Factors affecting hypocalcaemia following total thyroidectomy: a prospective study.

OBJECTIVE: After thyroidectomy hypocalcaemia is the most significant complication for clinicians. In this study, we investigated the factors associated with development of hypocalcaemia after thyroidectomy. MATERIALS AND METHODS: We investigated the patients prospectively for age, gender, preoperative diagnosis, hormonal status, operative time, operating surgeon, existence of parathyroid gland injury at the operation, parathyroid gland auto-transplantation, preoperative use of anti-thyroid drugs and amount of bleeding at the operation. After operation in 1 and 2 days, serum calcium and phosphor, and in the 1 day parathyroid hormone values were evaluated. The chi-square test was applied in the analysis of categorical variables. Logistic regression model was used to determine the risk of hypocalcaemia in the univariate analysis. RESULTS: Hypocalcaemia developed in 47 of 196 patients. Female gender, preoperative diagnosis of thyroid cancer and toxic nodular goitre, <3cm nodule size, parathyroid injury and auto-transplantation and low vitamin D levels were factors found to be associated with hypocalcaemia in the Logistic regression analysis. CONCLUSION: The factors associated with hypocalcaemia were defined to be "gender, preoperative diagnosis, parathyroid gland injury, nodule size and vitamin D deficiency", it is a multifactorial problem and it would not be proper to define a few etiological factors.

The predictive value of routine preoperative laboratory parameters in patients with sporadic and solitary parathyroid adenoma.

OBJECTIVE: Primary hyperparathyroidism (pHPT) is a disease in which the diagnosis depends increasingly on laboratory tests since the majority of patients are elderly people without typical symptoms. The aim of this study was to calculate the specificity and sensitivity rates, and positive predictive value of blood Ca, P, ALP, and iPTH levels in patients with PA. MATERIALS AND METHODS: We calculated the specificity and sensitivity rates, and positive predictive value of blood calcium (Ca), phosphorous (P), alkaline phosphatase (ALP), and intact parathormone (iPTH) levels in patients with sporadic and solitary parathyroid adenoma (PA). RESULTS: Twenty six patients with PA were included in the study. The mean age was 44.5±14.9 (18-70) years. Blood levels of Ca, P, ALP, and iPTH were 2.5±0.3 mmol/L, 0.8±0.3 mmol/L, 21.4±31.5 µkat/L, and 518.0±633.4 ng/L, respectively. With respect to the diagnosis of pHPT, the sensitivity of blood levels of iPTH, P, Ca, and ALP were 96%, 94%, 81%, and 73%, respectively. The specificity and positive predictive value of all parameters were 100% for the diagnosis of PA. CONCLUSION: Routine laboratory parameters are specific and predictive for pHPT. However, the sensitivities of P and iPTH are higher than those other parameters.

Neuropad indicator test for diagnosis of sudomotor dysfunction in type 2 diabetes.

Neuropad is a new indicator test used to diagnose sudomotor dysfunction, a component of autonomic neuropathy. In this cross-sectional study, Neuropad is evaluated and compared with corrected QT (QT c), another test used in the diagnosis of autonomic neuropathy. The indicator test measures sweat production on the basis of a color change of cobalt (II) chloride solution from blue to pink upon absorption of water. This study involved 105 patients (43 men, 62 women) with type 2 diabetes with a mean age of 56.2+/-11.5 y and a mean disease duration of 10.0+/-6.3 y. Age, sex, disease duration, glycosylated hemoglobin, and QT c were compared between patients with normal and abnormal test results. The QT c interval was measured and the new indicator test was applied in all patients. The 2 tests were compared, and the sensitivity, specificity, positive predictive value, and negative predictive value for the indicator test were calculated. Autonomic neuropathy was diagnosed in 40 patients (38.1%) with QT c interval measurement and in 72 patients (68.6%) with the new indicator test (P=.001). The sensitivity, specificity, positive predictive value, and negative predictive value for the indicator test were 87.5%, 43.1%, 48.6%, and 84.8%, respectively. Patients with abnormal test outcomes had longer QT c than those whose test results were normal (0.433 vs 0.398 s; P=.002). Study results suggest that the new indicator test has an acceptable sensitivity but a low specificity and is not superior to other tests in the diagnosis of sudomotor dysfunction.

