Bekir Cakir

Insulin Resistance in Nonobese Patients with Polycystic Ovary Syndrome

Objectives: Most patients with polycystic ovary syndrome (PCOS) are obese and known to have insulin resistance. Obesity per se is a cause of insulin resistance. This study was performed to determine whether insulin resistance occurs in patients with PCOS in the absence of obesity and acanthosis nigricans. Method: For this purpose, an euglycemic hyperinsulinemic clamp study was performed in 12 nonobese patients with PCOS and in 10 healthy control subjects matched for age and weight. Results: The mean serum testosterone and luteinizing hormone (LH) levels were significantly elevated (4.09 ± 1.32 vs. 1.18 ± 0.53 pg/ml, p < 0.001, and 11.63 ± 5.37 vs. 4.98 ± 2.73 mIU/ml, p < 0.001, respectively), and the serum sex hormone binding globulin level was significantly reduced (40.96 ± 14.94 vs. 73.98 ± 30.40 nmol/l, p < 0.001) in patients with PCOS as compared with the values in control subjects. The mean serum insulin level was also elevated in patients with PCOS as compared with control subjects (32.33 ± 4.98 vs. 19.56 ± 2.21 µU/ml, p < 0.05). The insulin sensitivity was lower in patients with PCOS as compared with the control subjects (200 ± 27.8 vs. 427.8 ± 88.9 µmol kg–1min–1, p < 0.001). In patients with PCOS, the serum levels of free testosterone (r = –0.89, p < 0.001) and LH were inversely correlated with the insulin sensitivity (r = –0.63, p < 0.05). Serum follicle-stimulating hormone, prolactin, and dehydroepiandrosterone sulfate levels were similar in both groups. Conclusions: These results indicate that a significant degree of insulin resistance exists in nonobese patients with PCOS and that this insulin resistance is significantly related to serum LH and free testosterone levels. Thus, measures to decrease insulin resistance may have to be considered earlier to decrease the potential risks of developing diabetes mellitus and coronary artery disease at later ages of life in these patients.

Plasma Soluble Intercellular Adhesion Molecule 1 Levels Are Increased in Type 2 Diabetic Patients with Nephropathy

Background/Aim: Intercellular adhesion molecule 1 (ICAM-1) is a mediator in the recruitment of leukocytes in the glomerular cells. The role of ICAM-1 in diabetic complications is still a matter of debate. This study was performed to investigate the relation of plasma soluble ICAM-1 (sICAM-1) to nephropathy in patients with type 2 diabetes mellitus. Methods: Ninety-three patients (24 males and 69 females) with type 2 diabetes mellitus were included into the study. Fifty patients had nephropathy, and 43 were free from nephropathy. Fifty healthy subjects (14 males and 36 females) served as the control group (group 1). Twenty-five of the diabetic patients had microalbuminuria (group 2), 25 had macroalbuminuria (group 3), and 43 had neither micro- nor macroalbuminuria (group 4). The plasma sICAM-1 levels were measured in blood samples drawn after fasting. Results: The mean plasma sICAM-1 levels were not different in the 93 diabetic patients as compared with the healthy controls (392.7 ± 119.5 vs. 350.1 ± 90.2 ng/ml, p > 0.05). The mean sICAM-1 level was significantly higher in the diabetic patients with nephropathy than in those without nephropathy (430.3 ± 78.2 vs. 368.2 ± 122.5 ng/ml, p = 0.03) and in the controls (430.3 ± 78.2 vs. 350.1 ± 90.2 ng/ml, p = 0.016). The difference in sICAM-1 levels between groups 2 and 3 was not significant (p > 0.05). The plasma sICAM-1 levels were significantly higher in both groups 2 and 3 than in both groups 1 and 4 (434.5 ± 129.2 vs. 427.2 ± 113.7 ng/ml and 368.2 ± 122.5 vs. 350.1 ± 90.2 ng/ml, respectively). Conclusions: The plasma sICAM-1 levels in patients with type 2 diabetes mellitus are not significantly different from those in nondiabetic subjects. High levels of sICAM-1 suggest that sICAM-1 may play a role in the development of nephropathy in patients with type 2 diabetes mellitus.

