct the recombinant vector in the PsiCHECK-2 vector with SHOXp2 ; The various CNEs were cloned into the recombinant vector. Recombinant vectors and the control group were transfected into HEK293T cells , the relative activity of fluorescence was measured.

Results:

1. Sanger sequencing verified positive cell lines, and U2OS cell line with CNE9 and CNE10 knocked out were acquired.

2. The protein expression decreased and had a significant difference among U2OS cell line with CNE9 and CNE10 knocked out ( P<0.01).

3. PsiCHECK-2-SHOXp2 vector was successfully constructed, and the recombinant vector containing CNE-5, CNE-3, CNE-2, CNE9, CNE10, CNE11 were constructed respectively.

4. Compared with Rluc/Fluc of the control group, the activity of the recombinant vector containing CNE-3, CNE-2 rose(P<0.01), and the activity of  CNE 9, CNE 10, CNE 11 reduced (P<0.01). It had a significant difference between Each of the CNE-3, CNE-2, CNE 9, CNE 10, CNE 11 and the control group. The  CNE-5 was no variation(P>0.05)  .

Conclusions:

1. We established U2OS cell line with CNE9 and CNE10 knocked out .The expression quantity of SHOX protein of control group is higher than that cell line with CNE9 and CNE10 knocked out. It proved that CNE9,CNE10 strengthened the transcription and translation of SHOX gene, CNE9 and CNE10 had enhanced activity and that provided a cell model for study of the regulatory mechanism of CNEs and SHOX gene.

2.It was verified that CNE-3, CNE-2 enhancing the activity of SHOXp2 may control the expression of SHOX  and CNE9,CNE10 inhibiting the activity SHOXp2 may inhibit the transcription and translation of SHOX gene;In short, CNEs of SHOX gene may regulate the expression of SHOX gene by using a different promoter.

377: P1-214

PARTHYROID ADENOMA IN TURNER SYNDROME: THE IMPORTANCE OF AN EARLY DIAGNOSIS
Ana D Alcalde De Alvare, MD; Magdalena Hawkins Solis, MD; Julia Yebra Yebra, MD; Gema García Romero De Tejada, MD; Sagrario García Sanchez, MD; Alfonso Cañete Garcia, MD, Hospital Universitario Infanta Sofia, Universidad Europea de Madrid, Madrid, Spain

Objectives: Primary hyperparathyroidism is a rare condition caused by the overactivity of the parathyroid gland, which can lead to severe deleterious effects due to untreated hypercalcemia (muscle weakness, fatigue, volume depletion, neuropsychiatric symptoms, osteopenia, osteitis fibrosa cystica and the formation of renal stones). The most common cause of primary hyperparathyroidism is a single gland adenoma in postmenopausal women.

Turner Syndrome (TS) is a chromosomal abnormality that occurs in 1/2500 live born females and it is associated with multiple comorbidities such as osteoporosis, obesity, hypothyroidism and hypertension. Only a few cases of primary hyperparathyroidism have been described in association with TS, and most of them occurred in adult women

Methods: We report a case of primary hyperparathyroidism in a teenager with TS, diagnosed during her routine follow up.

Results: A 15-year old girl with TS and chronic lymphocytic thyroiditis was found to have mild hypercalcemia (10.9 mg/dl) and a hypoecogenic nodular thyroid lesion during a routine outpatient review.

Hypercalcemia was confirmed on a repeated blood test (10.1 mg/dl) that also showed elevated levels of parathyroid hormone (PTH; 242pg/ml). There were normal levels of phosphorus, calcitonin, osteocalcin and vitamin D3; kidney function was also normal. Chest and neck technetium-99 scintigraphy showed images suggestive of parathyroid hyperfunctioning tissue in the left lower thyroid lobe. Abdominal ultrasound showed normal urinary tract.

The nodule was surgically excised, with a confirmed intra-surgery PTH decrease (from 255 to 32). Pathology showed a parathyroid adenoma.

After surgery, the patient was discharged with vitamin D treatment. Calcium and PTH levels returned back to normal.

Conclusions: Although rare, primary hyperparathyroidism has been described in patients with TS and should be considered and investigated in the presence of hypercalcemia, even when it is mild and the patient is asymptomatic. Our patient is one of the youngest reported with this association and our case illustrates how a high level of suspicion and consequently an early diagnosis of primary hyperparathyroidism can prevent a severe and irreversible damage due to untreated chronic hypercalcemia.

803: P1-215

HYPOPHOSPHATASIA: THREE NEW MUTATIONS IN ALPL GENE DESCRIBED IN TWO PATIENTS WITH UNCOMMON CLINICAL MANIFESTATIONS
Luiz Claudio Castro, PhD; Maria Carolina Medeiros, MD, University of Brasilia, Brasilia, Brazil; Daniel Rocha, PhD, Sarah Hospital, Brasilia, Brazil; Beatriz Ribeiro, MD; Paula Carrijo, MD; Lais Oliveira, MD; Naiara Martins, MD; Delia Braz, MD; Fernanda Lopes, MD; Renata Oliveira, MS/MA; Maria Do Carmo Scher, MS/MA, University of Brasilia, Brasilia, Brazil

Objectives: Hypophosphatasia (HPP) is a rare genetic disease due to inactivating mutations of ALPL gene, which encodes the non-specific tissue alkaline phosphatase enzyme -ALP. We report on three new ALPL gene mutations in two patients who presented unusual clinical manifestations.

Methods:  The ALPL gene sequencing was performed through PCR amplification and Sanger sequencing. New mutations went through in silico analysis by pathogenicity prediction softwares (PoliPhen;Mutation Taster).

Results: Description of cases and comments:
(1) Male, 21 year-old, diagnosis of PPH at 2 years of age, after surgery for correction of craniosynostosis. He presents extremely short stature and obesity, height 130.5 cm / 4ft 3in  (Z-score:-6.3 SDS), body mass index (BMI) 34.3 kg/m2 and waddling gait. At 20 years of age his laboratory evaluation showed: ALP 5 IU/L (reference: 30-120 IU/L), vitamin B6: 170.9 mcg/L (reference: 5.2-34.1 mcg/L). Three ALPL gene mutations were found: exon 11, c.1307A> G (deleterious, maternal inheritance; previously described); exon 3, c.97G> C (deleterious, PoliPhen) and c.112A> C (benign, PoliPhen), being last both of paternal inheritance and not previously described. Unusual manifestations: obesity, hepatic steatosis, autoimmune thyroiditis; asymmetric kidneys, hyperuricemia, hypocitraturia and proteinuria. There was no history of bone fractures. It is questioned whether such findings are part of a not yet known wider HPP spectrum or just coincidental.
(2) Female, 26 year-old, presents Turner syndrome (ST), karyotype 45,X/46Xi(X)(q10). Height 149 cm / 4 ft 11in (Z-score -2.2 SDS), BMI 40 kg/m2, hepatic steatosis, severe scoliosis. Despite a history of ALP dosages consistently low for age since adolescence, the suspicion and diagnosis of PPH was only made at 25 years of age: ALP 20 IU/L, vitamin B6 250 mcg/L. It was found a ALPL gene mutation in heterozygosity, exon 11, c.1238T> C, not previously described (pathogenic variant, Mutation Taster). There was no other clinical findings typical of HPP nor history of bone fractures. For this patient, the unusual manifestations were the severe obesity and ST-HPP association.

Conclusions:    These two cases illustrate the breadth of the potential clinical and biochemical genotype related-expression in patients with HPP.

824: P1-216

AUTOSOMAL DOMINANT HYPOCALCEMIA TYPE 1 AND LITERATURE REVIEW
Linqi Chen, Pediatrician, University of Soochow,Children's hospital of Soochow university, Suzhou , China; Hui Sun, pediatrician; Haiying Wu, MD; Rongrong Xie, pediatrician, University of Soochow, Suzhou, China

Objectives: To explore the clinical manifestation of patient with autosomal dominant hypocalcemia type 1 and to sequence the related CaSR gene of the patient.

 

Methods: A children with ADH1 was reported in regard to clinical manifestation, laboratory examination and genetic mutation. Some related literatures were reviewed.

Results: The patient was a girl, 1 months 11 days old, and had recurrent seizures for more than three weeks, aggravating for three days. Laboratory work-up revealed hypocalcemia, hypomagnesemia, hyperphosphatemia, suppressed PTH, increased urinary calcium-to-creatinine. The child was clinically highly suspected of ADH1. Targeted sequencing showed a reported mutation in exon 3 of CaSR Gene, c.392G>A, p.cys131Tyr, and both parents did not harbor the child’s mutation, indicating that her mutation had arisen de novo.

Conclusions: ADH1 is a rare endocrine disease caused by gain-of-function mutations in the CaSR gene, manifests familial or sporadic hypercalciuric hypocalcemia,that should receive more attention to avoid missing diagnosis. One pathogenic mutations (c.392G>A, p.cys131Tyr)in CaSR gene was found.

1117: P1-217

CLINICAL OUTCOMES WITH EARLY INITIATION OF TREATMENT IN A PATIENT WITH INCIDENTALLY DIAGNOSED INFANTILE HYPOPHOSPHATASIA
Sara Duffus, MD; Bradly Thrasher, DO; Ali S Calikoglu, MD, University of North Carolina, Chapel Hill, NC, United States

Objectives: To describe an unusual presentation of hypophosphatasia and the outcomes of treatment when initiated early in the disease course

Methods: Chart review was performed to obtain details related to the clinical case.

Results: A 4-week-old, term male was found to have a hip click bilaterally on exam by his primary care provider.  Hip films were interpreted as having an abnormal appearance of the proximal femurs concerning for non-accidental trauma.  Subsequent skeletal survey revealed cupping and metaphyseal irregularities in the majority of the long bones, in addition to rachitic rosary most consistent with rickets.  The patient had normal calcium (9.7 mg/dL), normal parathyroid hormone (25 pg/mL), only mildly elevated phosphorous (5.8 mg/dL), and significantly low alkaline phosphatase level (33 units/L).  Additional testing was consistent with hypophosphatasia, including elevated urine phosphoethanolamine (2228 nmol/mg creatinine, normal 0 – 372) and elevated vitamin B6 (1030 mcg/L, normal range 5 - 50). 

The patient was started on asfotase alfa 2 mg/kg three times weekly at 7 months of age.  After 1 month of therapy, his laboratory findings had normalized.  Repeat imaging revealed grossly normal long bone appearance with no evidence of low bone mineralization or metaphyseal flaring or widening. At 11 months of age, four months following initiation of therapy, he continued to have no apparent bony abnormalities or respiratory insufficiency.  His only notable clinical symptom was premature loss of two primary teeth. 

Conclusions: Infantile hypophosphatasia is a rare disorder that is life-threatening and frequently diagnosed late in the clinical course.  Without treatment, mortality is greater than 50% by 9 months of age.  This case report describes a unique presentation of infantile hypophosphatasia in which the diagnosis was incidentally made following evaluation to rule out congenital hip dysplasia, prior to the development of any clinically evident symptoms.  Treatment with enzyme replacement therapy was initiated early, after which significant radiographic and laboratory improvement was demonstrated.  Findings from this case emphasize the importance of early diagnosis and argue for timely implementation of enzyme replacement therapy.

73: P1-218

CYP3A4 INDUCTION BY RIFAMPIN: AN ALTERNATIVE PATHWAY FOR VITAMIN D INACTIVATION IN PATIENTS WITH CYP24A1 MUTATIONS
Colin P Hawkes, MD; Dong Li, PhD; Hakon Hakonarson, MD; Kevin E Meyers, MBBS, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; Kenneth Thummel, PhD, University of Washington School of Medicine, Seattle, WA, United States; Michael A Levine, MD, The Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: The P450 enzyme CYP24A1 is the principal inactivator of vitamin D metabolites. Biallelic loss-of-function mutations in CYP24A1 are associated with elevated serum levels of 1,25-dihydroxyvitamin D3 with consequent hypercalcemia and hypercalciuria, and represent the most common form of idiopathic infantile hypercalcemia (IIH). Current management strategies for this condition include a low calcium diet, reduced dietary vitamin D intake and limited sunlight exposure. CYP3A4 is a P450 enzyme that inactivates many drugs and xenobiotics and may represent an alternative pathway for inactivation of vitamin D metabolites. The aim of this study was to determine if rifampin, a potent inducer of CYP3A4, can normalize mineral metabolism in patients with IIH due to mutations in CYP24A1.

Methods: We treated two IIH patients with daily rifampin (10 mg/kg/day, up to a maximum of 600 mg). Serum calcium, phosphorus, parathyroid hormone, (PTH), liver and adrenal function and vitamin D metabolites, as well as urinary calcium excretion, were monitored during treatment for up to 11 months.

Results: Prior to treatment, both patients had hypercalcemia (10.5-10.7 mg/dL), hypercalciuria and nephrocalcinosis with elevated serum 1,25-dihydroxyvitamin D3 (55-99 pg/ml) and suppressed serum PTH (2-3 pg/ml). Daily treatment with rifampin was well tolerated and led to normalization or improvement in all clinical and biochemical parameters. At 10 months, serum calcium was 9.6-19 mg/dL, and serum PTH was 16-31 pg/ml. One patient stopped treatment for 2 months and serum calcium increased to 11.5 mg/dL with suppression of PTH to 3 pg/ml.

Conclusions: These observations suggest that rifampin-induced overexpression of CYP3A4 provides an alternative pathway for inactivation of vitamin D metabolites in patients who lack CYP24A1 function.

351: P1-219

TWO NOVEL IN-FRAME DELETIONS OF COMP IN PATIENTS WITH PSEUDOACHONDROPLASIA
Yosuke Ichihashi, MD; Tomohiro Ishii, MD, Keio University School of Medicine, Tokyo, Japan; Kenji Watanabe, MD, Kagoshima City Hospital, Kagoshima, Japan; Yuki Takagi, MD, Kawasaki City Hospital, Kawasaki, Japan; Gen Nishimura, MD, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan; Tomonobu Hasegawa, MD, Keio University School of Medicine, Tokyo, Japan

Objectives: Pseudoachondroplasia (PSACH) is a rare autosomal dominant skeletal disease which is exclusively caused by mutations in cartilage oligomeric matrix protein (COMP) gene. Mutations in the COMP gene are known to cause PSACH and multiple epiphyseal dysplasia (MED). Eighty-five percent of the COMP mutations are located in the type 3 thrombospondin (TSP) like repeat region, which is coded by exons 8-14. Approximately 76% of in-flame deletions in the type 3 TSP repeat region are responsible for PSACH, whereas 36% for MED. The genotype-phenotype correlation of COMP is still under investigation.

Methods: Our study involved two Japanese boys with sporadic PSACH. Case 1 was a 6-year-old boy. He had shown no signs of skeletal disease, until his growth retardation was evident at 2 years of age. He was diagnosed as having PSACH at 4 years, based on short stature (-2.8 SD), waddling gait, and specific radiologic findings including oval shaped platyspondyly, anterior breaking of vertebrae, small and irregular epiphyses, and irregular metaphyses. Case 2 was a 2-year-old boy. His mother noticed gait disturbance since he started walking. Radiologic survey revealed metaphyseal irregularity and epiphyseal hypoplasia of femur and tibia. He was diagnosed as having PSACH, based on short stature (-2.2 SD), waddling gait, and the radiologic findings. We extracted DNA from lymphocytes of both cases and examined all coding exons and flanking regions of introns of COMP by PCR-based Sanger sequencing.

Results: We identified a 12 base in-frame deletion in the exon 13 (c.1426_1437del12bp, p.476_479delGMPD) for Case 1 and a 9 base in-frame deletion in the exon 9 (c.934_942del9bp, p.312_314delCDP) for Case 2. The parents of both cases did not consent for familial analyses. Both deletions are located on type 3 TSP repeat region of COMP gene and have not been reported previously.

Conclusions: We identified two novel in-frame deletions in the type 3 TSP repeat region of COMP gene. Our findings support the notion that in-frame deletions of type 3 TSP repeat region preferentially cause PSACH rather than MED.

273: P1-220

NOVEL TRPM6 MUTATION IN HSH SYNDROME WITH INFANTILE SEIZURES
Swati Kanodia, MD; Archana D Arya, MD, Sir Ganga Ram Hospital, Delhi, India

Objectives:

Methods: Results: Conclusions:

1797: P1-221

SLC34A1 MUTATION IN 2 CHINESE PATIENTS WITH IDIOPATHIC INFANTILE HYPERCALCEMIA
Wenjing Li, MD, capital medical university, beijing children's hospital, beijing, China

Objectives: OBJECTIV:

Idiopathic infantile hypercalcemia (IIH) is a rare condition, which is characterized by severe hypercalcemia with failure to thrive, vomiting, dehydration, and nephrocalcinosis. The gene mutation of SLC34A1 can involve IIH, which encoding renal sodium-phosphate cotransporter 2A.

We first reported 2 cases with IIH from 2 non consanguineous families in China due to SLC34A1 mutation. The purpose of this study is to pay enough attention on this disease and to identify at early stage, so as to avoid the occurrence of severe renal damage.

Methods: METHODS:

Clinical manifestations and biochemical data of the patients were collected.

Genomic DNA of the probands and their family members was isolated from peripheral blood cells.

The next generation genomic analysis indentified with SLC34A3 gene mutation.

Results: RESULTS:

One boy was 1 month old. He complained of poor feeding, failure to thrive, vomiting with early-onset nephrocalcinosis. The other was a 6 months old girl and complained of failure to thrive, vomiting, dehydration, and nephrocalcinosis. Both patients received vitamin D supplements from birth according to the country’s recommendations.

We found they had polyuria after admission. Renal ultrasound demonstrated medullary nephrocalcinosis in both infants. The analysis of laboratory data at the time of initial manifestation revealed hypercalcemia and suppressed intact parathyroid hormone (iPTH) levels. The blood calcium level of the boy was high up to 5.35mmol/l, while of the girl was up to 4.16mmol/l. The iPTH values were low as 0.01pg/ml with the boy and 1 pg/ml with the girl (normal range 10-69pg/ml). The ratios of calcium to creatitine were up to 2.72 and 2.25 respectively (normal range below to 0.2). The level of phosphorus was low to 0.68 mmol/l and 0.57mmol/l (1.1-1.8). During hypercalcemia, the levels of active 1, 25-(OH)2D3 and 25-(OH) D3 were determined normal.

During acute treatment of hypercalcemia, vitamin D supplements were stopped in both patients. The therapeutic measures included intravenous rehydration and furosemide. A low calcium diet was initiated in boy. Thereafter, serum calcium levels decreased but continuously elevated in the following days. After both patients were proven SLC34A1 mutations, they were treated with oral phosphate supplementation. Both patients were normocalcemic and free of clinical symptoms in 3 days and, while hypophosphatemia were corrected. The The ratios of calcium to creatitine both decreased to 0.25.

The boy carried with heterozygous SLC34A1 mutation of c.1697_c.1698(exon13), ins T , p.P566Pfs*39. The girl carried with heterozygous SLC34A1 mutation of c.1322A>G, p.Y441C.

Conclusions: CONCLUSIONS:

The patient with Idiopathic infantile hypercalcemia had severe renal calcification that may eventually lead to severe damange kidney function. The clinical and laboratory findings persist despite cessation of vitamin D prophylaxis, but rapidly respond to phosphate supplementation. Therefore, early identification of SLC34A1 defects appears critical for targeted therapy in patients with IIH.

1149: P1-222

ALTERNATIVE TREATMENT OF MULTIPLE GIANT CELL LESIONS (MGCL) IN TWO BOYS WITH NOONAN SYNDROME (NS)
Marcio V Ortegosa, DDS; Maria Estela J Faria, PhD; Andre C Rocha, PhD; Alexander Jorge, PhD, Universidade de Sao Paulo, Sao Paulo, Brazil; Alexsandra C. Malaquias, PhD, Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo, Brazil

Objectives: To report the alternative treatment of two cases of NS caused by mutation in the PTPN11 and SOS1 genes.

Methods: A 9.3-year-old and 5.7-year-old boys with Noonan syndrome were referred to dentistry center for evaluation of a mandibular swelling causing facial asymmetry. The lesion was first noted about ten months before the first evaluation. The first boy was previously diagnosed with NS and identified mutation in SOS1 gene (p.M269R), dysmorphic face, pulmonary valve stenosis, and learning disabilities. The second one was a patient with NS and mutation in PTPN11 (p.Q510P), dysmorphic face, learning disabilities and no heart defects.

Results: Clinical examination revealed moderate facial asymmetry, secondary to an expansive mandibular growth, covered by intact mucosa. Both patients showed normal bone metabolism profile, except for the low level of vitamin D in the first patient. Panoramic radiography disclosed bilateral cystic lesions in the maxilla and mandible. Tomography showed large multilocular lesions bilaterally in the mandible and the paranasal region causing expansion of the cortical and displacement of the teeth. The mandibular canal was not evident. Based on images and previous NS diagnosis, MGCL was suspected. Regarding systemic risks and undesirable damage to the jaw and teeth, surgical curettage was not the choice for both patients. We opted for an alternative therapy with daily administration of salmon calcitonin nasal spray that was given for two years. No calcification has occurred after the treatment in both boys. The youngest patient showed discrete expansion of the lesions. To promote calcification of the lesions, we opted for once-yearly intravenous therapy with zoledronic acid. After one year, calcification was also inadequate despite no lesions progression. Bone turnover markers showed improvement from 1 to 6 months after zoledronic acid but rose again after one year.

Conclusions: Benign MGCL should be considered as a clinical feature of Noonan syndrome caused by dysregulation of the RAS-MAPK pathway. Calcitonin and zoledronic acid do not seem to improve calcification and lesion volume in this condition.

598: P1-223

AN INFANTILE HYPOPHOSPHATASIA CASE DUE TO A NOVEL MUTATION IN TNSALP GENE
Eda Mengen, MD, Ankara Children's Hematology and Oncology Training Hospital, Ankara, Turkey; L. Damla Kotan, PhD; A. Kemal Topaloglu, MD; Bilgin Yuksel, MD, Çukurova University Faculty of Medicine, Adana, Turkey

Objectives: It is a rare congenital metabolism disease characterized with defective bone mineralization related with serum and bone alkaline phosphatase activity due to mutation in hypophosphatasia tissue nonspecific alkaline phosphatase (TNSALP) gene.

Methods: Case: The infant was born as the first alive baby of a 29 year old mother from her first pregnancy with a birth weight of 3370 gr through C/S in the 40th week of pregnancy and she was hospitalized in an external center due to the seizure and respiratory difficulty starting on the postnatal first day. The metabolic scannings, cranial usg and brain MR were reported as normal for the patient who was previously hospitalized for 12 days in the intensive care due to convulsion and respiratory difficulty. She was discharged with antiepileptic drugs. Our patient referred to us when she was 52 days old. She had seizures, respiratory problem and groaning. Her parents were not relatives. According to the physical examination, her body weight was 4250 gr, height was 54 cm and head circumference was 36 cm. She had frog pose and hypotonia. In the head examination FF was open 4x5 cm and the sutures were open. Ca was 9.9 mg/dl, P was 5.1 mg/dl and ALP was 1 U/L. Spread rickets findings were observed in bone graphies. Plasma PLP:>500 μg/L (0-50) level was detected high. Infantile hypophosphatasia was considered for the patient with these findings and results.

Results: TNSALP gene and neighboring intronic areas were examined for possible mutations through DNA sequence analysis. p.I218S (C.653T>G) homozygote mutation was detected in TNSALP gene.

Conclusions: Patients are normal at birth in infantile hypophosphatasia cases and clinical findings appear in the first six months. Demineralization and rachitic changes are observed in metaphyses. There may be respiratory problems due to rachitic deformities and the patients generally die due to this. Hypophosphatasia should be considered in distinctive diagnosis in cases with persistent convulsions and respiratory problems in newborn period.

894: P1-224

SEVERE HIPERPARATIROIDISM DUE TO MULTIPLE ADENOMA IN A MALE TEENAGER: RESPONSE WITH CINACALCET.
Eduard Mogas Viñals, MD; Ariadna Campos Martorell, PhD; Maria Clemente León, PhD; Diego Yeste Fernandez, PhD, Vall Hebron Hospital, Barcelona, Spain

Objectives: Parathyroid adenoma is the most common cause of primary hyperparathyroidism (PHPT). In most cases it is unique and the treatment is surgery. In adults, cinacalcet, a calcium-sensing agent that increases the sensitivity of the calcium sensor (CaRS), has been successfully used. In paediatric patients, cinacalcet is a common drug for treatment of secondary hyperparathyroidism, but its use in PHPT it’s exceptional.

Methods: Case report

Results: Our patient was a 13-year-old teen from Senegal who underwent a medical examination at his arrival. Hypercalcemia 13.8mg/dL, hipophosphoremia 2.9mg/dl, parathormone (PTH) 1250 pg/dL, alkaline phosphatase 1587 UI/L and severe vitamin D deficiency (7.9ng/mL) were reported. The study was completed with calciuria 9.7mg/kg/day and normal urine catecholamine excretion. There was no familiar history of hypercalcemia.

Physical examination showed height at –4 SDS, sable deformity in forearms and bilateral genus valgus. In whole-body skeletal X-ray, Looser-Milkan lines were observed in both tibias and also diffuse osteoporosis with bone reabsorption signs in clavicles, phalanges and metacarpals. Nephromegaly and nephrocalcinosis were reported in the abdominal ultrasound. Ultrasonography, cervical scan and sestamibi-Tc99m scintigraphy showed a left parathyroid adenoma of 12x10x45cm.

Patient received intensive treatment for hypercalcemia (maximum levels of 16 mg/dL) with hyper-hydration, diuretics, methylprednisolone, two calcitonin doses and surgical excision of the adenoma without incidences. CaRS and MEN-1 genetic studies were performed with both negative results.

Follow-up showed normal calcium and vitamin D but PTH (250 pg/dL) was persistently elevated. Cervical MRI and scintigraphy were performed again and a 12x8x4.9 cm right parathyroid adenoma was found. Given the complex surgical approach and the normality of calcium values, treatment with cinacalcet was initiated. After one year follow-up, patient has normal serum calcium, a decrease in PTH levels (50 pg/dL) and a 0.61 mg/mg calcium/creatinine ratio.

Conclusions: Severe hyperparathyroidism, such as in this case, causes bone and metabolic alterations that cause morbidity. In our patient, treatment with cinacalcet allowed to avoid a new surgery on the parathyroid gland.

953: P1-225

PERINATAL SEVERE OSTEOGENESIS IMPERFECTA TYPE VIII DUE TO A NOVEL HOMOZYGOUS LEUCINE PROLINE-ENRICHED PROTEOGLYCAN 1 (LEPRE1) MUTATION: A CASE REPORT.
Patrick C Shepherd, MD; Satja Issaranggoon Na Ayuthaya, MD; Pisit Pitukcheewanont, MD, Children's Hospital Los Angeles, Los Angeles, CA, United States

Objectives: Osteogenesis imperfecta (OI) type VIII is a rare, autosomal recessive form of OI caused by a mutation in the Leucine proline-enriched proteoglycan 1 (LEPRE1) gene which encodes prolyl 3-hydroxylase 1 protein, a component of the collagen prolyl 3-hydroxylation complex, leading to altered post-translational collagen modification.   Most cases are perinatal lethal, although some live into childhood or even rarely into adulthood.  Severity of the disorder cannot always be determined by the genotype.  OI type VIII can be difficult to distinguish clinically and radiographically from the autosomal dominant forms OI type II and type III, although characteristic features of OI type VIII include white to light blue sclera, rhizomelia, undertubulation of the long bones, gracile ribs without beading, and small to normal head circumference.  OI type VII and type VIII are indistinguishable in infancy and early childhood.

Our objective is to summarize distinguishing characteristics of OI type VIII compared with other similar types of OI.

Methods: We present a case of OI type VIII with a novel homozygous mutation in LEPRE1 gene (c1354delC) and review existing literature.

Results: Our patient was a 2 day old term female infant who presented with multiple bony deformities and fractures.  She had IUGR and was born SGA at 38 weeks with light blue sclera, rhizomelia, mesomelia, microcephaly, and bowed legs.  Skeletal survey revealed multiple fractures, a small, thin rib cage, and diffuse osteopenia.  Lab analysis was unremarkable except for low vitamin D levels.  At one month of age she was intubated for deteriorating respiratory status but ultimately extubated and weaned to nasal cannula.  Due to new fractures she was treated with cyclic IV pamidronate but continued to have fractures and died at 5 months.  Since her clinical signs and symptoms could not allow for differentiation between other perinatal lethal forms of OI, genetic testing was performed which revealed a novel homozygous mutation in LEPRE1 gene (c1354delC).

Conclusions: This is a fatal case of OI type VIII with a novel homozygous mutation in LEPRE1 gene (c1354delC).  Genetic evaluation would be very helpful to differentiate OI type VIII from other perinatal lethal and severe forms of OI.

1238: P1-226

INFANTILE HYPERCALCEMIA IN A CASE WITH NEUROFIBROMATOSIS TYPE 1 TIBIAL PSEUDARTHROSIS
Shigeru Suzuki, MD, PhD, Asahikawa Medical University, Asahikawa, Japan; Takashi Sato, MD, Asahikawa-Kosei General Hospital, Asahikawa, Japan; Tokuo Mukai, MD, PhD, Asahikawa Kosei General Hospital, Asahikawa, Japan; Keiichi Ozono, MD, PhD, Osaka University Graduate School of Medicine, Osaka, Japan; Akiko Furuya, MD; Yusuke Tanahashi, MD, PhD; Hiroshi Azuma, MD, PhD, Asahikawa Medical University, Asahikawa, Japan

Objectives: Tibial pseudarthrosis is a serious but infrequent osseous manifestation of neurofibromatosis 1 (NF1). The pathogenesis of the skeletal abnormality of this disorder is not well understood. Although infantile hypercalcemia is caused by various condition, no report is so far available on the association with NF1.

Methods: Case report.

Results: The patient is a 3 year-old boy born at 32 weeks’ gestation. His birth weight and length was 1496 g (-1.1SD) and 49.5 cm (-0.4SD), respectively. Physical examination showed some café-au-lait spots, left tibial bone bowing and mild bilateral ptosis leading to diagnosis of NF1. Although he was admitted to NICU because of prematurity, the clinical course was favorable and he was discharged at 2 months of age. However, he was admitted to the hospital again because of inability to sit without support and failure to thrive with emesis at 9 months of age. The laboratory data then revealed hypercalcemia (serum total calcium, 15.4 mg/dl) and hypercalciuria (a calcium/creatinine ratio of urine, 0.95 and fractional excretion of calcium, 1.3%). Intact PTH (1.5 pg/ml) and PTHrP (<1.1 pmol/l) were low. 1,25 (OH)2D (5 pg/ml) was low and 25OHD (44 ng/ml) was normal, indicating that CYP24A1 deficiency was unlikely. ALP activity of 303 IU/l was slightly low (age-adjusted reference range: 420-1580). Therefore, ALPL gene was analyzed but no mutation was identified. Williams-Beuren syndrome was also ruled out by FISH analysis for 7q11.23. Skeletal radiographic study showed no abnormal findings except for left tibial pseudarthrosis, which had been noticed since birth. Treatment with intravenous fluid infusion and furosemide was effective for normalizing serum calcium levels. He took a low calcium milk until 2 years of age. His serum calcium levels have been within normal range after discontinuation of calcium restriction.

Conclusions: Hypercalcemia in this patient seems to result from the unexplained elevated calcium absorption because all of PTH, PTHrP and 1,25(OH)2D levels were low. We speculate that the pathology might be relative elevated bone resorption due to possibly reduced bone mineralization as seen in the mouse model for NF1 skeletal dysplasia.

261: P1-227

HEREDITARY HYPOPHOSPHATAEMIC RICKETS WITH HYPERCALCIURIA: CASE SERIES HIGHLIGHTING VARIABLE PHENOTYPE
Komal A Vora, MBBS, The Children's Hospital at Westmead, University of Sydney, Westmead, Australia; Peter Simm, MD, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne , Melbourne, Australia; Andrew Biggin, PhD; Craig Munns, PhD, The Children's Hospital at Westmead, University of Sydney, Westmead, Australia

Objectives: Hereditary hypophosphatemic rickets with hypercalciuria (HHRH – OMIM #241530) is a rare autosomal recessive renal phosphate wasting disorder which results from a loss-of-function mutation in the SLC34A3 gene. HHRH usually manifests in childhood or early adolescence with severe rickets, skeletal deformity and short stature. Rarely, HHRH may present as idiopathic hypercalciuria, nephrocalcinosis or nephrolithiasis without apparent bone disease. We aim to describe the variable clinical phenotype and genotype of four cases from our institution.

Methods: There are less than 50 reported cases of HHRH worldwide. Here we present 4 cases of HHRH from three kindred who presented with variable clinical phenotype.

Results: As shown in the attached table, all of our cases had typical biochemistry suggestive of HHRH i.e. low serum phosphate, elevated alkaline phosphatase, low parathyroid hormone, reduced tubular resorption of phosphate, hypercalciuria and elevated 1,25(OH)2D levels. However, all cases differed in their clinical presentation. Case one and case two had severe bone fragility phenotype with low trauma fracture and low bone mineral density. However, cases three and four (siblings) had normal bone phenotype but progressive severe nephrocalcinosis.

Parental carriers in the first two cases had no demonstrable clinical or biochemical abnormality except borderline elevation in 1,25(OH)2D. Parental carrier of the siblings had a history of recurrent nephrolithiasis.

Conclusions: The cases demonstrate wide variation in clinical presentation of HHRH. Importantly, HHRH may present as idiopathic hypercalciuria, nephrocalcinosis or osteoporosis and hence a high index of suspicion is necessary for appropriate diagnosis and management. Variations in clinical phenotype may be due to the genotype variations, although further studies are needed to determine genotype-phenotype correlation.

1738: P1-228

VITAMIN D TOXICITY IN A PEDIATRIC PATIENT: AN IMPORTANT LESSON ON TREATMENT AND MONITORING
Nazaneen M Eshragh, MD; Lisa Madison, MD, Oregon Health & Science University, Portland, OR, United States

Objectives: Identify barriers in treatment of vitamin D deficiency that can lead to vitamin D toxicity and potentially be prevented.

Methods: Vitamin D toxicity is rare in children, however over the past decade or so the benefits of vitamin D on bone health and other diseases has led providers to evaluate vitamin D states in children more commonly. There are an increasing number of different vitamin D formulations, recommended doses for daily requirements and treatment that place children at risk for vitamin D toxicity, in addition to, a lack of consensus on optimal levels and monitoring. This case is a great example of common pitfalls in treatment and monitoring of vitamin D deficiency that can lead to vitamin D toxicity requiring intervention. 

Results: 8 year old female with complex congenital heart disease admitted for fatigue, heart failure and multiple electrolyte abnormalities. Patient was noted to have vitamin D deficiency in 2010 with 25 hydroxy vitamin D level of 19 ng/mL. Patient was reportedly started on 5,000 units of ergocalciferol daily, however review of prescription revealed ergocalciferol 50,000 units daily. Unclear duration of this treatment. 25 hydroxy vitamin D level was rechecked in 2011 and was replete at 82 ng/dL, no change in management. Serum calcium levels were normal until 2015. Labs on admission were serum calcium 13 mg/dL, ionized calcium 1.4 mmol/L, phosphorus 8 mg/dL and PTH at 9 pg/mL. 25 hydroxy vitamin D level was 727.12 ng/mL and 1, 25 dihydroxy vitamin D level was >600 pg/mL. All exogenous forms of vitamin D were discontinued, hydration was optimized and she was continued on Lasix. Repeat levels in 1 week were downtrending, 25 hydroxy vitamin D 335.5 ng/mL. Calcium levels improved, but increased to maximum of 14 mg/dL. Glucocorticoids were started for treatment of hypercalcemia as bisphosphonates were not an option given acute kidney injury. Patient's 25 hydroxy vitamin D levels normalized 4 months later. 

Conclusions: This case demonstrates the importance of diligence when treating vitamin D deficiency as vitamin D toxicity can occur in the pediatric population. It is importanct to verify the correct dose and duration is being prescribed in addition to recommendations on monitoring levels following treatment. 

1569: P1-229

VITAMIN D STATUS IN TURKEY BETWEEN 2011 AND 2016
Deniz I Topcu, MD, Düzen Laboratuvari, Ankara, Turkey; Gul Yesiltepe Mutlu, MD, Koç University Medical School, Istanbul, Turkey; Abdullah Bereket, Professor, Marmara University, Faculty of Medicine, Istanbul, Turkey; Murat Oktem, MD, Düzen Laboratuvari, Ankara, Turkey; Sukru Hatun, Professor, Koç University, Medical School, Istanbul, Turkey

Objectives: Recently, requesting serum 25-hydroxyvitamin D (25OHD) measurement and prescribing vitamin D are increasing in Turkey.  In this study, the status of vitamin D in our country was analysed using a database of reliable and nationwide private laboratory.

Methods: Data analysis was carried out using serum 25OHD measurements performed by liquid chromatography tandem mass spectrometry (LC-MS/MS) method   between January 2011 and December 2016. In total 110774 serum 25OHD measurements were analysed according to to years, age groups and threshold vitamin D levels (0-11 ng / ml, 12-19 ng / ml, 20-49 ng / ml, 50-70 ng / ml and> 70 ng / ml). The correlation between 25OHD level and ALP and PTH was also assessed in cases which Alkaline Phosphatase (ALP) (14971 samples) and / or Parathyroid Hormone (PTH) measurement (7013 samples) were performed simultaneously.

Results: The mean 25OHD level was 37,80 ng/mL.  Median 25OHD level was 37.80 ng / mL under 1 year, 29.00 ng / mL in 1-3 years, 21.79 ng / mL in 4-8 years, 19.74 ng / mL in 9-13 years, 16.9 ng/ml in 14-18 yr, 15.40 ng/ml in 19-30 yr, 17.50 ng / mL in 31-50 yr, 19.50 ng / mL in 50-71 yr, and 18.34 ng / ml,  in > 70 yr group.  Mean 25OHD level under 3 years was significantly higher than the other age groups (p <0.01). The frequency of serum 25 OH D measurement has increased approximately 2.60 times (260%) in the ages of 0-18 years and 32% in the age of 18 years between 2011-2016. However, mean serum 25OHD level at these age groups did not show a significant difference over the years. Frequency of Vitamin D deficiency/insufficiency (<20 ng / mL) was the lowest in less than 1 year (13.4%) and highest in 19-30 years (62.4%) (table). 

Conclusions: Serum 25OHD levels in our country were similar to those of National Health and Nutrition Examination Survey (NHANES) carried out in 2001-2006, except under 1 year and 1-3 years age groups. These results support The Institute of Medicine (IOM) recommendations. The relatively high median 25OHD level in the first 3-year period and the low frequency of vitamin D deficiency and inadequacy were considered as positive effects of  free D vitamin supplement program applied in our country. 

434: P1-230

LONG-TERM GROWTH HORMONE TREATMENT AUGMENTS FINAL ADULT HEIGHT IN PATIENTS WITH ACHONDROPLASIA
Daisuke Harada, MD; Noriyuki Namba, MD; Yuki Hanioka, MD; Kaoru Ueyama, MD; Natsuko Sakamoto, MD; Masafumi Izui, MD; Yuiko Nagamatsu, MD; Hiroko Kashiwagi, MD; Miho Yamamuro, MD; Yoshihito Ishiura, MD, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan; Ayako Ogitani, MD, Nara Prefecture General Medical Center, Nara, Japan; Yoshiki Seino, MD, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan

Objectives: The objective of this study was to assess the gain in final height of achondroplasia (ACH) patients with long-term growth hormone (GH) treatment.

Methods: All patients had visited our hospital for treatment and were clinically diagnosed with ACH due to severe rhizomelic short stature, trident hands, characteristic facial features, and characteristic bone X-ray features. FGFR3 gene analysis was performed by direct sequencing and the typical p.Gly380Arg mutation was detected in all tested patients.

Medical records and/or questionnaires from 22 adult ACH patients (8 males and 14 females) that underwent GH treatment at a dose of 0.05 mg/kg/day were included in the retrospective analysis. Optionally, the Ilizalov method was used to perform tibial lengthening (TL) in 15 patients, and TL as well as femoral lengthening (FL) in 6 patients. Concomitant gonadal suppression therapy with buserelin acetate was applied in 13 patients.

Results: GH treatment was started at the mean age of 5.2±3.9 years and 5.5±2.7 years for boys and girls, respectively.

GH treatment augmented final height +0.60±0.52 SD (+3.5 cm) and +0.51±1.29 SD (+2.8 cm) in boys and girls, respectively, compared to non-treated ACH patients. Final height of ACH patients that underwent GH and TL increased +1.72±0.72 SD (+10.0 cm) and +1.95±1.34 SD (+9.8 cm) in males and females, respectively. GH, TL, and FL further increased final height +2.97 SD (+17.2 cm) and +3.41±1.63 SD (+17.3 cm) in boys and girls, respectively. Gonadal suppression therapy seemed to have no effect on final height.

Conclusions: Long-term GH treatment as well as GH in combination with limb lengthening improved final height in ACH patients.

 

2914: P1-231

ASSESSMENT OF RESTLESS LEGS SYNDROME DEVELOPMENT AND POOR SLEEP QUALITY IN NON-ANEMIC CHILDREN WITH VITAMIN D DEFICIENCY
Muge Atar, MD, S. Demirel University, Isparta, Turkey; Riza Taner Baran , MD, Antalya Training and Research Hospital, Antalya, Turkey; Ozgur Pirgon, MD; Nagehan Aslan, MD, S. Demirel University, Isparta, Turkey

Objectives: Restless legs syndrome (RLS) is a sensorimotor disorder that often has a profound impact on sleep. The aim of this study is to investigate the relationship between vitamin D (VitD) deficiency and RLS development and sleep quality in children.

Methods: Two hundred and ten children aged between 10 and 16 years were recruited for the study. VitD deficiency was defined as a serum 25-hydroxyvitamin D3 [25(OH)D] concentration

Results: RLS was diagnosed in 22 (10.4%) of the children and was more prevalent in VitD deficient group 13.6% (n=12) compared to the VitD insufficient 9.4% (n=8) and VitD sufficient groups 5.4% (n=2) (p<0.001). Total PSQI scores were significantly higher in VitD deficient subjects than VitD sufficient group (5.58 vs. 4.47, p=0.03). Lower VitD levels were negatively associated with age (r:-0.18, p:0.01) as expected and also negatively correlated with sleep characteristics such as sleep quality scale (r:-0.17, p: 0.02) and sleep duration (r:-0.16, p: 0.03).

Conclusions: VitD deficiency is common in childhood and may be the cause of or a contributor to RLS and RLS related poor sleep quality. Therefore, children with RLS need to be assessed for the VitD levels and to support regarding sleep quality

2924: P1-232

CONTINUOUS SUBCUTANEOUS INFUSION OF PTH FOR AUTOSOMAL DOMINANT HYPOCALCAEMIA.
Evelien F Gevers, MD, Queen Mary University London / Barts Health NHS Trust, London, United Kingdom; Jacky Buck, MD, Ipswich Hospital, Ipswich, United Kingdom; Neil Ashman, MD, Barts Health NHS Trust, London, United Kingdom; Rajesh Thakker, MD, University of Oxford, Oxford, United Kingdom; Jeremy Allgrove, MD, Great Ormond Street Hospital, London, United Kingdom

Objectives: Autosomal Dominant Hypocalcaemia (ADH) is due to gain-of-function mutations of the CASR resulting in constitutive activation of the GPCR Calcium Sensing Receptor (CaSR) leading to hypercalciuric hypocalcaemia, hypoparathyroidism and occasionally Bartter syndrome type V. Patients usually present with hypocalcaemic seizures at young age. Conventional treatment is with Alfacalcidol and Calcium or PTH injections. We aimed to assess whether continuous subcutaneous treatment with PTH using insulin pumps is able to stabilise calcium concentrations and symptoms.

Methods: Five patients with ADH in whom stabilization of calcium concentrations could not be achieved with conventional treatment, were started on continuous subcutaneous PTH infusion (CSPI) using Medtronic and Omnipod patch pumps to deliver diluted PTH(1-34). Treatment was started in an inpatient setting and adjusted to achieve low-normal calcium concentration. Outcome parameters were number of seizures, hospital admissions, nephrocalcinosis, and calciuria.

Results: CaSR mutations were p.Thr828Asn, not previously described, and p.Ala843Glu, p.Tyr829Cys, p.Phe821Leu. In vitro functional analysis showed constitutive activation of the P.Thr828Asn variant. Patients presented with hypocalcaemic seizures or tetany in the first weeks of life. Additional features were bilateral cataracts, hypomagnesaemia, Bartter type V. Two patients had nephrocalcinosis before CSPI. Age at start of CSPI was 3 weeks, 6 weeks, 6 months, 6 years and 20 years.  Duration of CSPI treatment is currently 1-3 years. PTH requirement was 0.21, 0.13, 0.15, 0.5 and 3 mcg/kg/day. Calcium concentration stabilised and patients continue to require weekly or bi-weekly blood tests. Number of admissions reduced during CSPI. Seizures stopped in all patients on CSPI. Current calcium concentrations range from 1.75-2.15mmol/l. Current urine Calcium/creat ratios are 1.2- 2.5 mol/mol. Nephrocalcinosis has remained stable. One patient stopped pump treatment temporarily due to instable calcium concentrations.

Conclusions: Continuous subcutaneous PTH infusion is a suitable treatment for ADH that cannot be controlled conventionally.  Longer follow up is required to assess whether continuous sc PTH treatment delays the progression of nephrocalcinosis.

2932: P1-233

ADAPTIVE VITAMIN D METABOLISM AT THE EQUATOR CAN PREDISPOSE TO INSUFFICIENCY IN CHILDREN OF FIRST GENERATION AFRICAN IMMIGRANTS IN THE US
Elwaseila Hamdoun, MBBS, University of Minnesota, Minneapolis, MN, United States; Brandon Nathan , MD; Zahra Mahamed, BS/BA, University of Minnesota , Minneapolis , MN, United States; Sarah E Cusick, PhD, University of Minnesota, Minneapolis, MN, United States; Thereza Piloya-Were, MBBS, University of Makerere, Kampala , Uganda; Antoinette Moran, MD, University of Minnesota, Minneapolis, MN, United States; Anna Petryk , MD, University of Minnesota , Minneapolis , MN, United States; Muna Sunni, MBBCh, MS, University of Minnesota, Minneapolis, MN, United States

Objectives: The goal of this multi-center international cross-sectional observational study was to define vitamin D status in Somali immigrants living in northern US

Methods: Healthy children aged 6 months to 7 years living in Minnesota (US-born of Somali descent, n=55) or Uganda (n=95) were enrolled. 25OHD and other vitamin D metabolites (24,25(OH)2D) were measured by immune-affinity extraction and liquid chromatography-tandem mass spectrometry. Parathyroid hormone (PTH) and hypocalcemia status were used as primary markers of vitamin D insufficiency. DBP haplotypes were determined.

Results: Compared to the Ugandan group, and despite superior nutritional status (vitamin D fortified milk intake), MN Somali children had lower 25OHD (23.7 vs 30.1 ng/mL; p<0.0001), calcium levels (9.1 vs 9.5 mg/dL; p<0.0001), and higher PTH levels (47 vs 36 pg/mL; p<0.0001). Ninety-one percent of the MN Somali participants had 25OHD levels <30 ng/ml (vs 48% in Ugandans). Somalis had higher frequency (57% vs 14% in Ugandans; p<0.001) of calcium in the lower level of normal even at 25OHD levels >20 (American Academy of Pediatrics [AAP] cutoff for sufficiency) and this was not significantly different from the Somali group with 25OHD <20 ng/mL (p=0.3). The high-affinity allele Gc1f (which limits free forms of vitamin D) was the predominant DBP variant in both MN Somalis and Ugandans, but Somalis had a higher percentage of low serum calcium status. The Somali group had a higher level of vitamin D inactivation (greater 24,25(OH)2D, less 1,25(OH)2D levels, p=<0.001) despite having lower 25OHD levels raising a concern of maladaptive vitamin D metabolism and inherent susceptibility to vitamin D deficiency independent of limited cutaneous vitamin D synthesis as a result of darker skin tone.

Conclusions: These results suggest that even at the AAP cutoff for sufficiency (>20 ng/mL), clinically significant low 25OHD levels were common in African immigrant children. Also, while African children at the equator possess adaptive mechanisms to protect against excessive acquisition and utilization of vitamin D, but those same mechanisms may render them susceptible to low 25OHD when migrating to high-latitude regions such as Minnesota.

1727: P1-234

THE TRPM6 GENE MUTATIONS IN TWO SIBLINGS OF GENETIC HYPOMAGNESEMIA WITH HYPOCALCEMIA AND HYPOPARATHYROIDISM
Nese Akcan, MD; Nedime Serakinci, MD, Near East University, Nicosia, Cyprus; Umut Mousa, MD; Hasan Sav, MD, Nalbantoglu Training and Research Hospital, Nicosia, Cyprus; Ruveyde Bundak, MD, Kyrenia University, Kyrenia, Cyprus

Objectives: Magnesium is essential to the proper functioning of numerous cellular processes. Hypomagnesemia can cause neuromuscular irritability, seizures and cardiac arrhythmias. Mutations in the gene for the DCT- and colon-specific apical Mg2+ channel, TRPM6, cause the most profound genetic hypomagnesemia. We described two siblings with TRPM6 mutations.

Methods: First case was applied with seizure at 5-month old and hypomagnesemia, hypocalcemia and low level of parathyroid hormone were detected. Second case had also seizure with hypomagnesemia, hypocalcemia on newborn period.

Results: The molecular analysis confirmed the genetic cause of hypomagnesemia in these siblings by identifying the pathological homozygous variants c.2667+1G>A in TRPM6 gene.

Conclusions: To conclude, magnesium levels should also be checked in cases with hypocalcemia and hypoparathyroidism, genetic causes should be considered in case of hypomagnesemia and molecular analysis should be prioritized for early diagnosis.

735: P1-500

SEVERE HYPERINSULINISM IN INFANTS WITH BECKWITH-WIEDEMANN SYNDROME AND HETEROZYGOUS KATP CHANNEL MUTATIONS: MORE THAN FOCAL OR DIFFUSE DISEASE
Amanda M. Ackermann, MD, PhD; Changhong Li, PhD, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Katherine Lord, MD, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; Kara E. Boodhansingh, BS/BA; Jennifer M. Kalish, MD, PhD; Tricia R. Bhatti, MD; Lisa States, MD; N. Scott Adzick, MD; Charles A. Stanley, MD, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Diva D. De León, MD, The Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: Congenital hyperinsulinism (HI) causes severe hypoglycemia, most often due to mutations in the beta cell ATP-gated potassium (KATP) channel. Homozygous KATP mutations result in Diffuse HI (dHI), while paternally-inherited heterozygous mutations (KATPpMut/+) can cause Focal HI (fHI) when paternal uniparental isodisomy (pUPD) of chromosome 11p15 occurs in a specific pancreas region. Chromosome 11p15 includes the KATP genes and an imprinted region that is affected in Beckwith-Wiedemann Syndrome (BWS). BWS is a spectrum of overgrowth disorders associated with HI via an unclear mechanism.  We compared clinical and biochemical features of HI in infants with pUPD BWS and KATPpMut/+ to those with fHI, dHI, or BWS alone.

Methods: Medical records were reviewed. Fresh pancreatic tissue resected during therapeutic pancreatectomy (Px) was collected for islet isolation and functional testing.

Results: We identified 6 infants with HI associated with KATPpMut/+ and pUPD BWS. All subjects were born large for gestational age (4,040-5,946 g), presented within 24 hours with severe hypoglycemia, required a high glucose infusion rate (max 13-34 mg/kg/min), and did not respond to diazoxide. 18-fluoro-DOPA PET showed enlarged pancreas in 4 cases and focal uptake in 2 cases. All subjects underwent extensive (70-100%) Px, after which 3 of the infants did not require additional treatment, 2 required continuous enteral dextrose, and 1 required enteral dextrose and octreotide. Histology in all cases revealed increased endocrine tissue in multiple areas of the pancreas with variable numbers of islet cell nucleomegaly. Functional testing of islets from 3 cases showed elevated basal intracellular calcium and/or insulin secretion, increased responsiveness to amino acids, and minimal or no response to glucose.

Conclusions: We found that pUPD BWS with KATPpMut/+ caused severe HI requiring aggressive intervention. Islet functional assays demonstrated features of both KATP HI and BWS HI, indicating that both pathophysiologic mechanisms contribute to clinical severity. Histologic features distinguish this clinical entity from dHI, fHI, and BWS HI. It is important to identify these cases early by KATP mutation analysis and SNP array karyotyping.

1351: P1-501

INCREASED NUMBERS OF SEPTAL ISLETS REPRESENT A PHASE SHIFT IN PANCREATIC DEVELOPMENT IN CONGENITAL HYPERINSULINISM
Charlotte E Watson, B.Sc., University of Manchester, Manchester, United Kingdom; Maria Salomon-Estebanez, MD; Bing Han, M.Sc.; Walaa Mal, M.Sc., The University of Manchester, Manchester, United Kingdom; Edmund Cheesman, MD, Manchester Children's Hospital, Manchester, United Kingdom; Karen E Cosgrove, PhD, The University of Manchester, Manchester, United Kingdom; Indraneel Banerjee, MD, Central Manchester University Hospitals, Manchester, United Kingdom; Mark J Dunne, PhD, The University of Manchester , Manchester, United Kingdom

Objectives: Congenital Hyperinsulinism of Infancy (CHI) is a disease of islet cells associated with excessive secretion of insulin leading to profound hypoglycaemia in affected children. During pancreatic ontogeny, some islets are formed within the septum of the pancreatic tissues, and remain in the septum until following birth. Little is known about the organization of septal islets (SI) or their association with the pathobiology of disease.

Methods: We characterized the general properties of SI in post-natal neonatal tissue (n=7 cases; n=48 SI), adult control tissue (n=4), and CHI tissue following surgery from either diffuse (n=16 patients; n=378 SI) or focal (n=11 patients; n=102 SI) cases. Tissue samples were fixed in 4% paraformaldehyde and embedded in paraffin wax; 5 µm thick sections were prepared for immunostaining. Images were acquired and digitized by a 20x/0.80 Plan Apo objective using the 3D Histech Pannoramic 250 Flash II slide scanner. Pannoramic Viewer and HistoQuant software packages were used for data analysis and high-content cell counting (3DHISTECH Ltd, Hungary).  

Results: SI were on average 2-fold larger than non-SI (range 1831.9-122946.5μm2 (n=531) vs. 1589.5-39907.6μm2 (n=257)) and associate with expression of insulin, glucagon and somatostatin. SI appear to be more highly vascularized than non-SI and establish close connections with neural branches; however these are similar in proximity to non-SI. In control tissue, SI were only seen in neonatal tissue, but their incidence was found to be >2-fold higher in CHI tissue compared to controls; 2.1x10-7 SI per μm2 (n=480) vs. 9.32x10-8 SI per μm2 (n=48). The incidence of SI was higher in the non-lesion parts of the pancreas of focal CHI cases (3.33x10-7 per μm2 (n=102)) than in diffuse CHI (1.47x10-7 per μm2 (n=378)). The role of SI in the pathobiology of CHI has not been determined, but in addition to an increased incidence in the hyperinsulinism pancreas, SI were also found to be proliferative (Ki67+ expression) and associated with nucleomegaly; a feature only seen in SI from CHI tissue.

Conclusions: Our findings that SI are more prevalent in CHI tissue supports previous observations that the CHI pancreas is naïve and more closely aligned to the foetal pancreas rather than age-matched control tissue.

1170: P1-502

PERSISTENT HYPERINSULINEMIC HYPOGLYCEMIA, SERIES OF CASES IN 20 YEARS IN A SINGLE HOSPITAL IN MEXICO.
Lorenzo Garcia-Sanchez , MD, Hospital Infantil de Mexico , Ciudad de México , Mexico; Patricia G Medina-Bravo, MD, Hospital Infantil de Mexico, Ciudad de Mexico, Mexico

Objectives: To describe clinical, biochemical, medical and / or surgical treatment and complications in patients with persistent hypoglycemia hyperinsulinemic over a period of 20 years (January 1997 to January 2017).

