Telemedicine experiences at a pediatric endocrinology clinic during the COVID-19 pandemic

BACKGROUND

The coronavirus 19 (COVID-19) pandemic has affected all aspects of life, including the routine follow-up of patients with chronic illnesses. In this study, we aim to share our experience of telemedicine in our pediatric endocrinology clinic during the pandemic.

METHODS

We were able to continue caring for children with endocrine disorders using various communication methods such as e-mail and e-message.

RESULTS

A total of 267 patients received telemedicine care over the course of 608 contacts. The number of hospital visits and physical contact was effectively reduced to help protect against the COVID-19 infection. The patients were supported in terms of receiving their prescriptions and patient education also continued. No complications were observed.

CONCLUSION

The advantages and disadvantages of telemedicine were discussed and consequently, we propose that telemedicine can be utilized to maintain and continue the care of children with endocrine disorders during and even after the pandemic. Further studies are needed to standardize this method for general use.

Radıologıcal Evaluatıon of the Recesses on the Posterıor Wall of the Nasopharynx wıth Cone-beam Computed Tomography

Background

The posterior wall of the nasopharynx is composed of loose connective tissue that includes many important anatomical structures. Various structures, such as the opening of the Eustachian tube (ET), the Rosenmüller fossa (RF), and the pharyngeal bursa (PB) are found here.

Aim

To evaluate the nasopharynx posterior wall anatomic structures, including the Eustachian tube, Rosenmüller fossa, and pharyngeal bursa with cone-beam computed tomography.

Materials and Methods

The depth, width, and length of the Eustachian tube, Rosenmüller fossa, and pharyngeal bursa were measured in 150 patients using axial-sagittal cone-beam computed tomography. The Eustachian tube and Rosenmüller fossa distance to the midsagittal plane, the coronal region passing through the posterior end of the nasal septum, the superior-inferior extremity of the recesses, and the nasal floor plane distance were measured. The relationship between Rosenmüller fossa types and other parameters were evaluated.

Results

The incidence of right Rosenmüller fossa types 1, 2, and 3 were 16%, 18%, and 66%, respectively, and that of the left Rosenmüller fossa types 1, 2, and 3 were 16%, 19.3%, and 64.7%, respectively. The mean pharyngeal bursa width, length, and depth were 10.8, 5.7, and 4.0 mm, respectively; those of the Eustachian tube were 5.6, 7.1, and 7.3 m, respectively; those of the right Rosenmüller fossa were 4.0, 12.4, and 10.5 mm, respectively; and those of the left Rosenmüller fossa were 3.8, 12.5, and 10.9 mm, respectively.

Conclusions

The posterior wall of the nasopharynx contains several important anatomical structures. Evaluation of these using cone-beam computed tomography has many clinical and radiological advantages. To understand and interpret the coincidental findings in CBCT, dental radiologists should have access to more detailed information concerning the anatomy of the nasopharynx.

Comparison of plasmapheresis with medical apheresis in terms of efficacy and cost in the acute treatment of hypertriglyceridemia in children with lipoprotein lipase deficiency

OBJECTIVES

We aimed to compare plasmapheresis and medical apheresis as lipid-lowering therapies in children with familial lipoprotein lipase (LPL) deficiency.

METHODS

The data of 13 patients who were followed up after a diagnosis of LPL deficiency were retrospectively analyzed. Plasma triglyceride, cholesterol, amylase, and lipase values and complications were recorded before and after each patient underwent plasmapheresis or medical apheresis.

RESULTS

The mean follow-up period of the patients was 99.64 ± 52.92 months in the medical apheresis group and 118 ± 16.97 months in the plasmapheresis group. While the mean triglyceride level before plasmapheresis was 1,875.38 ± 547.46 mg/dL, it was 617 ± 228.28 mg/dL after plasmapheresis. While the mean triglyceride level before medical apheresis was 1,756.86 ± 749.27 mg/dL, it was found to be 623.03 ± 51.36 mg/dL after medical apheresis. Triglyceride levels were decreased by 59.62% with medical apheresis and 65.57% with plasmapheresis. The cost of treatment for medical apheresis was found to be lower compared to plasmapheresis 296.93 ± 29.94 Turkish lira (USD 43.34 ± 4.01) vs. 3,845.42 ± 156.17 Turkish lira (USD 561.37 ± 20.93; p<0.001).

CONCLUSIONS

Although there is no standardized strategy for the acute treatment of hypertriglyceridemia due to LPL deficiency, medical apheresis is a safe and effective treatment with a low risk of side effects. Unlike plasmapheresis, medical apheresis can be performed in any center, which is another important advantage of the procedure.

Use of complementary and alternative medicine in patients with inherited metabolic disease

Background There are no studies on the use of complementary and alternative medicine (CAM) therapies in subjects with inherited metabolic disease (IMD) in the current literature. This study aimed to determine the type, frequency of and reasons for the use, and factors associated with the use of CAM therapies. Methods Subjects included in this study consisted of 335 children (95.7%) and 15 (4.3%) adults with a median age of 5.66±6.16 (0.08-48) years with inherited metabolic disease. A single physician conducted face-to-face interviews with the mother and/or father for pediatric subjects and with the subjects themselves for adults of a normal intelligence. Data were obtained from responses to the questions in the standard survey form. Results Our study included 350 patients in total, of whom 164 (46.9%) were female and 186 (53.1%) male. We found that 144 of the patients (41.1%) had used at least one CAM therapy method. The highest rate of use among the CAM therapy methods was of the mind-body approach therapies (n=98, 28%). This was followed by biologically-based (n=75, 21.4%) and manipulative and body-based (n=5, 1.4%) therapies, respectively. The most commonly used herbal product was herbal tea (n=21, 6%), and the most commonly used dietary supplementation was a royal jelly and pollen mixture (n=9, 2.6%). Significant differences in the subjects' age, their follow-up duration, their mother's and father's ages, and CAM therapy use were identified from sociodemographic data. Conclusions In our study, the use of CAM therapies was determined at a high rate. This is important when dealing with clinical problems and for clinicians who follow-up with IMD subjects and suspect they may be using CAM therapy.

