Allergic rhinitis and its relationship with autoimmune thyroid diseases.

BACKGROUND: Autoimmune thyroid diseases are the most common of all autoimmune diseases. In the literature, Hashimoto thyroiditis (HT) is considered to be a T-helper (Th) type 1 dominant condition, and Graves disease is considered a Th2-dominant condition. OBJECTIVE: The aim of this study was to highlight a new aspect of the relationships among Th cell subgroups by determining the incidence of autoimmune thyroid disease in patients with allergic rhinitis (AR). METHODS: Patients were diagnosed with AR based on their medical histories, physical examinations, and skin-prick test results in an outpatient clinic. The levels of free triiodothyronine, free thyroxine, thyroid-stimulating hormone, thyroid peroxidase antibodies, and thyroglobulin antibodies were measured in peripheral blood samples from all study subjects. RESULTS: A total of 1239 patients with AR and 700 consecutive, age- and sex-matched healthy subjects were included in the study. Thyroid function tests showed that 1037 patients with AR (83.7%) had normal thyroid function, 171 (13.8%) had euthyroid HT, and 31 (2.5%) had hypothyroid HT. Among the control subjects, thyroid function test results showed that 688 subjects (98.2%) had normal thyroid function, 10 subjects (1.4%) had euthyroid HT, and 2 subjects(0.4%) had hypothyroid HT. CONCLUSION: The incidence of HT in the general population is 1.5%; in contrast, it was observed in 16.3% of our patients with AR, which represented a much higher rate than that in the overall population. Graves disease was not detected in our study subjects. A high incidence of HT in patients with AR, in which Th2 responses are dominant, indicates that further studies of the relationships among atopy, autoimmune diseases, and Th cell subgroups are needed.

Vitamin D status among adults in the Aegean region of Turkey.

BACKGROUND: Vitamin D is a lipid-soluble hormone found in certain foods and synthesized from precursors in the skin when exposed to ultraviolet light. Vitamin D plays a critical role in bone metabolism and many cellular and immunological processes and low levels have been associated with several chronic and infectious diseases. Vitamin D status is assessed by measuring the concentration of serum 25-hydroxyvitamin D [25(OH)D]. Vitamin D deficiency is reported to be common worldwide, but little has been reported about the vitamin D status of adults in Turkey. In this cross-sectional study, we determined the prevalence of 25(OH)D deficiency in adults residing in a city in the Aegean region of Turkey. METHODS: A survey was conducted on a representative sample of adults over 20 years old in a non-coastal city at the end of the winter season. Of the 209 households selected by random sampling, 8.6% (n = 18) were unoccupied and 21.5% (n = 45) refused to participate. Blood samples were taken and questions about medical history, vitamin supplementation, sunlight exposure, and dietary calcium and vitamin D intake were asked in face-to-face interviews of 391 adults living in the remaining households. RESULTS: The mean serum 25(OH)D concentration was 16.9 ± 13.09 ng/mL, with 74.9% of the subjects having 25(OH)D deficiency (<20 ng/mL), 13.8% having insufficiency (20-29.99 ng/mL), and 11.3% of the subjects having sufficient 25(OH)D (≥ 30 ng/mL) levels. 25(OH)D deficiency was more common among females (78.7%) than males (66.4%, p < 0.05). CONCLUSION: Adults living in an urban, non-coastal setting in Turkey have a high prevalence of vitamin D deficiency.

The prevalence of hyperprolactinaemia in overt and subclinical hypothyroidism.

