"Who am I?" A qualitative meta-synthesis of Chemotherapy-induced alopecia and body image perception in breast cancer patients

BACKGROUND

Since alopecia may be the first physical evidence and sign of cancer diagnosis and treatment, it may have a more serious and challenging effect on a woman than the loss of breast tissue.

OBJECTIVE

The purpose of this study was to summarize the current qualitative research which explores the body image perceptions of breast cancer patients with chemotherapy-induced alopecia.

MATERIAL AND METHODS

We searched three electronic databases and reviewed studies from December 2011 to December 2021 for qualitative results analysing the experiences of women with breast cancer and chemotherapy-induced alopecia. The Joanna Briggs Institute critical (JBI) appraisal tool was used to assess the quality of the targeted studies. The Meta-synthesis process developed by Sandelowski and Barroso was used to collect and analyse the data.

RESULTS

We discovered two main and five sub-themes from the meta-synthesis findings of 11 qualitative studies involving 225 women. The main themes were "I am not comfortable in this body" and "Who am I?". The first main theme revealed patients' intense reactions to their hair loss: "I'm in emotional chaos", "I am looking for a place to hide" and "I knew it and now I'm experiencing it".The second main theme of "Who am I?" contained two sub-themes: "What did my hair take from my femininity when it was gone?" and "Will I lose my partner after my hair?".

CONCLUSION

Meta-synthesis provided an up-to-date and integrated interpretation of scientific results about the experiences of women with breast cancer, alopecia, and their body image perceptions. This interpretation will facilitate a more comprehensive understanding of the alopecia-body image relationship. Thus, the aim of the meta-synthesis results is that these will contribute to nurses' understanding of how alopecia, although a temporary symptom, affects women's perceptions of body image.

The impact of the multifocality and subtypes of papillary thyroid carcinoma on central compartment lymph node metastasis

OBJECTIVE

Papillary thyroid carcinoma (PTC) may often appear as multifocal disease. Few studies demonstrated a higher rate of central compartment lymph node metastasis (CCLNM) in multifocal PTC patients. Therefore, the effect of different histological subtypes of multifocal PTC on CCLNM is another subject for further examination. The aim of the present study is to evaluate the rate of central lymph node positivity in multifocal PTC as compared to unifocal disease, and to identify the role of different histologic subtypes of PTC on central neck lymph node positivity.

PATIENTS AND METHODS

Patients with PTC who underwent total thyroidectomy (TT) + central cervical lymph node dissection (CCLND) at authors' institution between January 2012 and June 2016 were included (n=274). Independent Samples t-test, Mann-Whitney U test and Chi-square tests were used to determine univariate associations, and multivariate analysis was conducted by logistic regression.

RESULTS

The rate of CCLND positivity in multifocal PTC is higher than unifocal tumors and the difference is significant (p < 0.05). The univariate analysis demonstrated significant relation with male sex, lymphovascular invasion and size of dominant nodule > 10 mm regarding of CCLND positivity in multifocal PTC patients. The comparison between solitary and mixed histologic subtype of multifocal PTC is also significant (p < 0.05).

CONCLUSIONS

Multifocality is an important risk factor for CCLNM. Male sex, dominant tumor size >10 mm and mixed histological subtype in multifocal PTC may play an important role in CCLND positivity.

The risk of hypoparathyroidism after central compartment lymph node dissection in the surgical treatment of pT1, N0 thyroid papillary carcinoma

OBJECTIVE

The role of central compartment lymph node dissection (CCLND) in the treatment of papillary thyroid carcinoma (PTC) is still controversial. The benefits of CCLND should be weighed against its potential risks. We aim to evaluate the positivity of central lymph nodes in pT1, N0 PTC and to establish the complication rates of total thyroidectomy (TT)+CCLND.

PATIENTS AND METHODS

This is a retrospective study on prospectively collected data over a 45-month period. A total of 329 patients were included. Total thyroidectomy was performed in 130 (39.5%) of these patients due to benign thyroid pathologies, and 199 (60.5%) pT1, N0 PTC patients had TT+CCLND. Our TT technique was applied in the same way in both groups. Central lymph node positivity, the number of lymph nodes removed during CCLND and the operative complications were evaluated. T-test and chi-square analysis were conducted in independent groups for statistical evaluation.