Homozygous loss-of-function mutations in SLC26A7 cause goitrous congenital hypothyroidism

Defects in genes mediating thyroid hormone biosynthesis result in dyshormonogenic congenital hypothyroidism (CH). Here, we report homozygous truncating mutations in SLC26A7 in 6 unrelated families with goitrous CH and show that goitrous hypothyroidism also occurs in Slc26a7-null mice. In both species, the gene is expressed predominantly in the thyroid gland, and loss of function is associated with impaired availability of iodine for thyroid hormone synthesis, partially corrected in mice by iodine supplementation. SLC26A7 is a member of the same transporter family as SLC26A4 (pendrin), an anion exchanger with affinity for iodide and chloride (among others), whose gene mutations cause congenital deafness and dyshormonogenic goiter. However, in contrast to pendrin, SLC26A7 does not mediate cellular iodide efflux and hearing in affected individuals is normal. We delineate a hitherto unrecognized role for SLC26A7 in thyroid hormone biosynthesis, for which the mechanism remains unclear.

Chromhidrosis due to exogenous oxidizing heavy metals: Clinical and laboratory findings

BACKGROUND/OBJECTIVES

Chromhidrosis is a rare condition of which there are only a few case reports in the literature. The aim of this study was to evaluate clinical, laboratory, and possible environmental factors in 13 patients with chromhidrosis to elucidate causative agents.

METHODS

Data were obtained from the medical records of 13 patients with colored sweating between October 2015 and November 2016 (7 infants <1 year of age, 5 adults, 1 adolescent).

RESULTS

Physical examination was normal in all patients. Nine of 12 had high calculated serum free copper (75%). Urine glutamine was measured in 13 patients and was high in 11 (84.6%). Ten patients drank natural mineral water from Uludag Mountain, and two were exposed to an intrauterine device containing copper. One patient (8%) was not exposed to Uludag Mountain natural water or an intrauterine device.

CONCLUSION

We propose that chronic exposure to water or devices that contain high amounts of heavy metal and ammonium may contribute to CH.

Outcomes of mitochondrial derived diseases: a single-center experience

BACKGROUND

The purpose of this study is to help elucidate which part of the mitochondria is causing a problem through anamnesis, physical examination, and routine biochemical tests in the event of a suspected mitochondrial disease case.

METHODS

The data were obtained retrospectively from the medical records of 75 cases; the mitochondrial-derived disease (MDD) cases were observed in our center from 2011 to 2017.

RESULTS

The most commonly observed MDDs were oxidative phosphorylation disorders at 44%, followed by fatty acid oxidation disorder at 40%, pyruvate metabolism disorder at 12%, and ketone metabolism disorder at 4%, respectively. The most common clinical presentation at the time of referral to the hospital was metabolic acidosis (20%), and the most common symptom was respiratory distress (24%). There were abnormal findings in 84.3% of the cases subjected to cranial magnetic resonance imaging (MRI), with the most common being hyperintensity in the bilateral basal ganglia (49.0%).

CONCLUSIONS

Anamnesis, physical examination, and simple laboratory data could provide some important clues in assessing MDD. Blood gas should definitely be measured in cases with respiratory symptoms, particularly if they have a history of consanguineous marriage or a sibling suffering from a similar disease. If metabolic acidosis exists in the blood gas, MDDs should absolutely be included in the differential diagnosis. Furthermore, ophthalmic and cardiac assessment and cranial MRI will also reveal significant data for diagnosing MDDs.

Myocardial Muscle Bridge: An Unusal Cause of Acute Myocrdial Infarction

Myocardial muscle bridge is an uncommon cause of acute myocardial infarction. Although several treatment modalities including medical therapy have been suggested, agreement on optimal treatment has not yet been determined. We describe a case of myocardial bridging which presented as ST segment elevation myocardial infarction, and was treated successfully with medical treatment.

Evaluation of strain values of critical anatomic regions for two different pterygomaxillary approaches in Le Fort I osteotomy: An experimental study

Background

The purpose of this experimental study was to measure stresses both on the pterygoid plates and the skull base following two different pterygomaxillary approaches in Le Fort I osteotomy.

Material and Methods

The prepared skull models were randomly divided into 2 groups of 7. In the first group (A), the pterygomaxillary area was left intact. In the second group (B), pterygomaxillary separation was performed with a fine bur. The stresses were measured by using strain gauges. These strain gauges were attached to 6 different anatomical sites. The skull models were mounted on a servo-hydraulic testing unit. Each model was then subjected to a continuous linear tension until a plastic deformation was seen.

Results

The statistical analyses showed that there were no significant differences (p >.05) between the 2 groups regarding the strain values. Moreover, no statistical differences (p >.05) were found between the two groups in terms of maximum applied forces.

Conclusions

Considering the clinical conditions, the present study shows that when Le Fort I osteotomy performed without pterygomaxillary separation, there is no significant stress on the skull base during the downfracture. Moreover, it is considered that there is no need for an excessive force applied to perform downfracture in Le Fort osteotomies without pterygomaxillary separation.

Key words:Le Fort I, osteotomy, strain, base of skull, pterygoid process.