Methods: Case series. Descriptive statistics were used for the analysis of data with measures of central tendency, dispersion and frequency. SPSS Program 22.

Results: Out of 55 records reviewed, we were able to confirm the diagnosis of hyperinsulinemic. Found a higher prevalence in males 52% (n = 12). The medications used to control hypoglycemia were octeotride (83.75%), hydrocortisone (42.1%) and diazoxide (41.65%), 60.2% required subtotal pancreatectomy of 95%. The most common sequelae were psychomotor retardation (82.6%), seizures (34.7%), secondary diabetes (13%), hypoglycemia (8.7%).

Conclusions: The clinical picture and the sequelae of this disease are similar in what is reported in other series worldwide. Treatment differs since  steroid  used as the drug of choice in the acute control of hypoglycemia. We have a greater number of patients with neurological sequelae probably secondary to the late diagnosis. The use of glucagon as a first line medication for the control of hypoglycemia in the acute period of the disease is required.

933: P1-503

CALCIUM/CALMODULIN DEPENDENT PROTEIN KINASE 2 (CAMKK2) MUTATION – A NOVEL GENETIC CAUSE OF CONGENITAL HYPERINSULINISM
Dinesh Giri, FRCPCH, University of Liverpool & Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; John W Scott, PhD, University of Melbourne, Melbourne, Australia; Bruce E Kemp, PhD, Australian Catholic University, Melbourne, Australia; Anthony R Means, PhD, Baylor College of Medicine, Houston, TX, United States; Senthil Senniappan, PhD, University of Liverpool & Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom

Objectives: Ca2+/calmodulin-dependent protein kinase 2 (CaMKK2) belongs to the Serine/Threonine protein kinase family and alternative splicing results in multiple transcripts encoding distinct isoforms. CaMKK2 mRNA has been shown to express in mouse pancreatic islets and loss of CaMKK2 increases the glucose mediated insulin secretion. We report, for the first time, CaMKK2 mutation as a novel genetic cause of congenital hyperinsulinism (CHI).

Methods: A Caucasian child born to non-consanguineous parents at 33 weeks gestation presented with hypoglycaemic seizures at 7 months of age requiring intravenous glucose load up to 15mg/kg/min. The investigations confirmed CHI [plasma insulin concentration of 37pmol/L and supressed β hydroxy butyrate (<100mmol/L) during hypoglycaemia]. No mutation was identified in ABCC8, KCNJ11 or GCK. The 18-Fluro-DOPA PET CT scan suggested diffuse CHI and the patient responded well to diazoxide therapy. At the age of 5 years, the patient requires 10mg/kg/day of diazoxide and has features of developmental and speech delay.

Results: Whole exome sequencing was performed on the genomic DNA of the patient and the biological parents. A de novo heterozygous frameshift mutation (p.G539fs*4) was found at the terminal exon (exon 16) of CaMKK2 (NM_001270486.1) (isoform-7). CaMKK2 isoform-7 (WT) and the pG539fs*4 mutant were expressed in COS7 cells and the pG539fs*4 mutant was noted to have significantly higher basal and Ca2+-CaM dependent kinase activity compared with WT isoform-7.  Both isoform-7 and the pG539fs*4 mutant have elevated basal activity compared with isoform-1, the major CaMKK2 isoform expressed in most tissues.

Conclusions: We describe for the first time, CaMKK2 mutation as a novel genetic cause of persistent CHI. The potential mechanism is likely to involve alteration in the AMPK (substrate for CaMKK2) regulated insulin secretion driven specifically by isoform 7. This has wider implications in understanding the molecular genetic aetiology of CHI as well as monogenic diabetes mellitus.

520: P1-504

INSULIN-LIKE GROWTH FACTOR I IN CORD BLOOD IS PREDICTIVE FOR FINAL HEIGHT IN MONOZYGOTIC TWINS WITH DISCORDANT GROWTH
Bettina Gohlke, MD; Charlotte Kasner, MS/MA, University of Bonn, Bonn, Germany; Sandra Schulte, MD; Felix Schreiner, MD; Peter Bartmann, PhD, University Children's Hospital Bonn, Bonn, Germany; Joachim Woelfle, MD, University of Bonn, Bonn, Germany

Objectives: We investigated catch-up growth and final height of monozygotic twins with discordant birth-weight and the predictive value of birth-weight, birth-length, and concentration of IGF-I in cord-blood and at the age of 4 yrs.

Methods: 25 monozygotic twin-pairs [16 discordant with an intra-twin birth-weight SD score (SDS) difference>1] were studied at birth, at 4 yr, and at final height. Several parameters including IGF-I serum concentration were analyzed in cord blood. In 20 pairs parameters were re-analyzed at 4 yr of age and at final height. Intra-twin differences (Δ) in birth weight, birth length, and longitudinal growth until final height were correlated with Δ in concentration of the respective biochemical parameters.

Results: We found a gradual reduction of intra-twin Δ height SDS from birth to final height, with the main catch-up growth of the smaller twin occurring during the first year of life. In the formerly concordant twin-pairs final height was nearly identical (Δ 0.03 SDS) whereas in the discordant group the former smaller twin was still an average of 0.74 SDS shorter than the co-twin. Correlation coefficients were used to identify factors predicting existing differences at final height. Birth-weight difference (r=0.45; P=0.01) and Δ IGF-I in cord blood (r=0.4; P=0.01) were both of similar predictive value. Although there was still a significant difference for intra-twin Δ height-, weight-, and BMI-SDS  at four years there was no intra-twin difference but a highly significant intra-twin correlation for IGF-I serum concnetration (r=0.88; p<0.001). In contrast to cord-blood IGF-I, IGF-I at the age of 4 yrs was of no predictive value for further catch-up growth until final height of the smaller twin.

Conclusions: Genetically identical twins with discordant birth-weights showed gradual convergence in height with still a remaining significant difference at final height. Predictive of catch-up growth until final height were difference in birth-weight and in cord-blood IGF-I, but not IGF-I at the age of four years.

1266: P1-505

GLUCOCORTICOIDS IN NEONATAL HAIR: REFLECTION OF INTRAUTERINE HPA-AXIS ACTIVITY?
Jonneke J. Hollanders, MD; Bibian Van Der Voorn, MD, VU University Medical Center, Amsterdam, Netherlands; Noera Kieviet, PhD; Koert M. Dolman, PhD, Psychiatry Obstetrics Pediatrics Expert Center OLVG West, Amsterdam, Netherlands; Joost Rotteveel, MD, VU Medical Center, Amsterdam, Netherlands; Adriaan Honig, PhD, Psychiatry Obstetrics Pediatrics Expert Center OLVG West, Amsterdam, Netherlands; Martijn J.J Finken, PhD, VU University Medical Center, Amsterdam, Netherlands

Objectives: The value of glucocorticoids (GCs) measured in neonatal hair is not known, although it might provide a retrospective view of fetal HPA-axis activity. We aimed to describe factors associated with infant hair GC levels in early life, as well as their relation with maternal HPA-axis activity.

Methods: Mother-infant pairs donated hair samples directly pp (n=108, GA=39.5±1.8, 54.5% male), and during an outpatient visit (OPV) at 43±13 days pp (n=72). Cortisol and cortisone levels were determined by LC-MS/MS. Analyses were performed with regard to (1) factors associated with infant hair GCs directly pp, (2) the course of GC levels pp, and (3) associations between maternal and infant HPA-axis activity.

Results: (1) Infant hair GCs directly pp were positively associated with gestational age (GA) (log-transformed β [95%CI]: cortisol: 0.07 [0.05-0.10]; cortisone: 0.03 [0.01-0.06]) and perinatal infection (cortisol: 0.15 [0.03-0.26]; cortisone: 0.21 [0.12-0.29]). Other neonatal and maternal factors (e.g., gender, birth weight, respiratory distress, pre-eclampsia) did not influence infant hair GCs directly pp.

(2) Between birth and the OPV, infant hair GCs decreased, although they were still 5-15 times higher compared to maternal levels. Longer gestation was associated with a steeper cortisol decrease and higher hair cortisol at the OPV. Infection was associated with a steeper decrease in cortisone.

(3) Maternal hair cortisol was positively associated with infant hair cortisol directly pp (r: 0.31, p=0.001; β: 0.21 [0.08-0.33]) and at the OPV (r: 0.47, p<0.001; β: 0.38 [0.20-0.56]), while associations between maternal and infant hair cortisone were not found.

Conclusions: Our findings suggest that infant hair GCs are mainly influenced by the positive feedback loop, a placenta-driven phenomenon causing an increase in GCs in the third trimester, represented by a positive association with GA. Perinatal complications and maternal HPA-axis activity had minor influences on infant hair GCs. At 1.5 month pp, infant hair GCs seemed to reflect both the intra- and extra-uterine period. From our data, it is not possible to discern at which point pp infant hair GCs represent the extra-uterine environment only.

126: P1-506

NEONATAL HYPOGLYCEMIA DIAGNOSES BEFORE AND AFTER GUIDELINE RELEASE: A PEDIATRIC HEALTH INFORMATION SYSTEM DATABASE INQUIRY
Katherine Kutney, MD, University Hospitals, Cleveland, OH, United States; Sarah Macleish, DO, UH Rainbow Babies and Children's Hospital, Cleveland, OH, United States; Steven Subichin, MS/MA, independent , Cleveland, OH, United States

Objectives: The Pediatric Endocrine Society (PES) updated the hypoglycemia guidelines in August 2015. Our primary aim is to assess change in hypoglycemia diagnoses in neonates, infants, and children after guideline release. Our secondary aim is to evaluate institutional variation in implementation.

Methods: We queried the Pediatric Health Information System database to determine the frequency of hypoglycemia diagnoses in 49 US Children’s Hospitals before (Jan 1-June 30, 2015) and after (Jan 1-June 30, 2016) guideline release.

The rate of hypoglycemia was determined by dividing cases of hypoglycemia by total number of admissions. Cases were defined by the presence of an ICD9 or ICD10 diagnostic code for hypoglycemia, excluding those for diabetes patients. This analysis was completed for 3 age groups: neonates (0-30 days), infants (31 days-1 year), and children (1-18 years). We tested for statistical significance using binomials.

Results: In the neonatal group, there were 11.8 cases per 100 admissions in the six months preceding guideline release (5,973 cases for 53,175 admissions). There were 13.5 cases per 100 admissions for the six months after guideline release (6,707 cases for 52,429 admissions). Therefore, neonatal hypoglycemia cases increased by 1.7 per 100 admissions after guideline release (p<0.01). There was no significant increase in hypoglycemia diagnoses in either the infant (p=0.64) or children (p=0.30) group overall.

In the neonatal group, 14 of 49 institutions had a significant increase in hypoglycemia diagnosis rates (p<0.05), while 35 of 49 institutions showed no significant change. No institution had a significant decrease in neonatal hypoglycemia.

Conclusions: A national increase in neonatal hypoglycemia diagnoses followed release of the PES guidelines. Just under a third of institutions are responsible for the increase. Explanations for institutional variation include: inadequate guideline dissemination, disagreement with the guidelines, and high pre-guideline diagnosis rates. There was no concurrent rise in hypoglycemia diagnoses in older infants or children, in whom it is less common and easier to diagnose. The incidence of neonatal hypoglycemia in this database inquiry is consistent with published estimates of 5-15%.

280: P1-507

CLINICAL PRESENTATION AND INSULIN MANAGEMENT IN 88 PARTICIPANTS DIAGNOSED WITH DIABETES UNDER 1 YEAR OF AGE
Lisa Letourneau, MPH, RD; David Carmody, MD; Kristen Wroblewski, MS; May Sanyoura, PhD; Rochelle Naylor, MD; Louis H. Philipson, MD, PhD; Siri A Greeley, MD, PhD, University of Chicago, Chicago, IL, United States

Objectives: To characterize diabetes diagnosis presentation and insulin management of participants diagnosed ≤1 year of age in the US Monogenic Diabetes Registry and to compare features by type of diabetes (genetic cause versus likely type 1 diabetes).

Methods: Participants enrolled through the US Monogenic Diabetes Registry were included if they were diagnosed with diabetes ≤13 months of age and had a valid medical record release form on file. Medical records from time of diabetes diagnosis were requested. Data was analyzed using Stata Version 14 (StataCorp, 2015). For group comparisons, Kruskal-Wallis tests and Fisher’s exact tests were performed. The relationship between age at diagnosis and days hospitalized (Spearman rank correlation) and diabetic ketoacidosis (DKA) (logistic regression) was also determined. Study data was collected and managed using REDCap electronic data capture tools.

Results: 301 participants met eligibility criteria for this study and 88 had substantive records from time of diabetes diagnosis. The majority were male (52.3%), Caucasian (62.5%), alive at time of analysis (97.7%), and had permanent forms of diabetes (86.4%). The most common genetic cause was KCNJ11-related diabetes (37.5%) followed by unknown genetic cause/likely type 1 diabetes (21.6%). Median age at diagnosis of diabetes was 10.4 weeks (IQR: 5.2-26.5 weeks). Several parameters were significantly different among subgroups, including DKA (Table 1). The most common signs/symptoms at diagnosis were polyuria and tachypnea. Therapies used were not significantly different by mutation subtype. Earlier diagnosis age was associated with more days spent in the hospital (rs=-0.64). Participants diagnosed at a later age had a greater likelihood of DKA at diagnosis (OR: 1.23 [95% CI 1.04, 1.45]).

Conclusions: Severe presentation of diabetes was common in this young population. Prevalence of DKA at diabetes diagnosis in this study was >1.5 times higher than one previous study of children diagnosed between 0-4 years old. This may be due to delay in diagnosis, since later age at diagnosis increased likelihood of DKA. Efforts to reduce any possible delay in diagnosis may help to prevent diabetes-related morbidity in this vulnerable population.

614: P1-508

INFANTS BORN SMALL-FOR-GESTATIONAL AGE HAVE DIFFERENT PLACENTAL EXPRESSION OF MICRORNAS
Hanna Östling, MD; Robert Kruse, PhD; Gisela Helenius, PhD; Maria Lodefalk, PhD, Örebro University, Örebro, Sweden

Objectives: To investigate the placental microRNA expression profile in children born small-for-gestational age (SGA) and exposed to low maternal gestational weight gain (GWG).

Methods: 13 full-term newborn babies with birth weights < - 2 SD from the population mean exposed to maternal GWG ≤ 10 kg (group 1) were identified in a placental biobank. 9 children with birth weights < - 2 SD and GWG 11.5–16.0 kg constituted group 2. 20 children with normal birth weights but GWG ≤ 10 kg constituted group 3 and 26 children with both normal birth weights and GWG constituted group 4. The infants in groups 2–4 were matched with group 1 with respect to gender, gestational age, maternal parity, and maternal age.

Total RNA were extracted from the placental biopsies. After microRNA preparation, next generation sequencing using Illumina technology was performed. Comparisons between the groups were done with ANOVA for unequal variances and Benjamini-Hochberg’s correction for multiple testing.

Results: The mean (SD) birth weight and maternal GWG in group 1 were 2,834 (296) g and 9.2 (1.2) kg, respectively. The corresponding numbers in group 2 were 2,636 (211) g and 13.6 (1.0) kg, respectively, in group 3 3,696 (355) g and 9.1 (1.0) kg, respectively, and in group 4 3,747 (356) g and 15.0 (1.2) kg, respectively. 48 of the 68 children were boys.

The minimum reads/sample were 9.2 millions. The expression of 16 microRNAs differed significantly between group 1 and group 2. The expression of 12 microRNAs differed significantly between group 2 and 4. Ten of the differentially expressed microRNAs differed in both comparisons (miR-3679-5p, miR-4532, miR-335-3p, miR-379-3p, miR-380-3p, miR-369-5p, miR-330-5p, miR-519e-3p, miR-105-5p, and miR-3065-5p).

Conclusions: The mechanism behind poor fetal growth may involve differential expression of microRNAs in the placenta. Low maternal weight gain during pregnancy seems to influence the placental microRNA expression in full-term in children born SGA but not in children with normal birth weights.

1216: P1-509

MIRNAS IN UMBILICAL CORD OF SMALL-FOR-GESTATIONAL-AGE INFANTS AT BIRTH: ASSOCIATION WITH POSTNATAL CATCH-UP GROWTH
Judit Bassols, PhD; Sílvia Xargay-Torrent, PhD, Biomedical Research Institute of Girona (IDIBGI), Girona, Spain; Alexandra Bonmatí, MD, Hospital Dr. Josep Trueta, Girona, Spain; Anna Prats-Puig, PhD, Escola Universitària de la Salut i l'Esport (EUSES), Girona, Spain; Gemma Carreras-Badosa, PhD; Esther Lizarraga-Mollinedo, PhD, Biomedical Research Institute of Girona (IDIBGI), Girona, Spain; Emília Badosa, BSN, Hospital Dr. Josep Trueta, Girona, Spain; Francis De Zegher, PhD, University of Leuven, Leuven, Belgium; Lourdes Ibáñez, PhD, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Abel Lopez-Bermejo, PhD, Hospital Dr. Josep Trueta and Girona Institute for Biomedical Research, Girona, Spain

Objectives: The vast majority of infants born small-for-gestational-age (SGA) develop spontaneous catch-up growth beyond birth. The mechanisms underpinning the presence versus absence of postnatal catch-up growth in SGA infants are poorly understood. We postulated that postnatal catch-up growth in SGA infants may relate to prenatal miRNA profiles, and tested this hypothesis by studying miRNAs in the umbilical cord of SGA infants with versus without postnatal catch-up growth.  

Methods: MicroRNA PCR Human Panels were used to study the miRNA profile in umbilical cord tissue, free of blood vessels, of SGA infants with (SGA-CU) versus without catch-up growth (SGA-nonCU). Relationships were studied between miRNAs differentially expressed (SGA-CU versus SGA-nonCU) in umbilical cord at birth and body size at the postnatal age of 1 year.

Results: 12 miRNAs were differentially expressed between SGA-CU and SGA-nonCU, 7 being upregulated in SGA-CU (miR-128-3p, miR-576-5p, miR-628-5p, miR-222-5p, miR-300, miR-940 and miR-374b-3p), and 5 being downregulated in SGA-CU (miR-876-3p, miR-873-5p, miR-770-5p, miR548c-5p and miR501-3p) (p between <0.05 and <0.0005). miR-300 and miR-548c-5p associated with Z-scores of weight and height at age 1 year (all p <0.05), and predicted catch-up growth (miR-300: β = 0.725, R2 = 0.53, p = 0.008; and miR-548c-5p: β = -0.721, R2 = 0.86, p = 0.004). In silico analysis suggests that these miRNAs share targets of metabolic pathways including WNT and TGF-β which relate to cell growth and proliferation.

Conclusions: The miRNA profile in the umbilical cord of SGA infants at birth was found to relate to postnatal catch-up growth. The potential of prenatal miRNA profiles as predictors of postnatal growth deserves to be further explored.

1111: P1-510

LANREOTIDE IS A SAFE AND EFFECTIVE TREATMENT FOR CONGENITAL HYPERINSULINISM
Katherine Lord, MD; Nicole Stewart, RN; David Langdon, MD; Diva D. De León, MD, The Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: Congenital hyperinsulinism (HI), resulting from dysregulated insulin secretion, causes severe and persistent hypoglycemia. Without effective treatment, children with HI are at risk of poor neurologic outcomes. However, few medical therapies exist. These include diazoxide, to which many patients fail to respond, and octreotide, which requires multiple daily injections. Lanreotide is a long-acting somatostatin analogue, which is administered every 28 days and has been shown to improve glycemic control in children with HI. We describe a single center’s experience with the use of lanreotide to treat congenital HI.

Methods: We conducted a retrospective chart review of patients with HI treated with lanreotide at the Children’s Hospital of Philadelphia

Results: Between June 2015 and December 2016, 18 children (10M) with HI initiated therapy with lanreotide. Fourteen children had mutations in the KATP channel genes, 1 had Beckwith Wiedemann syndrome and 3 had no mutations identified. Nine children (50%) had a history of near-total pancreatectomy (n=7) or partial pancreatectomy (n=2). The median age at initiation of lanreotide was 2.3 yrs (1-7.6 yrs). At initiation of lanreotide, medical therapy included: octreotide and overnight enteral dextrose (n=16); octreotide, diazoxide and overnight enteral dextrose (n=1); diazoxide (n=1). Initial lanreotide dosing was 30 mg (n=10); 60 mg (n=7); 90 mg (n=1). Twelve patients (71%) were able to discontinue octreotide and 6 (35%) were able to discontinue enteral dextrose. Five children are treated with lanreotide alone, 7 with lanreotide and overnight enteral dextrose and 1 with lanreotide and diazoxide. Five subjects failed to respond to lanreotide and discontinued treatment. Side effects included irritation at the injection site (n=2) and headaches (n=1).

Conclusions: Lanreotide provides convenient and effective treatment for children with HI. The majority of children were able to transition from multiple daily octreotide injections to monthly lanreotide. Future studies are needed to determine protocols for transition from octreotide to lanreotide and to identify risk factors for lanreotide failure.

979: P1-511

REDUCING ERRORS IN HYPOGLYCAEMIC SCREENS IN A TERTIARY NEONATAL INTENSIVE CARE UNIT - OPTIMISING THE SYSTEM
Sinead Mcglacken-Byrne, MS/MA, Royal College of Physicians of Ireland, Dublin, Ireland; John Murphy, MD, National Maternity Hospital, Holles St, Dublin, Ireland

Objectives: Neonatal hypoglycaemia is a common physiological phenomenon in the first days of life. However, persistent hypoglycaemia requires investigation. A hypoglycaemic screen ("critical sample") taken during spontaneous hypoglycaemia can diagnose underlying endocrine or metabolic conditions. However, resource limitations and educational deficits compromise the speed and accuracy with which these critical samples are taken. We designed a quality improvement project to optimise the system underlying the critical sampling process, aiming to reduce the number of errors associated with hypoglycaemic screens in our NICU from 100% to 50% over six months. 

Methods: A series of "Plan, Do, Study, Act" (PDSA) cycles guided the project. The first cycle involved process mapping to understand the system of critical sampling. In the second cycle, a retrospective audit was performed of critical samples taken between August 2014 and December 2016. A Pareto diagram was then constructed to identify key areas of improvement. The third cycle is ongoing and measures the impact of these changes over time using re-audit and run charts. Data analysis utilised SPSS software. 

Results: Process mapping revealed the critical sampling process to be multidisciplinary, involving doctors, nurses, biochemists, and lab technicians. Our audit demonstrated that 257 errors had been made in 45 critical samples performed on 36 patients over a 53-month period. The Pareto diagram revealed major contributing errors to be:

Other significant issues stemmed from haemolysed samples (22.2% of all screens), insufficient samples (77.8% of all screens), or incorrectly timed samples (40% of all samples). 

Conclusions: Improvement efforts targeting key areas were implemented: 

1010: P1-512

18F-DOPA MANUFACTURED BY A MODIFIED ONE POT METHOD IS OF HIGH ENOUGH SPECIFIC ACTIVITY TO PRODUCE QUALITY IMAGES OF THE PANCREAS WHEN INJECTED UP TO 6 HOURS POST MANUFACTURE.
Paul Thornton, MD, Cook Children's Medical Center, Fort Worth, TX, United States; Rachid Nazih, PhD; Sudha Garg, PhD, Biomedical Research Foundation, Shreveport , LA, United States; Lisa Truong, CPNP; Larry Rodriguez, RN; Courtney L Reynolds, MPH; Jonathon Nedrelow, MD; John Uffman, MD; Irene Sanchez, MD, Cook Children's Medical Center, Fort Worth, TX, United States; Amol Takalkar, MD, Biomedical Research Foundation, Shreveport, LA, United States; Burton Putegnat, MD, Cook Children's Medical Center, Fort Worth, TX, United States; Pradeep Garg, PhD, Biomedical Research Foundation, Shreveport, LA, United States

Objectives: PET imaging with 18F-DOPA is the only currently effective available imaging technique in patients with CHI. Most centers throughout the world manufacture the 18F-DOPA in close proximity to the imaging center because 18F-DOPA has a short half-life of 110 minutes. We report our experience with a novel nucleophilic manufacturing process that allows us to inject between 4-6 hours after end of synthesis (EOS). The aim of this study is to determine if we could generate high quality images of the pancreas using 18F-DOPA with a higher specific activity (SA)that is manufactured at a distance of 200 miles away and injected 4-6 hours later.

Methods: We modified a previously reported one pot technique to manufacture 18F-DOPA. Two doses of 18 F-DOPA designed to be injected at 30 minutes apart were shiped. A dose of 0.12-0.16 mCi/kg was administered IV and  the patients had a low dose attenuation CT, followed by 10 minute PET scans at 20, 30, 40, and 50 minutes with a contrast CT between the 30 and 40 minute scans. The 18F-DOPA was manufactured and administered under an IND held by the PI.

Results: 33 patients underwent the 18F-DOPA PET CT. All 33 images were good quality exams. The mean SA at EOS was 259.2 mCi/mg DOPA. The mean SA at the time of injection was 41.4 mCi/mg DOPA. The mean injection time from EOS was 292.5 minutes. The total synthesis time was about 120 minutes, the radiochemical yields of 18F-FDOPA produced were about 10±7%. The radiochemical and enantiomeric purities were about 98±2%.  26 of 33 patients went to surgery. There were 15 focal surgeries, 13/14 of which were cured with minimal pancreatectomy. One had persistent hypoglycemia despite removal of head and pancreatico-jejunostomy.  Overall, focal surgery had a 93% cure rate. There were two LINE surgeries performed. Both patients were cured with pancreatectomy of 30-50%. Six patients had diffuse surgery with hypoglycemia post 98% pancreatectomy. There were 3 patients with atypical focal surgeries who also had hypoglycemia post-op with 50-98% pancreatectomy.

Conclusions: This modified novel production method of 18F-DOPA results in a product with higher specific activity which allows it to be transported by ground up to 200 miles and injected up to 6 hours after EOS and results in excellent quality images.

468: P1-513

IMPACT OF 2015 PES GUIDELINES ON CLINICAL FEATURES OF NEONATAL HYPOGLYCEMIA
Rozeanna Skovrlj, MD; Seth Marks, MD, FRCP(C); Celia Rodd, MD, FRCPC, University of Manitoba, Winnipeg, MB, Canada

Objectives: After the 2015 Pediatric Endocrine Society (PES) recommendations for evaluation of hypoglycemia in neonates, infants and children, our Department of Pediatrics revised its protocol for evaluating persistent hypoglycemia in neonates ≥72 hours of age. Previously, a glucose of >2.6 mmol/L (47 mg/dL) was the target at any age. The new protocol stated that a glucose of <3.3mmol/L (60 mg/dL) at ≥72 hours of age would trigger a critical sample and consult to Pediatric Endocrinology.

The primary objective of this study was to determine if there was a significant increase in the number of consults to Pediatric Endocrinology post-protocol implementation. Our secondary objectives were to evaluate the etiologies of persistent hypoglycemia, and the number of infants requiring treatment for hyperinsulinemia. Other variables collected were: gestational age, sex, age at presentation, presenting signs, maternal hypertension and lifestyle, consanguinity, anthropometric data, critical lab values, dextrose requirements, presence of genetic syndromes, and length and type of treatment.

Methods: A retrospective chart review was conducted for all consults to Pediatric Endocrinology for neonatal hypoglycemia from November 2012 to October 2016 at our two tertiary care centers. All referrals for hypoglycemic infants included with no exclusion criteria.

Results: Sixty percent of consults (33/56) occurred after implementation of the new protocol (in the last 12 of 48 mo.), a statistically significant increase over time. Mean age of infants was 8.2 days and half were IUGR (27/54). Approximately 80% were males (44/56). Half (27/54) of mothers reported smoking in pregnancy. The average blood glucose at ≥72 hours of age was 2.8 mmol/L (50.5mg/dL). Hyperinsulinemia was the most common etiology for hypoglycemia (51/56 infants). Diazoxide treatment was utilized in more than 50% (26/56) of infants, with an average length of treatment of 95 days (range 5-219). Two infants developed pulmonary hypertension with diazoxide.

Conclusions: There has been an increase in the number of consults to Endocrinology since implementation of PES guidelines. Hyperinsulinemia is the most common cause of hypoglycemia with significant proportions requiring treatment with diazoxide.

654: P1-514

GLYCATED ALBUMIN LEVEL DURING LATE PREGNANCY AS A PREDICTIVE FACTOR FOR NEONATAL OUTCOMES OF WOMEN WITH DIABETES
Daisuke Sugawara, MD; Hiroaki Sato, PhD; Ko Ichihashi, PhD, Saitama Medical Center Jichi Medical University, Saitama, Japan

Objectives: Investigate association between glycated albumin in diabetic mothers and complications in their children, and determine glycated albumin cut-off values for predicting complications in infants

Methods: This hospital based case control study involved Japanese 71 mothers with diabetes and their children. The mean glycated albumin of mothers were compared between mothers of infants with complications and those without complications. Receiver operating characteristic analysis was conducted to set the glycated albumin cut-off values with respect to complications of infants. The relation between glyacated albumin and the numbers of complications of infants was investigated by Pearson’s correlation coefficient.

Results: Glycated albumin was significantly higher in mothers of infants with hypoglycemia (15.8 ± 3.2 vs. 12.6 ± 1.2%, p < 0.001), respiratory disorders (15.7 ± 3.6 vs. 12.9 ± 1.9%, p < 0.001), hypocalcemia (15.9 ± 3.7 vs. 13.1 ± 1.8%, p <0.001), polycythemia (15.7± 2.3 vs. 13.8 ± 2.1%, p =0.009), myocardial hypertrophy (16.1 ± 3.7 vs. 13.1 ± 2.3%, p <0.001), and large-for-date status (15.8 ± 2.4 vs. 13.7 ± 3.1%, p = 0.006). The cut-off values of glycated albumin were as follows: hypoglycemia (13.6%), respiratory disorders (13.9%), hypocalcemia (14.2%), polycythemia (14.5%), large-for-date status (14.7%), myocardial hypertrophy (14.2%). Glycated albumin showed significant a positive correlation with the numbers of complications of infants (r=0.704, 95%CI: 0.579-0.797, p<0.001).

Conclusions: Glycated albumin is useful for considering pregnancy outcome of mothers with diabetes during pregnancy. To keep glycated albumin lower is important to prevent complications in infants. The relationship between glycated albumin and the numbers of complications of infants was strong.

192: P1-515

RELATIONS OF BIRTH HEAD CIRCUMFERENCE / BIRTH CHEST CIRCUMFERENCE RATIO TO CIRCULATING INSULIN-LIKE GROWTH FACTOR-I IN THE NOT-LIFE-THREATENED NEWBORN: ROLE OF BIRTHWEIGHT AFTER CONTROLLING FOR THE PRESENCE OF PRETERM BIRTH, RESPIRATORY SUPPORT MEASURES AND FOR CALORIC INTAKE
Cesare Terzi, MD, Azienda Ospedaliero-Universitaria di Parma - University of Parma, Viale A. Gramsci n. 14, Italy; Werner F Blum, MD, University of Giessen, Giessen, Germany; Cristiana Magnani, MD; Gabriele Tridenti, MD, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Reggio Emilia, Italy; Andrea Cerioli, PhD, Professor; Marco Riani, PhD, Professor, University of Parma, Parma, Italy; Lidia Garavelli, MD, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Reggio Emilia, Italy; Gian Luigi De Angelis, MD, Professor; Sergio Bernasconi, MD, Professor; Raffaele Virdis, MD, Professor, Azienda Ospedaliero-Universitaria di Parma - University of Parma, Parma, Italy; Giacomo Banchini, MD, Professor, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia - University of Parma, Parma, Italy

Objectives: The ratio of birth head circumference(HC) to birth chest circumference(CC)(HC through CC, HC/CC) is related to birth gestationa age(GA) in the human newborn(NWB). We intended to evaluate the relevance of birthweight(BW) to correlations of HC/CC with blood serum Insulin-like Growth Factor-I(IG1) after control for gender(SEX), preterm birth(birth at<=36 completed weeks GA; PTB) postnatal age(PNA), respiratory oxygen supplementation(O2S), assisted ventilation of any kind (AV) and caloric intake(KT) in not-life-threatened NWBs.    

Methods: NWBs with any among total parenteral nutrition, life-threatening disease, diabetes mellitus(DM), endocrine diagnosis out of DM, malformation, clinically relevant trunk trauma, and mother with DM were excluded. Each of 78 included NWBs had available data for: 1) SEX, GA(range=28-42 completed weeks), BW(range=1200-4150g), HC(range=27.0-36.0cm), CC(range=22.0-39.0cm), HC/CC(range=0.82-1.28cm/cm) and BW<=10th centile for GA(SGA) and 2) same-day records at one of the first 5 postnatal days(x), 5 days after x(y) and 10 days after x(z) for PNA(unit:day), O2S, AV, KT(as KCal/kg/24h or, for PNA<24h, KCal/kg/PNA) and IG1 RIA measurements(unit:uM/dl)(male SEX, n, 43; PTB, n, 46; SGA, n, 20; O2S, n, x=22, y=11, z=1; AV, n, x=8, y=4, z=1). Natural-log-transformed IG1(IG1-LN) was near-normally distributed. Multiple Linear regression(MLR) was used to predict IG1-LN at x-y-z(computations; male SEX, PTB, O2S, AV, condition present=1, condition absent=0). 

Results: MLR showed 1) a significant partial correlation(PC) coefficient(r) of HC/CC PCs with outcome IG1-LN at x-y when including together as predictors O2S-AV-KT-PNA chronologically corresponding to IG1-LN, as well as SEX, PTB and HC/CC(HC/CC vs IG1-LN; x, r=-.240, p=.0422; y, r=-.255, p=.0305) but 2) no significant HC/CC PC with outcome IG1-LN when including together as predictors O2S-AV-KT-PNA chronologically corresponding to IG1-LN, as well as SEX, PTB, HC/CC and BW(each considered MLR model was significant; MLR R2 range=.27-.55).

Conclusions: BW could be involved in negative HC/CC relations to IG1-LN not explained by SEX, PTB, PNA, O2S, AV and KT in the not-life-threatened NWB.

702: P1-516

TRANSIENT HYPERINSULINISM IN INFANCY : A SINGLE CENTER EXPERIENCE
Joanna YL Tung, MBBS; Anne Kwok, MBBS, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong; Grace Poon, MBBS, The University of Hong Kong, Hong Kong, Hong Kong; Pik-To Cheung, MBBS, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong

Objectives: Transient hyperinsulinism (THI) can occur without underlying genetic defects and may be associated with perinatal stress. However, limited information on the clinical characteristics in this group is available. The objective of this study is to describe the clinical characteristics and natural history on infants with THI in a single institute.

Methods: The records of all infants diagnosed with ‘hyperinsulinism’ (HI) in our unit between 2006 and 2015 were retrospectively reviewed. HI was diagnosed if infants had hypoketotic hypoglycemia concomitant with high plasma insulin and required high intravenous glucose infusion rate (IV GIR) of >8 mg/kg/min. Those with transient, diazoxide-responsive HI were included, while those with maternal gestational diabetes and underlying genetic conditions were excluded.

Results: Thirty-two patients were included (Male: Female = 27: 5). Mean gestation age was 38.1 ± 1.9 weeks. Birth weight percentile was 16.0 ± 28.9th and 72% were small for gestation age. There was no apparent perinatal stress, including maternal preecalmpsia, fetal distress, sepsis or chorioamnionitis in 14 patients. Mean age and blood glucose at presentation were 3.0 days and 1.6mmol/L correspondingly. Most were discovered during routine blood glucose monitoring (n = 21), while some presented with seizure (n = 4) or other non-specific symptoms (n = 7). Mean IV GIR was 14.2mg/kg/min. Diazoxide and hydrochlorothiazide was started at a mean age of 11.9 days, at 14.2mg/kg/day and 2.9mg/kg/day respectively. Hyponatremia was observed in 24 patients and 12 required oral sodium supplements. No other side effect was observed. Diazoxide was stopped at a mean age of 11.8 months. Mean age at last follow-up was 5.0 years. Two had autistic spectrum disorder and one had developmental coordination disorder. Others had normal development.

Conclusions: While perinatal stress was described to be associated with THI, it was not apparent in most patients in this cohort. Hyponatremia was a common side effect and serum sodium should be monitored after initiation of medical treatment. THI resolved mostly before the age of two years. Some were observed to have developmental issues. Regular follow-up on their developmental outcome is necessary.

350: P1-517

SALIVARY CORTISOL IN LATE PRE-TERM INFANTS
Lucie Zwimpfer, MS/MA; Dawn Elder, PhD; James Stanley, PhD; Esko Wiltshire, MD, University of Otago Wellington, Wellington, New Zealand

Objectives: Salivary cortisol is a non-invasive, easy to collect and cost effective marker of HPA axis function and stress.  Limited data exist on salivary cortisol values in pre-term infants. As part of studies (including a crossover randomized controlled trial on the impact of silence or empathetic vocal soothing on infant stress) we obtained salivary cortisol results, adding to normative data.

Methods: We studied healthy 32-35 week gestation infants between days 5 and 10. Heelsticks were for bilirubin or glucose monitoring. Salivary cortisol samples were collected using a Salivette™ swab in the infant’s mouth for 3 minutes and measured by in-house ELISA (intra-/inter- assay CV 7.6%/8.6%), requiring >50 µL saliva.  In pilot studies we determined saliva volumes with/without a stimulant and non-interference of the stimulant with the assay. In the main study 50 infants were studied in each condition on 2 separate days at 3 timepoints: before the heelstick, at 20 mins (peak) and at 50 mins (recovery). 

Results: In pilot studies, saliva volumes were too low without stimulant use in all but 2 subjects. One drop of 5% citric acid solution improved saliva volume significantly (150±99.5 vs 76±31.4 µL, p=0.043) with no difference in cortisol values in 8 adult volunteers when samples were collected with/without stimulant.

Cortisol levels from the main study are reported in the table. Baseline values on the 2 days did not correlate significantly (r=0.05,p=0.77).

Table: Salivary cortisol results  (nmol/L)

 

Day 1

Day 2

 

Baseline

Peak

Recovery

Baseline

Peak

Recovery

Minimum

11

11

8

5

9

5

25th centile

14

18

17

18.5

21

24

Median

24

28.5

27

29

31

31

75th centile

52.3

41.5

46

39.5

43

44

Maximum

199

506

119

101

152

199

Conclusions: Salivary cortisol is a useful non-invasive measure of the HPA axis and stress in late pre-term infants. Care with sample collection and a non-interfering salivary stimulant are required at this gestation. These normative salivary cortisol values in late pre-term infants, at baseline and following a painful procedure, indicate substantial intra-individual variability.

480: P1-518

CO-INHERITANCE OF DOMINANT AND RECESSIVE ABCC8 MUTATIONS IN A CASE OF FAMILIAL CONGENITAL HYPERINSULINISM (CHI):- MOLECULAR AND FUNCTIONAL STUDIES.
Louise S Conwell, PhD, Lady Cilento Children's Hospital, Children's Health Queensland; Children's Health Queensland Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia; Show-Ling Shyng, PhD; Balamurugan Kandasamy, PhD; Yi Wu, PhD, Oregon Health & Science University, Portland, OR, United States; Ivan Mcgown, BS/BA, Mater Health Services, Brisbane, Australia; Kelvin L Choo, MBBS; Craig A Mcbride, MBBS, Lady Cilento Children's Hospital, Children's Health Queensland; Children's Health Queensland Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia

Objectives: A male with CHI was born to an unaffected mother. His father had CHI with incomplete diazoxide response in infancy, then maintained on diazoxide (ceased at 7 years). The neonate had intensive medical support, a more severe phenotype, less diazoxide response (ceased due to pulmonary hypertension) and required surgery (diffuse disease).

Objective (i) Molecular analysis: ABCC8, KCNJ11; (ii) Functional studies of likely pathogenic variants

Methods: (i) Targeted massively parallel sequencing with Sanger sequencing confirmation (ii) COSm6 cells (green monkey kidney) transfected with wild type (WT) SUR1 and WT Kir6.2, or mutant SUR1 and WT Kir6.2. Western blots to assess SUR1 protein expression with processing efficiency estimated by core- and complex-glycosylated bands. Inside-out patch-clamp recording assessed channel gating properties (MgADP stimulation).

Results: (i) Two heterozygous ABCC8 variants were detected. A paternal ABCC8 missense variant (c.4532T>C, p.Ile1511Thr) was predicted to have potentially damaging functional effects (previously reported monoallelic variant in diazoxide-responsive diffuse CHI). A maternal ABCC8 nonsense variant (c.742C>T, p.Arg248*) resulting in a premature stop codon was predicted to have loss of function (previously reported recessive variant in diffuse CHI).

(ii) I1511T SUR1: reduced protein bands compared to WT SUR1. R248* SUR1: no protein bands.

Paternal (I1511T SUR1 co-expressed with WT SUR1 at 1:1 molar ratio; with Kir6.2): SUR1 bands similar intensity to WT SUR1. Maternal (R248* SUR1 with WT SUR1): reduced SUR1 bands. Proband: (I1511T SUR1 with R248* SUR1): reduced SUR1 bands.

I1511T channels: reduced MgADP response. R248* channels: no detectable channel activity. I1511T and R248* channels: little MgADP response.

Conclusions: Paternal mutation reduces channel function (reducing expression and MgADP response), predicting a dominant-negative effect. Maternal mutation affects WT allele expression, but residual WT channels reaching the cell surface respond to MgADP, hence mother clinically unaffected. The proband likely had an additive effect: maternal truncation mutation does not make it into the channel; paternal allele, although expressed, has lower maturation efficiency and reduced MgADP response compared to WT allele.

303: P1-519

DIAZOXIDE-RESPONSIVE HYPERINSULINISM ASSOCIATED WITH NEUROBLASTOMA
Dalia Dalle, MD, Rainbow's Babies and Children Hospital, Cleveland, OH, United States; Beth Kaminski, MD, Rainbow Babies and children Hospital, Cleveland, OH, United States

Objectives: Neuroblastoma-associated paraneoplastic syndromes include opsoclonus myoclonus syndrome or secretion of vasoactive intestinal peptide. Excess secretion of insulin is uncommon although the association of hyperinsulinism and neuroblastoma has been reported in the setting of Beckwith Weidemann syndrome (BWS) and described in other cases as a type of complex neurocristopathy with associated nesidioblastosis.We describe a case of hyperinsulinism associated with neuroblastoma, with negative genetic testing for both BWS and congenital hyperinsulinism.

Methods: Non applicable

Results: Our patient presented at 2 months of age with abdominal distension, hepatomegaly and elevated urine VMA and HVA. Further work up led to the diagnosis of neuroblastoma stage 4S and chemotherapy was initiated. Hypoglycemia initially occurred during hospital admission after an 8.5 hour fast with a glucose level of 37 mg/dL. He required a glucose infusion rate (GIR) of 10.2 mg/kg/min to maintain euglycemia. Biochemical markers showed non-ketotic hyperinsulinism with insulin level of 10 mU/L and Beta-hydroxybutyrate

Conclusions: To our knowledge, this is the first reported case of neuroblastoma and hyperinsulinism presenting at two months of age and responsive to diazoxide therapy. This atypical presentation of hyperinsulinism and neuroblastoma, along with negative genetic testing, indicates that the underlying association requires further investigation.

1020: P1-520

CONTINUOUS GLUCOSE MONITORING IN POST-OPERATIVE MANAGEMENT OF CONGENITAL HYPERINSULINISM
Ayca Erkin-Cakmak, MD, MPH, University of California San Francisco, SAN FRANCISCO, CA, United States; Alyssa Huang, MD, University of California, San Francisco, San Francisco, CA, United States; Jenise Wong, MD, PhD; Christine Ferrara, MD, PhD, University of California San Francisco, SAN FRANCISCO, CA, United States

Objectives: Congenital Hyperinsulinism (CHI) is the leading cause of severe, persistent hypoglycemia in newborns. CHI due to KATP channel mutations is particularly severe and in the case of diffuse disease, requires subtotal pancreatectomy. Post-operatively, only 25% of patients are considered “cured”, with 50% remaining hypoglycemic and 25% developing diabetes. Close monitoring of blood glucose (BG) levels is necessary  to detect glycemic fluctuations due to dysregulated insulin secretion from residual pancreatic tissue. Using periodic point of care (POC) BG is the standard of care to monitor glycemic control; however, glycemic variability may be unrecognized with infrequent measurements.

Methods: We report a case series of 3 term infants (2 males,1 female) with diffuse CHI due to ABCC8 mutations, requiring near total pancreatectomies whose post-operative management was guided by the use of continuous glucose monitoring (CGM).

Results: In case 1 and 2, consistent patterns of hypoglycemia identified on CGM directed both octreotide initiation and dose titration. CGM trends also led to the recognition of tachyphylaxis and the discontinuation of octreotide. To achieve and maintain euglycemia, CGM was utilized to adjust continuous enteral glucose infusion rates and timing. In case 3, we identified initial pre-prandial hypoglycemia and then persistent post-prandial hyperglycemia with CGM, which re-directed management from octreotide injections to introducing insulin therapy.  Without CGM, persistent hypoglycemic or hyperglycemic episodes may have gone unrecognized, delaying changes in medical management.

Conclusions: Management of CHI is challenging as patients have chaotic insulin secretion leading to unpredictable glycemic control, which is particularly critical for neurocognitive outcomes in developing infants. Our experience demonstrates the tremendous potential of CGM for both acute and long term management. CGM was used to identify individual glucose trends that otherwise would not be easily recognized with standard POC BG monitoring. This ultimately led to personalized medical management.  Our case series highlights the need for larger studies to optimize the use of CGM in post-operative management of CHI.

749: P1-521

LONG ACTING OCTREOTIDE AND NEONATAL CONGENITAL HYPERINSULINISM
Georges Nicolas, MD; Myriam El Amm, MD; Juliana Souaiby, MD; Marie-Claude Fadous Khalife, MD, Holy-Spirit University of Kaslik Lebanon, Byblos, Lebanon

Objectives: Congenital hyperinsulinism is a rare inherited disease. Its incidence is estimated 1 in 50000 newborns. It's a major cause of persistent hyperinsulinimic hypoglycemia of infancy. This inappropriate oversecretion of insulin from pancreatic beta-cells induces severe and irreversible brain damage. Therefore, an aggressive treatment to prevent neurologic damage is required. In our report, we give prominence to the role of long acting octreotide in the treatment options of congenital hyperinsulinism. Respectively, we described and followed a case of severe hypoglycemia in a newborn over a period of 9 years.

Methods: A 32 gestational week boy was admitted to the NICU for respiratory distress with a glycemia of 0 mg/dl in the first hour of life. A progressive oral feeding and intravenous infusion of glucose up to a 25 mg/kg/min was administered, but he remained hypoglycemic. Glucagon and hydrocortisone infusion were required. During hypoglycemic episodes, the highest documented insulin level was 82.8 microU/ml. Thus, a neonatal congenital hyperinsulinism was confirmed whereas metabolic diseases, hypopituitarism, GH and cortisol deficiency were eliminated.

Results: After 45 days of hospitalization, our patient was discharged home on diazoxide 15 mg/kg/day and octreotide 50 microg/kg/day. He had a regular medical monitoring and adjustment of the treatment dosing. At the age of 6 months, genetic studies revealed a mutation of the gene ABCC8; the same mutation was identified in his father. Pet-scan showed a diffused form of hyperinsulinism. Diazoxide was discountinued due to its multiple side effects, and only octreotide remained at 57 microg/kg/day. At 2 years of age, we switched to octreotide long acting 20 mg every 3 weeks. Currently our patient is receiving the same dose every 7 weeks.

Conclusions: In conclusion, congenital hyperinsulinism is a heterogeneous disorder. The response to pharmacologic therapy is variable. To the best of our knowledge, neonates with autosomal recessive mutations respond most likely to surgical therapy than to pharmacologic and dietary therapy. However in our case, long acting octreotide therapy was successful and our patient maintained a normal psychomotor development.

920: P1-522

RECURRENT HYPOGLYCEMIA IN TODDLER WITH BETA-BLOCKERS THERAPY
Veronique Pepin, MD, University of Sherbrooke , Sherbrooke, QC, Canada; Nancy Gagné, MD; Diane Rottembourg, MD, University of Sherbrooke, Sherbrooke, QC, Canada

Objectives: Hypoglycemia is a well-known side effect of propanolol. However,it seems to rarely be associated with severe and recurrent hypoglycemia in older children. We describe the case of a girl presenting with atypical features of propanolol associated hypoglycemia.

Methods: A four year old girl experienced four episodes of severe hypoglycemia. She was born from an uneventful pregnancy and diagnosed with permanent junctional reciprocating tachycardia on her first day of life. She was starded on propanolol,digoxin and amiodarone. She first presented to us at 20 months of age with altered level of consciousness following a viral episode. Her serum glucose was 1.3mmol/l at that time. Between the ages of 3 to 4 years, she presented three episodes of morning seizures. Each time she was found to have serum glucose around 1mmol/l. Notably only one of these episodes was associated with diminished food intake the night before. Her physical exam revealed short stature. On investigation, the critical sample showed an appropriately elevated cortisol and GH level, an appropriately suppressed insulin and normal metabolic work up with only midly elevated ketones. She didn't respond to glucagon challenge, but each episode responded rapidly to glucose boluses. Between the episodes, glucose monitoring was normal, even on CGM for five days. She had no other episode of hypoglycemia for the past 1 1/2 year.

Results: Propanolol is a non-selective beta adrenergic blocking agent.It blunts the adrenergic response which is normally induced by low glucose level therefore promoting hypoglycemia. Those hypoglycemic episodes are generally associated with prolonged fasting periods and ketosis which was not the case of our patient.

Conclusions: This case illustrates the high risk of beta blocker associated hypopglycemia in a patient considered low risk. It also emphasizes unusual associated features such as low ketones production.

1581: P1-523

AN UNUSUAL CASE OF FOCAL CONGENITAL HYPERINSULINISM
Maria Salomon Estebanez, MD; Amish Chinnoy, MD, Royal Manchester Children's Hospital, Manchester, United Kingdom; Alexander J Ryan, PhD, The University of Manchester, Manchester, United Kingdom; Guftar Shaikh, MD, Royal Hospital for Children, Glasgow, United Kingdom; Sian Ellard, Professor; Sarah Flanagan, PhD, University of Exeter Medical School, Exeter, United Kingdom; Mark J Dunne, PhD, The University of Manchester , Manchester, United Kingdom; Indi Banerjee, MD, Royal Manchester Children's Hospital, Manchester, United Kingdom

Objectives: Congenital Hyperinsulinism (CHI) is a heterogeneous condition caused by dysregulation of insulin secretion. Mutations in ABCC8 and KCNJ11 are the most common cause of CHI. Focal CHI (CHI-F) involves the inheritance of a paternal ABCC8/KCNJ11 mutation and somatic loss of the maternal chromosome in the 11p15 allele. CHI-F is limited to a small area of the pancreas and is generally cured after selective lesionectomy.

Methods: We investigated focal CHI by initial genetic analysis, followed by 18 F DOPA PET-CT scanning and pancreatic tissue analysis to understand the pathophysiology of focal CHI.

Results: Our patient presented with hypoglycaemic seizures in the first day of life and CHI was subsequently confirmed. She showed partial response to diazoxide and was managed with continuous octreotide infusion as well as oral diazoxide. She was found to be negative for the known genetic mutations associated with CHI and was transferred to our centre for 18 F FOPA PET-CT scan at the age of 2.8 years. 18 F DOPA PET-CT showed a possible focal lesion in the tail of the pancreas.

Histopathology following partial pancreatectomy showed abnormal increase in islet tissue within the lesion, interspersed with normal exocrine pancreas. Analysis of pancreatic tissue from the lesion showed maternal loss of heterozygosity (LOH) at the 11p15 locus. In vitro studies showed that 0.1 mM  diazoxide inhibited 20mM glucose induced secretion and insulin release initiated by 10 mM leucine. Following the surgical procedure the patient was initially hyperglycaemic for 48 hours and then returned to euglycaemia, thereby achieving cure.

Conclusions: Our case represents deviation from the paradigm of focal CHI due to paternally inherited heterozygous mutations in ABCC8/KCNJ11. Pancreatic LOH confirmed the mechanism of focal CHI in the absence of mutations identified in the peripheral blood DNA analysis. In CHI patients with persistent need for medical treatment but without mutations in ABCC8/KCNJ11, it is important to perform 18F DOPA- PET-CT scan to exclude or detect a possible focal lesion that could potentially be cured with selective lesionectomy. Our case may represent an alternative mechanism for focal CHI which needs to be replicated in other cohorts.

777: P1-524

A MATERNAL ANTIBODY (AB) CAUSING FALSE POSITIVE NEWBORN SCREENING (NBS) RESULTS FOR CONGENITAL HYPOTHYROIDISM (CH)
Megan Kozlowski, MD, Goryeb Children's Hospital, Morristown, NJ, United States; Donald W. Chandler, PhD, LabCorp, Calabasas, CA, United States; Denise C. Hassinger, MD, Goryeb Children's Hospital, Atlantic Health System, Morristown, NJ, United States; Lawrence A Silverman, MD, Goryeb Children's Hospital, Atlantic HeMorralth System, Morristown, NJ, United States

Objectives: NBS programs for CH have existed for over 40 years. NBS methods include primary TSH, primary T4, or combination screening. The assays used are immunoassays, employing two different Abs: capture and label.  TSH bridges the two Abs causing a quantifiable result. Assays are subject to interference from both heterophile and anti-thyroid hormone Abs, and are transferable to a NB from the mother during pregnancy. Assays using different Abs, capture and detection systems, may be affected by other interfering substances and Abs.

Methods:  An infant was born to a mother with no history of thyroid disease. The NBS lab reported a TSH >555 IU/L and  tT4 of 10 mcg/dl. Repeat labs, via Siemens Vista assay confirmed a TSH >500 IU/L but a normal fT4 of 1.99 ng/dl. The baby was started on L-T4. Imaging revealed a normal appearing gland, normal uptake, and a normal position. Due to the lack of correlation between imaging and labs, a Siemens Centaur chemiluminescence assay was performed and reported a TSH of 23 IU/L and fT4 of 11.7 mcg/dl. L-T4 was discontinued, and a maternally transferred Ab was postulated.

Results: See Tables: Testing of maternal serum via Siemens Vista assay 2 weeks post partum revealed a TSH of 178 IU/L and fT4 of 0.72 ng/dl. Siemens Centaur assay noted a near normal TSH of 7.3 IU/L. No anti-thyroid or anti-TSH receptor antibodies were present in either mother or NB. Neither the mother nor NB's samples showed linear dilution; treatment to remove HAMA did not restore dilutional linearity.

Conclusions: While TSH assays are generally reproducible, and not routinely subject to interference from competing substances, there are rare reports of heterophile or HAMA Abs interfering with TSH assays. The discordant TSH values from the various assays are consistent with a yet to be identified circulating Ab. As NBS relies on whole blood assays, there is a theoretic increase in the likelihood for interfering substances to affect the assay. One additional case from an unrelated adult is being investigated. In the patient described, neither the T4 level nor the results of imaging were consistent with the markedly elevated TSH; an alternative explanation was considered and discovered, reminding the clinician to always consider the whole clinical picture when evaluating a laboratory finding.

1414: P1-525

A NEWBORN WITH DIABETES MELLITUS
Ho-Chung Yau, MD, Prince of Wales Hospital, Hong Kong, Hong Kong

Objectives: Neonatal diabetes mellitus is a rare condition affecting approximately 1 in 300,000-500,000 live births. It can be classified into transient and permanent types, depending on the duration of initial insulin requirement.

Methods: We reported a case of transient neonatal diabetes mellitus.

Results: A baby girl was born at 38 weeks weighing 2.2 kg. She was first-born of non-consanguineous parents. Antenatal course was uneventful, and there was no family history of diabetes mellitus. She was found to have non-ketotic hyperglycemia shortly after birth.  She has no facial dysmorphism, skeletal anomalies, kidney diseases, cardiac defects, nor epilepsy. Investigations showed insulin <2.5 mIU/L and C-peptide 0.2 microgram/L while plasma glucose was 25.1 mmol/L. Anti-islet cell antibody was negative.