The aims of this study were to: 1) determine the prevalence of hyperprolactinaemia in patients with newly diagnosed subclinical and overt hypothyroidism, and 2) investigate the change in PRL levels with treatment. In this observational study, patients with a new diagnosis of hypothyroidism in our endocrinology clinic were approached for participation, as were healthy controls. Patients with medical reasons for having elevated PRL levels, lactating and pregnant women were excluded from the study. No patient had kidney or liver disease. After examination to determine if clinical causes of PRL elevation were present, serum levels of thyrotropin (TSH), free thyroxine, free triiodothyronine and PRL were measured and correlation of PRL levels with the severity of hypothyroidism (overt or subclinical) was performed. Fifty-three patients (45 women, 8 men, mean age 45.3 ± 12.2 years) had overt hypothyroidism. One hundred forty-seven patients (131 women, 16 men, mean age 42.9 ± 12.6 years) had subclinical hypothyroidism. One hundred healthy persons (85 women, 15 men, mean age 43.9 ± 11.4 years) participated as controls. The same blood tests were repeated in patients after normalization of TSH levels with L-thyroxine treatment. PRL elevation was found in 36% of patients with overt hypothyroidism, and in 22% of patients with subclinical hypothyroidism. PRL levels decreased to normal in all patients after thyroid functions normalized with L-thyroxine treatment. In the hypothyroid patients (overt and subclinical) a positive correlation was found between TSH and PRL levels (r=0.208, p=0.003). PRL regulation is altered in overt and subclinical hypothyroidism, and PRL levels normalize with appropriate L-thyroxine treatment.

Psychometric properties and responsiveness of the Turkish version of the Diabetes Treatment Satisfaction Questionnaire (s) on a sample of diabetics of three consecutive monitoring periods.

The aim of this study is to test the psychometric properties and the responsiveness of the original (status) version of Turkish DTSQ. The study sample included 88 patients with diabetes mellitus who were evaluated in three consecutive time points. The first data collection time point was during their initial contact to the clinic, and the two following (3rd month and 6th month) were during the monitoring visits to the Celal Bayar University Endocrinology Department in 2007. After the adaptation of the DTSQ to Turkish language by following standard procedures, this instrument was applied to the patients along with WBQ-12 and World Health Organization Quality of Life Measure (WHOQOL-Bref). The reliability of the DTSQ was evaluated by running internal consistency analysis (Cronbach Alpha) and item analysis. Construct validity of the instrument was evaluated by various tests such as Principal Components analysis, Confirmatory Factor Analysis, Concurrent validity and "Known Groups" comparisons. Finally the sensitivity (responsiveness to change) of the DTSQ scores to the changes of the metabolic conditions were assessed. 50.0% of the participants were male with a mean age of 51.1 ± 11.4 (min 22, max 78). Majority of them had type 2 diabetes (86.4%) and 72.7% of these patients had at least one co-morbid chronic conditions. While 53.4% of the patients had been treated by insulin the remaining 46.6% had been taking oral anti-diabetic agents. The results revealed satisfactory alpha values for DTSQ (α > 0.70). All of the three metabolic measures (i.e., FBG, PBG, and HbA1c) had significant correlations with the DTSQ scores. The criterion and construct validity of the scale were found to be very satisfactory. The Turkish version of the DTSQ showed acceptable fit indices (RMSEA = 0.03, CFI > 0.90) with the original (hypothetic) construct. Almost all of the sub-dimensions of the WBQ and WHOQOL were correlated with the DTSQ as expected, indicating a good concurrent validity. DTSQ status version was found to be a reliable and valid instrument for the assessment of treatment satisfaction in Turkish diabetes mellitus patients.

Down-regulation of the auto-aggressive processes in patients with hypothyroid Hashimoto's thyroiditis following substitutive treatment with L-thyroxine.