Comprehensive Screening of Eight Known Causative Genes in Congenital Hypothyroidism With Gland-in-Situ

CONTEXT

Lower TSH screening cutoffs have doubled the ascertainment of congenital hypothyroidism (CH), particularly cases with a eutopically located gland-in-situ (GIS). Although mutations in known dyshormonogenesis genes or TSHR underlie some cases of CH with GIS, systematic screening of these eight genes has not previously been undertaken.

OBJECTIVE

Our objective was to evaluate the contribution and molecular spectrum of mutations in eight known causative genes (TG, TPO, DUOX2, DUOXA2, SLC5A5, SLC26A4, IYD, and TSHR) in CH cases with GIS. Patients, Design, and Setting: We screened 49 CH cases with GIS from 34 ethnically diverse families, using next-generation sequencing. Pathogenicity of novel mutations was assessed in silico.

PATIENTS, DESIGN, AND SETTING

We screened 49 CH cases with GIS from 34 ethnically diverse families, using next-generation sequencing. Pathogenicity of novel mutations was assessed in silico.

RESULTS

Twenty-nine cases harbored likely disease-causing mutations. Monogenic defects (19 cases) most commonly involved TG (12), TPO (four), DUOX2 (two), and TSHR (one). Ten cases harbored triallelic (digenic) mutations: TG and TPO (one); SLC26A4 and TPO (three), and DUOX2 and TG (six cases). Novel variants overall included 15 TG, six TPO, and three DUOX2 mutations. Genetic basis was not ascertained in 20 patients, including 14 familial cases.

CONCLUSIONS

The etiology of CH with GIS remains elusive, with only 59% attributable to mutations in TSHR or known dyshormonogenesis-associated genes in a cohort enriched for familial cases. Biallelic TG or TPO mutations most commonly underlie severe CH. Triallelic defects are frequent, mandating future segregation studies in larger kindreds to assess their contribution to variable phenotype. A high proportion (∼41%) of unsolved or ambiguous cases suggests novel genetic etiologies that remain to be elucidated.

The Etiology and Clinical Features of Non-CAH Gonadotropin-Independent Precocious Puberty: A Multicenter Study

AIM

The causes of gonadotropin-independent precocious puberty are diverse, and often have overlapping clinical and biochemical features. With the exception of congenital adrenal hyperplasia (CAH), disorders that cause gonadotropin-independent precocious puberty (GIPP) are uncommon. The literature is devoid of any large-scale studies on the etiologic distribution of GIPP. The aim of this study was to determine the frequency of each etiology in a cohort of patients with GIPP (excluding those with CAH), and to evaluate the clinical and laboratory features of these patients.

MATERIALS AND METHODS

This multicenter, nationwide web-based study collected data on patients who presented with non-CAH GIPP in Turkey.

RESULTS

Data were collected for 129 patients (102 girls and 27 boys) from 29 centers. Based on the data collected, the estimated prevalence of non-CAH GIPP in the studied population was 14 in 1 000 000 children. Functional ovarian cyst was the most common etiology, accounting for 37% of all cases, followed by McCune-Albright syndrome (MAS) (26%). Among the patients with MAS, 11.7% had fibrous dysplasia, 32.3% had café-au-lait spots, and 52.9% had both. Human chorionic gonadotrophin-secreting tumors included choriocarcinoma of the liver, hepatoblastoma, and germ cell tumors of the sellar-suprasellar region and mediastinum. Patients with adrenocortical tumors presented at an earlier age than those with other etiologies. Ovarian tumors included mature cystic teratoma, dysgerminoma, juvenile granulosa tumor, and steroid cell tumor. Despite overlapping features, it was possible to identify some unique clinical and laboratory features associated with each etiology.

CONCLUSION

This largest cohort of patients with non-CAH GIPP to date yielded an estimation of the frequency of non-CAH GIPP in the general pediatric population and showed that girls were affected at a rate 4-fold greater than that of boys owing to functional ovarian cysts and MAS, which were the two most common etiologies. The data collected also provided some unique characteristics associated with each etiology.

Pediatric patients with pheochromocytoma: Experience of a tertiary health center

BACKGROUND

The aim of this retrospective study was to investigate pheochromocytoma (pheo), which is a rare endocrine tumor in the pediatric population.

METHODS

The medical records of five children with pheo were studied. The age, gender, clinical presentation, family history, physical findings, coexisting pathology, laboratory evaluation, surgical treatment, and postoperative course were investigated.

RESULTS

The patients were four girls and one boy with a mean age of 13.2 years (range, 9.57-15.95 years). None of the patients had paroxysmal hypertension and one had normal blood pressure. No malign pheo was identified. Mean height and weight standard deviation scores (SDS), body mass index (BMI), and BMI SDS were -0.24, 0.04, 20.9 kg/m(2), and 0.20 at the time of diagnosis, and 0.03, 0.43, 23.8 kg/m(2) and 0.49 1 year after operation, respectively. BMI increased significantly after operation. Three patients had normal epinephrine and metanephrine, but elevated norepinephrine and normetanephrine on 24 h urine. Vanillylmandelic acid on 24 h urine sample was elevated in all patients. Ultrasonography failed to visualize tumors in two patients with bilateral pheo. One patient had postoperative severe hypotension. Insulin resistance associated with severe acanthosis nigricans observed in one patient regressed postoperatively.

CONCLUSIONS

Pheo in children may present with different symptoms and findings. Decreased catecholamine in the postoperative period may lead to weight gain.

Evaluation of electrocardiographic parameters for early diagnosis of autonomic dysfunction in children and adolescents with type-1 diabetes mellitus

BACKGROUND

The aim of this study was to identify the sensitivity of electrocardiogram (ECG) in early diagnosis of cardiac autonomic function disorder in children with type 1 diabetes mellitus.

