Leucocyte volume, conductivity, and scatter at presentation in COVID-19 patients

Background

In COVID-19 patients, besides changes in leucocyte count, morphological abnormalities of circulating blood cells have been reported.

Aim

This study aims to investigate the relationship between the morphological and functional properties of leucocytes and the severity of the disease in COVID-19 patients.

Materials and Methods

Blood samples were collected from COVID-19 patients (n = 130) at the time of admission. The patients were stratified according to the comorbidity, age, LDH, lymhocyte count score as mild, moderate, and severe. Complete blood count and the cell population data were analyzed by the Volume, conductivity, scatter (VCS) technology on Beckman Coulter LH-780 hematology analyzer. Kruskal-Wal'lis test was used to assess the differences between the groups with subsequent Bonferroni correction.

Results

Neutrophil count was increased, and lymphocyte count was decreased in severe patients compared to mild patients. The increase in the percent of neutrophils and the neutrophil/lymphocyte ratio in the severe patient group was significant in comparison to both the moderate and the mild group. The dispersion of the neutrophil volume and conductivity showed significant changes depending on the severity of the disease. The lymphocyte volume, lymphocyte-volume-SD and lymphocyte-conductivity as well as the monocyte-volume and monocyte-volume-SD were significantly increased in severe patients in comparison to mild patients. The increase of lymphocyte and monocyte volume in severe patients was also significant in comparison to moderate patients.

Conclusions

COVID-19 infection leads to important changes in cell population data of leucocytes. The volumetric changes in lymphocytes and monocytes are related to the severity of the disease.

The association of antiviral drugs with COVID-19 morbidity: The retrospective analysis of a nationwide COVID-19 cohort

Background and objectives

Although several repurposed antiviral drugs have been used for the treatment of COVID-19, only a few such as remdesivir and molnupiravir have shown promising effects. The objectives of our study were to investigate the association of repurposed antiviral drugs with COVID-19 morbidity.

Methods

Patients admitted to 26 different hospitals located in 16 different provinces between March 11–July 18, 2020, were enrolled. Case definition was based on WHO criteria. Patients were managed according to the guidelines by Scientific Board of Ministry of Health of Turkey. Primary outcomes were length of hospitalization, intensive care unit (ICU) requirement, and intubation.

Results

We retrospectively evaluated 1,472 COVID-19 adult patients; 57.1% were men (mean age = 51.9 ± 17.7years). A total of 210 (14.3%) had severe pneumonia, 115 (7.8%) were admitted to ICUs, and 69 (4.7%) were intubated during hospitalization. The median (interquartile range) of duration of hospitalization, including ICU admission, was 7 (5–12) days. Favipiravir (n = 328), lopinavir/ritonavir (n = 55), and oseltamivir (n = 761) were administered as antiviral agents, and hydroxychloroquine (HCQ, n = 1,382) and azithromycin (n = 738) were used for their immunomodulatory activity. Lopinavir/ritonavir (β [95% CI]: 4.71 [2.31–7.11]; p = 0.001), favipiravir (β [95% CI]: 3.55 [2.56–4.55]; p = 0.001) and HCQ (β [95% CI]: 0.84 [0.02–1.67]; p = 0.046) were associated with increased risk of lengthy hospital stays. Furthermore, favipiravir was associated with increased risks of ICU admission (OR [95% CI]: 3.02 [1.70–5.35]; p = 0.001) and invasive mechanical ventilation requirement (OR [95% CI]: 2.94 [1.28–6.75]; p = 0.011).

Conclusion

Our findings demonstrated that antiviral drugs including lopinavir, ritonavir, and favipiravir were associated with negative clinical outcomes such as increased risks for lengthy hospital stay, ICU admission, and invasive mechanical ventilation requirement. Therefore, repurposing such agents without proven clinical evidence might not be the best approach for COVID-19 treatment.

ASSOCIATION BETWEEN HASHIMOTO'S THYROIDITIS AND PAPILLARY THYROID CANCER: A SINGLE CENTER EXPERIENCE

PURPOSE

To investigate the association between papillary thyroid cancer (PTC) and Hashimoto's thyroiditis (HT).

DESIGN

This study is a retrospective study that conducted during 7 consecutive years with a median 119.5 months follow-up.

SUBJECTS AND METHOD

Patients who underwent thyroidectomy in Dokuz Eylül University Hospital during 7 consecutive years were included. Patients' demographics, biochemical, radiological, and pathological results were retrospectively assessed.

RESULTS

Four hundred sixty nine patients were evaluated. Among 469 patients who underwent thyroidectomy, 132 (28.1%) were malignant, while 182 patients were diagnosed with HT (38.8%). PTC was ranked first at 92.4% (n: 122). The prevalence of HT was 54.9% in patients with PTC and 33.1% in patients without PTC diagnosis (p<0.001). Younger age and the presence of HT were independently associated with PTC. The presence of HT was associated with increased risk of development of PTC (OR: 2.2, %95 CI: 1.4-3.5, p<0.001) but not with TNM stage or recurrence. Lymph node metastasis at presentation was the strongest predictor of recurrence (OR: 13.9, CI: 3.5-54.6, p<0.001).

CONCLUSIONS

HT was an independent risk factor for development of PTC. According to our findings, HT patients (particularly with nodular HT) should be observed carefully and thyroid fine needle aspiration biopsy (TFNAB) should be encouraged if necessary.

Risk factors for diabetic foot ulcers in metreleptin naïve patients with lipodystrophy

AIM

Patients with lipodystrophy are at high risk for chronic complications of diabetes. Recently, we have reported 18 diabetic foot ulcer episodes in 9 subjects with lipodystrophy. This current study aims to determine risk factors associated with foot ulcer development in this rare disease population.

METHODS

Ninety metreleptin naïve patients with diabetes registered in our national lipodystrophy database were included in this observational retrospective cohort study (9 with and 81 without foot ulcers).

RESULTS

Patients with lipodystrophy developing foot ulcers had longer diabetes duration (p = 0.007), longer time since lipodystrophy diagnosis (p = 0.008), and higher HbA1c levels (p = 0.041). Insulin use was more prevalent (p = 0.003). The time from diagnosis of diabetes to first foot ulcer was shorter for patients with generalized lipodystrophy compared to partial lipodystrophy (p = 0.036). Retinopathy (p < 0.001), neuropathy (p < 0.001), peripheral artery disease (p = 0.001), and kidney failure (p = 0.003) were more commonly detected in patients with foot ulcers. Patients with foot ulcers tended to have lower leptin levels (p = 0.052). Multiple logistic regression estimated significant associations between foot ulcers and generalized lipodystrophy (OR: 40.81, 95% CI: 3.31-503.93, p = 0.004), long-term diabetes (≥ 15 years; OR: 27.07, 95% CI: 2.97-246.39, p = 0.003), and decreased eGFR (OR: 13.35, 95% CI: 1.96-90.67, p = 0.008).

CONCLUSIONS

Our study identified several clinical factors associated with foot ulceration among patients with lipodystrophy and diabetes. Preventive measures and effective treatment of metabolic consequences of lipodystrophy are essential to prevent the occurrence of foot ulcers in these high-risk individuals.

Machine Learning Models for Classification of Cushing's Syndrome Using Retrospective Data

Accurate classification of Cushing's Syndrome (CS) plays a critical role in providing the early and correct diagnosis of CS that may facilitate treatment and improve patient outcomes. Diagnosis of CS is a complex process, which requires careful and concurrent interpretation of signs and symptoms, multiple biochemical test results, and findings of medical imaging by physicians with a high degree of specialty and knowledge to make correct judgments. In this article, we explore the state of the art machine learning algorithms to demonstrate their potential as a clinical decision support system to analyze and classify CS to facilitate the diagnosis, prognosis, and treatment of CS. Prominent algorithms are compared using nested cross-validation and various class comparison strategies including multiclass, one vs. all, and one vs. one binary classification. Our findings show that Random Forest (RF) algorithm is most suitable for the classification of CS. We demonstrate that the proposed approach can classify CS with an average accuracy of 92% and an average F1 score of 91.5%, depending on the class comparison strategy and selected features. RF-based one vs. all binary classification model achieves sensitivity of 97.6%, precision of 91.1%, and specificity of 87.1% to discriminate CS from non-CS on the test dataset. RF-based multiclass classification model achieves average per class sensitivity of 91.8%, average per class specificity of 97.1%, and average per class precision of 92.1% to classify different subtypes of CS on the test dataset. Clinical performance evaluation suggests that the developed models can help improve physicians' judgment in diagnosing CS.

