Stria Research Articles

THU621 Mifepristone In Exogenous Cushing's Syndrome

Abstract Disclosure: S. Priyadarshan: None. D.O. Blavo: None. Introduction: Cushing’s syndrome is characterized by elevated cortisol levels in the body and is associated with significant morbidity and mortality. It can be broadly divided into endogenous and exogenous Cushing’s depending on etiology. Endogenous (body-produced) Cushing’s is diagnosed using Late Night Salivary Cortisol(LNSC), Dexamethasone Suppression Test(DST), or 24-hr Urinary-Free Cortisol(UFC) and after ruling out exogenous glucocorticoid administration. Hyperglycemia and weight gain are two of the many manifestations of Cushing’s that have hitherto proven to be a challenge to treat. Mifepristone is a glucocorticoid receptor antagonist that was recently FDA-approved for treating endogenous Cushing’s syndrome following the breakthrough SEISMIC trial. Literature regarding the utility of Mifepristone in exogenous Cushing’s has been limited since its approval. This case aims to fill that void. Case: A 35-year-old female with past medical history of rheumatoid arthritis was referred to endocrinology for further evaluation due to complaints of weight gain, dorso-cervical fat pad, abdominal striae, bruising of her right breast, and hirsutism requiring her to shave twice a week. She had previously been on prednisone 10mg-20mg daily for 2-3years for rheumatoid arthritis and was later weaned off due to her developing bruising, perioral abscess and dorsocervical fat pad. She was hospitalized for pneumonia later that year and discharged with dexamethasone. Her baseline weight at the time had been around 380lbs and she had a rapid weight gain over the next few weeks with a peak of 467lbs, associated with facial swelling and shortness of breath. For this, a DST was done per her primary provider among other labs and showed a cortisol level of 0.5mcg/dL(n<2mcg/dL). At the endocrine clinic, she had an extensive workup done including renin, aldosterone, plasma metanephrines, LH/FSH levels which all returned within normal limits. A1c was elevated at 6.7%(n <5.7%) and she was started on Metformin 1000mg BID. She had a repeat DST which suppressed cortisol appropriately however her midnight salivary cortisol was elevated. She was diagnosed with exogenous Cushing’s syndrome and started treatment with Mifepristone at 300mg daily. Her only side effect was mild nausea that later resolved. In 4 months, she had already lost 50lbs since her initial visit and HbA1c was down to 5.8. The dose was subsequently increased in increments up to 1200mg. In 7 months since starting Mifepristone, her weight was down to 312lbs, a total of 164lbs down from her initial weight. Her HbA1C was 4.6, down from her initial value of 6.7. Conclusion: This case is an excellent example of the effectiveness of Mifepristone in achieving glycemic control and weight reduction in Cushing’s syndrome with minimal side effects. More specifically, it serves to illustrate its utility in exogenous Cushing’s syndrome. Presentation: Thursday, June 15, 2023

FRI249 New Onset Heart Failure In A Patient With Rapidly Progressive Adrenocortical Carcinoma

Abstract Disclosure: J. Peeples: None. S. Shu: None. K.G. Romo: None. J. Tereul: None. B.B. Grissett: None. Background: Adrenocortical carcinomas (ACC) are rare, relatively large (>4cm), lipid-rich, and often aggressive tumors. They may be functional, which typically presents as Cushing’s syndrome and/or virilization, or non-functional, which typically presents as an abdominal mass or incidental finding. They occur in two peak incidences: at the first decade of life and between 40-50 years of age. Over half of adult patients with ACC present with an advanced tumor stage. This case describes a young man with new onset heart failure and adrenal mass with metastases who was found to have biopsy-confirmed ACC. Clinical Case: A 20-year-old man with a history of cigarette smoking and marijuana use, but otherwise in prior good health, presented as a transfer for new onset heart failure in the setting of hypertensive emergency (SBP 260s), and CT findings of left adrenal mass, with multiple lung and liver masses. He noted 2 months of rapidly progressive weight gain, easy fatigability, dyspnea on exertion, and leg swelling. Exam revealed central adiposity with abdominal striae, bilateral clavicular and cervical fat pad, and bilateral lower extremity swelling. Investigations revealed hypercortisolism and ventricular ejection fraction 20-25%. Liver mass biopsy revealed metastatic ACC. Family history was significant for multiple members with early onset hypertension and congestive heart failure, including the death of maternal grandmother at age 40. The patient was initially managed in the ICU with an etomidate drip for adrenal suppression. Cortisol levels appropriately decreased to goal. Additionally, he started IV dexamethasone while inpatient. He was discharged once euvolemic on PO furosemide and follow-up was scheduled with cardiology, oncology, and endocrinology. At discharge, he transitioned to PO hydrocortisone (HC) and was placed on trimethoprim/sulfamethoxazole for PJP prophylaxis, doxazosin, and ketoconazole. He also started mitotane for his cancer treatment, with HC to prevent adrenal insufficiency while on mitotane. Subsequently, he started and failed carboplatin plus etoposide palliative chemotherapy with a continued increase in adrenal mass size. Now, he is on second line pembrolizumab with an ECOG score of 2. Conclusion: ACC is a rare and often aggressive tumor that should be considered in the setting of hypercortisolism and cushingoid features. This is particularly important for patients with a relatively unremarkable history and new onset heart failure with dyspnea on exertion. In these cases, mitotane can be used for hypercortisolism associated with ACC. Unfortunately, these tumors are usually diagnosed when they have already progressed to a late stage, and the prognosis for ACC is poor. Presentation: Friday, June 16, 2023