METHODS

A total of 150 children and adolescents with type 1 diabetes mellitus were enrolled between June 2009 and June 2010, as well as 100 age- and sex-matched healthy control children. Twelve-lead ECG was done in all cases and heart rate, QT and QTc interval, dispersion of P wave (Pd), and of QT (QTd) and QTc interval (QTcd) were measured. The clinical and demographic features such as age, gender, duration of follow up and level of HbA1c and fasting glucose were obtained and the effects of these parameters on ECG measurements were investigated.

RESULTS

The mean age of the patients and controls was 11.61 ± 3.72 years and 10.92 ± 3.2 years, respectively. QT and QTc interval and QTcd interval were significantly higher in diabetic children compared to healthy controls but these ECG findings were not associated with the duration of diabetes or glycemic state. Pd was significantly higher in the diabetic patients with HbA1c >7.5% compared to control, and this was also found in patients that were followed up >1 year.

CONCLUSIONS

Cardiac autonomic function disorder, which is one of the most important causes of morbidity and mortality, may emerge in the course of type 1 diabetes mellitus. It can be diagnosed on ECG even when the patients are asymptomatic.

An essential splice site mutation (c.317+1G>A) in the TSHR gene leads to severe thyroid dysgenesis

Congenital hypothyroidism (CH) is the most common neonatal endocrine disorder and 2% of cases have familial origin. Our aim in this study was to determine the genetic alterations in two siblings with CH coming from a consanguineous family. Because CH is often inherited in autosomal recessive manner in consanguineous/multicase-families, we first performed genetic linkage studies to all known causative CH loci followed by conventional sequencing of the linked gene. The family showed potential linkage to the TSHR locus, and we detected an essential splice site mutation (c.317+1G>A) in both siblings. RT-PCR analysis confirmed the functionality of the mutation. The mutation was homozygous in the cases whereas heterozygous in carrier parents and an unaffected sibling. Here we conclude that thyroid agenesis in both siblings in this study originates from c.317+1G>A splice site mutation in the TSHR gene, and this study underlines the importance of detailed molecular genetic studies in the definitive diagnosis and classification of CH.

Etiological evaluation of adolescents with primary amenorrhea

OBJECTIVES

To determine causes of amenorrhea in adolescents with primary amenorrhea and to emphasize general approach to primary amenorrhea.

METHODS

Thirty-nine patients, evaluated between January 2007 and May 2011, were divided into normogonadotropic hypogonadism, hypergonadotropic hypogonadism and hypogonadotropic hypogonadism groups. Means of age, height, weight, body mass index and standard deviation scores, gonadotropin levels, and accompanying diseases were evaluated.

RESULTS

Mean values of age, height, height standard deviation score, weight and, weight standard deviation score were 15.54 ± 1.52 y. 152.0 ± 1.1 cm, -1.37 ± 1.3, 48.2 ± 14.3 kg, 0.96 ± 1.75, respectively. There were no statistical significances in the auxological parameters. Patients were distributed as 18 cases (46.1 %) with normogonadotropic hypogonadism, 12 cases (30.8 %) with hypergonadotropic hypogonadism, 9 cases (23.1 %) with hypogonadotropic hypogonadism. In the group of normogonadotropic hypogonadism, there were 6 patients with chronic diseases, 5 patients with insulin resistance, 4 patients with prolactinomas, 3 patients with müllerian agenesis. Of the hypergonadotropic hypogonadic patients, 3 were idiopathic primary ovarian failure, 3 were 46,XY disorders of sex development, 2 were Turner syndrome, 2 were ovarian insufficiency due to drug, one was 17 alpha-hydroxylase deficiency and one was autoimmune oophoritis. The group of hypogonadotropic hypogonadism included 5 patients with normosmic hypogonadism, 2 patients with constitutional delay of growth and puberty, 1 patient with panhypopituitarism and 1 patient with anosmic hypogonadism.

CONCLUSIONS

Chronic diseases, prolactinoma, and insulin resistance may lead to hypogonadism without altering gonadotropin levels. Turner syndrome, primary ovarian failure, and autoimmune oophoritis should be investigated in cases with hypergonadotropic hypogonadism. 46, XY disorders of sex development also should be elucidated. Constitutional delay of growth and puberty should be distinguished from isolated hypogonadotropic hypogonadism.

A deletion including exon 2 of the TSHR gene is associated with thyroid dysgenesis and severe congenital hypothyroidism

Congenital hypothyroidism (CH) is the most common neonatal endocrine disorder and 2% of cases have a familial origin. Our aim in this study was to determine the genetic alterations in two siblings with CH coming from a consanguineous family. As CH is often inherited in an autosomal recessive manner in consanguineous/multi case-families, we first performed genetic linkage studies to all known causative CH loci followed by conventional sequencing of the linked gene. The family showed potential linkage to the TSHR locus and our attempts to amplify and sequence exon 2 of the TSHR gene continuously failed. Subsequent RT-PCR analysis using mRNA and corresponding cDNA showed a large deletion including the exon 2 of the gene. The deletion was homozygous in affected cases whilst heterozygous in carrier parents. Here we conclude that CH in both siblings of this study originates from a large deletion including the exon 2 of the TSHR gene. This study demonstrates that full sequence analysis in a candidate CH gene might not always be enough to detect genetic alterations, and additional analyses such as RT-PCR and MLPA might be necessary to describe putative genetic causes of the disease in some cases. It also underlines the importance of detailed molecular genetic studies in the definitive diagnosis and classification of CH.