The predictors of COVID-19 mortality in a nationwide cohort of Turkish patients

The COVID-19-related death rate varies between countries and is affected by various risk factors. This multicenter registry study was designed to evaluate the mortality rate and the related risk factors in Turkey. We retrospectively evaluated 1500 adults with COVID-19 from 26 centers who were hospitalized between March 11 and July 31, 2020. In the study group, 1041 and 459 cases were diagnosed as definite and highly probable cases, respectively. There were 993 PCR-positive cases (66.2%). Among all cases, 1144 (76.3%) were diagnosed with non-severe pneumonia, whereas 212 (14.1%) had severe pneumonia. Death occurred in 67 patients, corresponding to a mortality rate of 4.5% (95% CI:3.5–5.6). The univariate analysis demonstrated that various factors, including male sex, age ≥65 years and the presence of dyspnea or confusion, malignity, chronic obstructive lung disease, interstitial lung disease, immunosuppressive conditions, severe pneumonia, multiorgan dysfunction, and sepsis, were positively associated with mortality. Favipiravir, hydroxychloroquine and azithromycin were not associated with survival. Following multivariate analysis, male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were found to be independent risk factors for mortality. Among the biomarkers, procalcitonin levels on the 3rd-5th days of admission showed the strongest associations with mortality (OR: 6.18; 1.6–23.93). This study demonstrated that the mortality rate in hospitalized patients in the early phase of the COVID-19 pandemic was a serious threat and that those patients with male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were at increased risk of mortality; therefore, such patients should be closely monitored.

Validity and reliability of the Turkish version of the Michigan Neuropathy Screening Instrument

Background/aim

The aim of this study was to demonstrate the validity and reliability of the Turkish version of the Michigan Neuropathy Screening Instrument (MNSI-TR).

Materials and methods

The study included 127 patients aged 45–76 years who were previously diagnosed with type 1 or 2 diabetes. Stability of the instrument was assessed by intraclass correlation coefficient. Reliability of the MNSI-TR was assessed using the Kuder–Richardson formula 20 test, item-total correlations, and floor/ceiling effect. Validity was evaluated with receiver operating characteristic curve analysis. A logistic regression model was used to determine to what degree the MNSI-TR explain nerve conduction study (NCS) results in the prediction of neuropathy.

Results

With a cut-off value of 3.5 for the questionnaire, sensitivity and specificity of the MNSI-TR were 75.5% and 68.1%, respectively. A cut-off of 2.75 for the physical assessment part of the scale resulted in 87.5% sensitivity and 93.6% specificity. The scale was able to diagnose neuropathy in the rate of 71.5% of the patients diagnosed with neuropathy by NCS.

Conclusion

The MNSI-TR is a valid and reliable method for evaluating diabetic peripheral neuropathy in Turkish speaking societies. It must be obtained a minimum of 4 points from the questionnaire part and a minimum of 2.5 points from the physical assessment part for the diagnosis of neuropathy

Physical activity in women with subclinical hypothyroidism

PURPOSE

Physical activity is associated with many health-related benefits. However, there is a shift towards inactive lifestyles around the world. Subclinical hypothyroidism (SCH) may have adverse effects similar to hypothyroidism. The presence of symptoms and reduced physical performance in SCH may contribute to an inactive lifestyle. Therefore, the present study aimed to compare physical activity levels (PALs) between women with subclinical hypothyroidism and healthy controls.

METHODS

Thirty-two women with newly diagnosed SCH and 28 healthy women were enrolled in this cross-sectional study. Arterial stiffness was evaluated by pulse wave velocity (PWV). Neuromuscular symptoms were questioned. Participants wore a physical activity monitor (SenseWear^® Armband) for 4 consecutive days. Handgrip and quadriceps muscle strength were assessed by dynamometer. Functional exercise capacity was assessed by 6-minute walk test (6MWT).

RESULTS

There was no significant difference in sociodemographic variables between the groups. PWV was significantly higher in the SCH group (P = 0.006). Physical activity duration and number of steps were significantly lower in the SCH group (P < 0.05). There was significant difference in neuromuscular symptoms, handgrip and quadriceps muscle strength, and 6MWT distance between the groups (P < 0.05).

CONCLUSIONS

This study demonstrates that women with SCH had lower PALs compared to healthy controls. Women with SCH should participate in exercise programs to increase physical activity and muscle strength to achieve adequate PALs.

Evaluation of Mediterranean diet adherence in patients with a history of coronary revascularization

INTRODUCTION

Lifestyle modification is an important component of the secondary prevention strategies; and a healthy diet is one of the cornerstones in management of the coronary heart disease. We aimed to investigate the dietary habits of the patients with history of coronary revascularization, characteristics of the ones with good adherence by using alternate MedDiet questionnaire.

METHODS

We included outpatients who had a history of coronary revascularization at least 6 months prior to enrollment. Each participant filled out a questionnaire to collect the data of demographics and clinical characteristics. Alternate MedDiet score was calculated to evaluate the Mediterranean style dietary adherence. Alternate MedDiet was originally based on 14-item questionnaire; we adjusted it to our population (max 13 points).

RESULTS

We enrolled 226 consecutive outpatients (age 61.7±10.9 years, 72% males). The median duration after revascularization was 60 months. A total of 112 (49.6%) patients had previous percutaneous coronary intervention (PCI), 77 (34.1%) had coronary by-pass graft surgery (CABG), and 36 (15.9%) had both revascularization procedures. The median MedDiet score was 6. Patients were stratified into two subgroups (MedDiet score ≥7 vs. <7). A total of 61 (26.9%) patients had MedDiet score ≥7. By univariate analysis, good MedDiet scores were associated with older age, waist circumference, body mass index, high education level, regular follow-up, duration after first revascularization and revascularization with CABG+PCI. In the multivariate analysis, high education level (P=.002, OR=8.212, 95%CI: 2.155-31.291) and duration after revascularization (P=.034, OR=1.007, 95%CI: 1.001-1.013) were independent predictors of good MedDiet scores.

CONCLUSION

The adherence rate to a healthy diet was low in patients with previous coronary revascularization. MedDiet score seems to be practical and useful item to evaluate the dietary habits in outpatient setting. Mediterranean diet adherence rates were associated with high education level, and duration after revascularization.

The prevalence and systemic risk factors of diabetic macular edema: a cross-sectional study from Turkey

Background

The aim of this study was to evaluate the prevalence of diabetic macular edema (DME) utilizing optical coherence tomography (OCT), and to clarify the effects of the systemic findings and risk factors on the development of DME.

Methods

This cross-sectional study was conducted in the departments of ophthalmology and endocrinology at the Dokuz Eylul University School of Medicine in Izmir, Turkey. The demographics, type and duration of diabetes mellitus, treatment modality, smoking and alcohol consumption habits, as well as the systemic blood pressure, renal functional tests, hemoglobulin A1c level, serum lipid profile, and 24-h urine albumin level were noted and statistically analyzed. The relationships between the systemic findings and DME were studied.

Results

Four-hundred and thirteen eyes of 413 diabetic patients who were examined between January 2011 and July 2012 were enrolled in this study. The prevalence of DME was 15.3% among the patients. The males exhibited DME significantly more frequently than the females (p = 0.031), and the duration of diabetes was significantly longer in those patients with DME (p < 0.001). Those patients without DME frequently used antihyperlipidemic drugs and had a higher level of high density lipoprotein cholesterol (p = 0.040 and p = 0.046, respectively). The patient’s alcohol consumption, nephropathy, neuropathy, previous cataract surgery, severity of diabetic retinopathy, and insulin usage were statistically significant factors with regard to the DME prevalence.

Conclusions

This study demonstrated the prevalence of DME in Turkey by utilizing OCT. The development of DME can be avoided or limited and the response to treatment may be improved by the regulation of the DME risk factors.

Roles of ultrasound and power Doppler ultrasound for diagnosis of Hashimoto thyroiditis in anti-thyroid marker-positive euthyroid subjects

PURPOSE

The present study was performed to investigate the contribution of ultrasonographic (US) findings to diagnosis in anti-thyroid marker-positive patients with normal hormone levels among euthyroid subjects with Hashimoto's thyroiditis (HT).

