Engin Guney

Effect of Weight Loss on Bone Metabolism: Comparison of Vertical Banded Gastroplasty and Medical Intervention

Background: We studied the effects of weight loss on bone metabolism. Methods: 16 consecutive surgically-treated (14 female, 2 male) morbidly obese patients and 65 obese (53 male, 12 female) medically-treated patients were enrolled in an observational study. Surgical treatment for morbidly obese patients was vertical banded gastroplasty (VBG). Studies were performed prior to and 12 months after the start of treatment. Bone mineral density (BMD), bone turnover markers, sex steroids, calcium excretion and parathyroid hormone measurements were done at each visit. Results: Weight loss was more prominent with surgical than with medical treatments. Bone loss was also pronounced in the surgical treatment group, and occurred at the hip level only (P<0.05). Compared to previously reported studies, where the effects of malabsorptive treatments for obesity on bone metabolism were studied, calcium excretion and parathyroid hormone levels did not change after VBG or medical therapy. For both groups, bone markers indicated an increased bone turnover, evidenced by increased urinary excretion of deoxypyridinoline and serum levels of osteocalcin (P<0.05). Sex steroid measurements revealed a decrease in estradiol levels in the surgical treatment group, but not in medical treatment group. This finding was thought to be secondary to less weight loss in the medical group. Conclusion: Our data indicate that weight loss causes bone loss. The bone loss is independent of the method of weight reduction. However, the mechanism of the bone loss is not clear. It may be explained partly by reduced estradiol levels in female patients. Because the mechanisms of bone disease after weight loss remain unclear, it is difficult to determine the most effective treatment. It is important to detect osteopenia early, before fractures occur. Measuring BMD appears to be the only reliable method for screening.

Pituitary apoplexy: an overview of 186 cases published during the last century

BackgroundPituitary apoplexy is a rare and life-threatening complication occurring in 0.6–10.5% of all cases of pituitary adenomas. Although the association between pituitary apoplexy and visual dysfunction has been recognized for a long time, the optimal management of this problem still remains controversial. The purpose of this overview was to present the surgical experience by analyzing the literature on the management of pituitary apoplexy for better treatment of these cases.Materials and methodTo establish a new guideline for the surgical treatment of this entity, publications reported during the last century and databases containing medical literature were analyzed. In addition, an illustrative case with pituitary apoplexy presenting with complaints of sudden onset severe headache associated with nausea, vomiting, and a sudden loss of vision was described. In fact, the experience in our complicated patient prompted us to review the available literature on the management of pituitary apoplexy to date.ConclusionsBased on an overview of 186 cases of apoplectic pituitary adenoma presenting with monocular or binocular blindness, we highlight the importance of correct diagnosis and an early, but not necessarily emergency, surgery within the first week of admission to optimize visual outcome of such patients. The illustrative case further exemplifies the value of close interaction between members of the management team for optimal outcome.

The relationship between mean platelet volume with microalbuminuria and glycemic control in patients with type II diabetes mellitus

Microalbuminuria is the best predictor of diabetic nephropathy development in patients with type II diabetes mellitus (DM). It is also accepted as an indicator of diabetic microangiopathy. Increased activation of platelets has been suggested to be involved in the pathogenesis of vascular complications. In light of these findings, this study was designed to investigate the association of microalbuminuria — an indicator glycemic control and microangiopathy — with mean platelet volume (MPV). Subjects underwent laboratory analyses and their MPV, HbA1c, serum creatinine, fasting, and postprandial blood glucose levels and 24-hour urine albumin levels were recorded. All statistical analyses were performed using SPSS v13.0 for Windows XP. Mann–Whitney U-test, students t-test, spearman correlation analysis, ROC analysis, categorical regression analysis, and chi-square test were used for statistical evaluations. The study included 354 patients with type II DM. The median MPV value of microalbuminuria-positive patients was 9 (8–9.5) fl while MPV of patients without microalbuminuria was 8.5 (8–9.2) fl and the difference was statistically significant (p = 0.004). We determined positive correlation between MPV and 24-hour urine microalbuminuria (r = 0.14, p = 0.009). There were no significant differences between patients with HbA1c levels below and above 7% in terms of MPV (p > 0.05). We determined no correlation between MPV and HbA1c levels (r = −0.36, p = 0.64). This study determined a significant positive relationship between microalbuminuria — a microvascular complication of diabetes — and MPV. No significant correlation was identified between poor glycemic control and MPV in diabetic patients. However, we are in the opinion that the association between poor glycemic control and MPV in type II diabetic patients should be investigated in prospective studies with larger samples.