BACKGROUND: Hashimoto's thyroiditis is a chronic, organ-specific autoimmune disease. It is the most common cause of primary hypothyroidism during the adolescent period, via autoimmune thyroid tissue destruction, affecting 2% of the population. The pathogenesis of Hashimoto's thyroiditis involves a complex interaction between predisposing genetic and environmental factors. OBJECTIVE: In this study, we wanted to investigate the role of cytokines such as IL-2, IL-4, IL-12 and IFN-gamma in the pathogenesis of the disease, and the changes to cytokine levels brought about by treatment with L-thyroxine. METHODS: Sixty five female patients, aged 18-73 years with Hashimoto's thyroiditis, referred to the Celal Bayar University Medical Faculty Endocrinology out-patients clinic, were included in this study. After a 10-12 week period of L-thyroxine treatment, all patients were restored to the euthyroid state. At the beginning and end of the treatment period, serum-free triiodothyronine (FT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH), autoantibodies against thyroid peroxidase (anti-TPO), autoantibodies against thyroglobulin (anti-Tg) levels were measured using a chemiluminecent, immunometric method, and cytokine levels were measured using ELISA. RESULTS: There was a statistically significant decrease in the serum levels of TSH (p < 0.0001) and a concomitant increase in FT4 serum levels (p < 0.0001). Also, during the post-treatment period, serum levels of anti-Tg (p < 0.01) and anti-TPO (p < 0.001) were significantly lower than during the pre-treatment period. A statistically significant decrease was shown for interleukin (IL)-12 serum levels during the post-treatment period (p < 0.001). However, the decrease in interferon (IFN)-gamma serum levels was not statistically significant (p = 0.276). On the other hand, no change was demonstrated in serum IL-2 and IL-4 levels (p = 0.953 and p = 0.313, respectively) after treatment with L-thyroxine. CONCLUSION: Considering that our study involved a 10-12 week period of treatment, the statistically significant decrease in serum IL-12 levels, and the statistically non-significant decrease in IFN-gamma levels, might indicate that a T helper type 1 inflammatory process had been halted or slowed down.

Evaluation of markers of inflammation, insulin resistance and endothelial dysfunction in children at risk for overweight.

OBJECTIVE: Childhood obesity is associated with impaired endothelial function, insulin resistance and inflammation. Being at risk for overweight has been defined as having a body mass index (BMI) between the 85th and 94th percentile for age and sex. In this study, we looked for features linked to cardiovascular risk in children who are at risk for overweight. DESIGN: Twenty-one children who were at risk for overweight (study group) and 20 children with a BMI between the 25th-74th percentiles (controls) were studied. Fasting blood levels of glucose, insulin, total cholesterol, HDL cholesterol, triglycerides, uric acid, fibrinogen and high sensitive C-reactive protein (CRP) were assessed in both groups. LDL-cholesterol, HOMA-IR and QUICKI indices were calculated. Flow-mediated Vasodilatation (FMD) was determined for the evaluation of endothelial function. RESULTS: Increased HOMA-IR was observed in children who were at risk for overweight. Waist circumference was the main predictor of insulin resistance in these children. Higher levels of CRP were found in the study group compared to controls, while plasma fibrinogen did not differ in the two groups. The children who were at risk for overweight had lower FMD values and slightly elevated lipids compared to controls; however, these differences were not statistically significant. CONCLUSION: Insulin resistance and inflammation indices were higher in children who were at risk for overweight as has been shown for obese children. The data suggest that appropriate treatment strategies for weight control are essential not only for obese children but also for those at risk for overweight.

Influence of the selective oestrogen receptor modulator (raloxifene hydrochloride) on IL-6, TNF-alpha, TGF-beta1 and bone turnover markers in the treatment of postmenopausal osteoporosis.

BACKGROUND: Osteoporosis that is encountered frequently in postmenopausal women, may cause an increased incidence of vertebral and iliac fractures that are associated with excess morbidity. Raloxifene hydrochloride, a selective oestrogen receptor modulator, has been shown to increase bone mineral density and decrease biochemical markers of bone turnover in postmenopausal women, without stimulatory effects on breast or uterus. Levels of proinflammatory cytokines, including IL-6, and TNF-alpha and TGF-beta1 which are important cytokines involved in remodeling, have been evaluated previously in in vitro studies of osteoporosis. However, there seems to be a paucity of in vivo research concerned with changes in these cytokines in osteoporosis. OBJECTIVE: In this study, we evaluated the effects of raloxifene (Evista); Lilly Pharmaceutical Co. USA, 60 mg/day) on biochemical bone turnover markers, serum parathyroid hormone, and 25-OH vitamin D, as well as the serum levels of IL-6, TNF-alpha and TGF-beta1, in 22 postmenopausal, osteoporotic women before and after 12 weeks of raloxifene treatment. METHODS: Well-matched, postmenopausal, non-osteoporotic control subjects were also enrolled in the study. Serum levels of all the parameters were measured in postmenopausal, osteoporotic women at baseline and end of the study. RESULTS: It was found that serum osteocalcin and parathyroid hormone, and urine deoxypyridinoline levels decreased to normal levels with treatment. Serum 25-OH vitamin D levels after treatment in the patient group were higher than those in the control group. Serum IL-6, TNF-alpha and TGF-beta1 levels did not change significantly with treatment. However, serum levels of IL-6 and TGF-beta1 in the patient group after treatment, decreased to levels lower than those found in the control group. Serum TNF-alpha levels in the patient group before and after treatment, were lower than those in the control group. CONCLUSION: Raloxifene treatment reduces bone turnover biochemical markers, parathyroid hormone and induces 25-OH vitamin D in postmenopausal women. Moreover, it also affects some serum cytokine levels in the postmenopausal period.