METHODS

Forty premenopausal euthyroid patients with a median age of 32 years (range, 20-44 years) with normal levels of free triiodothyronine (FT3) and free thyroxine (FT4), and elevated anti-thyroid peroxidase (TPO) antibodies were enrolled in this study. A control group of 46 healthy individuals with a median age of 29 years (range, 18-43 years) was composed of randomly selected volunteers. The examinations included basic morphometric (measurement of thyroid gland dimensions in three axes, the volume of each thyroid lobe, and the total thyroid volume), morphological grayscale imaging (echogenicity, nodularity, septations, undulation of the margins, and reactive lymph nodes), and thyroid gland vascularity.

RESULTS

There were no statistically significant differences in morphometric parameters of the thyroid gland between the study and control groups. There were significant differences in the presence of nodularity, undulation of the gland margins, septations inside the glands, infrathyroidal and/or pretracheal reactive lymph nodes, and increased vascularity on power Doppler imaging between the groups. The use of all parameters together yielded a sensitivity of 90%, specificity of 84.8%, positive predictive value (PPV) of 83.7%, negative predictive value (NPV) of 90.7%, and accuracy of 87.2% for diagnosis of HT.

CONCLUSIONS

US and power Doppler US are helpful for the diagnosis of HT in anti-thyroid marker-positive patients with normal thyroid hormone levels.

Insulin need in gestational diabetes is associated with a worse cardiovascular risk profile after pregnancy

OBJECTIVE

Women with gestational diabetes mellitus (GDM) treated with insulin are more likely to develop type 2 diabetes after pregnancy compared to mild GDM cases treated with medical nutrition treatment (MNT) alone. We aimed to compare levels of subclinical atherosclerosis markers in women with previous GDM treated with insulin and MNT alone.

METHODS

Eighty-one women with previous GDM (45 treated with insulin, 36 treated with MNT) and 35 age-matched lean controls were included. Fasting glucose, insulin and lipids, circulating fibrinogen, CRP, PAI-1 and IL-6 levels were assayed. Carotid intima media thickness (IMT) was measured.

RESULTS

Women with previous GDM treated with insulin in pregnancy had significantly higher fasting glucose, plasma PAI-1 levels and carotid IMT compared to women treated with MNT alone. In multiple regression analysis, insulin need in pregnancy was associated with increased carotid IMT and plasma PAI-1 levels (corrected for age, BMI, postpartum duration, fasting glucose and lipids; model r(2)=0.132; beta=0.297, p=0.014 for carotid IMT; model r(2)=0.198; beta=0.345, p=0.003 for PAI-1).

CONCLUSION

Women with previous GDM treated with insulin in pregnancy had a worse cardiovascular risk profile compared to mild GDM patients. An intensive preventive approach for cardiovascular disorders is particularly essential for this subgroup of women.

Acute phase reactants predict the risk of amputation in diabetic foot infection

BACKGROUND

prediction of amputation would aid clinicians in the management of diabetic foot infections. We aimed to assess the predictive value of baseline and post-treatment levels of acute phase reactants in the outcome of patients with diabetic foot infections.

METHODS

we collected data prospectively during minimum follow-up of 6 months in patients with infected diabetic foot ulcers hospitalized in Dokuz Eylul University Hospital between January 1, 2003, and January 1, 2008. After excluding patients who did not attend the hospital for follow-up visits regularly (n = 36), we analyzed data from 165 foot ulcer episodes.

RESULTS

limb ischemia and osteomyelitis were much more frequent in patients who underwent amputation. Wagner grade, which assesses ulcer depth and the presence of osteomyelitis or gangrene, was higher in patients who needed amputation. Ulcer size was slightly larger in the amputation group. Baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, white blood cell counts, and platelet counts were significantly elevated in patients who underwent amputation. Albumin levels were significantly suppressed in the amputation group. Univariate analysis showed that a 1-SD increase in baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, and white blood cell counts and a 1-SD decrease in post-treatment albumin levels were significantly associated with increased risk of amputation. Post-treatment C-reactive protein level was strongly associated with amputation risk.

CONCLUSIONS

circulating levels of acute phase reactants were associated with amputation risk in diabetic foot infections.

The effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers

Reduced creatinine clearance is related to an increased risk for diabetic foot ulcer development. Wound healing has been reported to be worse in diabetic patients with impaired kidney functions than general diabetic population. This study aimed to investigate the effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers. Data from 147 neuropathic diabetic foot ulcer episodes were included in this observational study. Patients were admitted to Dokuz Eylul University Hospital between January 2003 and June 2008. Patients were excluded if they had limb ischemia. Diabetic nephropathy was investigated by 24h urinary albumin excretion and serum creatinine levels. Creatinine clearance was calculated according to Cockcroft-Gault formula. Foot ulcers were followed up for 6 months to determine the outcome. Our short-term follow-up revealed that neuropathic diabetic ulcers healed worse in patients with decreased creatinine clearance than in those who had normal creatinine clearance. Amputation rates were also found to be higher. Our results suggest that creatinine clearance is an important factor affecting wound healing in patients with neuropathic diabetic foot ulcers.

The levels of soluble CD40 ligand and C-reactive protein in normal weight, overweight and obese people

OBJECTIVE

Obesity has been suggested as an independent risk factor for cardiovascular disease. Increasing evidence shows that engagement of soluble CD40 ligand (sCD40L) with its receptor plays a crucial role in the pathogenesis of atherosclerosis. The aim of the present study was to test whether obesity is associated with low-grade systemic inflammation as measured by serum high-sensitive C-reactive protein (hsCRP) and sCD40L concentration.

METHODS

Serum hsCRP and sCD40L concentrations were measured in 148 nondiabetic people. The participants were divided into three groups depending upon their body mass index (BMI) levels: Group 1 (normal weight), BMI<25 kg/m(2); Group 2 (overweight), BMI 25 kg/m(2) to 29.9 kg/m(2); and Group 3 (obese), BMI>or=30 kg/m(2).

RESULTS

Obese people had more elevated hsCRP levels than both their normal weight and overweight counterparts (P=0.000 and P=0.000, respectively). Similarly, serum concentrations of sCD40L were significantly higher, statistically, in obese subjects compared with normal weight subjects (P=0.003). In addition, obese subjects had higher values of sCD40L than overweight subjects, but the difference did not reach statistical significance (P=0.063). The levels of high-density lipoprotein cholesterol were significantly lower in obese subjects compared to normal weight subjects (P=0.048). The analysis of platelet count disclosed a statistically significant difference between obese subjects and normal weight subjects (P=0.028). The levels of BMI were positively correlated with the serum levels of hsCRP and sCD40L in all subjects (r=0.514, P=0.000 and r=0.283, P=0.000, respectively). Levels of hsCRP were positively correlated with waist circumference, fasting glucose, total cholesterol, triglyceride, low-density lipoprotein cholesterol, leukocytes, platelets, systolic and diastolic blood pressure. Similarly, soluble CD40L levels were positively correlated with waist circumference, fasting glucose and leukocytes.

CONCLUSION

Obese patients showed a significant increase of hsCRP and sCD40L levels compared with normal weight subjects, which might contribute to the known proinflammatory milieu found in these patients.

Incidence of thyroid dysfunction and thyroid cancer in renal transplant recipients: a single center experience

BACKGROUND

The prevalence of thyroid cancer in renal transplant population has not been widely studied, and there is no consensus on the management of thyroid cancer in transplant patients. The aim of this study was to evaluate changes in thyroid hormone levels and investigate the incidence of the thyroid cancer after renal transplantation.

MATERIALS AND METHODS

From October 1989 to April 2007, 122 renal allograft recipients that were being followed underwent thyroid ultrasonography to determine nodules together with thyroid hormone levels. Ultrasound-guided fine-needle aspiration biopsy (FNAB) was performed to the nodules > 10 mm or those with 8-10 mm diameter but with calcifications.

RESULTS

One hundred and eight patients (88.5%) had normal thyroid function. None of the patients had overt hypothyroidism, 2 had subclinical hypothyroidism, 10 subclinical thyrotoxicosis, and 2 low T3 syndrome. Mean thyroid volume was 14.2 +/- 7.2 ml. In all, 91.8% was diagnosed with goiter (n = 112). Seventy-two thyroid nodules were detected in 49 kidney allograft recipients (single nodule in 30, multiple in 19 patients). Eighty-four biopsy samples were reported as benign (n = 21, 87.5%), 8 as suspicious (n = 2, 8.3%), and 4 as inadequate (n = 1, 4.1%). After surgery, one of the patients (0.8%) with suspicious FNAB was reported as papillary thyroid carcinoma.