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

Background:This study observes the effect of surgical weight loss on free radical and antioxidant vitamin balance. Patients and Methods: 22 consecutive morbidly obese patients undergoing vertical banded gastroplasty (VBG) were chosen for the study. Postoperative studies were done at 12 and 24 weeks. Plasma antioxidant and vitamin determinations were performed by HPLC method. Results: Subjects lost a significant amount of weight (P<0.01). Compared to preoperative measurements, postoperative measurements of plasma betacarotene were not statististically different both at 12 and 24 weeks (13.86±1.26 μg/dl, 12.35±1.2, P=0.44; 14.33±2.03, P=0.77; preoperatively, 12 and 24 weeks respectively). Alpha-tocopherol increased slightly at the 12th week; the difference was not significant (8.50±0.77; 9.56±0.82, P=0.37; preoperatively and 12th week respectively). The levels of alpha-tocopherol rose at 24th week significantly (10.89±0.55, P=0.028). The indicator of lipid peroxidation (malondialdehyde) decreased with weight loss (1.505±0.11 μmol/L preoperatively; 0.75±0.062 at 12th week, P=0.01; 0.712±0.05 at 24th week, P<0.01). Conclusion: Our data show that free radical generation falls markedly in association with weight loss after VBG. Surgical weight loss leads to significant decrease in oxidant production and also leads to increase in some antioxidant vitamins. The demon stration of decreased free radical generation and correction of balance between free radicals and antioxidant vitamins has important implications for oxidative mechanisms underlying obesity-associated disorders.

Sympathetic skin response in idiopathic and diabetic carpal tunnel syndrome

BACKGROUND In carpal tunnel syndrome (CTS), certain changes were expected in sympathetic skin response (SSR) because median nerve carries postganglionic unmyelinated fibres. PURPOSE To investigate the median and ulnar SSR in idiopathic and diabetic CTS without autonomic dysfunction in hands and to find possible relations with electrophysiological features of these diseases. PATIENTS AND METHODS SSRs were elicited by electrical stimulation on the supraorbital nerve and recorded from the median and ulnar territories in the hand from 20 diabetic patients with only CTS (29 hands), 24 idiopathic CTS patients (42 hands) and 13 normal subjects (26 hands). Hands with ulnar neuropathy at the wrist without symptoms and normal hands of unilateral CTS were excluded. In addition to classical parameters and comparative methods, SSR waveform changes and percentile method was used in finding abnormality. RESULTS Median SSRs had significant delayed latency compared to ulnar latency in both CTS patients but this was not important clinically (1.38/1.37 s for idiopatic CTS; 1.43/1.36 s for diabetic CTS). Median and ulnar SSR amplitude, area, median/ulnar latency difference, amplitude and area ratio were compared and only median/ulnar latency difference and median/ulnar latency ratio were found different between the three groups. Four idiopathic CTS hands were outside of the limits or absent (9.5%). SSR waveforms were significantly different from normal subjects in CTS patients. P type SSR replaced M type in idiopathic CTS and N type in diabetic CTS. CONCLUSIONS Findings regarding SSR parameters suggest that unmyelinated C fibers were affected in CTS. These values were not useful because they were too small. Data on SSR were not normally distributed and the percentile method seems to be more convenient for finding any abnormality in clinical practice. Also, SSR waveform analysis could give us valuable data and should add to the SSR examination parameters.

The effect of pioglitazone on antioxidant levels and renal histopathology in streptozotocin-induced diabetic rats.

Objective. Diabetic nephropathy is the most commonly seen cause of chronic renal failure, and oxidative stress is important in etiology. In the present study, favorable effects (if any) of the treatment with a thiazolidinedione group drug, pioglitazone, on antioxidant enzyme levels in the renal tissue, renal histopathology, and inflammatory cytokine levels have been investigated. Method. Forty male Wistar rats were divided into 4 groups as the control, diabetic control, and 10 and 30 mg pioglitazone-administered diabetic groups. After 4 weeks, antioxidant enzyme levels in renal tissues and inflammatory markers were investigated. Results. Blood glucose levels did not differ between the diabetic control and drug-administered groups. In pioglitazone-administered rats, histopathological findings such as tubular dilation, necrotic tubular epithelium, glomerular focal necrosis, and vascular consolidation were observed at a lesser extent than the diabetic control group. Any difference was not detected between the diabetic groups with respect to the levels of malondialdehyde, superoxide dismutase, catalase, glutathione, nitric oxide, interleukin-6, and tumor necrosis factor-alpha. Conclusion. Pioglitazone regressed development of histopathological lesions such as glomerular focal necrosis, tubular epithelial necrosis, tubular dilation, and vascular wall consolidation. However, any favorable effect on antioxidant enzyme levels in renal tissues and inflammation markers was not detected.