The Association Between Thyroid Carcinoma and Hashimoto's Thyroiditis: The Ultrasonographic and Histopathologic Characteristics of Malignant Nodules

BACKGROUND Some but not all reports, particularly those of a retrospective nature, have noted an increased risk of carcinoma in thyroid nodules in patients with Hashimotos thyroiditis (HT). Thyroid cancer (TC) in patients with HT, however, have been reported to have a better prognosis. In the presence of HT, the ultrasonography (US) appearance of the thyroid gland might vary greatly, making it more difficult to differentiate between benign and malignant nodules. The aim of this study was to determine if there is an association between TC and HT and to determine if the US and histopathologic characteristics of malignant nodules in patients with and without HT are similar. METHODS Six hundred thirteen patients who underwent total thyroidectomy between 2005 and 2008 for nodular goiter were included in this study. The preoperative US characteristics and postoperative histopathologic features in patients with and without HT were compared. The diagnosis of HT was based on histopathologic features. RESULTS Ninety-two patients had HT. The prevalence of TC in the HT patients was 45.7%. In contrast, it was 29% in patients without HT (p = 0.001). The prevalence of HT in the patients with TC was 21.8% and in patients without TC was 11.9% (p = 0.001). The rate of incidental TC, defined as TC identified during surgery or following histopathologic examination of permanent sections despite preoperative benign cytology results, was higher in patients with HT (33.3%) than in those without (13.0%) HT (p = 0.004). The US characteristics of papillary thyroid carcinoma, which included number of nodules, echogenity, echoic texture, microcalcifications, macrocalcifications, halo sign, and regularity of margins, were similar in the group with HT compared with the group without HT. When the histopathologic characteristics of papillary thyroid carcinoma in patients with and without HT were compared, again there was no significant difference. CONCLUSIONS We suggest that there is an association between HT and TC, and HT may predispose to the development of TC. This indicates the need for close observation of neoplastic changes in patients with HT. Nevertheless, the presence of HT seems to have no effect on the US and histopathologic characteristics of malignant nodules in TC patients. This finding may indicate that evaluation of nodules and initial treatment of TC in these patients does not require different management.

Follow-up of atypia and follicular lesions of undetermined significance in thyroid fine needle aspiration cytology.

N. Dincer, S. Balci, A. Yazgan, G. Guney, R. Ersoy, B. Cakir and G. Guler 
Follow‐up of atypia and follicular lesions of undetermined significance in thyroid fine needle aspiration cytology

Effects of percutaneous laser ablation treatment in benign solitary thyroid nodules on nodule volume, thyroglobulin and anti-thyroglobulin levels, and cytopathology of nodule in 1 yr follow-up

Objective: To investigate the effects of ultrasound (US)-guided percutaneous laser ablation (PLA) in the treatment of benign solid hypoactive thyroid nodules on nodule volume, thyroid functions, nodule cytology and patients’ complaints. Material and method: Criteria for enrollment in the study were as follows: patients with euthyroid, benign, hypofunctional nodule who had compressive symptoms or cosmetic complaints, but considered inoperable, or who rejected surgical treatment. PLA procedure at 3–5 watts (W) was applied to 15 thyroid nodules of 12 patients (4 male and 8 female; age range 20–78 yr, mean age 47.42±17.05 yr), and patients were followed up for 12 months. Thyroid functions and nodule volumes (ultrasonographically) were evaluated. US-guided fine needle aspiration biopsy (FNAB) was performed before and after the procedure, and biopsy specimens were cytologically evaluated. Results: The mean nodule volume before the procedure was 11.97 ml (min-max 0.95–26.30 ml). However, 12 months after the procedure the mean nodule volume was 2.21±2.32 ml (min–max 0.10–7.65 ml). The mean reduction in nodule volumes was 82%. Thyroglobulin levels reached peak values at 1 month after the procedure, and anti-thyroglobulin levels at 3 months after the procedure. FNAB performed at 12th month showed neutrophil polymorphs, macrophages, abundant cell debris, colloid, multinucleated giant cells, and small fragments of fibrous stroma which indicated that PLA procedure led to degenerative changes in nodules. Conclusion: US-guided PLA is a new, successful treatment method which is reliable in the long term in benign solid thyroid nodules for selected patients who are inoperable or do not prefer surgery.