SAT340 Matters Of The HAART - Ritonavir Induced CYP3A4 Inhibition of Intranasal Fluticasone Leading To Cushing’s Syndrome

Abstract Disclosure: A. Ramachandran: None. S. Ghaith: None. A. Ramachandran: None. Background: Ritonavir, a potent inhibitor of the CYP3A4 enzyme, can lead to high systemic concentrations of even intranasal steroids causing Cushing’s syndrome. Case: A fifty-seven-year-old man with history of HIV on HAART presented with a 3-month history of fatigue, weight gain and easy bruising. History was negative for heat/cold intolerance, hair loss, constipation, erectile dysfunction. Medications included emtricitabine-tenofovir-alafenamide and ritonavir at stable doses for several years. He denied taking any oral or topical steroids, but reported using over the counter (OTC) fluticasone propionate (FP) for the past 6 months for seasonal allergies. Physical examination was significant for moon facies and abdominal striae. Labs were remarkable for low serum morning cortisol of 0.6 µg/dl (0.4-22.6 µg/dl), and low serum ACTH of <5 pg/ml (7-69 pg/ml). A diagnosis of exogenous steroid induced Cushing’s syndrome, as a result of ritonavir induced increase in FP levels was made. FP was gradually tapered and stopped. Serum cortisol and ACTH levels normalized at 15 µg/dl and 13 pg/ml respectively and his symptoms resolved completely after three months. Discussion: Ritonavir, a protease inhibitor (PI), is one of the strongest known inhibitors of CYP3A4 and is generally used to boost the plasma levels of other PIs. FP, a potent glucocorticoid, is generally used as monotherapy or as a combination inhaler in the treatment of asthma. It is rapidly metabolized by CYP3A4 and hence produces minimal side effects. However, its concurrent use with ritonavir results in increased serum concentration of FP leading to systemic adverse effects of glucocorticoids. Due to emerging awareness about this drug-drug interaction among physicians, prescription of inhalational steroids in patients on ritonavir is avoided. However, FP is an OTC intranasal glucocorticoid that is easily accessible, and its self-use is often times not reported by patients which makes it difficult for physicians to track on their patient’s medication list. A thorough review of OTC medications/supplements needs to be done when Cushing’s syndrome from exogenous steroids is suspected. It is also imperative that patients on ritonavir be counseled about the risks of taking any form of steroid formulations by any route. Conclusion: Educating patients on ritonavir about steroids being a component of many OTC medications/supplements, and a careful medication history and drug-drug interaction assessment is important in preventing steroid related adverse effects. Presentation: Saturday, June 17, 2023

SAT347 Surprising Turn Of Events In A Patient With Weight Gain: Simultaneous Diagnosis Of Macroprolactinoma And Polycystic Ovary Syndrome

Abstract Disclosure: A.N. Keskinkilic: None. D. Sistla: None. Background: The differential diagnoses of excess weight gain are broad and endocrinopathies constitute a small proportion of these etiologies. A pattern of associated symptoms, classical exam findings and hormonal testing can signal some endocrine causes. However, diagnosis can still be challenging due to overlapping clinical and biochemical features and concurrent presentations of endocrine disorders. Here, we present a diagnostically challenging rare case of a young female with weight gain who had simultaneous diagnosis of macroprolactinoma and PCOS. Clinical Case: A 34-year-old healthy female presented with one year of weight gain despite lifestyle changes. She also reported headaches, acne, hirsutism, stretch marks, excessive sweating, and had 10 years of amenorrhea while on oral contraceptives (OCs). Labs revealed mildly low free T4 of 0.72 ng/dl (n: 0.70-1.48 ng/dl) and significantly elevated prolactin (PRL) of 259.8 ng/ml (n: 1.2-29.9 ng/ml); normal FSH, LH, GH, IGF, TSH, ACTH, 1 mg dexamethasone suppression test, and 24-hour urinary cortisol. HbA1c, lipid panel, plasma metanephrine and androgen levels were normal. MRI pituitary revealed a 2.1 x 1.9 x 1.5 cm macroadenoma with mild compression to the optic chiasm. A low dose levothyroxine and cabergoline 0.25 mg twice weekly was started with dose increment to 0.5 mg twice weekly. At 6-month follow-up, PRL decreased to 30 ng/ml. Repeat MRI showed a decrease in size of the pituitary adenoma (1.5 x 1.4 x 1.3 cm). However, she could not tolerate cabergoline due to persistent headaches and depression. Hence, she elected to undergo transsphenoidal pituitary resection. Tumor pathology showed sparsely granulated lactotroph adenoma. Post op PRL level normalized, and MRI showed radiological cure of the adenoma. Headaches improved but amenorrhea persisted despite discontinuation of OCs for 6 months. Progesterone challenge tests resulted in withdrawal bleed suggesting anovulation. Repeat work-up ruled out nonclassical CAH, Cushing’s, and androgen-secreting tumors. However, subsequent pelvic ultrasound confirmed polycystic ovarian morphology, suggesting PCOS. The patient preferred to avoid OCs and could not tolerate metformin. She elected progesterone IUD placement for endometrial protection in combination with lifestyle changes with notable improvement in her symptoms. Conclusion: PCOS is a diagnosis of exclusion. Thorough evaluation of symptoms like weight gain, amenorrhea, clinical hyperandrogenism is recommended to rule out serious pathology like prolactinoma. Dual diagnosis of PCOS and macroprolactinoma is rare and should be suspected if menstrual abnormalities persist even after treatment of hyperprolactinemia. Presentation: Saturday, June 17, 2023