RESULTS

The rate of central lymph node positivity in TT+CCLND group was 38%. The average number of lymph nodes removed by CCLND is 10.2 (1-36). Complication rates between TT and TT+CCLND groups were statistically significant (3.8% vs. 11.1%, respectively) (p<0.05). The difference was found to be particularly more pronounced for transient hypocalcemia. Although there was no significant relation between the number of lymph nodes removed during CCLND and the number of parathyroid glands detected in the pathology specimens (p>0.05), the relation between the development of symptomatic hypocalcemia and the number of the parathyroid glands removed during surgery was significant (p <0.05).

CONCLUSIONS

Central compartment lymph node metastasis in PTC is common. CCLND may increase the rate of transient hypocalcemia.

Role of milk protein-based products in some quality attributes of goat milk yogurt

Goat milk yogurts were manufactured with the fortification of 2% (wt/vol) skim goat milk powder (SGMP), sodium caseinate (NaCn), whey protein concentrate (WPC), whey protein isolate (WPI), or yogurt texture improver (YTI). Yogurts were characterized based on compositional, microbiological, and textural properties; volatile flavor components (with gas chromatography); and sensory analyses during storage (21d at 5 °C). Compared with goat milk yogurt made by using SGMP, the other goat milk yogurt variants had higher protein content and lower acidity values. Goat milk yogurts with NaCn and WPC, in particular, had better physical characteristics. Using WPI caused the hardest structure in yogurt, leading to higher syneresis values. Acetaldehyde and ethanol formation increased with the incorporation of WPI, WPC, or YTI to yogurt milk. The tyrosine value especially was higher in the samples with NaCn and YTI than in the samples with WPC and WPI. Counts of Streptococcus thermophilus were higher than the counts of Lactobacillus delbrueckii ssp. bulgaricus, possibly due to a stimulatory effect of milk protein-based ingredients other than SGMP on the growth of S. thermophilus. Yogurt with NaCn was the best accepted among the yogurts. For the parameters used, milk protein-based products such as NaCn or WPC have promising features as suitable ingredients for goat milk yogurt manufacture.

Knowledge, attitudes and behaviors of physicians towards thyroid disorders and iodine requirements in pregnancy

PURPOSE

Thyroid disorders including iodine deficiency during pregnancy are important health problems worldwide. However, considering real life, assessment of knowledge, attitudes, and practice of physicians is lacking. We aim to evaluate knowledge, attitudes and behaviors of physicians towards thyroid disorders and requirements of iodine during pregnancy on a nationwide basis.

METHODS

Clinicians from different medical disciplines most likely to encounter pregnant women in daily practice (i.e., obstetricians, endocrinologists, and family physicians) were included. Family physicians were selected from primary care centers; endocrinologists and gynecologists were selected from state hospitals. Randomly selected 322 physicians from seven geographical regions of Turkey were included. Subjects filled a questionnaire which consisted of three sections about knowledge, attitudes and behaviors towards thyroid disorders and iodine requirements during pregnancy.

RESULTS

Physicians had insufficient and/or erroneous knowledge about thyroid disorders during pregnancy. 73.1 % of endocrinologists, 32.7 % of family physicians, and 17.8 % of obstetricians knew the correct level of TSH during pregnancy (p < 0.001). 67.1 % of physicians thought it is unnecessary to offer iodine supplementation to pregnant women. Endocrinologists achieved the highest scores in each section, and also had the highest total scores (p < 0.001). Family physicians achieved higher scores than obstetricians.

CONCLUSIONS

Physicians who encounter pregnant women in Turkey do not have sufficient information about management of thyroid disorders and providing iodine support during pregnancy and lactation.

The prevalence of benign breast diseases in patients with nodular goiter and Hashimoto's thyroiditis

PURPOSE

The evidence regarding association between thyroid disorders and benign and malignant breast diseases is increasing. The studies exploring the relationship between thyroid and breast diseases usually have focused on thyroid autoimmunity and functions in patients with breast pathologies. In this study, we aimed to reveal the frequency of benign breast conditions in patients with nodular thyroid disease (NTD) and Hashimoto's thyroiditis (HT).

METHODS

Seventy-one women with NTD, ninety-five women with HT and seventy-two healthy people as a control group were included in the study. Serum thyroid-stimulating hormone, free triiodothyronine, free thyroxine, and thyroid peroxidase autoantibody levels were measured, and thyroid and breast ultrasonography were performed by a single operator in order to determine thyroid and breast pathology.

RESULTS

Benign breast diseases were detected in 54.9% of patients with NTD, in 47.4% of those with HT, and 29.2% of control group in the study (p < 0.01 for nodular and Hashimoto groups versus control group). Simple cyst was found to be the most frequent pathology among benign breast diseases; fibrocystic changes, mixed lesions, benign solid mass, ductal ectasia, and complex cyst followed it. No significant relation was found regarding thyroid function and autoimmunity in patients diagnosed with benign breast disease (p > 0.05).

