Ibrahim Sacit Tuna

Brief communication: pituitary volume and function in competing and retired male boxers.

Context Reports suggest that 25% to 50% of patients with traumatic brain injury have pituitary dysfunction. Boxing carries a high risk for traumatic brain injury, yet there has been little systematic study of pituitary function in boxers. Contribution In this cross-sectional study of 61 active and retired boxers from the Turkish National Boxing Team, growth hormone and adrenocorticotropic hormone deficiencies were more frequent than would be expected in a general population. Nearly one half of retired boxers, the study participants with the longest boxing histories, had growth hormone deficiency. Implication Physicians should be alert for pituitary dysfunction in patients who have participated in boxing. The Editors Recent data clearly demonstrated that traumatic brain injury (TBI) is an important public health problem and may result in hypopituitarism (1, 2). After TBI, 25% to 50% of patients have some degree of pituitary dysfunctiongrowth hormone (GH) deficiency in particular (13). Concussion is reported to be the main diagnosis after TBI. This injury is associated with such sports as boxing, kickboxing, and football (4). Recent data suggest that sports injury may cause TBI and pituitary dysfunction (57). Boxing, which is among the most common combative sports, is associated with chronic head trauma that may cause unconsciousness, brain injury, and neurologic abnormalities (8). Although the relationship between boxing and TBI is well documented, pituitary consequences of chronic head trauma in boxing have not been investigated in detail. We investigated pituitary function in 61 retired or active amateur boxers. Methods After obtaining permission from the Turkish Boxing Federation, we approached all amateur, elite boxers on the Turkish National Boxing Team. We included all 61 actively competing (n= 44) or retired (n= 17) male boxers (mean age, 26 years [range, 17 to 53 years]) (Table 1). The ethics committee of Erciyes University Medical School, Kayseri, Turkey, approved this study, and we obtained informed consent from each participant. None of the boxers reported any comorbid conditions or previous pituitary disorders, and none was currently taking any medications. Table 1. Age Categories and Measured Variables Variables Assessed in the Participants Age categories and measured variables of the boxers are shown in Table 1. Assessment of Lipid Profile and Body Composition We measured total serum cholesterol (reference range, 1.8 to 5.7 mmol/L [70 to 220 mg/dL]), high-density lipoprotein cholesterol (0.8 to 1.8 mmol/L [30 to 70 mg/dL]), and triglyceride (0.4 to 2.3 mmol/L [40 to 200 mg/dL]) by using an autoanalyzer (Konelab, Espoo, Finland). We estimated low-density lipoprotein cholesterol (1.5 to 4.4 mmol/L [60 to 170 mg/dL]) levels according to the formula suggested by Friedewald and colleagues (9). We also measured body mass index (BMI) and waist circumference. We assessed body composition variables, including fat ratio, fat mass, abdominal fat ratio, and abdominal fat mass, by using a bioelectrical impedance analyzer (Tanita Body Composition Analyser BC-418, Tokyo, Japan). Assessment of Pituitary Volume We performed pituitary volume measurement with magnetic resonance imaging in 38 of 61 boxers who were randomly selected by a computerized random-number generator. We used coronal- and sagittal-weighted 3-dimensional magnetic resonance imaging volumetry to obtain the pituitary volume as described elsewhere (Philips Gyroscan Intera 1.5 Tesla, Best, the Netherlands) (10). Two radiologists, who were blinded to demographic data of the groups and hormone status of the boxers, measured the volume. Assessment of Pituitary Function Basal Hormone Levels We measured serum-free triiodothyronine (normal range, 1.8 to 5.7 pmol/L), free thyroxine (9.9 to 21.8 pmol/L [7.7 to 17.1 ng/dL), thyroid-stimulating hormone (TSH) (0.2 to 3.7 mU/mL), adrenocorticotropic hormone (ACTH) (3.9 to 23.3 pmol/L), prolactin (0.09 to 0.81 nmol/L), follicle-stimulating hormone (1.4 to 18 U/L), luteinizing hormone (1.5 to 9.3 U/L), total testosterone (4.6 to 21.7 nmol/L [134 to 625 ng/dL]), free testosterone (39.9 to 85.0 pmol/L [11.5 to 24.5 pg/mL]), and insulin-like growth factor I (IGF-I). The IGF-I reference ranges were 25 to 62 nmol/L for 18- to 30-year-olds, 13 to 64 nmol/L for 31- to 40-year-olds, and 13 to 39 nmol/L for 41- to 50-year-olds. We defined gonadotropin deficiency (follicle-stimulating hormone and luteinizing hormone) as both basal total and free testosterone levels below the normal range in the presence of normal or low gonadotropin values. We defined TSH deficiency as a free thyroxine level below the normal range in the presence of normal or low TSH values (11, 12). Assessment of Somatotropic and Corticotropic Function We used GH-releasing hormone (GHRH) plus GH-releasing peptide-6 (GHRP-6) test and glucagon-stimulation test (GST) to assess the GHIGF-I axis in boxers. We