CONCLUSION

Because of the high incidence of thyroid dysfunction in transplant patients, screening of thyroid function should be a part of follow-up. Our results suggest that although frequency of nodules is increased in kidney transplant patients, prevalence of thyroid cancer is slightly, but not significantly, higher than that of the normal population.

Enhanced levels of soluble CD40 ligand and C-reactive protein in a total of 312 patients with metabolic syndrome

The metabolic syndrome (MS) is associated with a systemic inflammatory response that plays an important pathogenetic role in atherothrombotic disease. Increasing evidence indicates that CD40-CD40 ligand interactions constitute an important mediator for vascular inflammation. The purpose of this study was to assess whether high-sensitivity C-reactive protein (hs-CRP) and soluble CD40 ligand (sCD40L) levels were increased in patients with MS. During the study period from January 2004 to August 2004, 312 patients with MS and 98 control subjects were included. Anthropometric measurements, blood pressure assessment, electrocardiography, and blood measurements including fasting blood glucose, postprandial blood glucose, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, glycated hemoglobin, white blood cell (WBC), platelets, hs-CRP, and sCD40L were performed. Patients with MS were divided into 3 groups based upon their glucose tolerance (group 1, normal glucose tolerance; group 2, prediabetic group; and group 3, diabetes mellitus). Patients with MS showed a significant increase of WBC, hs-CRP, and sCD40L levels compared with control subjects. The levels of both hs-CRP and sCD40L were positively correlated with body mass index (BMI). High-sensitivity CRP levels were also positively correlated with waist circumferences, fasting blood glucose, postprandial blood glucose, and glycated hemoglobin, and negatively correlated with high-density lipoprotein cholesterol. In patients with MS, both hs-CRP and sCD40L levels were positively correlated with WBC count. We found a positive correlation between sCD40L and platelets. Among the subgroups of patients with MS, the mean levels of WBC, hs-CRP, and sCD40L did not show any significant differences. In conclusion, elevated levels of WBC, hs-CRP, and sCD40L in MS patients provide further insight into the relationship between MS and inflammation. In our study, positive correlations between BMI and both hs-CRP and sCD40L levels suggest that BMI is an important determinant of a chronic inflammatory state in patients with MS. Moreover, this study reports significantly increased levels of WBC, hs-CRP, and sCD40L not only in diabetic subjects with MS but also in prediabetic subjects and nondiabetic subjects with MS compared with control subjects. Our data suggest that MS patients have proinflammatory state independent of their glucose tolerance status. In our study, the positive correlation between the levels of sCD40L and platelets in patients with MS supports previous reports indicating that sCD40L are derived predominantly from platelets.

Allergic reactions to human insulin: a review of current knowledge and treatment options

Although the incidence of insulin allergy decreased after the introduction of recombinant human insulin preparations, it is still a major problem which may be life-threatening in some cases. In this article, we attempted to review current knowledge concerning allergic reactions to human insulin and discuss the available treatment options of insulin allergy.

Adrenal incidentaloma, clinical, metabolic, follow-up aspects: single centre experience

To investigate clinical characteristics, metabolic parameters and follow-up findings of subjects with incidentally discovered adrenal tumors. 376 consecutive subjects who have been evaluated since 2002 were included. Initial radiological examination was CT. Hormonal evaluation included 8.00 a.m. cortisol, DHEA-S, ACTH and in hypertensive subjects, plasma renin activity, and serum aldosterone. Urinary free cortisol (UFC), urinary normetanephrine, and metanephrine were measured. Overnight 1 mg dexamethasone suppression test was performed. Radiological evaluation was performed at 6th and 12th months and annually in subsequent visits. Hormonal evaluation was performed 6 months after the initial visit and annually in subsequent visits. Additionally, patients were evaluated for the development of Type 2 diabetes mellitus, hypertension, hyperlipidemia, and metabolic syndrome in 6-month intervals. Mean age of the participants was 54.7 ± 13.1. Female subjects were more commonly affected (70%). CT was the most frequent radiological intervention that discovered adrenal masses (57%). The vast majority of the participants (85.6%) had benign adrenal adenomas. Primary adrenocortical malignancy was detected in 4 subjects (1.1%). Subjects with adrenal adenomas had significantly smaller tumor diameters (P ≤ 0.001 vs. other tumors). Sensitivity and specificity of 40 mm as a cut-off value in the differentiation of adrenal gland malignancies from benign tumors was 73.3 and 54.8%, respectively. Most of the adrenal adenomas were non-functioning (73.5%). Subclinical Cushing syndrome (sCS) was detected in 12.5%. The overall prevalence of Type 2 diabetes mellitus, hypertension, hyperlipidemia, and metabolic syndrome was 18.4, 54.9, 59.6, and 48.1%, respectively. They were significantly more common in middle-aged and elderly subjects. During 24 months follow-up 10.2% of adenomas featured increase in tumor diameter and 2.06% developed sCS. Young subjects featured more stable tumor diameter and hormonal status. Most of the incidentally discovered adrenal tumors were non-functioning adrenal adenomas. Clinically overt hormone hypersecretion syndromes were mainly shown in young subjects, while adrenal gland malignancies and sCS were more common in older ages. Mass enlargement and development of subclinical cortisol secretion were not rare and observed especially in middle-aged and elderly subjects. Metabolic derangements were common; however, a possible independent association between adrenal adenoma and metabolic problems need to be elucidated with prospective studies.

Prospective evaluation of tumor size and hormonal status in adrenal incidentalomas

BACKGROUND

Because of the increased use of imaging interventions, more subjects have been diagnosed with adrenal incidentaloma in recent years.

AIM

To evaluate the risk of mass enlargement, hormone hypersecretion and development of adrenal carcinomas during short-term followup.

SUBJECTS AND METHODS

There were 317 subjects with incidentally discovered adrenal tumors in the registry. Forty subjects were excluded because of clinically overt hormone secretion at diagnosis and subjects with complete data were included in radiological (no.=150) and hormonal (no.=150) follow- up. Radiological evaluation was performed with computed tomography (CT) and/or magnetic resonance imaging (MRI). There were 143 subjects with adrenal adenomas and 7 subjects with other tumor types (cyst or myelolipoma). Median follow-up duration was 24 months.

RESULTS

Increase in tumor size was detected in 25 subjects (17.4%) with adenomas and 1 subject with adrenal myelolipoma (14.3%). Decrease in tumor size was found in 7 subjects (4.8%) with adrenal adenomas. One patient was diagnosed with adrenocortical carcinoma during follow-up. In subjects with non-functioning adrenal adenoma (NFA, no.=120) or subclinical Cushing syndrome (sCS) (no.=30), no subject developed clinically overt hormone hypersecretion, while 8 (6%) subjects in the NFA group developed sCS. Tumor diameter and follow-up duration were significantly higher in subjects who developed sCS.

CONCLUSION

In conclusion, we demonstrated that, despite being infrequent, adrenal tumors may increase in size, develop overt or subclinical hormone secretion or feature malignant transformation. Therefore, radiological and hormonal follow-up should be recommended to the patients. More investigations are needed for the establishment of long-term follow-up protocols.

Predictors of amputation in diabetics with foot ulcer: single center experience in a large Turkish cohort

OBJECTIVE

Prediction of diabetic foot ulcer outcome may be helpful for clinicians in optimizing and individualizing management strategy. The aim of the present study was to examine the possibility of predicting the outcome of patients with diabetic foot ulcers by using easily assessed clinical and laboratory parameters at baseline.

DESIGN

In this observational study, data were collected prospectively in 670 consecutive diabetic foot ulcer episodes in 510 patients examined between January 1999 and June 2008 and were used to evaluate potential predictors of amputation retrospectively. After exclusion of patients who did not come to the hospital for follow-up for a minimum of six months, data of 574 foot ulcer episodes were evaluated.

RESULTS

Limb ischemia, osteomyelitis and presence of gangrene and ulcer depth, determined by the Wagner classification system, were the major independent predictors of overall and major amputations. Older age, presence of coronary artery disease, smoking and ulcer size were found to be associated with either overall or major amputations. Baseline levels of acute phase reactants (white blood cell count, polymorphonuclear leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and albumin) and decreased hemoglobin levels were associated with amputation risk. Multivariate analysis showed that one standard deviation increase in baseline CRP and ESR levels were independent predictors of overall and major amputations, respectively.

CONCLUSIONS

The presence of limb ischemia, osteomyelitis, local and diffuse gangrene and ulcer depth were independent predictors of amputation. Baseline levels of ESR and CRP appeared to be helpful for clinicians in predicting amputation.