THU517 Aggressive Cushing’s: A Rare Case Of Pancreatic ACTHoma In A Young Female

Abstract Disclosure: O.C. Reyes: None. A. Sison: None. M. Villa: None. D. Dimayuga: None. Introduction: Adrenocorticotropic hormone-producing pancreatic neuroendocrine neoplasm (ACTHoma) is a rare type of pancreatic neuroendocrine tumor that causes ectopic adrenocorticotropic hormone syndrome. Cushingoid manifestations and metabolic abnormalities can occur rapidly. High index of suspicion is required for early diagnosis. Case: A 31-year-old Filipino female presented with facial and ankle swelling that occurred 6 weeks before the visit. She also had acne, easy bruising, amenorrhea and frequent mood swings. There was reported weight gain of 3 kg a month prior. She had no history of hypertension and diabetes, and had no unusual family history. At the time of admission, vital signs were blood pressure of 130/80mmHg, pulse of 92/min, respiratory rate 20/min and body temperature of 37.2C. Her body mass index was 28kg/m2. She had muscle atrophy of the upper and lower extremities, facial flushing, posterior cervical fat pad, abdominal violaceous striae, and skin pigmentation. Her external genitalia was normal, Tanner Stage 5 consistent with adult pattern. Neurologic exam was unremarkable. She was examined for Cushing’s syndrome. On initial tests, glucose was 406 mg/dl, HbA1C 10.7%, thyroid stimulating hormone 0.122 (NV: 0.55-4.78), Free T3 0.77 (NV: 2.3-4.2), Free T4 0.58 (NV: 0.89-1.76). Creatinine was 0.86 mg/dL, sodium was 140 mEq/L, potassium was 2.1 mEq/L showing hypokalemia. There was leukocytosis on her blood count, white blood cells 15,310/mm3 (neutrophils 94%, lymphocytes 3%). In the low-dose dexamethasone suppression test (DST), the serum cortisol concentration was 991.03nmol/L. Her adrenocorticotrophic hormone (ACTH) level was elevated at 577pg/mL. After high-dose DST, the serum cortisol concentration was > 1750 nmol/L. No tumor was observed on pituitary magnetic resonance imaging. On abdominal computed tomography (CT), a large, lobulated, heterogeneously-enhancing mass arising from the pancreatic body and tail measuring 7.5cm x 10cm x 10.9cm was seen. The mass had infiltrated the gastric fundus, and encased the splenic artery. Multiple non-calcified subcentimeter pulmonary nodules were observed on chest CT. CT-guided biopsy of the pancreatic mass was done. On microscopic examination, numerous atypical cells arranged with small clusters and sheets and scattered singly were found in the tumor. The cells had small to enlarged, hyperchromatic, ovoid to round nuclei and scant to ample delicate cytoplasm. On immunohistochemical staining, the tumor cells were stained positive for synaptophysin and chromogranin A, which are both neuroendocrine markers, as well as ACTH. However, the patient died prior to any definitive management. Conclusion: ACTHoma is a very rare disease that causes hypercortisolemia. Reporting of similar cases will provide insight into its clinical features, immunohistochemical characteristics, diagnosis, therapy, and prognosis. Presentation: Thursday, June 15, 2023

THU016 Hiding In Plain Sight: Florid Cushing’s Disease Presenting As A Severe Extremity Cellulitis