used the GHRH plus GHRP-6 test as described elsewhere (13). We performed the GST to assess ACTH deficiency (14). The details of the tests and the cutoff values for the diagnosis of GH and ACTH deficiencies were recently published (7). Analytic Hormone Measurement We measured all other serum hormones by using radioimmunoassay, immunoradiometric assay, or chemiluminescent methods with commercial kits. Statistical Analysis We performed statistical analysis by using SPSS software, version 10.0 (SPSS, Chicago, Illinois). All data are presented as means (SDs); P< 0.050 was considered statistically significant. We compared the differences between 2 groups by using unpaired t tests and among more than 2 groups by using 1-way analysis of variance (post hoc Scheffe analysis). We used Pearson correlation analysis to determine whether statistically significant correlations existed between chosen variables. Role of the Funding Source This study was funded by the Scientific and Technical Research Council of Turkey. The funding source had no role in the study design, data collection, data analysis, or data interpretation or in the decision to submit the manuscript for publication. Results Sixty-one actively competing (21 young boxers [age range, 17 to 19 years] and 23 adult boxers [age range, 19 to 28 years]) and retired boxers (age range, 32 to 53 years) were included. Evaluation of Pituitary Hormone Deficiencies The boxers had no TSH or follicle-stimulating hormone and luteinizing hormone deficiencies. Nine of 61 boxers (15%) had GH deficiency on the GH-stimulation test. All boxers with GH deficiency except 1 were retired. Therefore, 8 of the 17 retired boxers (47%) had GH deficiency. On the basis of GST results, 5 of 61 boxers (3 on the active team and 2 retired) (8%) had peak cortisol levels lower than the cutoff value; we classified them as ACTH-deficient. Of the 61 boxers, 8 (13%) had isolated hormone deficiencies (6 had isolated GH deficiency and 2 had isolated ACTH deficiency) and 3 (5%) had combined GH and ACTH deficiencies. Overall, 11 of 61 boxers (18%) had pituitary dysfunction. Comparison of Boxers with Normal versus Abnormal Pituitary Function Table 2 compares boxers who had normal (n= 50) versus abnormal (n= 11) pituitary function. Age, age at retirement, total number of bouts, body composition variables, and triglyceride levels were statistically significantly higher in boxers with abnormal pituitary function (P< 0.050). Levels of high-density lipoprotein cholesterol, IGF-I, peak cortisol after GST, peak GH after GST, and peak GH after the GHRH plus GHRP-6 test were statistically significantly (P< 0.050) lower in boxers with pituitary dysfunction than in those with normal pituitary function. Table 2. Body Composition, Hormone Variables, and Lipid Profiles in Boxers with Normal and Abnormal Pituitary Function Results of Volumetric Pituitary MRI We measured pituitary volume in 11 young boxers (mean age, 17 years [SD, 0.3]), 17 adult boxers (mean age, 22 years [SD, 2.8]), and 10 retired boxers (mean age, 44 years [SD, 4.7]). Mean pituitary volume was statistically significantly lower in adult (446 mm3 [SD, 140]) and retired (423 mm3 [SD, 120]) boxers than in young boxers (681 mm3 [SD, 141]) (P= 0.001). When we compared the pituitary volumes of 7 GH-deficient boxers (6 retired and 1 active) and 31 GH-normal boxers (4 retired and 27 active), mean pituitary volume was statistically significantly lower in GH-deficient boxers (373 mm3 [SD, 93]) than GH-normal boxers (538 mm3 [SD, 173]) (P= 0.019). In addition, GH-deficient retired boxers had statistically significantly lower pituitary volume (364 mm3 [SD, 99]) than GH-normal retired boxers (510 mm3 [SD, 101]) (P= 0.040), and mean ages were similar in both groups (45 years [SD, 3.9] and 43 years [SD, 6.2], respectively). Correlation Analysis in Boxers There were statistically significant (P< 0.050) negative correlations between GH peak values after GHRH plus GHRP-6 testing versus all body composition variables (data not shown). We also demonstrated statistically significant negative correlations between length of boxing career and IGF-I level (Pearson r= 0.46; P 0.001), GH peak value after GHRH plus GHRP-6 testing (r= 0.28; P= 0.026), and GH peak value after GST (r= 0.36; P= 0.005). Discussion This systematic study of pituitary function and volume in amateur competing and retired male boxers suggests that chronic head trauma due to sports injury in boxers may be associated with pituitary dysfunction and decreased pituitary volume. Growth hormone deficiency was the most frequent hormone deficiency, particularly in retired boxers. A literature search (English-language studies in MEDLINE to December 2007) identified only 2 studies evaluating the pituitary function in combative sports (5, 7); both were done in Turkey. The first study included 11 amateur boxers, 5 (45%) of whom had isolated GH deficiency (5). The second study included 22 male and female kickboxers, of whom 5 (23%) had GH deficiency and 2 (9%) had ACTH

Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia

OBJECTIVE To define the value of multislice computed tomography (CT) in the diagnosis of acute mesenteric ischemia (AMI). MATERIALS AND METHODS Two hundred patients (age range: 20-92 years) who were referred to the emergency CT department with a clinical suspicion of AMI were prospectively included in the study. CT examinations were performed with a multislice (16) CT scanner and the protocol included pre-contrast, arterial and venous phase acquisitions. Images were evaluated by using multiplanar reconstruction, maximum intensity projection and volume-rendering techniques at the CT workstation. RESULTS Ninety-four patients (47%) underwent surgery for AMI or for other causes of acute abdominal pain. One hundred-six patients (53%) were followed conservatively according to clinical, radiologic and laboratory findings. Of the 94 patients who underwent surgery, 49 (25%) were found to have AMI. All of these 49 patients with a proven AMI diagnosis were diagnosed with CT. In the other 45 patients who underwent surgery, CT findings were negative for AMI. None of the patients, who were followed conservatively, were eventually diagnosed as having AMI except 1 patient. This patient was unfit for surgery although his clinical and radiologic findings were consistent with AMI and died in 3 days. The sensitivity and specificity values of CT for the detection of AMI were calculated to be 100% for each. CONCLUSIONS Multislice CT is an effective imaging technique for the diagnosis of AMI with excellent sensitivity and specificity values.

Detection of bifid mandibular condyle using computed tomography.

Objective: To determine the frequency and characteristics of bifid mandibular condyle (BMC) using computed tomography (CT) evaluation. Study Design: A retrospective study was carried out using the CT records of 550 patients referred to the Medical School of Erciyes University (Kayseri, Turkey) between 2007 and 2010. T-tests were used to compare frequency of BMC between the left and right sides and between female and male patients. Statistical analysis was performed using SPSS software and a chi-squared test. Results: Of the 550 Patients, 10 patients (1.82%) were found to have BMCs. Five patients were female (50%) and five were male (50%). Of these 10 patients, 7 (70%) had unilateral and 3 (30%) had bilateral BMCs. As a result, a total of 13 BMCs were found in 10 patients. No statistically significant differences were found between either the right- and left-sided BMCs or between female and male patients (p >.05). Conclusions: To our knowledge, this is the first retrospective study investigating the prevalence and characteristics of BMC using computed tomography. Although BMC is an uncommon anomaly, it may be a more frequent condition in the Turkish population. Further studies and research on the orientation of duplicated condylar heads should be carried out. Key words:Computed tomography, bifid condyle, double-headed condyle, orientation, frequency.

Atypical Imaging Findings of Infantile Hemangioendothelioma: A Case Report

Infantile hemangioendothelioma is the third most common hepatic tumor in children, and the most common benign vascular tumor of the liver in infancy. On computed tomography (CT) and magnetic resonance imaging (MRI), typical enhancement patterns similar to those seen in adult hemangiomas may help establish the diagnosis. However, atypical enhancement patterns may also occur. In this paper, we report a rare form of solitary infantile hemangioendothelioma that showed a rim-like calcification and rim-like enhancement on CT and MRI.