Relation of Leptin and Tumor Necrosis Factor α to Body Weight Changes in Patients with Pulmonary Tuberculosis

In this study we investigated whether leptin and TNFα levels change with improvement in body weight with antituberculotic therapy in active tuberculosis patients. 30 patients (8 females and 22 males) with active pulmonary tuberculosis formed the patient group, and 25 sex- and age-matched healthy subjects (8 females and 17 males) served as the control group. Body weight, body mass index (BMI) and serum leptin and plasma TNFα levels are measured before and in the sixth month of therapy in all patients. Before the initiation of therapy, BMI of the patients was significantly lower than BMI of the controls (20.2 ± 1.6 vs. 25.2 ± 2.7 kg/m2, respectively; p < 0.05). After treatment, BMI of the patients increased significantly to 21.4 ± 1.9 kg/m2 (p < 0.05), but was still lower than that of the controls (p < 0.05). Pretreatment serum leptin (4.5 ± 0.9 vs. 2.1 ± 0.2 ng/ml, respectively; p < 0.05) and plasma TNFα (27.9 ± 3.4 vs. 23.9 ± 3.0 pg/ml, respectively; p < 0.05) levels of the patients were significantly higher than those of the controls. After treatment, serum leptin levels increased to 6.7 ± 2.2 ng/ml, but this rise was not statistically significant (p > 0.05). Treatment did not result in any significant change in TNFα levels, either. Δ leptin was highly related to Δ BMI in patients with tuberculosis (r = 0.68, p = 0.02). In the pretreatment period, there was a significant correlation between leptin and TNFα levels in the whole patient group (r = 0.78, p < 0.001), and in female (r = 0.74, p < 0.001) and male patients separately (r = 0.74, p = 0.035). In conclusion, leptin and TNFα may be responsible for the weight loss in pulmonary tuberculosis patients, but their levels do not change with improvement in body weight with antituberculotic treatment.

Gynecomastia: Clinical evaluation and management

Gynecomastia is the benign enlargement of male breast glandular tissue and is the most common breast condition in males. At least 30% of males will be affected during their life. Since it causes anxiety, psychosocial discomfort and fear of breast cancer, early diagnostic evaluation is important and patients usually seek medical attention. Gynecomastia was reported to cause an imbalance between estrogen and androgen action or an increased estrogen to androgen ratio, due to increased estrogen production, decreased androgen production or both. Evaluation of gynecomastia must include a detailed medical history, clinical examination, specific blood tests, imaging and tissue sampling. Individual treatment requirements can range from simple reassurance to medical treatment or even surgery. The main aim of any intervention is to relieve the symptoms and exclude other etiological factors.

Preoperative and Postoperative Evaluation of Thyroid Disease in Patients Undergoing Surgical Treatment of Primary Hyperparathyroidism

OBJECTIVE To evaluate the occurrence of thyroid disease in patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS In this case series, records of all patients with a diagnosis of primary hyperparathyroidism who underwent parathyroidectomy between January 2005 and December 2008 in our clinic were analyzed retrospectively. Preoperatively, all patients were evaluated with ultrasonography and parathyroid scintigraphy; when needed, thyroid scintigraphy and ultrasound-guided fine-needle aspiration biopsy (FNAB) were used. All patients underwent standard neck exploration. Postoperative histopathologic findings of thyroid tissue were classified as nodular/multinodular hyperplasia, Hashimoto thyroiditis, papillary thyroid carcinoma, or normal. RESULTS Fifty-one women and 9 men were included. In the 60 patients, preoperative ultrasonography revealed thyroiditis (without nodules) in 13 (22%), a solitary nodule in 9 (15%) (coexistent with thyroiditis in 7 patients), multinodular goiter in 24 (40%) (coexistent with thyroiditis in 5 patients), and normal findings in 14 (23%). Rates of thyroiditis and nodular goiter were 42% and 55%, respectively. Collectively, prevalence of thyroid disease was 77%. Total thyroidectomy was performed in 27 patients, and hemithyroidectomy was performed in 15 patients. Indications for total thyroidectomy were nondiagnostic or suspicious FNAB results in 5 patients, hyperthyroidism in 4 patients, ultrasonography findings in 11 patients, and intraoperatively recognized suspicious nodularity in 7 patients. Postoperatively, thyroid carcinoma was diagnosed in 9 patients (15%). CONCLUSIONS Thyroid disease, particularly thyroid carcinoma, is common in patients with primary hyperparathyroidism. This association should be considered when selecting the surgical procedure. Intraoperative evaluation of the thyroid is as important as preoperative evaluation with ultrasonography and FNAB in patients with thyroid disease and primary hyperparathyroidism.

