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Discovery and activity of (1R,4S,6R)-N-[(1R)-2-[4-cyclohexyl-4-[[(1,1- dimethylethyl)amino]carbonyl]-1-piperidinyl]-1-[(4- fluorophenyl)methyl]-2-oxoethyl]-2-methyl-2- azabicyclo[2.2.2]octane-6-carboxamide (3, RY764), a potent and selective melanocortin subtype-4 receptor agonist

Patients typically present after sudden movements, poor posture over time, or trauma

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Pale or jaundiced skin , often linked to megaloblastic anemia from inadequate B12