Beneficial effect of endocrinologist-performed ultrasonography on preoperative parathyroid adenoma localization

OBJECTIVE

To evaluate whether endocrinologist-performed ultrasonography improves the localization of parathyroid adenomas in patients with primary hyperparathyroidism.

METHODS

We performed a retrospective analysis of consecutive patients with primary hyperparathyroidism due to a single adenoma who underwent surgery at the Dokuz Eylul University Hospital in Izmir, Turkey, between January 2000 and January 2008. Data regarding the localization of adenomas were obtained from surgical reports. Neck ultrasonography was performed in all patients as first-line imaging. Parathyroid ultrasonography was performed by a staff radiologist between January 2000 and December 2004. Beginning January 2005, parathyroid ultrasonography was performed blindly by an endocrinologist in addition to the staff radiologist. In the case of discordant preoperative localization between the endocrinologist- and radiologist-performed ultrasonography, surgery was performed according to the technetium Tc 99m sestamibi (MIBI) scan and endocrinologist-performed ultrasonography localization results.

RESULTS

A total of 156 patients with primary hyperparathyroidism due to a single adenoma were included. Of the 156 patients, 139 also underwent MIBI scan. Ultrasonography localized 102 parathyroid adenomas (65%). The accuracy of the ultrasonography was improved in patients who underwent endocrinologist-performed ultrasonography. Endocrinologist-performed ultrasonography localized the adenoma correctly in 19 patients for whom the staff radiologist had reported a negative or unsuccessful localization. When ultrasonography results were combined with the MIBI scan findings, parathyroid adenomas were again more likely to be localized in patients who underwent operation after January 2005 and thus had endocrinologist-performed ultrasonography.

CONCLUSION

Our results suggest that endocrinologist-performed ultrasonography improves the preoperative localization of parathyroid adenoma.

Hypercalcemia due to Graves' disease in a patient with thyroid hemiagenesis

Thyroid hemiagenesis is a rare anomaly due to failure of development of one thyroid lobe during embryological life. A lot of thyroid disorders may accompany thyroid hemiagenesis. In this report, we present a case of thyroid hemiagenesis, who had moderate hypercalcemia due to Graves' disease. A 43-year-old woman presented with weight loss of more than 5 kg within one month, heat intolerance, and increased sweating. For the past month, she had been troubled by intermittent symptoms of vomiting, thirst, and constipation. On examination, she had tachycardia with no signs of dehydration. Pulse rate was 110 per minute. She had fine tremor, proximal muscle weakness, and asymmetric smooth goiter and hyperplasia in the right thyroid gland. Thyroid function tests confirmed the diagnosis of hyperthyroidism. Although hypercalcemia may be detected in patients with thyrotoxicosis, to the best of our knowledge, this is the first case report of thyroid hemiagenesis accompanying hypercalcemia due to thyrotoxicosis.

Soluble CD40 ligand, plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor-1-antigen in normotensive type 2 diabetic subjects without diabetic complications. Effects of metformin and rosiglitazone

OBJECTIVE

To evaluate subclinical inflammation and fibrinolysis in low-risk type 2 diabetic subjects and to assess the efficacy of metformin and rosiglitazone in this group.

SUBJECTS AND METHODS

Sixty-one normotensive, normoalbuminuric type 2 diabetic subjects without diabetes-related complications were included in a 4-week standardization period with glimepiride. After the standardization period, 21 subjects were excluded and the remaining 40 were randomly divided into two groups matched for age, gender, body mass index and disease duration. The first group (n = 20) received metformin (1,700 mg/day), the second group (n = 20) rosiglitazone (4 mg/day) for 12 weeks. Patients with low-density lipoprotein-cholesterol higher than 130 mg/dl at the beginning of the randomization period were treated with simvastatin (maximum dose 20 mg/day). Twenty-three healthy controls were also recruited. Cytokine measurements were performed with ELISA kits.

RESULTS

Baseline plasma plasminogen activator inhibitor-1 (PAI-1) level of type 2 diabetic subjects was significantly elevated (p = 0.038), but baseline levels of soluble CD40 ligand (sCD40L) and thrombin-activatable fibrinolysis inhibitor-1 (TAFI) antigen did not differ from healthy controls. Twelve weeks of metformin or rosiglitazone therapy did not cause significant changes in sCD40L, PAI-1 and TAFI antigen levels. In simvastatin-treated subjects (n = 9) significant reductions of PAI-1 were achieved (p = 0.028), while sCD40L and TAFI-Ag did not differ from baseline values.

CONCLUSION

Our results showed that nonobese diabetic patients at low cardiovascular risk had similar levels of subclinical markers of inflammation and fibrinolysis as matched healthy controls. Neither metformin nor rosiglitazone caused marked changes in sCD40L, PAI-1 and TAFI antigen levels. A subset of patients who received simvastatin showed a modest decrease in PAI-1 level and could contribute to beneficial vasculoprotective effect of the drug in type 2 diabetics.

Gestational diabetes has no additional effect on plasma thrombin-activatable fibrinolysis inhibitor antigen levels beyond pregnancy

Pregnancy is a prothrombotic condition with increased levels of several circulating coagulation factors. Decreased fibrinolytic activity has been shown in gestational diabetes. Gestational diabetes has been found to be associated with higher plasma plasminogen activator inhibitor-1 (PAI-1) antigen levels than normal pregnancy. The aim of the present study is to investigate the effect of gestational diabetes on plasma thrombin-activatable fibrinolysis inhibitor (TAFI) antigen levels. Plasma TAFI and PAI-1 antigen levels were measured in 26 pregnant women with gestational diabetes, 25 pregnant women with normal glucose tolerance, and age-matched 24 non-pregnant women with no history of gestational diabetes. Increased plasma TAFI antigen levels were found in pregnant women compared to non-pregnant controls. However, no statistically significant difference in TAFI antigen levels was observed between women with gestational diabetes and pregnant controls. Plasma PAI-1 antigen levels were higher in gestational diabetes than pregnant and non-pregnant controls. Our study revealed that pregnancy was associated with elevated plasma TAFI antigen levels. However, no additional effect of gestational diabetes was found on plasma TAFI antigen levels beyond pregnancy. We suggest that pregnancy is associated with enhanced coagulation and impaired fibrinolysis. Despite increased PAI-1 antigen levels associated with gestational diabetes, the effect of gestational diabetes on TAFI antigen levels is lacking.

Serum transforming growth factor-beta 1 levels in normoalbuminuric and normotensive patients with type 2 diabetes. Effect of metformin and rosiglitazone

OBJECTIVE

a)To determine serum Transforming Growth Factor-beta 1 (TGF-beta 1) levels in patients with type 2 diabetes who do not have diabetes related complications and in healthy controls, b) to evaluate the effects of metformin and rosiglitazone on TGF-beta 1 levels.

DESIGN

In the washout period, 61 patients with Fasting Plasma Glucose levels (FPG) higher than 140 mg/dl, Postprandial Glucose (PPG) levels higher than 180 mg/dl and A1c levels exceeding 6.5% were treated with glimperide. After 4 weeks, 39 of these patients were randomised to receive either metformin or rosiglitazone for 12 weeks. Thirty healthy controls were also studied.

RESULTS

There were no significant differences with regard to age, gender, body weight and BMI between patients and healthy controls. Type 2 diabetics had higher waist circumference, FPG, total cholesterol, LDL-cholesterol and triglyceride levels. Baseline TGF-beta 1 levels in diabetics were higher than in controls (29.84+/-7.04 ng/ml vs 11.37+/-4.06 ng/ml, p<0.001). Metformin or rosiglitazone did not significantly modify the TGF-beta 1 levels. In a multiple regression analysis FPG was the only variable that was significantly associated with plasma TGF-beta 1 levels.

CONCLUSION

The elevated levels of TGF-beta 1 in subjects with type 2 diabetes possibly indicate a tendency for renal and endothelial damage in such patients. The association of TGF-beta 1 with FPG possibly links poor diabetic control to vascular damage, leading to diabetic complications. Lack of changes in the levels of TGF-beta 1 after therapy may reflect inadequate therapy duration.

Plasminogen activator inhibitor-1 and thrombin activatable fibrinolysis inhibitor levels in non-alcoholic steatohepatitis

AIM

This study was conducted to demonstrate the plasminogen activator inhibitor- 1 (PAI-1) and thrombin activatable fibrinolysis inhibitor antigen (TAFI-Ag) levels in non-alcoholic steatohepatitis (NASH).