Hypoglycemia induced by hydroxychloroquine in a patient treated for rheumatoid arthritis.

THE CASE A 72-year-old woman had been diagnosed with RA 4 years ago. She was using HCQ 200 mg daily, leflunomide 20 mg daily for 4 years, and methylprednisolone 12 mg/d for 8 months. She presented to the emergency service for abrupt syncope and loss of consciousness. Her serum glucose level was 15 mg/dL. She was administered intravenous 250 mL of dextrose 10%. When her serum glucose level reached 150 mg/dL, she regained consciousness and her symptoms disappeared. The patient was hospitalized to investigate the cause of her hypoglycemia. In her physical examination, her conjunctivas were pale; her elbows, metacarpophalangeal joints, and proximal interphalangeal joints were swollen; and there was swan-neck deformity at the first finger of each hand. Because the patient had similar symptoms at hospitalization, her fingertip glucose level was measured again and was found to be 38 mg/dL, whereas simultaneous venous blood glucose level was 26 mg/dL, serum insulin level was 121 KIU/mL (reference range, 0Y28.4KIU/mL), C-peptide level was 15.6 ng/mL (reference range, 1.1Y5 ng/mL), and cortisol levelwas 13.6Kg/dL. With recurrent incidents of hypoglycemia during follow-up, the patient was started on intravenous infusion of dextrose 10%. Her insulin/glucose level was high at 4.65, and her emergency computed tomographic (CT) scan of the pancreas obtained to assess her preliminary diagnosis of insulinoma yielded normal findings. Intragastric endoscopic ultrasonography was planned for the differential diagnosis of insulinoma. In the laboratory examination of the patient, HbA1c value was 6.8%, hemoglobin was 10.9 g/dL, hematocrit level was 32.8%, leukocyte count was 10,000/KL, platelet count was 231,000/KL, and mean corpuscular volume was 90 fL. Serum urea, creatinine, liver enzymes, thyroid functions tests, serum albumin, international normalized ratio, iron, iron saturation, vitamin B12, and ferritin levels were normal. Esophagogastroduodenoscopy and colonoscopy for the cause of anemia did not demonstrate any finding of malignancies. The patient was also examined for causes that may lead to fasting hypoglycemia and noninsulinoma malignancies. No finding suggestive of a malignancy was observed in either abdominal CT scan, lung radiograph, or cranial CT scan. She was questioned about her drugs for causative hypoglycemic medications. Her drugs did not include oral antidiabetics and insulin. Hydroxychloroquine was stopped for its potential hypoglycemic effect as reported in the literature. Dextrose infusion was also discontinued because her capillary glucose levels remained greater than 200 mg/dL during her follow-up. Her capillary blood glucose levelwas measured hourly. A 72-hour fasting test was performed because hypoglycemia did not recur during follow-up. This 72-hour measurement did not demonstrate hypoglycemia. The patient’s repeat fasting blood glucose level in venous blood was measured as 262 mg/dL, whereas her fasting blood insulin was 28.1 KIU/mL and postprandial blood glucose level was 320 mg/dL after the patient began oral feeding. The patient was diagnosed with diabetes mellitus (DM). Metformin 2 g daily was given to the patient. The diagnosis diverged from investigating for a possible insulinoma because a marked hyperglycemia persisted after cessation of HCQ, and the patient did not have hypoglycemia and was diagnosed with DM. Endoscopic ultrasonography was not performed. The patient is currently at month 11 of her follow-up on metformin, and no incidences of hypoglycemia have been observed.