Plasma tumor necrosis factor-alpha levels and insulin resistance in nondiabetic hypertensive subjects.

Objectives: Tumor necrosis factor-α (TNF-α) is associated with insulin resistance in certain conditions. However, whether TNF-α is related to insulin resistance in hypertensive subjects is still controversial. The aim of this study was to determine the status of TNF-α and insulin resistance in hypertension. Methods: Newly diagnosed nondiabetic 17 essentially hypertensive (6 men, 11 women) patients, and 11 control healthy subjects (5 men, 6 women) are involved in the study. Body mass index (BMI), insulin, fasting blood glucose, cholesterol, triglyceride, and TNF-α levels were measured. Insulin resistance is assessed according to homeostasis model of assessment (HOMA-IR). Results: Serum insulin (8.4 ± 2.7 vs. 6.1 ± 1.4 mIU/ml; p < 0.01), triglyceride (245.0 ± 39.9 vs. 193.0 ± 22.8 mg/dl; p < 0.01), and TNF-α (4.2 ± 0.7 vs. 3.0 ± 0.6 pg/ml; p < 0.001) levels, and HOMA-IR (2.0 ± 0.8 vs. 1.3 ± 0.3; p < 0.001) were significantly higher in the hypertensive patients compared to the normotensive control group. There were positive correlations between TNF-α levels and body mass index (r = 0.64, p < 0.01), and triglyceride (r = 0.55 p = 0.02) levels in the whole study group. However, there was no correlation of either TNF-α or HOMA-IR. Conclusions: Our data revealed that hypertensive patients have insulin resistance and higher TNF-α levels, but there is no relation between TNF-α levels and insulin resistance.

CA 19-9 level in patients with type 2 diabetes mellitus and its relation to the metabolic control and microvascular complications.

Introduction:The aim of this study is to compare CA 19-9 levels in patients with type 2 diabetes mellitus (DM) and healthy control group. The relation of CA 19-9 levels to metabolic control and microvascular complications in patients with diabetes was also investigated. Methods:Three hundred forty patients with type 2 DM and age-, sex- and body mass index-matched 214 healthy controls group were included in the study. HbA1c, duration of DM and microvascular complications of DM were reviewed. CA 19-9 levels (normal range, 0–35 U/mL) were measured in all participants. Results:Median CA 19-9 level was significantly higher in patients with diabetes compared with control group [19.5 U/mL (0–214.8 U/mL) versus 7.4 U/mL (0.4–47.0 U/mL)] (P < 0.001). Prevalence of high CA 19-9 levels in patients with diabetes was 31.2%, and CA 19-9 level was positively correlated with age, duration of diabetes, HbA1c and number of complications. Effects of duration of diabetes, HbA1c and diabetic nephropathy were still continuing in multiple linear regression analysis. Using regression coefficients of all variables in multiple regression analysis, this study tried to determine a new cutoff value for CA 19-9 level in patients with diabetes. The cutoff value at 97th percentile was 57.14 U/mL. Conclusions:High CA 19-9 value in patients with diabetes may indicate the need for a careful evaluation of blood glucose regulation and investigation of complications. Defining a new cutoff value in these patients would prevent unnecessary laboratory or imaging procedures.