CONCLUSIONS

The results of our study support the association between benign breast diseases and thyroid diseases. An important implication of this finding may be demonstration of the necessity of scanning for potential breast pathology in women with nodular or autoimmune thyroid disease in clinical practice.

Iodine intake is still inadequate among pregnant women eight years after mandatory iodination of salt in Turkey

BACKGROUND

A recent study showed first sign of reduction in goiter prevalence and elimination of iodine deficiency state among school-age children in Turkey after a decade of mandatory iodination of table salt. However, iodine status among pregnant women is a still debated issue in our country.

AIM

To investigate iodine status, iodized salt consumption rate, and goiter prevalence in 1st trimester pregnant women 8 yr after the mandatory iodination. MATERIAL/ SUBJECTS AND METHODS: One hundred and forty-one 1sttrimester pregnant women who had been followed-up between January and October 2006 in the obstetric outpatient clinics in Turkey were included. Besides a physical examination, subjects underwent laboratory investigations for free T(3), free T(4), and urinary iodine concentration (UIC). All subjects completed a questionnaire regarding sociodemographic parameters, use of iodized salt, and pregnancy history. Goiter status was revealed by a palpation method according to World Health Organization (WHO) guidelines.

RESULTS

In this study, we found that the median UIC of pregnant women was 149.7 microg/l (range 20.9-275.1 microg/l). Almost half of the subjects were below the WHO, United Nations Children's Fund, and International Council for the Control of Iodine Deficiency Disorders lower median reference limits of 150 microg/l. Total goiter prevalence was 24.8%, of which 9.2% were visible goiters. Among the study patients, 2.1% had subclinical hypothyroidism, and 0.7% had overt hypothyroidism. The rate for iodized salt use among the pregnant women was 95%.

CONCLUSION

Our study revealed that iodine deficiency still remains a serious problem for pregnant women. Based on our results, antenatal follow-up protocols in the primary care setting in Turkey must include iodine supplementation.

Systolic pulmonary artery pressure and echocardiographic measurements in patients with euthyroid Hashimoto's thyroiditis

BACKGROUND

The aim of this study was to investigate systolic pulmonary artery pressure (SPAP) and echocardiographic findings in patients with euthyroid Hashimoto's thyroiditis (HT).

METHODS

Thirty (8 male, 22 female, mean age 47.4+/-10.5 yr) consecutive patients with euthyroid HT and 30 (9 male, 21 female, mean age 46.4+/-10.7 yr) healthy controls were included in the study. Transthoracic echocardiography was performed for all patients and levels of thyroid hormones, thyroid autoantibodies, glucose, insulin, urea, and creatinine were compared.

RESULTS

There were no significant differences in sex, age, body mass index, serum free T4, serum TSH, lipid profiles between patients and controls. Mean SPAP in patients with euthyroid HT were significantly higher than in controls (31.6+/-5.0 vs 25.6+/-4.5 mmHg, p=0.005). Late diastolic transmitral velocity and isovolumic relaxation time were also significantly higher in patients in comparison to controls. In addition, euthyroid HT patients with tricuspid or mitral regurgitation had a higher grade. Correlation between SPAP and antithyroid antibodies and TSH, however, was not significant in this population.

CONCLUSIONS

Pulmonary arterial pressure is higher in patients with euthyroid HT. There may be a relationship between elevated pulmonary arterial pressure and autoimmune thyroid disease independent from thyroid function status. However, further investigations are needed to determine the exact mechanism of association between autoimmune thyroid diseases and pulmonary hypertension.

Prevalence and clinical significance of antineutrophil cytoplasmic antibody in Graves' patients treated with propylthiouracil