Rapid-acting insulin infusion was started on day 1 up to 0.004 unit/kg/hour, and was successfully weaned off on day 4. Blood glucose ranged 5.4-11.9 mmol/L at glucose load of 8.4 mg/kg/minute. However, blood glucose rose to 19.4 mmol/L again on day 11, requiring resumption of insulin infusion at 0.0009 unit/kg/hour. Breast feeding was started while glycemia control was stable with insulin infusion. Route of insulin administration was changed to subcutaneous on day 13. Diluted insulin detemir was started at 0.04 unit twice daily (~0.04 unit/kg/day). Glycemic control was suboptimal with blood glucose ranged 16.8-23.5 mmol/L. Diluted insulin detemir was gradually stepped up to 0.14 unit every 8 hourly (~0.15 unit/kg/day). Blood glucose was successfully controlled at 4.8-10.3 mmol/L without hypoglycemia. Insulin was gradually titrated down since day 35, and successfully weaned off on day 48.  Repeated testing after weaning off insulin found C-peptide of 0.5 microgram/L. Blood glucose was well controlled between 4.3-9.4 mmol/L, and baby was discharged on day 57. Mutational analysis showed a methylation defect in 6q24 locus due to paternal uniparental disomy.

Conclusions: Transient neonatal diabetes mellitus is a rare imprinting disease due to over-expression of 6q24 with paternal expression. The initial hyperglycemic phase was successfully managed with subcutaneous diluted insulin analog. Although the condition went into remission, it might recur later in life.

2899: P1-526

NEONATAL DIABETES : MUTATION ANALYSIS, ROLE OF ORAL SULFONYLUREAS AND OUTCOME
Garima Chawla , MD, Sir GangaRam Hospital , New Delhi, India; Vasundhara Chugh, MD, Sir Ganga Ram hospital , New Delhi , India; Archana Arya, DO, Sir Ganga Ram Hospital, New Delhi., New Delhi, India

Objectives: Neonatal diabetes(NDM) has an  incidence of 1: 200000 to 1: 400000. Sulfonylurea therapy proves to be an effective measure to achieve euglycemic status and thereby reduce the insulin requirement and improve the quality of life in the affected infants. Objective of our case series is to lay emphasis on genetic testing for this rare entity thereby, introducing oral sulfonylureas, replacing insulin injections wherever possible and improving the quality of life of young infants.

Methods: We report herein ten cases of neonatal diabetes being treated at Sir Ganga Ram Hospital, a tertiary care hospital in Northern India.

All ten patients had onset of hyperglycemia within first 6 months of life. Five patients had diabetic ketoacidosis(DKA) at presentation. Blood sample for genetic mutation was sent in nine out of ten patients.

Results: Two patients showed mutation in KCNJ11 gene and two patients had mutation in ABCC8 gene. In these four patients insulin was stopped and euglycemia was achieved with gilbenclamide alone. One patient had insulin (INS) gene mutation and is being treated with isophane insulin.

In rest of the four patients, no common mutation was detected. Three patients had transient neonatal diabetes and are maintaining euglycemia  without any medication.

One female patient in whom mutation was not detected has positive tissue transglutaminase antibody, thyroid peroxidase antibody but negative GAD 65 and Islet cell antibodies and is receiving insulin injections to maintain euglycemia.

One patient had Sensorineural deafness & Megaloblastic anaemia along with diabetes at 6 months of age. Multiple system involvement may be present depending upon the gene mutation.

Cases have been summarized in the attached table.

Conclusions: Neonatal Diabetes, though rare, should be kept in mind while dealing with infantile onset diabetes mellitus.

Molecular understanding helps in switching over the treatment from insulin to sulfonylureas. Mutation can be detected in 82% of the cases.  Prognosis depends upon early recognition and treatment , severity of the disease, associated malformations and metabolic control.

Pharmacogenomic approach improves in a tremendous way the quality of life of the young diabetic patients.

833: P1-800

COMPARISON OF THE EFFECTS OF L-DOPA AND INSULIN TOLERANCE TESTS ON CORTISOL SECRETION
Sezer Acar, MD, Dokuz Eylül University, Faculty of Medicine, Izmir, Turkey; Ahu Paketçi, MD; Hale Ü Tuhan, MD; Korcan Demir, Assoc. Professor; Ece Böber, MD; Ayhan Abaci, MD, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey

Objectives: Adrenal insufficiency, which is one of the life-threatening diseases, is assessed by several pharmacological tests. There is growing evidence that L-dopa may increase cortisol secretion by activating hypothalamus-hypophysis-adrenal (HPA) axis and thus, L-dopa is suggested to use in assessment of HPA axis. The aim of this study is to evaluate the effect of L-dopa on secretion of cortisol and ACTH in short children, and to compare its performance with ITT in a large number of patients.

Methods: A total of 29 short but otherwise healthy children who had inadequate GH response to ITT, which was performed as the first test, were consecutively enrolled to the study. GH, cortisol, and ACTH were measured just before administration of L-dopa and then at 30-min intervals for a total of 120 minute. Peak concentrations of cortisol and ACTH exceeding 18 µg/dL (496 mmol/L) and 46 pg/mL (10.2 pmol/L), respectively, were defined as an adequate response.

Results: Twenty-nine otherwise healthy cases [mean age, 9.5±3.1 years (range, 3.7-14.9 years)] with short stature were studied. Twenty-six out of the 29 children (89.7 %) found to have a peak serum cortisol >18 µg/dL after L-dopa test, while 23 children (79.3 %) had an adequate cortisol response after ITT. Normal ACTH response (>46 pg/mL) were found in 24 (82.8 %) patients in L-dopa test. Peak cortisol levels were higher, but statistically insignificant, in children with normal ACTH response than those with subnormal ACTH response (25.6±6.2 vs 19.5±6.4 µg/dL, p=0.054).

Conclusions: This is the first time to demonstrate that L-dopa test is superior to ITT, as a gold standard test, in terms of effective cortisol stimulation, lack of life-threatening side effects, and convenience for the assessment of HPA axis during evaluation of suspected GH deficiency. As a result, L-dopa test can be used safely instead of ITT.

458: P1-801

VARIATION IN ADULT HEIGHT EXPLAINED BY QEPS GROWTH FUNCTIONS, SIZE AT BIRTH AND PARENTAL HEIGHTS.
Kerstin Albertsson-Wikland, MD,PhD; Aimon Niklasson, MD,PhD; Anton Holmgren, MD; Andreas FM Nierop, PhD, Sahlgrenska Academy; University of Gothenburg, Gothenburg, Sweden

Objectives: To explain variation in adult height and the relative importance of size at birth, parental heights and QEPS growth functions.

Methods: Multivariable regression analyses including the variables known at birth i.e. gestational age, birth lenght/weight, mother/father heights and the QEPS growth model function estimates Emax, Etimescale (Exponential), Qmax (Quadratic), Pmax, Ptimescale, AgeP05 (Pubertal).

Material: The healthy cohorts GrowUpGothenburg born 1974 (n 2280; 1139 girls, 1141 boys) and born 1990 (n 1901; 929 girls, 972 boys), with 95 419 measures from birth to adult height, mean 22/24 per child. Adult height for 1974/1990 cohort was for girls 167.7/168.3cm and for boys 180.7/181.7cm with for girls & boys in 1974/1990 cohort Emax 63/63 & 65/65cm, Qmax 98/98 & 104/105cm, Pmax 13/13 & 17/17cm and with T(QEPS)pubgain during ageP05-95 of 26/27 & 29/29cm.

Results: In girls (Fig left) variation in adult height of 1974/1990 cohorts was to 45/51% explained by information available at birth (only size 14/19% and parental heights); to 73/72% explained adding QE-function estimates (only Q 66/69%); to 78/79% explained adding age at onset of puberty; to 99.3/99.2% explained adding P-function estimates.  

In boys (Fig right) variation in adult height of 1974/1990 cohorts was to 46/45% explained using information available at birth (only size 18/15% and parental heights); to 76/75% explaind adding QE-functions estimates (only Q 71/71%); to 79/78% by adding age at onset of puberty; to 99.5/99.5% explained adding P-function estimates. 

The QE-function (Emax,Qmax) could alreaddy in early-childhood be estimated with acceptable accuracy. 

Conclusions: With information available at birth around half of the variation in adult height could be explained. Adding information of prepubertal growth functions another 25% could be explained, whereas adding age at onset of puberty only explained another 5%. Finally, adding also the specific pubertal growth function explained the remaining 25% of variation in adult height. QE-functions, possible to estimate in early childhood, could information available at birth when missing. 

271: P1-802

FINAL ADULT HEIGHT OF ADOLESCENTS WITH BETA THALASSEMIA MAJOR: RELATION TO THEIR GH SECRETION.
Noura Alhumaidi, MD; Mohamed Yassin, MD; Noura Alhumaidi, MD, Hamad Medical Center, Doha, Qatar

Objectives: To evaluate the effect of growth hormone status and iron overload on their final adult height in patients with Beta Thalassemia Major (BTM). Our study is a cross-sectional analysis of data on growth in a group of patients with Beta thalassemia Major (BTM) who have completed puberty spontaneously and have attained their adult height. 

Methods: 15  adolescent patients with BTM (6 females and 9 males) on regular blood transfusion and iron chelation using desferrioxamine administration since the age of 2 years that was changed to Exjade oral therapy for the past 3 years were studied.   Growth parameters (height, weight) were measured and BMI and HtSDS were calculated. Bone age showed complete fusion of the hand and wrist epiphyseal plates.  We measured their  Free T4, TSH, fasting and 2h blood glucose levels after oral glucose load (75g) , fasting insulin and C-petide, and IGF-I concentrations.    Patients were categorized according to their peak GH response to clonidine provocation into : 9 patients with normal GH secretion (GHN) and 6 patients with GH deficiency (GHD) ( Peak GH < 7 ng/ml) .

Results: All patients had normal thyroid function and glucose homeostasis.  Two females and 3 males on hormonal replacement therapy for hypogonadotropic hypogonadism started at 13 and 14 years of age respectively. The final stature of adolescents with BTM = 159.1 +/- 6.42 cm, with HtSDS = -1.94 +/- 0.83 which had been spontaneously achieved at an age ranging from 21 +/- 3 years. The HtSDS of patients with GHD was significantly lower than those with NGH with a mean difference of 1SD.  IGF-I, fasting insulin and C-peptide concentrations, fasting and 2h blood glucose after oral glucose load (75 g) did not differ  among the two groups.  The final HtSDS were correlated significantly with the Peak  GH secretion ( r = 0.788, p = 0.0008).  Neither ferritin level nor IGF-I concentrations were correlated with the HtSDS.  HtSDS were positively related to their mid-parental height (r=0.58, P<0.01).

Conclusions: The final adult height of patients with BTM and GHD is significantly shorter compared to their pears with GHN. rhGH therapy is recommended in thalassemic children with GHD in addition to proper blood transfusion ad intensive chelation to improve their adult height

737: P1-803

BONE AGE DETERMINATION BY ULTRASOUND (BAUS): VALIDATION IN BRAZILIAN STUDENTS
Marcela L. Amaro, MD; Matheus A Alvares, MD; Kochi Fernanda , Medical Student; Juliana P Sant Ana, Medical Student; Avritchir Roberto, MD; Tatiane S Silva, PhD; Kochi Cristiane, PhD; Carlos A Longui, PhD, Santa Casa de Sao Paulo , sao paulo, Brazil

Objectives: Validation of Bone Age Determination by Ultrasound (BAUS)

Methods: We evaluated 248 students (F:131; M:117), age range 6-17y, and BMI between ±2SDS. BAUS was performed employing the SonicBone Medical device and BARx was done using a portable Rx device. BARx was established after reading of 3 experienced investigators (2 pediatric endocrinologists and 1 radiologist).

Results: Discordant BARx occurred in 4/131girls and 11/117 boys; the final BA was established after review and concordance of at least two investigators. A significant correlation between BAUS and BARx was identified both in girls (r=0.91; p<0.001) and boys (r=0.92; p<0.001). A significant correlation was also detected between chronological age (CA) and BA methods (BAUS: r=0.9 and BARx: r=0.94, p<0.001). Differences between both methods were predominantly detected in the upper age limits. In girls older than 13y, BAUS was around 2y less than BARx and CA; in boys older than 15y, BAUS was similar to CA, but 8months delayed in comparison to BARx.

Conclusions: We concluded that there are significant positive correlation among BAUS, BARx and CA. BAUS determination in Brazilian students needs a formula adjustment in ages older than 13y and 15y in girls and boys, respectively. BAUS is a safe and practical method of bone age determination, and seems to have a potential clinical applicability.

1057: P1-804

SHORT CHILDREN BORN SMALL FOR GESTATIONAL AGE (SGA) TREATED WITH GROWTH HORMONE (GH): ADULT HEIGHT AND FACTORS IMPLICATED IN LONG-TERM RESPONSE.
Anunciación Beisti Ortego, PhD, Calahorra's Hospital , Calahorra, Spain; Antonio De Arriba Muñoz, PhD, Miguel Servet's Hospital, Zaragoza, Spain; Cristina Fuertes Rodrigo, MD, Calahorra's Hospital, Calahorra, Spain; Marta Ferrer Lozano, MD; Jose Ignacio Labarta Aizpun, PhD, Miguel Servet's Hospital, Zaragoza, Spain

Objectives: The aim of this study was to evaluate height gain, puberty and adult height (AH) during rhGH treatment and factors related with long-term response such as pubertal stage at start, treatment duration before puberty, diagnosis of GH deficiency (GHD) or familiar short stature (FSS) and combined treatment with GnRH analogues.

Methods: Retrospective, longitudinal cohort study of 139 short children born SGA treated with rhGH; 115 reached AH (28 males) and 36 received GnRHa.

Results: Auxological data are presented in Table 1. Prepubertal children at start of treatment reached higher AH compared with pubertal children (-1.4±0.6 vs -1.9±0,6 respectively, p<0,01). Patients treated ≥ 2 years in pre-puberty showed a significantly higher height gain than those treated < than 2 years (1.32±0.5 vs. 0.99±0.6, respectively, p<0,05). Height gain does not depend on the presence of GHD or FSS. Factors associated with higher height gain were: a) lower height (r= -0.59, p<0.001), weight (r= -0.58, p<0.001), and BMI (r= -0.42, p<0.001) at onset of treatment b) younger chronological age (r= -0.23, p=0.013) and bone age (r= -0.49, p<0.001), c) lower pre-treatment IGF-I values (r= -0.45, p<0.001), d) greater distance with target height (r= -0.53, p<0.001), e) higher first year (r= 0.47, p<0.001) and second year (r= 0.55, p=0.032) growth velocity f) and higher prepuberty and puberty height gain (r= 0.42, r= 0.49, respectively, p<0.001). Compared with reference population, patients treated with rhGH had less height gain during puberty (males 23.19±4.23 vs 26.20±4.2 cm, females 17.94±3.93 vs 20,30±4.4 cm, p<0.001). However, females treated with combined rhGH/GnRHa showed higher height gain during puberty than reference population (23.78±0.60 vs 20.30±4.4 cm, p<0.05). No differences were observed in AH SDS or adult BMI SDS between the two treatment groups.

Conclusions: rhGH treatment in short SGA children results in variable height gain but allows in most of them to reach their target height. Best results are found in prepuberal children with longer treatment duration before puberty. Patients with early puberty and poor adult height prediction can benefit from combined rhGH/GnRHa treatment.

1085: P1-805

THE GH RECEPTOR GENE EXON 3 DELETION IS ASSOCIATED WITH POSTNATAL SPONTANEOUS GROWTH IN SMALL FOR GESTATIONAL AGE CHILDREN.
Malena Berger, MD, Hospital de Pediatria J P Garrahan, Buenos Aires, Argentina; Natalia Perez Garrido, MS/MA, Hospital de Pediatria Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina; Yamila Paulon, MD, Hospital de Pediatria J P Garrahan, Buenos Aires, Argentina; Gabriela Guercio, PhD, Hospital de Pediatria Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina; Matias Pujana, Biochemistry, Hospital de Pediatria J P Garrahan, Buenos Aires, Argentina; Veronica Zaidman, Biochemistry, Hospital Nacional de Pediatría JP Garrahan, Buenos Aires, Argentina; Marco A Rivarola, PhD; Alicia Belgorosky, MD,PhD, Hospital de Pediatria Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina

Objectives: The GH receptor gene (GHR) contains an unusual genetic polymorphism caused by deletion of exon 3 that mimics alternative splicing. The exon 3 deletion has been linked to increased responsiveness to rhGH treatment in small for gestational age (SGA) patients. However, the association between spontaneous catch-up growth and GHR polymorphism has been poorly addressed in this population. The aim of this study is to determine the association between GHR polymorphism, postnatal catch-up growth and serum IGF-I levels in SGA children.

Methods: We conducted an observational cross-sectional study. Fifty prepubertal and early pubertal children (30 boys) aged 4-12.41 yr were evaluated at a tertiary center for pediatric endocrinology. Ninety-four appropriate for gestational age (AGA) children served as a control group. The GHR polymorphism was genotyped by polymerase chain reaction (PCR) duplex assay. Anthropometric measures were recorded, while age of pubertal onset was assessed by clinical examination and serum gonadotropin, estradiol and testosterone levels. Serum IGF-I levels prior to the rhGH treatment were also evaluated. Those patients who have reached height >-2 SDS without treatment, were defined as spontaneous catch-up group.

Results: The GHRd3/d3 genotype was underrepresented in the SGA group (2%) when compared with the control group (13.8%) p = 0.03. No difference in the frequency of the GHRfl/fl or GHRfl/d3 genotype was found between SGA patients and the control group. The percentage of SGA patients that achieved spontaneous catch-up growth was greater in those with at least one d3 allele (n=10/18; 55%) when compared with the GHRfl/fl group (n=6/31; 19%), p = 0.01. A tendency towards greater IGF-I levels expressed as SDS was found in the exon 3 deleted genotype (0.22 ±1.1) when compared with those with GHRfl/fl group (-0.35 ±0.82 ), p=0.06.

Conclusions: In SGA children, the exon 3 deletion was associated with greater catch up growth, and higher serum IGF-I levels. Thus, we propose that this common polymorphism could play a role in, postnatal spontaneous growth in SGA children.

1516: P1-806

CHANGES OF THYROID FUNCTION DURING HGH THERAPY IN GROWTH HORMONE DEFICIENCY CHILDREN
Anamaria Bursuc, MD, University of Medicine and Pharmacy Gr. T. Popa , Iasi, Romania; Alina Belceanu, MD, University of Medicine and Pharmacy "Gr.T. Popa" , Iasi, Romania; Ioana Armasu, MD, University of Medicine and Pharmacy Gr T. Popa, Iasi, Romania; George Zmau, MD, University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania; Maria Christina Ungureanu, MD, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Romania; Letitia Leustean, PhD, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Iasi, Romania; Cristina Cristea, MD, University of Medicine and Pharmacy Grigore T. Popa, Iasi, Iasi, Romania; Valentina Adomnicai, RN, University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania; Carmen Vulpoi, Professor, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Iasi, Romania

Objectives: Introduction: Growth hormone deficiency (GHD) is an important cause of short stature in childhood and the goal of growth hormone (GH) therapy is to promote linear growth, restore body composition and improve the quality of life. Normal thyroid hormone secretion or appropriate L-thyroxine (L-T4) substitution is necessary for the optimal effect of the GH administration.

Aim: To evaluate the effect of rhGH administration on thyroid function in children with GHD during one year of therapy, as well as to to assess its influence on rhGH therapy effectiveness and potential indications to thyroid hormone supplementation.

Methods: Method: The study enroled 55 children (36 boys,19 girls, 4-14 years old) with confirmed GHD (decreased or low GH, two negative tests). All of them were treated with a mean dose of GH=0.04+/-0.005 mg/kg/day and followed for at least 1 year. Clinical (body height, height velocity) and hormonal (IGF1, TSH, fT4) data, as well as radiographic bone age assessments were documented at the beginning, 6 months and after one year of treatment.

Results: Results: Before treatment, all patients had the height SDS less than −2.5, delayed bone age, decreased or low normal IGF1 and normal thyroid function. During the initial 6 and 12 months of rhGH administration, a moderate decrease of fT(p=0.428, respectively p=0.013) without significant changes of TSH (p=0.074) was observed. In 6 children, either the decreased fTlevel, increased TSH or both led to administration of L-T4 substitution. After 1 year of rhGH, HV improvement was significantly lower in those children who were hypothyroid even for a relatively short period (mean 0.47 vs 0.78, p<0.05).

Conclusions: Conclusions: Impaired thyroid function during the first year of rhGH treatment in children with GHD and the negative effect of even transient thyroid hormone deficiency on growth rate should be taken into account while beginning rhGH. Our study highlight the importance of a closer monitoring of thyroid function in this patients.

606: P1-807

COMPARATIVE STUDY OF SAFETY, EFFICIENCY AND BIOCOMPATIBILITY BETWEEN A MEXICAN RECOMBINANT GROWTH HORMONE AND GENOTROPIN, IN CHILDREN WITH GROWTH HORMONE DEFICIENCY
Raúl Calzada-León, PhD; María De La Luz Ruiz-Reyes, PhD; Lissette Arguinzoniz-Valenzuela, PhD, Instituto Nacional de Pediatría, Mexico City, Mexico

Objectives: To investigate safety, efficiency and biocomparability of recombinant human growth hormone from a Mexican pharmaceutical laboratory PiSA.

Methods: Phase III, prospective, randomized, parallel and comparative study during 12 months.

Inclusion criteria: prepubertal male and female, proven diagnosis of GH deficiency, height less than -3SD, bodily proportions, growth velocity less than 10 percentile, naive to rGH treatment and parents informed consent signature. Exclusion and elimination criteria: chronic and/or systemic disease, genetic syndrome, intrauterine growth retardation, active or past oncology disease-radiotherapy-chemotherapy, use of drugs that interfere with growth hormone action.

The study was approved by the Investigation and Ethical Committees of the National Institute for Pediatrics

54 patients were included (80% power and alpha 0.05 = 50 patients), and ended the study 24 patients in PiSA (rGH-1) and 26 patients in Genotropin (rGH-2). Every two months a complete somatometry and biochemical safety profile (blood cytometry, blood chemistry, electolites, thyroid, lipid and hepatic profiles, urine analysis, pre and postprandial glucose and insulin, oral glucose tolerance test, IGF-1, IGFBP-3), were performed.

Results: Growth velocity increased (10.82cm/year in rGH-1, 10.24cm/year in rGH-2, p<0.001), and height gain was suitable (0.944SD in rGH-1 and 0.877SD in rGH-2 p<0.001), and there was not statistical significance between rGH-1 and rGH-2 (p>0.05).

No alteracions were observed in biochemical safety profile, and no severe adverse events were reported, and the two more frequent non-related adverse events were viral upper airway infections, and transient headache, without differences between the two groups (p>0.05).

ANOVA (CI 95%) was used for efficiency analysis, with subgroups adjusted by Bonferrani method; U-Mann-Whitney and Fisher test were used for safety analysis

Conclusions: There are not statistical differences in efficiency, safety and biocomparability between rGH-1 and rGH-2. PiSA rGH is a safety, efficient and biocompatible option for the treatment of growth hormone deficient children.

1629: P1-808

SHOX DEFICIENCY: GENETICS ALTERATION AND THERAPEUTIC EFFICACY AND SAFETY OF GROWTH HORMONE TREATMENT.
Lidia Castro-Feijóo, PhD, Hospital Clínico Universitario y Universidad de Santiago de Compostela. IDIS., Santiago de Compostela, Spain; Cecilia García Villaronga, MD, Universidad de Santiago de Compostela, Santiago de Compostela, Spain; Celsa Quinteiro García, PhD, Fundación Pública Galega de Medicina Xenómica, Santiago de Compostela, Spain; Paloma Cabanas Rodríguez, PhD, Hospital Clínico Universitario y Universidad de Santiago de Compostela. IDIS., Santiago de Compostela, Spain; Rosaura Leis Trabazo, PhD, Hospital Clínico Universitario y Universidad de Santiago de Compostela. CiberObn. IDIS. , Santiago de Compostela, Spain; Lourdes Loidi Fernández De Trocóniz, PhD, Fundación Pública Galega de Medicina Xenómica, Santiago de Compostela, Spain; Jesús Barreiro Conde, PhD, Hospital Clínico Universitario y Universidad de Santiago de Compostela. IDIS., Santiago de Compostela, Spain; Manuel Pombo Arias, Professor, Universidad de Santiago de Compostela. IDIS., Santiago de Compostela, Spain

Objectives: SHOX deficiency (SHOX-D) is a frequent cause of short stature. The SHOX gene resides in the telomeric PAR1 region on the short arm of both sex chromosomes and escapes X inactivation. The diagnosis of SHOX deficiency has acquired relevance in the last decade due to advances in the knowledge of the genetic and molecular mechanisms involved in its aetiopathogenia and also due to the recent use of growth hormone therapy to improve the height of these patients.

Objectives. 1) To detect the genetic alteration in the SHOX gene for the SHOX-D diagnosis. 2) To asses auxological and clinical data as well as therapeutical efficacy and safety after one year and at the end of treatment with growth hormone (GH).

Methods: Monocentric retrospective observational study. Data were examined for 19 GH-treated SHOX-deficient children (10 girls and 9 boys). Genetic study: PCR and direct sequencing of SHOX coding exons and flanking regions plus MLPA for detection of deletions.

Results: All patients had some type of genetic alteration in SHOX or in its regulatory areas. The deletion of SHOX was the most frequent genetic alteration and 26.31% presented SHOX missense mutations (p.Arg178Trp, p.Tyr199Stop, p.Phel136Leu and p.Ala170Pro). At the beginning of the GH treatment , the mean height of all Growth Hormone-treated SHOX-deficient children was -2.43 ± 0.35 SDS with a mean chronological age (CA) of 9.88 ± 2.95; girls CA: 8.91 ± 2.65 and height SDS -2.58 ± 0.36 and boys CA: 9.84 ± 3.42 and height SDS -2.21 ± 0.22. After one year of GH treatment, the mean height in girls was -2.07 ± 0.42 SDS and in boys -1.68 ± 0.31 SDS. The mean height of the patients at the end of GH treatment was -1.35 ± 0.77 SDS: girls -1.66 ± 0.84 SDS and boys -0.9 ± 0.38 SDS. Overall, the height increased throughout the treatment being higher in boys than in girls (figure 1). Likewise no serious adverse effects were observed during the GH treatment.

Conclusions: The results obtained indicate that the treatment with growth hormone is safe in SHOX-D and improve the growth of these patients, since it increases the height not only during the first year of GH therapy but also at the end of the treatment. On the other hand, the most frequent genetic alteration was the SHOX deletions.

1454: P1-809

THE RISK OF METABOLIC SYNDROME ACROSS TERTILE OF DELTA CHANGES IN SDS-HEIGHT DURING GROWTH HORMONE THERAPY IN PRE-PUBERTAL CHILDREN WITH GROWTH HORMONE DEFICIENCY (GHD)
Francesco Chiarelli, MD, University “G. d’Annunzio” , CHIETI, Italy; Stefania De Marco, MD; Cosimo Giannini, MD; Nella Polidori, MD; Marika Bagordo, MS/MA, University of Chieti, G. D'Annunzio, Chieti, Italy; Angelika Mohn, MD, University “G. d’Annunzio” , CHIETI, Italy

Objectives: Growth hormone deficiency (GHD) in adults is associated with metabolic and cardiovascular(CV) complications. Obesity, dyslipidemia, hypertension, insulin resistance are components of the Metabolic Syndrome and in adults are positively affected by growth hormone (GH) treatment. Few data are available in youth especially evaluating the metabolic effects across changes of sds-height (sds-h) at the end of GH treatment. To evaluate changes in insulin resistance index, lipid profile and blood pressure in pre-pubertal GHD children across tertiles of sds-h changes at the end of GH replacement therapy.

Methods: 15 pre-pubertal normal weight children with GHD (age: 11.4± 2.3 years; sds-h: -2.25± -1.94). In all children IGF-1, lipid profile (total cholesterol [TC], triglycerides [TG], HDL-cholesterol [HDL]), glucose metabolism (fasting glucose[FG] and insulin [FI],HbA1c levels), and insulin resistance index(HOMA, TG/HDL ratio) were evaluated before and at the end of GH treatment and delta changes were calculated for each variable. Subjects were divided according to tertile of delta-changes of sds-h (1st tertile: < 1.03; 2nd tertile:1.03-1.37;3nd tertile:> 1.37) at the end of therapy.

Results: In each tertile group a significant increase of sds-height was documented (all p<0.05). Delta changes of glucose metabolism (FG, FI, HOMA, TG/HDL, HbA1c) and lipid profile (TG, HDL, TC) indexes significantly improved across tertile groups showing the highest tertile a better metabolic pattern. Blood pressure was not different across the three tertiles

Conclusions: GH therapy is associated with improvement of indexes of metabolic syndrome. Delta changes seem to be more evident in those children with a higher tertile of delta sds-h at the end of therapy. A tailored therapy aimed to reach a proper goal in sds-h at the end of GH therapy might be necessary in order to reduce cardiovascular risk in GHD children.

396: P1-810

GENETIC SCREENING OF PATIENTS WITH CONGENITAL GH DEFICIENCY IN THE GENESIS OBSERVATIONAL PROGRAM: CLINICAL INDICATORS FOR IDENTIFICATION OF MUTATIONS.
Werner F Blum, MD, University of Giessen, Giessen, Germany; Christopher J Child, PhD, Eli Lilly and Company, Windlesham, United Kingdom; Jürgen Klammt, PhD; Heike M Pfäffle, MTA, University of Leipzig, Leipzig, Germany; Serge Amselem, MD, Hôpital d'Enfants Armand-Trousseau , Paris, France; Marie Legendre, PhD, Hôpital Trousseau , Paris, France; Marie-Laure Sobrier, PhD, Inserm US013 , Paris, France; Christine Jones, PhD; Alan G Zimmerman, PhD, Eli Lilly and Company, Indianapolis, IN, United States; Roland W Pfäffle, MD, University of Leipzig, Leipzig, Germany

Objectives: Congenital GH deficiency (GHD) may be caused by mutations in genes involved in pituitary development, GH synthesis or secretion. Defects in GH1 and GHRHR commonly cause isolated GHD (IGHD). Defects in genes for transcription factors (GLI2, HESX1, LHX3, LHX4, SOX3, PROP1, POU1F1) that shape the developing pituitary and specify hormone producing cells, cause multiple pituitary hormone deficiencies (MPHD). Using data from the DNA Analysis Sub-study of the GeNeSIS observational program of outcomes in children with short stature, we aimed to identify patient characteristics that predicted for a GHD causing mutation.

Methods: SSCP, dHPLC and direct sequencing analyses were performed based on a candidate gene approach in patients with IGHD or MPHD. DNA variants were classified as pathogenic according to American College of Medical Genetics and Genomics standards. Data submitted by physicians at baseline and during the course of follow-up were combined for statistical analysis. Logistic multivariable regression analysis (mutation yes = 1, no = 0) was performed with various cohorts and sets of variables.

Results: Data for the best regression model for patients with IGHD or MPHD are shown in the table. MPHD, low baseline height minus target height standard deviation score (SDS), low log stimulated GH peak were found to be significant indicators of a relevant mutation in the tested genes. When the analysis focused on patients with IGHD (N = 398), significant indicators of GH1 or GHRHR mutation were low baseline age (odds ratio 0.74; 95% confidence interval 0.60–0.92; P = 0.005) and low log stimulated GH peak (0.37; 0.21–0.66; P <0.001). In patients with MPHD (N = 259), the only significant indicator of mutation in GLI2, HESX1, LHX3, LHX4, POU1F1, PROP1 or SOX3 was low baseline height minus target height SDS (0.71; 0.58–0.87; P <0.001). Sex, baseline bone age SDS, or baseline IGF-I SDS were not significant indicators of mutations in any models.

Conclusions: The most relevant clinical indicators for a mutation in the investigated genes are MPHD, younger age at start of GH therapy, low baseline height minus target height SDS, and low GH peak in stimulation testing. These data may assist in identifying patients with GHD for DNA testing.

1009: P1-811

CHANGES IN THE CIRCULATING INSULIN-LIKE GROWTH FACTOR SYSTEM IN RESPONSE TO SHORT-TERM HIGH FAT INTAKE
Santiago Guerra-Cantera, BS/BA, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, CIBEROBNN, Madrid, Spain; Francisca Díaz, MS/MA, Hospital Infantil Universitario Niño Jesús, CIBEROBN, Madrid, Spain; Purificación Ros, MD, PhD, Hospital Universitario Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Spain; Alejandra Freire-Regatillo, MS/MA, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain; Sandra Canelles, TS; Vicente Barrios, PhD, Hospital Infantil Universitario Niño Jesús, CIBEROBN, Madrid, Spain; Claus Oxvig, PhD, Aarhus University, Aarhus, Denmark; Jan Frystyk, MD, Aarhus University Hospital, Aarhus, Denmark; Jesús Argente, MD, PhD, Hospital Infantil Universitario Niño Jesús. UAM, Madrid, Spain; Julie A Chowen, PhD, Hospital Infantil Universitario Niño Jesús, CIBEROBN, Madrid, Spain

Objectives: The insulin-like growth factor (IGF) system is important for growth and metabolism during development, while in adulthood it maintains tissue integrity and continues to be involved in metabolic control. However, little is known regarding the effect of diet on more recently identified members of this family such as pregnancy-associated plasma protein-A2. This metalloproteinase cleaves IGF binding protein (IGFBP) 3 and 5 to release IGF-1 from the ternary complex.

Our aim was to analyze the changes in the circulating levels of members of the IGF in response to a short-term dietary change.

Methods: Male and female Wistar rats were given a high fat diet (HFD, 60% fat, 5.1 kcal/g), low fat diet (LFD, 10% fat, 3.76kcal/g) or normal rat chow (Ct, 3.1 % fat, 2.9 kcal/g) for 1 week (n = 6). Food intake and weight gain were monitored and total IGF-1 (tIGF1), free IGF-1 (fIGF1), IGFBP-3, IGFBP-5 and PAPP-A2 levels measured in serum by ELISA at 70 days of age.

Results: Energy intake was higher in rats on HFD and LFD compared to Ct diet in both sexes, with HFD males ingesting more kcal than LFD males. HFD males gained more weight than those on LFD or chow. In females diet had no effect on weight gain. Percent visceral fat was not significantly affected by diet. Males had higher tIGF1 levels than females on all diets (p<0.0001). In males HFD and LFD tended to decrease tIGF1, but increase it in females (p<0.05). Males had higher fIGF1 than females on all diets (p<0.0001). In males LFD decreased fIGF-1 (p<0.02). Diet had no effect on IGFBP3 levels with higher levels in males than females (p<0.0001) on all diets. Males had higher levels of IGFBP5, but this was only significant under HFD (p<0.0001). PAPP-A2 levels were unaffected by diet, but were higher in females than in males. See table.

Conclusions: After only one week of dietary change modifications in body composition and the circulating IGF1 system can be observed, with males more affected than females. The circulating IGF1 system is sexually dimorphic with males having higher levels of all factors measured compared to females except PAPP-A2, where females had higher levels. Whether changes in the IGF system affect the long-term response to dietary challenges remains to be determined.

720: P1-812

INCREASED ABDOMINAL PERIMETER (AP) AT BIRTH OF CHILDREN BORN SMALL FOR GESTATIONAL AGE (SGA) DUE IUGR (INTRAUTERINE GROWTH RETARDATION)
Antonio De Arriba, PhD, Hospital Miguel Servet/University of Zaragoza, Zaragoza, Spain; Marta Ferrer, MD, Hospital Miguel Servet, Zaragoza, Spain; Carmen Rueda, MD; Beatriz Puga, PhD, Centro Andrea Prader, Zaragoza, Spain; José Ignacio Labarta, PhD, Hospital Miguel Servet/University of Zaragoza, Zaragoza, Spain; Ángel Ferrández-Longás, PhD, Centro Andrea Prader, Zaragoza, Spain

Objectives:  

The metabolic syndrome (MS) is related to central obesity and observed during infancy, in children born SGA. Since abdominal fat reflects the perivisceral fat, predisposing factor to MS, we wanted to study besides the classical parameters Height (H), Weight (W), Head Circumference (HC) at birth, also the non included in the neonatal exploration Abdominal Perimeter (AP) in a sample of newborns SGA.

Methods:  

41 SGA (H, W or both < SD) born at term (38-42 weeks of gestation) without confounding factors like syndromic cases, complicated pregnancies and being in good clinical condition, were measured by experienced nurses, just after having cut the umbilical cord. The obtained values were compared to our longitudinal Growth Study from birth until adulthood.

Results: Figure 1 shows the values of W, H, HC and AP compared to our normal standards and expressed in SD.

H and W and in a lesser extent HC are clearly below the mean standards whereas as a new finding the AP is on the contrary very normal, even slightly above the mean. Other biochemical and ecographic signs suspicious of MS are now in process.

Conclusions:  

Newborns SGA due to IUGR show an increased AP, even above the mean standards, with a clear difference to the H, W and HC. This increased AP is the expression of an intraabdominal obesity, as a consequence of a fetal thrifty energy expenditure. This clinical finding alerts about the risk to develop a MS at very early ages and advises to control it at birth specially in newborns SGA. In such cases an adequate nutrition and stimulation of physical activity are mandatory to avoid an MS. Also the early use of growth hormone not only for the growth but to prevent the MS must be taken into consideration.

717: P1-813

HOW FREQUENT ARE PARTIAL AND COMPLETE ACID-LABILE SUBUNIT DEFICIENCY (ACLSD) IN CHILDREN WITH IDIOPATHIC SHORT STATURE (ISS)?
Horacio Domené, PhD, Hospital de Niños R. Gutiérrez, Buenos Aires, Argentina; Paula A Scaglia, MS/MA, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina; Ana Keselman, MD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez“, Buenos Aires, Argentina; Lucía C Martucci, MS/MA; Liliana M Karabatas, PhD, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina; María G. Ballerini, MS/MA; María G. Ropelato, PhD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez“, Buenos Aires, Argentina; Alicia S Martínez, MD; Hamilton R Cassinelli, MD; Sabina Domené, PhD, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina; Débora Braslavsky, MD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez“, Buenos Aires, Argentina; Mariana L Gutiérrez, PhD, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina; Sonia V Bengolea, MD, Hospital "Dr. Juan Fernández", Buenos Aires, Argentina; Viviana R Pipman, MD, Hospital "Dr. Enrique Tornú", Buenos Aires, Argentina; Juan J Heinrich, MD, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina; Ignacio Bergadá, MD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez“, Buenos Aires, Argentina; Rodolfo A Rey, PhD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina; Héctor G Jasper, MD, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina

Objectives: Idiopathic short stature (ISS) is a clinical condition defined as height 2 SD below the mean in children without evidence of systemic, endocrine, nutritional, or chromosomal abnormalities. ISS children have normal birth weight and are GH sufficient. Several molecular defects have already been characterized in a subgroup of ISS children, including GHR, GHSR, SHOX, NPR2, IGFALS genes among others. The aim of this study was to characterize the IGFALS gene in normal and ISS children, identify potential pathogenic variants and determine their impact on the IGF system and the frequency of partial and complete ACLSD. 

Methods: We have studied 125 normal prepubertal children (62 males; age 6.67±2.89; height -0.05±0.95) and 103 ISS prepubertal children (76 males; age 7.82±2.54; height -2.77±0.45). Levels of IGF-I, IGFBP-3 were determined by ICMA and ALS by RIA or ELISA and expressed as SDS. The IGFALS gene was sequenced in both controls and patients.   

Results: Levels of IGF-I (-0.77±1.27 vs. -0.01±1.02), IGFBP-3 (-0.77±1.57 vs. 0.09±1.24), and ALS (-1.24±1.36 vs. -0.09±1.03) were significantly lower in ISS compared to controls (all P<0.0001). While heterozygous synonymous variants (SV) were found in both controls and ISS children (5.6 vs. 1.9%), non-synonymous variants (NSV) were more frequent in ISS children (15.5 vs. 4.8%; P=0.0039). In those 16 ISS children with NSV, one presented complete ACLSD (compound heterozygous for p.Glu35Glyfs*17/p.Ser490Trp), and other 5, presented partial ACLSD (heterozygous carriers  for p.Glu35Glyfs*17, p.Arg277His, p.Pro287Leu, and 2 p.Arg548Trp). Only IGFALS variants p.Glu35Glyfs*17 and p.Ser490Trp were classified as pathogenic by in silico bioinformatic tools and confirmed by in vitro expression.

Conclusions: Although IGFALS gene variants are frequently found in both normal and ISS children, NSV are much more frequent in ISS children. However, only a fraction of them (about 5% of ISS children) presented a biochemical profile suggestive of partial ACLSD and less of 1% presented complete ACLSD. Identification of partial ACLSD in ISS children could have practical implications, considering that these children have shown a positive response to rhGH treatment.

698: P1-814

FIVE YEARS OF GROWTH HORMONE THERAPY AT CHILDREN WITH GROWTH HORMONE DEFICIENCY
Corina Galesanu, MD, University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania; Andra I Sandru, MD, University of Medicine and Pharmacy 'Grigore T.Popa', Iasi, Romania; Mihail R Galesanu, MD, Romanian Academy of Medical Sciences, Iasi, Romania

Objectives:  Growth hormone (GH) has been available for more than 5 decades for the treatment of growth hormone deficiency (GHD); the growth velocities particularly rise during the first 5 years of GH therapy. Our aim has been to assess the growth and safety during the first 5 years of GH treatment in 38 GHD children.

Methods: We reviewed clinical data of 38 prepubertal children (26 boys, 12 girls):34 with IGHD (isolated GH deficiency), 4 with MPHD (multiple pituitary hormone deficiency).All of them were treated with a mean dose of GH=0.036mg/kg/d and followed for at least 5 years (mean 6.74ys).

Results: The mean height gain in standard deviation score (SDS) was 2.15SDS; the change in height SDS decreased in time. The mean IGF-1 levels achieved remain within the normal range using age-appropriate standards. A significant acceleration of bone maturation was recorded after the first year of therapy and persisted until the fifth year.

Table1-Growth data during first 5 years of GH therapy in 38 GHD children.

Parameter

Baseline

1yr

2ys

3ys

4ys

5ys

Chronological age(ys)

8.79

9.79

10.79

11.79

12.79

13.79

Bone age(ys)

6.57

7.42

8.92

10.47

11.87

13.26

IGF-1 mean values (ng/ml)

73.1

248.3

221

284.4

378.5

529

Height SDS

-2.85

-2.19

-1.61

-1.08

-0.77

-0.7

Height velocity(cm/yr)

-

10.74

7.54

6.32

6.71

5.68

Weight SDS

-1.88

-1.24

-0.94

-0.89

-0.24

-0.15

Within first 5 years of therapy none of these children developed diabetes mellitus,9 patients(23.68%) presented transient increase in fasting glucose,2 patients(5.26%) had transiently impaired glucose tolerance,5 patients(13.15%) developed hypothyroidism and 2 patients(5.26%) had transiently increased TSH levels. No malignancies were observed to date.

Conclusions: The onset of therapy was followed in all patients by an important height gain, wich attained its zenith during the first year of treatment (10.74cm/yr) and became progressively less evident during the next 4 years. Early diagnosis and therapy initiation optimized growth outcomes.

1359: P1-815

SOMATOTROPHIC AXIS FUNCTION IN ADOLESCENT GIRLS WITH HYPERANDROGENISM
Maria Hernandez, MD, Faculty of Medicine, University of Chile, Santiago, Chile; Ximena Gaete, MD, Hospital Clínico San Borja Arriarán, Santiago, Chile; Patricia Lopez, BSc, Hospital San Borja Arriaran, Santiago, Chile; Claudio Villarroel, MD, University of Chile, santiago, Chile; Gabriel Cavada, PhD, University of Chile and University of los Andes, santiago, Chile; German Iñiguez, PhD, University of Chile/Faculty of Medicine, Santiago, Chile; Fernando Cassorla, MD, School of Medicine, University of Chile, Santiago, Chile

Objectives:

Hyperandrogenism may develop during adolescence. It has been suggested that the somatotrophic axis may be related to the development of hyperandrogenism in non-obese adult women with PCOS.

 To investigate the relationship between the function of the somatotrophic axis and ovarian hyperandrogenism in young postmenarchal girls.

Methods:

Design:  Cross-sectional study of adolescent girls.

Patients:  We studied non-obese adolescent girls with hyperandrogenism (HA; n=21) that were matched with control girls (C; n=25) for chronological age, age at menarche and body mass index.

Methods: We obtained a fasting blood sample for the measurement of serum glucose, insulin, 17-hydroxyprogesterone, dehydroepiandrosterone sulfate, androstenedione, SHBG, total testosterone, IGF-I, IGF-II, IGFBP-1, IGFBP-3 Ghrelin, leptin, AMH, LH and FSH during the follicular phase of the menstrual period. In addition, we performed an OGTT to determine blood glucose, ghrelin and insulin levels, and we collected urine samples to measure urinary GH levels.

Results:

 As expected, HA had higher Ferriman scores (13± 4 in HA vs 1± 2 p=0.001), and higher levels of basal total testosterone(nmol/l) (2.4 ± 0.7in HA vs 1.0 ± 0.3 in C, p< 0.001), FAI (FAI 9.2 ± 5.7in HA vs 2.4 ± 1.3 in C,p< 0.001), androstenedione  (nmol/l) (12.9 ± 4.5 in HA vs 8.7 ± 2.8 in C, p< 0.001) and AMH  (44.0 ± 24.1 in HA vs 27.7 ± 14.2 nmol/L p= 0.005) compared with C. Serum IGF-I, IGF-II, IGFBP-III and urinary GH did not differ between HA and C, but four HA with the highest serum testosterone ( > 2.43 nmol/L) had urinary GH> 10 pg/mg creatinine. There was a correlation between urinary GH and FAI in the entire group of girls (r 0.29,p<0.05). In addition, in HA girls FAI correlated with insulin, HOMA, and basal and stimulated ghrelin correlated with IGF-1, IGFBP-3 and basal insulin.

Conclusions:

We observed a correlation between urinary GH and Ghrelin with FAI in the hyperandrogenic and control girls. In addition, Ghrelin correlated with IGF-1 and IGFBP-3 in HA girls suggesting that the function of the somatotrophic axis may influence the secretion of androgens in adolescent girls.

714: P1-816

CLINICAL CHARACTERISTICS OF CHILDHOOD ONSET GROWTH HORMONE SECRETING PITUITARY ADENOMA
Junko Ito, MD; Toshihiko Takiura, MD; Tomoko Ota, MD; Atsushi Ogawa, MD; Tetsushi Ogawa, MD; Shozo Yamada, MD, Toranomon Hospital, Tokyo, Japan

Objectives: Despite growth hormone secreting pituitary adenoma (GHoma) is rare in childhood, correct diagnosis of pituitary gigantism is essential in treating the patients with tall statue. We report clinical characteristics of case series with childhood onset GHoma.

Methods: We performed retrospective review of five cases with GHoma diagnosed during 2011 to 2016. The diagnosis of GHoma was made based on excessively rapid growth and/or acral enlargement and acromegalic facial changes associated with elevated GH/IGF-1 and detection of pituitary adenoma with MRI.

Results: We included three males and two females. Mean age at diagnosis was 13.6 years (range 7.5~16.3 years). Their initial chief complaints were tall statue (2), visual disturbance (2) and dental problem (1). Mean height S.D. score at diagnosis were +2.8 (range 1.0~4.7). The younger patient had the greater height S.D. score.  Four patients, in whom the delay from symptom to diagnosis was longer than three years, had acral enlargement and acromegalic facial changes.  Serum IGF-1 values were greater than +2SD of age and gender matched standards. All of the patients had macroadenoma and three were with cavernous sinus invasion.  Somatostatin analogues (SSA) suppressed serum GH level and tumor size. All tumors were totally removed by trans-sphenoidal surgery (TSS) and IGF-1 levels decreased to normal range. AIP mutation was found in two patients, one was youngest boy and the other was familial GHoma.

Conclusions: In childhood onset GHoma, the younger patient had the greater height SDS.  IGF-1 values were useful in diagnosis.  Macroadenomas were controlled after SSA and TSS treatment but careful follow-up is required.

1296: P1-817

CLINICAL AND BIOCHEMICAL RESPONSE TO RHGH TREATMENT IN CHILDREN WITH HETEROZYGOUS VARIANTS IN THE IGFALS GENE.
Ana Keselman, MD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez“, Buenos Aires, Argentina; Paula A Scaglia, MS/MA; Liliana M Karabatas, PhD, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina; Braslavsky Debora, MD, Centro de Investigaciones Endocrinologicas "Dr Cesar Bergada" (CEDIE) CONICET-FEI_ Division de Endocrinologia Hospital de Niños" Ricardo Gutierrez", Buenos Aires, Argentina; Ballerini Gabriela, MS/MA, Centro de Investigaciones Endocrinologicas Dr "Cesar Bergada" (CEDIE) CONICET-FEI_ Division de Endocrinologia Hospital de NIños "Ricardo Gutierrez", Buenos Aires, Argentina; Martucci Lucia, MS/MA, Centro de Investigaciones Endocrinologicas Dr "Cesar Bergada "(CEDIE) CONICET-FEI_ Division de Endocrinologia Hospital de Niños "Ricardo Gutierrez", Buenos Aires, Argentina; Gutierrez Mariana, PhD; Domene Sabina, PhD, Centro de Investigaciones Endocrinologicas "Dr Cesar Bergada" (CEDIE) CONICET-FEI_ Division de Endocrinologia Hospital de Niños "Ricardo Gutierrez", Buenos Aires, Argentina; Martinez Alicia, MD, Centro de Investigaciones Endocrinologicas "Dr Cesar Bergada " (CEDIE) CONICET-FEI_ Division de Endocrinologia Hospital de Niños "Ricardo Gutierrez", Buenos Aires, Argentina; Ropelato Gabriela, PhD; Bergada Ignacio, MD, Centro de Investigaciones Endocrinologicas "Dr Cesar Bergada" (CEDIE) CONICET-FEI_ Division de Endocrinologia Hospital de Niños "Ricardo Gutierrez", Buenos Aires, Argentina; Hamilton R Cassinelli, MD, Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" /CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina; Horacio Domene, PhD; Hector Jasper, MD, Centro de investigaciones Endocrinologicas "Dr Cesar Bergada", CEDIE-CONICET-FEI, División de Endocrinologia Hospital de Niños "Ricardo Gutierrez", Buenos Aires, Argentina

Objectives: Acid-labile subunit (ALS) is crucial to stabilize IGF-I in circulating ternary complexes.  Complete ALS deficiency is characterized by short stature, severe reduction of serum IGF-I and IGFBP-3 levels and poor response to rhGH treatment. Less information is available on the response to rhGH treatment in children heterozygous carriers for IGFALS gene variants.

Aim: Evaluate auxological and biochemical responses to one year of rhGH treatment in short children homozygous wild-type (WT) or heterozygous carriers (HC) for non-synonymous IGFALS variants.

Methods: Patients:  Short children (height ≤ -2.5 SDS) presenting normal stimulated GH levels (GH max ≥ 4.7 ng/ml) were recruited. Six patients (5 boys, aged 6.7±2.2) had heterozygous IGFALS gene variants:  4 probably pathogenic by in silico or in vitro assessment: p.E35Gfs*17 (n=2), p.G506R (n=1), p.H128R (n=1), and 2 probably benign: p.R548W (n=1) and p.P22L (n=1). Other 6 idiopathic short stature (ISS) children (4 boys, aged 6.5±2.0) were homozygous WT. Height and IGF-I, IGFBP-3 levels were evaluated before and after one-year of rhGH treatment (dose of 0.33 mg/kg/week).  ALS levels were evaluated only before treatment [HC: -1.95±-0.15 (n=6); WT: 1.57±2.00 (n=4); NS).

Results: Auxological and biochemical data are shown in the Table.

Conclusions: Short children HC for IGFALS variants showed a satisfactory and similar response to one year rhGH treatment compared to WT-ISS children, although with a lower increase in IGF-I levels. This suggests that short children, carriers for IGFALS variants, could be more sensitive to IGF-I, that paracrine action of locally produced IGF-I has a more important effect on linear growth, or a combination of both. The impact of rhGH treatment on adult height in carriers for IGFALS variants remains to be determined.

1126: P1-818

GHR-EXON 3 AND -202 A/C IGFBP3 POLYMORPHISMS AND RESPONSE TO GROWTH HORMONE TREATMENT IN KOREAN CHILDREN WITH GROWTH HORMONE DEFICIENCY
Eun Young Kim, MD, Department of Pediatrics, Chosun University School of Medicine, Gwangju, Korea, Republic Of; Kyung Hee Yi, MD, Wonkwang University Sanbon Medical Center, Seoul, Korea, Republic Of; Seung Yang, MD, Kangdong Sacred Heart Hospital, Seoul, Korea, Republic Of; Il Tae Hwang, MD, Hallym University College of Medicine, Seoul, Korea, Republic Of

Objectives: The GHR-exon 3 and the -202 A/C IGFBP3 polymorphisms have been suggested to affect responses to recombinant human growth hormone (rhGH) therapy in some individuals with short stature. This study aimed to assess the influences of the two polymorphisms on treatment outcomes in patients with growth hormone deficiency (GHD).

Methods: In 72 (32 girls and 40 boys) children with confirmed diagnosis of GHD, genotyping and serial measurements of auxological and endocrinological parameters were performed. Forty-nine patients who remained in the prepubertal state after 1year of GH treatment were analyzed.

Results: Distribution of the GHR-exon3 genotypes was as follows: d3/d3 genotype 2.8%; d3/fl genotype 15.3%; and fl/fl genotype 81.9%. Frequencies of the -202 A/C IGFBP3 genotypes were as follow: A/A genotype 55.5%; A/C genotype 38.9%; and C/C genotype 5.6%. In comparing the d3/d3 and d3/fl group with the fl/fl group, there was no significant difference in first-year height velocity. Likewise, comparing the A/A group with the A/C and C/C group, no significant difference was observed in height velocity. Combined analysis of the two polymorphisms showed no significant interaction on the first year height velocity. 

Conclusions: Our results suggest that the GHR-exon3 and -202 A/C IGFBP3 polymorphisms are not major factors in the modulation of growth response to GH therapy in Korean children with GHD.

1426: P1-819

DELAYED BONE-AGE MAY ACCELERATE THE GROWTH RESPONSE TO TREATMENT IN SHORT SMALL FOR GESTATIONAL AGE (SGA ) CHILDREN
Jung E Moon, MD, Kyungpook National University Chidren's Hospital, Daegu, Korea, Republic Of; Su J Lee, MD; Cheol W Ko, MD, Kyungpook National University Children's Hospital, Daegu, Korea, Republic Of

Objectives: SGA is one of major causes of short stature in children. It has been known that the effectiveness of growth hormone (GH) treatment for short SGA children depends on the GH dose, the age of the child and family-corrected individual height (Albanase A et al, Horm Res, 1997). This study was conducted to see the growth response to treatment by bone-age (BA) in short SGA children.

Methods: Study patients consisted of 29 short SGA children. Their age at diagnosis (yrs) was 7.2±1.9. Male to female ratio was 10:17. Their medical records were reviewed retrospectively. 

Results: Eighteen patients (67%) showed >2 yrs BA delay when compared with chronological age (delayed BA group). Nine patients (33%) showed < 2 yrs BA delay (control group). In delayed BA group, initial height SDS was significantly increased at 6 mo after treatment, when compared with 'control group', -2.45±0.34 to -1.87±0.82  in 'delayed BA group' (p=0.01) vs -2.68±0.58 to -2.50±0.61 in 'control group' (p=0.538). At 12 mo after treatment 'delayed BA group' showed significant height increase, -2.45±0.34 to -1.63±0.65 in 'delayed BA group' (p=0.001) vs -2.68±0.58 to -2.27±0.70 in 'control group' (p=0.483). Age at diagnosis, initial sIGF-I level and BMI were not significantly different between two groups.

Conclusions: Delayed BA (>2 yrs) could be one of factors related to the magnifitude of the growth response to treatment in short SGA children. Further large-scaled long-term study is necessary.