Conjunctival flora in patients with type 1 or type 2 diabetes mellitus.

Patients with diabetes mellitus (DM) are prone to infection because glucose in the skin, urine, mucous membranes, and tears promotes growth of microorganisms. Conjunctival flora develops soon after birth, and some saprophytic conjunctival flora play a pathogenic role when immune function is compromised, which can lead to serious infection. DM is one condition that may compromise immune status. In lacrimal function tests of DM patients, a decrease in breakup time (BUT) of lacrimal film and a decrease in Schirmer's test results were seen. In the present study, conjunctival flora in patients with DM was compared with that in controls with regard to type and duration of diabetes and results of lacrimal function tests. Seventeen patients with type 1 DM (n=34 eyes), 66 patients with type 2 DM (n=132 eyes), and 50 control subjects (n=100 eyes) were included. The control group consisted of age-matched patients with no ophthalmologic problems other than refractive error. Glycosylated hemoglobin values were measured with highpressure liquid chromatography with the Hi-AUTOA1c analyzer (Kyoto Daiichi Kagatu Co., Ltd., Kyoto, Japan). Type and duration of diabetes and demographic data were recorded, and routine ophthalmologic examinations were performed; the BUT of lacrimal film was determined, and the results of Schirmer's test were assessed. Microbiologic sampling was performed twice for both eyes with sterile cotton swabs. One sample was incubated in 2 mL of brain-heart infusion broth agar; the other was incubated for the presence of fungi in Sabouraud dextrose agar. Colony morphology, hemolysis, and Gram's stain, as well as catalase, oxidase, and coagulase tests were performed. No growth was observed in 12 of 17 patients (35.4%) with type 1 DM, 28 of 66 patients (21.2%) with type 2 DM, and 25 of 50 control subjects (50%). Staphylococcus epidermidis (11.79%) and Staphylococcus aureus (11.7%) were the most frequently isolated organisms in the type 1 DM group, and S epidermidis (24.2%) and S aureus (21.2%) were the predominant organisms in the type 2 DM group. In control subjects, S epidermidis (22%), S aureus (12%), and Corynebacterium spp (10%) were the most frequently isolated organisms, and the number of eyes with growth of S aureus was significantly higher in the type 2 DM group than in the other groups (P<.01). Patients with diabetes are more prone to postoperative endophthalmitis than are nondiabetics, and preoperative application of antiseptic or antimicrobial agents to the conjunctiva may not sterilize the area. Impaired integrity of the posterior capsule may also increase the risk of endophthalmitis. Postoperative endophthalmitis is usually associated with gram-positive organisms (75%-80%); gram-negative organisms (15%-29%) and fungi (3%-13%) account for a smaller number of cases. A high rate of resistance to penicillin, ampicillin, and tetracycline was observed in S aureus isolates, although resistance to vancomycin was absent, rendering this molecule the most effective therapeutic option. In this study, S epidermidis and S aureus were the 2 most frequently isolated organisms in patients with DM. It is concluded that the conjunctival flora in diabetic subjects differs from that in nondiabetic subjects. This should be considered preoperatively and postoperatively, and prophylactic and postoperative treatment should be administered accordingly to diabetic patients.

Exophthalmometric values in a normal Turkish population living in the northeastern part of Turkey.

BACKGROUND: Exophthalmometry is a simple examination procedure used for the early diagnosis of many of the orbital pathologies. The exophthalmometric measures tend to vary with age, sex, and race. Therefore, a lot of investigators conducted researches to determine the minimum, maximum, and normal values of exophthalmometric measures in their populations. OBJECTIVE: We planned this study to gather data about the normal exophthalmometric measures in our population. DESIGN: In this study, 240 male and 240 female subjects with age ranging from 3 to 80 years were included. The results of measures from both the eyes were evaluated for the study subjects. The protrusions of both the eyes were measured simultaneously in daylight via Hertel exophthalmometry. RESULTS: The minimum and maximum measures of Hertel exophthalmometry for the male subjects were found to be 8 and 20 mm, respectively, with the mean being 13.49 +/- 2.6 mm. No statistically significant difference existed either between the eyes or between the age groups for the male subjects. The minimum and maximum measures of Hertel exophthalmometry for the female subjects were 8 and 19 mm, respectively, with the mean being 13.39 +/- 2.6 mm. Similar to the males, no statistically significant difference existed either between the eyes or between the age groups for the females. When the results of Hertel measurements for male and female subjects were compared, no significant difference could be found. CONCLUSIONS: As it provides results of exophthalmometry for the Turkish population, our study is important. However, larger, nationwide, and multisite studies examining more subjects may provide more valuable data about the Turkish population.