Development of antineutrophil cytoplasmic antibody (ANCA) during therapy with propylthiouracil (PTU) is not uncommon and PTU-induced ANCA-positive vasculitis is also reported. The aim of this study was to assess the presence and clinical significance of ANCA positivity in Graves' patients treated with PTU. Newly diagnosed Graves' disease patients (prospective group, n = 58) were evaluated before and during therapy with PTU to investigate the development of ANCA positivity. ANCA positivity is also investigated in previously diagnosed Graves' patients who had already been receiving PTU treatment (cross-sectional group, n = 51). Comparisons with Hashimoto thyroiditis (n = 55) and toxic nodular goitre (n = 20) patients, and healthy control subjects (n = 20) were carried out to define the possible influence of hyperthyroidism and/or thyroid autoimmunity on ANCA positivity. At baseline evaluation, ANCA was negative in all newly diagnosed Graves' patients. Only 28 of the 58 patients in prospective group completed 2 years of follow-up which occurred at 3-month intervals. ANCA positivity was detected 32.1% (n = 9) in a mean period of 11.7 +/- 6.1 months in prospective group. Only two (3.9%) patients in a cross-sectional group had ANCA positivity in a mean treatment period of 7.6 +/- 4.6 months. None of the patients with ANCA positivity developed symptoms and signs related to vasculitis. None of the patients with Hashimoto thyroiditis and toxic nodular goitre, and healthy control subjects had ANCA positivity. PTU therapy is associated with asymptomatic production of ANCA in a time-dependent manner, which mostly disappears after discontinuation of therapy. Hyperthyroidism or autoimmunity per se does not appear to have effect on development of ANCA positivity.

Unresectable huge sternal and mediastinal metastasis of follicular thyroid carcinoma; radiotherapy as first-line and palliative therapy

Distant metastases as initial manifestation of follicular thyroid carcinoma is rare. We report a case of an unusual initial presentation of follicular thyroid carcinoma on follow-up. A 52- year-old woman presented with a 12-month history of progressively enlarging mass in the anterior chest wall. The mass was fixed to the chest wall, measuring 12 x 10 cm in diameter. Computed tomography demonstrated a lobulated soft-tissue mass (17 x 11 x 6 cm) destructing sternum and extending into the anterior mediastinum. There was no lung metastasis. Invasion of tumor to the ascending aorta, superior vena cava, and right atrium could not be excluded. Multiple lymph nodes were observed in the supraclavicular regions. Ultrasonography of the thyroid gland showed 46 x 37 mm nodule in the left lobe with milimetric gross calcifications and cystic-necrotic areas. Hyperthyroidism was detected. Biopsy from this nodule and the sternal mass revealed typical histology of follicular carcinoma. She was considered inoperable. Since there was huge tumor burden and iodinated contrast exposure for several times during evaluation, we decided to treat the patient with external beam radiotherapy (EBRT) rather than radioiodine as first-line therapy. After a course of conventional radiation with 50 Gy in 25 fractions over 4 weeks, encompassing the thyroid bed and the gross disease, tumor regressed remarkably in 6 months. In conclusion, when surgical resection is not possible, EBRT may be used for palliative purpose to obtain local control for extensive disease as first-line therapy. The indications of EBRT for differentiated thyroid cancer still remain poorly defined.

Towards Drugs Targeting Multiple Proteins in a Systems Biology Approach

Protein-protein interactions are increasingly becoming drug targets. This is understandable, since they are crucial at all levels of cellular expression and growth. In practice, targeting specific disease-related interactions has proven difficult, with success varying with specific complexes. Here, we take a Systems Biology approach to targeting protein-protein interactions. Below, we first briefly review drug discovery targeted at protein-protein interactions; we classify protein-protein complexes with respect to their types of interactions and their roles in cellular function and as being targets in drug design; we describe the properties of the interfaces as related to drug design, focusing on hot spots and surface cavities; and finally, in particular, we cast the interactions into the cellular network system, highlighting the challenge of partially targeting multiple interactions in the networks as compared to hitting a specific protein-protein interaction target. The challenge we now face is how to pick the targets and how to improve the efficiency of designed partially-specific multi-target drugs that would block parallel pathways in the network.

Comparison of orlistat and sibutramine in an obesity management program: efficacy, compliance, and weight regain after noncompliance

To describe the comparative efficacy of orlistat and sibutramine in an obesity management program, with specific attention to compliance and weight regains after noncompliance. We prospectively evaluated 182 obese patients who were randomized to treatment with orlistat (n=98) or sibutramine (n=84) along with the diet and exercise prescriptions. Compliance (or compliant patient) was defined as adherence to scheduled visit times (at 3- month intervals) and following the prescribed drug regimen. A telephone survey was conducted in case of noncompliance. Significant body weights improvements were seen in both treatment groups. Patients lost a mean of 7.6+/-2.8% and 10.5+/-2.9% of initial body weights after a mean drug use of 8.8+/-5.7 and 8.3+/-3.7 months in the orlistat and sibutramine groups, respectively (p<0.05 vs. initial body weight). Patients in the sibutramine group lost more weight than the orlistat group (p<0.05). A total of 102 patients (56%) were compliant (53.1% in the orlistat group and 59.5% in the sibutramine group). Factors associated with compliance included weight reduction of more than 5% in the first 3 months and adherence to physical activity. Higher initial body weight, prior anti-obesity therapy, number of concurrent medications, and comorbidity were associated with noncompliance. Weight regains in noncompliant patient were a mean of 5.2+/-5.1 kg after a mean period of 9.2+/-4.2 months in the orlistat group, and a mean of 6.1+/-3.8 kg after a mean period of 9.1+/-3.9 months in the sibutramine group (p<0.05 vs. last visit for both groups, p>0.05 between groups). Both drugs in an obesity management program can achieve substantial weight loss. However, noncompliance and rebound weight regain after noncompliance are considerable problems.