Macular edema in unregulated type 2 diabetic patients following glycemic control.

BACKGROUND: We undertook this study to evaluate the changes in macular edema of uncontrolled type 2 diabetes mellitus patients with the regulation of hyperglycemia. METHODS: The study population was comprised of 35 type 2 diabetes mellitus patients who had poorly regulated blood glucose values. Ophthalmic examinations including baseline and 6-month macular edema index values of patients by Heidelberg Retinal Tomography (HRT) macular module were done. RESULTS: Twenty four (68.6%) female patients and 11 (31.4%) male patients with a mean age of 50.7 +/- 10.3 (mean +/- SD) years and mean diabetic duration of 9.8 +/- 7.5 years participated in the study. Twenty two (62.9%) did not have diabetic retinopathy (DR), whereas 13 (37.2%) had background DR with macular edema. There was a significant correlation between duration of diabetes and HRT-II macula edema index for the right and left eyes (r = 0.40, p = 0.21 and r = 0.40, p = 0.22, respectively). CONCLUSIONS: Macular edema did not change significantly by regulation of glycemic control in the study group.

Atherosclerosis risk factors in children of parents with the metabolic syndrome.

BACKGROUND: Metabolic syndrome is a constellation of disorders that produces a high risk of atherosclerosis. Endothelial dysfunction is the key event in atherosclerosis and already present even in the childhood. The aim of the present study is to investigate inflammatory and radiological signs of atherosclerosis in children who have parents with the metabolic syndrome. DESIGN AND METHODS: Fifty children of parents with the metabolic syndrome and 38 age- and sex-matched controls were studied. Anthropometric measurements, blood pressure assessment, echocardiography, flow-mediated vasodilatation (FMD) which is a non-invasive test for the evaluation of endothelial function and fasting blood measurements including blood glucose, insulin, total cholesterol, HDL cholesterol, triglyceride, hsCRP and soluble CD40 ligand were performed. RESULTS: Serum sCD40L and hsCRP levels were significantly higher in the study group compared to the controls. FMD values did not differ between the study and control groups. Increased serum sCD40L levels were positively correlated with body mass index, waist hip ratio, LDL/HDL cholesterol ratio, and the number of metabolic syndrome components in parents, whereas showed negative correlation with the serum HDL cholesterol levels. High hsCRP levels were positively correlated with body mass index and the number of metabolic syndrome components. Multiple regression analysis demonstrated that the number of metabolic syndrome components in parents presented as being a significant predictor of the serum sCD40L and hsCRP levels of their children. CONCLUSION: Our results suggest that children of patients with metabolic syndrome have higher values of the serum markers of inflammation, which may be associated with increased risk for development of cardiovascular disease.

Serum N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) levels in hyperthyroidism and hypothyroidism.

