Dilek Berker

Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

OBJECT Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor-I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature. METHODS The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure. RESULTS In total 214 patients with a mean age of 41.9 ± 12 years (range 17-75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs. 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria. CONCLUSIONS In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4-1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.

The Value of Fine-Needle Aspiration Biopsy in Subcentimeter Thyroid Nodules

BACKGROUND The need to perform fine-needle aspiration biopsy (TFNAB) on subcentimeter thyroid nodules is less clear than for larger nodules. We compared the ultrasonographic features of thyroid nodules less than and greater than one centimeter and correlated this information with the cytological results for TFNAB and the final histopathological diagnosis in selected patients. METHODS We evaluated 520 thyroid nodules (247 subcentimeter [group 1], 273 supracentimeter [group 2]) in 426 patients. Ultrasonography-guided fine-needle aspiration biopsy was performed on all nodules. Surgery was recommended for patients with TFNAB results that were read as malignant or suspicious. The results of ultrasonography, TFNAB, and histopathology were compared between the groups. RESULTS Out of 426 patients, 337 had one nodule, 84 had two, and five had three. There was indeterminate cytology in 20 cases, 10 from each group. Inadequate cytology was obtained in 41/247 (16.6%) nodules in group 1 and 61/273 (22.3%) nodules in group 2, and the difference in rate was not significant (p = 0.067). The malignancy rate as determined by TFNAB was 4.9% in group 1 and 1.5% in group 2 (p < 0.025). In patients who underwent surgery for thyroid nodules the malignancy rate was 6% in group 1 and 2.9% in group 2 (p = 0.08). Hypoechoic pattern, microcalcification, and a long axis/short axis ratio (LA/SA) of < 1.5 were associated with malignancy in subcentimeter thyroid nodules (group 1), while only a hypoechoic pattern was associated with malignancy in supracentimeter thyroid nodules (group 2). CONCLUSIONS The incidence of cancer in thyroid nodules < 1 cm does not appear to be lower than in larger nodules and may even be higher. Physicians should consider obtaining biopsy samples from subcentimeter hypoechoic nodules that contain microcalcification and have a relatively round shape (LA/SA < 1.5).

Compatibility of different methods for the measurement of visceral fat in different body mass index strata.

PURPOSE Obesity, particularly visceral obesity, is associated with increased risk of cardiovascular morbidity and mortality. Therefore, cardiovascular risk should be determined by evaluating visceral fat tissue not only in obese individuals but also in non-obese individuals. We aimed to evaluate the comparison of visceral fat tissue measurement methods with computed tomography (CT). MATERIALS AND METHODS One hundred four participants, 19 to 58 years of age (21 males, 83 females) were enrolled in this study. Participants underwent anthropometric evaluation, bioelectrical impedance analysis (BIA), ultrasonography (US), and CT examinations on the same day. RESULTS The mean body mass index (BMI) was 31.2 +/- 8.7 kg/m2 (73 individuals [70.2%] had BMI > or =30, and 31 individuals [29.8%] had BMI < 30). The non-obese group (BMI < 30) that showed the best correlation coefficient values were for visceral fat area (VFA) by BIA in all participants, males and women (r = 0.902, P < 0.001; r = 0.994, P < 0.001; r = 0.645, P = 0.01, respectively); in case of BMI > or =30 the best correlation coefficient values were for VFA by BIA (r = 0.774, P < 0.001) for all participants, and visceral fat thickness by US for males (r = 0.851, P < 0.001), and BMI (r = 0.786, P < 0.001) for females. Using multiple stepwise regression analysis, the methods best reflecting VFA by CT were as follows: In subjects with BMI < 25, BIA correlated best with CT measures of VFA; while in subjects with BMI > 30 waist-to-hip ratio showed the best correlation with CT measures of VFA. The method best reflecting VFA by CT was visceral thickness by US in males; and the method best reflecting VFA by CT in females was visceral thickness by US, BMI and waist circumference. CONCLUSION Anthropometric measurements and visceral fat tissue measurement methods such as US and BIA exhibit differences with respect to compliance with CT results in visceral fat tissue measurements by gender and BMI levels.

Is insulin lispro safe in pregnant women : Does it cause any adverse outcomes on infants or mothers?

AIM To determine the rate of major congenital anomalies and complications retrospectively in offspring of women with diabetes mellitus treated insulin lispro. MATERIAL AND METHODS Twenty-seven patients had used insulin lispro (ILYS) and 59 patients had used regular human insulin (RHI) during the pregnancy period were evaluated. We also evaluated and analyzed the results of 53 of the 86 women who had gestational diabetes mellitus only. They were not using insulin aspart or insulin glarjine. We evaluated the birth weight, congenital anamolies, mode of delivery, abortus and stillbirth rates. RESULTS Mean HbA1c level was 6.27+2.23 for ILYS group and 7.07+2.09 for RHI group (p: 0.067). The duration of diabetes, gestational age, mode of delivery, type of diabetes, number of liveborn, stillbirth and miscarriages were not stastically different between all groups (p>0.05). Nine (15.25%) of 59 infants treated with RHI had congenital anomalies and one stillborn. The infants in ILYS-receiving group had no congenital anomalies but one pregnant (3.70%) had a stillborn. The difference in incidence of congenital anomalies between those using ILYS and RHI was not statistically significant (p: 0.157). There was also no difference in respect to congenital anomalies of gestational diabetic groups which used either ILYS or RHI. CONCLUSION Major congenital anomalies for offspring of mothers treated with ILYS are similar with RHI group. Although HbA1c levels were lower in ILYS group, all outcomes are similar with RHI. So ILYS is an alternative choice in treatment of pregnant women with DM.