MATERIALS AND METHODS

Twenty-seven patients with biopsy-proven NASH and 18 healthy controls (HC) were recruited for the study. Anthropometric data, liver histology (no.=20) and laboratory parameters including PAI-1 and TAFI-Ag assessments were recorded.

RESULTS

When compared with HC, patients with NASH had higher body weight, higher waist circumference, elevated blood pressure, higher fasting plasma glucose (FPG) levels and higher homeostasis model assessment (HOMA) scores. The mean plasma PAI-1 levels of patients was found to be higher than HC (87.60 ng/ml vs 30.84 ng/ml p=0.000) and mean plasma TAFI-Ag levels of patients was found to be significantly lower (8.69 microg/ml vs 12.19 microg/ml p=0.000). PAI-1 levels were correlated with systolic blood pressure, age, body weight, transaminases, waist circumference, FPG, body mass index, and HOMA score. TAFI-Ag levels were found to be negatively correlated with transaminases, waist circumference, and body weight. In multiple regression analysis, BMI was the independent variable effecting PAI-1 levels. We did not show any association between PAI-1, TAFI-Ag, disease activity score and fibrosis score. HOMA was the independent variable effecting liver fibrosis in our patients.

CONCLUSION

In this study we demonstrated that patients with biopsy-proven NASH had higher PAI-1 and lower TAFI-Ag expression than HC. Elevated levels of PAI-1 in NASH is the consequence of insulin resistance state. Lower TAFI-Ag levels may be related to the overactivation of TAFI pathway resulting in TAFI-Ag depletion. Furthermore, liver function disturbances may impair TAFI production in NASH. We also showed that NASH patients even with slight elevations of transaminases feature marked insulin resistance and components of metabolic syndrome.

The alteration of serum soluble CD40 ligand levels in overt and subclinical hypothyroidism

OBJECTIVE

There is controversy as to whether hypothyroidism increases cardiovascular risk. The effect of levothyroxine on the cardiovascular risk profile is also unclear. Recent studies suggest that there is evidence of inflammation and endothelial dysfunction in hypothyroidism. Soluble CD40 ligand (sCD40L) is a protein expressed mainly by activated platelets which have been found to be associated with cardiovascular events. The aim of our study was to investigate serum sCD40L levels and the effect of levothyroxine replacement on sCD40L levels in overt and subclinical hypothyroidism.

DESIGN

We assessed lipid profile, serum sCD40L and hsCRP levels in 21 overt and 22 subclinical hypothyroid age-matched female patients with chronic autoimmune thyroiditis at baseline and one month after achieving euthyroidism by levothyroxine replacement, and compared them with the data from 22, age-matched, healthy controls.

RESULTS

Overt and subclinical hypothyroid patients had decreased sCD40L levels compared to age-matched controls. The patients with subclinical hypothyroidism had slightly increased hsCRP levels, but the result was not statistically significant. In multiple regression analysis, FT3 and FT4 were found to be independent predictors of sCD40L levels. After levothyroxine replacement, serum sCD40L levels increased significantly in the patients with overt hypothyroidism. Although an increase was also observed in the subclinical hypothyroid group, it was not statistically significant. Levothyroxine replacement had no significant effect on hsCRP levels in the patients with overt hypothyroidism. However, the subjects with subclinical hypothyroidism showed a significant reduction in hsCRP levels after levothyroxine.

CONCLUSION

The values of sCD40L and hsCRP in our study suggest that inflammatory pathways are complex and may be affected by different factors in hypothyroidism.

Thrombin activatable fibrinolysis inhibitor antigen levels are inversely correlated with plasminogen activator inhibitor-1 antigen levels in hyperthyroid patients

Both increased and decreased fibrinolytic activity have been reported in patients with hyperthyroidism. Elevated levels of plasma plasminogen activator inhibitor-1 (PAI-1) antigen have been found in hyperthyroid patients. Thrombin activatable fibrinolysis inhibitor (TAFI) is a novel plasma protein, which inhibits fibrinolysis through removal of C-terminal lysines from partially degraded fibrin. Previously, we showed that plasma TAFI antigen levels were increased in patients with overt and subclinical hypothyroidism. The aim of this study is to investigate plasma levels of TAFI and PAI-1 antigens in hyperthyroid patients. PAI-1 and TAFI antigen levels were measured in the plasma of 29 patients with hyperthyroidism (14 overt hyperthyroid and 15 subclinical hyperthyroid), and 26 healthy individuals. Although there were increased levels of PAI-1 antigen in hyperthyroid patients, plasma TAFI antigen levels were significantly lower compared to controls (80.79 ng/ml vs. 32.42 ng/ml, p = 0.000 for PAI-1; 10.42 microg/ml vs. 12.24 microg/ml, p = 0.009 for TAFI). Elevated PAI-1 antigen levels were positively correlated with free thyroid hormones, although TAFI antigen levels were in negative correlation with free thyroxine. Furthermore, an inverse correlation between PAI-1 and TAFI antigen levels was found. Our study demonstrated that TAFI antigen levels were decreased in patients with hyperthyroidism. Inverse correlation with PAI-1 suggests that the decrease in TAFI antigen levels may be due to activation of TAFI pathway. Further studies evaluating the underlying mechanisms of low TAFI antigen levels in hyperthyroidism should be undertaken.

Transforming growth factor-beta 1 levels in women with prior history of gestational diabetes mellitus

It is known that women with prior history of gestational diabetes mellitus (pGDM) feature obesity, insulin resistance and endothelial dysfunction which cause premature atherosclerosis. Transforming growth factor-beta 1 (TGF-beta1) is a key cytokine in obesity and insulin resistance and also play important roles in the development of atherosclerosis. This study was conducted to demonstrate the serum TGF-beta1 levels of people with pGDM. Thirty women with pGDM, 20 women with type 2 diabetes mellitus (T2DM) and 20 healthy women were enrolled. Serum TGF-beta1 levels of people with pGDM were found to be significantly higher than healthy controls and significantly lower than women with T2DM. TGF-beta1 levels were found to be correlated with postprandial glucose and age and inversely correlated with body mass index (BMI) and waist circumference. On multiple regression analysis postprandial glucose level, age and BMI were determined as the most important factors affecting TGF-beta1 levels. This study demonstrates elevated TGF-beta1 levels in pGDM. The inflammatory response to hyperglycemia and insulin resistance could be the major factors for the increased expression of TGF-beta1.

Low transforming growth factor-beta1 serum levels in idiopathic male osteoporosis

INTRODUCTION

Although the etiology of osteoporosis is different between men and women, the underlying pathophysiological mechanism is similar, namely an absolute or relative increase in bone resorption, leading to progressive bone loss. Transforming growth factor (TGF)-beta1 is a growth factor in human bone, which is produced by osteoblasts, and which has various effects on osteoclasts and osteoblasts. The aim of our study was to determine serum TGF-beta1 levels in male patients with idiopathic osteoporosis.

METHODS

Twenty five males with idiopathic osteoporosis and 25 age-matched controls were studied. Osteoporosis was defined by a T score of <-2.5 in the lumbar spine or at the femoral neck. We measured levels of TGF-beta1, estradiol, total and bioactive testosterone. Various markers of bone remodeling were also measured.

RESULTS

TGF-beta1 was significantly lower in osteoporotic patients than in controls (3.706 ng/dl, 25-75 percentiles: 2.81-5.33 vs 8.659 ng/dl, 25-75 percentiles: 4.837-11.835; p=0.000). Moreover, TGF-beta1 levels were positively correlated with bone mineral density (BMD) at the femoral neck (r=0.439, p=0.028), and at the lumbar spine (r=0.41, p=0.042). No correlation was found between serum estradiol, testosterone and TGF-beta1 levels.

DISCUSSION

Serum TGF-beta1 levels are depressed in osteoporotic men and are positively correlated with hip and spine BMD. The results of our study suggest that TGF-beta1 may play a role in the pathogenesis of idiopathic male osteoporosis.

Can impairments of thyroid function test affect prognosis in patients with respiratory failure?