150: P1-820

DYNAMIC CHANGES IN IGF-I DURING SOMAVARATAN THERAPY IN PEDIATRIC SUBJECTS WITH GROWTH HORMONE DEFICIENCY FROM THE VISTA LONG-TERM SAFETY STUDY
George M. Bright, MD, Versartis, Inc., Menlo Park, CA, United States; Bradley S. Miller, MD, PhD, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States; David Ng, PhD, ResearchPoint Global, Inc., Austin, TX, United States; Daniela Rogoff, MD, PhD; R W Charlton, MD, Versartis, Inc., Menlo Park, CA, United States

Objectives: IGF-I response to daily rhGH has been described to increase over time, but the nature of the increment is not well understood. Somavaratan is a long-acting rhGH fusion protein under study as a twice-monthly alternative to daily rhGH for pediatric growth hormone deficiency (PGHD). To determine whether IGF-I response is stable during long-term treatment with somavaratan, IGF-I changes over time were assessed in ongoing PGHD subjects who completed 3 years of treatment, the last 2 years on 3.5 mg/kg twice-monthly dosing, in the VISTA long-term safety study.

Methods: IGF-I samples were collected at expected times for peak (Months 21, 27, and 33) and trough values (Months 24, 30, and 36). IGF-I SDS was calculated based on samples from healthy pediatric subjects with no active medical problems and normal physical exams. Time-related IGF-I changes were calculated as the slope from linear regressions of consecutive peaks and consecutive troughs for each subject. A t-test was used to test for mean slope of zero.

Results: From Months 21 to 36, multiple IGF-I samples were collected from 44 subjects (23 female [mean±SD age: 10.56±2.2 years] and 21 males [mean age: 10.99±2.7 years]). The mean slope of consecutive peak IGF-I over time was 7.1 ng·month/mL (95% confidence interval [CI]: 4.46, 9.75; P=0.015). In contrast, no definitive changes over time were noted in consecutive trough IGF-I (2.18 ng·month/mL; 95%CI: -0.16, 4.52; P=0.067) or IGF-I SDS (-0.01 SD·month/mL; 95%CI: -0.03, 0.02; P=0.70).

Conclusions: In this initial examination, both peak IGF-I and peak IGF-I SDS increased over time, but the increase in consecutive peak IGF-I concentrations was more prominent than that of peak IGF-I SDS, suggesting that effects were related more to age-related physiological changes than a cumulative drug effect. This suggests that peak IGF-I changes are developmentally driven during long term somavaratan treatment. The lack of changes in consecutive trough values of IGF-I and IGF-I SDS suggests that no accumulation or loss of drug effects occurred during this time period.

318: P1-821

IMPACT OF THE UNDERLYING ETIOLOGY OF GROWTH HORMONE DEFICIENCY ON SERUM IGF-I SDS LEVELS DURING GH TREATMENT IN CHILDREN
Juliane Léger, MD; Damir Mohamed, MS/MA; Sophie Dos Santos, MS/MA; Myriam Ben Azoun, MD; Delphine Zénaty, MD; Dominique Simon, MD; Anne Paulsen, MD; Laetitia Martinerie, MD; Didier Chevenne, MS/MA; Corinne Alberti, MD; Jean-Claude Carel, MD; Sophie Guilmin-Crepon, MD, University of Paris, Robert Debré Hospital, Paris, France

Objectives: Regular monitoring of serum IGF-I levels during growth hormone (GH) therapy has been recommended, for assessing treatment compliance and safety, in terms of potential long-term cancer risk. We aimed to investigate the serum IGF-I levels during GH treatment in children with GH deficiency, and to identify potential determinants of these levels.

Methods: This observational cohort study included all patients (n = 308) with childhood-onset non-acquired or acquired GHD included in the database of a single academic paediatric care center over a period of 10 years for whom at least one serum IGF-I determination during GH treatment was available. These determinations had to have been carried out centrally, with the same immunoradiometric assay. Serum IGF-I SDS levels were expressed for sex, age and pubertal stage, according to our normative data.

Results: Over a median of 4.0 (2–5.8) years of GH treatment per patient, at a median initial dose of 36 (33-40) µg/kg/day, 995 serum IGF-I determinations were recorded with a median of 3.0 (2.0; 4.5) measurements per patient. Serum IGF-I SDS values were in the normal range for most patients, with wide individual variation. However, very low and high serum IGF-I SDS values were observed with 54 individual serum IGF1 determinations 2.5 SDS obtained from 56 patients, on at least one occasion during GH treatment. The multivariate model revealed that, throughout the study period and in addition to the positive effect of BMI SDS, height SDS and GH dose (p<0.01), etiological group (p<0.01) had a significant effect on serum IGF-I SDS levels, with patients suffering from acquired GHD having higher serum IGF-I SDS levels than those with non-acquired GHD, whereas sex, age, pubertal stage, treatment duration, hormonal status (IGHD vs MPHD) and initial severity of GHD, had no effect.

Conclusions: These original findings have important clinical implications for long-term management and highlight the need for careful and appropriate monitoring of serum IGF-I concentration and GH dose, particularly in patients with acquired GH deficiency, to prevent the unnecessary impact of potential comorbid conditions.

912: P1-822

COMPARISON OF GROWTH RATE RANGES IN CHILDREN USING FOUR DIFFERENTS STUDIES
Mauricio J Llano, MD, Universidad El Bosque, Colombia, Bogotá, Colombia; Juan P Llano, MD, Laboratorio de Investigacion Hormonal, Bogotá, Colombia; Camila Cespedes, MD, Universidad Javeriana, Bogotá, Colombia

Objectives: Normal variants of pubertal maturation shows differences in centiles of height during early adolescence.

Tanner & Whitehouse & Tanner Davies charts are still in use not only in North America population showing theses differences.

Recently Kelly et al. in a longitudinal multicenter studypublished data that differ significantly from Tanner Whitehouse & Tanner Davies charts.

Representative sampling to compare and validate our local result and compare to british and north american population, evaluating differences in pubertal time in height velocity, considering standard, early and late maturers in both sexes in a healthy pediatric population.

Methods: Descriptive and comparative study, using similar parameters elaborated by Kelly et al. including data of healthy subjects both sexes located between 3 and 97th percentile followed for two yearly intervals (average) between 6 - 19 years obtained from 2004 to 2016.

In 2,193 girls, 5025 observations (average 2,29 years), and 1,803 boys, 5,759 observations (average 3,19 years) were made.

Data obtained of Height, height percentile, weight, body mass index percentile, annual height velocity, pubertal time.

Result was expressed as age in years, average, maximun, minimun and standard deviation.

Results: Early maturers girls reach de maximum height velocity between 10 a 11 years reaching a media of 7,3 cm/y, average girls between 11 and 12 years reaching a media of 6,7 cm/y and late maturers at 12 and 13 years reaching a media of 6,3 cm/y.

Early boys reached the media height velocity of 8,3 cms/y between 12 and 13 years, average boys 7,9 cms /y between 13 and 14 years, and late maturers reached 7,5 cm/y at age of 14 to 15 years.

Conclusions: Our results show that the pattern of pubertal growth differ to those expressed by Tanner & Whitehouse (1976) and NCHS data set for Tanner Davies (1984), being very similar to those presented by Kelly et al (2014).

Our data confirms variations in growth velocity in tempo as showed by Tanner and confirmed by Kelly, but differences in the amplitude and differences in time of pubertal peak is less than expected compared with Tanner.

Prospective studies are need searching differences in differents countries and also using BMI to evaluate the importance of body weight in theses variations.

850: P1-823

THE LEIDEN EXPERIENCE IN DIAGNOSTICS FOR SHORT STATURE: GENE PANEL BASED MUTATION ANALYSIS BY NEXT GENERATION SEQUENCING ON THE ION TORRENT PGM
Hermine A Van Duyvenvoorde, PhD, Leiden university Medical Centre, Leiden, Netherlands; Anneliese JEM Grimbergen, BS/BA; Sitha A Scheltinga, BS/BA; Sander H.B. Bollen, MS/MA; Wilma Oostdijk, MD, Leiden University Medical Center, Leiden, Netherlands; Sabine E Hannema, MD, PhD; Martine C De Vries, MD, PhD, Leiden University Medical Centre, Leiden, Netherlands; Sebastiaan EE Schagen, MD; Christiaan De Bruin, PhD; Jan M Wit, Professor; Sarina G Kant, MD; Nienke Van Der Stoep, PhD, Leiden University Medical Center, Leiden, Netherlands; Monique Losekoot, PhD, Leiden University Medical Centre, Leiden, Netherlands

Objectives: Short stature is usually classified based on phenotypic characteristics, such as pre- or postnatal onset, proportionate or disproportionate stature, and biochemical data. Defining a specific genetic diagnosis in a young child can have important therapeutic consequences. Furthermore, it provides insight in recurrence risks, plays a role in family planning, contributes to knowledge on prognosis and surveillance and overall gives more insight in the regulation of longitudinal growth. Routine diagnostic procedures usually include targeted gene-by-gene testing using Sanger sequencing, MLPA and SNP-array analysis which is laborious and time consuming and often does not lead to a definite diagnosis. The LUMC in Leiden is one of the Dutch national centres of expertise for growth disorders. Here we present the results of the implementation of gene panel based analysis with which we aim to enhance the diagnostic efficiency and yield.

Methods: Gene panel based sequencing was implemented using a custom made Ion AmpliSeqTM kit followed by sequencing on the Ion TorrentTM Personal Genome Machine. Genetic variants are identified using the SeqNext module in Sequence Pilot software from JSI. Using this approach we simultaneously analyze 14 genes (COMP, FGFR3, GH1, GHR , GHSR, IGF1, IGFALS, IGFBP3, IGF1R, NPR2, NPR3, PAPSS2, SHOX, STAT5B). In addition MLPA for GH1, GHR, IGF1, IGFALS, IGF1R, SHOX and STAT5B was performed.

Results: With this approach we have so far identified (likely) pathogenic mutations in 24 out of 138 tested patients. Of these, 5 carried pathogenic mutations in GH1, GHR or COMP and 15 carried one or two  variants of uncertain clinical significance (VUCS). Deletions/duplications were detected in 4 patients using MLPA (3 in SHOX and 1 in GH1). A total of 17 different VUCS in 8 different genes were detected. Four patients had a variant in 2 different genes which might have been missed in a classical gene-by-gene approach.

Conclusions: Although our approach has a similar diagnostic yield as conventional gene-by-gene analysis, it allows a more efficient and complete analysis of growth related genes. In 2 cases a combination of variants in 2 different genes illustrates the increased value of this strategy. The addition of other genes to our panel should further increase the yield.

123: P1-824

TREATMENT WITH GROWTH HORMONE: EVALUATION OF THE RESPONCE AT FIRST YEAR OF THERAPY IN DIFFERENT PAEDIATRIC CATEGORIES
Gemma Marinella, MD; Gabriella Pozzobon, MD; Cristina Partenope, MD; Dario Gallo, MD; Chiara Damia, MD; Roberta Pajino, MD, San Raffaele Hospital, Milan, Italy; Giovanna Weber, Professor, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy

Objectives: -To analyse the height gain obtained by our cohort of paediatric patients with idiopathic short stature after a year of treatment with growth hormone and to compare it with the other categories of patients treated with growth hormone in our hospital (partial GH deficiency, SGA and Turner syndrome) and with the criteria of good response to growth hormone therapy in the literature (figure 1).
-To compare the growth hormone dose used by our hospital with doses proposed in the literature evaluating the differences in terms of height gain obtained, biological risk, meant as an increase in IGF1 and HOMA-ir values, and economic costs.

Methods: Our study was conducted on 113 prepubertal patients (61 males and 52 females) of which 33 (29%) ISS, 34 (30%) GHD-p (partial, peak between 5-8 ng/mL), 33 (29%) SGA and 13 (12%) Turner. All patients (mean age 9aa at beginning of the study) were treated with rhGH for one year. 

Results: In our population, all categories have respected the criteria of good response found in literature. The height gain of patients with ISS was lower than other categories although the different height gain is statistically significant only for GHD-p. This difference doesn’t have an univocal interpretation, but is probably due to the low dose of growth hormone used in our centre. Our study shows that our dosage has a good safety profile because our patients have normal IGF1 values (only two patients have IGF1 values>2SDS) in contrast to the population of the literature that has IGF1 values ≥2SDS (value considered at risk).

Conclusions: -Despite the low dosage used in our patients, in the first year of rhGH treatment all categories have respected the criteria of good response of the literature, in particular the population of GHD-p and Turner syndrome;

-Although the height gain of patients with ISS is below other paediatric categories, such as GHD-p (+0.53 SDS), SGA (+0.51 SDS), Turner syndrome (+ 0.74SDS), their growth is acceptable because it respect the criteria of good response, therefore treatment appears useful and justified;
-Dosages used by our centre, above all for ISS, are equally efficient, more secure and cheaper.

1307: P1-825

HIGHLY INCREASED RISK OF GROWTH HORMONE DEFICIENCY (GHD) IN CHILDREN WITH A HISTORY OF SURGERY OF THE SELLAR OR SUPRASELLAR REGION OR ANOTHER ANTERIOR PITUITARY DEFICIENCY.
Sabrina P. Martin Benitez, MD, Centro de Investigaciones Endocrinológicas" Dr Cesar Bergadá " (CEDIE) CONICET-FEI-División de Endocrinología, Hospital de Niños Dr. Ricardo Gutierrez, Buenos Aires, Argentina), Buenos Aires, Argentina; Florencia Clement, MD, Centro de Investigaciones Endocrinológicas" Dr Cesar Bergadá " (CEDIE) CONICET-FEI-División de Endocrinología, Hospital de Niños Dr. Ricardo Gutierrez., Buenos Aires, Argentina; Romina P. Grinspon, PhD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina; Débora Braslavsky, MD; Ana Keselman, MD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez“, Buenos Aires, Argentina; Alicia Martinez, MD; Maria G Ropelato, PhD; Maria G Ballerini, PhD, Centro de Investigaciones Endocrinológicas" Dr Cesar Bergadá " (CEDIE) CONICET-FEI-División de Endocrinología, Hospital de Niños Dr. Ricardo Gutierrez., Buenos Aires, Argentina; Ignacio Bergadá, MD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños "Ricardo Gutiérrez“, Buenos Aires, Argentina; Gabriela Finkielstain, PhD, Centro de Investigaciones Endocrinológicas" Dr Cesar Bergadá " (CEDIE) CONICET-FEI-División de Endocrinología, Hospital de Niños Dr. Ricardo Gutierrez, Buenos Aires, Argentina), Buenos Aires, Argentina; Rodolfo A Rey, PhD, Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina

Objectives: Growth hormone stimulation testing (GHST) has been a standard practice required for the diagnosis of growth hormone deficiency (GHD). However, GHST may raise safety issues in a patient with co-morbidities.

The objective was to test whether there is an increased risk of GHD in patients having a history of surgery of the sellar and/or suprasellar region, one or more anterior pituitary hormone deficiencies associated with diabetes insipidus, congenital hypogenitalism in males, neonatal hypoglicaemia, neonatal cholestasis, craniofacial midline defects or pituitary dysgenesis by imaging studies.

Methods: Case-control study to assess the association between highly suggestive risk factors and the existence of GHD.

Retrospective clinical chart review of all patients meeting the criteria for GHST, according to the Summary Statement of the GH Research Society, during a period 10 years (6/2004-5/2014). GHD diagnosis was based on maximal stimulated- GH < 6.0 ug/L (WHO 80/505) or < 4.7 ng/ml (WHO 98/574) after pharmacological stimuli of arginine (0.5 g/kg body weight) and/or clonidine (100 ug/m2 body surface) tests.

Results: A total of 671 patients were analyzed. Out of 142 patients with GHD, 93 had the postulated risk factors, while these were found in 7 of the 529 patients without GHD. There was a strong association between GHD and the existence of at least one of the postulated risk factors (Fisher´s exact test P <0.0001); the risk of having GHD was approximately 6-fold higher (RR: 6,09, 95% CI: 4,49-8,27) in patients with one of the postulated risk factors, and the probability of having a risk factor was 141-fold higher (OR: 141, 95% CI 62-322) in the GHD group.

Conclusions: Our findings have clearly identified surgery of the sellar or suprasellar region and coexistence of congenital multiple pituitary hormone deficiencies with hypogenitalism in males, neonatal hypoglycemia or cholestasis, diabetes insipidus or midline defects as major risk factors for GHD in pediatric patients. Our results suggest that GHST might not be necessary in these patients, thus avoiding unnecessary and invasive procedures.

889: P1-826

KINETIN IMPAIRS GH-1 SPLICING IN AN IN VITRO MODEL OF GROWTH HORMONE DEFICIENCY TYPE II
Maria Consolata Miletta, PhD, University Children's Hospital , Bern, Switzerland; Anna Biason-Lauber, MD, University of Fribourg, Fribourg, Switzerland; Mauro Bozzola, MD, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Christa E. Flück, MD, University Children's Hospital, Bern, Switzerland

Objectives: Isolated GH deficiency type II (IGHD II), the autosomal dominant form of GHD, is primarily a splicing disorder which results from heterozygous splice-site mutations in GH-1 gene that weaken recognition of exon 3 splice-sites and lead to mRNA missplicing.  In vitro and transgenic animal data indicate that the IGHD II phenotype relates to the proportion of aberrant transcripts and suggest the pharmacologic correction of aberrant splicing as a possible therapeutic approach to IGHD II. In order to test this hypothesis we tested kinetin, a plant cytokine which was recently proven to act as a splicing modulator.

Methods: Rat pituitary cell line stably expressing hGrowth Hormone Releasing Hormone Receptor (GC-GHRHR) cells were transiently transfected with either wt-GH or different GH splice-site mutants, stimulated with GHRH (10nM) and/or treated w/wo different concentrations of kinetin. Twenty-four h after treatment extracellular GH secretion was measured in the cultured medium by DSL-GH ELISA and, after RNA extraction, the 17.5-kDa vs 22-kDa transcript ratio was determined by qRT-PCR. Further,  to analyze the role of splicing regulators, the expression of several serine/arginine (SR)-rich proteins and SR–like splicing factors were assessed by Western blot. As a marker of transactivation via the GHRH activation, intracellular cAMP was measured.

Results: Treatment with kinetin impairs the correct splicing of GH-1 by decreasing the 22-kDa mRNA by transcription activation. At the protein level, we could observe a decreased synthesis of the 22-kDa isoform (P<0.05) and therefore a decreased 17.5/22-kDa ratio (P<0.05). Overall, the imbalance between the two GH isoforms resulted in a statistically significant decrease of GH secretion (P<0.01) in all GH splice-site mutants analyzed. Our data demonstrate that the kinetin does not directly activate GHRHR, as assessed through the lack of increase in cAMP levels after kinetin stimulation, suggesting that its action is mediated by a pathway different from that of GHRHR.

Conclusions: Our results demonstrate that this approach might be useful to identifying drugs able to revert abnormal splicing, and could open the way for novel therapeutic strategies for IGHD II and potentially other RNA-missplicing diseases.

1129: P1-827

PITUITARY STALK INTERRUPTION SÍNDROME. CLINICAL, BIOCHEMICAL AND NEURORADIOLOGICAL RELATIONSHIPS
Mirta Miras, PhD, Hospital de Niños de Córdoba, Córdoba, Argentina; Laura Castro, MD; Silvia Martin, MD, Hospital de Niños de la Santísima Trinidad , Córdoba, Argentina; Sebastián Bulacio, MD, Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina; Daniela Dichko, MD; Liliana Muñoz, Biochemistry, Hospital de Niños de la Santísima Trinidad , Córdoba, Argentina; Gabriela Sobrero, Biochemistry; Liliana Silvano, Biochemistry Doctor, Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina

Objectives: Pituitary stalk interruption syndrome (PSIS) is characterized by the association of an interrupted or thin pituitary stalk, absent or ectopic posterior pituitary and anterior pituitary hypoplasia. It is manifested as isolated (IGHD) or combined pituitary hormone deficiencies (CPHD) of variable degree and timing of onset with a wide spectrum of clinical phenotypes. PSIS may constitute an isolated morphological abnormality or be part of a syndrome. To evaluate retrospectively clinical signs and syntoms present at early life stages and analize their relationship with hormone laboratory tests and diagnostic imaging in children with Congenital Hypopituitarism (CPH) and PSIS.

Methods: This retrospective, single-center, case-cohort study was perfomed in 42 children out of a total of 80 patients with CHP in a pediatric hospital over 26 years. The CA range: 5d-9.5y.

Results: The patients analized were 26/42 (62%) with CPHD and 16/42 (38%) with IGHD. The perinatal histories showed hypoglycemia (61% CPHD vs 19% IGHD p: 0.01) jaundice(38% CPHD vs 25% IGHD) micropenis (75% CPHD) hypoglycemic seizures (75% CPHD) and cholestasis (19%CPHD). The CPHD patients consulted at the average age of 2.1y, 30% in neonatal period, 70% before 2 y. MRI showed that CPHD patients had 81% absence and 19% thin pituitary stalk (p:0.0001); IGHD patients presented 56% absence and 44% thin pituitary stalk (p:0.5067). The 100% of the patients diagnosed in the neonatal stage had absent pituitary stalk. 

Conclusions: Characterization of GH deficient patients by presence and type of hypothalamic-pituitary imaging abnormality provides valuable information as a predictor of phenotypic severity, treatment response and the potential to develop additional hormonal deficiencies. Based on our data we conclude that MRI shoul be part of research protocols in early periods of life in patients with an evocative clinical spectrum of hypopituitarism. The erly diagnosis of CHP can be performed with accuracy based on a high index of clinical suspicion, late recognition may increase morbidity and mortality with potential permanent deleterius effects.

540: P1-828

COMPLICATIONS IDENTIFIED IN THE NATIONAL PROGRAM FOR HGH USE IN THE DOMINICAN REPUBLIC
Elbi Morla, MD; Rosario Almanzar, MD; Denny Guillen, MD, Intec University, Santo Domingo, Dominican Republic

Objectives: Human Growth Hormone (HGH) deficiency is the primary indication for the use of this hormone for treatment in children.Although the FDA and EMA have approved its use for entities such as Turner , SGA, Prader Willi, Gen Shox deficiency, CRI, Noonan and idiopathic short stature, the efficacy and safety of the application of HGH is a controversial issue due to its varied use in a number of pathologies where there is no deficit and as any medication is not complication-free.

Methods: A longitudinal, retrospective, descriptive study was performed in patients receiving rGH for 7 years (January 2010 - 2017) pertaining to the national GH program. From these we analyzed their age, sex, dose, etiology, time of therapy and complications

Results: 149 cases  were included, from which: 82 female ( 55%) and 67 male (45%).

23 (15.4%) of these cases (10/23 Deficit GH, 13/23 others ) presented complications [13 female (56.5%) and 10 male (43.5%)] .  Details are as follow: Intracranial hypertension: 8 (34.7%); Scoliosis: 7 (30.4%);  Hyperglycemia: 6 (26.0%); Edemas: 2 (8.6%), Allergy: 1 (4.3%), Thymoma: 1 (4.3%).  Two patients presented both intracranial hypertension and scoliosis, and scoliosis and femoral epifisiolisis. 

When relating the dose of GH in mg / kg / day was observed: 0.025 mg / kg / day (34%);  0.035 mg/kg/day (17.3%); >0.05 mg/kg/day (47.8 %).  The time of onset of complications among patients with GH treatment: 0-6 months (17.3%), 6-12 months (30.4%), 1-3 years (52.1%), > 3 years (8.6%)

Conclusions: Conclusions: Our observations are in accordance with the complications reported in the literature when using GH ,except for the development of a patient with thymoma , and are more frequent at higher doses between 1-3 years of treatment and in non-deficient cases of GH where it is advisable to carefully evaluate its use as GH is being added where it already exists.

883: P1-829

SMALL FOR GESTATIONAL AGE BABIES: GROWTH PROGNOSIS AT EARLY ADOLESCENCE.
Georges Nicolas, MD, Holy-Spirit University of Kaslik Lebanon, Byblos, Lebanon; Stephanie El Hajj, MD; Nahi Ajaka, MD; Rayanne Ghiye, MD; Georges Abi Fares, MD, Holy Spirit University of Kaslik - Lebanon, Byblos, Lebanon

Objectives: Small for gestational age babies are at increased risk of growth retardation. This topic lacks attention and deserves better guidance. The objective of this paper is to illustrate the importance of this critical issue and to outline growth prognosis at the beginning of adolescence of female and male babies born small for gestational age in comparison to controls born appropriate for gestational age. It is also a descriptive epidemiologic study of small for gestational age infants.

Methods: Our study is a case-control descriptive study of children born small for gestational age in 2002-2003 at Notre Dame Des Secours university hospital, Byblos. The weight, height and head circumference at birth have been retrieved from the medical charts and the diagnosis of intra-uterine growth retardation (IUGR) have been made based on the growth curves published by I. Oslen et al in 2010. The current height and weight are taken for the two groups and compared with each other using the ‘t test’ for a better understanding of the prognosis of growth in children born SGA. Fourty cases and fourty controls were recruited with neonatal infection and chromosomal abnormalities being the criteria of exclusion. The prevalence of children born SGA is 4.9 % in this study. Maternal risk factors including smoking and eclampsia were noted in both groups.

Results: The majority of children with IUGR catch similar growth to that of their controls. No adverse consequences are observed in these children at the age of 11-12 years. No correlation observed between IUGR and current weight and height of the children except for the current weight of the girls born SGA which is less compared to that of the controls. None of those children born SGA needed a GH treatment for the achievement of their optimal growth.

Conclusions: Children born SGA have similar dimensions in early adolescence compared to those born with a size appropriate for gestational age (AGA) except for the weight of the girls born SGA. The awareness of physicians and parents is important for early referral to treatment with GH therapy if necessary.

1385: P1-830

EASYPOD™ CONNECT OBSERVATIONAL STUDY (ECOS) – FRENCH CASE HISTORIES AND GROWTH OUTCOMES
Marc Nicolino, PhD, Hôpital Femme-Mère-Enfant, Lyon, France; Régis Coutant, MD, University Hospital of Angers, Angers, France; Maithé Tauber, MD, Hôpital d’enfants, Toulouse, France; Virginie Ribault, MD, Centre Hospitalier Universitaire, Caen, France; Yeriley López, PharmaD; Anne Besserve, PharmaD, Merck France, Lyon, France

Objectives: ECOS (a 5-year, open-label, observational study in 24 countries, started in 2010) assessed ‘real-world’ adherence and effects on growth outcomes of children treated for growth disorders with SaizenÒ recombinant human growth hormone (r-hGH, somatropin) administered by the easypod™ electronic auto-injector device. We report an interim analysis of the final results from ECOS in France (NCT01291394).

Methods: Data from 202 children (mean [SD] age 9.56 [3.65] years; 54% male) were available for analysis (111 GHD, 71 SGA, 18 Turner syndrome and 2 with chronic renal failure). The majority (180 [90%]) were r-hGH naïve at baseline.

Results: Mean treatment adherence was 81% (95% CI 79-84 [81% GHD and SGA, 83.6% TS]). Adherence was ≥80% for 180 patients (89%) at 3 months, 175 (86%) at 6 months, 145 (72%) at 1 year, 93 (46%) at 2 years and 38 (19%) at 3 years.

After 1 year, r-hGH-naïve children had a median (Q1:Q3) change in height SDS of +0.45 (0.24:0.69), height velocity of 7.98 cm/year (6.80:9.13) and change in height velocity SDS of 1.89 (0.38:3.79). The Spearman’s product-moment correlation for adherence rate and change in height SDS was 0.035. Adherence rate was analysed by subgroups (e.g. age, gender, pubertal stage, self/non-self-injection and regimen): median adherence was ≥90% and was similar in all the subgroups. Median adherence was >90% for patients with injections 6 days/week vs. with 7 days/week.

Conclusions: The cohort above were not sufficiently granular to prove a strong relationship between adherence and patient growth. Study cases were solicited to evaluate the impact in monitoring and these show the benefits of patient monitoring using the easypod™ device to alert the physician to potential red flags (e.g. puberty and poor family support) for on-going compliance.

136: P1-831

ESTRADIOL AND TESTOSTERONE POTENTIATE THE EFFECT OF GH ON JAK2/STAT5 ACTIVATION AND IGF-I GENE EXPRESSION IN HEPG2 CELLS
Paula Ocaranza, PhD; German Iñiguez, PhD; Maria Cecilia Johnson, MS/MA, University of Chile/Faculty of Medicine, Santiago, Chile; Fernando Cassorla, MD, School of Medicine, University of Chile, Santiago, Chile

Objectives: To evaluate the effects of estradiol (E2) and testosterone (T) on the activation of JAK/STAT5 and IGF-I gene expression induced by GH in a human hepatic cell line (HEPG2).

Methods: HEPG2 cells were grown in a steroid free medium. At 80% confluence, cells were treated with or without a low concentration of E2 (20 pg/mL), or a high concentration of T (10 ng/mL), and were subsequently stimulated with rhGH 40 ng/mL for 15 min. Cytoplasmic JAK2, STAT5 and nuclear STAT5 phosphorylation was analyzed by Western immunoblotting. IGF-1 expression was studied by qRT-PCR after 24 h incubation with each sex hormone, which was followed by 24 h co-stimulation with each sex hormone and GH. The data were analyzed by Mann-Whitney Test and expressed as mean ± SEM. Results are shown in the Table, p < 0.05 was considered significant.

Results: GH significantly stimulated the phosphorylation and the expression of all the molecules studied in HEPG2 cells. In cells preincubated with E2, GH showed an increase in cytoplasmic JAK2 and STAT5 and in nuclear STAT5 phosphorylation when compared with GH stimulation alone. In preincubated cells with T, GH showed a significant increase in cytoplasmic JAK2, whereas cytoplasmic STAT5 phosphorylation showed a decrease compared to GH alone. Nuclear STAT5 phosphorylation however, was similar to that observed after stimulation with GH alone. The expression of IGF-1 increased when E2 and GH stimulation were combined, but this significant increase was not observed when T and GH were combined.

 BasalGHGH + E2GH + T
pJAK2/JAK20.51 ± 0.050.91 ± 0.031.80 ± 0.11*1.81 ±0.16**
C-pSTAT5/STAT50.39 ± 0.030.78 ± 0.391.02 ± 0.07*0.36 ±0.05**
N-pSTAT5/STAT50.36 ± 0.051.04 ± 0.243.23 ± 0.80*1.48 ±0.17
IGF-10.05 ± 0.020.19 ± 0.040.69 ± 0.15*0.47 ±0.14

*p<0.05 GH+E2 vs GH; **p<0.05 GH+T vs GH

Conclusions: Low concentrations of estradiol and high concentrations of testosterone, potentiate the JAK2/STAT5 signaling pathway induced by GH, suggesting that critical concentrations of steroids may modulate GH sensitivity in HEPG2 cells.

Supported by SOCHED 2016-03

1387: P1-832

THE EFFECTS OF GH TREATMENT IN EXTREMELY LOW BIRTH WEIGHT CHILDREN BORN SMALL FOR GESTATIONAL AGE
Shinsuke Onuma, MD; Masanobu Kawai, MD; Akiko Konishi, MD; Shinnosuke Tsuji, MD; Mikiko Koizumi, MD; Hiroyuki Yamada, MD; Yasuko Shoji, MD; Yuri Etani, MD; Shinobu Ida, MD, Osaka Women's and Children's Hospital, Osaka, Japan

Objectives: The effects of growth hormone (GH) treatment have not been sufficiently evaluated in extremely low birth weight (ELBW) children born small for gestational age (SGA). The expected effect of GH treatment is an increase in height SD score (SDS) without accelerating bone age to achieve normal adult height. We evaluated the effects of GH treatment in SGA short stature with ELBW on height and bone age.

Methods: Thirty-eight children, who were born SGA with ELBW were recruited in this study. SGA was defined as both birth weight and birth length being below the 10th percentile of gestational age, and either of which being less than -2.0 SD. They were divided into three groups based on the presence of catch-up growth within the first 3 years of life (CU) and GH treatment (GH); CU-/GH+ (n=22), CU+/GH- (n=9) and CU-/GH- (n=7). Height SDS and bone age in prepubertal periods was retrospectively determined based on their medical records and compared among three groups.

Results: At the initiation of GH treatment, the mean age was 4.5 years (range; 3.0 to 8.4 years), and the mean height SDS was -2.9 in CU-/GH+. The mean height SD scores at prepubertal age in CU-/GH+, CU+/GH- and CU-/GH- were -1.3, -1.4 and -2.2, respectively. The mean height SDS of CU-/GH+ was significantly greater than that of CU-/GH-. Importantly, GH treatment increased height SDS by 1.6 such that the height SDS at prepubertal age of CU-/GH+ was comparable to that of CU+/GH-. The mean ratios of bone age to chronological age (BA/CA) at prepubertal period of CU-/GH+, CU+/GH- and CU-/GH- were 1.07, 1.06 and 1.07, respectively. There were no significant differences of BA/CA among three groups.

Conclusions: The current study revealed that the bone age was not accelerated by GH treatment in SGA children with ELBW. Moreover, GH treatment resulted in an increase in height SDS to the values comparable to SGA children with ELBW who showed catch-up growth. These findings indicate that GH treatment is an effective approach to normalize the adult height without accelerating bone age in SGA children with ELBW.

428: P1-833

IMPACT OF RISK FACTORS FOR FETAL GROWTH RESTRICTION (FGR) ON INTRAUTERINE GROWTH AND BIRTHWEIGHT
Reena Perchard, MBBS; Higgins Lucy, PhD; Edward Johnstone , PhD; Peter Clayton, Professor; Andrew Whatmore, PhD, University of Manchester, Manchester, United Kingdom

Objectives: Abnormal uterine artery Doppler at 23 weeks is considered to be a risk factor for FGR. However, the incidence of being born small for gestational age (SGA) in those with abnormal Doppler is not defined.

1. To determine the incidence of birthweight <2nd centile (BW<C2nd) in pregnancies at high risk of FGR

2. To determine the effect of specific antenatal FGR risk factors on fetal growth trajectory and birthweight

Methods: Data were obtained from women seen in a clinic for those at high risk of FGR. Entry criteria were low first trimester PAPP-a or second trimester raised inhibin +/- αFP, and abnormal uterine Doppler ultrasound at 23 weeks (defined by mean pulsatility index >1.3 or notching on one or both waveforms). Pregnancies were categorised according to FGR risk subgroup; small placenta (<10cm) and high resistance index (>0.7, sPhRI), small placenta & normal RI (sPnRI), normal placenta & high RI (nPhRI), normal placenta & normal RI (nPnRI).

Results: 599 pregnancies that resulted in full term livebirths were recruited (sPhRI; 29, sPnRI; 48, nPhRI; 65 and nPnRI; 457) of which, 67 (11%) were SGA births. The proportion of babies with BW< C2nd was highest in the sPhRI group (13/29, 49%), compared with the sPnRI (6/48,13%), nPhRI (12/65, 18%) and nPnRI (36/457, 8%) groups. ANOVA analysis of fetal growth trajectories between 23 weeks and term showed differences between FGR risk groups in Δ weight (sPhRI =1.97kg, sPnRI =2.50, nPhRI =2.41, nPnRI =2.61; p<0.001). Mean birthweight was also significantly different (sPhRI =2.59kg, sPnRI =3.13, nPhRI =3.02, nPnRI =3.23; p<0.001).

Conclusions: In pregnancies considered to be at higher risk of FGR, 11% were born SGA, rising to 49% for those with a small placenta and high RI. Serum markers combined with uterine artery RI and placental size can be used to identify adverse growth trajectory and small size at birth. The postnatal growth trajectories and cardio-metabolic development of this cohort are currently under investigation.

1235: P1-834

ACAN GENE MUTATIONS WERE FOUND IN 22 % PATIENTS BORN SGA WITH FAMILIAR SHORT STATURE AND ACCELERATED BONE AGE
Lukas Plachy, MD; Lenka Elblova, PhD; Veronika Sornova, MS/MA; Barbora Obermannova, PhD; Stanislava Kolouskova, MD; Marta Snajderova, PhD; Dana Zemkova, MS/MA; Zdenek Sumnik, PhD, Second Faculty of Medicine/Charles University in Prague/University Hospital Motol, Prague, Czech Republic; Jan Lebl, MD, Motol University Hospital in Prague, Prague, Czech Republic; Stepanka Pruhova, PhD, Second Faculty of Medicine/Charles University in Prague/University Hospital Motol, Prague, Czech Republic

Objectives: Heterozygous mutations in the ACAN encoding a proteoglykan aggrecan cause autosomal dominant familiar short stature (FSS). The phenotypical spectrum ranges from proportionate short stature to a mild skeletal dysplasia. What makes people with the ACAN mutations strikingly different from the other patients with short stature is the accelerated bone age that causes premature growth cessation. The aim of the study is to search for the ACAN mutations in the patients treated for short stature in our center.

Methods: Among all children treated for primary growth failure in our center, we selected patients with growth hormone deficiency (GHD) and those born short for gestational age (SGA). From both groups, patients with FSS (height -2 SD or lower before growth hormone (GH) treatment and at least one parent with height -2 SD or lower) and accelerated bone age (bone age equals calendar age or higher) were investigated. Exons, exon–intron boundaries and promotor region of ACAN were analyzed using direct sequencing.

Results: Out of 432 patients with GHD and 178 with SGA, 72 have FSS. Of these, 21 patients have accelerated bone age (12 in GHD, 9 in SGA). Their median height was -2.84 SD (range -2.07 to -4.12 SD) and their median of bone age acceleration was +0.8 years (range 0.0 to +2.8 years). We identified heterozygous ACAN mutations in 2/21 patients and in all affected family members with short stature: a frameshift mutation c.1425delA (p.Val478Serfs) and a missense substitution c.916A>T (p.Ser306Cys). Both patients were born SGA. Their height before GH treatment was -3.5 SD, resp. -3.4 SD, the height of their affected parent was -2.9 SD, resp.-3.6 SD and bone age was accelerated by 2 years in both. We have found no apparent phenotypic differences in patients with ACAN mutation if compared to those with no mutation.

Conclusions: Whereas the proportion of subjects with ACAN mutation among patients with GHD and/or SGA was quite low (0.3 %), in a selected subgroup of children with FSS born SGA and having accelerated bone age was the frequency of ACAN mutation detection 2/9, i.e. 22 %. Targeted genetic testing is worth using in routine clinical praxis in this selected subgroup of patients.

The study was supported by Ministry of Health of the Czech Republic, grant no. 16-31211A.

934: P1-835

EFFECT OF COMMUNITY-BASED FOOD SUPPLEMENTATION IN IMPROVING GROWTH OF STUNTED UNDER-FIVE CHILDREN IN WEST NUSA TENGGARA
Aman B Pulungan, PhD; Dini A Mirasanti, MD, University of Indonesia, Jakarta, Indonesia

Objectives: Stunted children have become a global health problem. Indonesia ranked fifth within countries with highest prevalence of stunting. Prevalence of underweight children in West Nusa Tenggara is as high as 30% and the province also ranked third in number of stunted children in Indonesia. Local government has tried to tackle this problem by giving supplementary food to underweight children. We aimed to assess whether community-based food supplementation was successfully improved children’s growth

Methods: We conducted a prospective cohort study for 10 months. The children were given supplementary food according to Ministry of Health guidance which consist of formula milk, high calorie biscuit, and eggs until their weight was considered normal according to their current age and sex. Child’s weight and height was measured every 3 months and the result was plotted in WHO growth charts for weight-for-age, height-for-age, and weight-for-height. Z score <-3 SD was classified as severely wasted, severely underweight, or severely stunted. Z score between -2 and -3 SD was classified as wasted, underweight, or stunted and –score >-2 SD was classified as normal.

Results: Twenty-five under-five children were participated in this study. Subjects’ median age was 29 months old. None of the subjects had normal weight-for-age Z-score at the beginning of the study. Eighty four percent (N=21) of the subjects were severely underweight. Only 8% (N=2) subject had normal height-for-age z-score and 88% (N=22) of them were severely stunted. However, 80% (N=20) of the subjects had normal nutritional status. Changes of weight-for-age z-score throughout the study were varied. The highest median score was in the tenth month of follow up (-3.82). The highest median score of height-for-age score and weight-for-height score was also in the last month of follow up. At the end of the study, only one subject had normal weight-for-age score (4%) and none of the subjects had normal height-for-age score (N=0, 0%)

Conclusions: Supplementary food given by the government has not been successful in improving both body weight and height of under-five children in our study

1293: P1-836

TREATMENT OUTCOMES IN CHILDREN WITH NOONAN SYNDROME – AN ANALYSIS FROM NORDINET® IOS AND ANSWER PROGRAM
Alicia A Romano, MD, New York Medical College, Valhalla, NY, United States; Daniel Konrad, MD, PhD, University Children's Hospital , Zurich, Switzerland; Anita I Chudecka, MSc, Novo Nordisk Health Care AG, Zurich, Switzerland; Birgitte T Pedersen, MSc, Novo Nordisk A/S, Søborg, Denmark; M. Jennifer Abuzzahab, MD, Childrens Hospitals and Clinics of Minnesota, Saint Paul, MN, United States; Jovanna Dahlgren, Professor, University of Gothenburg, Gothenburg, Sweden

Objectives: To describe the characteristics of growth hormone (GH)-treated patients with Noonan syndrome who achieved near adult height.

Methods: Baseline characteristics and growth response to GH treatment to near adult height were evaluated for GH-naïve patients with Noonan syndrome enrolled in two complementary non-interventional, multicenter studies – NordiNet® International Outcome Study (IOS) (NCT00960128) and the ANSWER Program (NCT00615953) – which evaluated the long-term effectiveness and safety of Norditropin® ([somatropin] Novo Nordisk A/S, Denmark) as prescribed by treating physicians in a real-life clinical setting. Near adult height was defined as height achieved at age >18 years for boys and girls, or >17 years for boys and >15 years for girls with height velocity <2.5 cm/year. Height standard deviation score (SDS) was calculated using national and Noonan syndrome-specific (Ranke) references. Data are presented as median [Q1; Q3].

Results: Of 318 enrolled patients, 28 (32% girls) achieved near adult height: age at GH start was 11.1 [9.1–13.3] years for girls, 14.0 [11.8;15.4] years for boys; height SDS (national) at GH start was –2.6 [–2.9; –2.5] for girls, –2.9 [–4.0; –2.4] for boys; height SDS (Ranke) was 0.1 [0; 0.3] for girls, –0.9 [–1.5; –0.1] for boys; midparental height SDS was –0.4 [–0.8; 0] for girls, –0.7 [–1.3; 0.2] for boys. Age at near adult height was 15.5 [15.3; 16.6] years for girls, 18.1 [17.5; 19.3] years for boys. Duration of treatment to near adult height was 4.3 [2.7; 6.2] years for girls, 4.3 [3.4; 6.1] years for boys. Average GH dose during treatment was 43.1 [40.6; 49.8] μg/kg/day for girls, 44.6 [37.1; 51.7] μg/kg/day for boys. Near adult height SDS (national) was –1.5 [–2.0; –1.0] for girls, –1.7 [–2.4; –1.2] for boys. Near adult height SDS (Ranke) was 0.9 [0.8; 1.1] for girls, 0.8 [0.2; 1.7] for boys. At enrollment, 96% (n=27) of patients had height below the normal range. At near adult height, 67.9% (n=19) had height SDS (national) within the normal range (≥–2 SDS).

Conclusions: Approximately two-thirds of GH-naïve patients with Noonan syndrome achieved a near adult height SDS within the normal range after an average of 4 years of GH treatment.

1741: P1-837

DEVELOPMENT OF A LONG-ACTING (LA) GROWTH HORMONE (GH): SIZE MATTERS
Paul Saenger, MD, Albert Einstein College of Medicine of Yeshiva University, Mineola, NY, United States; David B. Karpf, MD, Stanford University School of Medicine, Mountain View, CA, United States; Eva Mortensen, MD, Ascendis Pharma, Inc., Palo Alto, CA, United States; Michael Beckert, MD, Caracs, Berlin, Germany; Kennett Sprogoe, PhD, Ascendis Pharma, Hellerup, Denmark; Jonathan A. Leff, MD, Ascendis Pharma, Inc., Palo Alto, CA, United States

Objectives: Multiple attempts have been made over 25 years to develop a LA-GH, to improve poor compliance associated with daily injections.1-3 Initial depot formulations were compromised by poor skin tolerability (pain, nodule formation and lipoatropy).3,4 Protein fusion technologies have been developed to extend the half-life of hGH, leveraging increased molecular weight (MW) from ~60 kDa to >100 kDa3 to reduce clearance.3 To date only LA-GH based on the release of unmodified GH have gained regulatory approval.

Methods: N/A

Results: GH is highly conserved across species, with MW ranging from 19.4 kDa to 22 kDa.5 It is likely that GH size has been under evolutionarycontrol so that GH can interact with its receptor in various tissues, including both well-vascularized organs (eg, liver, muscle and heart) and poorly vascularized tissues (eg, the growth plate and fat). While IGF-1 from hGH binding in liver appears to account for 80-85% of long bone growth, hGH needs to diffuse into the growth plate to provide 15-20% of growth, via direct effects and induction of IGF-1 release within the growth plate.6 Studies with labeled dextrans show a 40 kDa MW cut-off for diffusion into the growth plate of mice.7 It is thus possible that large GH analogs might generate hepatic IGF-1, which diffuses into the growth plate and fat cells, but if the diffusion of GH is impeded suboptimal growth and increased fat mass/BMI may occur due to unopposed IGF-1.

TransCon hGH is a novel LA-GH prodrug in which rhGH is transiently linked to an inactive carrier, extending the half-life of the hormone. Unmodified 22 kDa hGH is sustainably released via physiological pH and temperature-induced linker hydrolysis. It is the only LA-GH based on unmodified hGH that is dosed at the same mg/kg dose and provides comparable exposure to daily hGH.8

Conclusions: A 6-month Phase 2 randomized study of TransCon hGH at 0.14, 0.21, or 0.30 mg/kg/week vs. daily Genotropin™ at 0.21 mg/kg/week demonstrated similar annualized HV of 11.9, 12.9, and 13.9 cm/year, respectively vs. 11.6 cm/year for daily Genotropin™, and stable BMI values, with mean change in BMI (kg/m2) of -0.04, 0.36, and -0.26 kg/m2, respectively8, strongly suggesting that the unmodified 22 kDa hGH reached GH receptors in all tissues.

699: P1-838

PEAK GROWTH HORMONE AFTER GLUCAGON STIMULATION TEST CORRELATES BETTER WITH IGF-I LEVELS IN SHORT CHILDREN
Ashraf Soliman, MD, University of Alexandria, Alexandria, Egypt; Ashraf Adel, MD; Mahmoud kh Alzyoud, MD; Nagwa Eldarsy, RN; Farida Umer, RN, Hamad Medical Center, Doha, Qatar

Objectives: to investigate the diagnostic value of the glucagon test versus clonidine test in relation to IGF-I level in children and adolescents with short stature.

Methods: 100 children and adolescents with short stature ( HtSDS = or < -2) underwent GH stimulation test  using either Glucagon (n =22) or clonidine ( n = 78) standard tests. Their mean age was 10 +/- 2.9 years ; (30 females and 70 males).  Apart from short stature, all had normal physical examination, normal renal and hepatic functions and normal hemogram. None had history of systemic disease, irradiation or head trauma.  They had normal serum free T4 and TSH concentrations.  IGF-I was measured in all children as a screening test. 22 children underwent Glucagon stimulation test while 78 children underwent clonidine stimulation test, without priming with sex steroids.  Random selection is achieved because the ordering endocrinologists were blinded for the study.  

Results: Mean GH peak response to glucagon was significantly lower  than that observed after clonidine  (P < 0.01). GH peak after glucagon was less than 7 μg/l in 33% of subjects versus 20% of subjects after clonidine. The magnitude of the GH peak after glucagon was correlated significantly with IGF-I level ( r = 0.31, p = 0.04) but not with the peak after clonidine stimulation ( r = 0.14, p > 0.05). (table)

Conclusions: This study shows that glucagon has an effective GH-releasing activity and can be used to evaluate somatotroph function in young children with short stature. Peak GH secretion after glucagon stimulation correlate better with IGF-I levels compared to peak GH peak after clonidine. Data for this test in young children need to be established before its use in clinical practice. Normative data need to be established before use in clinical practice.

609: P1-839

SOMAPACITAN BINDS REVERSIBLY TO HUMAN ALBUMIN AT DOMAIN III
Peter Thygesen, PhD; Anders D Nielsen, PhD; Eva Johansson, PhD; Helle Demuth, PhD, Novo Nordisk A/S, Maaloev, Denmark

Objectives: To identify binding sites for somapacitan on human albumin. Somapacitan is a human growth hormone (hGH) derivative. Somapacitan binds reversibly to albumin via a fatty acid moiety attached to a single mutated amoino acid on the hGH backbone. Somapacitan is currently in clinical development for once weekly treatment of growth hormone disorders.

Methods: X-ray crystallography, small angle X-ray scattering (SAXS), size exclusion chromatography (SEC) and isothermal titration calorimetry (ITC) were used to identify somapacitan binding sites on human albumin. A ternary complex of somapacitan, human albumin and the neonatal Fc receptor (FcRn) was crystallised. FcRn binds human albumin domains I and III potentially blocking binding sites on these domains. The binding stoichiometry of somapacitan to human albumin and albumin subunit preparations was examined. Human alkbumin subunits used were domains I+II and III. ITC was used to investigate the binding of somapacitan to human albumin and human albumin subunits.

Results: One somapacitan binding site on domain II was identified by X-ray crystallography. SEC suggested a possible binding site on domain III. ITC analysis revealed that somapacitan binds to high and low affinity binding sites on subunits I+II and III in a temperature-dependent manner. At 37°C somapacitan only binds to a high affinity binding site on domain III.

Conclusions: A model of human albumin with somapacitan binding at two sites was identified. One binding site on domain II determined by crystal structures, and one on domain III determined from SEC and ITC analysis. The somapacitan binding is temperature-dependent. At 37°C somapacitan only binds to the high affinity binding site on domain III.

645: P1-840

THE IMPACT OF GROWTH HORMONE TREATMENT ON HEIGHT GAIN OVER 3 YEARS AND FINAL HEIGHT OF CHILDHOOD CANCER SURVIVORS AFTER HEMATOPOIETIC SCT WITH CRANIOSPINAL IRRADIATION OR TOTAL BODY IRRADIATION
Aram Yang, MD; Jinsup Kim, MD; Ji Won Lee, MD; Keon Hee Yoo, MD; Ki Woong Sung, MD; Hong Hoe Koo, MD; Dong-Kyu Jin, MD, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic Of; Sung Yoon Cho, PhD, Sansung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic Of; Su Jin Kim, MD, Myongji hospital, Kwandong University College of Medicine, Goyang, Korea, Republic Of

Objectives: Childhood cancer survivors (CCS) who have been treated with cranial or total body irradiation (TBI) are at risk for growth hormone deficiency (GHD). We evaluated effect of GH on height in CCS who underwent hematopoietic stem cell transplantation (HSCT) with craniospinal irradiation (CSI) or TBI.

Methods: Retrospective cohort study (2004-2016) of 38 CCS (31 males) undergoing HSCT treated with GH for irradiation-induced GHD (23 CSI; 15 TBI). Diagnoses included: medulloblastoma (n = 23), neuroblastoma (n =10), acute leukemia (n = 5). We analyzed the following data: sex, age, BMI, IGF-1, puberty stage, other hormone deficiency and adverse effects including secondary neoplasms (SNs). Heights at specific time points were analyzed: diagnosis of primary cancer, HSCT, start of GHT, after 1 yr GHT, after 2 yrs GHT, after 3 yrs GHT and final height (FH) compared using height SDS (HSDS) and cumulative SDS change.

Results: The mean age at start of GH treatment was 9.4 yrs. Significant change was found in mean HSDS from cancer diagnosis to after 3 yrs of GH therapy (-2.07±0.87 at tumor diagnosis; -2.21±0.87 at HSCT; -2.31±0.89 at start of GHT; -1.99±0.79 at after 1 yr; -1.85±0.77 at after 2 yrs; -1.57±0.86 at after 3 yrs of GHT, all mean HSDS, p<.001). For the 18 patients for whom final height measurements were available, mean FH HSDS increased by -1.99±1.35 SDS, but had no statistical significance (p= 0.281). Height gain SDS over 3 yrs from start of GHT was positively correlated with female (p=0.001), younger age (p<.001) and IGF-1 SDS increment during 3 yrs from start of GHT (p<.001). Type of radiation, age at HSCT, age at TBI or CSI, duration of GHT, age at start of GHT and BMI did not correlate with height gain SDS and FH SDS. In multiple linear regression, only female was positively correlated with FH and total height gain (p=0.002). SN was diagnosed in 3 patients, meningioma, papillary renal cell carcinoma and papillary thyroid carcinoma.

Conclusions: In our CCS undergoing HSCT with CSI or TBI, GH therapy did not show significant increase in FH SDS. But when considering a positive impact of GH therapy on height gain and associated positive factors from this study, further study investigation and close long–term follow up of GH therapy are needed.

1240: P1-841

THE CORRELATION BETWEEN SERUM NT-PROCNP LEVELS AND GROWTH IN HEALTHY CHILDREN
Seung Yang, MD, Kangdong Sacred Heart Hospital, Seoul, Korea, Republic Of; Il Tae Hwang, MD, Hallym University College of Medicine, Seoul, Korea, Republic Of

Objectives: C-type natriuretic peptide (CNP) has been shown to play a critical role in linear growth. Its bio-inactive aminoterminal propeptide (NT-proCNP) is easily measurable in plasma, and levels re?ect the rate of CNP biosynthesis. Previous studies showed that serum NT-proCNP levels positive correlated with height velocity in healthy children, and increased after GH treatment in children with achondroplasia/hypochondroplasia. The aim of this study was to investigate the correlation of serum NT-proCNP levels with current growth status in healthy Korean children.

Methods: Our subjects included 115 boys and 91 girls aged 3-15years. All children with growth disorder (ex. short stature, precocious puberty and other endocrine or chromosomal disorder) were excluded. Serum NT-proCNP levels were measured by enzyme-linked immunosorbent assays (Biomedica, Austria). We analysed for relationship between NT-proCNP and other auxological factors (age, Height-SDS) by pearson correlation. A Mann-Whitney U test was performed between group A (Ht-SDS<25percentile) and group B (Ht-SDS>75percentile) for NT-proCNP levels.

Results: There were no significant difference in ages between boys and girls (8.7±2.8: 8.8±2.7, P=0.648). There were no significant difference in serum NT-proCNP levels between boys and girls (5.9±3.3: 6.6±3.6, P=0.124). For both gender, Serum NT-proCNP levels were higher in infants and declined with age until puberty. Serum NT-proCNP levels were negatively correlated with age in all subjects (r=-0.177, P=0.011). During puberty, median NT-proCNP levels peaked at Bone age 12-13 years in boys and at 12 years in girls. Serum NT-proCNP levels were lower in subjects with group B compared with group A. however, that is not statistically significant.

Conclusions: In this studies, Serum NT-proCNP levels were not reflect the degree of the current height status. However, Serum NT-proCNP levels correlated with height velocity by age in healthy children.

1005: P1-842

SHORT STATURE DUE TO TWO NOVEL HETEROZYGOUS IGF1R MUTATIONS AND RESPONSE TO GH TREATMENT
Anenisia C Andrade, MD, PhD; Alexandra Gkourogianni, MD, PhD, Karolinska Institutet and University Hospital, Stockholm, Sweden; Emma Segerlund, MD; Antje Werner-Sperker, MD, Sunderby Hospital, Sunderby, Sweden; Eva Horemuzova, MD, Karolinska Institutet and University Hospital, Stockholm, Sweden; Jovanna Dahlgren, MD, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden; Ola Nilsson, Professor, Karolinska Institutet and University Hospital, Stockholm, Sweden; Ola Nilsson, Professor, MD, PhD, Örebro University and University Hospital, Örebro, Sweden

Objectives: Heterozygous mutations in the type I insulin-like growth factor receptor gene (IGF1R) cause pre- and postnatal growth failure and microcephaly.