Preclinical impairment of myocardial function in rheumatoid arthritis patients. Detection of myocardial strain by speckle tracking echocardiography

OBJECTIVES

The incidence of heart failure is higher in patients with rheumatoid arthritis (RA) than in the general population and contributes to elevated cardiovascular mortality and morbidity rates. Impaired myocardial function can be detected by a novel echocardiographic method, speckle tracking echocardiography (STE), when conventional methods have yielded normal findings. The aim of our study was to investigate the effect of disease duration on myocardial strain and strain rate parameters in patients with RA.

METHODS

This cross-sectional study included 37 RA patients [n=16, female gender n=16, mean age, 45.7 ± 9 years in the early-stage disease (ESD); n= 21, female gender n=19, 45.7 ± 16.8 years in the advanced-stage disease (ASD) group] who were compared according to early disease duration and advanced-stage disease (2.8 ± 1.2 vs. 14.6 ± 6.8 years, respectively). Hypertension, diabetes mellitus, and other cardiovascular risk factors were excluded. Offline analysis of STE was performed and data between the two groups were compared.

RESULTS

RS, RSR-E, and RSR-E/A values were statistically significantly lower in patients with ASD. Circumferential strain and strain rate were similar between the two groups. Except for LSR-E/A values, LS, LSR-S, LSR-E, and LSR-A values were decreased in patients with ASD.

CONCLUSION

RA patients without clinical evidence of cardiovascular disease and in the absence of traditional cardiovascular risk factors can be followed up with STE. In this way, early impairment of myocardial deformation can be detected before the appearance of any clinical evidence of cardiac involvement.

Thyroid dyshormonogenesis is mainly caused by TPO mutations in consanguineous community

OBJECTIVE

In this study, we aimed to investigate the genetic background of thyroid dyshormonogenesis (TDH).

CONTEXT

Thyroid dyshormonogenesis comprises 10-15% of all cases of congenital hypothyroidism (CH), which is the most common neonatal endocrine disorder, and might result from disruptions at any stage of thyroid hormone biosynthesis. Currently seven genes (NIS, TPO, PDS, TG, IYD, DUOX2 and DUOXA2) have been implicated in the aetiology of the disease.

DESIGN

As TDH is mostly inherited in an autosomal recessive manner, we planned to conduct the study in consanguineous/multi-case families.

PATIENTS

One hundred and four patients with congenital TDH all coming from consanguineous and/or multi-case families.

MEASUREMENTS

Initially, we performed potential linkage analysis of cases to all seven causative-TDH loci as well as direct sequencing of the TPO gene in cases we could not exclude linkage to this locus. In addition, in silico analyses of novel missense mutations were carried out.

RESULTS

TPO had the highest potential for linkage and we identified 21 TPO mutations in 28 TDH cases showing potential linkage to this locus. Four of 10 distinct TPO mutations detected in this study were novel (A5T, Y55X, E596X, D633N).

CONCLUSIONS

This study underlines the importance of molecular genetic studies in diagnosis, classification and prognosis of CH and proposes a comprehensive mutation screening by new sequencing technology in all newly diagnosed primary CH cases.

TSHR is the main causative locus in autosomal recessively inherited thyroid dysgenesis

Congenital hypothyroidism (CH) is the most common neonatal endocrine disorder and results in mental retardation if untreated. Eighty-five percent of CH cases are due to disruptions in thyroid organogenesis and are mostly sporadic, but about 2% of thyroid dysgenesis is familial, indicating the involvement of genetic factors in the aetiology of the disease. In this study, we aimed to investigate the Mendelian (single-gene) causes of non-syndromic and non-goitrous congenital hypothyroidism (CHNG) in consanguineous or multi-case families. Here we report the results of the second part (n=105) of our large cohort (n=244), representing the largest such cohort in the literature, and interpret the overall results of the whole cohort. Additionally, 50 sporadic cases with thyroid dysgenesis and 400 unaffected control subjects were included in the study. In familial cases, first, we performed potential linkage analysis of four known genes causing CHNG (TSHR, PAX8, TSHB, and NKX2-5) using microsatellite markers and then examined the presence of mutations in these genes by direct sequencing. In addition, in silico analyses of the predicted structural effects of TSHR mutations were performed and related to the mutation specific disease phenotype. We detected eight new TSHR mutations and a PAX8 mutation but no mutations in TSHB and NKX2-5. None of the biallelic TSHR mutations detected in familial cases were present in the cohort of 50 sporadic cases. Genotype/phenotype relationships were established between TSHR mutations and resulting clinical presentations. Here we conclude that TSHR mutations are the main detectable cause of autosomal recessively inherited thyroid dysgenesis. We also outline a new genetic testing strategy for the investigation of suspected autosomal recessive non-goitrous CH.

Time-dependent alterations in growth and bone health parameters evaluated at different posttreatment periods in pediatric oncology patients

Bone mineral density (BMD) and anthropometric measurements in pediatric cancer patients were evaluated and compared at early and late posttreatment periods. Sixty-six pediatric cancer patients who recovered completely following treatment longer than at least a 6-month period were included in the study. Patients were evaluated cross-sectionally and prospectively with regard to anthropometric measurements and BMD twice; the first being at a mean period of 2.62 ± 1.44 years and the second of 6.55 ± 1.71 years after the completion of treatment. Rates of osteoporosis and osteopenia at first or second evaluation were 25.8% and 39.4% or 10.6% and 19.7%, respectively. Mean BMD z-scores were (-1.26) ± 1.12 [(-4.3)-2.0] and (-0.48) ± 1.25 [(-3.30)-3.40] at first and second evaluations, respectively. BMD findings obtained at second evaluation revealed statistically significant recovery compared with those obtained at first evaluation (P = .001). BMD z-scores were significantly lower in patients who received, as opposed to those who did not receive, radiotherapy (RT) at both evaluations. Anthropometric parameters of patients such as height, weight, and body mass index (BMI) were increased at both evaluations compared with values obtained at diagnosis (P < .05). Height standard deviation score (SDS) decreased at first evaluation compared with that measured at diagnosis, whereas it increased at second evaluation. Conversely, weight SDS and BMI SDS increased (P < .05) at first evaluation compared with that measured at diagnosis, whereas they decreased at second evaluation. The authors conclude that early impairments in anthropometric measurements recover in the long term, whereas BMD is continually reduced in children who recovered from cancer.

