Ihsan Ustun

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).

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.

National prevalence of underweight, overweight and obesity in Turkey: cross sectional study of a representative adult population

The aim of this study was to determine underweight, overweight, and obesity prevalence in representative sample of adult (≥ 18 years old) Turkish population living in urban and rural area of Turkey. Turkish citizens aged ≥ 18 who can represent adult population and permanently resident in Turkey were taken to this study in 1999–2000. The nationally representative sample population was selected from the target population using the census which was performed by national institute of statistics at 1997. Target population was 13.570 individuals living in these houses and 8674 people who aged ≥ 18 are chosen for the study. BMI was used as widely accepted diagnostic criteria of obesity. This study demonstrated that the prevalence of underweight was 10.7% in men, 5.9% in women and 8.1% for overall. The prevalence of overweight was 17.4% in men, 20.4% in women and 19% for overall. The prevalence of obesity was 7.8% in men, 22.1% in women and 15.6% for overall. The prevalence of overweight is higher (19.6%) in urban areas but prevalence of obesity is higher (17%) in rural areas of Turkey. Age, educational level and marital status seem to have association with obesity prevalence. The data we obtained showed us that while the underweight is still an issue for men, the overweight and obesity prevalence is high and needs to take early prevention steps for Turkish population.

Early severe pre-eclamptic findings in a patient with Cushing's syndrome.

Cushings syndrome occurs rarely in pregnancy because of ovulatory disturbances including anovulation which is caused by hypercortisolism, but it can cause maternal complications such as hypertension, gestational diabetes, spontaneous abortion, premature birth, pre-eclampsia and stillbirth. Herein we present the case of a 22-year-old patient in the 11th week of pregnancy who was admitted to our hospital with Cushings syndrome complicated by early pre-eclampsia. Severe pre-eclampsia has high maternal and perinatal morbidities, and therefore the possibility of this complication requires that Cushings syndrome, although rare in pregnancy, be given a high clinical suspicion. Medical therapy and/or surgical therapy should be considered promptly to influence outcome favorably.

Brucella glomerulonephritis: case report and review of the literature.

The authors present the case of a 17-year-old shepherd who was diagnosed with diffuse proliferative glomerulonephritis and diffuse tubulointerstitial nephritis during the course of Brucella infection. The pathogenesis and the mechanism of renal involvement in brucellosis is discussed in light of the pertinent literature.

Severe hyponatremia due to rosiglitazone use in an elderly woman with diabetes mellitus: a rare cause of syndrome of inappropriate antidiuretic hormone secretion.

OBJECTIVE To describe the first case of syndrome of inappropriate antidiuretic hormone secretion with life-threatening hyponatremia due to rosiglitazone therapy. METHODS We describe the clinical, laboratory, and imaging findings of the study patient. RESULTS An 89-year-old woman with a 5-year history of type 2 diabetes mellitus was admitted to the emergency department because of unconsciousness. She had reported generalized weakness for 15 days and nausea and vomiting for 3 days. Findings from laboratory analysis showed severe hyponatremia (sodium, 110 mEq/L). She had normal renal, cardiac, and adrenal function, and she did not have edema or volume depletion. The cause of hyponatremia was syndrome of inappropriate antidiuretic hormone secretion. We did not find any cause for her condition other than rosiglitazone, an antihyperglycemic drug that is increasingly being used in patients with type 2 diabetes mellitus. According to her medical history, rosiglitazone was prescribed 1 month previously after withdrawal of gliclazide. We stopped the rosiglitazone and administered hypertonic saline infusion to treat the hyponatremia. Saline infusion was stopped and blood sodium levels were stabilized in the normal range after 2 days. The patients plasma sodium concentration has remained in the reference range at follow-up visits. CONCLUSIONS This is the first reported case of syndrome of inappropriate antidiuretic hormone secretion as an adverse effect of rosiglitazone, and this drug should possibly be considered for addition to the list of drugs that cause this condition.