Thyroid function test (TFT) impairments can be detected in extrathyroidal dysfunction, primarily in chronic obstructive pulmonary disease (COPD) with acute respiratory failure (RF). The aims of this study were to: (i) evaluate TFT impairments in patients with RF, (ii) compare TFT results to a control group without RF and (iii) assess the effects of thyroid dysfunction on clinical outcome and prognosis of RF. The TFT parameters were assessed in 65 patients (65.0 +/- 10.0 years, 49 males) with RF and compared to 18 patients (64.4 +/- 9.8 years, 13 males) with lung disease and no RF (p> 0.05). Arterial blood gas analysis, free T3 (FT3), free T4 (FT4) and TSH levels were all measured. The impairments of TFT were demonstrated in 34 (52.3%) patients with RF and 8 (44.4%) patients without RF (p> 0.05). The most common finding was a decrease in at least one of the TFT parameters in both groups (43.1% vs. 44.4%, respectively). In RF group, there was no significant association between TFT results and gender, age, diagnosis and co-morbid disease. However, need for invasive mechanical ventilation was higher both in patients with low FT3 and low FT4 when compared to those with normal TFT results (p= 0.001 and p= 0.003, respectively). In-hospital mortality rate was also higher both in the patients with low FT3 and low FT4 than the others (p= 0.006 and p= 0.01, respectively). We conclude that TFT impairments are not observed more frequently in patients with RF when compared to the patients without RF. However, low FT3 and FT4 levels increase the rates of invasive mechanical ventilation and mortality.

Plasma thiobarbituric acid-reactive substance levels in subclinical hypothyroidism

OBJECTIVE

The purpose of this study was to determine thiobarbituric acid-reactive substance (TBARS) levels in subclinical hypothyroidism and to examine the effect of levothyroxine replacement on TBARS levels.

SUBJECTS AND METHODS

A cohort of 28 female patients with subclinical hypothyroidism and 24 healthy controls were enrolled in this study. The levels of plasma TBARS, serum lipids, and high-sensitive C-reactive protein (CRP) in patients with subclinical hypothyroidism at baseline and after achieving euthyroid state by levothyroxine were assessed.

RESULTS

TBARS levels of the patients were similar to those of the control group in the subclinical hypothyroid state and after restoration of euthyroidism by levothyroxine replacement. TBARS levels decreased after levothyroxine treatment, but did not reach statistical significance. There was no significant correlation between TBARS, lipid and CRP levels. Serum CRP levels were higher in subclinical hypothyroidism (4.28 +/- 0.9 mg/l) than in the control group (1.95 +/- 0.34 mg/l) and the difference was statistically significant (p = 0.03). After achieving euthyroid state, CRP levels decreased significantly in patients with subclinical hypothyroidism from 4.28 +/- 0.9 to 2.32 +/- 0.6 mg/l (p = 0.006).

CONCLUSION

Our findings suggest that there is no significant alteration of plasma TBARS levels neither in subclinical hypothyroid state nor after achieving euthyroid state. Serum CRP level is higher in patients with subclinical hypothyroidism than in the control group. Normalization of thyroid state seems to effectively reduce serum CRP levels in subclinical hypothyroidism without any correlation with TBARS activity.

Cushing's syndrome due to ectopic CRH secretion by adrenal pheochromocytoma accompanied by renal infarction

Ectopic production of corticotropin-releasing hormone (CRH) by a pheochromocytoma is an infrequent cause of Cushing's syndrome. We report the case of a 43-year-old man with Cushing's syndrome due to a CRH-producing adrenal pheochromocytoma. The patient had clinical and biochemical evidence of hypercortisolism in conjunction with high ACTH levels and non-suppressible serum cortisol levels on low-dose and high-dose dexamethasone suppression testing. In addition to these clinical features of one month's duration, the patient developed symptoms of pheochromocytoma including headache, hypertension that was resistant to conventional therapy and excessive sweating. Biochemical testing confirmed elevated 24-hour urinary catecholamines and metabolites. Abdominal CT revealed a 4.5 x 4 x 3.5 cm mass in the left adrenal gland. He underwent elective left adrenalectomy. Light microscopic and immunochemical studies revealed a pheochromocytoma that contained immunoreactive CRH and was negative for ACTH. Plasma ACTH and dexamethasone supression tests normalized after surgery. This is an unusual case of a CRH-secreting pheochromocytoma. This was complicated by renal infarction, illustrating further the complexity of Cushing's syndrome in a patient with pheochromocytoma caused by CRH hypersecretion.

Endocrine and metabolic effects of rosiglitazone in non-obese women with polycystic ovary disease

We hypothesized that the administration of rosiglitazone, an insulin-sensitizing agent of the thiazolidinedione class, would improve the ovulatory dysfunction, hirsutism, hyperandrogenemia, and hyperinsulinemia of polycystic ovary syndrome (PCOS) patients. Forty women with PCOS and impaired glucose tolerance test (IGT) were randomly assigned to the 8-month treatment with rosiglitazone at either 2 mg/day or 4 mg/day. We compared changes in ovulatory function, hirsutism, hormonal levels (total and free testosterone, estradiol, estrone, androstenedione, LH and FSH), and measures of glycemic parameters (fasting and post-challenge levels of glucose and insulin, HOMA-IR, hemoglobin A1c), between the study groups. The patients' baseline characteristics were similar across all treatment arms. Fifteen of 20 women in the 2 mg group and 19 of 20 women in the 4 mg group achieved normal glucose tolerance; 14 of 20 women in the 2 mg group and 17 of 20 women in the 4 mg group achieved ovulatory menses at the end of the study period. The decreases of free testosterone levels were better in the 4 mg group than the 2 mg rosiglitazone group (-1.89+/-0.35 pg/ml vs. -2.21+/-0.39 pg/ml; P<0.01). There were neither any serious adverse events nor any liver enzyme elevations in our study patients during the treatment period. This study demonstrated that rosiglitazone improves the ovulatory dysfunction, hirsutism, hyperandrogenemia, and insulin resistance of PCOS in a dose-related fashion, with minimal adverse effects. This drug may be a good choice for lifetime treatment of patients with PCOS, especially for the ones who failed to show satisfactory results in metformin therapy.

TSH influences serum leptin levels independent of thyroid hormones in hypothyroid and hyperthyroid patients

Leptin is considered to play a role in maintenance of energy balance and body weight by neuroendocrine mechanisms. The physiological mechanisms for thyroid hormone-induced alteration in serum leptin are not well known. In the present study, the relationship between thyroid hormones and leptin levels was investigated in patients with overt hypothyroidism and hyperthyroidism before and after successful treatment. Leptin levels were determined by radioimmunoassay and body mass index (BMI) was calculated for each subject. Serum leptin levels of 26 hypothyroid and 22 hyperthyroid patients were compared with those of 20 healthy volunteers who comprised the controls. Serum leptin levels of hypothyroid patients (28.4 +/- 4.1 ng/ml) were found to be significantly higher than the controls (19.1 +/- 3.2 ng/ml) (p<0.01), whereas hyperthyroid patients had lower levels (10.7 +/- 1.2 ng/ml) (p<0.01). In hypothyroid patients, serum leptin levels were decreased significantly to 20.6 +/- 2.1 ng/ml with thyroxin treatment (p<0.05). However, in hyperthyroid group, serum leptin levels were increased to 12.4 +/- 2.2 ng/ml by treatment (p>0.05). BMI was not changed with the treatment in either group. The serum leptin levels were correlated with BMI and thyrotropin (TSH) in both hypothyroid and hyperthyroid patients. Serum leptin levels are affected in thyroid disorders and the correlation of leptin with TSH is independent of thyroid hormones.

Plasma homocysteine levels in polycystic ovary syndrome and congenital adrenal hyperplasia

The purpose of this study was to determine whether polycystic ovary syndrome (PCOS) and nonclassic 21-hydroxylase deficiency (CAH) are related to hyperhomocysteinemia, and to investigate if there is a correlation between homocysteine levels and insulin sensitivity in women with PCOS and CAH. Fifty patients with PCOS, 50 patients with CAH and 25 control women were included in the study. Blood samplings were performed in the early follicular phase for measuring hormone profile, Vitamin B(12), folate, homocysteine levels and fasting blood glucose. Ovulatory status was assessed with timed serum progesterone measurements. Homeostasis model assessment-insulin resistance (HOMA-IR) was calculated as a measure of insulin resistance. Mean homocysteine levels were found as (8.9 + 1.9 micromol/l and 17.7 + 3.6 micromol/l) in the normal group and PCOS respectively (p<0.001), but there was no statistical significance between nonclassic 21-hydroxylase deficiency (9.0 + 2.2 micromol/l) and control group. Most of the patients in PCOS group (35 of 50) were significantly insulin resistant. However, there was no insulin resistant patient in CAH or control group. When we compare the two subgroups of PCOS women, the patients with insulin resistance had significantly higher homocysteine levels than the ones who were not insulin resistant. There were positive correlations among serum homocysteine, insulin and androgen levels in PCOS patients. There were no correlations among these parameters in CAH and control groups. Increased homocysteine levels may contribute to increased cardiovascular disease risk in patients with PCOS. The reason for hyperhomocysteinemia seems to be related to insulin resistance but not high androgen levels.