Clozapine plasma level monitoring for prediction of rehospitalization schizophrenic outpatients

INTRODUCTION

The aim of this naturalistic exploratory study was to examine whether blood antipsychotic drug concentrations can predict rehospitalizations in chronically medicated patients.

METHODS

The study included schizophrenic outpatients under clozapine (CLZ) maintenance treatment, supervised by therapeutic drug monitoring (TDM). Patients were observed for a period of 21 months. Their on average monthly measured plasma levels and the date of rehospitalizations were recorded. The variability of the first 3 CLZ plasma levels, measured in 3.6 months, was compared between patients with and without rehospitalization.

RESULTS

23 patients participated of which 6 patients were rehospitalized. Mean plasma concentrations of CLZ were similar in patients without (471 ± 180 ng/mL) and with rehospitalization (446 ± 266 ng/mL). However; coefficients of variation (CV) of plasma concentrations in the first 3 blood samples differed significantly between the rehospitalized and non-rehospitalized groups (37.1% vs. 13.0%, respectively, P = 0.012). A CV ≥ 19.8% was predictive for later rehospitalization with 100% sensitivity and 70.6% specificity.

DISCUSSION

Variability in CLZ plasma concentrations may be useful in identifying patients at risk of relapsing under maintenance therapy. Because of the small number of patients the findings need to be confirmed in a larger study.

The use of complementary and alternative medicine in patients with common variable immunodeficiency

OBJECTIVES

Complementary and alternative medicine (CAM) usage is a reality in patients with chronic diseases, but there are no data on CAM usage in immunodeficiency diseases necessitating intravenous immunoglobulin (IVIG) therapy.The aim of this study was to investigate the rate of CAM usage in patients with common variable immunodeficiency (CVID).

METHODS

Forty-three patients (29 boys and 14 girls) with CVID and receiving IVIG every 3 weeks were included. Data were collected through a questionnaire completed by the parents. Those using treatments other than their medical therapies that were defined as CAM by the National Center for Complementary and Alternative Medicine were classified as CAM users.

RESULTS

The mean (SD) age at diagnosis was 7.56 (9.44) years (range, 6 months to 44 years) and the mean IVIG treatment duration was 6.02 (3.84) years (range, 1 to 20 years). Thirty-six (83.7%) of the 43 patients analyzed had used at least 1 CAM approach. The most common modalities were herbal medicines (65.1%), dietary supplements (62.8%), vitamins (46.5%), and religion (34.9%). Only 11% of those interviewed had informed their doctor that they were using CAM. The most common reason for CAM usage was the desire to improve body resistance. Eighteen parents (50%) claimed that their children had benefited from CAM.

CONCLUSION

Our findings reveal that there is a remarkably high tendency to use CAM in patients with CVID. Although no side effects were reported by the families, potential drug interactions should be considered.

Novel TSHR mutations in consanguineous families with congenital nongoitrous hypothyroidism

OBJECTIVE

Nonsyndromic autosomal recessively inherited nongoitrous congenital hypothyroidism (CHNG) can be caused by mutations in TSHR, PAX8, TSHB and NKX2-5. We aimed to investigate mutational frequencies of these genes and genotype/phenotype correlations in consanguineous families with CHNG.

DESIGN

Because consanguinity in individuals with a presumptive genetic condition is often an indicator of an autosomal recessive inheritance and allows firmer correlations to be established between genotype and phenotype, we planned to execute our study in consanguineous families.

PATIENTS

Hundred and thirty-nine children with CHNG phenotype born to consanguineous families.

MEASUREMENTS

First, we investigated cases for evidence of linkage to the four known CHNG genes by microsatellite marker analysis. Mutation analysis by direct sequencing was then performed in those cases in whom linkage to the relevant candidate gene could not be excluded. In addition, in silico analysis of the predicted structural effects of TSHR mutations was performed and related to the mutation-specific disease phenotype.

RESULTS

Homozygous germline TSHR mutations were detected in six families (5%), but no mutations were detected in PAX8, TSHB and NKX2-5. Four of TSHR mutations had not previously been described. Genotype-phenotype correlations were established and found to be related to the predicted structural effects of the mutations.

CONCLUSIONS

Known causative genes account for the development of CHNG only in a minority of cases, and our cohort should provide a powerful resource to identify novel causative genes and to delineate the extent of locus heterogeneity in autosomal recessively inherited CHNG.

Association of left ventricular diastolic function abnormalities with aortic elastic properties in asymptomatic patients with type 2 diabetes mellitus. A tissue doppler echocardiographic study

BACKGROUND

The aim of this study was to investigate the association between the aortic elastic properties and the left ventricular diastolic function measured by tissue Doppler echocardiography (TDE) in asymptomatic type 2 diabetes mellitus.

METHODS

Fifty-seven asymptomatic patients with type 2 diabetes (33 women, mean age: 49 +/- 6 years) and 25 healthy control subjects (19 women, mean age: 46 +/- 7 years) were included in the present study. Diastolic filling indices were measured by conventional (CE) and tissue Doppler echocardiography. The aortic elastic properties [Aortic stiffness index (ASI), aortic distensibility and strain] were measured as previous definition.