Abstract Disclosure: C.M. Godar: None. E.B. Noble: None. N.O. Vietor: None. T.S. Knee: None. Background: Cushing’s syndrome may rarely present as an emergency known as Florid Cushing’s Syndrome. Patients can exhibit severe hyperglycemia, hypertension, hypokalemia, infections, and hypercoagulability. Cushing’s syndrome is a rare disease, and the constellation of clinical features can be overlooked if clinicians are not aware of the manifestations of hypercortisolism. We present the case of a patient with Cushing’s syndrome that went unrecognized with life-threatening sequelae. Case presentation: A 52-year-old woman with well-controlled type 2 diabetes and hypertension was admitted to the hospital for severe left lower extremity cellulitis. Prior to hospitalization she had noted rapid weight gain, fatigue, weakness, mental clouding, and moodiness. She was admitted for antibiotics and surgical debridement. The infection persisted despite broad spectrum antibiotics, multiple surgical debridements, and skin grafting. She became bacteremic, and extremity amputation was considered. She additionally developed hypertensive emergency, refractory hypokalemia, and hyperglycemia to 396 mg/dL. Exam was notable for facial plethora, supraclavicular fullness, dorsocervical fat pad, and violaceous abdominal striae. Cushing’s Syndrome was suspected, and labs revealed a significantly elevated random serum cortisol of 60.5mcg/dL (Ref 6.2-19.4), significantly elevated 24H urine cortisol of 2157mcg/24H (Ref 0-50), and ACTH elevated to 81.8pg/mL (Ref 7.2-63.3) that confirmed Cushing’s Disease. MRI sella and octreotide scans did not localize a lesion. Inpatient therapy included multiple antihypertensive agents, insulin drip, aggressive potassium repletion, and initiation of ketoconazole to reduce cortisol levels. Ketoconazole was maximally dosed and she underwent surgical exploration and removal of a small pituitary microadenoma. Following surgery, she developed transient adrenal insufficiency requiring hydrocortisone and she no longer required antihypertensives, insulin, or potassium therapy. Follow up 7 years later has revealed no recurrence of Cushing’s Disease. Discussion: Cushing’s Syndrome may present with a variety of clinical features and rarely may present as a medical emergency. Delay in diagnosis can lead to Florid Cushing’s Syndrome which carries high risk for morbidity and mortality. This case illustrates the need for clinician awareness of the features of Cushing’s Syndrome: hypertension, hyperglycemia, rapid weight gain, cushingoid exam features, hypokalemia, hirsutism, virilization, infection, and/or hypercoagulable state. Severe hypercortisolism was responsible for this patient’s refractory infection, and if not controlled, she likely would have endured a lower extremity amputation. Rapid detection with elevated random serum and/or urine cortisol and treatment with a cortisol-lowering agent is critical and lifesaving. Presentation: Thursday, June 15, 2023

SAT383 Case Study: Impact of Weight Reduction and Oral Contraceptive Pills on Hyperandrogenism

Abstract Disclosure: A. Syeda: None. T.L. Anderson: None. D. Millar: None. P. Madhavan: None. Introduction: Polycystic ovarian syndrome (PCOS) is a commonly encountered cause of hyperandrogenism which could interfere with fertility. Typical therapeutic options for hyperandrogenism including hormonal contraceptives and anti-androgen medication are contraindicated when planning pregnancy. This case highlights the profound impact of weightloss and oral contraception use to treat severe hyperandrogenism in select cases. Case: A 31-year-old female presented for initial evaluation of hyperandrogenism noted during evaluation for infertility. Laboratory investigations revealed a free testosterone level of 172 ng/dL (n:9-55 ng/dl), SHBG of 17 nmol/L (25-122 nmol/L), DHEAS of 306 ug/dL (n:99-340 ug/dL), TSH of 1.79 uIU/mL (n:0.35-4.96 uIU/mL), ACTH of 12.1 (n:7.2-63.3 pg/mL), cortisol of 9.6 ug/dL (7-23 ug/dL), prolactin of 7.85 ng/mL (3.34-26.72 ng/mL). The patient reported hirsutism, increasing body hair, darkening of skin and significant weight gain over the past 4 years. Menstrual cycles have been reported as being irregular since menarche. Vital signs were stable with a blood pressure of 112/84 mm Hg. Physical examination was remarkable for generalized obesity, hirsutism, and acanthosis nigricans, no abnormal abdominal striae were appreciated. Considering significant elevation in testosterone levels despite low SHBG, an MRI of abdomen and pelvis was obtained which demonstrated ovarian cysts with no concern for ovarian malignancy. CT of the abdomen without contrast was negative for adrenal mass. The overall clinical picture was suggestive of a diagnosis of PCOS. As the patient was planning pregnancy, oral contraceptive agents and spironolactone were deferred initially. The patient was encouraged to lose weight with lifestyle modifications and was started on up titrating dose of Metformin as tolerated. The patient complied with the recommendations and over the course of two years her weight decreased from 171 lbs. to 158 lbs. In the interim, she was placed on oral contraceptive pills for 2 months to undergo hysteroscopy. Subsequently, the testosterone levels normalized to 17 ng/dL. Conclusion: Although previous research has demonstrated the significance of weight loss, for reducing symptoms in patients with PCOS, this role has not been well elucidated in cases of severe hyperandrogenism without a neoplastic cause. The mechanism of interaction between weight loss, oral contraceptive pills and decreased androgens is based on the reduction in insulin resistance which causes a decrease in theca cell androgen synthesis and an increased SHBG. Additionally, a decrease in adiposity reduces the conversion of Δ4-androstenedione to testosterone. Notably, in this case there is potentially a causal relationship between the patient's weight loss of 13 pounds (7.6% of her body weight), OCP use and her return to normal testosterone levels. Presentation Date: Saturday, June 17, 2023