Significance of the RET proto-oncogene polymorphisms in Turkish sporadic medullary thyroid carcinoma patients

Several single nucleotide polymorphisms (SNP) of the RET gene have been identified in medullary thyroid carcinoma (MTC) patients as well as in the general population. However, the relevance of SNP for MTC patients is still controversial, whether these allelic variants play other interacting, predisposing or modifying roles in clinical behavior of MTC. The aim of this work is to elaborate allelic frequencies of the RET proto-oncogene polymorphisms in Turkish sporadic MTC patients and to demonstrate if there is an association between SNP and the clinical disease features, specifically the age at onset of MTC and lymph node involvement at diagnosis. We analyzed the allelic frequencies of SNP of the exon 11, 13, 14 and 15 of the RET proto-oncogene in blood samples from 50 sporadic MTC patients, using the polymerase chain reaction methodology followed by DNA sequencing. The observed allelic frequencies were 24% for G691S polymorphism in exon 11, 29% for L769L polymorphism in exon 13, 5% for S836S polymorphism in exon 14, and 26% for S904S polymorphism in exon 15. These frequencies are similar to those reported in other countries. We did not observe any significant association of all four SNP with the age at onset of MTC. Our results indicate a possible association between the presence of lymph node involvement at the time of diagnosis (extent of disease) and L769L or S836S polymorphism. However, it is not possible to draw definitive conclusions that these two polymorphisms play a significant role in clinical behavior of MTC. Further studies are needed to evaluate the role of this polymorphism in the clinical behavior of MTC.

Long-term effects of elevated gastrin levels on calcitonin secretion

Gastrin and pentagastrin stimulate thyroid C cells and elevate serum calcitonin levels. Gastrin levels may be elevated when histamine-2 receptor blockers (H2RB) and/or proton pump inhibitors (PPI) are used, or in patients with pernicious anemia (PA). This study was designed to investigate the long-term effects of elevated gastrin levels on serum calcitonin levels. We conducted a pentagastrin stimulation test to evaluate C cell reserves in patients who had been using PPI and/or H2RB for an extended period, as well as in patients with PA. We compared the results with a healthy control group of similar age and sex. A total of 40 controls (26 women, 24 men) and 25 patients (15 women, 10 men) using H2RB and/or PPI, and 37 patients (24 women, 13 men) with PA were enrolled. The groups were similar in terms of mean age and sex distribution. Mean fasting gastrin levels, and mean baseline and pentagastrin-stimulated calcitonin levels were significantly higher in the H2RB+PPI and PA groups than in controls. No significant differences were observed between the H2RB+PPI and PA groups. There was no correlation between gastrin and calcitonin levels. However, mean calcitonin levels were significantly higher in subjects with high baseline gastrin levels than in controls. The prevalence of autoimmune thyroid disease was 32% in the PA group. Patients with PA and thyroiditis had significantly higher baseline gastrin levels than patients with PA only (p<0.01). PA with autoimmune thyroid disease had also significantly higher baseline and pentagastrin-stimulated calcitonin levels than did PA patients without autoimmune thyroid disease. In conclusion, chronic elevated gastrin levels led to elevated calcitonin levels. Further histopathological studies showing C cell hyperplasia are needed to confirm the mechanism of this relationship.

Prevalence and prediction of malignancy in cytologically indeterminate thyroid nodules

OBJECTIVE

Controversy surrounds the evaluation of nodules with indeterminate cytology results. Malignancy rates in these nodules are not low. We examined the malignancy rates in nodules that showed follicular neoplasm or atypical cells on cytology and attempted to predict malignancy based on ultrasonographic features.

DESIGN AND PATIENTS

We retrospectively analysed 5 years' cytopathology results of fine-needle aspiration biopsy (FNAB) specimens of indeterminate follicular thyroid lesions prior to thyroidectomy. The prevalence of malignancy on final histology was determined. The sonographic features of the thyroid nodules with respect to size, echogenicity, echo structure, border shape and presence of calcification were analysed.