Methods: Case presentations: Proband of family 1, a 7.5-year-old male, presented with proportionate short stature (height -2.0 SDS). He was born SGA (birth weight SDS -2.1) and small head circumference (-2.0 SDS). Evaluation revealed a delayed bone age and elevated levels of IGF1 and IGFBP3. The father (38 yo) had also been born SGA (birth weight -3.8 SDS), had childhood short stature (height SDS -3.0) and had been treated with rhGH (0.46mg/kg/wk) from 9 to 18 years of age and had reached an adult height of 168.5cm (SDS -1.1; delta height SDS +1.9; Fig. 1). Paternal grandmother is also short (-1.6 SDS) and has a low head circumference. The mother’s and younger brother’s heights were normal (+1.5 and -0.5 SDS, respectively). Proband 2 is a healthy 8y10m old girl with short stature (height SDS 2.4), born SGA (birth weight SDS -1.5) to healthy parents of normal height (father -0.3; mother +1.1 SDS). The patient has IGF1 and IGFBP3 levels in the upper limit of normal and a normal GH profile (max peak 15microg/L), which taken together with the clinical picture raised the suspicion of mild IGF1 insensitivity. 

Results: In each family, a novel heterozygous non-synonymous missense IGF1R variant were identified by Sanger sequencing. In family 1, c.3364G>T (pGly1122Cys) in the proband, his father and grandmother, but not in the unaffected brother. In family 2, a de novo missense variant c.3530G>A (pArg117His) was detected. Both variants were rare (not present in the ExAC or the 1000 genomes database) and predicted to be damaging by at least 4 of 5 in silico prediction tools. Interestingly, the father of proband 1 had been treated with GH for 9 years with a height gain of 1.9 SDS (Fig 1).

Conclusions: Our study presents two novel heterozygous IGF1R mutations causing short stature and microcephaly. One individual treated with GH for 9 years at relatively high dose suggest that individuals with heterozygous IGF1R mutations respond to GH treatment. However, further studies are needed to elucidate the efficacy of GH treatment in this condition.

957: P1-843

TWO SISTERS WITH TURNER SYNDROME
Meryem Bensalah, MD; Yamina Aribi, MD; Aicha Lachkham, MD; Malek Iabassen, MD; Samia Ouldkablia, PhD, Central Hospital of Army, Algiers, Algeria

Objectives: Turner syndrome (TS) is a sporadic disease due to partial or total absence of the second X chromosome in a phenotypic female and has a prevalence of 1/2500 live female births. 45,X monosomy is found in approximately 50% of cases. Familial forms of TS have been documented rarely with <10 cases since the first report in 1963 of an aunt and niece this was followed in 1978 by seven affected women in three generations of the same family.we report a familial case of TS.

Methods:  Two sisters from non-consanguineous parents attended our unit with short stature. Clinical biological and morphological findings are summarized in the table below

Results:
Parameters

Patient 1

Patient 2

Age (years)

6

9

Range in siblings

2/4

1/4

Height(cm)

100(-3SDS)

113(<-3SDS)

Dymorphism

Short neck, cubitus valgus, epicanthus, hypertelorism, high arched palate, wide-spaced nipples

Short neck, cubitus valgus, epicanthus, high-arched palate, wide-spaced nipples, shield chest.

Karyotype

45,X

45,X

Heart ultrasound

No congenital malformation

No congenital malformation

Kidney ultrasound

Horseshoe kidney

Normal size and position of kidneys

Ear examination

normal

normal

Thyroid function

TSH:1,7-µUI/ml

TSH:2,18µUI/ml

Other abnormalities

None

Celiac disease

Conclusions:

This family adds to the spectrum of reported cases of familial TS .It is possible that this malfunction arose as a mutation in one or the other parent's germ cell line. An alternative mechanism could be the presence of mosaicism in either parent's gonadal tissue. The chromosomal abnormalities including mosaicism and genetic defect can be transmitted to the descendants in familial cases and predispose to chromosomal fragility leading to chromosomal aneuploidy

1445: P1-844

NOVEL ACAN MUTATIONS IN FOUR CHILDREN WITH SHORT STATURE FROM TWO FAMILIES WITHOUT CONSISTENTLY ADVANCED BONE AGE
Hermine A. van Duyvenvoorde, PhD; Ivonne J.H.M. van Minderhout, BS/BA; Quint P. Hottentot, BS/BA; Sander H.B. Bollen, MS/MA; Martine C. de Vries, PhD; Sabine E. Hannema, PhD; Christiaan de Bruin, PhD, Leiden University Medical Center, Leiden, Netherlands; Monique Losekoot, PhD, Leiden University Medical Centre, Leiden, Netherlands; Jan M. Wit, Professor; Wilma Oostdijk, MD; Sarina G. Kant, PhD, Leiden University Medical Center, Leiden, Netherlands

Objectives: Heterozygous ACAN mutations have been reported to cause short stature associated with advanced bone age and various other clinical features. We used whole exome sequencing to identify the genetic cause of short stature observed in 4 children belonging to 2 families, and found two novel ACAN mutations. This enabled us to further expand the phenotype of patients with ACAN mutations.

Methods: The exome was sequenced in 2 siblings and both parents from one family (A), and in two siblings from another family (B). All children were born at term with normal birth weights. The children (age 2.6-7.6 yrs) presented with short stature (height -3.3 to -2.4 SDS), SH/H ratio ranging from +0.75 to +3.0 SDS, and armspan/H ratios ranging from 0.93 to 1.0. Bone ages varied from delayed (7 and 24 months) in two children to equal to chronological age and advanced (+1.1 yrs) in one child. At follow-up, bone age was still delayed in 1 patient, consistent with chronological age in 2 children, and advanced in 1. In both families 1 parent also had short stature, suggesting autosomal dominant inheritence. The exome sequences were analysed with a stringent post-sequencing annotation pipeline including a gene panel of 109 genes for filtering of the data.

Results: In all 4 children a heterozygous nonsense mutation in the ACAN gene was identified, inherited from the mother in family A (height -4.1 SDS), segregation analysis in family B is still ongoing. Several of their family members are known with short stature. The mutations were located in the G1 domain (c.706C>T,p.(Arg236*)) in family A, and in the GAG attachment region (c.6673C>T,p.(Gln2225*)) in family B. In three short relatives belonging to family B severe osteochondritis dissecans was observed as an extra clinical manifestation.

Conclusions: Two novel heterozygous nonsense mutations in ACAN were identified in two families with short stature, with osteochondritis dissecans segregating with short stature in one family. Remarkably, the bone age was only advanced in one of the four children, whereas in the other three children the bone age varied from delayed to consistent with chronological age. This indicates that the absence of advanced bone age should not be considered a contraindication for testing for ACAN mutations in children with short stature. 

1141: P1-845

IMPAIRED LINEAR GROWTH IN SIBLING BOYS WITH FAMILIAL HYPERKALEMIC PERIODIC PARALYSIS ASSOCIATED WITH THERAPY INDUCED RENAL TUBULAR ACIDOSIS
Michele Gortakowski, MD, Baystate Children's Hospital/ U Mass Medical School, Springfield, MA, United States; Holley F Allen, MD/MSPH, Baystate Children's Hospital/U Mass Medical School, Springfield , MA, United States; Rushika Conroy, MD, Baystate Children's Hospital/ U Mass Medical School, Springfield, MA, United States; Gregory Braden, MD, Baystate Medical Center/ U Mass Medical School, Springfield, MA, United States

Objectives: Hyperkalemic periodic paralysis (HyperPP) is a channelopathy characterized by episodic muscle weakness or paralysis with hyperkalemia. Recently, dichlorphenamide (Keveyis), a carbonic anhydrase inhibitor, was FDA approved for use in HyperPP. Since starting dichlorphenamide, siblings with HyperPP had significant decrease in frequency of episodes, but developed worsening impairment of linear growth velocity (GV) and renal tubular acidosis (RTA).  

Methods: JS was evaluated for short stature (height 2.6th %ile, MPH between 25-50th %ile) at 6.5 yrs. IGF-1 level was 64 ng/mL (63-292 ng/mL) with delayed bone age (-2.4 SDs).  GH stim testing was normal (peak GH 18.5 ng/mL). The working diagnosis was CDGP. He was re-referred at age 9 yrs with declining GV (height 0.8th %ile, GV 3.9cm/yr).  He transitioned from acetazolamide to dichlorphenamide 5 months prior. His weight had increased from the 9th to 25th %ile since previous visit. Repeat IGF-1 was 79 ng/mL (81-255 ng/mL), with delayed bone age (-4SDs). Lab work revealed a normal anion gap acidosis, positive urine anion gap with normal renal function, consistent with RTA. He was prescribed sodium citrate.  

His brother, SS, was evaluated for short stature (height 9th %ile) at 11 yrs. He had a gradual decrease in his height percentile with GV of 3.3cm/yr over 3 yrs with most significant decline in the past year. He had stable weight gain between the 50-75th %ile. He transitioned from acetazolamide to dichlorphenamide 6 months prior to evaluation. IGF-1 level was 139 (81-255 ng/mL) and bone age was congruent with chronological age. GH stim testing results are pending. Lab work revealed evidence of RTA, and he was prescribed sodium citrate.

Results: The etiology of the boys’ deceleration in GV is multifactorial. Both are treated with low dose stimulants for ADHD, and JS also has CDGP. However, RTA is an important cause of growth failure that impairs the action of GH and IGF-1, and increases bone resorption. 

Conclusions: We hypothesize that treatment of the acidosis caused by dichlorphenamide will improve their linear GV. It is important for providers to be aware of potential development of metabolic acidosis while on dichlorphenamide and how it can negatively impact linear growth.

247: P1-846

HETEROZYGOUS IRS1 MUTATION CAUSES PRE- AND POSTNATAL GROWTH RETARDATION: A FAMILY WITH HETEROZYGOUS IRS1 MUTATION AND IGFALS MUTATION.
Yuki Kawashima Sonoyama, MD, Tottori University Faculty of Medicine , Yonago, Japan; Fumihiko Hakuno, PhD, The University of Tokyo, Tokyo, Japan; Akiko Hasegawa, MS/MA, Tottori University Faculty of Medicine , Yonago, Japan; Masachika Kai, Physician's Assistant; Kaori Adachi, PhD, Tottori University, Yonago, Japan; Masanobu Fujimoto, MD; Naoki Miyahara, MD; Rei Nishimura, MD; Yukiko Sawa, MD; Keiichi Hanaki, MD, Tottori University Faculty of Medicine , Yonago, Japan; Eiji Nanba, PhD, Tottori University, Yonago, Japan; Shin-Ichiro Takahashi, PhD, The University of Tokyo, Tokyo, Japan; Susumu Kanzaki, MD, Tottori University Faculty of Medicine , Yonago, Japan

Objectives: IRS1 is a key element for both insulin and IGF1 signaling. To date, there have been no reports of IRS1 mutations in patients with growth failure. We report the first identified small for gestational age (SGA) familial cases with short stature and heterozygous mutations in IRS1 and/or IGFALS.

Methods: Case 1 was a 14-year-old Japanese girl born at full term, with a low birth weight (-1.9 SD) and height (-3.8 SD). Her father had a normal stature, and her mother had a short stature (-2.2 SD) with a low birth weight (-1.6 SD). At 6 years old, the height a of patient 1 were -2.5 SD; therefore, GH treatment for SGA short stature was started. case 2 was a 17-year-old Japanese girl who was also the elder sister of case 1. She was born at full term, with a low birth weight (-2.2 SD) and height (-2.5 SD). Although she was -2.0 SD for short stature before starting puberty, her final height was only 144 cm (-2.7 SD). Both patients were healthy except for the short stature, and mental development was normal. For the genetic analysis of these patients, we performed a targeted resequencing using the TruSight One sequencing panels. For the functional analysis of mutant IRS1 and IGFALS proteins, we constructed FLAG-tagged IRS1 or IGFALS vectors, and then performed immunoblotting of both IRS1 and IGFALS by using HEK293 cells or L6 myoblasts transfected with wild type or mutant proteins.

Results: Case 1 and 2 and their mother were heterozygous for a p.Ser685_686del mutation in IRS1. Furthermore, case 1 and her father were heterozygous for a p.Arg229His mutation in IGFALS. The HEK293 cells transfected with the mutated IRS1 construct showed decreased IRS1 expression levels, and the L6 myoblasts stably transfected with the same construct revealed increased degradation of IRS1. Furthermore, HEK293 cells transiently transfected with mutated IGFALS showed significantly lower expression of IGFALS.

Conclusions: Our findings suggest that the IRS1 mutation led to a dysfunction of IRS1 by increasing IRS1 degradation, thus resulting in pre- and postnatal growth retardation. Additionally, the IGFALS mutation led to decreased production of IGFALS and  result in more severe growth retardation in case 1. Thus, we speculate that mutations in IRS1 can cause SGA short stature.

198: P1-847

ASSOCIATION OF HYPOCHONDROPLASIA WITH ACANTHOSIS NIGRICANS AND INSULIN RESISTANCE
Huseyin Anil Korkmaz, MD, Balikesir Atatürk State Hospital, Balikesir, Turkey

Objectives: We aimed to evaluate association of hypochondroplasia with acanthosis nigricans and insulin resistance.

Methods: Hypochondroplasia is associated with short limbs, short stature and lumbar lordosis, usually exhibiting a milder phenotype than achondroplasia. The occurrence of insulin resistance and acanthosis nigricans in patients with hypochondroplasia is rarely reported.

Results: A 14.5 years old female patient presented to our clinic with short stature. The patient was born with 2000 gr by caesarean section, followed with uncomplicated pregnancy. On physical examination; Height: 128 cm (2 SDS)], brachydactyly, limitation of elbow extension, short legs [sitting height/height ratio: 0.6 (>2.5 SDS)], a short arm span (10 cm shorter than her total height) and acanthosis nigricans. Full blood count, biochemical analysis and thyroid function tests were normal. Since the clinical features were consistent with skeletal dysplasia, a heterozygous p.N540K (c.1620C>A) mutation was detected in FGFR3 gene. Fasting blood glucose was 90 mg/dl (75-100), fasting insulin was 18,1 IU / mL (2-18) and HbA1c value was 5.8. The homeostasis assessment index for insulin resistance (HOMA-IR) was 4.04 (normal range 0.36–2.41) indicating insulin resistance. Postprandial glucose was 121 mg/dl and postprandial insulin was 42.7 IU / mL, which suggested insulin resistance.

Conclusions: This finding demonstrates insulin insensitivity and acanthosis nigricans associated with hypochondroplasia. Long-term follow-up for patients with hypochondroplasia is requied to clarify the risk of long-term metabolic complications.

245: P1-848

INTELLECTUAL DISABILITY AND OVER-GROWTH --A CASE CAUSED BY NOVEL MUTATION OF NFIX GENE BASED ON WHOLE-EXON SEQUENCING
Wei Lu, PhD, Children's Hospital of Fudan University, Shanghai, China; Bing-Bing Wu, PhD; Ping Zhang, BS/BA; Hui-Jun Wang, PhD; Lin Yang, PhD; Wen-Hao Zhou, PhD; Fei-Hong Luo, PhD, Children’s Hospital of Fudan University, Shanghai, China

Objectives: Intellectual disability and overgrowth can be seen in some genetic disorders.Here we report a patient showing moderate Intellectual disability with overgrowth (height > 3SD) , who diagnosed with Marshall–Smith syndrome caused by a novel mutation of NFIX gene identified by whole-exon sequencing (WES).

Methods: Genomic DNA from the proband was extracted from peripheral blood leukocyte. Karyotype analysis was performed on metaphase cells. Array-based comparative genomic hybridization of DNA from the patient’s peripheral blood lymphocytes and WES were performed respectively.

Results: The proband, a 4yr2mon old girl, is the first child of healthy nonconsanguineous Chinese parents. She was born by uterine-incision delivery after 41 weeks of gestation. Her birth weight was 3.5 kg. She showed an distinctive face including prominent forehead, high anterior hairline, downslanting palpebral fissures, prominent chin and blue sclera. During further development, delay in language and motor skills as well as poor coordination were noted. She presents poor wound healing, bruising susceptibility, accelerated skeletal maturation (+2.5 years) and constipation. Her heigt was 122cm (> 3SD) and her fingers were long. Brain MRI performed less white matter. Karyotyping was 46, XX and array CGH analysis was normal. Then we performed WES for this patient and identified a novel frameshift mutation of NFIX gene.

Conclusions: NFIX analysis should be considered in patients presenting with overgrowth, macrocephaly and developmental delay including those in whom Sotos syndrome has been considered clinically but are negative for pathogenic NSD1 variants or chromosome microdeletion.

1599: P1-849

MECASERMIN TREATMENT OF A CHILD WITH CONGENITAL HYPERINSULINISM LINKED TO INS-R MUTATION
Maria Cristina Maggio, MD, University of Palermo, Palermo, Italy; Marcello Vitaliti, MD, ARNAS PALERMO, Palermo, Italy; Giuliana Vitaliti, MD, University of Palermo, Palermo, Italy; Fabrizio Barbetti, MD, University of Rome Tor Vergata, Rome, Italy; Giovanni Corsello, MD, University of Palermo, Palermo, Italy

Objectives: Mecasermin is recombinant human insulin-like growth factor 1 (IGF1) which is approved for the treatment of short stature in children with documented primary IGF1 deficiency.

Leprechaunism, also known as Donohue syndrome, is a severe disease, secondary to a severe congenital insulin resistance, with prenatal and neonatal growth retardation, typical dysmorphic features, glycaemic dysregulation characterized by hyperinsulinemia and hyperandrogenism. These patients have a poor prognosis with death in the first year of life.

Methods: We describe the case of a 3.5 years child, born at 35,4 weeks, with severe fetal growth restriction (weight 1149 gr; length: 38 cm; cranial circumference: 28 cm), typical facial features with low implant ears, low implant hairs, hypertrichosis, hypertrophic external genitalia, postnatal growth failure, and severe hyperglycaemia (327 mg/dl) alternated with hypoglycaemia (10 mg/dl) also during i.v. infusion of glucose; significant hyperinsulinism (1000 mcU/dl) with elevated C peptide levels (43,41 ng/ml), persistent hypertension (113/74 mmHg). He has consanguineous parents (cousins) and the mother underwent abortions before the baby was born.

Results: A treatment with diazoxide (5 mg/kg/day) was tried with limited efficacy. He was treated with ACE-inhibitor (Captopril) at the dose of 0,02 mg/kg/day with a low response. The Captopril dose was increased at 0,04 mg/kg/day with a regulation of the blood pressure (76/54mmHg). The genetic study of INS-R was showed a homozygote mutation in the insulin receptor (INS-R) gene. The mutation reported was c.3289C>T (CAG->TAG) p.Gln1097Stop (Q1097X). For the growth delay and the hypotrophic muscular masses he started a off-label treatment with mecasermin at increasing doses. He had no adverse events linked to the treatment. Otherwise, he improved growth and muscular strength.

Conclusions: The singular case is of relieve for the rarity of the disease and for the good response to the treatment with mecasermin, the real opportunity for these children with a severe disease otherwise with a poor prognosis.

1115: P1-850

FIRST REPORT OF AN IGFALS MUTATION IN A CHILEAN PATIENT WITH GROWTH HORMONE INSENSITIVITY AND LOW LEVELS OF IGF1 AND IGFBP3
Helena Poggi, MS/MA, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile; Felipe Benavides, MS/MA, Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago de Chile, Chile; Alejandro Martinez-Aguayo, MD, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile

Objectives: The main role of the acid-labile subunit (ALS) is to stabilize the IGFBP3/IGF complexes in the vascular compartment, extending thereby the otherwise very short half-life of circulating IGFs. Inactivating mutations in the gene coding for ALS (IGFALS) results in IGF1 deficiency, short stature and delay puberty. The aim of these study was to identify the genetic cause in a patient with suspected ALS deficiency.

Methods: .

Results: The proband is the third son of non-consanguineous parents (mother 150 cm, father 162 cm), evaluated for the first time at the age of 17 4/12 years because of his short stature (154.4 cm, -2.84 SD), with a bone age of 16 years and a body mass index in the 61th percentile. He was born with a normal birth weight and length (3,150 g and 49 cm). Sexual development and pubic hair correspond to Tanner stage 2, both testes showing a 10 mL volume. Hepatic and renal function, lipid and thyroid profile were normal, as well as his fasting glycaemia (88 mg/dL) and insulin level (16.3 uUI/mL). FSH, LH and total testosterone were concordant with his pubertal stage: 2.7 mIU/mL, 1.9 mIU/mL, and 139.2 ng/dL, respectively. Further studies showed low levels of IGF1 (45 ng/mL) and IGFBP3 (IGFALS gene coding regions was performed. The patient was found to be homozygous for a missense variant, c.1871C>T, p.Pro624Leu (rs756451070; NM_001146006.1, NP_001139478.1), reported as very rare by the Exome Aggregation Consortium (1 allele among 44.672 individuals) but not in a clinical context. According to ACMG recommendations, this is a likely pathogenic variant.

Conclusions: Identification of IGFALS mutations is a useful tool to confirm the diagnosis of ALS deficiency since it is a probable cause of growth retardation in children with low IGF1 levels, and contributes to clinical decision making about growth hormone replacement.

492: P1-851

GROWTH HORMONE DEFICIENCY IN A BOY WITH NEPHROGENIC DIABETES INSIPIDUS
Niamh Mcgrath, MD, Children's University Hospital Temple St , Dublin, Ireland; Caoimhe S Costigan, , Children's University Hospital, Temple St, Dublin, Ireland; Sinead Moloney, , Children's University Hospital Temple St, Dublin, Ireland; Michael Riordan, , Children's University Hospital, Tempel St, Dublin, Ireland; Nuala P Murphy, Professor , University College Dublin, Children's University Hospital, Temple Street, Dublin, Ireland

Objectives: Background

Diabetes insipidus (DI) is a rare disorder of urinary concentrating ability caused by arginine vasopressin (AVP) insufficiency (central diabetes insipidus) or impairment of renal tubular response to AVP (nephrogenic diabetes insipidus). X-linked nephrogenic diabetes insipidus (AVPR2 gene mutations) has an estimated prevalence of 4 in 1,000,000 while CNDI caused by AQP2 mutation is rarer and estimated to occur in 1 in 20 million births. Growth hormone deficiency in association with cranial DI is well described. This is the first reported case of isolated GH deficiency in a child presenting with CNDI.

Results: Case

A 4 year old boy presented to the emergency department with a short history of vomiting and diarrhoea. He was dehydrated and laboratory studies confirmed hypernatremia (serum sodium 155mmol/L).  His parents reported chronic polyuria and polydipsia with longstanding daily intake of approximately 4-5 litres of water. He was short ( height 94cm, G p.Ser318Arg). Insulin tolerance testing revealed a suboptimal peak growth hormone of 3.8ug/L, consistent with isolated growth hormone deficiency. Bone age was consistent with chronological age. He was commenced on growth hormone 0.025mg/kg/day with good growth response.

Conclusions: This is the first reported case of GH deficiency and CNDI. This case describes an interesting combination of two rare conditions, not previously decribed in association.

1524: P1-852

GH THERAPY IN A NON-GHD SHORT CHILD WITH SYRINGOMYELIA AND CHIARI I MALFORMATION
Alex Moretti, MD; Daniela Simoncini, MD; Paola Cianci, MD; Alessandro Salvatoni, MD, University of Insubria, Varese, Italy

Objectives: Syringomyelia is a dilatation of the central canal of the cord frequently associated with congenital malformation of the cranial-cervical junction and Chiari I malformation. GH deficiency is also reported in these subjects and replacement therapy with GH seems not only to increase growth velocity but also to improve Chiari I malformation and syringomyelia.

Methods: We report the case of a 4 year old child who undertook a RMN for a venous facial angioma which showed incidentally Chiari I malformation and cervical syringomyelia. Following neurosurgical decompression, he required surgical revision for cerebral spinal fluid fistula and recurrence of syringomyelia. He was then referred to our clinic for short stature (Height-3SDS; Growth velocity -1.83SDS). The main organic causes of short stature, such as coeliac disease, hypothyroidism and GH deficiency were excluded (GH arginine stimulation test peak value 12.7 ng/ml). GH therapy (0.5 mg/day) was started on the basis of previous studies reported in the literature showing an improvement of the syrinxes during GH treatment in absence of significant side effects. Since the response to treatment was unpredictable, we performed a close clinical follow-up with quarterly auxological examinations and annually RMN imaging.

Results: The child showed during 3 years of GH treatment a significant increase of stature (from -3 to -1,7SDS) and Growth Velocity (from -1.83SDS to 3.67SDS). Furthermore the RMN showed a stabilization of the cranial-cervical junction and partial reduction of the syrinx cavity.

Conclusions: Our case suggests the possible efficacy of GH therapy in children with short stature and syringomyelia regardless of the presence of GH deficiency.

798: P1-853

GROWTH HORMONE THERAPY FOR SHORT STATURE ASSOCIATED WITH WOLFRAM (DIDMOAD) SYNDROME
Kalie L Tommerdahl, MD; Sasigarn A Bowden, MD, Nationwide Children's Hospital/The Ohio State University, Columbus, OH, United States

Objectives: We report an interesting case of Wolfram syndrome (WFS) treated with growth hormone for poor growth.  Limited data exist concerning growth hormone therapy in WFS.

Methods: Case report.

Results: A 10 year-old female presented for endocrinologic evaluation following diagnosis of bilateral optic nerve atrophy after ophthalmology evaluation for progressive visual impairment. She had onset of polyuria, polydipsia since age 1 year. She had bilateral sensorineural hearing loss diagnosed at age 3 years, requiring cochlear implants. She was diagnosed with type I diabetes mellitus (DM) at age 5 years with initial HbA1c of 10.5%. She received insulin therapy at a total daily dose of 0.3-0.4 unit/kg/day, with HbA1c of 6.6%-8.9%. Upon diagnosis of optic atrophy, in the setting of DM and deafness, WFS was diagnosed and subsequently confirmed by WFS1 gene mutation. Diabetes insipidus (DI) was also diagnosed based on her continued polyuria, polydipsia, and enuresis despite insulin therapy, mild hypernatremia (148 mmol/L) and low urine specific gravity and osmolality. Her DI symptoms resolved after oral desmopressin. She had slow growth with decreasing height percentile from the 5th% (Z score -1.7) at age 5 years to <1stpercentile (Z score -2.4) at age 10 years. Her mid-parental height was at the 75th%. She had normal TSH obtained annually after her DM diagnosis and her celiac screen was negative. Further pituitary studies showed low IGF-1 (84 ng/mL, normal 96-537), normal IGF-BP3 (3.2 ug/mL, normal 1.8-7.1). A growth hormone stimulation test showed peak growth hormone of 11.9 ng/mL. She had normal cortisol on ACTH stimulation test. Because of her poor growth, growth hormone was initiated at 0.22 mg/kg/week. Her growth velocity improved from 3.7 cm/year pretreatment to 9.6 cm/year after a year of treatment.

Conclusions: WFS with DI should be suspected in any patient with DM who continues to have polyuria and polydipsia after insulin therapy, especially in the setting of known hearing loss and vision changes. Early recognition of WFS allows timely pituitary workup and early treatment with desmopressin to alleviate DI symptoms. This case highlights benefit of growth hormone therapy for poor growth in WFS as growth hormone neurosecretory dysfunction may be present as a result of the neurodegenerative process.

1114: P1-854

DE NOVO IGF2 MUTATION ON THE PATERNAL ALLELE IN A PATIENT WITH SILVER-RUSSELL SYNDROME AND ECTRODACTYLY
Kaori Yamoto, MD; Hirotomo Saitsu, Professor, Hamamatsu University School of Medicine, Hamamatsu, Japan; Norio Nakagawa, MD; Hisakazu Nakajima, MD; Tatsuji Hasegawa, MD, Kyoto Prefectural University of Medicine, Kyoto, Japan; Yasuko Fujisawa, PhD, Hamamatsu University School of Medicine, Hamamatsu, Japan; Masayo Kagami, PhD; Maki Fukami, PhD, National Research Institute for Child Health and Development, Tokyo, Japan; Tsutomu Ogata, Professor, Hamamatsu University School of Medicine, Hamamatsu, Japan

Objectives: Background: Although paternally expressed IGF2 gene is known to play a critical role in placental and body growth, only a single mutation has been found in IGF2. Here, we report a de novo IGF2 mutation that occurred on the paternal allele in a patient with Silver-Russell syndrome (SRS) and ectrodactyly.

 

Methods: Case report: This Japanese male infant was delivered by a cesarean section at 31 weeks of gestation because of intrauterine growth arrest and fetal distress. At birth, his length was 34.0 cm (–3.7 SD for gestational age), his weight 764 g (–4.1 SD), and his occipitofrontal circumference (OFC) 27.0 cm (–1.0 SD). Placenta weighed 176 g. Physical examination revealed SRS-compatible craniofacial features, undermasculinized genitalia, and bilateral hand and left foot ectrodactyly. On the latest examination at 18 months of age, his length was 65.4 cm (–4.2 SD), his weight 7,100 g (–2.9 SD), and his OFC 45.0 cm (–1.6 SD). Serum IGF-1 was 37.4 nmol/L (age- and sex-matched normal range, 1.8–19.3), IGF-2 46.9 nmol/L (44.5–85.5), LH <0.5 IU/L (<0.5), FSH 1.0 IU/L (<1.5), and testosterone <0.35 nmol/L (<0.35).

Results: Molecular studies: Whole exome sequencing followed by Sanger sequencing revealed a de novo IGF2 indel mutation leading to frameshift (c.110_117delinsAGGTAA, p.(Leu37Glnfs*31)) that satisfied the condition for the occurrence of nonsense mediated mRNA decay. Furthermore, the mutation was shown to reside on the paternal allele by sequencing the long-PCR product harboring the mutation and methylation sensitive SmaI and SalI sites before and after SmaI/SalI digestion.

Conclusions: Conclusions: We identified a de novo IGF2 indel mutation that occurred on the paternal allele in a patient with SRS and ectrodactyly. The results, together with the previous findings in four familial cases with a paternally inherited IGF2 nonsense mutation and those in patients with variable H19-DMR epimutations leading to compromised but not abolished IGF2 expression, suggest that the whole phenotype of this patient including SRS and ectrodactyly is explainable by the IGF2 mutation, and that phenotypic severity is primarily determined by the IGF2 expression level in target tissues.

2952: P1-855

REDUCED THYMIC ACTIVITY AND TREC LEVELS IN CHILDREN WITH GROWTH HORMONE DEFICIENCY
Yonatan Yeshayahu, MD; Yael Bezalel, MD; Atar Lev, MD; Yael Levy-Shraga, MD; Raz Somech, MD, Safra children's hospital, Sheba medical center/Tel-Aviv university medical school, Tel-Hashomer, Ramat-Gan, Israel

Objectives: The thymus is the primary locus for development and maturation of T cells.   T cell receptor (TCR) exicion circles (TREC), are DNA fragments which serve as a sensitive tool for the assessment of T cell production and thymic maturity.   Previous studies have shown that hormones produced in the hypothalamic-pituitary axis can affect thymic degradation.  Growth hormone (GH) has a positive effect on thymic activity as observed in mouse models, where GH deficiency led to disturbances in T cell production. Mouse models show that supplementary GH improves thymic cellularity, divergence of TCR and recovery of the hematopoietic system in immunocompromised patients and elderly. One proposed mechanism is through the JAK2/STAT pathway.  The aim of our study was to show correlation between GH levels and thymic activity using TREC measurements as a marker.

Methods: In a case-control study, serum samples of GH deficient (GHD) and sufficient (GHS) children with short stature, were analyzed.   Real Time PCR was performed and number of copies of TREC were quantified.  Clinical data was collected from the medical charts.

Results: A total of 32 patients were recruited.  15 patients (47%) with GH deficiency (study group) and 17 patients (53%) with GH sufficiency (control group).  Both groups were similar in age and height.   TREC quantification was 1513 and 2309 in the study and control groups respectively (p-0.07).  A linear correlation was found between the peak GH level and TREC quantification (p<0.01).    

Conclusions: TREC levels were lower in GHD patients compared to GHS with a tendency towards significance.  A strong correlation was seen between peak GH levels during a stimulation test, and TREC levels.  These results support the role that GH may play in thymic activity.  A larger cohort of patients is needed to establish these correlations significantly.

2856: P1-856

SILVER RUSSELL SYNDROME CAUSED BY MUTATION IN THE ONCOGENIC PATHWAY HMGA2-PLAG1-IGF2
Frédéric Brioude, MD; Walid Abi Habib, PhD, Hopital Trousseau, Paris, France; Thomas Edouard, MD, Paul-Sabatier University, Toulouse, France; James T Bennett, MD, Seattle Children's Research Institute, Seattle, WA, United States; Anne Lienhardt-Roussie, MD, Centre Hospitalo-Universitaire de Limoges, Limoges, France; Frédérique Tixier, MD, Hôpital Debrousse, Lyon, France; Tony Yuen, MD, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Salah Azzi, PhD; Yves Le Bouc, MD, Hopital Trousseau, Paris, France; Madeleine D Harbison, MD, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Irene Netchine, MD, Trousseau Hospital, Paris-Est university, Paris, France

Objectives: IGF2 is an imprinted gene known to have a major role in the control of fetal growth. Silver Russell syndrome (SRS) is characterised by severe fetal and post-natal growth retardation, and is mainly caused by epigenetic defects within the 11p15 region (which includes IGF2). Indeed, loss of methylation at the paternal H19/IGF2:IG-DMR and chromosome 7 maternal uniparental disomy (upd(7)mat) are the main molecular mechanisms of SRS. However, despite a clinical diagnosis of SRS, about 40% of  the patients do not have a molecular defect identified. Therefore, we aimed to look for new molecular defects in patients with suspected SRS and no methylation defect at chromosome 11 or upd(7)mat.

Methods: Whole exome sequencing (WES) was performed on DNA from a familial case of SRS.  Targeted high throughput sequencing was then carried out on DNA from 192 sporadic patients referred for suspected SRS.

Results: From a familial case of SRS, we identified by WES a heterozygous mutation in the PLAG1 gene. As PLAG1 has been linked to HMGA2 and IGF2, targeted sequencing of these three genes  allowed the identification of five new mutations within the HMGA2-PLAG1-IGF2 pathway in five sporadic cases of SRS. In vitro studies with si-RNA mediated HMGA2 and PLAG1 silencing demonstrated the upstream regulation of IGF2 expression by this pathway through a specific P3-IGF2 promoter interaction, therefore confirming the implication of these mutations in the SRS phenotype.

Conclusions: Genetic disruption of the oncogenic HMGA2-PLAG1-IGF2 pathway represents a new molecular mechanism of foetal and post-natal growth restriction and cause of SRS. This confirms the role of this pathway in the regulation of physiological growth.

1849: P1-857

SHORT STATURE IN PRETERM BORN CHILDREN
Adriane A Cardoso-Demartini, PhD; Regina Paula GVC Da Silva, PhD; Francisca De Lara, social assistent; Margaret CS Boguszewski, PhD, Universidade Federal do Parana, Curitiba, Brazil

Objectives: Identify short stature in preterm born children.

Methods: Measurements at birth, 6, 12 and 24 months corrected age and at recall [6.4±0.5 years (5.2-8.0)]. Weight and length/height SDS were calculated (Fenton & Kim until 50 weeks; WHO 2006-2007, after). Short stature was defined as height SDS ≤-2, and extrauterine growth restriction (EUGR) as difference ≥2SD between birthweight and/or length to 40 weeks post-conception.

Results: 170 children (97 boys), gestational age (GA) 32.5±2.9 weeks (24.0-36.7), median birth weight 1772.5g (range, 580-3135), length 41.3±4.6cm (30-49). Fifteen children were extremely preterm (GA<28 weeks), 20 were small for GA (SGA). 32.7% of preterm children born appropriate for GA (AGA) had EUGR. Median weight SDS at 6, 12 and 24 months corrected age and at recall were -0.6, -0.2, -0.5 and -0.3, respectively. Correspondent values for lenght/height SDS were -0.4,-0.3, -0.3 and -0.3. Children born with GA<32 weeks and children born preterm SGA were leaner and shorter compared with those born after 32 weeks (p<0.01) and those born AGA (p<0.05). Twelve (7.1%) were underweight and 8 (4.7%) had short stature, which 4 were also underweight. Significant difference was observed only in height SDS of children whose mothers had eclampsia or severe preeclampsia (-1.0 vs. -0.3 SD, p=0.03). Nine children (5.9%) were short stature at 2 yrs. corrected age and remained significantly lower in weight and height at recall (p=0.02 and p<0.001, respectively) compared to normal height children at 2 yrs. Girls and boys height SDS was higher than their mothers' height (-0.3 vs. -0.8, p=0.03 and -0.3 vs. -0.9, p<0.001, respectively), but excluding from this analysis overweighted and obese children, the differences were not maintained. The main determinants of short stature were length SDS at 12 month corrected age (OR=0.29, p=0.02) and maternal height SDS (OR=0.13, p=0.01). Weight SDS at recall and length SDS at 24 months explained 87% of the height variation at recall (R=0.87, p<0.001).

Conclusions: Most preterm children recovered weight and length until 6 months of life. SGA birth, GA<32 weeks, lower maternal height, maternal eclampsia or preeclampsia and EUGR are risk factors for growth disorders in preterm born children.

1567: P1-858

GH THERAPY EFFICIENCY IN FETAL ALCOHOL SYNDROME
Georgiana Constantinescu, MD, University of Medicine and Pharmacy Gr. T. Popa Iasi, Iasi, Romania; Ioana Armasu, MD, University of Medicine and Pharmacy Gr T. Popa, Iasi, Romania; Mariana Cabac, MD, University of Medicine and Pharmacy Grigore T. Popa, Iasi, Iasi, Romania; Cristina Preda, MD, University of Medicine and Pharmacy "Gr. T. Popa", iasi, Romania; Elena Braha, MD, University of Medicine and Pharmacy Gr T Popa, Iasi, Romania; Anda Esanu, MD, University of Medicine and Pharmacy Gr. T. Popa, Iasi, Iasi, Romania; Carmen Vulpoi, Professor, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Iasi, Romania

Objectives: Fetal alcohol spectrum disorders describe a range of marked by impaired neurological and physical development, secondary to fetal alcohol exposure. Fetal Alcohol Syndrome (FAS) represents the most commonly recognized part of the spectrum with neurological and functional deficits. It associates characteristic clinical features such as smooth philtrum, thin upper lip, low nasal bridge, epicanthal folds, short nose and micrognathia, as well as intellectual impairment.  Growth delay secondary to growth hormone deficiency (GHD) represents one aspect. 

 To evaluate growth pattern in FAS children compared to GH deficient children. We present 5 clinical cases (1 girl and 4 boys- mean height 107.1±19.7cm, mean weight  14kg ± 2.65kg with mean age of 7.64 ±3.18 years) diagnosed with FAS  by suggestive phenotype in association with growth hormone deficiency (GHD) treated with rhGH. 

Methods: They were evaluated at initiation and 12 months after GH treatment. The clinical (height, weight, BMI) and biological response to treatment was compared with age-matched children (3 girls and 11 boys).

Results: GH treatment (mean 0.04 ±0.013 mg/kg/day) was introduced after confirmation of GH deficiency, with low IGF1 levels (mean 75.9 ± SD: 49.6ng/dl) at introduction. Comparisons were made between FAS and 14 sex and aged matched children with short stature in treatment with growth hormone.

There was no difference in growth rate between FAS children and the reference group (t test= 0.793, p=0.439). There was also no difference in growth gain in standard deviations between FAS children and the reference group (t test= 0.202, p=0.843). On the other hand, in order to obtain a growth rate comparable to children with hypopituitarism a higher dose of rhGH was needed (mean 0.040±0.013ui/kgc/day) compared to reference group (mean 0.0322±0.004ui/kg/day).

Conclusions: Fetal alcohol syndrome is a complex, non-curable entity without a specific treatment. Growth deficit represents one aspect of the disease, manageable by growth hormone treatment with similar results to children deficient in GH, without FAS. However, higher rhGH doses might be needed in order to attain the same growth rate and final height.

2896: P1-859

MEIER-GORLIN SYNDROME: COULD IGF1 DEFICIENCY PLAY A ROLE IN THE PATHOGENESIS OF SHORT STATURE IN THESE PATIENTS?
Gilda Belli, MD, Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Florence, Italy; Giovanni Poggi, MD, Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital , Florence, Italy; Laura Dosa, MD; Angelica Pagliazzi, MD, Anna Meyer Children's University Hospital, Florence, Italy; Stefano Stagi, MD, Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital , Florence, Italy

Objectives: We investigate the role of GH-IGF1 axis in Meier-Gorlin syndrome (MGS).

Methods: We performed clinical and endocrinological evaluation of a 3.9 years old male child from Senegal, referred to our hospital for dwarfism and microcephaly, reduced appetite and vomit.

Results: At the admission the weight was 4.860 g (-10.1 DS), height 64 cm (-9.3 DS) and OFC 45.5 cm (-3.0 DS). There was no data on prenatal growth. At clinical examination, he showed a triangular face, retro/micrognathia, microstomia, full lips, frontal bossing, clinodactyly of forth and fifth finger of both hands. Ears were underdeveloped, low set and rotated backwards. He also showed bilateral cryptorchidism and micropenis. Motor and speech development was delayed. Endocrine work-up evidenced a delayed bone age (9 months), unremarkable thyroid function tests, ACTH, cortisol, basal GH (6.37 ng/ml), while low levels of IGF1 (GMNN, encoding geminin, a DNA replication inhibitor; interestingly, so far other 3 cases of MGS with heterozygous GMNN gain-of-function mutations have been described. Considering the very low level of IGF1 and basal value of GH, we performed an IGF1 generation test: daily subcutaneous administration of GH at a dose of 0,03 mg/kg for ten days. IGF1 levels remained persistently low after stimulation (

Conclusions: In MGS, the variable results of GH stimulation tests and variable efficacy of GH therapy reported in literature suggest a wide range of GH sensitivity as possible contribute to the severity of phenotype in this syndrome. Nevertheless, the scarcity of data in literature about GH-IGF1 axis in MGS allows us only to speculate about the possible role of GH resistance in these patients, thus further studies are needed. Considering our data, we wonder if IGF1 replacement therapy might be useful to improve linear growth in these patients.

255: P1-860

THE EVALUATION OF PATIENTS RECEIVING GROWTH HORMONE THERAPY
Ayca Torel Ergur, MD; Sevinc Odabasi Gunes, MD; Ugur Can Kara, MD, Kirikkale University Faculty of Medicine, Kirikkale, Turkey

Objectives: Growth is a complicated process, which is affected by genetic, environmental factors, hormones and growth factors. One of the most important factors is growth hormone deficiency (GHD), which causes many serious problems in not only growth but also many other systems. In this study growth velocity (GV) and effect growth hormone therapy (GHT) on organs systems of patients who were diagnosed GHD and received (GHT) were discussed.

Methods: Forty-four patients who had low GV and diagnosed pathological short stature were involved in the study. Growth hormone stimulation tests were done in order to evaluate GHD. Peak growth hormone <5 ng/ml was diagnosed total GHD, 5-10 ng/ml was diagnosed partial GHD. GHT was started in adjusted dosages according to the etiology of GHD and patients were called for follow-up for every 3 months in order to investigate anthropometric measurements and effect of GHT on other systems by evaluating fasting blood glucose, fasting insulin,HbA1c, thyroid functions, total blood count, IGF1, IGFBP3. At the end of every year, GHT was discontinued for 6 weeks and insulin tolerance test was done in order to evaluate GHD.

Results: 22 girls and 22 boys, whose age was 10.36 ± 2.72 years and bone age was 8.04 ± 2.8 were involved in the study. Diagnoses of the patients were as follows: 19 total GHD, 20 partial GHD, 4 syndromic short stature (SSS) (2 Turner syndrome, 1 cleidocranial dysostosis, 1idiopathic), 1 neurosecratory dysfunction. GV of 29 patients who completed first year treatment was 9.46 ± 2.23 cm/year, 8 patients who completed second year treatment 7.03 ± 1.52 cm/year, 4 patients who completed third year treatment 6.67 ± 1.86 cm/year. 3 patients dropped out of treatment. HbA1c levels of the patients did not elevate during therapy and IGF1-IGFBP3 levels were within the secure limits.

Conclusions: We suggest that it’s important to close follow-up of patients receiving GHT for clinical and laboratory parameters in order to reach optimal predicted height. We believe that close follow-up of titration and application of dosage of growth hormone contributes to high GV results of our patients.

1207: P1-861

EFFICACY OF ONCE-WEEKLY ADMINISTRATION OF CTP-MODIFIED HUMAN GROWTH HORMONE (MOD-4023): 36-MONTH COMPLETE DATABASE RESULTS OF A PHASE 2 STUDY IN CHILDREN WITH GROWTH HORMONE DEFICIENCY
Nataliya Zelinska, MD, PhD, Ukrainian Children Specialized Clinical Hospital, Kyev, Ukraine; Yulia Skorodok, MD, State Pediatric Medical Academy, St. Petersburg, Russian Federation; Oleg Malievsky, MD, PhD, Bashkir State Medical University, Ufa, Russian Federation; Valentina Peterkova, MD-PhD, Institute of Pediatric Endocrinology, Moscow, Russian Federation; Lubov Samsonova, MD, Russian Medical Academy of Postgraduate Education, Moscow, Russian Federation; Ron G Rosenfeld, MD, Oregon Health & Science University, Portland, OR, United States; Zvi Zadik, MD, Kaplan Medical Center, Rehovot, Israel; Ronit Koren, PhD; Shelly Vander, MSc; Gili Hart, PhD, OPKO Biologics, Kiryat Gat, Israel; Dmitri Raduk, MD, PhD, 2nd Children City Clinic, Minsk, Belarus

Objectives: Growth hormone (GH) replacement therapy currently requires daily injections, which may cause poor compliance, inconvenience and distress for patients. CTP-­modified hGH (MOD-­4023) has been developed by OPKO Biologics for once­-weekly administration in growth hormone-deficient (GHD) adults and children. The 36-month efficacy of once-weekly subcutaneous (SC) administration of MOD-­4023 was evaluated in a Phase 2 study in GHD children.

Methods: An open-label extension of randomized, controlled Phase 2 study was conducted in children with GHD receiving once-weekly SC injections of one of three MOD-4023 doses (0.25, 0.48, and 0.66 mg/kg/week). During the 3rd year of treatment, patients on the two low doses of MOD-4023 were switched to a MOD-4023 dose of 0.66 mg/kg/week with growth to be routinely assessed until marketing approval. Height velocity (HV) results during the 3rd year of MOD-4023 treatment were compared to historical controls (Ranke et al., 2010), and IGF-1 and IGFBP-3 levels were monitored as well.

Results: The height velocity analysis included the full dataset for patients who completed 36 months of treatment. All 3 doses of MOD-4023 demonstrated promising 3rd year growth, in line with reported age-­ and GHD severity­-matched historical controls (Ranke et al., 2010).

Conclusions: The efficacy of single weekly MOD-4023 administration for the treatment of pediatric GHD was further confirmed during the 3rd year of treatment as part of the open-label extension of a Phase 2 study. This further affirms that a single weekly MOD-4023 injection has the potential to replace daily hGH in GHD children. Based on the above, a pivotal Phase 3 study will be initiated shortly at a dose of 0.66 mg/kg/week. Patients in the Phase 2 study who have been switched to the high dose in the 3rd year will continue to be followed and monitored for long-term assessment.

Disclosure: RGR: consultant for OPKO Biologics. OM: Investigator, Ascendis Pharma. Nothing to disclose: NZ, YS, VP, LS, ZZ, RK, SV, GH, DR.

1260: P1-862

FINAL HEIGHT IN KOREAN PATIENTS PRESENTED WITH SHORT STATURE, CLINICAL UTILITY AND ANALYTICAL VALIDITY OF HEIGHT PREDICTION METHODS IN KOREA
Ja Hyang Cho, MD; Byung Ho Kang , MD, Kyunghee university hospital , Seoul, Korea, Republic Of; Hae Woon Jung, MD, Kyung Hee University Medical Center, Seoul , Korea, Republic Of; Kye Shik Shim, MD, Kyung Hee University Hospital at Gangdong, Seoul, Korea, Republic Of

Objectives: Predicted adult height (PAH) is often used to evaluate children with short stature or precocious puberty. As the performance of such prediction of final adult height (FAH) is often crucial to decision-making about treatment with human growth hormone (GH) or gonadotropin-releasing hormone agonist (GnRH agonist), we sought to evaluate programs used to PAH. This study aims at evaluating clinical utility and analytical validity of height prediction testing in patients untreated with GH.

Methods: We retrospectively analyzed clinical findings and evaluated FAH of 46 patients (22 males, 24 females) who visited our clinic between August 2006 and August 2016 and reached FAH. The patients treated with GH or GnRH agonist were all excluded. Multiple data including gender, physical findings, midparental target height, and PAH were assessed. FAH was also compared with the PAH by the methods of Bayley-Pinneau (BP), Tanner-Whitehouse Mark II (TW II) and Roche-Wainer-Thissen (RWT).

Results: Among 46 patients who were referred for short stature, FAH was 165.27± 5.35 cm(- 0.45± 0.58 SDS) in males and 154.35±5.34 cm(- 0.71 ± 0.71 SDS) in female, both of them were lower than PAH. Of these, the difference between FAH and PAH was larger in male than female group. PAHs in male were -0.22± 0.72 SDS by TW II, -0.07± 0.68 SDS by RWT, and 0.24±0.86 SDS by BP, respectively. PAHs in female were -0.08 ± 0.69 SDS by TW II, 0.19± 0.56 SDS by RWT, and -1.24± 0.82 SDS by BP, respectively. The difference between the FAH and the PAH was -0.22 ± 0.68 SDS by TWII, -0.38 ± 0.72 SDS by RWT, and -0.69 ± 0.81 SDS by BP in male, respectively. The difference between the FAH and the PAH was -0.62 ± 0.88 SDS by TWII, -0.89 ± 0.6 SDS by RWT, and 0.53 ± 0.6 SDS by BP in female, respectively. PAH using BP was more strongly correlated with FAH than other methods in female (R=0.698, P<0.05)

Conclusions: BP method is more useful to predict FAH than other methods in female. Although these prediction tools can be helpful in making decisions, careful attention is still required when using them because there was an inaccuracy in PAH.

319: P1-900

COEXISTENCE OF ENDOCRINOPATHIES IN CHILDHOOD RHEUMATIC DISEASES
Doha S. Alhomaidah, MD, Farwanya Hospital, Sabah Al-Naser, Kuwait; Afaf Alsaghier, MD; Sulaiman M Al-Mayouf, MD, King Faisal Hospital and research center, Riyadh, Saudi Arabia

Objectives: * To screen the endocrine dysfunction in SLE and JIA patients.

* To identify the pubertal delay in these patients.

Methods: * A cross-sectional study was conducted on Saudi children with SLE and JIA who are followed at King Faisal Specialist Hospital and Research Center, Riyadh between September 2013 and April 2015.

* All patients were reviewed for demographic data, disease duration. Patients have completed the clinical assessment including family history of autoimmune diseases, growth parameters and tanner stage as well as the following investigations: parathyroid hormone, 25-OH vitamin D levels, TSH, FT4, thyroglobulin antibodies, thyroperoxidase antibodies, random blood sugar, HbA1C, IGF1, IGFBPIII, LH, FSH.

* For SLE patients, complement (C3, C4) levels, anti-double-stranded DNA antibody and anti-nuclear antibody were included. 

* Furthermore, we calculated the disease activity score using Systemic Lupus Erythematosus Disease Activity Index (SLEDAI).

* The proposal approved by the Research Affairs Council at KFSHRC.

Results: * A total of 42 (30 female) of consecutive Saudi children, 22 with JIA and 20 with SLE were included.

* All SLE patients had multiple organs involvement. 

* JIA patients comprised 13 patients with polyarticular subtype, 4 patients with oligoarticular subtype and 5 patients with systemic onset subtype.

* The most common autoimmune disease among family members was hypothyroidism.

* The most frequent endocrinopathies were vitamin D insufficiency (35%) and thyroid disease (31%).

* Nineteen patients (11 SLE, 8 JIA) were short for their age and gender; 7 patients (4 SLE and 3 JIA) had growth hormone insufficiency as confirmed by low IGF1, IGFBPIII.

* Sixteen SLE patients found to have active disease with a mean of SLEDAI score 6. The levels of 25-OH vitamin D correlated inversely with SLEDAI scores but not statistically significant.

Conclusions: * Our findings showed that coexistence of endocrinopathies are not uncommon in children JIA and SLE.

* Abnormal thyroid function occurs frequently and similar in SLE and JIA.

* Screening for possible endocrinopathies namely thyroid disease during assessment of SLE and JIA children is worth to consider.

1150: P1-901

HORMONAL PROFILE OF CHILDREN AND ADOLESCENTS WITH PRADER-WILLI SYNDROME
Iuliana Gherlan, MD, ”C.I.Pahon” National Insitute of Endocrinology , Bucharest, Romania; Cristina Patricia Dumitrescu, PhD; Andra Caragherogheopol, MS/MA; Florin Alexiu, Physicist, ”C.I.Pahon” National Institute of Endocrinology, Bucharest, Romania; Camelia Procopiuc, MD, "CI Parhon" National Institute of Endocrinology, Bucharest, Romania

Objectives: Prader-Willi syndrome (PWS) is a genetic disorder characterized by severe infantile hypotonia and failure to thrive in infancy, hyperphagia with early-childhood onset obesity, central hypogonadism, characteristic dysmorphic features and developmental delay. Growth hormone insufficiency is frequent, but a complete description of the entire hormonal profile of those patients is rare.

Methods: We retrospectively reviewed the medical records of PW patients admitted to paediatric endocrinology department between 2010 and 2016.

Results: 15 PW patients (11 boys, 4 girls, mean age at diagnosis 5.6 years), were investigated in a 6 year period.

12/15 patients had height below mean, 3/15 (20%) patients were 2 SD below mean at first admission.

93.33% of patients had a BMI above 2 SD at first evaluation. IGF1 had values below mean in 84.6 % cases, in average -1.2 SD±1.24 SD compared to age and sex.

freeT4 was persistently in normal range in all patients, only one patients had  repeatedly increased values of TSH indicating subclinical hypothyroidism.

Low values of morning plasmatic cortisol were described in 4/15 (26.67%) patients; in all cases central adrenal insufficiency was excluded by performing 1µg Synacthen stimulation test – interestingly, all these patients had high normal values of plasmatic cortisol at 6 A.M., indicating a dysregulation of circadian rhythm of hormonal secretion. 60% patients had serum levels of DHEAS above normal range, 1 female patient had clinical evident precocious adrenarche.  

81.8% boys had uni/bilateral cryptorchidism, 75% boys at pubertal age had no signs of pubertal onset.

Conclusions: PW syndrome in children and adolescents is associated with a pleomorphic hormonal profile (aside GH deficiency); an extended protocol of endocrine evaluation needs to be applied.

1035: P1-902

CLINICAL AND ENDOCRINOLOGIC MANIFESTATIONS OF ANOREXIA NERVOSA IN ADOLESCENT AND YOUNG ADULT MALES VERSUS NORMAL WEIGHT CONTROLS
Karol Silla, Student, Weill Cornell Medicine in Qatar, Doha, Qatar; Kathryn Brigham, MD, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Mark Goldstein, MD, Massachusetts General Hospital, Harvard Medical School , Boston, MA, United States; Shreya Tulsiani, BS/BA; Madhusmita Misra, MD; Vibha Singhal, MD, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States

Objectives: Current literature suggests a female predominance for anorexia nervosa (AN). The reason for this gender bias could be under reporting in males or a true biological bias in females. Enhanced provider awareness and higher index of suspicion could prevent the delay in the diagnosis in males. Clinical and endocrinologic features associated with AN are well characterized in females, but not in males with the disorder. We aimed to delineate the clinical and endocrinologic features at presentation in males with AN.

Methods: A retrospective chart review was conducted between 2000 and 2016 of 53 males-36 with AN and 17 normal-weight healthy controls (HC), aged 10-23 years. AN was diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV or V (depending on the year of diagnosis). Data were extracted from electronic medical records.