Evaluation of Ovarian Reserve Based on Hormonal Parameters, Ovarian Volume, and Antral Follicle Count in Women with Type 2 Diabetes Mellitus

OBJECTIVE The aim of this study was to evaluate ovarian reserve of women with type 2 diabetes mellitus (T2DM). METHODOLOGY Eighty-nine women with T2DM and 73 healthy controls were enrolled and divided into three age groups [group 1 (20-29 yr), seven diabetics and 18 healthy controls; group 2 (30-39 yr): 35 diabetics and 35 healthy controls; and group 3 (40-49 yr): 47 diabetics and 20 healthy controls]. All participants were subjected to transvaginal ultrasonographic examination on the third day of their menstrual periods for the determination of ovarian volume and total antral follicle count (AFC). RESULTS A significant difference in mean FSH levels (international units per liter) was observed between women with diabetes and healthy controls in all age groups (group 1, 7.8 ± 0.9 vs. 5.0 ± 1.0; group 2, 8.2 ± 1.1 vs. 7.2 ± 1.8; group 3, 9.5 ± 3.2 vs. 6.4 ± 2.4; P < 0.001 for all). Similarly, mean AFC was significantly lower in patients with T2DM than in healthy controls in all age groups (group 1, 21.1 ± 4.8 vs. 25.0 ± 9.1; group 2, 10.4 ± 5.2 vs. 23.0 ± 9.5; group 3, 6.0 ± 3.5 vs. 21.7 ± 2.1; P < 0.001 for all). A statistically significant difference in total ovarian volume was only observed in group 1 (9.7 ± 3.0 in T2DM patients vs. 6.8 ± 2.7 in healthy controls; P = 0.002). AFC was found to be negatively correlated with FSH (r = -0.406, P < 0.001), age (r = -0.618, P < 0.001), glycolized hemoglobin (r = -0.505, P < 0.001), and fasting blood glucose (r = -0.687, P < 0.001). CONCLUSION In this pioneer study, the first to evaluate ovarian reserve in T2DM patients, we managed to demonstrate lower ovarian reserves in women with diabetes compared with healthy controls.

Gestational diabetes and subclinical inflammation: Evaluation of first year postpartum outcomes

AIM The aim of this study was to evaluate the relationship between sublinical inflammation and glycemic status in patients with gestational diabetes mellitus (GDM). METHODS Sixty-one patients with GDM and 40 healthy pregnant women were included in the study. Fasting blood glucose (FBG), insulin, high sensitivity C-reactive protein (hsCRP), lipid parameters and carotid artery intima-media thickness (CIMT) were measured. Fifty-five of the patients with GDM returned for a follow-up visit scheduled at 1-year post-partum. These patients were subjected to 75 g oral glucose tolerance test (OGTT) followed by an evaluation of metabolic and subclinical inflammatory parameters were evaluated. RESULTS The mean FBG, insulin, homeostasis model assessment insulin resistance (HOMA-IR), triglyceride (TG), hsCRP levels and CIMT in the women with GDM were significantly higher than those in the control group. C-reactive protein and CIMT were positively correlated with insulin, HOMA-IR, glucose value at the time of the OGTT 50, prepregnancy body mass index, TG and FBG. Multivariate logistic regression analysis on patients with sustained hyperglycemia one-year postpartum revealed elevated hsCRP levels to be independent risk factors for the development of dysglycemia. CONCLUSIONS Elevated hsCRP levels could be predictors of progression to T2DM later in life in patients with GDM.

A comparative study of pre-operative imaging methods in patients with primary hyperparathyroidism: Ultrasonography, 99mTc sestamibi, single photon emission computed tomography, and magnetic resonance imaging

Aim: This study compares the accuracy rates achieved in ultrasonography (US), 99mTc-sestamibi (MIBI), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI) as imaging methods used in the pre-operative localization of the enlarged parathyroid glands. Subjects and methods: For the purposes of this study, US, MIBI, SPECT, and MRI were performed on 98 patients with primary hyperparathyroidism (pHPT). All patients underwent parathyroidectomy. Results: Pre-operative localizaion of an abnormal parathyroid gland was successfully performed in 82 of the cases scanned with US (83.7%), while the result was 66 in the cases scanned with MIBI (67.3%), 71 of the cases were successfully localized with SPECT (72.4%), while MRI revealed the diseased gland in only 60 of the total cases (61.2%). In MIBI-positive and -negative patients there was a statistically significant difference among cases in terms of adenoma volume (1.30±1.51 vs 0.58±0.91, p<0.05). Sensitivity, specificity and diagnostic accuracy values were 87.2%, 25.0%, and 83.0%; 70.2%, 50.0%, and 69.4%; 75.5%, 50.0%, and 74.5%; 63.8%, 50.0%, and 63.3% for US, MIBI, SPECT, and MRI, respectively. The respective values for sensitivity, specificity, and diagnostic accuracy were 94.9%, 25.0%, and 91.1 % when US was combined with MIBI. Conclusions: Combining US and MIBI as imaging methods for pre-operative imaging of pHPT often produces more satisfactory results. While the accuracy of US is relatively low in the ectopic localizations, the size of the lesion can be an important factor in the accuracy achieved with MIBI.