RESULTS

Compared with control subjects, the ratio of LV diastolic abnormalities measured by CE and TDE were found higher in patients with type 2 diabetes (36% and 73.6%, p = 0.001, respectively, and 52% and 89.4%, p < 0.001, for septal annulus; 48% and 89.4%, p < 0.001 for septal basal respectively). The ASI was significantly higher (p < 0.001), aortic distensibility and aortic strain were also significantly lower in patients with type 2 diabetes than control subjects (p < 0.001 and p < 0.001 respectively). In the regression analysis, Ao distensibility was correlated to age (beta = -0.299, p = 0.004), septal basal Em/Am ratio (beta =0.543, p < 0.001) and HDL-cholesterol (beta = 0.192, p = 0.039). ASI was also correlated only to age (beta = 0.255, p = 0.044), the presence of diabetes mellitus (beta = 0.304, p = 0.009), mitral A wave (beta = 0.322, p = 0.013) and mitral annulus Em wave (beta = -0.505, p < 0.001).

CONCLUSION

The aortic elastic function is impaired in asymptomatic patients with type 2 diabetes. Increased ASI and decreased Ao distensibility are closely associated with diastolic filling indices measured by CE and TDE.

Evaluation of diagnosis and treatment results in children with Graves' disease with emphasis on the pubertal status of patients

This retrospective study evaluated the clinical and laboratory characteristics at presentation and treatment results of patients with Graves' disease (GD) with respect to pubertal status. Records of 143 patients (108 F, 35 M) were reviewed in a multicenter study. At diagnosis, 38% of patients were prepubertal. Anti-thyroid drugs (ATD) were used as initial therapy. There was no significant difference in clinical and laboratory characteristics at diagnosis, during treatment and adverse reaction to ATD with respect to pubertal status. Twenty patients (7 prepubertal, 13 pubertal) reached remission on ATD. Surgery was performed in seven and radioiodine (RAI) in four patients. Duration of treatment needed to achieve remission was longer in prepubertal (4.2 +/- 1.0 yr) than in pubertal patients (3.1 +/- 1.3 yr) (p = 0.02). The rate of remission was not different between prepubertal (25.9%) and pubertal patients (33.3%) (p = 0.59). ATD were associated with low remission rate in pediatric GD and required longer duration of therapy in prepubertal patients. For definitive treatment in older children, RAI could be evaluated as the initial therapy.

Reference values for neonatal thyroid volumes in a moderately iodine-deficient area

BACKGROUND

The reference ranges of thyroid volumes in neonates vary according to the iodine status of a specific region. In different studies, it ranged between 0.47 and 1.62 ml. It has been previously shown that Bursa city was a moderately iodine-deficient area. We therefore aimed at determining normal reference ranges of neonatal thyroid volumes in our moderately iodine-deficient area.

METHODS

In this cross-sectional study, thyroid volumes of 100 healthy fullterm neonates (51 boys and 49 girls; mean gestational age 38.9+/-1.1 weeks; and mean birth-weight 3370+/-446 g) were measured during the first week of life using thyroid ultrasonography. These data were compared with the gestational age, birth weight, gender, and TSH values of neonates as well as with maternal factors such as gestational diabetes, preeclampsia, smoking, medication use, and heart disease.

RESULTS

All blood samples for TSH were taken during the first 5 days (mean 1.09+/-0.9 days). The mean TSH levels in all male and female neonates were 3.77+/-3.71, 4.57+/-3.61, and 2.93+/-3.66 mIU/l, respectively. This difference was statistically significant (p=0.006). Mean thyroid volumes for all male and female neonates were calculated as 0.82+/-0.18 (range 0.51-2.04), 0.84+/-0.21 (range 0.51-2.04), and 0.80+/-0.14 ml (range 0.58-1.30), respectively. There were no statistically significant differences in thyroid volumes with respect to gestational age, birth weight, gender, TSH values of neonates and maternal factors.

CONCLUSION

Normal thyroid volumes in neonates vary between different regions. Local reference values should be used in thyroid volume assessment. Our results are in concordance with the literature and can be used as reference values for our region.

Bilateral multiple pulmonary arteriovenous fistulas and duplicated renal collecting system in a child with Noonan's syndrome

Noonan's syndrome involves the association of multiple congenital abnormalities, with a variety of cardiac defects. We describe here the association of Noonan's syndrome with multiple pulmonary arteriovenous fistulas and bilateral duplicated renal collecting systems. To the best of our knowledge, this is the first reported case of an association of the Noonan phenotype with pulmonary arteriovenous fistulas.

Severe hypospadias associated with Robertsonian translocation

In this study, we report a 3-year-old boy with severe scrotal hypospadias with Robertsonian translocation [45,XY,t(13q;14q)]. The patient was born at term with a low birth weight and hypospadias. There was no endocrinological abnormality. His father also has a balanced 13-14 Robertsonian translocation. Two-stage hypospadias repair was carried out. The presence of this chromosomal anomaly and hypospadias are unique to our patient, compared to others with the 45,XY,t(13q;14q) translocation. Although no such association has been reported so far, we thought that severe hypospadias in this case might be associated with this translocation.

Meropenem decreases serum level of valproic acid

Concomitant administration of meropenem has been reported to decrease serum level of valproic acid both in humans and in animals. This report describes three children who required simultaneous administration of valproic acid and meropenem. Meropenem rapidly decreased serum valproic acid concentration to subtherapeutic levels in all three children, and serum valproic acid levels were returned to therapeutic levels in a short time after discontinuing simultaneous meropenem therapy. Valproic acid was not changed to another antiepileptic agent, because no seizure activity was observed. To our knowledge, this is the first case report on the simultaneous administration of meropenem and valproic acid in childhood. In conclusion, it is clear that concomitant meropenem administration decreases serum valproic acid concentration, and we believe that there may be no need to change the antiepileptic drug during this period, provided that the patient has no seizure. More detailed studies are required.