RESULTS

A total of 86 patients (15 men, 61 women; mean age 52.1 +/- 12.5 years) with indeterminate cytology underwent thyroidectomy and had histopathological diagnoses. The average nodule was 18.9 +/- 12.3 mm. The prevalence of malignancy in patients with atypical cell cytology was 51.7% (30 of 59), and the prevalence of malignancy in patients with follicular neoplasm cytology was 15% (4 of 27). Malignancy prevalence was higher in patients who had follicular neoplasm cytology with atypical cells than in those without atypical cells (2 of 7 and 2 of 20, respectively). We found no significant correlations between sonographic or clinical features and malignancy in this patient group. Sonographic features and nodule size are not useful predictors of malignancy.

CONCLUSION

Until better molecular markers for malignancy are developed, surgical consultation remains necessary after examination of cytologically indeterminate FNAB specimens in patients with follicular thyroid lesions. But in follicular lesions without atypical cells the malignancy rate is low and reassessment later on could be an alternative approach.

Polycythemia as the first manifestation of Cushing's disease

A 39-yr-old man presented to our hospital with unexplained erythrocytosis and hypertension. His follow-up for erythrocytosis had begun 2 yr earlier in another hospital and he had been diagnosed with polycythemia rubra vera. On admission to our hospital he was hypertensive (165/95 mmHg) and, except for the presence of moon-like face and facial plethora, his physical examination was normal. His hemoglobin concentration was 19.2 g/dl, and hematocrit was 58.9% with an increased red blood cell mass of 58 ml/kg as measured by radioisotope (Cr51). Blood film, other hematological indices except for elevated leukocyte alkaline phosphatase score, arterial gas analysis, and examination of aspirated bone marrow were all normal. An abdominal ultrasonography showed no evidence of splenomegaly. A diagnosis of probable secondary erythrocytosis was made. Early-morning serum cortisol and 24-h urinary free cortisol concentration as well as serum ACTH were high. Serum cortisol was not suppressed by low-dose dexamethasone, but suppressed by high-dose dexamethasone. Pituitary magnetic resonance imaging showed no lesion. After inferior petrosal sinus sampling suggesting right-central ACTH secretion, the patient underwent transnasal-transsphenoidal pituitary adenomectomy. Both hypercortisolemia and erythrocytosis regressed completely after the adenomectomy. After the operation, the patient's hemoglobin concentration and hematocrit decreased steadily, and 1 month post-adenomectomy his hemoglobin is 14.9 g/dl and hematocrit 44.8%. Thus, Cushing's syndrome should be a routine part of evaluation of unexplained polycythemia.

Iodine deficiency and goiter prevalence in Turkey after mandatory iodization

OBJECTIVE

The determination of (a) iodine deficiency, and (b) the relation between the iodized salt consumption in the Isparta province of Turkey.

METHODS

Five hundred students between 6-11 yr of age were evaluated. With a questionnaire, the subjects were asked whether they were using iodine-containing salt or not. After their body weight and height were measured, thyroid glands were examined with palpation, thyroid volumes were determined with ultrasonography (USG), and urinary iodine concentration was analyzed.

RESULTS

The median urinary iodine concentration (UIC) of children was 7.00 microg/dl. This value reveals that Isparta is a region with mild iodine deficiency. The total goiter prevalence was 30.4% with palpation and 26% with USG. The goiter prevalence by ultrasonography was 14.2% for the urban and 36.2% for the rural areas. This difference was statistically significant (p<0.05). The rate of total iodized salt consumption was 68%, which was not a satisfactory level. The consumption of iodized salt in the urban areas was significantly higher than that in rural areas (74 vs 62%, p<0.05). The median UIC value was 10.00 microg/dl in urban areas compared to 5.00 microg/dl in rural areas.

CONCLUSIONS

Our results indicate that although Isparta is a region with mild iodine deficiency, goiter prevalence remains a serious problem.

Which thyroid-stimulating hormone level should be sought in hypothyroid patients under L-thyroxine replacement therapy?