Iodine deficiency and goiter prevalence of the adult population in Erzurum.

It is believed that total goiter prevalence in Turkey is as high as 30.5%. The iodine deficiency is the distinct etiologic factor in the development of goiter. The aim of this study was to determine goiter prevalence and iodine deficiency in adults living in Erzurum (1659 m above sea level) for at least 10 year. The study involved 340 people (192 females, 148 males). The median age was 38.5 year (ranging from 20 to 76 years). Ultrasound-measured thyroid volume (TV) for men (TV>25 ml) and for women (TV>18 ml) was considered goiter indicator. By this evaluation, goiter was diagnosed in 94 (27.6 %) cases, whereas the goiter prevalence, based on the palpation method, was 5.6%. Urinary iodine concentration (UIC) was measured by ammonium persulfate method. UIC in subjects with goiter was significantly lower than that of the others (median values 5.0 vs 7.8 microg/dl, p<0.0001). While the value of UIC > or = 10 microg/dl (no. 121, 36.6%) was accepted normal, the extent of iodine deficiency in other subjects was classified as severe (UIC<2.0 microg/dl, no.53, 15.6%), moderate (UIC=2.0-4.9 microg/dl, no.75, 22%) and mild (UIC=5.0-9.9 microg/dl, no.91, 26.8%). TV values were found to be significantly different among the four groups (p<0.05). TV values were significantly correlated with body surface area and UIC (r=0.15 and r=-0.16, respectively, p<0.005). Also, the prevalence of thyroid nodules was estimated as 2.1% by palpation and 18% by ultrasonography. We conclude that goiter originating from iodine deficiency has been an important health problem in Erzurum. Besides taking measures at national level, local factors and risks which interfere with the nationwide efforts should also be dealt with for the eradication of the iodine deficiency problem. In the region, periodical evaluation of iodine level and iodine related disorders will guide the measures to be taken for the well being of people's general health.

The effects of calcitonin on bone resorption in hyperthyroidism: a placebo-controlled clinical study.

The effects of intranasal calcitonin on bone metabolism were investigated in patients with hyperthyroidism. Urinary deoxypyridinoline (uDPD) levels were measured as a bone turnover marker and lumbar spine (L2) bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA) in 7 patients who were given only antithyroid drug (group 1), in 10 patients who were given antithyroid drug plus intranasal calcitonin (group 2), and in 10 healthy subjects who were given placebo (group 3) at the beginning and at the end of the study. The study continued until the patients with hyperthyroidism became euthyroidic according to the laboratory values. This period was approximately 3 months in groups 1 and 2. At the beginning of the study, uDPD was 21.5 +/- 2.6 nM DPD/mM creatinine in group 1, 23.3 +/- 3.6 nM DPD/mM creatinine in group 2, and 4.3 +/- 1.2 nM DPD/mM creatinine in group 3. uDPD levels measured in groups 1 and 2 were significantly higher than those in group 3 ( P << 0.001). Area BMD Z scores of the patients in groups 1 and 2 were significantly lower than the healthy controls ( P << 0.01, for both). At the end of the study, uDPD was 11.5 +/- 1.6 nM DPD/mM creatinine in group 1, 5.3 +/- 0.6 nM DPD/mM creatinine in group 2, and 4.4 +/- 1.3 nM DPD/mM creatinine in group 3. The levels of uDPD obtained in group 1 were significantly higher than those obtained in groups 2 and 3 ( P << 0.05, for both). The difference between groups 2 and 3 was not significant. Area BMD Z scores measured at the end of the study were found to be increased in groups 1 and 2 compared to early values, but the values were slightly lower than the normal values. In comparison of early and late uDPD values, the decrease in late period was statistically significant in groups 1 ( P << 0.05) and 2 ( P << 0.001). We concluded that bone turnover is high in hyperthyroidism. The treatment of hyperthyroidism decreases the rate of bone turnover, but it is not sufficient to prevent the degradation of bone in hyperthyroidism. The addition of intranasal calcitonin to the treatment of hyperthyroidism prevents the degradation of bone.