Imatinib-associated bilateral gynecomastia and unilateral testicular hydrocele in male patient with metastatic gastrointestinal stromal tumor: A literature review

Imatinib mesylate is a drug that has been approved for treatment of advanced gastrointestinal stromal tumors (GISTs) and patients with leukemia such as chronic myeloid or Philadelphia chromosome-positive acute lymphoblastic. Although it has been described only in one patient with testicular hydrocele and gynecomastia in the literature, several cases of male gynecomastia have been reported with the use of imatinib mesylate in chronic myeloid leukemia (GML). Generally, male mastoplasia resolves after discontinuation of imatinib treatment. We report a 73-year-old male with metastatic GISTs who developed gynecomastia and unilateral testicular hydrocele while receiving imatinib mesylate. Nine months after commencing imatinib treatment, gynecomastia and testicular hydrocele were determined. Hormone analyses requested showed serum testosterone levels below and serum estrogen levels above normal limits. During the first month after discontinuing imatinib mesylate treatment, serum testosterone level was normal and there was a partial regression in gynecomastia and testicular hydrocele. To our knowledge, this is the second report of male gynecomastia following imatinib mesylate treatment of a patient with GIST. In conclusion, male patients who are to receive treatment with imatinib mesylate may be monitored for serum testosterone levels and for other reproductive hormone profiles before initiation of the treatment and their breasts may be examined during follow-up visits.

Minimally invasive parathyroidectomy without using intraoperative parathyroid hormone monitoring or gamma probe

OBJECTIVE Minimal invasive parathyroidectomy (MIP) is a common surgical technique for the treatment of primary hyperparathyroidism (PHPT) and is usually done in conjunction with positive imaging techniques. We aimed to assess the results of this technique, performed without the use of intraoperative tests, in cases with PHPT caused by a single parathyroid adenoma. MATERIAL AND METHODS The data for patients who were diagnosed with PHPT were assessed retrospectively. Only those who had undergone a parathyroid adenoma localization study with ultrasonography (US) and parathyroid scintigraphy (PS) before the surgery, along with those patients for whom the MIP technique was routinely performed with frozen pathology, were included. RESULTS The study group was made up of 65 patients who had undergone the MIP technique. The mean age of the patients was 56±14 (20-81), with most being females [M/F: 19 (29.2%)/46 (70.8%)]. The mean calcium values before the operation were 11.24±1.26 mg/dL (8-15.5) (normal range: 8.4-10.2), and the parathyroid hormone (PTH) values were 388 pg/mL (249-707.75). These same values, measured 24 hours after the operation, were determined as 9.04±1.04 mg/dL (6.8-13.9) and 27 pg/mL (6-86), respectively. The follow-up period for the patients was an average of 26.6±9.4 (3-76) months, and only 3 (4.6%) cases of persistent hyperparathyroidism were detected within this period. CONCLUSION Our success rate with MIP in PHPT cases was determined to be 95.4%; therefore, this technique may be applied with a high success rate without any assistance from intraoperative tests, such as rapid serum PTH (rPTH) assays or gamma probes, in the presence of localization results of PS and US.

Mean platelet volume and arterial stiffness in patients with acromegaly

OBJECTIVE There are still contradictory data in the literature whether patients with acromegaly are under risk in terms of atherosclerotic heart disease. Increased arterial stiffness develops before atherosclerosis and is evaluated to be a risk factor for atherosclerosis. Mean platelet volume (MPV) is currently gaining interest as a new independent cardiovascular risk factor. There are contrasting views about arterial stiffness in patients with acromegaly. There is no report in literature studying MPV in acromegaly patients. The aim of this study was to evaluate MPV and arterial stiffness in patients with acromegaly. METHODS This study was designed as an observational cross-sectional, case-controlled study. Twenty-eight patients with acromegaly and 22 healthy volunteers were recruited for the study. The arteriography device Mobil-O-Graph® (IEM GmbH. Stolberg, Germany) which can perform oscillometric measurements was used to measure arterial stiffness. The Mann-Whitney U test, Students t-test, Spearmans nonparametric correlation analysis and the chi-square test were used to statistical analyze. RESULTS Aortic pulse wave velocity (PWV) value was found to be 6.41 ± 2.12 m/s in the patient group with active acromegaly and 5.24 ± 1.04 m/s in the healthy control group. The difference was statistically significant (p=0.03). The mean MPV value was found to be 9.68 ± 1.11 in the patient group with active acromegaly and 8.53 ± 1.18 in the healthy control group. There was a statistically significant difference between the two groups (p=0.004). In patients with acromegaly, a positive correlation was found between MPV and insulin-like growth hormone-I (IGF-1) level (p=0.021, r=0.434). CONCLUSION We determined an increase in aortic PWV and MPV in patients with acromegaly. In conclusion, evaluation of MPV and arterial stiffness in future studies could be beneficial in determining the risks for cardiovascular disease in patients with acromegaly.