We sought to determine whether relationships exist between level of thyroid-stimulating hormone (TSH) suppression and cardiovascular risk parameters such as plasma homocysteine, C-reactive protein (CRP), fibrinogen, D-dimer and serum cholesterol in patients taking L-thyroxine-replacement therapy (LT4-RT). Four hundred and two hypothyroid patients under LT4-RT were cross-sectionally evaluated. Patients were grouped according to their achieved TSH (mIU/l) levels under LT4-RT on an arbitrary manner. Those patients having a TSH value 0.4-2 were defined as group 1 (n = 154), a TSH level of 2 to less than 5.5 were defined as group 2 (n = 176) and a TSH level of 5.5 to less than 20 with a normal free T3 and free T4 level were defined as group 3 (n = 72). The three groups of patients were also compared with overt hypothyroid patients (n = 71) and healthy controls (n = 97). Homocysteine levels (micromol/l) were significantly different between the three groups (10.4 +/- 4 for group 1, 11.3 +/- 3.7 for group 2 and 13.5 +/- 4.7 for group 3; p < 0.01 for all groups). Significant differences in CRP (mg /l) levels were present between the three groups (2.6 +/- 2.6 for group 1, 3.3 +/- 2.9 for group 2 and 4.8 +/- 4.1 for group 3; p < 0.01 for all groups). Univariate analysis showed that both homocysteine and CRP levels significantly correlated with free T4 and TSH level (p < 0.01 for both groups). No statistically significant differences were noticed in respect to fibrinogen and d-dimer levels between three groups. In examining the effect of LT4-RT on lipid parameters, a tendency towards beneficial effects without achieving statistical significance was observed. Practically speaking, a target TSH level of less than 2 might be advisable to lower CRP levels and homocysteine levels, and possibly lipid parameters.

Severe reversible dilated cardiomyopathy in a patient with multiple endocrine neoplasia 2A syndrome

Pheochromocytoma may infrequently lead to dilated cardiomyopathy, which may reverse partially or completely after treatment. Progressive dyspnea, palpitations, and paroxysmal attacks of severe hypertension leading to cardiac failure had developed in a 25-yr-old woman. Chest radiography and echocardiography revealed a massive 4-chamber dilatation of the heart with an ejection fraction of 12%. Twenty-four-h urinary vanillylmandelic acid and metanephrine levels were elevated. Magnetic resonance imaging detected a large mass lesion in the right adrenal gland. Oral glucose tolerance testing revealed diabetes mellitus. Medical drug therapy with alpha-blocker, angiotensin converting enzyme inhibitor, beta-blocker, digoxin, and diuretic rapidly improved her cardiac condition. Repeat echocardiogram showed that the left ventricular function had improved substantially. The clinical condition of excess catecholaminemia (and thus, arterial hypertension and the abnormality of the glucose metabolism) subsided with complete resolution of the congestive heart failure following the surgical removal of the tumor. Evaluation for medullary thyroid carcinoma (MTC) revealed an elevated calcitonin level demonstrated by fine needle aspiration biopsy. There were no biochemical evidences for primary hyperparathyroidism. Multiple endocrine neoplasia 2 (MEN 2A) syndrome was diagnosed. An overwhelming secretion of catecholamine might cause severe cardiomyopathy and impair glucose metabolism, as evidenced by the improvement of both conditions following the medical treatment of catecholaminemia and surgical resection of the tumor.

Multiple endocrine neoplasia type 2A/localized cutaneous lichen amyloidosis associated with malignant pheochromocytoma and ganglioneuroma

We hereby present a rare variant of multiple endocrine neoplasia type 2A (MEN2A) associated with a rare skin disease primary cutaneous lichen amyloidosis and discrete malignant pheochromocytoma in both adrenal glands and pancreatic tail, and interestingly accompanied ganglioneuroma located in retroperitoneum in a 34-yr-old female. The presence of composite tumor of pheochromocytoma and ganglioneuroma arising in the adrenal glands has been described previously in MEN2A and in sporadic cases. The patient displayed classical signs and symptoms of catecholamine excess. Biochemical screening proved pheochromocytoma. Computed tomography revealed multiple mass lesions in both adrenal glands. It also showed a large heterogeneous mass that clearly discriminated from right adrenal gland in retroperitoneal location. After surgical exploration, both adrenal glands and the suspicious mass in pancreatic tail were removed successfully together with subtotal resection of the retroperitoneal tumor. Histopathologic examinations confirmed the presence of pheochromocytoma in both adrenal glands as well as pancreatic lesion. A retroperitoneal ganglioneuroma was also present. Symptomatic and biochemical evidence of pheochromocytoma subsided after the operation. Further evaluation for medullary thyroid carcinoma and primary hyperparathyroidism confirmed MEN2A. Mutation analysis of the ret proto-oncogene revealed a missense point mutation at position 634 in exon 11, which gives rise to the substitution of a cysteine codon with a tyrosine residue.