Results: AN and HC did not differ for age or height. As expected, AN had lower BMI (17.8±1.7 vs.21.3±2.6 kg/m2; P<0.0001) and BMI%ile [8.38 (2.81–19.49) vs.57.1 (44.46–77.14)] than HC. The mean age at AN diagnosis was 15.9±3.0 years. A sizeable proportion of males with AN had low random plasma glucose (17%) and polycythemia (29%). There was no difference between groups in serum sodium or potassium levels. 16.7% patients had a previous history of obesity. The most prevalent mode of weight loss (after calorie restriction) was over exercising, which was seen in 38.9% of the group.

55% of AN males were hypogonadal. For the subset in whom testosterone levels were available (AN n=14; HC n=8), at Tanner 5 by exam, AN had significantly lower total testosterone levels compared to HC (P<0.0001).  Total testosterone levels were positively associated with %median BMI for age (r=0.52, P=0.0015), BMI%ile for age (r=0.55, P=0.0006), red cell count (r=0.48, P=0.014), hemoglobin levels (r=0.47, P=0.016), and fasting plasma glucose levels (r=0.42, P=0.014).

Conclusions: Over exercising is the second most prevalent mode of weight loss in males with anorexia nervosa. Anorexia nervosa should be considered in a post pubertal male with hypogonadism. Low testosterone levels are common in this condition and may contribute to clinical features such as anemia.

577: P1-903

INSULIN SENSITIVITY REGULATING MIRNAS SHOW CHANGES IN GRANULOSA CELLS (GC) FROM POLYCYSTIC OVARY SYNDROME (PCOS) OVARIES
Francesca Cirillo, PhD; Pietro Lazzeroni, MD; Chiara Sartori, MD; Daria Morini, MS/MA; Alessia Nicoli, MS/MA, Arcispedale S. Maria Nuova- IRCCS, Reggio Emilia, Italy; Paolo Giorgi Rossi, PhD, AUSL Reggio Emilia, Reggio Emilia, Italy; Sergio Amarri, MD, Arcispedale S. Maria Nuova- IRCCS, Reggio Emilia, Italy; Giovanni B La Sala, MD, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy; Maria E Street, MD, Arcispedale S. Maria Nuova- IRCCS, Reggio Emilia, Italy

Objectives: Changes in miRNA levels are associated with insulin resistance and inflammation, that are features of PCOS. FOXO1, a key factor in insulin signaling, is also cystic fibrosis transmembrane conductance regulator(CFTR)-dependent. We showed that CFTR and FOXO1 genes are downregulated in PCOS ovaries (unpublished data). MiR155 was reported as an HMGB1induced inflammation suppressor in the liver.We aimed to assess differences in miR146a, miR155, miR320, and miR370 in GC of women with or without PCOS undergoing IVF, all FOXO1 and insulin sensitivity regulators.

Methods: We enrolled 20 women(CA:31.1±1.2yr;BMI:25.2±1.2Kg/m2;hirsuteN.4;with amenorrhoea N.2; oligomonerrhoea N.9; regular cycles N.9) with PCOS according to the Rotterdam Criteria, undergoing ovarian stimulation for IVF, and 30 healthy women(CA:36.2±0.7yr; BMI:23.9±0.9Kg/m2), fertile oocyte donors, with tubarian or unknown infertility causes, normal endocrine exams and menstrual cycles(CTRL).

RNA from GC, isolated from follicular fluid(FF),was extracted using the MirVana kit. MiRNAs of interest were assessed using TaqMan qPCR and normalized with respect to U6 snRNA and RNU48. Relative gene expression was calculated as dCTs and fold change. HMGB1 was assayed in FF using a specific ELISA kit. The N. of dominant follicles(>17mm) after stimulation was also considered for statistical analyses.

Results: miR155 was lower in PCOS compared with CTRL(6.1±0.2 vs 7.1±0.1dCT,p<0.05).

In the entire group, miR155 correlated with both HMGB1(r:-0.28; p:0.05) and miR146a(r:0.49;p:0.001), and miR155 with CA(r:0.29;p:0.04) and with N. of follicles(r:-0.43;p:0.003). MiR320 correlated with both miR370 (r:0.60;p:0.001) and CA(r:-0.29;p:0.04). In PCOS, miR146a correlated with miR155(r:0.75;p:0.001) and miR320 correlated with both miR370(r:0.65;p:0.005) and CA (r:-0.61;p:0.009). MiR370 correlated with CA(r:0.5;p:0.042). In CTRL, miR146a correlated with both miR320(r:0.48;p:0.008) and miR370 (r:0.38;p:0.039). MiR155 correlated with both miR320(r:0.53;p:0.003) and CA(r:-0.38;p:0.04). Finally, miR320 correlated with miR370(r:0.54;p:0.002).

Conclusions: These miRNAs showed relationships with HMGB1,reflecting glucose metabolism and inflammation, CA, and N. of dominant follicles. In PCOS GC, miR155 was lower.

407: P1-904

HIGH MOBILITY GROUP BOX 1 (HMGB1) IS INCREASED AND CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR (CFTR) AND WINGED HELIX FORKHEAD (FOXO1) ARE REDUCED IN OVARIES FROM POLYCYSTIC OVARY SYNDROME (PCOS)
Francesca Cirillo, PhD; Chiara Sartori, MD; Pietro Lazzeroni, MD; Cecilia Catellani, BS/BA; Daria Morini, MS/MA; Alessia Nicoli, MS/MA, Arcispedale S. Maria Nuova- IRCCS, Reggio Emilia, Italy; Paolo Giorgi Rossi, PhD; Pamela Mancuso, BS/BA, AUSL Reggio Emilia, Reggio Emilia, Italy; Sergio Amarri, MD; Giovanni B La Sala, MD; Maria E Street, MD, Arcispedale S. Maria Nuova- IRCCS, Reggio Emilia, Italy

Objectives: We described in cystic fibrosis related diabetes, reduced FOXO1 and increased HMGB1 both dependent on CFTR loss of function. HMGB1 was related with insulin-resistance, glucose tolerance state and inflammation. Inflammation is a feature also of PCOS. Therefore, we hypothesized that CFTR and FOXO1 could be reduced in granulosa cells(GC) and HMGB1 increased in follicular fluid (FF) in PCOS.

Methods: We enrolled, 30 women(CA:33.2±1.0yr;BMI:25.6±0.9kg/m2; hirsute N.12; with amenorrhoea N.5; oligomonerrhoea N.14; regular cycles N.11) with PCOS according to the Rotterdam Criteria, undergoing ovarian stimulation for IVF, and 50 women (CA:36.8±3.7yr; BMI:24.3±0.4kg/m2), fertile oocyte donors, with tubarian or unknown infertility causes, with normal endocrine exams, regular menstrual cycles, no hyperandrogenism, as controls(CTRL). Subjects with genetic diseases, chronic diseases, coeliac disease, tumors and endometriosis were excluded.

RNA was extracted from GC isolated from FF using Ficoll in 8 PCOS and 8 CTRL using the MirVana kit. CFTR and FOXO1 were evaluated using TaqMan qPCR, normalized with respect to β-Actin, as housekeeping gene. PCOS dCts were differentially expressed with respect to the pool of CTRL dCts. Relative gene expression was calculated as fold change. HMGB1was assayed in FF using a specific ELISA kit. Statistical analyses were performed and stratified regression models used separately for PCOS and CTRL to test the effect of E2, N. of dominant follicles(>17mm at pickup), CA, BMI, hirsutism and features of menstrual cycles (only in PCOS) on HMGB1. All models were adjusted for CA and BMI. Estradiol (E2) was assayed in serum at pickup.

Results: CFTR and FOXO1 gene expression were downregulated in PCOS(-0.4±0.008 and -0.1±0.003, respectively).

HMGB1 was higher in PCOS than in CTRL, independent of CA and BMI(42.4±4.4 vs 30.9±3.2ng/ml p<0.05). E2 was also higher in PCOS than in CTRL (2013.6±268.9 vs 1348.1±127.4pg/ml, p<0.05).

Both in PCOS and CTRL, CA, BMI, and N. of follicles were not associated with HMGB1. In CTRL, HMGB1 was significantly associated with E2 (p:0.02;[CI 0.001-0.014]).

Conclusions: CFTR and FOXO1 gene expression are reduced in the ovaries of PCOS women and this is associated with an increase in HMGB1. This increase is independent of CA and BMI.

1090: P1-905

OCCULT INSULINOMA, GLUCAGONOMA AND ENDOCRINE PANCREATIC PSEUDOTUMOUR IN A PATIENT WITH MULTIPLE ENDOCRINE NEOPLASIA TYPE 1.
Tonje D Erichsen, MBBS; Sönke Detlefsen, PhD; Henrik Pedersen, MD; Lars Rasmussen, MD, Odense University Hospital, Odense, Denmark; Svend Pörksen, MD, Roskilde Hospital, Roskilde, Denmark; Henrik t Christesen, PhD, Odense University Hospital, Odense, Denmark

Objectives: To describe exceptional pancreatic features of Multiple Endocrine Neoplasia type 1 (MEN1) in an adolescent.

Methods: Prospective patient evaluation.

Results: A 14 year old adolescent MEN1 patient with a novel MEN1 mutation, c.1391dupC, p.Ala465GlyfsTer66, presented with severe hyperinsulinemic hypoglycemia, but repeated imaging with endoscopy, MRI, 68Ga-DOTA-NOC PET/CT, 18F-DOPA PET/CT and 111-Indium-exendin SPECT failed to identify the occult insulinoma. An identified pancreatic tumor was resected, but revealed to be a glucagonoma.  Resection of the pancreatic head failed to cure the patient despite increased caput labelling. By the third surgery, a lesion that we termed a pancreatic endocrine pseudotumor was resected, representing increased pancreatic islet tracer DOPA PET labelling due to severe aggregation of islets of Langerhans after inflammatory destruction of exocrine pancreatic tissue as the result of the previous surgery. The insulinoma was only detectable and removed after eight months of search despite extensive diagnostic imaging including several different PET/CT scans.

Conclusions: A pancreatic endocrine pseudotumour occurred as a novel manifestation of MEN1 after repeat pancreatic surgery. Prolonged conservative treatment instead of surgery in MEN1 without clearly visible pancreatic tumors at imaging should be balanced against the risk of development of metastases, side effects, and quality of life.

1357: P1-906

A CASE OF CONGENITAL GENERALIZED LIPODYSTROPHY TYPE 2 WITH NOVEL BSCL2 GENE MUTATION
Fatih Gurbuz, MD; Ihsan Turan, MD; Mehmet Tastan, MD; Ali K Topaloglu, MD, Cukurova University, Adana, Turkey; Bilgin Yuksel, MD, Çukurova University Faculty of Medicine, Adana, Turkey

Objectives: Congenital generalized lipodystrophy (CGL), or Berardinelli-Seip syndrome [OMIM 269700], is a rare autosomal recessive disorder characterized by the generalized absence of adipose tissue, extreme insulin resistance, hypertriglyceridemia, hepatomegaly, hepatic steatosis and early onset of diabetes mellitus. Four unrelated genes have been identified as causative genes for CGL; AGPAT2 gene cause type 1 (CGL1), BSCL2 gene cause type 2 (CGL2), CAV1 gene cause type 3 (CGL3) and, PTRF gene cause type 4 (CGL4). Herein, we described a case with CGL2 due to novel homozygous BSCL2 gene mutation.

Methods: Case: Three years-seven months old girl presented with a general lack of subcutaneous fat, prominent muscular hypertrophy, hollow cheeks, triangular face, acanthosis nigricans nigricans in fold areas; especially in the neck and bilateral axilla and hypertrichosis in arms and legs,  abdominal swelling due tohepatomegaly, which are all of characteristic physical findings of CGL. Her parents were first degree cousins. She was born as a term neonate weighing 2500 g with no perinatal complications. In laboratory findings (reference ranges) were as follows: glucose 75 mg/dL (70-105), C-peptide 6.8 ng/mL (0.9-4.3), insulin 47.4 µIU/mL (1.9-23), HbA1c 5.2% (4.8-6.0). total cholesterol 132 mg/dl (<200), triglyceride 134 mg/dl (<200), AST 39 U/L, ALT 55 U/L.  Hypertriglyceridemia was first detected at 5 years of age in patients with metformin therapy for insulin resistance. Despite taking metformin treatment, the patient's insulin levels increased steadily, and serum AST levels were also elevated. At the age of nine years, grade-2 hepatic steatosis with hepatomegaly was detected in abdominal ultrasonography.

Results: During follow-up, her HbA1c level elevated to 6.5% at the age of eleven year and three months. The fasting and 2-hour post-OGTT glucose-insulin levels of patient were 152 mg/dL-158.3 µIU/mL and 209 mg/dL-95.8 µIU/mL, respectively. Insulin detemir was started in addition to metformin treatment because of diagnosis diabetes.

A clinical diagnosis of CGL was corrected by the identification of a novel homozygous mutation (IVS2+2 T>C) of the BSCL2 gene. 

Conclusions: Analyzes with GenSplicer and HumanSplicingFinder modeling programs show that this mutation can cause this disease.

943: P1-907

CENTRAL PRECOCIOUS PUBERTY, GROWTH HORMONE DEFICIENCY AND SEVERE PROGRESSIVE SCOLIOSIS IN NON-CLASSIC CONGENITAL ADRENAL HYPERPLASIA (NCAH) WITH PRESERVATION OF FINAL ADULT HEIGHT: A CASE STUDY
Irena Hozjan, MN; Denis Daneman, MD; Irena Hozjan, MN, University of Toronto, Toronto, ON, Canada

Objectives: Background:

Treatment of NCAH presents a challenge as interventional therapies are often required to manage the hormonal effects of the diagnosis. Occasionally, there are additional challenges.

Methods: Case presentation:

Young male, first seen at 5.5 years of age with a two year history of virilising changes (↑Pubic hair, ↑ phallus size) and tall stature. No family history of precocious puberty or other health conditions. Mid-parental height 170 cm. Height 128cm (++>97 centile), weight 29.8 kg, mild facial acne, mild facial hair, skin pigmentation normal, T3 PH, testes 3 mls. Bone age 10 years, 17OHP 144, De-oxycortisol 171, Renin 0.83 (0-1.7). Homozygous for intron 2 mutation in 21 OH gene, NCAH. Glucocorticoid therapy initiated.

At 6.4 years, poor treatment adherence and pubertal progression noted, testes 4 mls, BA 12-13 years. LHRH stimulation test noted a pubertal response, and GnRH agonist initiated.

At 10.9 years poor growth velocity noted and subsequent provocative GH stimulation testing indicated growth hormone deficiency (GHD) and GH therapy initiated.

At 13 years, a moderate S-shaped thoraco-lumbar scoliosis was noted. Over time, worsening scoliosis with unbalanced curves developed. MRI brain/spine noted no cause of scoliosis. Spinal fusion surgery ultimately required. Final adult height (FAH) 171.4cm.

Results: N/A

Conclusions: The diagnosis of central precocious puberty was anticipated in the management of NCAH; however, GHD was novel as was the development of a severe progressive S-shaped scoliosis while on GH therapy. GHD and scoliosis are not known risk factors in NCAH. Scoliosis is reported in less than 1% of the patients in post marketing GH surveillance databases. Spinal curvature progression may occur during growth acceleration in adolescence, and a causal association with GH treatment has not been substantiated. Progression of scoliosis is associated with double major curves and GH may increase the risk of progression, as in this patient scenario, and requires vigilance by the treating practitioner. 

324: P1-908

ADRENOCORTICOTROPIC HORMONE DEFICIENCY AS PRESENTATION FORM OF MULTIPLE HORMONE RESISTANCE IN PSEUDOHYPOPARATHYROIDISM TYPE 1A: DESCRIPTION OF 2 CASES.
Nadya K Jaimes, MD, Hospital Vall d´Hebron, Barcelona, Spain; Lisa Bianco, MD, Hospital Vall Hebron, Barcelona, Spain; Giomar Perez, MD, OSI Araba Txagorritxu. , Vitoria-Gasteiz, Álava, Spain; Ariadna Campos, PhD, Hospital Vall d´Hebron, Barcelona, Spain; Diego Yeste, PhD, Hospital Vall d´Hebron/ Autonomous University. CIBERER, Barcelona, Spain; Maria Clemente, MD, Hospital Vall Hebron, Barcleona, Spain

Objectives: Pseudohypoparathyroidism type 1a (PHP1a) is caused by mutations in the GNAS gene (coding for the Gs-alpha protein), and may be associated with multiple hormone resistance, most frequently thyroid-stimulating hormone (TSH) and parathyroid hormone (PTH).

Methods: CASE 1

A 6-year-old boy had a history of desmoplastic medulloblastoma (currently stable), spastic tetraparesis and developmental delay. In the neonatal period, hypothyroidism was detected together with asymptomatic hypoglycaemia with hyperinsulinaemia and hypocortisolism. (Table 1) No other hypothalamic-pituitary alterations were detected in blood tests or by MRI. Throughout evolution, he was reevalued on 3 occasions with fasting cortisol values <3µg/dL and ACTH <25pg/mL. At 6 months of age, he presented asymptomatic hypocalcaemia with hyperphosphoraemia, elevated serum PTH and low vitamin D3 levels. Renal function is normal. The patient presents round facies, obesity and generalised brachydactyly of hands and feet.

CASE 2

A 5-year-old girl had a history of neonatal sepsis, spastic tetraparesis, epilepsy and overall developmental delay. In the context of neonatal sepsis, she presented hypoglycaemia with low cortisol and hypothyroidism. (Table 1). Thyroid ultrasonography was normal and MRI showed no alterations in the hypothalamic–pituitary axis. On several occasions, she presented low values of ACTH and cortisol and fasting hypoglycaemia coinciding with the withdrawal of hydrocortisone. From 4 years of age, she presented high serum PTH levels and calcium, phosphorus and 25 OH vitamin D levels were normal. She presented short stature, obesity, round facies and brachydactyly (shortening of the fourth and fifth metacarpal bones). 

Results: Owing to the clinical history and analytical reports in association with the features of Albright’s hereditary osteodystrophy (AHO), it was decided to study the GNAS gene which showed the same change in heterozygosity in exon 9, a substitution of arginine for cysteine in position 232. (p.R232C; c.697C>T).

Conclusions: ACTH deficiency, though rarely described, may be an early manifestation of PHP1a, perhaps a specific mutation. The association of peripheral hypothyroidism and ACTH deficiency raises the suspicion of multiple hormone resistance syndrome.

851: P1-909

GROWTH HORMONE DEFICIENCY, HYPERGONADOTROPIC HYPOGONADISM AND COHEN SYNDROME FEATURES IN TWO SISTERS-A NEW SYNDROME?
Mirjana Kocova, PhD; Elena Sukarova-Angelovska, PhD, University Pediatric Clinic, Medical faculty, Skopje, Macedonia, The Former Yugoslav Republic Of; Jurgen Klammt, PhD, University of Leipzig, Leipzig, Germany; Bernard Aral, PhD, Univeristy of Dijon, Dijon, France; Mehul Dattani, Professor, UCL Great Ormond Street Institute of Child Health, London, United Kingdom

Objectives: Background: Rare diseases have become a new field in medicine. However, overlapping and various symptoms frequently make the clinical diagnosis cumbersome.

Objective and hypotheses:To present two sisters with unusual association of clinical symptoms with a complex diagnostic approach. It might be a new syndrome.

Methods: Methods:GH deficiency was diagnosed through L-dopa test. LH, FSH and estrogens were analyzed. Internal genitalia were assessed using ultrasound and pelvic MRI. Genetic testing for GH and GHRH gene, as well as COH1 gene were performed in collaboration with different laboratories.

Results: Both girls had severe dwarfism starting early in infancy. They had some of the features of Cohen syndrome (obesity, short philtrum, severe myopia and ambliopia but without chorioretinal dystrophy, thick hair and leucopenia). Testing for GH confirmed complete isolated GH deficiency and therapy with GH was carried for 14 and 12 years respectively with excellent response (reaching final height at 25%o). Puberty did not occur and FSH and LH values were high (FSH=60.2 IU/ml, GH-37.3 IU/ml, and FSH= 56 IU/ml,LH=33 IU/ml respectively).Estrogenes were not detectable. Ultrasound and MRI showed absence of the ovaries and severe hypoplasia of the uterus. There were no mutations of Prop or Pit 1 gene, and only one splicing mutation in the COH1 gene was detected, rejecting the autosome recessive Cohen syndrome. No patient with Cohen syndrome has been reported with GH deficiency, nor with hypergonadotrophic hypogonadism.  The older syster was with normal development and graduated from university, whereas the younger had moderate mental retardation requiring special schooling. Exon sequencing of the candidate gene is underway for a possible detection of a new syndrome.

Conclusions: This is a complex syndrome involving dysmorphic features, eye involvement, GH deficiency and hypergonadotropic hypogonadism. Molecular analyses performed so far suggest that it might be a rare variant of Cohen syndrome or a new syndrome.

384: P1-910

A CASE OF GENETICALLY CONFIRMED 29-MONTH-OLD BOY WITH FAMILIAL MULTIPLE ENDOCRINE NEOPLASIA TYPE 1(MEN1)
Jun Hui Lee, MD, Catholic university of Korea, Seoul, Korea, Republic Of; Moon Bae Ahn, MD, College of medicine, The Catholic University of Korea, Seoul, Korea, Republic Of; Min Ji Son, MD; Shin Hee Kim, MD; Su Yeon Kim, MS/MA, Catholic University of Korea, Seoul, Korea, Republic Of; Won Kyoung Cho, PhD, College of medicine, The Catholic University of Korea, Seoul, Korea, Republic Of; Kyoung Soon Cho, MD; Sung-Dae Moon, PhD; Kyoung Soon Cho, MD, Catholic university of Korea, Seoul, Korea, Republic Of; Min Ho Jung , PhD, College of medicine, The Catholic University of Korea, Seoul, Korea, Republic Of

Objectives: Multiple endocrine neoplasia type 1 (MEN1) is an inherited disorder recognized as tumors within 2 or more endocrine glands in a single patient. MEN1 is caused by mutations inactivating tumor suppressor gene MEN1 and follows an autosomal dominant inheritance with 50 % chance of passing the affected gene onto the subsequent offspring.

Methods: A 29-month-old boy was referred with familial history of MEN1. The index patient was his father who underwent tumor resection of multiple organ sites including parathyroid gland, pancreas, duodenum, and thyroglossal duct. Other relatives in the pedigree, except for the patient’s aunt who was also affected by the disorder, had never been screened. The patient showed no clinical signs or symptoms without any evidence of abnormal findings on physical examination and biochemical studies.

Results: Genetic testing revealed a heterozygous nonsense mutation, which was identical to his father’s, caused by conversion of tryptophan into stop on codon 471 of exon 10 of MEN1 (W471X). According to the disease characteristics, tumor progression can occur as early as the age of 5 (i.e. insulinoma or anterior pituitary tumor), therefore, identification of a germline MEN1 mutation should soon be preceded especially for a first degree with family history.  Afterwards, timely mannered biochemical and radiological approaches are suggested for systematic evaluation and effective long term management.

Conclusions: A child suspicious of MEN1 should be referred to pediatric endocrinologist to undergo accredited genetic testing and counselling and confirm the diagnosis in prior to any particular biochemical and radiological screening is proposed.

1208: P1-911

PROHORMONE CONVERTASE 1/3 DEFICIENCY DUE TO A HOMOZYGOUS PCSK1 MUTATION AS CAUSE OF CONGENITAL MALABSORPTIVE DIARRHEA IN ASSOCIATION WITH BLUE-DIAPER SYNDROME
Thomas Meissner, MD, University Children`s Hospital Düsseldorf, Düsseldorf, Germany; Diran Herebian, PhD, University Children’s Hospital , Düsseldorf, Germany; Sebastian Kummer, MD, University Children's Hospital , Düsseldorf, Germany; Michael Friedt, MD, University Children’s Hospital, Düsseldorf, Germany; Ertan Mayatepek, MD, University Children's Hospital , Düsseldorf, Germany; Tim M Strom, MD, Technical University of Munich, München, Germany; Tobias B Haack, MD, University of Tübingen, Tübingen, Germany; Felix Distelmaier, MD, University Children’s Hospital, Düsseldorf, Germany

Objectives: To identify the origin of clinical symptoms in a neonate of healthy consanguineous parents from northern Syria who presented with severe malabsorptive diarrhea. In addition, a bluish discoloration of the diaper was noted at several occasions, leading to the suspicion of Blue-diaper syndrome (BDS), an enigmatic disease entity characterized by urinary excretion of indigo derivates.

Methods: The underlying genetic cause of the disease was analyzed by whole-exome sequencing. To further support the idea of BDS, we analyzed urine samples of the child at different time intervals using a triple quadrupole mass spectrometer Xevo TQ-S coupled with an UPLC-I-class system.

Results: Extensive diagnostic work-up including intestinal and liver biopsies could not clarify the underlying pathology. Whole exome sequencing revealed a homozygous frameshift mutation in PCSK1 (NM_000439.4: c.679del, p.Val227Leufs*12) while the parents were identified as heterozygous carriers. Mutations in PCSK1 have been reported as a rare cause of early-onset malabsorptive diarrhea and multiple endocrine dysfunctions. PCSK1 encodes prohormone convertase 1/3, which is a calcium-dependent serine endoprotease that is essential for peptide hormone processing and activation. Laboratory work-up confirmed the diagnosis of prohormone convertase 1/3 deficiency (e.g. by detection of massively increased serum proinsulin levels). Further investigations  demonstrated the presence of indigo derivatives in urine samples with highest concentrations during the first week of life. Of note, bluish discoloration of diapers was variable and not constantly visible, especially during later disease course.

Conclusions: The association of BDS and congenital malabsorptive diarrhea might be indicative of prohormone convertase 1/3 deficiency. The formation of indigo blue has been linked to unabsorbed tryptophan, leading to bacterial degradation of tryptophan to indole, which is absorbed and metabolized to 3-hydroxyindol. Urinary 3-hydroxyindol dimerizes under slightly basic pH conditions to indigo blue. Further studies measuring urinary indigo concentrations of patients with PCSK1 defects and/or of in infants with malabsorptive diarrhea might help to determine the specificity and prevalence of this phenomenon.

369: P1-912

PARATHYROID ADENOMA FIRST SIGN OF ENDOCRINE NEOPLASIA (MEN1)FAMILIAL TYPE
Liliana Mejia De Beldjenna , MD, Universities Libre and ICESI ,Fundations Clinics:InfantiL Club Noel and Clinic Valle del Lili , cali, Colombia; Juliana Llano , MD, Georgetown University/Providence Hospital, Washington , WA, United States; David Mejia , MD, Universidad Valle , cali, Colombia; Marcia Perez, MD, Fundation clinica Infanti Club Noel , Cali, Colombia

Objectives:  To describe  the importance of the presence  of PARATHYROID ADENOMA as the first sign of ENDOCRINE NEOPLASIA (MEN1)FAMILIAL TYPE 

Methods:

We would like to describe four  generations of  a Colombian family in  witch predominantes   presence to parathyroid adenoma   as the first  sign of the MEN type 1

Results:  VIEW PDF

Conclusions: Concerning the frequency of endocrine adenomas in endocrine neoplasia Multiple ,our findings agree with the literature in that parathyroid tumors are more common followed by pituitary and pancreatic . The presence of parathyroid adenomas often in the first sign of the disease .Early diagnosis prevents morbidity and mortality. Molecular test is in process inthis family

1740: P1-913

SHORT STATURE IN A CHILD WITH MULTIPLE ENDOCRINE NEOPLASIA TYPE 2 B
Marielisa Rincon-Subtirelu, MD; Lina Huerta-Saenz, MD, Children's Mercy Hospital , Wichita, KS, United States

Objectives:  Multiple Endocrine Neoplasia type 2 B (MEN2B) is an autosomal dominant syndrome characterized by medullary thyroid carcinoma (MTC), pheochromocytoma, mucosal neuromas, and thickened corneal nerves. Clinical features include full lips, thickened eyelids, high-arched palate, and marfanoid habitus. Short stature has not been described as part of the phenotype.

Methods: Case report.

Results: Case presentation: A 4-year-old Hispanic male was evaluated for failure to thrive. His past medical history was significant for low birth weight of 4 lbs 3oz at 39 week, and global developmental delays. The family history was negative, with midparental target height at 25-50th percentile. Review of systems was positive for gastroesophageal reflux and sleep disturbances. His height was at the 0.19th percentile, and weight at 1.14th percentile. Physical exam showed prominent abdomen and torso, but no obvious skeletal dysmorphologies. The skull was normal, with tall forehead and coarse facial features, epicanthal folds, prominent eyelashes, wide and depressed nasal bridge, full everted thick lips, wide spaced teeth, and thick gums. The rest of his exam was normal, including thyroid gland and skin. He was diagnosed with short stature and dysmorphic features. Initial laboratory evaluation was normal. He was referred to Genetics.

Follow up evaluation showed growth failure. He was found to have growth hormone (GH) deficiency after stimulation. GH therapy was never started due to pending evaluation for suspected sleep apnea. Exome Sequencing demonstrated a heterozygous likely pathogenic de novo variant in HECW2 gene, c.4436G>A (p.R1479Q), consistent with the diagnosis of HECW2-related disease, and he also had a heterozygous pathogenic variant in the RET gene, c.2753T>C (p.M918T), consistent with MEN2B syndrome. Subsequent thyroid ultrasound showed a small mass, and calcitonin level was elevated. He underwent a total thyroidectomy for MTC.

Conclusions: This is the first report of short stature and GH deficiency associated to MEN2B syndrome. It illustrates the need to consider extensive genetic testing in children with short stature and dysmorphic features. GH therapy for this patient is contraindicated due to tumor risk predisposition.

1242: P1-914

ALLGROVE SYNDROME: 3 CASES REPORT
Nihad Selim Abdelaziz, MD, University Hospital of Annaba, Annaba, Algeria; Foued Abdelaziz, MD, El Hadjar Medical Practice, ANNABA, Algeria; Amina Talbi, MD; Anissa Hammani, MD; Rym Bediar, MD; Nadira Bouchair, PhD, University Hospital of Annaba, ANNABA, Algeria

Objectives: Allgrove syndrome (triple A syndrome) is an autosomal recessive disorder characterized by achalasia, alacrimia and adrenal insufficiency with isolated glucocorticoid deficiency, it is a multisystem disease and in addition to cardinal manifestations there are associated features especially neurologic problemes. the aim of this report is to present different level of expression of the disease.

Methods: This report concerns three cases of Allgrove's syndrome

Results: The two first cases are brother and sister from consanguineous marriage aged 9 and 19 years with long-standing dysphagia and vomiting that started at age of 1 month. They had been diagnosed as achalasia and treated accordingly. The association with alacrimia and hypoglycemic seizures as a sign of glucocorticoid deficiency were consistent with Allgrove's syndrome. Additional features consisted of reduced visual acuity because of ambyopia, muscle atrophy, nasal speech and neurologic abnormalities with mental retardation more severe with the sister. The third case was diagnosed at the age of 4 years with glucocorticoid deficiency as he was presenting hyperpigmentation of his skin, hypoglycemic seizures and asthenia, at the age of 9 years further investigations including barium swallow along with the clinical evaluations showed the association with achalasia and alacrimia. the three patients are under glucocorticoids replacement and artificial tears eye drop.

Conclusions: Alacrimia is considered to be the earliest clinical manifestation of Triple A syndrome however achalasia is often the initial sign that causes the parent to consult. Early recognition of glucocorticoid deficiency would prevent hypoglycemic convulsions and neurological sequelae.

293: P1-915

PERSISTENT DIABETES MELLITUS POST-ADRENALECTOMY IN NEONATAL MCCUNE-ALBRIGHT SYNDROME
Mustafa Tosur, MD; George S Jeha, MD, Texas Children's Hospital / Baylor College of Medicine, Houston, TX, United States

Objectives: Introduction:

Neonatal McCune-Albright Syndrome (MAS) is a rare disease with severe clinical manifestations, including hyperglycemia associated with Cushing syndrome. However, there is no report on persistent diabetes mellitus following neonatal MAS. 

Methods: We report the first case of persistent diabetes mellitus post-adrenalectomy in neonatal MAS.

Results: Case Presentation:

A Hispanic female was born at 33 weeks of gestation with microcephaly, café-au-lait patches and small for gestational age (birth weight 1162 gram). In the first week of life, she developed hypertension, electrolyte abnormalities and neonatal diabetes mellitus (insulin 14 mIU/mL, blood glucose [BG] 206 mg/dL) requiring insulin. She was diagnosed with hyperthyroidism and put on propylthiouracil at 11 days of age. Hypercortisolism was noted at 3 weeks of age (random cortisol 128 mg/dL). She was transferred to our facility for suspected neonatal MAS. MRI of the adrenal glands showed homogenously enlarged glands. She developed malignant hypertension requiring multiple anti-hypertensives. She underwent to bilateral adrenalectomy at 2 months of age. Despite the improvement in blood pressure and glycemic control, anti-hypertensive and insulin needs persisted. Ultrasound of pancreas was normal and diabetes autoantibodies were negative. Hypoinsulinemic hyperglycemia (insulin 1.2 mIU/mL, C-peptide 1.2 ng/dL, BG 196 mg/dL) was confirmed. She underwent total thyroidectomy at 6 months of age. R201H (Arginine to Histidine) mutation was confirmed in GNAS1 gene on a serum sample. Peripheral precocious puberty, multi-focal bony involvement with osteopenia and multiple fractures, neonatal cholestasis, nephrocalcinosis and poor growth were among other findings. She died from multi-organ failure at 8 months of age.

Conclusions: We report the first case of persistent diabetes mellitus post-adrenalectomy in neonatal MAS. High disease burden affecting multi-organ system is suggestive of a somatic mutation very early in the development. We postulate that the constitutive activation of a G-protein coupled receptor (i.e., GPRC5B) in pancreas with or without beta cell toxicity effect of steroids could have led to a persistent hypoinsulinemic diabetes mellitus. 

1070: P1-917

NOVEL COMPOUND HETEROZYGOUS TRUNCATING MUTATIONS IN PHOSPHOGLUCOMUTASE 1 CAUSES GALACTOSE RESPONSIVE SEVERE HYPOGLYCEMIC EPISODES IN A PATIENT WITH PIERRE ROBIN SEQUENCE
Adi Auerbach, MD; Rebecca Brooks, MD, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Nitay D. Fraenkel , MD, Alyn Hospital, Jerusalem, Israel; Stanley Korman, MD, Shaare Zedek Medical Center, Jerusalem, Israel; Ann Saada, Professor, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Ariella Weinberg Shokrun, PhD; Ephrat Levy-Lahad, Professor, Shaare Zedek Medical Center, Jerusalem, Israel; David Zangen , Professor, Hadassah Hebrew University Medical Center, Jerusalem, Israel

Objectives: Phosphoglucomutase 1 (PGM-1) deficiency (glycogen storage disease type XIV) is a congenital disorder of glycosylation characterized by impaired glycogen and glycan biosynthesis and severe hypoglycemic episodes. Associated clinical features include brachial arch manifestations, myopathy, endocrinopathies, and elevated liver function tests.

Herein we report a unique case of novel PGM-1 mutation causing galactose responsive severe hypoglycemic episodes in a patient with Pierre Robin sequence.

Methods: A 1.25 years old child with Pierre Robin sequence presented with frequent fasting and postprandial hypoglycemic episodes, augmented following a nutritional switch to lactose free formula.

Repeated 'critical sample' laboratory studies, glucagon test, transferrin isoelectric focusing and PGM-1 gene sequencing were used throughout diagnostic investigation. Galactose supplementation was given as a therapeutic trial.

Results: In spite of almost continuous feeding via gastrostomy, glucose monitoring revealed frequent hypoglycemic episodes with low glucose variations and a paradoxical decline in glucose levels from 57 mg/dl to 44 mg/dl during glucagon test.

Repeated "critical samples" did not elucidate a pathophysiologic etiology for the hypoglycemia. Transferrin isoelectric focusing showed decreased tetrasialo-transferrins and increased asialo-, monosialo-, disialo and trisialotrasferrins indicating interrupted synthesis and processing of glycans - a highly specific pattern of PGM1 deficiency.

PGM-1 sequencing revealed novel compound heterozygotes mutations-  c.1140insT and  c.1348G>T - resulting in premature protein truncation.

A trial of galactose supplementation to allow efficient glycogenesis and glycan synthesis (as recently reported) resulted in profound clinical and biochemical improvement. It enabled significant pauses of 90 minutes between meals without hypoglycemia.

Conclusions: In this unique case of recurrent pre- and post-prandial hypoglycemic episodes- the identification of novel mutations causing glycosylation defect due to PGM-1 deficiency- enabled "personalized medicine". A dramatic clinical improvement was achieved by addition of Galactose - a relatively simple nutritional modification.

1766: P1-1000

NGS (NEXT GENERATION SEQUENCING) IN CONGENITAL HYPOPITUITARISM AND MIDLINE DEFECTS
Anna E M Allegri, MD, GENOVA, GENOVA, Italy; Massimo Acquaviva, biologist, Gaslini Children's Hospital, Genova, Italy; Natascia Di Iorgi, MD, University of Genova, Giannina Gaslini Insitutite, Genova, Italy; Flavia Napoli, MD, Istituto Giannina Gaslini, Genova, Italy; Annalisa Calcagno, MD, University of Genova, Giannina Gaslini Institute, Genova, Italy; Giuseppa Patti, MD, PhD student, GENOVA, Genova, Italy; Annalisa Gallizia, MD, Istituto Giannina Gaslini, Genova, Italy; Sara Notarnicola, MD, University of Genova, Giannina Gaslini Institute, Genova, Italy; Angela E Covone, biologist, Gaslini Children's Hospital, Genova, Italy; Mohamad Maghnie, MD, Giannina Gaslini Institute, Genova, Italy; Paola Diana, MD, University of Genova, Giannina Gaslini Institute, Genova, Italy

Objectives: Congenital hypopituitarism (CH) with midline brain and pituitary defects (MD-P )is often due to mutations of pituitary transcription factors. Most patients with CH/MD-P are not inherited and only few familial cases have been reported suggesting that mutations in others genes may be related to these rare conditions. The objectives were to improve molecular diagnosis and to detect new genes/variants involved in the development of midline structures and pituitary gland by using Whole Exome Sequencing (WES).

Methods: CH/MD-P patients were selected after clinical, visual and endocrine assessments; brain magnetic resonance investigation, cardiac and renal ultrasound; Karyotype, CGH-array and DNA extraction of "Trios"(proband and parents). WES was performed in "Trios".Ion Proton equipment and AmpliSeq technology for exome library preparation was used (Life Technology). Suitable bio-informatic tools were used as filtering strategy of exome sequencing data.The identified candidate causative variants will undergo Sanger validation and functional studies

Results: We conducted WES on 26 individuals belonging to 8 families. Our preliminary data showed a high-impact novel mutation/variant with high suspicion to be responsible of the condition observed in the proband in one family

Conclusions: We believe that identifying potential new mutations/variants will make it feasible to predict both clinical outcomes from genetic data and for assessing the risk of future affected individuals

214: P1-1001

CLINICAL CHARACTERISTICS AND THERAPEUTIC OUTCOMES IN 30 CHILDREN AND ADOLESCENTS WITH PROLACTINOMAS FOLLOWED IN A SINGLE TERTIARY REFERRAL CENTER.
Maria Isabel Di Palma, MD; Cinthia Chareca, MD; Carlos Rugilo, MD; Celeste Mansilla, MD; Fabiana Lubieniecki, MD; Javier Gonzalez Ramos, MD; Daniel Alderete, MD; Laura Fernandez Fatsuca, MD; Juan Manuel Lazzati , Biochemist; Diana Monica Warman, MD, Hospital Nacional de Pediatria "Juan P. Garrahan", Buenos Aires, Argentina; Mercedes Maceiras, Biochemist, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina; Alicia Belgorosky, MD,PhD; Marta Ciaccio, MD, Hospital de Pediatria Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina

Objectives:

Prolactinomas are rare in children. It has been described immunological dysfunction and autoimmune thyroid disease (AITD) in adult patients with prolactinomas. The aim is to report clinical presentation, response to treatment, and long-term follow-up of children and adolescents with prolactinoma followed in a single tertiary referral center.

Methods:

We retrospectively analyzed clinical data of 30 (15F/15M) young patients with prolactinoma seen in a tertiary referral center between 1988 and 2016. Chronological age was (mean±SD) 14.4±1.91 y (r 8,5-18). Mean duration of follow up was 3,9 years (r 0,16-10). 9 patients were referred after surgery, all received dopamine agonist (DA) and 1 radiotherapy.1 patient received surgery and radiotherapy after failure of DA. 20 patients were only treated with bromocriptine (BC) at doses ranging from 2.5 to 25 mg/day or cabergoline (CB) at doses ranging from 0.5 to 8 mg/week orally. Resistant patients received BC 15 to 25 mg or CB 3.5 to 8 mg.

Results:

We found equal prevalence of both sexes. Macroprolactinomas  were more prevalent 86%, F80% M93%.There were 26% invasive and 23% giant adenomas. PROL levels were higher in boys (M 7259±7732 F 2285±4059 ng/ml p 0.02). Symptoms at diagnosis were: headache 73.3%, pubertal disorder 70%, visual field defect 56.6%, over weight/obesity 40% and galactorrhea 33%. AITD was negative in all patients except one.1 patient had clinical and molecular diagnosis of MEN1. 80% of the group was sensitive to DA (100% Microprolactinomas 77% of Macroprolactinomas and 42% of Giant). Resistance to DA was associated to higher PROL levels (11235±8477 vs 2345±3635 ng/ml p 0.04).

Conclusions:

As in other series DA is the first line treatment in pediatric population. In our cohort macroprolactinomas have a higher prevalence and no sex difference is found, probably due that microprolactinomas are not referred to a tertiary center. DA resistance is associated with higher PROL levels. AITD is no present in this pediatric cohort but future studies are needed to clarify this point. DA resistance represents a challenge to find a new drug treatment in pediatric prolactinoma.  

600: P1-1002

CLINICAL AND ENDOCRINOLOGICAL CHARACTERISTICS OF PATIENTS WITH SEPTO-OPTIC DYSPLASIA AT THE CHILDREN'S HOSPITAL OF MICHIGAN.
Noelle Andrea V Fabie, MD; Lina Saadeh, MD; Doris R Taha, MD, Children's Hospital of Michigan/Wayne State University, Detroit, MI, United States

Objectives: Septo-optic dysplasia (SOD) is a disorder of brain development characterized by a combination of optic nerve hypoplasia, midline brain defects, and pituitary gland/hormone abnormalities. The purpose of this study is to review records of SOD patients and identify clinical features that are unique to this group of patients.

Methods: A retrospective study was performed and records of SOD patients younger than 18 years of age were reviewed. Data including demographic information, hormone levels, imaging results, growth parameters and results of genetic testing were obtained. Descriptive analysis was used. Qualitative data is presented as frequencies and percentages while quantitative data is presented as means+/- SD.

Results: Thirty-nine patients were diagnosed with SOD between the years 2000 and 2017; 67% (n=26) of them were males. Eleven (28%) of the patients had all three features of the disease. The average time of diagnosis was 0.9 years. Levels of cortisol, thyroid stimulating hormone, Free T4, Insulin-like growth factor 1, and Insulin-like growth factor-binding protein 3 were obtained. Eleven patients (28%) had undetectable IGF-1 levels at diagnosis; mean IGF-1 level was 64.27+/-54.64 ng/mL for those with measurable levels. Mean TSH and FT4 levels were 3.26+/-2.92 uIU/mL and 1.01+/- 0.32 ng/dL, respectively. A total of 27 patients (69%) developed some form of hormone deficiency and were started on hormone replacement therapy. Fifteen patients (38%) had central hypothyroidism (50% diagnosed at presentation). Adrenal insufficiency was seen in 16 patients (41%), growth hormone deficiency in 18 patients (46%). Seven patients (18%) had diabetes insipidus. Eleven patients had some genetic testing done and two (18%) had chromosomal deletions -  deletion of 5p15.33-5p13.3 and deletion of 1p31.1-p31.3.

Conclusions: Our findings suggest that SOD remains a disease with clinical variability. It is usually diagnosed within the first year of life and is slightly more predominant in males. Variable degree of hypopituitarism is common in these patients; growth hormone deficiency being the most common. Severe growth hormone deficiency is common with 28% of the patients having undetectable IGF-1 levels at diagnosis. Genetic studies may be helpful in elucidating a genetic abnormality in some patients.

1049: P1-1003

INCIDENCE OF PITUITARY HORMONE DEFICIENCIES IN CHILDREN RECEIVING PROTON BEAM RADIATION FOR BRAIN TUMORS.
Erika Zevin, MD, Indiana University School of Medicine, Indianapolis, IN, United States; Erica A. Eugster, MD; Nadine G Haddad, MD, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, IN, United States

Objectives: Children with a history of brain tumor who receive cranial radiation are at risk for pituitary hormone deficiencies (PHD). Compared to photon beam radiation therapy (RT), proton beam RT(PBRT) is a newer modality that allows the delivery of higher doses to the tumor while sparing normal tissue. There is minimal information regarding the frequency and type of PHD in children receiving PBRT. Our objective was to characterize endocrine abnormalities in children with a history of non-pituitary CNS tumors who received PBRT. We also sought to determine if certain tumor types incurred a higher risk of PHD than others.

Methods: Medical records of children with CNS tumors treated at Indiana University Health Proton Therapy Center in Bloomington, Indiana between 2000 and 2015 were reviewed. Only charts of patients who had undergone endocrine evaluation were included. Children with craniopharyngiomas were excluded due to high risk for PHD in these patients.

Results: Eighty three patients (48 boys) were identified. Average age at PBRT was 8.33 ± 4.67 years (range 1.2-17.5 years).  Average duration of follow up was 4.85 ± 2.70 years (range 0.6-15 years). All patients also received treatment with surgery, chemo or both.  

The most common CNS tumors were medulloblastomas (MB) (30%), gliomas (19%), ependymomas (16%), juvenile pilomyxoid astrocytomas (8%) and germinomas (7%). Growth hormone deficiency was the most common PHD occurring in 40% of patients, followed by central hypothyroidism (20%),  hypogonadotropic hypogonadism (18%) and ACTH deficiency (12%).  One patient had precocious puberty.

The frequency of PHD was highest in patients with MB (56%), all of whom were diagnosed with endocrinopathies within 5 years following completion of PBRT.

Conclusions: PHD are common in children who receive PBRT. Prospective studies are needed in order to define the time course and specific risk factors for the development of hypopituitarism in children who receive PBRT for CNS neoplasms.

1353: P1-1004

PERI-OPERATIVE MANAGEMENT OF DIABETES INSIPIDUS FOLLOWING BARIATRIC SURGERY FOR HYPOTHALAMIC OBESITY: EFFECTS ON DESMOPRESSIN
Vincent Horne, MD, University of Cincinnati, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, United States; Jonathan C Howell, MD, PhD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Thomas Inge, MD, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH, United States; Susan R Rose, MD, University of Cincinnati, Cincinnati, OH, United States

Objectives: Hypothalamic obesity (HyOb) causes rapid weight gain and early metabolic co-morbidities, typically in survivors of intracranial tumors. Tumor survivors with HyOb often develop panhypopituitarism. Bariatric surgery has been used for treatment of HyOb to cause weight reduction. Peri-operatively, management of diabetes insipidus (DI) may be complicated by surgical effects on fluid intake and medication absorption. We aim to determine effects of desmopressin dosing following surgery.

Methods: Retrospective review of patients with HyOb and panhypopituitarism including DI who completed bariatric surgery at our center was completed from 2004 until present. Patient demographics, timing of surgery, and desmopressin dosing used pre-operatively, at hospital discharge, and at follow up were collected. Comparative statistics were performed for analysis.

Results: Six patients (4 female, median age 18.3 years; inter-quartile range 25th-75th% [IQR], 15.6-18.8 years) were identified. Seven surgical events were identified (Roux-en-Y gastric bypass or RYGB, n=5, sleeve gastrectomy, n=2). One patient received 2 bariatric procedures, having sleeve gastrectomy initially and later undergoing RYGB. Oral desmopressin was used with 4 patients (5 of 7 procedures), 1 patient used subcutaneous and 1 used intranasal desmopressin formulations. Pre-operatively, median total oral desmopressin dose was 700mcg daily (IQR, 600-1600 mcg).  Post-surgical dosing decreased by 50% with median total dose 350mcg daily (IQR, 300-400 mcg). At median follow up of 5 months (IQR, 2-10 months), median total dose increased to 700mcg daily (IQR, 300-1400 mcg). Total intranasal (20 mcg daily) and subcutaneous desmopressin (5.2 mcg daily) doses did not change post-operatively.

Conclusions: For patients with HyOb and DI, bariatric surgery causes a temporary reduction in oral desmopressin requirements by a median of 50% in the immediate post-operative period. Dosing later returns near pre-operative requirements. Providers should be cautious with oral desmopressin use following bariatric surgery, and should plan for temporary reduction in dosing or use of intranasal or subcutaneous administrative routes to avoid desmopressin overtreatment.

1132: P1-1005

RELATIONSHIP BETWEEN LOWER HEART RATE VARIABILITY AND RISK FOR THE METABOLIC SYNDROME IN PATIENTS WITH CHILDHOOD-ONSET CRANIOPHARYNGIOMA
Hae Woon Jung, MD, Kyung Hee University Medical Center, Seoul , Korea, Republic Of; Hwa Young Kim, MD, Kangwon National University Hospital, Chuncheon, Korea, Republic Of; Gyung Min Lee, MD, Konyang University Hospital, Daejeon, Korea, Republic Of; Ji Young Kim, CNS; So Youn Kim, MD; Kyung A Jeong, MD; Keun Hee Choi, MD; Jung-Eun Cheon, MD; In-One Kim, MD; Choong Ho Shin, MD; Sei Won Yang, MD; Young Ah Lee, PhD, Seoul National University College of Medicine, Seoul, Korea, Republic Of

Objectives: Autonomic nervous system (ANS) dysfunction is implicated in the development of hypothalamic obesity and metabolic disturbances. We evaluated changes in ANS activity by measuring heart rate variability (HRV) in patients with childhood-onset craniopharyngioma and analyzed for relationships between HRV changes and obesity, hypothalamic involvement (HI) and the metabolic syndrome.

Methods: Fifty-three patients (31 males, 10–30 years old) with childhood-onset craniopharyngioma were enrolled between March 2014 and January 2016. The extent of HI was graded using magnetic resonance imaging. HRV indices of overall variability, parasympathetic and sympathetic modulation were measured. Anthropometric measurements, fasting glucose, insulin, lipid panel, and blood pressure were determined to assess for components of the metabolic syndrome.

Results: Patients with extensive HI showed increased body mass index (BMI) z-scores and waist circumference than those with mild HI (P < 0.05 for both). Measures of HRV did not differ between obese and non-obese subjects, while subjects with extensive HI had significantly lower overall HRV than those with mild HI (P < 0.05). Lower overall HRV was associated with increased insulin resistance, triglycerides, and systolic blood pressure, respectively (P < 0.05 for all). Lower overall HRV was independently associated with the metabolic syndrome after adjusting for sex, age, obesity and family history of metabolic and cardiovascular disease (P < 0.05).

Conclusions: Extensive HI is associated with obesity and decreases in overall HRV. Lower overall HRV is an independent risk factor for the metabolic syndrome in patients treated for childhood-onset craniopharyngioma.

1262: P1-1006

ENHANCED AT PUBERTY1 (EAP1) GENE EXPRESSION KNOCKDOWN DELAYS PUBERTY, BUT DOES NOT CHANGE HYPOTHALAMIC KISS1 GENE EXPRESSION IN VIVO.
Pin Li, PhD; Sheng Guo, PhD; Yong Fen Lv, MD, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China

Objectives: An intronless gene, enhance at puberty1 (EAP1) was recently reported to be an up-stream gene in the hypothalamus reproductive gene network. However, the mechanism underlying the regulation of puberty by EAP1 has not been elucidated. EAP1 is postulated to act on puberty by promoting the hypothalamic kiss1 metastasis-suppressor (kiss1) gene which is essential for initiating of puberty. The aim of this study was to test this hypothesis.

Methods: By using intraventricular microinjections of lentiviral-mediated RNA inference to knockdown EAP1 expression in 21-day-old rats, rats were divided into three experimental groups (lentivirus [LV]-EAP1-short hairpin RNA [shRNA], LV(-) control, and saline groups).

Results: Puberty was delayed and hypothalamic gonadotropin-releasing hormone (GnRH) mRNA was decreased. However, surprisingly, after blocking EAP1 gene, both Kiss1 mRNA and protein level were unchanged with respect to the control group.

Conclusions: These results indicate that EAP1 may act through other pathway rather than kiss1/G protein-coupled receptor (GPR54) signaling in vivo.

1561: P1-1007

PITUITARY IMAGING IN 189 PATIENTS WITH CONGENITAL GROWTH HORMONE DEFICIENCY.
Yasmine Ouarezki, MD, Public Hospital Hassen Badi El Harrach, Algiers, Algeria; Asmahane Ladjouze, PhD, CHU Bab El Oued, University of Algiers, Algiers, Algeria; Adel Djermane, MD, Public Hospital Hassen Badi El Harrach, Algiers, Algeria; Kahina Mohammedi, MD; Ourida N Taleb, MD, CHU Bab El Oued, University of Algiers, Algiers, Algeria; Abdennour Laraba, PhD, CHU Bab el oued, Algiers, Algeria; Tahar Anane, PhD, CHU Bab El Oued, University of Algiers, Algiers, Algeria

Objectives: Background:

Congenital Growth Hormone Deficiency (GHD) is often associated with specific pituitary anomalies. Brain MRI is therefore useful in both diagnosis and prognosis.

Objective: Evaluate the frequency of MRI anomalies in congenital GHD and correlate these findings with pituitary deficiency.

Methods: Retrospective study including all children seen in our clinic for Congenital Growth Hormone Deficiency (GHD) which was defined as peak GH of EITHER <20µU/l associated with abnormal pituitary OR peak GH less than 20µU/l in two stimulation tests (glucagon and insulin) when pituitary imaging was normal. Abnormal imaging included the presence of one to three of the following anomalies: Hypoplastic Anterior Pituitary (HAP), Missing/Interrupted Pituitary Stalk (IPS) and Ectopic Posterior Pituitary (EPH). Patients were divided in two groups: group 1 with Isolated GHD (IGHD); group 2 with Multiple Pituitary Hormone Deficiency (MPHD). Imaging findings were then compared between the two groups.

Results: Of 222 patients followed for GHD, 189 were included in the study (63 F/126M). Group 1 comprised 144 patients (76.1%), mean±SDS age at diagnosis being 7.15±3.75 years. Mean (SD) height at diagnosis in Group 1 was -3.08±0.8 SDS. Group 2 comprised 45 patients (23.8%), age at diagnosis 7.88±6.08years, height -3.93±1.46 SDS. GHD deficiency was most severe in group 2 with a peak GH of 3.37±5.04 µU/l versus 10.16±6.24µU/l in group 1 p<0.001. Brain MRI was abnormal in 61 (42.4%) patients in group 1 versus 35 (77.7%) patients in group 2 p<0.001. HAP was found in 39 patients: 33 (22.9%) in group 1 versus 6 (13.3%) in group 2. EPH was present in 26 (57.8%) cases from group 2 versus 24 (16.7%) cases in group 1 p<0.001. EPH was associated with a risk of MPHD with RR of 2.15 IC95% [1,5-3,1] and with severe GHD with RR of 4,4 IC 95% [2,3-8,5]. MRI triad was more frequent in MPHD 16(35.6%) versus 16(11.1%) in IGHD, Isolated IPS was presents in 4 cases (3 IGHD, 1 MPHD).

Conclusions: Pituitary imaging remains an important tool in the diagnosis of congenital GHD. Patients with EPH run a higher risk of developing MPHD and a more severe GHD. Genetic aetiology is suspected in some cases of IGHD in which genetic testing needs to be performed.  