SAT338 Desmopressin Stimulation Test As A Valuable Tool In Establishing Cushing Syndrome Etiology

Abstract Disclosure: A. Aponte Velez: None. A. Figueroa Cruz: None. M.M. Mangual Garcia: None. Hypercortisolism diagnosis may be challenging based on its nonspecific signs and symptoms. The challenge continues when establishing the etiology of Cushing’s syndrome (CS). Based on ACTH levels, which are episodic and can provide equivocal results, further testing is guided to determine pituitary, adrenal or ectopic etiology. Various approaches have been proposed to assess ACTH dependent CS with negative pituitary imaging leading to recommend invasive procedures such as IPSS. This procedure is not widely available and can lead to conflicting results which does not always assist in selecting appropriate therapy. Data on the use of desmopressin stimulation test has suggested a limited role in distinguishing etiology of CS. It is mostly recommended to distinguish Cushing Disease from ectopic secretion, but it can provide further information. A 30 year old female with medical history of arterial hypertension, prediabetes and hypothyroidism was referred due to inconclusive etiology of hypercortisolism. Patient reported a 1.5 year onset of worsening fatigue, lower extremity edema, hair loss, violaceous abdominal striae and easy bruising. Physical exam remarkable for an overweight patient, with elevated blood pressure, moon facies, abdominal violaceous striae >1cm, ecchymosis, dorsocervical fat pad, increased abdominal adiposity and proximal muscle weakness. Hypercortisolism was confirmed biochemically with elevated late night salivary cortisol test, urinary free cortisol and 1mg dexamethasone suppression test. ACTH was found inappropriately normal (19-33 pg/mL) suggestive of ACTH dependent CS. ACTH levels raised suspicion for pituitary etiology, for which brain MRI was performed twice and was found negative for pituitary adenoma. Further laboratories revealed low DHEA-S (7mcg/dL) that on the contrary suggested adrenal etiology. Based on this scenario, patient underwent desmopressin stimulation test without an increase in ACTH or cortisol levels suggestive of adrenal source of hypercortisolism. Adrenal CT scan with and without contrast demonstrated right adrenal mass with defined borders, approximately 2cm in diameter, and contrast enhancement with 65% washout. Patient underwent successful right unilateral adrenalectomy. She was started on glucocorticoid replacement therapy with improvement in clinical symptoms, weight loss and control of hypertension and prediabetes. Postoperative evaluation revealed suppressed cortisol levels, and no electrolyte imbalances. This case describes the challenge of determining the etiology of CS using a combination of endocrine tests and imaging. Owing to increased mortality of untreated CS, it is essential for adequate identification of cause for curative therapy. We promote a non-invasive approach using the desmopressin stimulation test for successful identification in patients with discordant serum and imaging results. Presentation: Saturday, June 17, 2023

SAT588 Cushing’s Syndrome Due To Ectopic ACTH Secretion From Ovarian Teratomas

Abstract Disclosure: Y. Kang: None. M.S. Gildenberg: None. B.J. Quade: None. R.A. Blair: None. Background: Approximately 9-18% of Cushing’s syndrome (CS) cases are secondary to ectopic ACTH secretion, most commonly from sources in the lung or mediastinum. However, ACTH-producing tumors are rarely found in distant organs, occasionally making the localization and management challenging. Clinical Case: A 32-year-old woman with class 3 obesity, hidradenitis suppurativa, anxiety, and depression experienced atraumatic pelvic and sacral fractures. DXA scan result showed Z-scores of -3.1 in the lumbar spine, -2.6 in the femur neck, and -0.5 in the total hip. She reported a steady weight-gain of 250 lbs over 7 years despite lifestyle modifications and liraglutide. On examination, she had a round face with plethora, acne, violaceous abdominal striae, and dorsocervical fat pad. Laboratory findings revealed elevated midnight salivary cortisol levels of 453 and 424 ng/dL (n: <100 ng/dL), elevated 24-hour urine cortisol levels of 254 and 741 (n: 3.5-45 mcg), and an abnormal 1 mg dexamethasone suppression test (DST) result at 15.1 ug/dL. AM plasma ACTH and cortisol levels were 190 pg/mL and 18.5 ug/dL, suggesting ACTH-dependent hypercortisolism. The plasma cortisol level after an 8 mg DST was unsuppressed at 13.1 ug/dL with a dexamethasone level of 3,380 ng/dL (n: >800 ng/dL). Abdominal CT and MRI scans showed large bilateral adnexal masses measuring up to 13.7 cm on the left and 9.3 cm on the right, with heterogeneous solid and cystic components, consistent with mature cystic ovarian teratomas. DOTATE-PET scan did not show any areas of increased uptake. The patient underwent a laparoscopic right cystectomy and left oophorectomy, with immediate drop in cortisol (1.6 ug/dL) and signs of adrenal insufficiency post-operatively, requiring hydrocortisone replacement. After holding hydrocortisone for 24 hours prior to laboratory assessment one week post-operatively, her ACTH and cortisol were undetectable, reflecting successful source removal. Pathology report showed neuroendocrine tumor with pituitary differentiation with positive ACTH immunohistochemical staining and Ki-67 proliferative index of 22.6% on the left adnexal mass, and a mature cystic teratoma on the right. Conclusion: Although rare, pituitary differentiation of ovarian teratomas should be considered as a possible source of ectopic ACTH secretion in CS patients without obvious sources identified in commonly involved organs. Presentation: Saturday, June 17, 2023