Role of endogenous cortisol on Helicobacter pylori colonization

BACKGROUND AND AIMS Helicobacter pylori infects the gastric mucosa and can lead to chronic gastritis, gastric ulcer and gastric cancer. Colonization of H. pylori in the gastric mucosa is influenced by a variety of host, bacterial and environmental factors. Host defense mechanisms have been affected by endogenous glucocorticoids. We aimed to investigate the relationship between H. pylori and endogenous glucocorticoid. MATERIALS AND METHODS Forty cases with endoscopically and histologically proven H. pylori and 26 patients who did not have H. pylori on gastric biopsy samples were enrolled in our study. Cortisol was tested from 24-h collected urine samples. RESULTS H. pylori (+) and H. pylori (-) groups consisted of 40 (28 women, 12 men; aged 44.85+/-12.52 years) and 26 (22 women, 4 men; aged 52.27+/-15.15 years) patients, respectively. Age and gender were similar in both groups. Body mass index, C-reactive protein and erythrocyte sedimentation rate were not statistically different between the two groups (p>0.05). 24-h urine cortisol amount was lower in patients with H. pylori (+) than H. pylori (-) cases. CONCLUSIONS Present study demonstrates that patients with gastric H. pylori colonization have significantly lower cortisol levels when compared with H. pylori negative cases. There is a negative correlation between H. pylori colonization and urine cortisol output.

Autoimmune thyroid disease in patients with anti-GAD positive type 1 diabetes mellitus

The aim of the study was to determine the frequency and titers of anti-thyroid peroxidase (Anti-TPO), anti-thyroglobulin (Anti-TG), and anti-glutamic acid decarboxylase (Anti-GAD) antibodies in Turkish patients with type 1 diabetes mellitus (DM), and to compare the frequency of anti-TPO and anti-TG titers in the presence or absence of anti-GAD. A total of 104 patients including 56 males and 48 females with type 1 DM and their age-, gender-, and body mass index-matched control group, including 31 males and 27 females, 58 cases in total with an age range of 15-50 years, were recruited into this study. In patients with type 1 DM, positive anti-GAD was detected in 30.8% (n=32). In patients with positive anti-GAD, rate of positive anti-TPO was 37.5%; however, in patients with negative anti-GAD, the rate of positive anti-TPO was 9.7% and the difference was statistically significant (p=0.001). In patients with positive anti-GAD, the rate of positive anti-TG was 18.8%. In patients with negative anti-GAD, the rate of positive anti-TG was 2.8%, and the difference between them was statistically significant (p=0.005). In patients with positive and negative anti-GAD, rates of both positive anti-TPO and anti-TG were 15.6% and 1.4%, respectively, with the difference showing statistical significance (p=0.004). Thyroid autoimmunity in type 1 DM patients with positive anti-GAD was apparently higher; therefore, these patients should be followed more frequently and carefully.

Pericardial Tamponade in a Patient with Thalassemia Major due to Hypothyoridism

megaly and pleural effusion. There was a decline in electrocardiographic voltage and the immediate echocardiography uncovered 4 cm of pericardial fl uid extending all around the heart, compressing the right atrium. The abdominal ultrasound was relevant with massive ascites and hepatosplenomegaly. Via external pericardial tube, 1,500 ml hemorrhagic fl uid was immediately drained. The fl uid was transudative and further analysis for adenosine deaminidase or polymerase chain reaction for tuberculosis turned out to be negative. Pericardial biopsy only had trace lymphocytic infl ammatory cells with hemosiderosis. The cultures were noncontributory. The tube was extracted after draining 500 ml more fl uid. On the other hand, simultaneous thyroid function tests also revealed hypothyroidism: free T 4 0.52 pg/ml, free T 3 0.07 ng/dl, and TSH 125.32 IU/ml. Anti-TPO antibody was positive and antithyroglobulin was negative. Thyroid sonography revealed normal-sized lobes with heterogenous parenchyme. The patient was successfully treated by drainage of the pericardial effusion along with L -thyroxine treatment. Subsequent control echocardiographies showed a decreased amount of pericardial effusion, which vanished at the end of the fi rst month. Besides the many other organs, the thyroid gland is also susceptible to iron accumulation in thalassemia patients. Despite the skepticism about its prevalence (11– 24%), such patients may consequently develop hypothy -Thalassemia major (BTM) still remains a disease that displays a surplus of clinical complications during its follow-up. Pericardial effusion has been mentioned to occur in these patients whereby pericardial tamponade is quite rare. On the other hand, hypothyroidism secondary to iron overload may also ensue in BTM patients, in whom pericardial effusion could be expected. However, cardiac tamponade is again rare. In this report we present a case of BTM with secondary hypothyroidism who eventually developed cardiac tamponade. A 19-year-old man, who had been followed since birth because of his BTM, was admitted with the complaints of dyspnea, cough and swellings in his legs and abdomen. His vital signs were as follows: blood pressure 80/40 mm Hg, pulse 110/min, respiration 26/min, and temperature 36.7 ° C. Physical examination disclosed orthopnea, dyspnea, bilateral jugular venous distention and bilateral pretibial pitting edema besides generalized mental motor retardation. On auscultation, decreased heart sounds, coarse lung sounds and bilateral rales below the scapulae were detected. His bulging abdomen was distended to palpation and revealed massive ascites along with hepatosplenomegaly. Laboratory analysis yielded albumin 3.1 g/dl, hemoglobin 8.1 g/dl, hematocrit 24 g/dl, erythrocyte sedimentation rate 52 mm/h, ferritin 2,700 ng/ml, and the peripheral smear was consistent with thalassemia. Posteroanterior chest X-ray demonstrated cardioReceived: August 29, 2005 Accepted after revision: September 24, 2005