Vascular Endothelial Growth Factor in Gingival Tissues and Crevicular Fluids of Diabetic and Healthy Periodontal Patients

BACKGROUND

Periodontal disease is one of the major oral problems encountered in patients with diabetes mellitus (DM). Vascular changes, neutrophil dysfunction, altered collagen synthesis, and genetic predisposition observed in DM may contribute to periodontitis; and the vascular alterations observed in such patients may depend on vascular endothelial growth factor (VEGF) actions. Few reports are available about the mechanism of neovascularization and the angiogenic factors that contribute to the periodontal pathology and the role of VEGF in periodontal diseases. The aim of this study is to compare VEGF expression in healthy and periodontally diseased tissues with gingival crevice fluid (GCF) of healthy persons and diabetic patients.

METHODS

Gingival tissue and GCF samples were collected from sites of periodontitis in 10 healthy subjects and in 10 type 2 diabetic patients, and from the sites of healthy gingiva within the same groups. Therefore, each patient became his/her own control. Additionally, 10 people without any systemic or periodontal diseases were enrolled, forming a negative control group. Thus, a total of 50 tissue and 50 GCF samples were provided.

RESULTS

No VEGF staining was observed in the negative control group or in the systemically healthy people's healthy tissue samples, whereas four samples of diabetic patients showed positive staining (P < 0.05). However, VEGF was revealed in two tissue samples of periodontal sites of systemically healthy people and in six samples of the diabetic patients (P > 0.05). In all test groups, GCF VEGF levels were higher in periodontal sites (P < 0.05) than in healthy sites.

CONCLUSION

The results of this study showed that VEGF is increased in all periodontal tissues of both groups and in the healthy sites of diabetic patients. Additionally, GCF VEGF values increased in periodontal sites of all test groups.

Thyroid hemiagenesis with multinodular goiter: a case report and review of the literature

Thyroid hemiagenesis is a very rare abnormality, in which one thyroid lobe fails to develop. Most of the patients diagnosed have an associated thyroidal disease. The true prevalence of thyroid hemiagenesis is not known, but it is estimated to be 0.02% in normal children. We report a forty-five year-old female patient with a multinodular goiter in left lobe, associated with hemiagenesis of right lobe and isthmus.

The effects of estrogen and raloxifene treatment on antioxidant enzymes in brain and liver of ovarectomized female rats

Recent studies documented that estrogen have antioxidant properties in-vitro, there are conflicting results on the effect of estrogen in vivo. We aimed to investigate the effects of estradiol and Raloxifene on the antioxidant enzyme [superoxide dismutase (SOD) and catalase (CAT)] activities and MDA levels in brain and liver homogenates of ovariectomized female rats. Twelve weeks after ovariectomy, female Sprague-Dawley rats (n = 26) were divided into three groups: (1) Ovariectomized placebo group (n = 6) was given physiologic saline. (2) Estrogen group (n = 10) was given Ethynyl estradiol, 0.1 mg/kg sc. (3) Raloxifene group (n = 10) was given raloxifene, 1 mg/kg sc during 8 weeks. Ten rats were used as naive controls without any treatment (Sham operated group, n = 10). Ovariectomy lead to an increase in the CAT activities in liver tissue samples compared to the sham group (p = 0.056, Mann-Whitney test). While estrogen treatment reversed to normal levels of CAT activities, raloxifene remained as ineffective. Superoxide dismutase activities and MDA levels in liver were remained unchanged in all groups. There was no significant change in the brain tissue SOD and CAT activities between the control ovariectomy, estrogen treated, and raloxifen treated groups. We determined an increase in MDA levels in brain of ovariectmised rat (p = 0.02). While raloxifene treatment reversed to normal levels of MDA (p = estrogen treatment failed. Our data showed that estrogen may play a role in regulation of CAT and SOD activities in liver due to its antioxidative effects. We can suggest estrogen and raloxifene exert their antioxidative effects in brain rather than liver. Since Raloxifene's effect is more clear than estradiol, raloxifene may be suggested primarily for treatment and/or prevention of diseases which can be resulted from oxidative stress in postmenopausal women.

The effects of estrogen and raloxifene treatment on the antioxidant enzymes and nitrite-nitrate levels in brain cortex of ovariectomized rats

Number of studies indicate that the female gonadal hormone estrogen protects women against several neurodegenerative diseases and cerebral ischemia via various mechanisms. The possible protective effects of estrogen are mediated mainly by three ways; the activation of steroid receptors and/or modulation of a neurotransmitter and/or direct antioxidative action. Therefore we aimed to investigate the effects of estradiol and raloxifene on levels of nitric oxide (NO) and antioxidant enzymes in brain cortex of ovariectomized female rats. Ten Sprague-Dawley rats were used as naive controls while 32 rats were ovariectomized at 120-140 days of age. Twelve weeks after ovariectomy: (1). Ovariectomized Placebo group (n=11), was given physiologic saline. (2). Estrogen group (n=10) was given Ethynyl estradiol, 0.1 mg/kg sc. (3). Raloxifene group (n=10) was given raloxifene, 1 mg/kg sc. At the end of the treatment period (8 weeks), rats were decapitated and cortex samples were dissected. Results showed that ovariectomy caused a decrease in total nitrite-nitrate levels. The NO levels of both the estrogen and the raloxifene group were higher than the placebo group. Catalase activities did not show any significant difference between the groups, while superoxide dismutase (SOD) activities were elevated via ovariectomy. Estradiol and Raloxifene treatment had no statistically significant effect on SOD activity.

Effect of surgical weight loss on free radical and antioxidant balance: a preliminary report

BACKGROUND

This study observes the effect of surgical weight loss on free radical and antioxidant vitamin balance.

PATIENTS AND METHODS

22 consecutive morbidly obese patients undergoing vertical banded gastroplasty (VBG) were chosen for the study. Postoperative studies were done at 12 and 24 weeks. Plasma antioxidant and vitamin determinations were performed by HPLC method.

RESULTS

Subjects lost a significant amount of weight (P < 0.01). Compared to preoperative measurements, postoperative measurements of plasma beta-carotene were not statististically different both at 12 and 24 weeks (13.86 +/- 1.26 microg/dl, 12.35 +/- 1.2, P = 0.44; 14.33 +/- 2.03, P = 0.77; preoperatively, 12 and 24 weeks respectively). Alpha-tocopherol increased slightly at the 12th week; the difference was not significant (8.50 +/- 0.77; 9.56 +/- 0.82, P = 0.37; preoperatively and 12th week respectively). The levels of alpha-tocopherol rose at 24th week significantly (10.89 +/- 0.55, P = 0.028). The indicator of lipid peroxidation (malondialdehyde) decreased with weight loss (1.505 +/- 0.11 micromol/L preoperatively; 0.75 +/- 0.062 at 12th week, P = 0.01; 0.712 +/- 0.05 at 24th week, P < 0.01).

CONCLUSION

Our data show that free radical generation falls markedly in association with weight loss after VBG. Surgical weight loss leads to significant decrease in oxidant production and also leads to increase in some antioxidant vitamins. The demonstration of decreased free radical generation and correction of balance between free radicals and antioxidant vitamins has important implications for oxidative mechanisms underlying obesity-associated disorders.

Spontaneous bilateral perirenal hematoma as a complication of polyarteritis nodosa in a patient with human immunodeficiency virus infection

We present a 29-year-old man with polyarteritis nodosa (PAN) having human immunodeficiency virus (HIV) infection. This patient fulfilled the American College of Rheumatology (ACR) 1990 criteria for PAN, and the diagnosis was confirmed by typical arteriographic findings, including microaneurysms. Due to the rupture of microaneurysms, perirenal hematomas occurred in both kidneys. Unilateral nephrectomy was performed, and renal histology confirmed that aneurysm rupture was the etiology of the perirenal hematoma. The occurrence of renal hematomas is a usual complication of PAN. However, bilateral renal hematoma during the course of HIV-associated PAN is quite rare, and to our knowledge, this would be the second case reported in the literature. When compared with other viral agents, the association of HIV with PAN may be considered rare. However, as suggested by various reports in the literature, HIV infection should always be kept in mind while evaluating patients with PAN.