Дослідження нелінійних горизонтальних коливань слабозакріпленого вантажу при русі автомобіля

The improvement of the methods of reducing dynamic loads in the elements of self-propelled transport machines and transported goods is based on the results of the analysis of dynamic phenomena that occur during their operation, which is due to the growth of load, increase of working speeds, combination of loading and unloading operations with other technological operations, increase in productivity.
 To prevent damage and ensure traffic safety, packaging and artificial cargoes are secured in car bodies, train carriages and ship holds with wire ties, thrust and spacer bars, tying and other methods.
 But during transportation, as a result of stretching and breaking of stretch marks and pulling out of nails, goods are damaged, moving in a body, wagon or hold. Therefore, it is very important at the design stage of the fastening structure to establish the possible movement of the load, as well as to ensure it within the given limits in order to prevent damage to the load.
 The authors proposed a method of calculating load fluctuations in the body of a truck using the example of two loads of different weights. A kinematic diagram of a self-propelled transport machine with sequential elastic coupling of transported loads was built and a study of nonlinear horizontal oscillations of a loosely secured load during the movement of the vehicle was carried out.
 According to the results of the research, graphs of the dependences of the dimensionless amplitude of the weight of the load relative to other loads depending on the gap between the fasteners were constructed. Maps of regions of stable movements are constructed and the region of unstable movements of loads is shown. It is noted that although such an area of unstable movements is quite small, but under certain conditions of movement of the vehicle and weakly secured cargo, phenomena can occur that can cause a traffic accident.

Gambaran Pemberian Olive Oil pada Ibu Hamil Trimester III dengan Striae Gravidarum

Pregnant women in the third trimester experience anxiety due to stretch marks, striae gravidarum, and heartburn. This research aims to determine the description of giving olive oil to pregnant women in the third trimester with striae gravidarum in the working area of Mulya Asri Health Center, West Tulang Bawang Regency in 2023. This type of research is qualitative descriptive with observational methods. The samples used in this research were 18 pregnant women in the third trimester at the Mulya Asri Community Health Center, Tulang Bawang Barat, with samples taken using the Purposive Sampling Technique. Data analysis techniques use statistical analysis and percentage formulas. The results of the study showed that the highest age of pregnant women was 21-34 years old, with 17 pregnant women (94.44%). Meanwhile, age > 35 years was 1 respondent (5.56%). striae gravidarum with multigravida status were 11 respondents (61.11%). Meanwhile, there were 7 respondents who experienced striae gravidarum with primigravida status (38.89). At the high school level the number of respondents was 10 (55.56%) and the least was at the D3 level, 1 respondent (5.56%). In this way, health services are expected to provide information for optimal knowledge of pregnant women.

Carboxytherapy on the treatment of managing cellulite and striae distensae: A systematic review

The use of carboxytherapy has shown excellent results in the treatment of various aesthetic conditions. The aim of this study was to investigate the effects of carboxytherapy on cellulite and striae distensae (SD). Therefore, a systematic literature review was accomplished on two databases, Medline via PubMed and Scopus, from July to August 2021. Studies that evaluated the effect of carboxytherapy on SD and cellulite were included, eight articles of all of them and that treated 299 people were included in this systematic review and the most studies classified as having low level of methodological quality. There was no consensus regarding the parameters used, but in most studies and applications were performed at a depth of 10 mm with a flow ranging from 50 to 150 mL / min. The results this intervention produced an improvement in skin aspects, with better texture, decreased severity of cellulite and SD, improved patient satisfaction, increased skin thickness, decreased edema and increased inflammatory infiltrate the number of collagen fibers. Some side effects were observed, such as transient erythema and post-inflammatory hyperpigmentation, leading to discomfort. However, all these adverse effects are transient, and patients can return to normal activities with the use of photoprotection. This review demonstrates the stimulatory effect of carboxytherapy on the symptomatology of patients with cellulite and SD.