Contrast-enhanced CT and MR imaging of renal vessels

AbstractIn the evaluation of renal vessels, the accepted diagnostic gold standard digital subtraction angiography is now being challenged by state of the art CT and MR imaging. Currently in many centers, cross-sectional imaging modalities are being used as a first line diagnostic tool to evaluate arterial and venous system of the kidneys and conventional angiography has been reserved only for therapeutic intervention. CT and MR imaging display not only the lumen of the vessel as in conventional angiography, but also allow the visualization of the vessel wall, renal parenchyma, collecting system, and other adjacent soft tissue structures. Therefore, CT and MRI have each become a one-stop shop for a thorough evaluation of kidneys. In this pictorial essay, we reviewed normal anatomical variants and wide range of pathologies involving renal arteries and veins with illustrated contrast-enhanced CT and MR imaging samples.

Functional and Dysfunctional Sensorimotor Anatomy and Imaging

The sensorimotor system of the human brain and body is fundamental only in its central role in our daily lives. On further examination, it is a system with intricate and complex anatomical, physiological, and functional relationships. Sensorimotor areas including primary sensorimotor, premotor, supplementary motor, and higher order somatosensory cortices are critical for function and can be localized at routine neuroimaging with a familiarity of sulcal and gyral landmarks. Likewise, a thorough understanding of the functions and dysfunctions of these areas can empower the neuroradiologist and lead to superior imaging search patterns, diagnostic considerations, and patient care recommendations in daily clinical practice. Presurgical functional brain mapping of the sensorimotor system may be necessary in scenarios with distortion of anatomical landmarks, multiplanar localization, homunculus localization, congenital brain anomalies, informing diffusion tensor imaging interpretations, and localizing nonvisible targets.

Is dedicated chest CT needed in addition to PET/CT for evaluation of pediatric oncology patients?

PURPOSE To assess the computed tomography (CT) portion of a positron emission tomography (PET)/CT, at lower dose without breath holding, as compared to diagnostic chest CT (dCTC), performed at regular dose with breath holding, and question the necessity of both for patient care in pediatric oncology. MATERIALS AND METHODS This retrospective study included 46 pediatric patients with histologically proven malignant tumors that had a total of 119 scans. RESULTS A total of 29 discrepancies were found between dCTC and PET/CT reports. CONCLUSION In the evaluation of metastatic thoracic disease in pediatric oncology patients, the non-breath holding CT portion of PET/CT has sensitivity and specificity that approaches dCTC.

Scheuermann's Disease of the Thoracolumbar Spine in a Boy.

Scheuermann’s disease (juvenile kyphosis dorsalis) is a structural kyphosis of the thoracic spine initially described by Scheuermann in 1921. It occurs commonly in adolescents (0.4–8.3% of the general population). It is characterized by irregularities of the vertebral end plates, the presence of Schmorl’s nodes, disk-space narrowing, and vertebral wedging. Scheuermann’s disease is rarely associated with neurological complications [1]. The cause of Scheuermann’s disease remains unknown. Several theories have been suggested involving release of excess growth hormone, defective formation of collagen fibrils with subsequent weakening of the vertebral end plates, juvenile osteoporosis, trauma, vitamin A deficiency, poliomyelitis, and epiphysitis [2]. We report the case of a nine-year-old boy with a history of chronic fatigue. He had no deformity. Scheuermann’s disease was discovered only because he underwent radiography. Lateral radiography showed multiple Schmorl’s nodes (long arrow), disk-space narrowing, and limbus vertebra (short arrow) in the lumbar spine (Figure 1). T1- and T2-weighted sagittal MR images revealed multiple Schmorl’s nodes, disk-space narrowing, and irregularities of the thoracic (Figure 2a) and lumbar (Figure 2b) vertebral end plates.

Texture analysis of liver hydatid cyst

Images which are obtained in clinical radiology are generally evaluated visually. Some information which is available in the images, but not possible to be seen visually can be useful for diagnosis of some diseases. Cyst hydatid which is a parasitic liver disease is still an important health problem in countries where animal breeding is widespread. In this study, we aimed at producing some objective measures using image analysis, which will be of assistance in the diagnosis of cyst hydatid. The prevalence rate of this condition is relatively high in Turkey. In order to differentiate between regions of liver with cyst hydatid and healthy parenchymal tissues, we have used second order texture features computed from gray level cooccurrence matrix of liver CT images. We have then used these features from the two groups in designing a classifier using probabilistic neural network. Our results indicate that the texture features computed from the gray level cooccurrence matrix do not constitute a good candidate to be used in classification and/or diagnosis of liver tissue as normal or cystic. This must be due to homogeneity of these two tissue types within themselves.