Hydatid cysts of the adrenal gland: review of nine patients.

Adrenal cysts are very rare lesions, especially with parasitic origin. But with the wider application of ultrasonography (US) and computed tomography (CT) more adrenal cysts are detected incidentally. To gain more insight into this entity, the records of nine patients with hydatid cysts of adrenal gland seen at our department from January 1980 till January 2002 are reviewed. There were four men and five women, and their ages ranged from 15 to 80 years (median: 41 years). All of the patients had unilateral cysts. Seven cysts were located on the right and two on the left side. Five of the cysts were primary and four were secondary. In three patients the cysts were found incidentally. The most common presenting symptom was pain, which was present in six patients. An indirect hemagglutination (IHA) test was positive in six cases. In all patients, US and CT successfully imaged all cysts, but the definitive diagnosis was made by macroscopic and microscopic examination of the cyst's content. The patients were treated surgically. In all patients adrenal glands with the cystic masses were removed. The median follow-up period was 16 months (range: 6-64 months). No evidence of recurrence was found in any patient. It should not be forgotten that cystic masses of the upper abdomen might also originate from the adrenal gland. The etiology and nature of the cyst should be well researched, and appropriate treatment should be given as soon as possible. Surgical excision of the gland, including the cyst is the treatment of choice.

The presence of the antigliadin antibodies in autoimmune thyroid diseases.

AIMS: To investigate the presence of the antigliadin antibodies in the patients with Graves' disease and Hashimoto's thyroiditis. METHODOLOGY: Four hundred patients with autoimmune thyroid disease (280 Graves' disease and 120 Hashimoto's thyroiditis ) were included in the study. The patients with celiac sprue patients were excluded. For the diagnosis of autoimmune thyroiditis, blood levels of thyrotropin (TSH), free thyroxine (FT4), and the titration of thyroid autoantibodies (TgAb and TmAb) were measured, and the thyroid gland was ultrasonographycally evaluated. After the diagnosis of autoimmune thyroid disease was established, the titration of antigliadin antibodies (Ig A and B) were routinely detected. RESULTS: Twenty two patients (5.5 per cent) with autoimmune thyroiditis had positive antigliadin antibodies. Polyglandular endocrine syndrome was diagnosed in most of these patients. CONCLUSIONS: We claim that polyglandular endocrine syndrome is the commonest cause of positivity of antigliadin antibodies in the patients with autoimmune thyroid disease.

The release of insulin in fatty liver.

AIMS: To evaluate the blood levels of lipids, insulin resistance and the release of insulin in the patients with fatty liver. METHODOLOGY: Ninety one patients with fatty liver and forty seven healthy subjects were included in the study. The diagnosis of fatty liver was established by measuring blood levels of lipids and measuring liver echogenity by ultrasound. Fasting plasma levels of lipids, glucose and insulin were measured in the patient group and control group, and the rate of insulin resistance was calculated. HOMA test was used to calculate the insulin resistance. INSULIN RESISTANCE: Fasting insulin value (microU/mL) x Fasting blood glucose value (mmol/L)/22.5 Liver echogenity was measured by a 3.75 mHz ultrasound probe and was graded by comparison with renal cortical paranchymal echogenity in both groups. Increased blood levels of lipids and increased liver echogenity on the ultrasonography were accepted as fatty liver. Liver biopsy was not applied. The patients with liver and/or renal paranchymal disease were excluded from the study. The rate of release of insulin was calculated according to the following formula. 20 x plasma levels of insulin (mIU/mL)/plasma levels of glucose (mmol/L)-3.5 RESULTS: In the fatty liver group, plasma levels of cholesterol were 253.5 +/- 41.0 (161-440) mg/dL, plasma levels of triglycerides were 231.8 +/- 74.4 (45-493) mg/dL, grading of liver echogenity was 1.9 +/- 0.6 (1-3), the rate of release of insulin was 111.5 +/- 82.2 (3-463.8) and the rate of insulin resistance was 22.4 +/- 4.1 (18.3-26.5). In the control group, plasma levels of cholesterol were 173.4 +/- 19.1 (122-207) mg/dL, plasma levels of triglycerides were 110.5 +/- 39.3 (40-185) mg/dL, grading of liver echogenity was 1.0 +/- 0.1 (1-1), the rate of release of insulin was 129.6 +/- 84.1 (14.5-360) and the rate of insulin resistance was 20.3 +/- 2.1 (18.2-22.4). The rate of release of insulin and insulin resistance were similar in both groups (p>0.5). CONCLUSIONS: We observed that the rate of release of insulin in the patients with fatty liver was not different from that of the healthy subjects.

