Mustafa Ünübol

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.

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.

Histopathologic Evaluation of Nonalcoholic Fatty Liver Disease in Hypothyroidism-Induced Rats

It is speculated that thyroid hormones may be involved in nonalcoholic fatty liver disease (NAFLD) pathogenesis. A literature scan, however, demonstrated conflicting results from studies investigating the relationship between hypothyroidism and NAFLD. Therefore, our study aims to evaluate NAFLD, from the histopathologic perspective, in hypothyroidism-induced rats. Wistar rats were divided into 2 groups: the experimental group consumed water containing methimazole 0.025% (MMI, Sigma, USA) for 12 weeks and the control group consumed tap water. At the end of week 12, serum glucose, ALT, AST, triglyceride, HDL, LDL, TSH, fT4, fT3, visfatin, and insulin assays were performed. Sections were stained with hematoxylin-eosin and “Oil Red-O” for histopathologic examination of the livers. In our study, we detected mild hepatosteatosis in all hypothyroidism-induced rats. There was statistically significant difference with respect to obesity between the two groups (p < 0.001). The mean fasting blood glucose was 126.25 ± 23.4 mg/dL in hypothyroidism-induced group and 102.63 ± 15.51 mg/dL in the control group, with a statistically significant difference between the groups (p = 0.032). The two groups did not differ statistically significantly with respect to visfatin levels (p > 0.05). In conclusion, we found that hypothyroidism-induced rats had mild hepatosteatosis as opposed to the control group histopathologically. Our study indicates that hypothyroidism can cause NAFLD.

Galactorrhea with normal prolactin levels associated with duloxetine.

2015 Wolters Kluwer Health, Inc. All rights re antipsychotics, gastrointestinal motility– enhancing agents, and verapamil can cause galactorrhea. Antidepressant drugs such as fluoxetine, paroxetine, and escitalopram may rarely lead to galactorrhea. We found only 3 case reports of galactorrhea associated with the use of duloxetine in the literature. This article presents a case study of galactorrhea without hyperprolactinemia in a woman being treated with duloxetine.

Coexistence of Multiple Endocrine Neoplasia Type 2B and Chilaiditi Sign: A Case Report

We present a 15-year-old female patient with medullary thyroid carcinoma, marfanoid habitus, and mucosal ganglioneuromatosis. Our case had a RET protooncogene mutation ser836 polymorphism in exon 14 and ser904 polymorphism in exon 15. Our patient is thought to be atypical MEN2B due to the absence of M918T or A883F mutations. Chilaiditi sign is an incidental radiographic finding of a usually asymptomatic condition in which a part of intestine is located between the liver and diaphragm; however, the term “Chilaiditi syndrome” is used for symptomatic hepatodiaphragmatic interposition. The patient had no symptoms as abdominal pain, constipation, diarrhea, or emesis. Incidentally, Chilaiditi sign was diagnosed with chest radiograph and thoracoabdominal CT. Our case is the first in the literature indicating the coexistence of Chilaiditi sign and MEN2B.

Clinical Features of 294 Turkish Patients with Chronic Myeloproliferative Neoplasms.

Objective: Myeloproliferative neoplasms (MPNs) share common clonal stem cells but show significant differences in their clinical courses. The aim of this retrospective study was to evaluate thrombotic and hemorrhagic complications, JAK2 status, gastrointestinal and cardiac changes, treatment modalities, and survival in MPNs in Turkish patients. Materials and Methods: Medical files of 294 patients [112 essential thrombocythemia (ET), 117 polycythemia vera (PV), 46 primary myelofibrosis, and 19 unclassified MPN cases] from 2 different universities in Turkey were examined. Results: Older age, higher leukocyte count at diagnosis, and JAK2 mutation positivity were risk factors for thrombosis. Platelet count over 1000x109/L was a risk factor for hemorrhagic episodes. Hydroxyurea treatment was not related to leukemic transformation. Median follow-up time was 50 months (quartiles: 22.2-81.75) in these patients. Patients with primary myelofibrosis had the shortest survival of 137 months when compared with 179 months for ET and 231 months for PV. Leukemic transformation, thromboembolic events, age over 60 years, and anemia were found to be the factors affecting survival. Conclusion: Thromboembolic complications are the most important preventable risk factors for morbidity and mortality in MPNs. Drug management in MPNs is done according to hemoglobin and platelet counts. Based on the current study population our results support the idea that leukocytosis and JAK2 positivity are more important risk factors for thrombosis than hemoglobin and platelet values.

The effect of Turkish bath on QT dispersion

OBJECTIVE It is known that QT intervals might differ from each other on electrocardiogram (ECG). It is also known that diversity of QT interval between derivations is an indicator of heterogeneity of repolarization and it is a leading electrophysiological cause of ventricular arrhythmias and sudden heart death. In this study, we evaluated the effects of the Turkish bath on QT dispersion. METHODS A total of 47 healthy volunteers were enrolled in the prospective study. The 12-lead ECG recordings were taken in all subjects before and after bath and QT dispersions were calculated. Blood pressure and the heart rate of each patient were recorded. QT dispersion was defined as the difference between the maximum and minimum QT intervals occurring in any of the 12 leads. Statistical analysis were performed using Wilcoxon rank test and paired t test. RESULTS The mean age was 49.47+/-11.64 years; range was between 23-70 years. The mean temperature of the bath was 39.72+/-1.75 degrees C, mean humidity percent was 84.42+/-4.74%. QTc dispersion were respectively determined as 0.047+/-0.025 sec and 0.047+/-0.019 sec (p=0.981) before and after bath. We determined no correlation between duration time at bath and QTc dispersion (r=-0.069 p=0.646). CONCLUSION In our study we found no meaningful difference in QTc dispersion in individuals who take bath. Our study is the first study in which we evaluated QTc dispersion in high temperature and humidity environment of the bath and we did not determine any effect on QTc dispersion.