Obstructive sleep apnea syndrome and its association with vitamin D deficiency

Background: Obstructive sleep apnea syndrome (OSAS) is a widespread disorder characterized by recurrent, partial or complete episodes of apnea due to upper airway tract obstruction during sleeping period. Deficiency of vitamin D has roles in development of many diseases. Association between presence and severity of OSAS and vitamin D has recently gained research interest. Aim: The aim of our study was to investigate the association between serum 25-hydroxy [25 (OH)] vitamin D levels and severity of disease in patients with OSAS. Material and Methods: One hundred and fifty OSAS patients (50 patients with mild, 50 with moderate, 50 with severe OSAS) who were diagnosed by polysomnography (PSG) and 32 non-OSAS controls who were referred to the Health Ministry Ankara Numune Training and Research Hospital, Endocrinology and Metabolism Department, from January 2010 to May 2011 were included in the study. Serum 25(OH)D, PTH, calcium and phosphorus levels were evaluated in all the patients who were recruited to the study. Results: There was no statistically significant difference in serum 25(OH)D levels between OSAS and controls (p>0.05). However, in subgroup analysis of OSAS, we found that the patients with severe OSAS had significantly lower levels of 25(OH)D as compared with other groups (p=0.003). Also, the number of patients with serum 25(OH)D deficiency (<10 µg/dl) were higher in OSAS group than in controls (p<0.05). Conclusions: We found that when the severity of OSAS increases, 25(OH)D deficiency becomes more pronounced.

Serum transforming growth factor-beta levels in patients with vitamin D deficiency

BACKGROUND Transforming growth factor-beta 1 (TGF-β1) contributes to tissue repair by promoting tissue fibrosis, and elevations have been reported in patients with bone marrow fibrosis. The aim of this study was to evaluate the relationship between TGF-β1 levels and vitamin D deficiency. METHODS All patients presenting to the outpatient Endocrinology and Metabolic Diseases clinic between June and September of 2008 were approached, and consenting patients who were deemed suitable candidates were enrolled. Hematological parameters were measured, along with serum levels of total and ionized calcium, phosphorus, parathyroid hormone, iron, folic acid vitamin B12 levels, 25 OH vitamin D3 (25OHD(3)) and TGF-β1. RESULTS A total of 132 patients were included in the study. Patients were divided into 4 groups based on levels of 25OHD(3) [group 1 (<5 ng/ml), 20 patients; group 2 (5-15 ng/ml), 38 patients; group 3 (16-30 ng/ml); and group 4 (>30 ng/ml), 28 patients]. TGF-β1 levels were higher in patients in group 1 compared to the other groups. Transforming growth factor-beta levels correlated negatively with vitamin D3 and positively with leukocyte count, platelet count, of MCV and MCH. Multiple regression analyses revealed TGF-β1 levels to be associated with 25OHD(3) as well as with platelet count. CONCLUSIONS Results of this study are suggestive of the presence of a significant relationship between TGF-β and vitamin D deficiency. Increased TGF-β1 and platelet count may be an early indicator of bone marrow fibrosis in patients with vitamin D deficiency.

Comparison of efficiencies of michigan neuropathy screening instrument, neurothesiometer, and electromyography for diagnosis of diabetic neuropathy.

Aim. This study compares the effectiveness of Michigan Neuropathy Screening Instrument (MNSI), neurothesiometer, and electromyography (EMG) in detecting diabetic peripheral neuropathy in patients with diabetes type 2. Materials and Methods. 106 patients with diabetes type 2 treated at the outpatient clinic of Ankara Numune Education and Research Hospital Department of Endocrinology between September 2008 and May 2009 were included in this study. Patients were evaluated by glycemic regulation tests, MNSI (questionnaire and physical examination), EMG (for detecting sensorial and motor defects in right median, ulnar, posterior tibial, and bilateral sural nerves), and neurothesiometer (for detecting alterations in cold and warm sensations as well as vibratory sensations). Results. According to the MNSI score, there was diabetic peripheral neuropathy in 34 (32.1%) patients (score ≥2.5). However, when the patients were evaluated by EMG and neurothesiometer, neurological impairments were detected in 49 (46.2%) and 79 (74.5%) patients, respectively. Conclusion. According to our findings, questionnaires and physical examination often present lower diabetic peripheral neuropathy prevalence. Hence, we recommend that in the evaluation of diabetic patients neurological tests should be used for more accurate results and thus early treatment options to prevent neuropathic complications.