Liver function tests during antithyroid therapy in hyperthyroidism.

AIMS: To investigate the liver function tests during antithyroid treatment in the patients with hyperthyroidism. METHODOLOGY: Four hundred sixty five patients with hyperthyroidism (285 Graves' disease and 180 toxic nodular/multinodular goiter) and fifty healthy subjects were included in the study. The patients who had abnormal liver function tests were excluded from the study. Blood levels of thyrotropin (TSH), free thyroxine (FT4), alanine transaminase (ALT) and aspartate transaminase (AST) were detected at the beginning of the treatment (basal levels), and at the third and sixth months of the treatment. The patients were treated with propylthiouracil (PTU). RESULTS: Average of age was 40.1 +/- 5.8 years in the patient group and was 37.3 +/- 4.5 years in the control group. TSH, FT4, ALT and AST levels measured in the patient and control group are shown in Table 1. Basal levels of TSH were lower in the study group than in the control group (p<0.001), and basal levels of FT4 were higher in the study group than in the control group (p<0.001). Basal levels of ALT and AST, and the levels of TSH, FT4, ALT and AST measured at the third and sixth months were similar in both groups. CONCLUSIONS: We did not find abnormal liver function tests during the antithyroid treatment in the patients with hyperthyroidism.

The effect of calcitonin and growth hormone on urinary deoxypyridinoline levels in burned patients.

Reduced bone formation and bone loss have been documented in patients following burn injury. Urinary deoxypyridinoline (DPD) is accepted as a marker of collagen breakdown activity. Because calcitonin (CT) diminishes bone resorption and growth hormone (GH) increases bone formation and density in GH-deficient patients, we studied the short-term effects of CT and GH on urinary DPD levels in burned patients. In 30 patients with severe burns, urinary DPD levels were investigated for 3 days following hospitalisation. Then the patients were divided into 3 groups of 10. In the CT group, CT 100U was injected subcutaneously daily for 5 days. In the GH group, GH 0.1mg/kg was injected subcutaneously three times in a week. In the control group, isotonic saline solution 0.1mg/kg was injected subcutaneously three times in a week. In all groups, following the last dose of the agents, urinary DPD levels were investigated for 3 days again. Mean burn size and age were not significantly different between the groups. Urinary DPD level obtained in the early period was 16.5 +/- 3.1nM in the CT group, 10.4 +/- 5.3nM in the GH group and 18.6 +/- 2.7nM in the control group. There were no statistical differences among the groups (P > 0.5, for all). Urinary DPD level obtained in the late period was 4.5 +/- 1.0nM in the CT group, 14.4 +/- 5.9nM in the GH group and 36.6 +/- 2.1nM in the control group. The differences between the CT group and control group, the CT group and GH group and the GH group and control group were statistically significant (P < 0.001, P < 0.01, P < 0.01, respectively). In the comparison of early and late urinary DPD levels, a significant decrease was only obtained in the CT group (P < 0.001, Z:6.5). In the other 2 groups, DPD levels increased in the late period. We concluded that GH is not effective in decreasing urinary DPD levels. On the contrary, CT was found to very effective in decreasing urinary DPD levels. This decrease in urinary DPD levels may be associated with diminished bone loss