E Natriuretic peptides represent a novel diagnostic tool in the assessment of heart failure. N-terminal-pro-B-type natriuretic peptide (NT-proBNP), a member of the natriuretic peptid family, is produced and released from cardiac ventricles. Changes in cardiac functions are observed in thyroid dysfunctions. The aim of this study was to assess the changes in serum NT-proBNP levels and to evaluate impact of thyroid hormones on serum NT-proBNP in patients with hyperthyroidism and hypothyroidism. Serum NT-proBNP levels were measured in 21 patients with hyperthyroidism and in 24 patients with hypothyroidism and compared with 20 healthy control subjects. Patients without cardiac disease were included into the study as well. Serum NT-proBNP levels were measured by electrochemiluminescence immunoassay. Serum NT-proBNP levels were higher in hyperthyroid patients than in hypothyroid patients and in control subjects, with mean values of 239.03 +/- 47.33, 45.97 +/- 13.48, 55.57 +/- 13.01 pg/ml, respectively (p < 0.0001). Serum NT-proBNP and thyroid hormones were correlated in all patients. Moreover, there was a significant positive correlation between serum NT-proBNP and serum free T4 (FT4) levels (r = 0.549, p = 0.012) in hyperthyroidic patients. Multiple regression analyses demonstrated that increasing FT4 was independently associated with a high serum NT-proBNP levels, whereas heart rate was not in hyperthyroid patients. Serum NT-proBNP levels are higher in the hyperthyroid state as compared with the hypothyroid and euthyroid state. Thyroid dysfunction affects serum NT-proBNP levels, possibly influencing the secretion of the peptide. Therefore, thyroid function has to be considered when evaluating high serum NT-proBNP levels in patients without cardiac dysfunction.

Impact of renal function or folate status on altered plasma homocysteine levels in hypothyroidism.

Hyperhomocysteinemia is an independent risk factor for coronary, peripheral and cerebrovascular diseases. Moderately elevated total homocysteine (tHcy) levels have been reported in patients with overt hypothyroidism. Plasma tHcy concentration is affected by several physiological factors and is elevated under conditions of impaired folate and cobalamin status and in renal failure. The aim of this study was to assess plasma tHcy concentrations and to evaluate the role of potential determinants of plasma tHcy levels in hypothyroid patients. Fasting plasma tHcy, serum homocysteine-related vitamins folate and vitamin B(12), serum cystatin C (CysC) and creatinine, were determined in 22 hypothyroid patients and compared with 25 healthy control subjects. Creatinine clearance (CCr) was calculated using the Cockroft-Gault formula. Plasma tHcy levels were determined by HPLC with fluorescence detection and serum CysC by automated particle enhanced immunoturbidimetry. Plasma tHcy, creatinine levels were significantly higher, and serum CysC levels, and creatinine clearance values were lower in hypothyroid patients than in control subjects. Folate levels were lower in hypothyroidic group compared to the control group. There were no differences in vitamin B(12) levels between hypothyroid and control groups. Positive correlation was noted between tHcy and creatinine levels in hypothyroid patients (r = 0.596); however, an inverse correlation was found between tHcy and folate levels (r = -0.705) in hypothyroid patients. In conclusion, tHcy was increased in hypothyroidism, and this increase was more strongly associated with changes in serum folate than in serum creatinine and CysC, suggesting an altered folate status.

Does thyroid replacement therapy affect pulmonary function tests in patients with subclinical hypothyroidism?

OBJECTIVE: Subclinical hypothyroidism is an elevation in serum thyroid-stimulating hormone (TSH) while having normal serum free thyroxine (FT4) and triiodothyronine (FT3) levels. The purpose of this prospective observational study was to evaluate the pulmonary function of patients diagnosed with subclinical hypothyroidism, both before and after treatment with thyroid hormone. METHODS: This study took place at the Medical Faculty, Celal Bayar University, Manisa, Turkey between February 2003 and June 2004. Thirty-eight patients (37 females, one male) with subclinical hypothyroidism between 20 and 65 years of age were included in the study. Most were mildly obese. Arterial blood gases and pulmonary function tests were performed before treatment with thyroid hormone, and afterwards, the TSH value reached the normal range (indicating euthyroidism). RESULTS: Oxygen saturation, but not partial oxygen pressure or partial carbon dioxide pressure, was statistically, but not clinically significantly higher after treatment with thyroid hormone (p=0.01). Pulmonary function tests were not significantly different before and after treatment with thyroid hormone. CONCLUSION: In our subclinical hypothyroidism patients, pulmonary function tests were normal and did not significantly change with thyroid hormone replacement. The advantages of thyroid hormone replacement therapy, at least regarding respiratory function, seem to be clearly present in patients with overt, clinical hypothyroidism but not in patients with subclinical hypothyroidism.

Homocysteine levels in acromegaly patients.