961: P1-1008

PEDIATRIC CUSHING’S DISEASE IN AN OBESE GIRL WITH DEVELOPMENTAL DELAY: A DIAGNOSTIC CHALLENGE
Tong Wooi Ch'Ng , MD, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, United States; Elna B Kochummen, MBBS, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, United States; Sumeet Arora, MD, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, United States; Salvador Castells, MD, Kings County Hospital Center, Brooklyn, NY, United States; Tong Wooi Ch'Ng, MD, SUNY Downstate Medical Center and Kings County Hospital Center , Brooklyn, NY, United States; Sheila Perez-Colon, MD, SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, United States

Objectives: Cushing’s syndrome is rare, with an incidence of 2-5 cases in a million people per year, 10% are children. After pre-school years, Cushing disease (CD) is the most common etiology. We present a case of CD. The diagnosis was challenging as initially the patient was considered to have obesity and developmental delay due to a genetic syndrome.

Methods: Case Report

Results: A 10 year old girl was referred to our Pediatric Endocrine clinic for obesity. She has history of developmental delay, head bobbing and frequent laughter for which she was evaluated by Neurology, with negative workup. Angelman syndrome/Prader Willi syndrome were rule out by genetic testing. She had significant rapid weight gain of 80lbs in the last 2 years. Her growth velocity was 4 cm/yr (decreased height from 95% to 65%), Ht 142.8cm(65%), Wt 72.5kg(>99%), BMI 31 kg/m2(>99%) and normal BP. Physical exam was significant for happy demeanor, moon face with plethora, acne, central obesity, buffalo hump, acanthosis nigricans, striae on abdomen, hyperpigmented face, fingernails and knuckles. Breast was Tanner stage II and Tanner IV pubic hair. Bloodwork revealed a random pm cortisol of 24.38ug/dl, ACTH 95pg/ml, insulin level 37.75 mU/L and HbA1c 6.4%. Eleven pm salivary cortisol levels were elevated at 487ng/dl, 480ng/dl and 166ng/dl (norm <130ng/dl). Twenty four-hour urine free cortisol level was elevated at 86mcg/24 hr (norm < 70mcg/24hr). Post-1mg dexamethasone suppression test resulted in 8am cortisol of 10.64ug/dl (norm <1.8ug/dl)) and post-8mg dexamethasone suppression test resulted in 8am cortisol of 1.13ug/dl, suppressed level, consistent with CD. Rest of the pituitary hormones were normal. MRI brain revealed a 1cm pituitary adenoma and MRI abdomen reported normal adrenal glands. She was then referred to Neurosurgery for tumor resection.

Conclusions: Pediatric patients with CD may not have all the typical features for the disease for which high index of suspicion is needed. Moreover, the presentation could be misleading for more common conditions, as in our case. However, physicians should consider CD when obesity, decreased growth velocity or emotional liability are present. Early diagnosis is imperative for treatment outcomes.

1314: P1-1009

RADIOTHERAPY AS FIRST-LINE TREATMENT FOR PEDIATRIC CUSHING'S DISEASE:TWO CASES FROM THE 1990'S
Oya Ercan, Professor; Olcay Evliyaoglu, MD; Aydilek Dagdeviren Cakir, MD; Hande Turan, MD; Ismet Sahinler, MD, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul, Turkey

Objectives: Nowadays, recommended first line therapy for pediatric Cushing’s disease(PCD) is transsphenoidal surgery(TSS). Pituitary radiotherapy(RT) was suggested as primary therapy before the development of TSS but is now preferred as second-line treatment after unsuccessful TSS. In this report, we aimed to evaluate the outcome of RT as first line therapy in PCD in two patients.

Methods: Medical records and present situation of two boys with PCD, now in their thirties, who had been treated with RT as first line therapy back in the 1990’s were investigated.

Results: Cases 1 and 2:Two boys, thirteen and twelve years old, had presented with typical signs and symptoms of Cushing syndrome. The findings of high and detectable ACTH respectively and decrease of cortisol only during high dose dexamethasone suppression test in both were compatible with CD. However, no lesions were visible in pituitary MRI’s. Inferior petrosal sinus sampling was not performed. External beam RT delivering 45 Gy in 25 fractions was given to both. Cortisol levels were reduced at the end of first month and retained so at the end of the sixth month. Cushingoid appearance had disappeared at the end of the third month. Long term follow-up was not optimal and their final heights were well below their target heights. However, in 2017, they are perfectly healthy with no recurrence. One patient is married and is a father.

Conclusions: The outcomes of the two patients suggest that RT might be used as first line of treatment in PCD in special circumstances when TSS can not be performed optimally. However close follow-up, especially for growth, is necesssary.

1554: P1-1010

PSEUDOTUMOR CEREBRI RESULTING IN EMPTY SELLA SYNDROME AND MULTIPLE PITUITARY HORMONE DEFICIENCIES
Rebecca Parrish, MD; Candace Percival, MD, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, United States

Objectives: Pseudotumor cerebri (PTC) is frequently associated with an empty sella turcica in neurologic literature. This radiologic abnormality is commonly asymptomatic, but it may present with non-specific neurological symptoms or more rarely with pituitary dysfunction. This case highlights a patient with PTC and secondary empty sella syndrome whose symptoms of hypopituitarism were attributed to the PTC, chronic pain, and medication side effects and resulted in delayed diagnosis and management.

Methods: A 17 year old male presented with concerns for delayed puberty and hypogonadism in the setting of known PTC. The patient was diagnosed with PTC seven years prior and had received medical and surgical management including a ventriculoperitoneal (VP) shunt requiring multiple revisions. The patient continued to suffer from chronic headaches and back pain despite prolonged opiate and lidocaine patch use. In addition to chronic pain, he had decreased energy, poor stamina, and frequent nausea and vomiting that was attributed to his underlying PTC, surgical interventions, and chronic narcotic use. This resulted in withdrawal from school and bedridden status for four years. Upon evaluation by pediatric endocrinology, previous CT and MRI images of the brain demonstrated a partially empty sella. Testing of the pituitary revealed multiple pituitary dysfunctions including hypogonadotropic hypogonadism, secondary adrenal insufficiency, and central hypothyroidism. He had a rapid increase in energy level following treatment with testosterone, hydrocortisone, and levothyroxine and was subsequently able to wean off his narcotic pain management and graduate from high school.

Results: N/A

Conclusions: PTC may cause secondary empty sella syndrome and thus potential for pituitary dysfunction. Serial pituitary function screening is necessary, especially in the setting of abnormal growth and development or poor energy. This patient had symptoms of hypopituitarism for several years, which were attributed to other factors. Early recognition and management of pituitary dysfunction is essential for normal growth and development. Avoidance of anchoring in a diagnostic evaluation may prevent unnecessary treatments and significantly increase quality of life.

68: P1-1011

MACROPROLACTINOMAS AND ANTERIOR PITUITARY DYSFUNCTION IN ADOLESCENT MALES
Sarah Allan, BS/BA; Hiba Al-Zubeidi, MD; Amit Lahoti, MD; Alicia Diaz-Thomas, MD, University of Tennessee Health Science Center, Memphis, TN, United States; Asim Choudhri, MD, Le Bonheur Children's Hospital, Memphis, TN, United States

Objectives: Prolactinomas are relatively uncommon in children and adolescents. Microprolactinomas are the most common prolactin-secreting tumors, and generally present with menstrual irregularities or galactorrhea in post-menarchal girls. We report three cases of adolescent boys presenting with macroprolactinomas associated with varying degrees of anterior pituitary dysfunction.

Methods: Three cases were reviewed and summarized from chart review.

Results: Two prepubescent boys presented with mild visual complaints, and one pubescent boy presented with new-onset psychosis. All three patients had prolactin levels >200 ng/mL, and all responded to cabergoline therapy. The two prepubescent boys showed progression of puberty, but continued to require cortisol and thyroid hormone replacement despite prolactin suppression. The third patient had ongoing psychiatric symptoms and slightly decreased testosterone levels at follow-up. 

Conclusions: Pituitary adenomas are uncommon in the pediatric population, and the majority of cases are microprolactinomas in adolescent girls. The occurrence of macroprolactinomas associated with hypopituitarism in three boys with non-specific presenting symptoms suggests a need for increased clinical suspicion for prolactinomas in adolescent males with non-specific symptoms, and close monitoring of anterior pituitary function in children with prolactinomas.

2944: P1-1012

NO DIFFERENCES IN SERUM BRAIN-DERIVED NEUROTROPHIC FACTOR BETWEEN LEAN AND OBESE ADOLESCENTS WITH POLYCYSTIC OVARY SYNDROME
Flora Bacopoulou, PhD; Aimilia Mantzou , PhD, National and Kapodistrian University of Athens Medical School, ATHENS, Greece; Charikleia Stefanaki, MD, MSc, National and Kapodistrian University of Athens, Athens, Greece; Despoina Apostolaki , MS/MA; Georgios Landis , RD; Eleni Koniari , PhD; Vasiliki Efthymiou , MS/MA, National and Kapodistrian University of Athens Medical School, ATHENS, Greece

Objectives: The purpose of this study was to evaluate potential differences in serum brain-derived neurotrophic factor (BDNF) concentrations between obese and lean adolescents with polycystic ovary syndrome (PCOS).  

Methods: Female adolescents, aged 13-21 years, with PCOS, who presented to the Centre for Adolescent Medicine and UNESCO Chair on Adolescent Health Care of the First Department of Pediatrics from January 2015 to May 2017, were eligible to enter the study. PCOS was diagnosed on the basis of at least two of the three Rotterdam ESHRE/ASRM PCOS Consensus Workshop Group (2004) diagnostic criteria. Exclusion criteria included other endocrinopathy or chronic disease, chronic medication or contraceptive use and pregnancy. Serum BDNF concentrations were measured in each adolescent participant by ELISA, using the R&D Systems Quantikine ELISA kit. The sensitivity was 20 pg/mL, the intra-assay precision ranged from 3.8% to 6.2% and the inter-assay sensitivity ranged from 7.6% to 11.3%. Student's t-test was used for the statistical analysis.

Results: A total of 28, obese and lean, age-matched, adolescent girls participated in the study; 17 obese females with PCOS (mean age ± SD, 15.3 ± 2.0 years, mean BMI ± SD 26.7 ± 3.3 kg/m2) and 11 lean females with PCOS (mean age ± SD 16.0 ± 2.3 years, mean BMI ± SD 21.0 ± 1.2 kg/m2). No statistically significant differences (p = 0.116) were observed in serum BDNF concentrations between obese (mean ± SD; 18033.6 ± 8241.3 pg/mL) and lean (mean ± SD; 13256.1 ± 6408.9 pg/mL) adolescents with PCOS.

Conclusions: Results suggest that in adolescents with PCOS, the BDNF levels in serum are not affected by BMI. Given the small study sample, these findings need to be confirmed in a larger number of adolescent girls with PCOS.  

2912: P1-1013

CRANIOPHARYNGIOMA IN CHILDHOOD AND ADOLESCENCE: ENDOCRINE-METABOLIC REPERCUSSIONS
Patricia T Hernandez, MS/MA, Federal University of Sao Paulo, SAO PAULO, Brazil; Angela M Spinola-Castro, Professor; Adriana A Siviero-Miachon, Professor, Federal University of São Paulo, São Paulo, Brazil

Objectives: To evaluate and correlate clinical and anthropometric characteristics, adiposity indexes, growth hormone deficiency, treatment with recombinant human growth hormone (rhGH) among craniopharyngioma patients.

Methods: 57 patients treated for craniopharyngioma were evaluated according to: clinical characteristics, hypothalamic involvement, tumor treatment, anthropometric variables [Z score of weight, height and body mass index (BMI), at diagnosis and post-treatment], adiposity indexes [category of BMI at diagnosis and post treatment - overweight or obesity, percentage of body fat (%BF) by dual-energy x-ray absorptiometry, waist circumference, subcutaneous and visceral adipose tissue by abdominal tomography] and criteria for metabolic syndrome. Correlations among these parameters were analyzed by multiple regression and logistic models. The sample was divided according to growth hormone deficiency and rhGH treatment therapy as follows: growth without growth hormone, current use of rhGH, prior use of rhGH, patients who did not use rhGH so far and non growth hormone deficient.

Results: Mean age at diagnosis was 9.6 year-old and 16.6 at study evaluation. 54/57 (94.7%) received at least two hormone replacements and 43/57 (75.4%) had hypothalamic involvement. 24/57 patients (42.1%) were treated with surgery and radiotherapy. At diagnosis, 12/57 (21%) were obese and 33/57 (57.9%) at study evaluation. There was no decrease of Z height, meaning that patients presented with real weight gain. BMI category worsened at a median of 3.2 year after first treatment. Z BMI at diagnosis influenced Z BMI (p=0.005) post-treatment, %BF (p<0.001), waist circumference (p<0.05) and the occurrence of metabolic syndrome (p<0.05). Visceral adipose tissue and %BF were decreased in patients using rhGH (p<0.05). 55/57 patients were growth hormone deficient and 26/57 (45.6%) presented growth without growth hormone.

Conclusions: Patients with craniopharyngioma worsened BMI category at a median of 3.2 year after the first treatment. The higher Z BMI at diagnosis, the higher Z BMI, %BF, waist circumference and the occurrence of metabolic syndrome post-treatment. Replacement of rhGH had a beneficial effect on adiposity, decreasing %BF and visceral adipose tissue.

2892: P1-1014

NOVEL LZTR1 GENE VARIANTS ASSOCIATED TO NOONAN SYNDROME AND GROWTH HORMONE DEFICIENCY
Marilena Nakaguma, MD, University of Sao Paulo, Medical School, São Paulo, Brazil; Alexander A L Jorge, PhD; Funari FA Mariana, MD, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Lerario M Antonio, PhD, University of Michigan, Ann Arbor, MI, United States; Correa A Fernanda, PhD; Carvalho RS Luciani, PhD; Mendonca B Berenice, PhD, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil; Ivo J Arnhold, PhD, University of São Paulo Medical School, SAO PAULO, Brazil

Objectives: Noonan syndrome is an autosomal dominant, multisystemic disorder caused by germline mutations that encode components of the RAS/MAPK signaling pathway. Pathogenic LZTR1 variants have been associated with RASopathies and Schwannomatosis. Short stature is a frequent finding but its pathophysiology poorly defined. Recently, transgenic mice with pituitary-specific overexpression of B-Raf presented dwarfism and abnormal pituitary development suggesting a role for B-Raf in hypopituitarism. The aim of this study is to describe a novel mutation of LZTR1 gene associated to Noonan Syndrome and GH deficiency (GHD).

Methods: A 12.5 year-old boy presented with short stature (Ht 123.6 cm, SDS –3.5) and typical Noonan Syndrome characteristics: triangular face, high-arched palate, low-set ears, micrognathia, pectus excavatum and transposition of the great vessels and pulmonary stenosis. Hormonal investigation revealed isolated GHD (basal IGF1 46 ng/mL < –2SDS, peak GH after clonidine and glucagon tests 1.4 ng/ml). Somatropin was provided from 12.5 to 22 years. Pituitary MRI revealed thickening of the left optic nerve and chiasm suggestive of glioma and no other abnormalities. Patient’s DNA was submitted to a customized target gene panel (Agilent Sure Select Technology) containing 28 genes associated with hypopituitarism and 60 other genes associated with short stature.

Results: Compound heterozygosity [c.2212C>T:p.Q738];[c.494G>T:p.R165L] in LZTR1 was identified. The patient was negative for the 17 other genes previously associated with Noonan Syndrome and for the GHD genes. Segregation in the family demonstrated that he received each variant from one of his progenitors with normal phenotype.

Conclusions: LZTR1, leucine-zipper-like transcription regulator 1, encodes a protein member of the BTB-kelch superfamily, highly expressed in the pituitary. This gene was recently identified in six non-related families with Noonan Syndrome phenotype with an autosomal dominant model, but still, its function is poorly known and possibly may be involved in the RAS MAPK pathway. We describe the first association between LZTR1 gene variants with NS associated to GHD. Further studies are required to demonstrate the relation of this gene with the RAS/MAPK signaling pathway and the etiology of hypopituitarism.

592: P1-1015

FLUCTUATING THYROID FUNCTION, INCONSISTENT SPONTANEOUS AND STIMULATED GH SECRETION, AND PITUITARY HYPOPLASIA IN A BOY WITH A NOVEL IGSF1 MUTATION
Iva H Stoeva, PhD; Ani V Aroyo, MD, University Pediatric Hospital/Medical University Sofia, Sofia, Bulgaria; Daniela D Dacheva, PhD, Medical University Sofia, Sofia, Bulgaria; Sjoerd D Joustra, PhD, Leiden University Medical Center, Leiden, Netherlands; Radka R Kaneva, PhD, Medical University Sofia, Sofia, Bulgaria; Monique Losekoot, PhD, Leiden University Medical Centre, Leiden, Netherlands; Jan M Wit, Professor, Leiden University Medical Center, Leiden, Netherlands

Objectives: The most frequent genetic cause of congenital central hypothyroidism (CeH) is the recently discovered X-linked IGSF1 deficiency. We describe the clinical and biochemical data of a patient carrying a novel IGSF1 mutation and thereby further extend the astonishing phenotypic variability of patients with this syndrome.

Methods: GH secretion was assessed by a 4x/hour night profile and an insulin tolerance test (ITT, 0.1U/kg). Serum hormones were measured with standard tests. After negative findings on Sanger sequencing for PROP1 and POU1F1, we sequenced IGSF1.

Results: A 7.5 year old boy, born at term with a weight of 3.3 kg and length of 51 cm, was referred for slow linear growth and delayed second dentition. Cognitive and psychomotor development were normal. His height SDS was -1.7, target height SDS +0.6 and bone age (BA) was delayed by 2.5y. A borderline low fT4 of 9.5 ng/l (reference 9.3-17 ng/l) and normal TSH (2.2 mU/L) suggested a mild CeH. Prolactin was low (66 mU/l). Treatment with 25 µg/d L-T4 was started and a GH night profile at 8y revealed sufficient peaks (up to 41 mU/l). No catch-up growth and BA advancement was observed in spite of increasing L-T4 doses up to 75 µg/d. After discontinuing L-T4 at age 11, serum FT4 remained normal (11.7 ng/l). At 12y an ITT showed partial GHD (GHmax 7.8 mU/L) and a normal cortisol response. The 3rd MRI showed a hypoplastic anterior pituitary. rhGH was started, followed by a substantial catch-up in growth and BA, but a decrease in FT4 (6.1 ng/l) for which L-T4 was reinstituted. Adrenarche was delayed. In contrast to a normally timed but fast progressive testicular growth (17ml by US at 15y), pubic and axillary hair appeared late (13.5y), and serum testosterone remained prepubertal until 15y while FSH and LH were normal. IGSF1 sequencing revealed a novel pathogenic mutation (c.2989C<T, p.Arg997*).  

Conclusions: In addition to characteristic features (CeH, disharmonious pubertal development, macroorchidism, hypoprolactinemia, delayed adrenarche) our patient showed three novel clinical features: 1) thyroid function fluctuating between low and normal; 2) discrepancy between a normal spontaneous GH peak and low GH response to ITT later in life; 3) pituitary hypoplasia. In boys with CeH, IGSF1 is the first candidate gene to be tested.

992: P1-1016

LATENT HYPOPITUITARISM IN AN INFANT WITH AN ABERRANT KARYOTYPE: 46 XY (9QH+)- IS THERE A CONNECTION?
Iulia Crumpei, MD; Cristina Preda, MD, University of Medicine and Pharmacy Gr. T. Popa, Iasi, Iasi, Romania; Letitia Leustean, PhD, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Iasi, Romania; Alina Belceanu, MD, University of Medicine and Pharmacy "Gr.T. Popa" , Iasi, Romania; Tirnovan Mirela, MD, University of Medicine and Pharmacy Gr. T. Popa, Iasi, Iasi, Romania; Lavinia Caba, MD, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Iasi, Romania; Simona Gavrilescu, MD, University of Medicine and Pharmacy Gr. T. Popa, Iasi, Iasi, Romania; Carmen Vulpoi, Professor, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Iasi, Romania; Anda Esanu, MD, University of Medicine and Pharmacy Gr. T. Popa, Iasi, Iasi, Romania

Objectives: Simultaneous alteration of several hormonal axes in congenital hypopituitarism can be caused by intrinsic pituitary disease, hypothalamic disorder or extrinsic extrasellar dysplasia. The phenotype can vary and the goal is the early diagnosis and precocious substitutive therapy implementation. The association of bilateral congenital undescended testis and microphallus in male neonate is presumptive evidence of congenital hypopituitarism.

Methods: CASE REPORT:  3 years old boy, born by caesarian section (presence of the nuchal cord), only child of a normal, healthy couple, born at term (40W), birth weight: 4000g, length:51cm. At birth it was raised the suspicion of intersexuality presenting bilateral undescended testis and micropenis (negative Barr test; karyotype: 46XY 9qh+ considered normal human polymorphism). At 8 months, the laboratory results revealed the diagnosis of partial hypopituitarism: central hypothyroidism, low levels of growth hormone, IGF1 and hypogonadotropism (stimulation tests revealed a subnormal response of follicle stimulating hormone and luteinizing hormone to gonadotropin releasing hormone stimulation, normal response of thyroid stimulating hormone to thyrotropin releasing hormone stimulation). Thyroid supplementation was immediately implemented with little or no effects on the growth velocity. Growth hormone deficiency became obvious around the age of 3, height: 92cm (-1.35SD), growth velocity: 0.28cm/month, delayed bone age~1year6 months. MRI showed hypoplastic tuber cinereum, lack of visualizing of the pituitary stalk, atrophic anterior pituitary gland. 

Results: The patient presents bilateral undescended testis and micropenis, secondary hypopituitarism due to hypotalamic deafferentation; genetic analysis found a chromosome 9 anomaly (9qh+)- which is considered to be a normal polymorphism, but this association has never yet been cited.

Conclusions: Cryptorhidism and especially microphallus can be a precocious sign of pituitary insufficiency. The early diagnosis preempts further complications and constant monitoring helps implement substitutive treatment without delay.

790: P1-1100

FISH OIL SUPPLEMENTATION DURING INSULIN RESISTANT PREGNANCY PREVENTS THE DEVELOPMENT OF INSULIN RESISTANCE IN THE ADULT OFFSPRING
Benjamin B Albert, PhD, University of Auckland, Auckland, New Zealand; Mark H Vickers, PhD, Liggins Institute, Auckland, New Zealand; Clint Gray, PhD; Clare M Reynolds, PhD; Stephanie A Segovia, BS/BA; José GB Derraik, PhD, University of Auckland, Auckland, New Zealand; Manohar L Garg, PhD, University of Newcastle, Callaghan, Australia; David Cameron-Smith, PhD; Paul L Hofman, MD; Wayne S Cutfield, MD, University of Auckland, Auckland, New Zealand

Objectives: This study aimed to determine in a rat model, whether supplementation with fish oil (rich in omega-3 fats), during the pregnancy of insulin resistant mothers, could prevent the development of insulin resistance and other aspects of metabolic dysfunction in the offspring.

Methods: Virgin female rats were time-mated and randomised into four treatment groups: Con-Con, dams fed a control diet (15% calories from fat) and administered water by gavage; Con-FO, control diet with 1ml of fish oil by gavage; HF-Con, high-fat diet (45% calories from fat) and water by gavage; and HF-FO, high-fat diet and fish oil by gavage. The fish oil was independently verified to be unoxidised (peroxide value 2.7meq/kg). Dams were fed ad libitum during pregnancy and lactation, but daily gavage occurred only during pregnancy. After weaning, male offspring consumed a chow diet ad libitum until adulthood, when they underwent detailed assessments of body composition and metabolism, including dual-xray absorptiometry and an oral glucose tolerance test with calculation of the Matsuda index of insulin sensitivity.

Results: Maternal high-fat diet led to increased food consumption (+89 g; p=0.044), adiposity (+6.4% body fat; p=0.008), systolic blood pressure (+12 mmHg; p<0.0001), and plasma triglyceride (+0.55mmol/l; p=0.014) and leptin (+4.1 ng/ml; p=0.002) concentrations in adult HF-Con offspring. HF-Con offspring also exhibited lower insulin sensitivity than Con-Con rats (Matsuda index 38% lower; p=0.036). Male offspring from HF-FO group were similar to HF-Con regarding food consumption, adiposity, and most metabolic parameters. However, insulin sensitivity in the HF-FO group was improved relative to the HF-Con offspring (Matsuda index 85% higher; p=0.014) and similar to the Con-Con offspring.

Conclusions: Supplementation of dams consuming a maternal high fat diet (an established insulin resistant model) with unoxidised n-3 PUFA rich oils prevented the development of insulin resistance, but had no impact on body composition or other metabolic parameters in adult male offspring. Future studies should assess whether this effect translates to obese human pregnancy.

960: P1-1101

CIRCULATING FIBROBLAST GROWTH FACOTR-21 (FGF-21): A BIOMARKER OF SUBCLINICAL ATHEROSCLEROSIS IN OBESE YOUTH WITH NONALCOHOLIC FATTY LIVER DISEASE (NAFLD)?
Fida Bacha, MD; Anca Tomsa, MD; Sara K Bartz, MD, Baylor College of Medicine, Houston, TX, United States; David Zili Chu, PhD; Sarah Barlow, MD, Texas Children's Hospital, Houston, TX, United States

Objectives: FGF-21 is highly expressed in the liver and is involved in glucose and lipid metabolism. Elevated FGF-21 concentrations are associated with obesity, atherogenic lipid profile, and NAFLD. It is not clear if FGF-21 may constitute a biomarker for subclinical atherosclerosis (SCA) in youth with NAFLD at high risk for the metabolic syndrome. We investigated the relationtionship of FGF-21 to endothelial function biomarkers of SCA in obese Hispanic youth with NAFLD (MRS hepatic fat fraction >5.5%) vs. without NAFLD across the spectrum of glucose regulation.

Methods: Obese Hispanic adolescents (mean age: 15.4±0.3 years), 13 with normal glucose tolerance,19 with prediabetes (PreD) and 16 with type 2 diabetes (T2D) underwent evaluation of reactive hyperemia index (RHI) and augmentation index (AIx) by peripheral arterial tonometry, blood pressure (BP), lipids, peripheral (IS) and hepatic insulin sensitivity (HIS) by hyperinsulinemic-euglycemic clamp with [6,6,2H2] glucose, body composition by DXA, visceral (VAT) and hepatic fat (HF) by MRI/MRS.

Results: The NAFLD vs. no-NAFLD groups did not differ in age, sex, glycemic status, HbA1c (5.6±0.1 vs. 5.8±0.1%), BP, % body fat or VAT. The NAFLD group had higher HF, ALT, FGF-21, LDL-cholesterol (98.0±4.5 vs. 79.0±4.9 mg/dl), lower IS, lower RHI (vascular reactivity) and higher AIx-75 (vascular stiffness) measures (Table).

FGF-21 concentrations were related to VAT, HFF (r=0.45, p=0.002), HIS (r=-0.39, p=0.009), RHI (r=-0.33,p=0.03), and AIx (r=0.45, p=0.02). In a multiple regression analysis, FGF-21 (β=-0.31) and HFF (β=-0.44) contributed to the variance in RHI independent of %BF, VAT, and age (R2=0.35, p=0.01). With AIx as the depednent variable in the regression model, FGF-21(β=0.4)  was the significant determinant of AIx (R2=0.44, p=0.004). This relationship was independent of HIS (as a variable in the regression model) for AIx but not for RHI.

Conclusions: Circulating FGF-21 levels are elevated in obese youth with NAFLD and are associated with measures of insulin sensitivity and endothelial dysfunction. FGF-21 may constitute a biomarker of higher risk for vascular dysfunction in these youth.

1355: P1-1102

PREDICTIVE FACTORS FOR CHANGE IN LEAN AND FAT MASS IN OBESE ADOLESCENTS AFTER A 3 MONTH INTENSIVE WEIGHT LOSS PROGRAM
Anaïs Rousseau, MD; Régis Coutant, MD, University Hospital of Angers, Angers, France; Marion Beaumesnil, MD, Capucins' medical center, Angers, France; Aurélie Donzeau, MD; Mathilde Louvigne, MD; Anne Decrequy, MD; Natacha Bouhours-Nouet, MD, University Hospital of Angers, Angers, France

Objectives: In France, 3 to 4% of adolescents are obese. Lifestyle interventions aim at loss of fat mass. However, the loss of lean mass is usually an unintended consequence of weight loss. The main objective of this study was to evaluate the changes in body composition of obese adolescents attending a 3 month inpatient intensive weight loss program and to analyze the predictive factors for these changes.

Methods: Retrospective, single-center study including 80 adolescents (11-18 y) with common obesity attending a 3 month inpatient intensive weight loss program at the Capucins’ medical center, Angers (France) between January 2012 and March 2015. Body composition (assessed by dual energy X-ray absorptiometry), anthropometric, metabolic and hormonal data were compared before and after the stay.

Results: Total weight (- 7.8 ± 4.3 Kg), BMI (– 3.3 ± 1.44 Kg/m²), total (- 6.7 ± 3.2 kg) and truncal (- 3.3 ± 1.8 kg) fat mass, lean body mass (-1.6 ± 2.6 kg), fasting glycaemia (-0.13 ± 0.4 mmol / L), fasting insulinemia [- 2.7 (-6.5 - 0.3) μU / ml], and HOMA [-0.43 (-1.4-0.05)] decreased significantly after the intervention (p < 0.05 for all paired comparisons). In univariate analysis, total and truncal fat loss were negatively correlated with baseline HOMA (r = -0.28; r = -0.27) and DHEAS (r = -0.39; r = -0.45) values (p < 0.05 for all comparisons). The loss of truncal fat mass was negatively correlated with baseline free T3 (r = -0.29; p = 0.04). Loss of total fat, truncal fat and lean mass were negatively correlated with baseline BMD (r = -0.433, r = -0.405, r = -0.549) (p < 0.05 for all comparisons). After multiple linear regression analysis, variables independently related to total fat mass loss were baseline free T3 (B = -5065; p = 0.008) and DHEAS levels (B = -602; p = 0.015). Variables independently related to total lean mass loss were baseline BMD (B = -5676 and p = 0.006) and triglycerides (B = -1900 and p < 0.01).

Conclusions: Our 3 month inpatient intensive weight loss program allows adolescent to decrease their BMI and to improve metabolic syndrome. High baseline T3 and / or DHEAS levels seem to predict greater fat loss during the program. High baseline BMD seems to predict greater lean loss.

505: P1-1103

POOR INITIAL WEIGHT LOSS AND WEIGHT REGAIN DURING THE SECOND YEAR AFTER GASTRIC BYPASS IN ADOLESCENTS: EFFECTS ON CARDIO-METABOLIC RISK MARKERS AND ASSOCIATION WITH LONG-TERM SURGICAL FAILURE
Markus Brissman, MS/MA; Kerstin Ekbom, PhD, Karolinska Institute, Stockholm, Sweden; Emilia Hagman, PhD, Karolinska Institutet, Stockholm, Sweden; Eva Gronowitz, PhD, University of Gothenburg, Gothenburg, Sweden; Carl-Erik Flodmark, PhD, Skåne University Hospital, Malmö, Sweden; Jovanna Dahlgren, Professor; Torsten Olbers, PhD, University of Gothenburg, Gothenburg, Sweden; Claude Marcus, Professor, Karolinska Institutet, Stockholm, Sweden

Objectives: To investigate the incidence of poor weight loss during the first year and weight regain during the second year in adolescents after Roux-en-Y gastric bypass (RYGB) and to examine how this affects risk markers for obesity related co-morbidities and finally to study if poor initial weight development affects surgical failure five years after surgery.

Methods: The prospective controlled Swedish multicenter study, Adolescent Morbid Obesity Surgery study (AMOS) have followed 85 participants whom were between 13-18 years old at time of surgery. Anthropometrics, body composition, blood chemistry were assessed at baseline, one, two and five years after surgery. For patients recruited from the Stockholm area (n=16), a frequently sampling intravenous glucose tolerance test was performed. Group comparison between those who had weight regain (WR) and none WR or fat% regain (FR) and none FR during the second year as well as an exploration of predictors for surgical failure, defined as weight loss 35 or excess weight loss <50%, five years after surgery was undertaken.

Results: Weight regain occurred in 41% and FR occurred in 39% of participants during the second year with an overlap of 68%. FR had a more pronounced impact on cardio-metabolic risk markers than WR. Differences of 0.3mmol/L in Δlow-density lipoprotein and 2.2 mu/L-1.min in Δinsulin sensitivity was observed between FR and none FR (p=0.011 and p=0.012 respectively) controlling for baseline BMI and respective baseline values. The relative risk of surgical failure was 8.7 times higher for participants with poor initial excess weight loss (<60%EWL in the first year) combined with WR during the second year, controlling for neuropsychiatric disorder. Poor weight loss did not affect metabolic parameters.

Conclusions: Two years after surgery WR was common and comprised of both fat-free and fat mass. FR had a marked negative impact on obesity related risk markers. Patients with the combination of poor initial weight loss and WR during the second year are at high risk for long-term failure and they should get increased support to optimize the effect of surgery. Also, intensified support during the first years after surgery might be of importance for long-term results.

1131: P1-1104

ASSOCIATION BETWEEN PARENTS’ METABOLIC SYNDROME AND 12-18 YEARS-OLD OFFSPRING’S OVERWEIGHT: RESULTS FROM THE KOREA NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEYS (K-NHANES) 2008-2013.
Won-Kyoung Cho, MD; Eunkyoung Lee, MD, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea,, Seoul, Korea, Republic Of; Junhui Lee, MD, Catholic university of korea, seoul, Korea, Republic Of; Moonbae Ahn, MD, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea,, Seoul, Korea, Republic Of; Shin Hee Kim, MD; Kyoung Soon Cho, MD; Kyoung Soon Cho, MD, Catholic university of Korea, Seoul, Korea, Republic Of; Min Ho Jung , PhD, College of medicine, The Catholic University of Korea, Seoul, Korea, Republic Of

Objectives: The association between parental obesity and offspring’s obesity has been reported. However, little information is available on the correlations of parents’ metabolic syndrome and offspring’s obesity in Korean adolescents.

Methods: Data were obtained from the Korean National Health and Nutrition Examination Survey conducted during 2008-2013. In the present study, 2275 adolescents aged 12–18 years-old and their parental pairs (father=1589, mother=2127) were analyzed. Of these 2275 adolescents, 1798 were normal weight (under age and sex specific BMI 85th percentile) and 477 (more than age and sex specific BMI 85th percentile) were overweight.

Results: In overweight adolescents, their parents’ data of metabolic risk factors including BMI {father (F), 24.0±0.1 vs. 25.5±0.2, P < 0.0001; mother (M), 23.0 ± 0.1 vs. 24.5 ± 0.2, P<.0001}, Fat (%) (F, 21.8 ± 0.3 vs. 23.6 ± 0.4, P <.0001; M, 32.3 ± 0.2 vs. 33.7 ± 0.4, P <.0001), Waist circumference (WC) (F, 84.1 ± 0.4 vs. 88.0 ± 0.6 cm, P <.0001; M, 76.5±0.3 vs. 80.3 ± 0.7, P<.0001), systolic blood pressure (SBP) (M, 111.6 ± 0.4 vs. 113.7 ± 0.8 mmHg, P <0.008), diastolic blood pressure (DBP) (F, 81.2 ± 0.5 vs. 82.9 ± 0.8, P <0.04; M, 73.8 ± 0.3 vs. 75.4 ± 0.6 mmHg, P < 0.01), fasting glucose (F, 100.1 ± 1.2 vs. 106.6 ± 2.2, P <0.007; M, 93.3 ± 0.5 vs. 98.8 ± 1.4 mg/l, P < 0.0003) were higher than that of normal weight adolescents’ parental data. BMI of offspring showed positive correlations with parental metabolic risk factors including WC (F, r=0.3, P<.0001; M, r=0.2, P<.0001), SBP (F, r=0.06, P<0.004; M, r=0.09, P<.001), DBP (F, r=0.07, P<0.02; M, r=0.09, P<.0006), fasting glucose (F, r=0.1, P<0.0006; M, r=0.2, P<.0007), TG (M, r=0.07, P<0.01), LDL(M, r=0.09, P<0.0009) and TC (M, r=0.1, P<0.0001). When their parents are classified as metabolic syndrome, the odds ratio for being offspring overweight at adolescent was significantly increased after adjusting for age, sex {F, 95% confidential index (CI), 1.5 (1.1-2.0);  M, 95% CI, 1.9 (1.4 - 2.7)} and age, sex, drink, smoke, exercise, income, daily average sleep time (F, 95% CI, 1.5 (1.1 – 1.9); M, 95% CI, 1.96 (1.4 – 2.7).

Conclusions: parental metabolic syndrome might be associated with offspring overweight in 12-18 year-old Korean adolescents.

1144: P1-1105

BONE HEALTH RISK EVALUATION IN EIGHT YEAR OLD BORN SMALL FOR GESTATIONAL AGE GIRLS
Sochung Chung, MD, Konkuk University School of Medicine, Seoul, Korea, Republic Of; Seon Hwa Lee, MD, Konkuk University Medical Center, Seoul, Korea, Republic Of

Objectives: Reduced bone mineral density (BMD) and bone mineral content (BMC) were reported in SGA infants. The risk of diseases such as obesity and metabolic syndrome, coronary heart disease in children born small for gestational age (SGA) were reported to be high. The aim of this study was to examine the impact of SGA on bone mineralization during prepubertal period compared with appropriate for gestational age (AGA) group and how to interpret pediatric body composition analysis reports in monitoring and management for children who have potential to develop osteoporosis in adulthood.

Methods: We reviewed hospital records of 85 girls who had anthropometric parameters and body composition analysis data with pediatric dual energy X-ray absorptiometry (DXA) at 7 or 8 years. All were full term and 38 girls were born with SGA and 47 were born with AGA. They visited at KUMC pediatric clinic for general examination including growth and pubertal development assessment between 2007 and 2016.

Results: Height, weight, body mass index (BMI) were not significantly different between the two groups. All SGAs were successful in the catch up growth. There was no significant difference between the two groups in body composition profiles; lean mass (LM), bone mineral content (BMC), fat mass (FM) and fat free mass (FFM). Biochemical and hormonal profiles were not significantly different. BMC showed a positive correlation with age and growth parameters; height, weight, BMI and their Z-scores. BMC showed a positive correlation with lean mass and fat mass. The positive correlation of BMC increase with FM increase was greater in SGA group than AGA group. In the relationship between FFMI and FMI, the FMI tends to increase further in the SGA group.

Conclusions: Catch-up growth in children born with SGA may reduce risk of osteoporosis later life, but excessive catch-up growth may contribute to the development of metabolic syndrome. Therefore, more attention for growth monitoring and life style education in early life should be stressed in children born SGA.

1534: P1-1106

NOVEL ROLE FOR STORE-OPERATED CALCIUM ENTRY IN REGULATION OF THE LIPID METABOLISM
Mate Maus, PhD, New York University School of Medicine, New York, NY, United States; Mario Cuk, PhD, University Hospital Centre and School of Medicine Zagreb, Zagreb, Croatia; Bindi Patel, PhD, Albert Einstein College of Medicine, New York, NY, United States; Jayson Lian, PhD; Mireille Ouimet, PhD; Ulrike Kaufmann, PhD; Jun Yang, PhD, New York University School of Medicine, New York, NY, United States; Rita Horvath, PhD; Hue-Tran Hornig-Do, PhD; Zofia Chrzanowska-Lightowlers, PhD, Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom; Kathryn J Moore, PhD, New York University School of Medicine, New York, NY, United States; Ana Maria Cuervo, PhD, Albert Einstein College of Medicine, New York, NY, United States; Stefan Feske, PhD, New York University School of Medicine, New York, NY, United States

Objectives: Calcium signaling is fundamental to many cellular processes. An important pathway for increasing intracellular Ca2+ levels is store-operated Ca2+ entry (SOCE) regulated by stromal interaction molecule 1 (STIM1), STIM2, and Ca2+ channel ORAI1. Alterations in cellular Ca2+ homeostasis have been reported in obesity and diabetes but the pathways involved are unclear. SOCE-deficient patients suffers from inherited disease: Calcium Release-Activated Calcium (CRAC) channelopathy characterized by immunodeficiency, autoimmunity, myopathy, and anhidrotic ectodermal dysplasia. We showed substantial evidence for a cell-intrinsic role of SOCE in the regulation of lipid metabolism both in mice and humans (Maus M et al. Store-Operated Ca2+ Entry Controls Induction of Lipolysis and the Transcriptional Reprogramming to Lipid Metabolism. Cell Metab. 2017 Jan 21.pii:S1550-4131(16)30654-4.doi:10.1016/j.cmet.2016.12.021).

Methods: Histologically, SOCE-deficient transgenic mice accumulate pathological amounts of lipid droplets in the liver, heart, and skeletal muscle. SOCE-deficient patients showed lipid droplets in their skeletal muscle. Following starvation, SOCE-deficient patient fibroblasts showed severe defect in lipid droplets mobilization on BODIPY stain as well as significantly reduced levels of free fatty acids and glycerol in medium and cyclic adenosine monophosphate (cAMP) in cytosol, respectively.

Results: mRNA and protein levels of hormone-sensitive lipase (HSL) and adipose triglyceride lipase (ATGL) were reduced. SOCE-deficient patient fibroblasts and NIH3T3-L1 mice cells expressed significantly lower basal and fasting mRNA levels of peroxisome proliferator-activated receptor gamma coactivator 1 alpha (PGC-1a) and peroxisome proliferator-activated receptor a (PPARa), transcriptional regulators of lipid metabolism. Thapsigargin-induced SOCE in wild type fibroblasts led to increased mRNA expression of PGC-1a and PPARa. That effect was reversed by adenylyl cyclase inhibitor. SOCE-deficient cells had impaired cAMP response element-binding protein (CREB) phosphorylation. That effect was rescued by elevating cAMP levels.

Conclusions: SOCE controls cAMP-dependent induction of PGC-1α/PPARα expression and lipolysis. Our data provide evidence for an important role of SOCE in lipid metabolism.

1477: P1-1107

NORMALIZATION OF TESTOSTERONE LEVELS IN SERUM IN ADOLESCENT BOYS AFTER UNDERGOING ROUX-EN-Y GASTRIC BYPASS FOR SEVERE OBESITY
Jovanna Dahlgren, Professor, University of Gothenburg, Gothenburg, Sweden; Andrew J Beamish, MD, Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Carina Ankarberg-Lindgren, PhD, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mats X Andersson, PhD, University of Gothenburg, Gothenburg, Sweden; Claude Marcus, Professor, Karolinska Institutet, Stockholm, Sweden; Carl-Erik Flodmark, PhD, Skåne University Hospital, Malmö, Sweden; Eva Gronowitz, PhD; Torsten Olbers, PhD, University of Gothenburg, Gothenburg, Sweden

Objectives: Males with severe obesity have low androgen levels owing to increased visceral adiposity and elevated aromatase activity. Laparoscopic Roux-en-Y gastric bypass (RYGB) is effective in achieving weight loss and causes changes in body composition. Little is known about its effects on sex steroid hormones in adolescents, although testosterone levels have been reported to normalize in males after surgery.

The objective was to evaluate possible changes in serum levels of sex steroids in adolescents undergoing bariatric surgery in the Adolescent Morbid Obesity Surgery (AMOS) study. The hypothesis was that testosterone levels increase to normal levels in young males.

Methods: Inclusion criteria were: age 3 and BMI >35 kg/m2. A total of 29 boys with median (range) age 16.9 (13.6-18.8) years; BMI 47.3 (35.1-58.3) kg/m2 were included. Nineteen of these underwent dual-energy X-ray absorptiometry (DXA, Lunar prodigyÒ, pediatric mode, v.11.4, GE Medical Systems, Madison, WI) and serum sampling for analysis of sex steroids before performing RYGB. Patients had follow-up at one, two and five years after surgery. A group of BMI- and gender-matched control males was prospectively identified in the national Swedish child obesity registry and assessed at five-year follow-up. Serum testosterone concentrations were determined with liquid chromatography-tandem mass spectrometry. Statistical analyses were performed with Wilcoxon Signed Rank Test.

Results: Median (range) BMI reduction was 14.2 (10.1-18.9) kg/m2 after one year and 13.5 (1.9-27.1) kg/m2 after five years. DXA revealed a substantial reduction in fat mass (p<0.001). Testosterone levels increased significantly, from 6.6 (2.1-18.6) to 14.6 (2.1-27.6) nmol/L at one year and 19.4 (7.4-30.9) nmol/L five years after surgery (p=0.001 for both). There were significant different testosterone levels between controls (20.0 nmol/L) and RYGB males 5 years later (p=0.021).

Conclusions: Testosterone levels increase to normal after RYGB in male adolescents with severe obesity, while low levels persist in controls over 5 years. Normalization may prevent feminization of habitus during this vulnerable developmental phase.

1559: P1-1108

LONGITUDINAL CHANGES AND DETERMINANTS OF FAT MASS PERCENTAGE IN EARLY LIFE
Kirsten S De Fluiter, MD, Erasmus Medical Center - Sophia Childrens Hospital, Rotterdam, Netherlands; Dennis Acton, PhD, Nutricia Research, Utrecht, Netherlands; Anita CS Hokken-Koelega, MD, PhD, Erasmus Medical Center / Dutch Growth Research Foundation, Rotterdam, Netherlands

Objectives: Determining longitudinal body composition in infants is of great importance. Changes in fat mass percentage (FM%) predominantly occur in the first three months after birth, the critical window for adiposity development. Accelerated gain in FM% during this critical window increases the risk for adult diseases. The objective of this study is to investigate longitudinal changes and determinants of FM% in infants from birth until the age of 2 years.

Methods: Of 168 term born infants (110 males), obstetrical data were obtained from medical records. Fat mass percentage was determined by PEA POD (COSMED, Italy) during visits at the age of 1, 3 and 6 months, and by DXA (Lunar Prodigy, GE Healthcare, UK) at the age of 2 years. To prevent movement during DXA, a vacuum cushion (465 75100, Schmidt, Germany) was used. All DXA scans were analyzed using enCORE software version 14.10.

Results: Median (IQR) FM% was 16.4 (14.1-19.3) at 1 month, 23.3 (19.8-25.9) at 3 months, 23.8 (20.1-27.4) at 6 months and 14.8 (12.8-17.7) at the age of 2 years.

Fat mass percentage at 1 month correlated with FM% at 3 months (r=0.411, p<0.001) and 6 months (r=0.409, p<0.001), but not at 2 years (p=0.13). FM% at 6 months correlated significantly with FM% at the age of 2 years (r=0.363, p<0.001).

Delta FM%1-3mo tended to correlate (r=0.149, p=0.078) and delta FM%1-6mo correlated with FM% at 2 years (r=0.271, p=0.002). Contribution of other variables to FM% at 2 years was assessed by multiple regression analyses. Birthweight and delta FM%1-3mo were positively associated with FM% at 2 years (p=0.013 and p=0.023, resp.) after adjustment for the non-significant variables for FM% at 2 years; gender, parity, pre-pregnancy BMI, mother’s weight gain during pregnancy and exclusive breast- or bottle feeding during 3 months.

Conclusions: This study shows longitudinal changes in FM% in infants until the age of 2 years, with highest increase between 1 and 3 months. Birthweight and delta FM%1-3mo correlated positively with FM% at the age of 2 years after adjustment for gender, type of feeding and maternal factors.

1759: P1-1109

VITAMIN D DEFICIENCY PREDICTS IMPAIRED FASTING GLUCOSE IN CHILDREN WITH OBESITY: A PROSPECTIVE FOLLOW-UP STUDY
Kerstin Ekbom, PhD; Veroniqa Lundbäck, MS/MA, Karolinska Institute, Stockholm, Sweden; Claude Marcus, Professor, Karolinska Institutet, Stockholm, Sweden

Objectives: We have previously shown, in a cross-sectional study, that VD deficiency (VDD) was associated with impaired fasting glycemia (IFG) in obese children. The aim of the present study was to investigate if VDD increases the risk for (IFG) 1-2 years later.

Methods: This study is a prospective follow-up study of 147 children with obesity according to IOTF criteria (51 % male, 49 % female, mean age 12 years, range 5-17. Children with IFG at baseline (n= 18) were excluded.

Fasting blood samples for VD and metabolic parameters were obtained at start and at the end of the study. Prescription of VD supplementation was documented. VDD was defined as 25(OH)D < 30 nmol/L. The mean follow-up time was 17.6 months, range 10-28.

Results: Eighteen children (12 %) developed VDD during the study period and 43 (29%) had VDD at baseline. Twenty-one (14.3%) had VDD both at baseline and follow-up. Eighteen children (12.5%) developed IFG during the study period with a higher risk for IFG in children who had VDD at baseline and follow-up compared with children without VDD at baseline and/or follow-up, independently of age, ethnicity, seasons, VD supplementation, onset of obesity and BMI z-score. No differences in metabolic risk markers were found when comparing VDD children with children being non-VDD at baseline and/or at follow-up.

Conclusions: VDD was associated with an increased risk for the development of IFG approximately one to two years later. However, the association between VDD and later IFG was not affected by VD supplementation, which may indicate that there are no directly causal link between VD and IFG. Thus, VDD predicts IFG but it is unclear whether differences in food intake or underlying metabolic factors affect both VD and fasting glucose levels.

616: P1-1110

IMPACT OF FITBITS ON PHYSICAL ACTIVITY IN OBESE CHILDREN ENROLLED IN A WEIGHT MANAGEMENT PROGRAM
Ryan Farrell, MD, Case Western Reserve University, Rainbow Babies and Children's Hospital, Cleveland, OH, United States; Naveen Uli, MD, University Hospitals Cleveland Medical Center, Cleveland, OH, United States; Sarah Macleish, DO, UH Rainbow Babies and Children's Hospital, Cleveland, OH, United States; Rose Gubitosi-Klug, MD, University Hospitals Cleveland Medical Center, Cleveland, OH, United States

Objectives: To determine if activity trackers combined with weekly telephone review of physical activity with families participating in the Healthy Kids program augment activity goals

Methods: This randomized, prospective study enrolled obese kids 7-18 years from the University Hospitals Healthy Kids (HK) program from May to October, 2015. Subjects were randomized either to receive a Fitbit Charge HR versus standard HK program. Subjects had baseline bloodwork, resting energy expenditure (REE), and recovery heart rate (RHR) following a 3 minute step test. Subjects also wore an Actigraph accelerometer for 7 days to measure intensity of physical activity. Patients underwent the 12 week HK program, and data from their Fitbit account was reviewed by telephone weekly. Subjects without Fitbits also received weekly calls to review subjective activity. Both groups were given goals to improve activity levels as tolerated. After 12 weeks, subjects had reassessment of REE, RHR, bloodwork, and Actigraph. Groups were compared for differences.

Results: 60 subjects were recruited; 35 (17 controls, 18 Fitbit) subjects returned for follow-up after the HK program. The remaining subjects never started the HK program, withdrew from our study, and/or became unreachable. 32/35 subjects completed at least 7 HK classes and completed at least 5 telephone calls.

There were no statistically significant differences in baseline demographics, BMI z-score, RHR, REE, or activity intensity. Compared to baseline Actigraph activity intensity, children wearing Fitbits trended to higher activity intensity by the end of 12 weeks, while children without Fitbits trended towards lower activity intensity from baseline. There were no statistical differences in other measured outcomes between the two groups.

Conclusions: We were unable to demonstrate that the use of Fitbits with remote monitoring of physical activity resulted in changes in cardiovascular fitness, resting energy expenditure, or BMI z-scores. However, children wearing Fitbits increased their overall activity level from baseline, while kids without Fitbits actually had a drop in activity intensity compared to baseline. Further studies evaluating the effectiveness of Fitbits in obese pediatric subjects are necessary.

114: P1-1111

THYROID STIMULATING HORMONE DOES NOT CORRELATE WITH WAIST CIRCUMFERENCE, BMI OR TESTOSTERONE IN ADOLESCENTS WITH POLYCYSTIC OVARY SYNDROME
Rachel Retsky, Undergraduate; Lauren Kanner, MD; Ellen L Connor, MD, University of Wisconsin - Madison, Madison, WI, United States

Objectives:

Thyroid Stimulating Hormone (TSH) levels in hypothyroid adolescents correlate with waist circumference. There is evidence that TSH levels are increased in obese adolescents compared to normal weight adolescents and that those with hyperandrogenism have a higher rate of autoimmune thyroiditis. What is unclear is if the thyroid axis perturbation is more due to 1) visceral fat distribution than BMI and 2) the degree of hyperandrogenemia when present and occurring before clinical hypothyroidism.  The hypothesis is that TSH levels correlate with increased visceral adiposity measured by waist circumference in adolescents with hyperandrogenism.

Methods: Retrospective chart review of adolescents in a multidisciplinary PCOS clinic.  Inclusion criteria: female sex, age 13-20 years, waist circumference and BMI measured, laboratory studies performed at the University Hospital laboratory, meeting the Androgen-Excess Society diagnostic criteria for PCOS.  Exclusion criteria: use of oral contraceptives or metformin at first visit.  Data analysis included linear and multivariate regression comparing TSH versus testosterone, WC and BMI z-scores.

Results: 46 females met inclusion criteria. Mean and SD of TSH was 2.4 +/- 1.8 uIU/mL.  No significant correlation was found between TSH and waist circumference (p=0.79), BMI (p=0.37), or free testosterone level (p=0.56).Multivariate analysis found no significant association for each combination of variables (Figure 1).

Conclusions: In a group of adolescent females with androgen excess, TSH levels were not significantly associated with waist circumference. BMI, or androgen levels. TSH levels can be elevated with increased adiposity due to leptin feedback on TRH secretion. Previous studies in both adults and prepubertal children have shown influences of fat distribution on serum leptin levels. The lack of association of TSH with WC in this study does not support that finding. Therefore, there may be another factor in fat distribution in euthyroid girls with hyperandrogenism and rising TSH.  Evolving androgen levels from puberty to adulthood may be responsible for differences in visceral fat distribution between adults and adolescents. 

This research is supported by a T32 grant DK077586.

778: P1-1112

RELATIONSHIP OF INSULIN RESISTANCE TO LIPIDS AND LIPOPROTEINS IN YOUTH WITH DOWN SYNDROME
Kannan Kasturi, MD, NIH, Bethesda, MD, United States; Stephanie T Chung, MBBS, National Institutes of Health, Bethesda, MD, United States; Sheela Magge, MD; Andrea Kelly, MD; Cochrane Claire, MD; Melissa Xanthopoulos, MD, CNMC, Washington , DC, United States; Rachel Walega, MS/MA, Children's National Health System, Washington, DC, United States

Objectives: Abstract (2,005 characters, including spaces)

Youth with Down Syndrome (DS) are at increased risk for obesity that may predispose them to a more atherogenic lipid profile. However, it is unknown whether the same level of obesity confers a similar degree of risk for cardiometabolic disease in youth with and without DS. Therefore, we compared the relationship of insulin resistance with fasting lipids and lipoprotein profile in 236 youth (148 with DS and 88 age and BMI-matched controls), age 14.8±6 (mean ± SD), BMI (92±7 kg/m2, 56% female and Tanner Stage I-V). Using fasting indices, insulin resistance was measured by homeostatic model assessment – insulin resistance (HOMA-IR) and lipoprotein profile assessed with nuclear magnetic resonance (NMR) spectroscopy. The log-transformed values were used for Pearson correlations and multiple regression analyses. In youth with DS compared to controls, there were no differences in waist circumference (P>0.05), prior history of dyslipidemia (P>0.05), or HOMA-IR (1.8 (0.6-6.2) vs. 2 (0.6-6.9), median (IQR)). Youth with DS, compared to controls, had higher triglycerides (88 (50-242) vs. 72 (38-175) mg/dl), total cholesterol (170 (115-239) vs. 151 (116-198) mg/dl, LDL cholesterol (107 (56-162) vs. 89 (57-129) mg/dl, large VLDL (3.9 (0.5-17.5) vs. 2.4 (0.6-9.8) nmol/L), and small LDL (518.5 (63-1067) vs. 417 (62-815) nmol/L, all P<0.001). HOMA-IR was positively related to triglyceride, total cholesterol, LDL, total HDL and IDL concentrations in both DS and controls (all P<0.001). In regression models, for a given HOMA-IR, youth with DS had higher triglycerides (Adj R2=0.18, P<0.001), large VLDL (Adj R2=0.14, P<0.001), and small LDL (Adj R2=0.09, P=0.01) compared to controls. The relationship between HOMA-IR and lipid/ lipoprotein panel were the same in youth with and without DS. In summary, compared to controls of the same age, BMI and insulin resistant score, youth with DS had a higher cardiometabolic lipid and lipoprotein risk profile.