E67 Still's disease in children refractory to usual treatments: recourse to biotherapies: challenges and opportunities

Abstract Background Still's disease in children is a rare autoinflammatory disease with distinct characteristics from other forms of Juvenile Idiopathic Arthritis. A better understanding of its mechanism has led to the use of targeted therapies with a significant improvement in patient prognosis. Despite these advances, there are still subtypes of Still's disease refractory to the usual treatments with serious complications. Objective demonstrate therapeutic escalation in the Child’s Still Methods We report the case of a patient unresponsive to multiple disease-modifying antirheumatic drugs (DMARDs), who required high doses of steroids. The biological ones were an inevitable recourse to improve the vital and functional prognosis; with at the end, a therapeutic escape with anti IL1 after two years of favorable response. Case report 12-year-old girl with no particular family history, with Still's disease diagnosed at the age of nine with a typical clinical form: thermal steeple concomitant with a morbiliform and evanescent skin eruption, polyarthritis, with hepatosplenomegaly. The diagnosis was confirmed by a major biological inflammatory syndrome with raise serum ferritin, serum C-reactive protein level and sedimentation rate. Despite doses > 0.5 mg/kg/d of prednisone, she showed high-threshold sensitivity to corticosteroids with the appearance of deleterious effects: Cushingoid obesity, stretch marks and bilateral cataracts. Methotrexate was added at a dose of 12 m/m2/week, without clinical response. She eventually developed severe macrophage activation syndrome which was successfully treated with bolus corticosteroids. Faced with this systemic form refractory to the usual treatments; biotherapy was used. Anakinra was added to his treatment at a dose of 2 mg/kg/day. Impressive improvement in systemic and joint clinical signs occurred within the first few weeks of treatment and acute phase reactants returned to normal. Anakinra was well tolerated and no adverse effects were observed. After 24 months of follow-up and complete clinical remission, without corticosteroid therapy, she presented with a severe flare of her disease with severe inflammatory runaway (SMA) and disseminated intravascular coagulation. After controlling this acute clinical condition with intravenous corticosteroids and ciclosporin; we switched to antiIL6 with a good clinical and biological evolution. Discussion The excellent response to anakinra in this case refractory to conventional treatments suggests that IL1 inhibition could be an important therapeutic target in some patients. Nevertheless, some subtypes of Still's disease escape anakinra after a few years of good response and this has been suggested by some authors. Conclusion Pro-inflammatory cytokines such as interleukin IL1, IL6, and IL18 have been implicated in the pathogenesis of childhood Still's disease. In recent years, targeted biologics have been used with several cases of successful treatment in forms refractory to conventional drugs.

Bullous striae distensae in a young patient with cardiomyopathy.

Striae distensae (SD), also known as stretch marks, are observable linear scars that appear where dermal damage has occurred as a result of prolonged stretching of the skin. The actual pathophysiology of SD is still up for debate because its origins are multifaceted. Generally, striae are benign lesions, but larger lesions may get traumatized and become ulcerated or rupture. In patients with edema and receiving systemic steroids, bullous SD could develop secondary to fluid buildup preferentially in striae. We report a case of a young patient with cardiomyopathy who received systemic steroids and developed bullous striae distensae.

Pediatric obesity and skin disease: cutaneous findings and associated quality-of-life impairments in 103 children and adolescents with obesity.

Little is known about specific cutaneous findings in children and adolescents with overweight and obesity. This study assessed the association of skin signs with pivotal auxological and endocrinological parameters and their influence on the quality of life (QoL) of young people with obesity. All patients initially recruited for a tertiary hospital's weight control program were offered participation in this interdisciplinary, single-center, cross-sectional study. All participants underwent a detailed dermatological examination, anthropometric measurements and laboratory examinations. QoL was assessed with validated questionnaires. A total of 103 children and adolescents (age 11.6 ±2.5 years, 41% female, 25% prepubertal, BMI SDS 2.6 ± 0.5, homeostatic model assessment (HOMA) score 3.3 ± 4.2; mean ± s.d.) were recruited in a 12-month study period. Skin affections were linearly associated with increasing BMI and higher age. The most common skin findings were (%) striae distensae (71.0), keratosis pilaris (64.7), acanthosis nigricans (45.0), acne vulgaris (39.2), acrochordons (25.5) and plantar hyperkeratosis (17.6). The HOMA score was associated with acanthosis nigricans (P = 0.047), keratosis pilaris (P = 0.019) and acne vulgaris (P < 0.001). The general mean QoL(QoL) score, as assessed by the WHO-5, was 70 out of 100. A total of 38.9% of participants reported impaired dermatological QoL. This study shows the high prevalence of skin lesions in children and adolescents with obesity. The association between skin lesions and the HOMA score indicates that skin manifestations are a marker of insulin resistance. To prevent secondary diseases and improve QoL, thorough skin examinations and interdisciplinary cooperation are necessary.