Acromegaly is associated with a two to three-fold increase in mortality related predominantly to cardiovascular disease. The excess mortality is associated most closely with higher levels of growth hormone (GH). Survival in acromegaly may be normalized to a control age-matched rate by controlling GH levels; in particular, GH levels less than 2.5 ng/mL are associated with survival rates equal to those of the general population. Hyperhomocysteinemia has also been recognized as a risk factor for cardiovascular disease, yet there are limited data on the prevalence of hyperhomocysteinemia in patients with acromegaly. Eighteen acromegaly patients (7 male, 11 female, mean age 42.8 +/- 11.0 years) in our endocrine clinic consented to having the following tests performed: complete blood count (CBC), thyroid hormones, folic acid, vitamin B12, plasma homocysteine levels, uric acid, fibrinogen, CRP, fasting glucose, insulin, C-peptide, total serum cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, GH, insulin-like growth factor-1 (IGF-1) and GH levels after an oral glucose tolerance test (OGTT). By history, fourteen had macroadenomas and four had microadenomas; eight had hypertension; two had glucose intolerance, and four had diabetes. Fifteen had had transsphenoidal or transfrontal surgery: two had been cured, but 13 others were taking long-acting octreotide. Five patients had undergone radiotherapy and the acromegaly in two was treated primarily with long-acting octreotide. CBC, thyroid hormone, folic acid, and vit B12 levels were normal in all patients. We divided the patients into two groups according to mean GH levels after an OGTT: Group 1 (GH<2.5 ng/mL, n=10), and Group 2 (GH<2.5 ng/mL, n=8). Comparison of the two groups using Mann-Whitney U testing revealed statistically significant lower levels in Group 1 of the following parameters: GH (1.91 +/- 0.90 vs. 8.58 +/- 5.55 ng/mL, p=0.002), IGF-1 (338.30 +/- 217.90 vs. 509.60 +/- 293.58 ng/dL, p=0.06), GH after an OGTT (1.42 +/- 0.81 vs. 9.01 +/- 4.53 ng/mL, p=0.001), plasma homocysteine (12.85 +/- 4.47 vs. 18.20 +/- 4.99 micromol/L, p=0.05), total cholesterol (164.0 +/- 20.81 vs. 188.0 +/- 22.26 mg/dL, p=0.05) and LDL cholesterol (81.0 +/- 9.64 vs. 116.70 +/- 13.03 mg/dl, p=0.01). Differences between the other parameters were not significantly different. Acromegaly patients with high GH levels after an OGTT have much higher levels of homocysteine than patients with lower GH levels. The role of elevated homocysteine levels as an independent cardiovascular risk factor in the mortality of acromegaly patients should be determined in future studies.

Effects of a statin group drug, pravastatin, on the insulin resistance in patients with metabolic syndrome.

BACKGROUND: In West of Scotland Coronary Prevention Study (WOSCOPS), development of type 2 diabetes mellitus (DM) was found to decrease by 30% in pravastatin-treated patients. In the study, it is suggested that pleiotropic effects of pravastatin may be responsible too as well as its lipid lowering effect. OBJECTIVE: The aim of this study was to assess the effects of pravastatin treatment on the insulin resistance in patients with metabolic syndrome with impaired glucose tolerance (IGT), by Homeostasis Model Assessment (HOMA) test, insulin sensitivity indices and glucose half activation time (glucose t1/2). METHODS: Study population consisted of 25 women who were diagnosed with metabolic syndrome. At baseline and 10 weeks after the 20 mg/daily tablet pravastatin treatment, waist/hip circumference, body weight and arterial blood pressure measurements, plasma glucose, total cholesterol, triglyceride, high density lipoprotein (HDL)-cholesterol, transaminases, glycosylated haemoglobin (A1C) and insulin level measurements were obtained along with HOMA test and insulin tolerance test after 12 h of fasting. Insulin sensitivity indices and glucose t1/2 were assessed. RESULTS: After the treatment, a statistically significant decrease was observed in arterial blood pressure values (P < 0.0001). While plasma total cholesterol, low density lipoprotein (LDL)-cholesterol, and triglyceride levels were found to decrease significantly and HDL-cholesterol levels increased significantly, a decrease in baseline insulin levels, an increase in insulin sensitivity levels were observed along with an decrease in glucose t1/2. Related to the improvement in aforementioned parameters, statistically significant decreases were noted in HOMA, postprandial and fasting glucose levels and A1C values (P < 0.0001). CONCLUSION: Our study suggests that using pravastatin in the dyslipidemia treatment of metabolic syndrome with IGT may be an effective approach by its advantageous effects on insulin resistance. Based on this result, it is possible to say that this can be a risk lowering treatment approach for the development of type 2 DM.