Cytotoxic activity and quality control determinations on Chelidonium majus

The quality control determinations on herba and radix Chelidonii prepared from Chelidonium majus L., growing wildly in Bursa, Uludağ surroundings, have been conducted according to DAB 9. Ash, humidity and total alkaloidal content have been carried out. LC(50) value of chelidonine and protopine, the most important alkaloids, and the alcoholic and water extracts of herba Chelidonii were determined using brine shrimp (Artemia salina) lethality bioassay.

Evaluation of the need for routine preoperative latex allergy tests in children

BACKGROUND

Recently, there was a great increase in allergic reactions to latex and this brought relatively more concern to the latex allergy. In this prospective study we aimed to identify the frequency of latex allergy in preoperative patients, and tried to clarify whether it is necessary to perform latex allergy tests routinely in the preoperative period or not.

METHODS

A total of 188 children, aged 1-14, who were admitted for various operations, were randomly included in this study and of them, 181 completed the study. Latex specific history was taken from all patients. Latex skin prick tests, challenge tests with latex gloves, total IgE and latex specific IgE measurements were performed.

RESULTS

Of 181 children, two (1.1%) had positive latex skin prick tests. Latex challenge tests were negative in all children. Latex specific IgE was positive in 12 children (6.6%) as class II or higher, but no patient had allergic reactions in operations. History of repeated operations was a risk factor for latex sensitization. The risk was higher in the presence of both history of repeated operations and history of allergic disease. However, the risk was not higher in patients with the history of only allergic disease, compared to ones who had a history of neither repeated operations nor allergic disease.

CONCLUSION

We conclude that routine preoperative latex allergy tests seem to be not necessary because of no allergic reactions during operation in spite of the sensitization of 6.6% detected by latex specific IgE. However, this should be investigated in larger studies.

Perception of angular head position during attempted alignment with eccentric visual objects

The perception of angular head position with respect to a visual object was investigated using three different methods: Pointer indication (P); in the dark, subjects' (Ss') heads were horizontally turned to various positions (range +/- 54 degrees); Ss then rotated a pointer carrying a light emitting diode (LED) so as to align it with head position. Active head pointing (A); again in darkness, the pointer was rotated to various positions; Ss then turned their heads so as to align them with the pointer. Reading from visible scale (V); Ss viewed a degrees scale on a circular screen; Ss' heads were turned as in P, and Ss reported head position in terms of this scale. The results obtained with all three methods indicate that head position is overestimated with respect to the visual object (LED, scale mark): object position exceeded head position by 6, 18, and 7% when measured with the P-, A-, and V-methods, respectively (median values). The observed misalignment between head and object suggests that subjective primary eye position is shifted in the direction of head rotation by a cross-talk of head position. Whether a functional advantage or merely a tolerated side-effect of other constraints, this behavior confers the impression of looking "straight ahead" in the literal sense when gaze is shifted by coordinated eye-head movements with a 10% eye and a 90% head share in total lateral displacement. In an attempt to probe a hypothesized internal representation of head position implied in head-to-object alignment, Ss were also to estimate head position in space using only neck proprioceptive information. In complete darkness, responses were often non-linear functions of head position with overestimation of large eccentricities. When a head-centered LED was added (which conveyed no position information), responses became more linear, suggesting that the mere presence of visual afferents may improve the perceptual interpretation of proprioceptive information.

Erectile dysfunction in premature ejaculation

Between October 1993 and December 1995, 45 patients with premature ejaculation were included in this study. The patients were divided into two groups etiologically, as having primary or secondary ejaculation. After a complete laboratory evaluation all patients underwent papaverine tests color Doppler ultrasonography pharmacocavernosometry-cavernosography and consequently organic etiology were investigated. Venous leakage was found in 5 (22,7%), arterial or mix insufficiency in 2 (9%) of the patients with primary premature ejaculation. In secondary premature ejaculation group, venous leakage was encountered in 9 patients (39,1%), arterial insufficiency in 2 patients (8,6%). In conclusion, investigation of organic etiology for the patients with premature ejaculation, particularly with secondary premature ejaculation, seems to be beneficial for correct diagnosis.

Comparative early results of transurethral electroresection and transurethral electrovaporization in benign prostatic hyperplasia

OBJECTIVE

To compare the results of conventional transurethral electroresection of the prostate (TURP) and transurethral electrovaporization (TUEP) in patients with symptomatic benign prostatic hyperplasia.

PATIENTS AND METHODS

The study comprised 46 patients with moderate or severe symptoms of prostatism and a maximal flow rate of < 15 mL/s. Pre-operatively, all patients underwent a digital rectal examination and the determination of prostatic volume by ultrasonography, and a symptom score, the maximal flow rate, post-void residual urine, routine biochemical variables and serum prostate specific antigen were measured. The haematocrit and blood Na+ levels were also determined pre-operatively and again 24 h after the operation. Patients were divided randomly into two groups: the first underwent a conventional TURP and the second TUEP using 240-300 W of cutting current. Three months after operation, all the variables were remeasured and the values compared with those before treatment and between the groups.

RESULTS

The improvements in symptom score, maximum flow rate and residual urine were slightly better after TURP than after TUEP but the differences between treatments were not statistically significantly different. However, TUEP used slightly less irrigant solution, allowed earlier removal of the urethral catheter, required no blood transfusions and was easier to perform.

CONCLUSION

Although the improvements in the objective variables 3 months after TUEP were almost the same as after TURP, there were advantages in using less resources: further studies with more patients and a longer follow-up are required to determine the efficacy and safety of this procedure.