Pathological fracture: an ill telltale in osteoporosis

A 31-year-old lady was admitted to our internal medicine ward for further evaluation after a previous episode of three concomitant fractures in her right ulna and radius last year. She described the cause as a fall down the stairs. Despite internal fixation, union was not achieved after 10 weeks, and a bowing deformity had simultaneously developed in her right humerus (Fig. 1). The medical history was uneventful except for goiter for the last 5 years that had been followed with a regimen of propylthyrouracil and propranolol. Her physical examination revealed tachycardia, tremor in her hands, wet skin, grade 2 diffuse palpable thyroid gland besides an obtrusive curvilinear forearm deformity. The laboratory analysis yielded Ca: 10.8 mg/dl (8.1–10.4), P: 3.38 mg/dl (2.6–4.5), alkaline phosphatase: 534 U/L (38–155), parathyroid hormone (PTH): 81 qmol/l (0.8–6.4), 25-OH vit-D3: 11.8 gg/ml (7.6–75), deoxypyridinoline: 23.4 nM/ day, free T3: 23.8 qmol/ml (1.45–3.48), free T4: 4.2 gg/dl (0.71–1.85), TSH: 0.06 lIU/ml (0.49–4.67), anti-thyroglobulin antibody: 483.5 U/ml (0–60), anti-microsomal antibody: 4358.8 U/ml (0–60). Bone mineral density was significantly decreased in the lumbar and hip regions ()2.75<T scores<-4.4). She was diagnosed with Graves’ disease along with a suspicion of parathyroid adenoma. She was then followed with the same drugs at higher doses, and further diagnostic interventions were carried out to uncover any parathyroid pathology. The ultrasonography was consistent with a diffuse enlargement of the thyroid gland with normal parathyroids. Thyroid scintigraphy demonstrated diffuse increased activity, while parathyroid scintigraphy with Tc-99m MIBI was normal. Therefore, although her age was atypical, we also considered Paget’s disease in the differential diagnosis. Accordingly, we performed bone scintigraphy which readily demonstrated multiple pathological sites of increased activity in the cranium, bilateral shoulders, right humerus, costae, right femur and tibia. Bone biopsy from the right humerus did not disclose any pathology. Due to the sustained increase in the subsequent PTH levels, we eventually decided to visualize the parathyroid glands and/or any likely ectopic foci secreting PTH with computed tomography (CT), which revealed a hypodense nodule with a diameter of 12 mm at the inferior pole of the left thyroid lobe (Fig. 2). Consequently, subtotal thyroidectomy and parathyroid adenectomy were performed, and the pathological evaluation was consistent with parathyroid adenoma. After discharge from the hospital, monitoring with serial thyroid function tests and bone turnover markers was planned, but she did not comply with her follow-up visits. Concurrent Graves’ disease and primary hyperparathyroidism is rare and accounts for hypercalcaemia in no more than 1% of thyrotoxic patients [1]. The clinical finding of increased calcium in such patients poses great diagnostic challenges to the physician. Hyperthyroidism itself, per se, can cause hypercalcaemia [2, 3], and thus the diagnosis of a parathyroid pathology may readily be overlooked. In our patient the consecutive PTH levels were found to be increased whereas, interestingly, the diagnostic interventions failed to ascertain the underlying disorder. Normally, ultrasonography and Tc-99m MIBI scintigraphy are highly sensitive for pathological parathyroids: 97.4% and 96.1%, respectively, and 100% when combined [4]. However, this adenoma could have only been demonstrated in the upper axial sections of the thorax CT, which also aimed to depict the presence of any extrasecretory foci. We also performed bone biopsy to rule out Paget’s disease which is known to accompany primary hyperparathyroidism or thyroid disease in Rheumatol Int (2004) 24: 187–188 DOI 10.1007/s00296-003-0385-1