Serum and urinary nitric oxide in Type 2 diabetes with or without microalbuminuria: relation to glomerular hyperfiltration.

BACKGROUND: Glomerular hyperfiltration is considered as one of the pathophysiological mechanisms for the development of diabetic nephropathy. Oxidative stress is enhanced in patients with diabetes mellitus. Reportedly, nitric oxide (NO) might be involved in the pathogenesis of hyperfiltration. We investigated the relationship between hyperfiltration and NO system, and malondialdehyde (MDA) levels in Type 2 diabetics with/without microalbuminuria. METHODS: In 39 microalbuminuric, 29 normoalbuminuric Type 2 diabetic patients and 32 healthy controls, serum creatinine, nitrite, nitrate, urinary microalbumin, nitrite, nitrate, plasma MDA and estimated glomerular filtration rate (EGFR) values, calculated according to the Cockcroft and Gault formula, were recorded. RESULTS: Serum and urine NO levels were higher in both microalbuminurics and normoalbuminurics than controls. There were no significant differences in EGFR between groups. However, hyperfiltration was determined in 31% of normoalbuminurics and 20% of microalbuminurics. Serum and urine NO levels were higher in patients with hyperfiltration. Plasma MDA levels were significantly elevated in both microalbuminurics and normoalbuminurics when compared with controls. Serum glucose and microalbuminuria were positively correlated in microalbuminuric diabetics. Serum NO levels were also positively correlated with EGFR in both normoalbuminurics and microalbuminurics. HbA1c levels were positively correlated with both urinary albumin excretion and plasma MDA levels in normoalbuminuric diabetics. CONCLUSIONS: Hyperglycemia is associated with an increased NO biosynthesis and lipid peroxidation. Increased oxidative stress may contribute to the high NO levels in Type 2 diabetes. Furthermore, the high NO levels may lead to hyperfiltration and hyperperfusion, which in turn leads to an increase in urinary albumin excretion and thus causes progression of nephropathy in early Type 2 diabetes.

The relationship between self-monitoring of blood glucose control and glycosylated haemoglobin in patients with type 2 diabetes with and without diabetic retinopathy.

BACKGROUND: Diabetes mellitus (DM) is a major health problem with long-term microvascular and macrovascular complications responsible for the majority of its mortality and morbidity. The development and progression of diabetic complications are strongly related to the degree of glycemic control. To decrease the occurrence of these complications, instruments for self-monitoring of blood glucose (SMBG) have been developed and have become widely used among diabetic patients. In this study, we determined the relationship between SMBG control and glycosylated haemoglobin (HbA(lc)) levels in patients with type 2 diabetes, with and without diabetic retinopathy. METHODS: Two hundred and sixty-seven type 2 diabetic patients (mean age [mean+/-S.D.]: 58.07+/-9.13 years, duration of diabetes: 8.63+/-6.8 years) participated in this study. Following an educational program on SMBG, glucometers and usage of oral antidiabetic agents or insulin, optic fundi were examined and HbA(lc) levels were measured at baseline and after 6 and 12 months. The patients were classified in three groups according to their funduscopic findings: without retinopathy (n=140, 52.4%), background retinopathy (n=75, 28.1%) and proliferative retinopathy (n=52, 19.5%). RESULTS: HbA(lc) levels at baseline, after 6 and 12 months were 9.09+/-2.69%, 7.47+/-1.78% and 7.12+/-1.4%, respectively, mean+/-S.D. The values decreased significantly after the education program (P<.001 for both values compared with baseline). The prevalence of retinopathy (both background and proliferative) was 0.8% in the group of diabetics with a mean HbA(lc) level <6%, 7.1% in those between 6.1% and 6.9%; 9.4% in those between 7% and 7.9%; 11.8% between 8% and 8.9%; and 70.9% in those exceeding a mean HbA(lc) level of 9%. There was a statically significant relationship between proliferative diabetic retinopathy and body mass index (BMI; P<.001). The same relationship was observed between duration of diabetes and diabetic retinopathy (P<.001), but not between sex and diabetic retinopathy (P=.46). CONCLUSIONS: Implementing a program of SMBG control in type 2 diabetic patients results in lower levels of HbA(lc) at 6 and 12 months. In the group without diabetic retinopathy at 6- and 12-month controls, the mean HbA(lc) concentration is less than 7%, but in the group with diabetic (background and proliferative) retinopathy, this value could not be reduced below 7%. These results imply that SMBG would allow us to maintain better metabolic control by improving HbA(lc) levels and we have always kept in mind that SMBG was a part of an educational program. On the other hand, improving glycemic control prevents the onset or progression of diabetic microvascular complications, such as diabetic retinopathy, nephropathy and neuropathy. Long-term clinical studies should be performed to determine cost-effectiveness and the effects of SMBG on diabetic complications, morbidity and mortality.