Intracranial aggressive fibromatosis presenting as panhypopituitarism and diabetes insipidus

Aggressive fibromatosis (AF) is a rare, locally aggressive, proliferative fibroblastic lesion affecting musculoaponeurotic structures, most often, of the limbs and trunk. Intracranial AF is extremely rare and requires aggressive treatment to prevent recurrence. We present a case of a 34 year-old male with AF involving intracranial structures causing panhypopituitarism and diabetes insipidus. Patient was admitted to hospital because of polyuria, polydipsia, and loss of libido, impotence, hearing loss, and gait disturbance. On cranial magnetic resonance imaging, the lesion extended through the sphenoid sinus into the both pterygoid recesses, destroying the left lateral wall of the sphenoid sinus and invading the retroorbital area. There was also a distinct lesion in the hypothalamic area. The tumor was markedly isointense on both T2- and T1-weighted images relative to gray matter, and enhanced strongly after administration of gadolinium. The patient underwent partial resection of the lesion via a transcranial approach. The pathological examination of the mass was reported as AF. No other sites were found to be involved by thorax and abdominal tomography. Hormonal assessment of hypothalamic-pituitary dysfunction revealed panhypopituitarism with central diabetes insipidus. Replacement therapy was instituted. In this case, standard treatment of wide-field surgical resection was impossible. On the basis of reports that radiotherapy is an effective treatment for this kind of tumor, we administered radiation to the affected area, since chemotherapy and hormonal treatment of non-resectable tumors are not satisfactory. To our knowledge, this is the first reported case of AF presenting as panhypopituitarism with central diabetes insipidus.

An ontology for collaborative construction and analysis of cellular pathways

MOTIVATION

As the scientific curiosity in genome studies shifts toward identification of functions of the genomes in large scale, data produced about cellular processes at molecular level has been accumulating with an accelerating rate. In this regard, it is essential to be able to store, integrate, access and analyze this data effectively with the help of software tools. Clearly this requires a strong ontology that is intuitive, comprehensive and uncomplicated.

RESULTS

We define an ontology for an intuitive, comprehensive and uncomplicated representation of cellular events. The ontology presented here enables integration of fragmented or incomplete pathway information via collaboration, and supports manipulation of the stored data. In addition, it facilitates concurrent modifications to the data while maintaining its validity and consistency. Furthermore, novel structures for representation of multiple levels of abstraction for pathways and homologies is provided. Lastly, our ontology supports efficient querying of large amounts of data. We have also developed a software tool named pathway analysis tool for integration and knowledge acquisition (PATIKA) providing an integrated, multi-user environment for visualizing and manipulating network of cellular events. PATIKA implements the basics of our ontology.

Relationships between amino acid sequence and backbone torsion angle preferences

Statistical averages and correlations for backbone torsion angles of chymotrypsin inhibitor 2 are calculated by using the Rotational Isomeric States model of chain statistics. Statistical weights of torsional states of phipsi pairs, needed for the statistics of the full chain, are obtained in two different ways: 1) by using knowledge-based pairwise dependent phipsi energy maps from Protein Data Bank (PDB) and 2) by collecting torsion angle data from a large number of random coil configurations of an all-atom protein model with volume exclusion. Results obtained by using PDB data show strong correlations between adjacent torsion angle pairs belonging to both the same and different residues. These correlations favor the choice of the native-state torsion angles, and they are strongly context dependent, determined by the specific amino acid sequence of the protein. Excluded volume or steric clashes, only, do not introduce context-dependent phipsi correlations into the chain that would affect the choice of native-state torsional angles.

PATIKA: an integrated visual environment for collaborative construction and analysis of cellular pathways

MOTIVATION

Availability of the sequences of entire genomes shifts the scientific curiosity towards the identification of function of the genomes in large scale as in genome studies. In the near future, data produced about cellular processes at molecular level will accumulate with an accelerating rate as a result of proteomics studies. In this regard, it is essential to develop tools for storing, integrating, accessing, and analyzing this data effectively.

RESULTS

We define an ontology for a comprehensive representation of cellular events. The ontology presented here enables integration of fragmented or incomplete pathway information and supports manipulation and incorporation of the stored data, as well as multiple levels of abstraction. Based on this ontology, we present the architecture of an integrated environment named Patika (Pathway Analysis Tool for Integration and Knowledge Acquisition). Patika is composed of a server-side, scalable, object-oriented database and client-side editors to provide an integrated, multi-user environment for visualizing and manipulating network of cellular events. This tool features automated pathway layout, functional computation support, advanced querying and a user-friendly graphical interface. We expect that Patika will be a valuable tool for rapid knowledge acquisition, microarray generated large-scale data interpretation, disease gene identification, and drug development.

AVAILABILITY

A prototype of Patika is available upon request from the authors.