Carboxytherapy in esthetic medicine – A review

Carboxytherapy is a minimally invasive method used not only in esthetic medicine. It is defined as the transcutaneous or subcutaneous application of carbon dioxide gas. The treatment exerts effects on various levels including improvement of tissue oxygenation, vasodilatation, stimulation of fibroblasts, and antimicrobial activity. In this review, we will focus on facial and neck esthetics, localized adiposities and cellulite, and scars and stretch marks. We discuss reported evidence for these indications and safety issues. We also mention possible combinations with other treatments. In general, a repeated application is necessary to achieve desired results.

Microneedling for Medical and Aesthetic Purposes: Current Indications and New Advances

Microneedling has become a valuable tool in dermatology, offering a non-surgical option to treat various skin conditions. The procedure creates microchannels in the skin, triggering the release of growth factors and promoting non-fibrotic skin remodeling. The current utilities for microneedling include treating wrinkles, scars, stretch marks, pigmentation disorders, warts, skin texture issues, rosacea, and hair regrowth. Multiple studies have shown its efficacy in improving these conditions, with significant improvements in patient assessments. However, further research is needed to optimize protocols and determine the ideal needle size, frequency, and interval between treatments for the best clinical outcomes for subjects. Through their novel research, clinicians have made significant advancements in microneedling, expanding its uses, and revolutionizing its application. Despite previous beliefs, microneedling can effectively treat active acne lesions without exacerbating the condition. It has also shown promise in treating facial spider veins, providing comparable efficacy to other methods with a better safety profile. Initiating microneedling treatment at an earlier stage for surgical scars improves outcomes compared to waiting for scar maturation. Microneedling combined with topical agents has shown positive results in treating gingival hyperpigmentation. Its expanding applications and recent advancements highlight the potential benefits of integrating microneedling into clinical practice.

Diabetes mellitus associated with type A insulin resistance

Insulin resistance type A is a monogenic disorder with insulin action defect, observed in females with acanthosis nigricans (AN), hyperandrogenism, hyperinsulinemia, insulin resistance (IR) without obesity. We present a family case of diabetes mellitus (DM) with IR in two sisters with obesity and positive family history of DM in three generations. Hyperglycemia was identified at the age of 13 in the older sister and at 11 in the younger sister after COVID-19. Type 2 diabetes (DM2) was diagnosed in mother in the same time with children. Maternal grandmother was diagnosed with DM2 in 58 years old. Patients were examined in 6 months after diagnosis hyperglycemia in Endocrinology Research Centre. The older sister had obesity, AN, and striae distensae. Glycosylated hemoglobin (HbA1c) 6.2%. Impaired glucose tolerance (IGT), hyperinsulinemia and IR, hyperandrogenism, non-alcoholic fatty liver disease (NAFLD), arterial hypertension were diagnosed. The younger sister had obesity, striae distensae. HbA1c — 6.0%. Impaired fasting glucose (IFG), IGT, hyperinsulinemia, IR, NAFLD were diagnosed. Antibodies (AAb) to ZnT8A, IA2, GAD absented in both sisters. A genetic test was provided, a heterozygous mutation in the INSR gene p.V167M was identified in both sisters, mother and grandmother. IR type A was identified in a family with the phenotype of DM2 in this case. This case demonstrated that children with carbohydrate metabolism disorders and obesity without Islet cell autoantibodies have to reffered for a genetic testing. Disordered carbohydrate metabolism was diagnosed in the same time after a COVID-19 in three family members who did not previously have disordered carbohydrate metabolism. We suppose that SARS-CoV-2 can be a trigger for the development of carbohydrate metabolism disorders in IR type A.

MEN1 syndrome presents as Cushing’s disease with proximal lower limb weakness: A rare phenomenon

Abstract The typical presentation of MEN 1 syndrome in most cases is primary hyperparathyroidism. The manifestation of hypercortisolism due to a functional Pituitary microadenoma in an adult as the first presenting feature in MEN 1 is rare. This report of Cushing’s disease presenting as proximal muscle weakness due to an adrenocorticotrophic hormone (ACTH) producing pituitary microadenoma as the initial feature of multiple endocrine neoplasia type 1 is an unusual occurrence. The patient had presented with proximal muscle weakness of lower limbs along with abdominal striae and uncontrolled diabetes. On hematological and radiological evaluations, she was detected to have a pituitary microadenoma along with a parathyroid adenoma causing increased levels of ACTH, serum (S) cortisol, parathyroid hormone, and S calcium. The patient underwent a transsphenoidal decompression of the pituitary microadenoma using frameless neuronavigation. Within 2 weeks of surgery, the patient achieved normal levels of S cortisol. She is off medication for blood sugar control. At 6 months, follow-up, she is symptom-free.

Micro needling in treatment of stretch marks

Micro needling in treatment of stretch marks