Methods: N/A

Results: N/A

Conclusions: N/A

829: P1-1113

EARLY CHILDHOOD BMI DEVELOPMENT IN MONOGENIC OBESITY DUE TO LEPTIN – OR LEPTIN RECEPTOR DEFICIENCY
Katja Kohlsdorf, MD, University Medical Center Ulm, Ulm, Germany; Adriana Nunziata, MS/MA, Ulm Medical School, Ulm, Germany; Jan-Bernd Funcke, MS/MA, Ulm University, Ulm, Germany; Stephanie Brandt, PhD; Julia Von Schnurbein, MD; Heike Vollbach, MD; Christian Denzer, MD, University Medical Center Ulm, Ulm, Germany; Maria Fritsch, MD, Medical University of Vienna, Vienna, Austria; Elke Fröhlich-Reiterer, Professor, Medical University of Graz, Graz, Austria; Belinda Lennerz, PhD, Boston Children`s Hospital, Boston, MA, United States; Guntram Borck, Professor, University of Ulm, Ulm, Germany; Klaus-Michael Debatin, Professor; Pamela Fischer-Posovszky, Professor; Martin Wabitsch, Professor, University Medical Center Ulm, Ulm, Germany

Objectives: To evaluate whether early childhood body mass index (BMI) and BMI standard deviation score (BMI-SDS) are appropriate indicators for monogenic obesity.

Methods: BMI, BMI-SDS and BMI courses in early childhood (0-5 years) were analyzed in a cohort of n=21 children living in Germany or Austria with monogenic obesity due to leptin deficiency (group A, n=6), leptin receptor deficiency (group B, n=6) and MC4 receptor deficiency (group C, n=9). BMI and BMI-SDS values at birth (T0), at 2 years (T1) and at 5 years of age (T2) were compared to severely obese controls (n=19) sampled from a large representative pediatric cohort.

Results: Group A and B showed a tremendous increase of BMI during the first 2 years of life with all patients displaying a BMI >25.0 kg/m² [27.2-38.4 kg/m²] at the age of 2 years and a BMI >30.0 kg/m² [33.3-45.9 kg/m²] at the age of 5 years. BMI-SDS was >4.0 at both time points. Group C and severely obese controls had a later onset of obesity with significant lower BMI and BMI-SDS at both time points.

Conclusions: As result of the investigation of early childhood BMI courses in this large pediatric cohort with monogenic obesity we suggest that BMI >25.0 kg/m² (or BMI-SDS >4.0) at the age of 2 years and BMI >30.0 kg/m² at the age of 5 years are indicators for monogenic obesity due to functional relevant mutations in the leptin gene or leptin receptor gene.

905: P1-1114

INSULIN RESISTANCE BETTER PREDICTS INCREASED ARTERIAL STIFFNESS IN OBESE CHILDREN THAN DYSLIPIDEMIA OR THE DEGREE OF OBESITY
Urh Groselj, PhD, University Medical Centre Ljubljana, Ljubljana, Slovenia; Emanuela Jovanovski, Student; Hema Krek, Student, University of Ljubljana, Ljubljana, Slovenia; Jernej Kovac, PhD; Tadej Battelino, PhD, University Children's Hospital Ljubljana, Ljubljana, Slovenia; Primoz Kotnik, PhD, University Medical Centre Ljubljana, Ljubljana, Slovenia

Objectives: Due to high prevalence of obesity in children and its grave health consequences, it is an imperative to screen early for  those at an increased risk of cardiovascular complications. Determination of arterial stiffness by pulse wave velocity (PWV) measurement is a valid measure of cardiovascular risk in children. We aimed to assess which biochemical and clinical parameters most accurately predict increased arterial stiffness in obese children and adolescents.

Methods: PWV measurement using Arteriograph (TensioMed Ltd.) was performed in 29 consecutive obese children and adolescents (14 females, age (mean±SD) 14.4±3.5 years, BMI-SDS 2.7±.7), after obtaining informed consent/parental authorization. Besides clinical examination, an extensive biochemical evaluation was performed including the level of insulin resistance (HOMA-IR), dyslipidemia status (total cholesterol, LDL-C, HDL-C, triglycerides, APOA1, APOB, Lp(a)) and liver enzymes (AST, ALT). Collected data were analysed for outliers using ROUT method, followed by the Spearman’s rank correlation analysis. All statistical calculations were made by GraphPad Prism 7.0 software.

Results: PWV was increased in the cohort, with significant deviation within the group (mean 2.03 SDS; range -1.12–8.99) and didn’t correlate with BMI-SDS or waist circumference. PWV-SDS best correlated with HOMA-IR (r=0,49, p=0.008), however it didn’t correlate with any of the other biochemical measures. On the other hand, HOMA-IR correlated well with the levels of TG (r=0.25, p=0.03), HDL (r=-0.33, p=0.004), apoB/apoA1 (r=.36, p=0.002), TG/HDL (r=0.3, p=0.01) and ALT (r=.28, p=0.02).

Conclusions: Insulin resistance (determined by HOMA-IR) was shown to be a superior predictor of increased arterial stiffness in obese children and adolescents, possibly better indicating their increased cardiovascular risk as compared to dyslipidemia or the degree of obesity.

1233: P1-1115

PEDIATRICIANS' PERCEPTION OF CHILDREN’S WEIGHT
Itay T Latzer, MD, Tel Aviv University, Tel Aviv, Israel; Orit Goz, MD, Jerusalem University, Jerusalem, Israel; Orit Pinhas-Hamiel, MD, Tel Aviv University, Tel Aviv, Israel

Objectives: Prevention of obesity demands early detection. Parents are known to underestimate their child’s weight, but are more likely to show concern to the issue if it was brought to their attention by a pediatrician. In this work, we aimed to explore pediatricians’ perception of child's degree of obesity in community centers and hospital clinics in Israel.  

Methods: In a multicenter study, 42 pediatricians were surveyed by being asked to estimate children’s weight, both by a verbal questionnaire and a sketch array divided and adjusted to the different age groups. The estimation was confronted by the real measurements of the patient. 250 children were included.

Results: The verbal calculated sensitivity for overweight and obese children was only 68% (CI 55-82%). Graphic sensitivity was the same: 68% (CI 54-82%). In younger children under 5 years old the sensitivity declined to 36% (CI 7.9-64%), whereas sensitivity increased in children older than 5 years, 79% (CI 65-93%). Verbal and graphic calculated sensitivity for obesity specifically was 35% (CI 14-55%). Most mistakes underestimated the child’s weight. The physicians that participated in the study were 60% females, aged 33-56 years and had clinical experience of 2-33 years. Sensitivity was not influenced by years of practice, gender, subspecialty of the physicians and weight of the pediatricians. Children who were frequently observed due to a chronic illness were evaluated more accurately.

Conclusions: Pediatricians’ verbal and graphic sensitivity for estimation of overweight and obese children is low, especially for those in the extreme weight category and under 5 years old.

1555: P1-1116

MEDICAL AND PSYCHOSOCIAL IMPLICATIONS OF ADOLESCENT EXTREME OBESITY – ACCEPTANCE AND EFFECTS OF STRUCTURED CARE PROGRAM – YES STUDY. A CONSORTIUM OF THE BMBF.
Belinda Lennerz, MD, Boston Children’s Hospital, Boston, MA, United States; Anja Moss, PhD; Stephanie Brand, PhD, Ulm University Hospital, Ulm, Germany; Annika Bickenbach, MD, Charite University Hospital, Berlin, Germany; Ester Bollow, , Ulm University, Ulm, Germany; Alexandra Geisler, BS/BA, Vestische Kinderklinik, Witten-Herdecke, Germany; Reinhard Holl, MD, University of Ulm, Ulm, Germany; Rolf Holle, PhD, Helmholz Center, Munich, Germany; Wieland Kiess, MD, University of Leipzig, Leipzig, Germany; Diana Luetke Brintrup, MD, Charite University Hospital, Pediatrics, Germany; Yvonne Muehlig, PhD; Madlen Neef, PhD; Claudia Ose, PhD, University Essen-Duisburg, Essen, Germany; Thomas Reinehr, PhD, University of Witten/Herdecke , Datteln, Germany; Andre Scherag, PhD, University Hospital Jena, Jena, Germany; Christine Teuner, PhD, Helmholtz Center, Munich, Germany; Susanna Wiegand, MD, Charité University medicine Berlin, Berlin, Germany; Barbara Wolters, MD, Vestische Kinderklinik, Datteln, Germany; Julia Von Schnurbein, MD, University Medical Center Ulm, Ulm, Germany; Johannes Hebebrand, MD, University Essen-Duisburg, Essen, Germany; Martin Wabitsch, Professor, University Medical Center Ulm, Ulm, Germany

Objectives: Adolescents with extreme obesity are at increased risk of early mortality, somatic and psychiatric comorbidity and social dysfunction. Nevertheless, only a small percentage seek medical care. Our goal was to characterize treatment seeking and non-treatment seeking adolescents with extreme obesity and to examine the acceptance and effects of a structured diagnostic program.

Methods: N=431 adolescents and young adults age 14 to 25 years, BMI ≥ 30 kg/m2 were recruited from 4 medical centers and one job center in Germany. Participants were offered a comprehensive diagnostic program for somatic and psychiatric comorbidity. Participants were assigned to an obesity group (BMI 30-34.9 kg/m2, n=150), and 2 extreme obesity groups (BMI > 35-40 kg/m2, n=122; BMI >40 kg/m2, n=159). The groups were described and explored for differences applying a two-sided significance threshold of 0.01.

Results: 384 adolescents (91%) participated in the recommended diagnostic program. When comparing the groups with ascending BMI, we found decreasing acceptance of the diagnostic program (95% vs 89% vs 85%), whereas comorbidity rates increased: Hypertension (40% vs 55% vs 66%), dyslipidemia (36% vs 33 % vs 51%), dysglycemia (9% vs 19% vs 20%), transaminitis (15% vs 27% vs 32%), depression (BDI II) (46% vs 45% vs 55%). With increasing BMI, quality of life (DISABKIDS, EQ5D) decreased, and adolescents had higher rates of truancy / unemployment (24% vs 24% vs 46%), alcohol use (26% vs 32% vs 43%) and nicotine use (10% vs 21% vs 20%). Notably, when comparing treatment seeking vs non treatment seeking youth, somatic and psychiatric comorbidity did not differ between youth who were recruited through the job center vs medical centers or in youth who had or had not previously sought obesity treatment.

Conclusions: The rising morbidity, including in the non-treatment seeking youth, accompanied by a falling acceptance even of a mere diagnostic program, emphasizes the importance of accessible structured care to meet the needs of adolescents with extreme obesity. To implement and investigate such new care strategies is the goal of the ongoing YES study, which includes a longitudinal observation study, an interventional trial, an observational study of bariatric surgery, and an economic analysis of adolescent extreme obesity.

1230: P1-1117

METABOLIC AND EPIGENETIC ABNORMALITIES OF ADIPOSE TISSUE IN PIGLETS BORN TO SOWS OVERFED DURING GESTATION: PARTIAL NORMALIZATION BY POSTNATAL METFORMIN TREATMENT
Sílvia Xargay-Torrent, PhD; Gemma Carreras-Badosa, PhD, Biomedical Research Institute of Girona (IDIBGI), Girona, Spain; Joan Tibau, PhD; Joaquim Pallissera, PhD, Institut de Recerca i Tecnologia Agroalimentàries (IRTA), Monells, Spain; Anna Prats-Puig, PhD, Escola Universitària de la Salut i l'Esport (EUSES), Girona, Spain; Esther Lizarraga-Mollinedo, PhD, Biomedical Research Institute of Girona (IDIBGI), Girona, Spain; Clive J Petry, PhD; David B Dunger, PhD, University of Cambridge, Cambridge, United Kingdom; Francis De Zegher, PhD, University of Leuven, Leuven, Belgium; Lourdes Ibáñez, PhD, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Judit Bassols, PhD, Biomedical Research Institute of Girona (IDIBGI), Girona, Spain; Abel Lopez-Bermejo, PhD, Hospital Dr. Josep Trueta and Girona Institute for Biomedical Research, Girona, Spain

Objectives: Metabolic programming of the offspring following maternal overfeeding during gestation may be mediated by epigenetic changes in adipose tissue, the mechanisms of which remain to be elucidated. No studies have been reported on the pharmacological reversibility of such processes early in life. In this context, our aims were: (1) to study the effects of maternal overfeeding on the metabolic and epigenetic programming of adipose tissue; and (2) to test the potential of postnatal metformin treatment to reverse these changes.

Methods: We studied male and female piglets born to commercial production sows (Sus scrofa domesticus) who were fed during gestation with a standard diet (control feeding piglets: CF piglets; n=16), or a hypercaloric diet (piglets from overfed sows: OF piglets; n=16). Piglets received treatment with metformin or vehicle (1:1) during lactation, and were sacrificed at weaning (28 days). At sacrifice, weight was assessed and metabolic markers in serum were analyzed: glucose, insulin, fructosamine, C-reactive protein (CRP), lipids and adiponectin. Visceral adipose tissue hypertrophy (size of the adipocytes), inflammation (gene expression of TNFA, IL6 and CCL2) and DNA methylation levels of adipogenesis genes (NDN and DLK1) were studied.

Results: OF piglets showed a worse metabolic profile (higher weight, increased levels of fructosamine and CRP, and lower HOMA-β and adiponectin) together with an inflammatory phenotype in visceral adipose tissue (higher expression of CCL2) and adipocyte hypertrophy (increased area, perimeter and diameter), all p<0.05. DNA methylation analysis of adipose tissue from OF piglets disclosed a decrease in the DNA methylation levels of the adipogenesis genes DLK1 and NDN (p<0.05). Metformin treatment attenuated the metabolic alterations in adipose tissue from OF piglets, decreased hypertrophy of the adipose tissue (adipocyte area, perimeter and diameter) and increased NDN methylation levels (all p<0.05).

Conclusions: Maternal overfeeding during gestation induced metabolic and epigenetic abnormalities in the adipose tissue of the offspring, and postnatal metformin treatment was found to partially reverse these abnormalities.

1133: P1-1118

DEVELOPING PEDIATRIC REFERENCE VALUES FOR BODY COMPOSITION IN MEXICAN CHILDREN AND UNDERSTATING THEIR ROLE AS PREDICTORS OF METABOLIC DISORDERS.
Desiree Lopez-Gonzalez, MD, MSC, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico; Montserrat Bello, MS/MA, HOSPITAL INFANTIL DE MEXICO FEDERICO GOMEZ, MEXICO CITY, Mexico; Regina Ambrosi, MS/MA, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico; Mario Cortina-Borja, Professor, University College London, London, United Kingdom; America Miranda, PhD, HOSPITAL INFANTIL DE MEXICO FEDERICO GOMEZ, MEXICO CITY, Mexico; Patricia Clark, PhD, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico

Objectives: Determine reference values of BC for Mexican children and establish their association with metabolic outcomes.

Methods: We carried a population based cross-sectional study in referred-as-healthy Mexican children aged 5-20 years. We carried clinical history & examination, anthropometric measurements, blood sampling for fasting serum glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, and triglycerides (TGL), and determined BC by dual-x-ray absorptiometry and multicomponent bioelectrical impedance analysis. We used descriptive statistics to report demographic and clinical data. We report BC by fat-mass (FM), lean-mass (LM), bone mineral content (BMC), fat-mass index (FMI), fat-free mass index. We developed age- and gender-specific smoothed percentile curves for LM, FM and BMC by means of lamda-mu-sigma (LMS) method. We assessed BC mean differences between groups according to metabolic outcomes and ran receiver operator curves (ROC) to assess classification potential of BC variables with metabolic outcomes.

Results: We have assessed 993 children and adolescents (515 males and 478 females). Nutritional status according to BMI classified 63% of subjects as normal weight, 15% overweight, 16% obese, and 6% underweight. Metabolic outcomes corresponded to 71% of subjects as healthy, 13% low HDL-C, 7% hyperTGL, 7% low HDL-C and hyperTGL, and 1% with blood pressure > 95th percentile. Noteworthy 22% of subjects classified by BMI as normal weight had at least one metabolic disorder. Classifying subjects by gender and absence/presence of any metabolic disorder, showed significant mean FMI differences: females 6.64 (IC95% 6.34-6.9) vs 8.13 (IC95% 7.62-8.64), and males 5.31 (IC95% 5.05-5.56) vs 7.79 (IC95% 7.22-8.36); P < 0.05). ROC showed FMI cut-off values of 7 and 5.6 kg/m2 for females and males respectively as best classificators.

Conclusions: Ethnic-specific reference values and risk cut-off points must be generated to improve health-status classification of children. We have developed such values for our population. We believe we have contributed to the improvement of nutrition and health status assessment.

264: P1-1119

LATE HYPERINSULINEMIC RESPONSE IN THE OGTT IS ASSOCIATED TO LOWER INSULIN SENSITIVITY AND A WORSE METABOLIC PROFILE IN OBESE CHIDREN
Gabriel Á. Martos-Moreno, MD; PhD., Hospital Infantil Universitario Niño Jesús. UAM. , Madrid, Spain; Julián Martínez-Villanueva, MD, Hospital Infantil Universitario Niño Jesús, MADRID, Spain; Rocío González-Leal, CCN, Hospital Infanil Universitario Niño Jesús., Madrid, Spain; Jesús Argente, MD, PhD, Hospital Infantil Universitario Niño Jesús. UAM, Madrid, Spain

Objectives: The insulin secretory pattern during the OGTT is associated to singularities in insulin sensitivity and predicts the development of T2DM in adults. Our aim was to study the insulin sensitivity indexes and metabolic profile in obese children according to their insulin pattern in the OGTT.

Methods: An OGTT for glucose and insulin (1.75g/kg, maximum 75g; fasting-30´-60´-120´) was performed in 808 obese patients (373 females/435 males; age 10.97±2.94 years; BMI: +4.16±1.37 SDS; 71.8% Caucasians; 48.6% prepubertal) and the fasting lipid profile and uric acid levels determined. Patients were classified according to their peak insulin in the OGTT as Early (peak at 30´), Middle (60´) or Late (120´). Groups were compared for BMI, uric acid, lipid profile, HOMA and WBISI, areas under the curve (AUC) for glucose (AUCg) and insulin (AUCi), and insulinogenic and oral disposition indexes (ODI) at 30 and 120 minutes. The influence of fasting hyperinsulinism (FH; > 15 mcU/ml; n=120 in prepubertal / n=230 in pubertal) on the studied parameters was also explored according to pubertal status (vs. patients without fasting or postprandial hyperinsulinism [n=191 in pre- / n= 126 in pubertal]).

Results: Patients with a late peak showed higher BMI-SDS, uric acid, triglyceride to HDL ratio and lower HDL than those with an earlier insulin peak (TABLE). They showed a higher AUCi and AUCi /AUCg ratio in the entire OGTT, as well as in the second hour of the test (all p<0.001). Despite their lower WBISI (p<0.001), the 120´ODI showed no difference between groups. The 30´ insulinogenic index and ODI were higher and the AUCg lower in the early peak group (p<0.001; TABLE).

In patients with a late peak, insulin sensitivity was lowest and metabolic profile worse when insulin secretion progressively increased throughout the entire test (30´< 60´< 120´).

Patients with FH were more severely obese (p<0.01) and showed higher uric acid, triglycerides and lower HDL, fasting and post-ingestion insulin sensitivity index and ODI (all p<0.001) than those without FH, both in pre-pubertal and pubertal children.

Conclusions: FH and a late insulin peak in the OGTT are associated to lower insulin sensitivity and worse metabolic profile in obese children and adolescents.

1634: P1-1120

BLACK HILLS PEDIATRIC OBESITY AND DIABETES PREVENTION PROGRAM
Jordan Needens, BS/BA; Eric W Jones, BS/BA, University of South Dakota, Rapid City, SD, United States; Luke Fuhrman, BS/BA, University of South Dakota, Sanford School of Medicine, Rapid City, SD, United States; Rachel Edelen, MD, University of South Dakota, Rapid City, SD, United States

Objectives: Childhood obesity has been a growing epidemic for decades with substantial health consequences including type II diabetes. In Rapid City, SD, the prevalence of obesity has grown from 11.6% in 2012 to 16.4% in 2015, and childhood type II diabetes has increased in parallel. Pediatric studies of type II diabetic patients show that over 1 year the beta cells of the pancreas decrease in function by 30% and the need for subcutaneous insulin in addition to oral therapy was 45%. Characteristics of children with type II diabetes in a clinical trial revealed: 26.3% with hypertension, 13% with microalbuminuria, 80% with high LDL cholesterol levels, and 10.2% with elevated triglycerides. These characteristics lead to early heart attacks, strokes, and kidney failure. In Rapid City, there are no organized obesity or diabetes prevention programs. CATCH (Coordinated Approach To Child Health) is an evidence-based program shown to reverse this trend of increasing obesity.

Methods: CATCH was first developed at the University of Texas and is now supported by 25 years and 120 academic papers that indicate an 11% decrease in obesity. CATCH incorporates physical activity, the lunchroom, the classroom, and the home to give adolescents a uniform message to help make healthy decisions. CATCH will first be integrated into pilot elementary and middle schools, and YMCA after school programs. Their success will be used to grow interest and support and proceed to involve all the schools in the district.

Results: Going forward, grant funding is being sought from pharmaceutical, health insurance, and local sources to pay for curriculum and training.  The success of the CATCH program will be monitored by faculty researchers from Black Hills State University, and also based on student, parent, and faculty satisfaction.

Conclusions: A diverse team of highly qualified individuals is pursuing implementation of an evidence-based program, CATCH, in Rapid City. Moving forward, support of local school districts as well as identifying pilot schools to implement the program this upcoming school year will be essential. Looking ahead we hope to expand the number of schools using CATCH, and potentially establish a clinic-based treatment model for obesity and diabetes.

1306: P1-1121

CENTRAL OBESITY IS ASSOCIATED WITH ALTERED CORTISOL METABOLISM IN GIRLS
Shin-Hye Kim, PhD, Inje University, Sanggye Paik Hospital, Seoul, Korea, Republic Of; Si-Eun Kim, PhD; Man Ho Choi, PhD, Korea Institute of Science and Technology, Seoul, Korea, Republic Of; Mi-Jung Park, MD, Inje University, Sanggye Paik Hospital, Seoul, Korea, Republic Of

Objectives:

Increased secretion of cortisol in adipose tissue has been implicated a mediator of central obesity in adult human and animal studies. However, evidence on altered cortisol metabolism in childhood obesity has been limited. We aimed to examine whether circulating cortisol metabolites and their ratios reflecting steroidogenic enzyme activities are associated with obesity in girls.

Methods:

A total of 227 girls (131 control, 45 overweight, 51 obese; aged 7 to 13 yr) were enrolled. Serum cortisol metabolites and cortisone concentrations were analyzed by gas chromatography-mass spectrometry. Enzyme activities involving cortisol metabolism including 11β–hydroxylase, 11β-hydroxysteroid dehydrogenase (HSD) type 1, 3α-HSD were assessed from the ratios of steroid metabolites.

Results:

Allo-tetrahydrocortisol (allo-THF) levels were significantly higher in obese girls compared with overweight and control girls, but the concentrations of other cortisol metabolites were not significantly different by obesity status. Obese girls showed significantly increased activity of 3α-HSD and marginally increased activity of 11β–HSD type 1, respectively, compared with overweight and control girls. Partial correlation analysis revealed positive associations of waist-to-height ratio and body fat percentage with allo-THF levels and activities of 3α-HSD and 11β-HSD type 1. Girls with central obesity determined by waist-to-height ratio ≥ 0.5 had 1.3 times higher allo-THF levels (6.30ng/mL vs. 4.94 ng/mL). Also, activities of 3α-HSD and 11β-HSD type 1 were significantly higher in girls with central obesity than controls.

Conclusions:

Central adiposity in girls was associated with increased activation of 11β-HSD type 1, and increased metabolic clearance of cortisol by 3α-HSD. Further studies are needed to reveal whether metabolic derangement of obesity are related with altered cortisol metabolism in adolescents.

1163: P1-1122

REGIONAL BODY FAT AND METABOLIC COMPLICATIONS IN CHILDREN WITH FAMILIAL PARTIAL LIPODYSTROPHY, DUNNIGAN VARIETY (FPLD2)
Nivedita Patni, MD; Beverley Adams-Huet , MS; Abhimanyu Garg, MD, UT Southwestern Medical Center, Dallas, TX, United States

Objectives: Background: FPLD2 is a rare autosomal dominant disorder due to heterozygous missense mutations in lamin A/C (LMNA) gene. Affected patients, particularly females, gradually lose subcutaneous (sc) fat from the extremities but gain fat in the face, neck and intra-abdominal region at the time of puberty; which results in insulin resistance and its complications such as dyslipidemia, diabetes, hepatic steatosis and premature atherosclerosis in adulthood. However, the precise onset of body fat changes and metabolic complications in children with FPLD2 remains unknown.

Objective: To compare metabolic parameters and regional fat in children with FPLD2 with the sex and age matched controls from the National Health and Nutrition Examination Survey (NHANES) 2005-2010.

Methods: We measured fasting triglycerides, glucose and various skinfold thicknesses; and determined regional body fat by dual energy X-ray absorptiometry (DEXA) in children (≤ 18 years) with FPLD2 and compared the data to those from NHANES.

Results: A total of 48 children (34F, 14M) had FPLD2; 69% were Caucasians, 13% Asians, 10% native Americans, 2% African American and 6% unknown. Patients had the following LMNA mutations: R482W (n=24); R482Q (n=10); R28W (n=3); R482L, R25L, R582S, and R582H (n=2 each), and G465D, K486N, and K515E (n=1 each). Females with FPLD2 did not develop metabolic complications or fat loss in early childhood (<12 y), but developed significant hypertriglyceridemia and loss of extremity fat from age 13-18 years; whereas FPLD2 males did not show significant changes till age 18 years (Table 1).

Table 1. Metabolic parameters and body composition in children with FPLD2 compared to NHANES controls.

Conclusions: Marked loss of extremity fat and hypertriglyceridemia occurs in late childhood in females with FPLD2 as compared to normal controls; whereas male children with FPLD2 do not show significant changes, possibly due to small sample size.

106: P1-1123

A WEIGHTY ISSUE IN DOWN SYNDROME
Melinda Pierce, MD; Katrina Ramsey, MPH; Joseph Pinter, MD, Oregon Health and Science University, Portland, OR, United States

Objectives: Although obesity is a commonly discussed issue in the medical management of children with Down syndrome, there are no large studies published on its prevalence or associations with other common comorbidities in this population.  This study seeks to calculate rates of overweight and obesity in a large cohort of children with Down syndrome.

Methods: Using a database of children from a single medical center specialty clinic, we calculated rates of overweight and obesity and examined possible associations with common comorbitidies including cardiac disease, thyroid disease, sleep apnea, autism, and visual and hearing impairment.  Overweight and obese were defined using the Center for Disease Control growth charts and BMI percentile cut-offs. 

Results: 833 visits from 417 unique patients ranging in age from 2 years to 18 years of age.  1.2% were underweight, 55.2% were normal weight , 23% were overweight, and 20.6% were obese.  BMI percentile increased with female gender, age, and height percentile for age.  Sleep apea was associated with higher BMI percentile, while autism was associated with lower BMI percentile.

Conclusions: Children with Down syndrome have higher rates of obesity that the general population, with especially high risk for girls.  Further research needs to be done to determine the age at which this increase starts to occur to target interventions for prevention, particularly in young girls. 

907: P1-1124

OMEGA 3 FATTY ACID SUPPLEMENTATION ATTENUATES ADIPOSE TISSUE INFLAMMASOME SIGNALING IN HEALTHY OBESE SUBJECTS
Rachana Shah, MD, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Kailey Roberts, BS/BA, Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: Adipose tissue inflammation is a crucial component of obesity-related metabolic dysfunction. The NLRP3 inflammasome, present in adipose tissue macrophages, is an integral sensor of diverse inflammatory stimuli. Activation of the inflammasome contributes to innate immunity; thus, inhibiting the inflammasome is a strategy for reducing obesity-related disregulation. We aim to determine effects of the fish oil-derived long chain omega-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) on adipose tissue inflammation and inflammasome gene expression in healthy obese subjects.

Methods: Healthy, non-diabetic obese subjects (BMI>30) aged 18-50 were recruited into the double-blind, placebo-controlled Fish Oils in Adipose Inflammasion Reduction (FAIR) study. Subjects were randomized to receive Lovaza (1.86 mg EPA and 1.5 mg DHA) (n=15) 4 grams/day or placebo (n=14) for 8 weeks. Subcutaneous gluteal adipose tissue biopsy was performed on each subjects pre- and post-treatment. mRNA was isolated from adipose and reverse transcribed to cDNA for quantification of mRNA expression by qPCR and analyzed by the 2-delta delta CT method.

Results: After 8 weeks of treatment, subjects in the Lovaza group had a modest reduction in relative gene expression of the inflammatory markers IL6 (mean expression relative to baseline of 0.85, p=0.04), CCL2 (0.86, p=0.03), and CX3CL1 (0.96, p=0.06) as well as the inflammasome components IL1beta (0.81, p=0.03) IL18 (0.68, p=0.01), NLRP3 (0.91, p=0.05), and ILR7 (0.78, p=0.04) in subcutaneous adipose tissue. There was also downregulation of the M1-macrophage associated gene iNOS (0.75, p=0.03) with upregulation of the M2 macrophage gene MRC1 (1.2, p=0.04) in the Lovaza group.. By contrast, subjects in the placebo group had no changes in gene expression of any of these markers (mean expression relative to baseline 0.98-1.1, p>0.05 for all genes).  

Conclusions: Omega 3 fatty acids reduce adipose inflammatory gene expression in human obesity, including those of the NLRP3 inflammasome. This dietary supplement represents a therapeutic option for preventing obesity-related inflammation and resultant metabolic disease.

419: P1-1125

VITAMIN D ANTAGONIZES EFFECTS OF HIGH-FAT DIET ON BRAIN TRANSCRIPTOME
Stephanie R Sisley, MD; Keisha Harrison, MS/MA; Suman Maity, PhD; Cristian Coarfa, PhD, Baylor College of Medicine, Houston, TX, United States

Objectives: Our lab has previously shown that vitamin D has actions in the hypothalamus of the brain to improve glucose tolerance and weight gain, but the known actions of vitamin D do not adequately explain how this may occur.  Thus, we sought to analyze the transcriptomic effects of vitamin D in the hypothalamus in order to determine what pathways/genes vitamin D may regulate specific to the brain. 

Methods: We treated both chow and high-fat fed male rats with either  1,25-dihydroxyvitamin D3 (1,25D3) or vehicle into the third-ventricle of the brain.   We then used RNA from their hypothalami and the unbiased approach of RNA-seq through the Genomic and RNA Profiling Core to determine the transcriptomic effects of 1,25D3 in the hypothalamus.    

Results: RNA-seq analysis revealed 98 genes differentially expressed (> 1.5 fold) in the hypothalamus of high-fat diet fed male rats treated with 1,25D3.  Through pathway analysis, we found that the most significantly affected processes were in nervous system development, transmission of nerve impulses, neurotransmitter release, and multiple ion channel pathways.  Also of note, multiple inflammatory, glucose metabolism, and gluconeogenesis pathways were differentially expressed.  We also performed RNA-seq on high-fat diet fed and chow-fed rats.  Interestingly, vitamin D affected pathways differently in chow vs. high-fat diet fed animals, demonstrating that nutritional factors interact with vitamin D action through unknown mechanisms.  Additionally, in many cases, treatment with vitamin D caused regulation of genes in the opposite manner of the effects of the high-fat diet alone implying that 1,25D3 was returning the gene/pathway to a more “chow-fed-like” state.  Of the top 50 differentially expressed genes by 1,25D3 treatment, the following genes were thought to be of particular importance to be suitable for further studies as potential targets of vitamin D in the brain:  ppara (PPAR-alpha), kcnh7 (potassium voltage-gated channel H), adra1a (alpha-1A adrenergic receptor), and slc2a4 (GLUT4).    

Conclusions: This data greatly expands the known role of vitamin D in the brain and provides insights into the mechanisms underlying vitamin D function in the brain which could lead to changes in health outcomes. 

954: P1-1126

ASIAN OBESE CHILDREN ARE MORE METABOLICALLY UNHEALTHY COMPARED TO CAUCASIAN OBESE CHILDREN
Anbezhil Subbarayan, MD, Apollo Children's Hospital, Chennai, India

Objectives: To compare the metabolic parameters between Asian and Caucasian obese children.

Methods: 1) Children between age group 5-18 yrs with simple obesity ( Defined as Body mass Index (BMI) >2 SDS after excluding all secondary causes) who attended a tertiary referral hospital in Chennai, India were prospectively recruited over a period of 2 years ( September 2014- August 2016).

2) All of them had their height, weight and blood pressure(BP) measured. Their fasting blood glucose, fasting insulin levels, alanine aminotransferase(ALT) and fasting lipid profile were checked.

3) Patients with BP>95th centile for their age and sex according to Fourth Report on High Blood Pressure were classified as hypertensive.

4) HOMA-IR was calculated and patients with HOMA-IR>2.5 were classified as Insulin resistant.

5) These metabolic parameters were compared to an age matched cohort of Caucasian obese children recruited by the author in a previous study (unpublished) done during the period January 2006 till August 2007 in a tertiary referral hospital in Manchester, U.K.

Results: 1) 92 Indian obese children with a mean age 11.7 yrs (SDS 3.0) were compared with 56 Caucasian children with a mean age 12.2 yrs (SDS 3.4).

2) The mean birth weight of Indian children was significantly less compared to that of the Caucasian children (3.0 vs 3.36 kg).

3) 76.1% of Indian children had one or both parents obese compared to 50% of Caucasian children p=0.001.

4) Caucasian children had significantly higher BMI {BMI SDS 5.2(1.5)} compared to Indian children {BMI SDS 3.5(1.5)} p=0.000.

5) But significant percentage of Indian children (93.4%) were insulin resistant compared to Caucasians (82.1%) p=0.04.

6) Indian children also had high ALT compared to Caucasian children (mean=67.7 vs 46.7 p=0.002).

7) Hypertension and dyslipidemia were more common in Indian obese children compared to Caucasians but they were not statistically significant (p>0.05).

Conclusions: Even at a lower BMI, Indian obese children become more metabolically unhealthy compared to Caucasian obese children. Hence it is justified to have a lower BMI cut-off for evaluation and treatment of metabolic problems in Indian obese children compared to western standards.

712: P1-1127

MC4R VARIANTS ARE RELATED WITH SEVERE EARLY ONSET OBESITY AND EXTREME GROWTH IN CHILDREN YOUNGER THAN 3 YEARS OF AGE
Meropi Toumba, MD, Iasis Hospital, Paphos, Cyprus; Vassos Neocleous, PhD; Pavlos Fanis, PhD; Christos Shammas, PhD, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus; Marie M Phelan, PhD, University of Liverpool, Institute of Integrative Biology, Liverpool, United Kingdom; Charilaos Stylianou, MD,PHD, Paphos General Hospital, Paphos, Cyprus; Nicos Skordis, MD,PhD, Paedi Center for specialized Pediatrics, Nicosia, Cyprus; Christos S Mantzoros, MD,PHD, Beth Israel Deaconess Medical Center, Boston, MA, United States; Leonidas A Phylactou, PhD, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus

Objectives: The objective of this study is to verify the association of Melanocortin-4-receptor (MC4R) mutations with very early onset of severe obesity and particularly before the age of 3 years. Children carrying such mutations show an overgrowth phenotype with very early onset of hyperphagia, extreme obesity, and rapid height acceleration starting even in infancy. To verify the association of MC4R mutations with this particular phenotype, MC4R gene was screened in a group of severely obese children selected on the basis of their phenotype. 

Methods: Patients (n=16) included in the study should meet the following criteria; 1)hyperphagia and obesity onset before the age of 3 years, 2) body mass index (BMI) z-score equal or more than +3SDS, 3) rapid growth acceleration with height z-score equal or more than +2SDS and 4) growth velocity (GV) z-score equal or more than +2SDS for age and gender. Direct sequencing of the MC4R gene was performed to all of the patients enrolled in the study. 

Results: A  novel heterozygous MC4R p.M215del (c.643_645delATG) deletion was identified in two siblings. Another 2 unrelated patients were found heterozygotes for the MC4R p.Val103lle polymorphism known to be associated with metabolic syndrome in aduthood. In the rest of the patients there were found no mutations. 

Conclusions: These preliminary data identified a novel p.M215del deletion as a disease causing mutation and confirmed the association betweem MC4R variants and overgrowth phenotype even in heterozygous patients. Identifying these patients at a very young age is crucial for early intervention and management of obesity and its complications.

1607: P1-1128

THE IMPORTANCE OF CDC BMI GROWTH CHART USE INSTEAD OF NEW DS-SPECIFIC BMI CHART FOR CARDIOMETABOLIC SCREENING OF YOUTH WITH DOWN SYNDROME
Sheela N. Magge, MD; Rachel Walega, MS/MA, Children's National Health System, 111 Michigan Ave NW, DC, United States; Claire I. Cochrane, BS/BA; Babette S. Zemel, PhD, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Andrea Kelly, MD, The Children's Hospital of Philadelphia, Philadelphia, PA, United States

Objectives: Obesity is prevalent in Down syndrome (DS), but obesity implications for cardiometabolic risk (CMR), previously downplayed in DS, are unknown. Updated growth charts based upon a contemporary U.S. DS cohort recently became available, but the extent to which the DS-specific BMI 85%ile identifies increased CMR is unknown. We aimed to determine differences in prevalence of abnormal CMR factor levels in DS youth identified using the CDC BMI 85%ile vs DS-specific BMI 85%ile, and the extent to which glucose and lipid abnormalities would be missed using the DS-specific chart.

Methods: Youth with DS (10-20yrs) were enrolled at two children’s hospitals. Age and sex-specific BMI z-scores were generated using both the 2000 CDC reference data (CDCz), and the DS-specific reference data (DSz). Fasting lipids and oral glucose tolerance tests (OGTT) were performed. Lipid abnormalities were defined using NHLBI guidelines. The prevalence of dyslipidemia and abnormal glucose tolerance (AGT) detected using screening of BMI≥ 85%ile (z-score=1.04) on the CDC vs DS-specific BMI charts were compared using the PR-test. The proportion of children with abnormal CMR missed using DSz 85%ile instead of CDCz for screening is reported.

Results: 144 DS youth (mean age 14.6±3.3y, 56.1% F, 19.6% African American, BMI 27.0±7.9) were studied. Prevalence of abnormal lipids and glucose was significantly higher using the CDCz  ≥ 1.04 as a screening cut-off, compared with the DSz ≥1.04, and many youth with abnormal CMR would be missed using the DSz: (listed as CDCz vs DSz, p-value, %missed using DSz): total cholesterol ≥ 170mg/dl- 38.2% vs 19.3%, p=0.0004, 18.9%; triglycerides(TG) ≥ 90 mg/dl- 36.8% vs 20.0%, p=0.002, 16.8%; TG ≥ 130 mg/dl- 22.9%  vs 10.7%, p=0.006, 12.2%; LDL-C ≥ 110 mg/dl- 34.3% vs 17.5%, p=0.001, 16.8%; non-HDL-C ≥ 120 mg/dl- 43.8% vs 25.0%, p=0.0009, 18.8%; HDL-C ≤ 40 mg/dl- 31.9% vs 18.6%, p=0.01, 13.3%; AGT (includes impaired fasting glucose and/or impaired glucose tolerance by OGTT)- 26.4% vs 11.4%, p= 0.02, 15.0%.

Conclusions: For CMR screening in youth with DS, providers should use the 2000 CDC BMI ≥85%ile as opposed to the DS-specific BMI ≥85%ile, to avoid missing a significant proportion of DS youth with glucose and lipid abnormalities.

210: P1-1129

PARENTAL OBESITY INFLUENCES THE EARLY ONSET OF OBESITY AND THE OVERWEIGHT DEGREE IN CHILDREN.
Malgorzata Wasniewska, PhD; Domenico Corica, MD; Mariella Valenzise, PhD; Maria Francesca Messina, MD; Tommaso Aversa, PhD; Angela Alibrandi, PhD; Filippo De Luca, PhD, University of Messina, Messina, Italy

Objectives: Childhood obesity is known to be associated with an increased risk of cardiovascular and metabolic complications in adulthood.

In this cross-sectional, observational study authors investigated which variables may influence precocious onset and severity of overweight and which laboratory alterations were already proven at the first assessment in a population of overweight and obese children.

Methods: We recruited 260 boys and girls(from 2 to 18 years),with simple overweight/obesity. Each patient underwent anamnestic avaluation, physical examination and fasting blood sampling for glucose, insulin and lipid profile. HOMA-IR, triglyceride-to-HDL-cholesterol ratio and atherogenic index of plasma were evaluated.

Results: Family history for obesity and/or arterial hypertension and/or diabetes was related to a more severe degree of overweight among children(p=0.002). A more severe obesity was demonstrated in younger children (p<0.0005).HOMA-IR resulted higher among children with the most severe obesity(p=0.04), who were younger. BMI SD was a significant predictor of HOMA-IR>2.5 (OR 2.39; 95% CI 1.15 to 4.97;p=0.01).

Conclusions: Family history of obesity and cardiometabolic disease must be considered a risk factor for precocious obesity onset in children. Insulin resistance is demonstrated even among the youngest. BMI SD is useful to stratify the severity of obesity in order to estimate the cardiometabolic-risk of each patient.

289: P1-1130

TREATMENT OF HYPOTHALAMIC OBESITY WITH DEXAMPHETAMINE – A CASE SERIES
Friederike Denzer, MD, University Medical Center Ulm, Ulm, Germany; Belinda Lennerz, MD, Boston Children’s Hospital, Boston, MA, United States; Christian Denzer, MD; Martin Wabitsch, Professor, University Medical Center Ulm, Ulm, Germany

Objectives: Published case reports and anecdotal experience suggest a positive effect of Dexamphetamine, a central nervous system stimulant on impetus and weight in patients with hypothalamic obesity. Based on these observations, patients presenting to our obesity clinic with hypothalamic obesity are offered off-label treatment with dexamphetamine.

Methods: Between 2010 and 2013, patients starting dexamphetamine treatment were enrolled in a prospective observation study. BMI z-score was determined and impetus was rated at baseline and every three months. A retrospective chart review was conducted to establish BMI z-score development prior to treatment initiation. Dexamphetamine administration was initiated at a single dose of 5 mg per day, and titrated to effect up to a dose of 20 mg/day in 2-3 single doses. Side effects were recorded in a standardized fashion. BMI z-score velocity was calculated as change in BMI z-score over standardized intervals of 12 months.

Results: 9 Patients (3 males) mean age 17.2 years (range: 13.0-23.8) were included in the study. The primary diagnoses were craniopharyngeoma (n=6 patients), ganglioglioma WHO °I (n=1), astrocytoma (n=1), and neonatal meningitis (n=1). Time from initial CNS insult to initiation of dexamphetamine treatment was 5.7 years on average (range 4 mo-17.4 yrs). All patients demonstrated a steady increase in BMI z-score from the time of initial diagnosis until initiation of treatment. Of the nine Patients, two were excluded from the evaluation because of proven non-compliance. Mean baseline BMI z-sore of the remaining 7 patients was 3.17 ±0.93 (1.9-4.4). Mean BMI z-score velocity decelerated to -0.18 ±0.12 during the first year of treatment, and stabilized at 0.05 ±0.32 during the second year of treatment. Over the two-year treatment period, mean score for impetus improved from 1.3 to 2.8. No significant side effects were reported.

Conclusions: Dexamphetamine treatment led to improved impetus and stabilization or reduction of BMI-SDS in a cohort of 7 patients with hypothalamic obesity. Considering the projected increase in BMI z-score according the natural course of the disease, these findings are promising and warrant further study.

2943: P1-1133

ELUCIDATING THE MOLECULAR MECHANISMS OF METABOLIC IMPROVEMENT FOLLOWING BARIATRIC SURGERY IN OBESE ADOLESCENTS
Ahlee Kim, MD; Amy Shah, MD; Michael Helmrath, MD; Kazutoshi Murakami, MD; Takahisa Nakamura, PhD, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Objectives: Bariatric surgery is increasing in popularity among pediatric patients with severe obesity due to its profound benefits including weight reduction and metabolic health outcomes, such as diabetes. The objective for our study is to perform comprehensive analyses focusing on circulating factors to elucidate the molecular mechanisms of the metabolic improvement following bariatric surgery.

Methods: We recruited patients (n=20; age range 12-19 years) undergoing elective abdominal surgical procedures, including bariatric surgery. Data collected included blood samples for molecular analyses, such as circulating RNA sequencing, at baseline and 1,3,6, and 12 months after surgery. Adolescents undergoing bariatric surgery were compared to lean and obese controls undergoing non-weight loss abdominal procedures.

Results: We observed a significant shift of circulating RNA expression pattern in obese adolescents before and 1 month after bariatric surgery, despite patients remaining quite obese (Figure 1). For example, miRNA-122a, a known hepatocyte associated microRNA showed increased expression pattern after surgery, whereas, miRNA-146, a known inflammation associated microRNA showed lower expression level following the surgery.

Conclusions: We observed drastic molecular changes in the circulating RNA expression pattern 1 month after bariatric surgery in obese adolescents. These effects seem to be independent of weight reduction. Whether these changes are associated with the profound metabolic improvement following bariatric surgery remains to be elucidated.

2919: P1-1134

PREVALENCE OF FOOD ADDICTION IN CHILDREN WITH OVERWEIGHT AND OBESITY
Juan Ramos, MD, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico; Idalia Cura, MD, Universidad Autonoma de Nuevo Leon , Monterrey, Mexico

Objectives: Obesity is a worldwide public health problem that has reached alarming numbers affecting adults, teenagers and children.

One way of facing this health problem is by placing it under a similar perspective used with problems of addiction where the individual becomes physically and psychologically dependent to food rich in sugars and fats.

The main objective was to determine the prevalence of food addiction in children that suffer of overweight and obesity problems with the YFAS-C. (Yale Food Addiction Scale in Children).

Methods: A prospective, descriptive and a prevalence study was realized, where a survey of addiction to food in children (YFAS-C) was applied to 285 children from April 2016 to April 2017, in the pediatrics area of a tertiary hospital at Monterrey Nuevo Leon, México.

The following data was obtained: gender, age, weight, height, BMI (Body Mass Index) and with these the percentile of each patient was obtained and according to the graphics of BMI of the CDC (Centers for Disease Control and Prevention) each patient was classified as overweight or obese. This survey was applied to 285 patients classified with overweight or obesity. The average of age was of 13.2 years old (range 8-17 years old) 56% male and 43.9% female.

Results: Survey results showed that 13.7 % of the children turned out with food addiction.

There is a higher prevalence in women and teenagers, plus, it was found that there is more relation of food addiction in children with obesity versus children that are overweight.

Conclusions: This is the very first study realized in a Hispanic population with the Yale scale for children, proving that food addiction in children has a prevalence of 13.7%.

2882: P1-1135

ASSESSMENT AND TRACKING OF GROWTH IN SEVERELY OBESE OR UNDERWEIGHT CHILDREN USING Z-SCORES AND PERCENTILE METHODS
Melissa Chambers, DO, Phoenix Children's Hospital, Phoenix, AZ, United States; Stephanie K Tanamas, PhD; Sayuko Kobes, BS/BA; Elena Clark, BS/BA; Sanil Reddy, BS/BA, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, United States; Diana Dunnigan, MD, Phoenix Indian Medical Center, Phoenix, AZ, United States; Chirag Kapadia, MD, Phoenix Children's Hospital, Phoenix, AZ, United States; Mary Hoskin, MS/MA; Dorota Wasak, RN; Robert L Hanson, MD; William C. Knowler, MD; Madhumita Sinha, MD, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, United States

Objectives: To illustrate the difficulties in optimal growth monitoring of children with severe obesity or underweight using the Centers for Disease Control and Prevention (CDC) 2000 age-sex-specific body mass index (BMI) percentile growth charts. To examine the utility of a new modified CDC BMI z-score chart to monitor growth in children with normal and extreme BMI percentiles using real-life clinical scenarios.

Methods: Modified BMI z-score charts were created using the 2000 CDC algorithm. Three cases of children with extreme BMI values and abnormal growth patterns were plotted using the standard CDC 2000 clinical growth chart, the modified BMI z-score chart, and the CDC BMI percentile chart with additional percentage of the 95th percentile curves (%BMIp95). Figures show two cases of obesity and one case of underweight, each plotted on the three different growth charts for comparison.

Results: Children with severe obesity could not be plotted on the standard CDC BMI percentile chart, as their BMI points lay above the chart cutoff. Children with low BMI (<3%) were also difficult to track on the standard BMI percentile chart. The addition of the %BMIp95 scale to the standard BMI% chart allowed tracking of severely obese children; however, it did not address severely underweight children and required a change of units within the chart when transitioning from normal to obese BMIs. The modified BMI z-score chart allowed uniform tracking in all categories.

Conclusions: The modified CDC z-score chart is suitable for growth tracking of children with normal and extreme growth patterns without changes in units or limits at either extreme. The measures correlate well with the %BMIp95, and the chart can be incorporated easily into existing electronic health record systems for clinical use.

2875: P1-1136

NOVEL MUTATION IN LEPR GENE CAUSING MONOGENIC OBESITY IN A CHILD
Maria Jose Ramirez, Pediat Endocrinol, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay; Victor Raggio, Geneticist; Alejandra Tapie, Geneticist; Rosario Guecaimburu, Geneticist; Ana Batalla, Geneticist; Laura Garcia, MD. PhD., Universidad de la Republica, Montevideo, Uruguay; Gabriela Cancela, Pediatrician; Eliana Perez, MD; Martin Vazquez, Pediatrician; Catalina Pinchak, Pediatr Neumologist; Isabel Moreira, Pediatr Neumologist, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay

Objectives: The objective is to present a novel mutation in LEPR gene.

A 16-months-old boy, born at term and with no complications, from consanguineous parents is brought due to severe obesity despite nutritional treatment  since he was 1 year-old. There are no obesity cases in the family. Body weight increased from 50th percentile to 97th percentile from birth to 2 month and has increased since then. Lenght was 50th percentile at birth and crossed 97th percentile at 10 month of age, also increasing until now. Weight/lenght index has increased since birth and was always above 97th percentile. On physical exam, the child was tetchy, weight 35 Kg (Z-score of +11), height 88 cm (Z-score of +2.89), head circumference with Z-score of +6, and BMI 45 Z-score of +10, abdominal perimeter 90cm, micropenis, normal testes, no dysmorphic signs. Vital signs were: BP 110/65, HR 110, and RR 48, and his temperature was 36ºC. The child is able to stand up with help but is not able to walk. Complementary studies confirmed dyslipemia with hepatic steatosis.

Methods: Monogenic obesity was the presumptive diagnosis. Genes of the leptin/melanocortin pathway: MC4R, LEP, LEPR, PC1, PCSK1, SIM1, NTRK2 and POMC, and other 30 obesity-related genes were analyzed. 

Next Generation Sequencing was performed using Sure Select Target Enrichment Kit (Agilent)  for libraries generation and enrichment, and  Illumina HiSeq 2000/2500 equipment. Raw data was aligned against the reference genome (UCSC hg19) using the BWA and the variants were determined with the GATK pipeline.

Results: A variant, not previously described,  was found in homozygosis in the LEPR (leptin receptor) gene: NM_001003679.3:exon10:c.1305_1306del:p.S435fs.  This mutation causes a change in the open reading frame and a stop in the following codon (the gene is 1165 aminoacids long and the variant is in S435) probably leading to severe leptin receptor deficiency. Since it is a variant that is expected to cause a loss of function of the gene product, in homozygosis for a recessive phenotype and compatible with the clinical presentation in the patient, it should be considered as a probably pathogenic variant which explains the phenotype of the patient.

Conclusions: This finding confirms, in practice, the diagnosis of monogenic obesity due to leptin receptor deficiency.

371: P1-1200

THE RELATIONSHIP OF OBESITY AND INSULIN RESISTANCE WITH HYPERANDROGENEMIA, ANTI-MÜLLERIAN HORMONE, INHIBIN A, INHIBIN B AND INSULIN-LIKE PEPTIDE-3 LEVELS IN PATIENTS WITH POLYCYSTIC OVARY SYNDROME
Aylin Yetim, MD, Istanbul University, Istanbul Medical School, Istanbul, Turkey; Firdevs Bas, Prof, Istanbul Faculty of Medicine, Istanbul, Turkey; Rüveyde Bundak, Prof; Sükran Poyrazoglu, Assoc Prof, Istanbul University, Istanbul Medical School, Istanbul, Turkey; Feyza Darendeliler, Prof, Istanbul Faculty of Medicine, Istanbul, Turkey

Objectives: To investigate the relationship of obesity and insulin resistance (IR) with hyperandrogenemia, AMH, INH-A, INH-B and INSL3 levels, the factors which had an impact on IR and which contribute to the emergence of the disease in adolescent girls.

Methods: 52 adolescent girls diagnosed with PCOS [subgroups: non-obese (NO), n=23; obese (O), n=29] and 26 girls without PCOS [NO, n=14; O, n=12] were included. Blood samples were obtained to measure leptin, AMH, INH-B, INH-A and INSL3 levels, together with hormonal and biochemical assessments. OGTT was performed in girls with PCOS and the Matsuda index(ISIcomp) was calculated. 

Results: The frequency of IR obtained by HOMA-IR (30.4%) was markedly lower than that by OGTT (56.5%) in the PCOS-NO, but no difference was in the PCOS-O group (72.4% and 79.3%, respectively). . The androstenedione (D4-A) and leptin levels were higher in the PCOS-O than in the PCOS-NO (p=0.004 and p<0.001, respectively). While there was no difference between the PCOS subgroups in terms of AMH and INH-A levels, INH-B and INSL3 levels were lower in the PCOS-O than in the PCOS-NO (p=0.014 and p=0.028, respectively). AMH level was markedly increased in the PCOS-O without IR. While INH-B was correlated with both HOMA-IR and ISIcomp. In linear regression analysis, INH-B (p=0.02) and FAI (p<0.001) were found to have an effect on HOMA-IR (R2=0.602) and similarly INH-B (p=0.002) and FAI (p<0.001) were found to have an effect on BMI SDS (R2=0.654). HOMA-IR (p=0.002) and AMH level (p=0.028) were found to have an effect on D4-A level (R2=0.261). In the logistic regression analysis, FAI (p=0.042) and AMH (p=0.024) were found to be associated with presence of IR in the adolescent girls with PCOS.

Conclusions: HOMA-IR is an insufficient criterion in specifying IR, especially in non-obese girls with PCOS in whom OGTT measurements were found more reliable. IR per se may contribute to the disease unrelated to obesity. Hyperandrogenemia was associated with IR and obesity parameters. AMH levels seem to be more valuable in terms of diagnosis, especially in obese girls without IR. INH-B levels are closely related to both obesity and IR parameters, so it can be used as IR indicator.

343: P1-1201

MODY IN UKRAINE: GENES, CLINICAL PHENOTYPES AND TREATMENT
Eugenia Globa, PhD, Ukrainian Center of Endocrine Surgery, Kyiv, Ukraine; Nataliya Zelinska, Professor; Iryna Shevchenko, PhD, Ukrainian Scientific Center of Endocrine Surgery, Kyiv, Ukraine; Lenka Elblova, PhD, Second Faculty of Medicine/Charles University in Prague/University Hospital Motol, Prague, Czech Republic; Petra Dusatkova, PhD; Ondrej Cinek, Prof., Charles University and University Hospital Motol, Prague, Czech Republic; Jan Lebl, MD, Motol University Hospital in Prague, Prague,