Ultrasonographic evaluation of pes anserinus tendino-bursitis in patients with type 2 diabetes mellitus.

OBJECTIVE: To assess musculoskeletal ultrasonographic (US) findings in patients with type 2 diabetes mellitus (DM) with and without pes anserinus (PA) tendinitis or bursitis syndrome; and to determine possible etiologic factors such as systemic diabetic microvascular disease complications in these patients. METHODS: The knee joints were examined with an ultrasound real-time scanner using a 10 MHz electronic linear transducer in 48 patients with type 2 DM and 25 controls. The presence of systemic diabetic microvascular disease complications was evaluated. RESULTS: On examination 23 (23.9%) knees of the 14 (29.1%) patients with type 2 DM were found to have PA tendinitis or bursitis syndrome. US revealed that only 4 (8.3%) of the diabetic patients with PA tendinitis or bursitis syndrome had PA tendonitis findings. There were no significant differences in the thickness of PA tendons between the diabetic patients with bilateral knee PA tendinitis or bursitis syndrome (9 patients) and controls, or between the asymptomatic and symptomatic knees in patients with unilateral PA tendinitis or bursitis syndrome (5 patients). The prevalence of morphologic changes of the medial meniscus, effusion and synovitis in the suprapatellar recess, popliteal cyst, and radiographic osteoarthritis (OA) in the diabetic patients with PA tendinitis or bursitis syndrome was found to be increased. CONCLUSION: The prevalence of PA tendinitis or bursitis syndrome is not uncommon on examination in patients with type 2 DM. However, patients with clinically diagnosed PA tendinitis or bursitis syndrome less frequently have morphologic US changes of the PA tendons. Our results also suggest that structural changes such as meniscus lesions that occur in consequence of OA might have a role in the etiology of medial knee pain in diabetic patients.

Depression and anxiety in hyperthyroidism.

BACKGROUND: Our objective was to determine symptomatology of depression and anxiety in patients with untreated hyperthyroidism and compare with euthyroid patients. METHODS: Thirty-two patients with hyperthyroidism (high free T3 and free T4, and suppressed TSH) and 30 euthyroid (normal free T3, free T4, and TSH) controls attending the Endocrinology Out-Patient Department at Celal Bayar University Hospital in Manisa, Turkey were included in the study. Hormonal screening was performed by immunoassay and hemagglutination method. For psychiatric assessment, Hospital Anxiety and Depression Scale [HAD], Hamilton Depression Rating Scale [HAM-D], and Hamilton Anxiety Rating Scale [HAM-A] were used. There was no difference between the two groups in terms of demographic features. RESULTS: Total scores obtained both from HAM-D and HAM-A were significantly greater in the hyperthyroidism group than that of the euthyroid group (p <0.05); there was no difference in terms of HAD. When compared in terms of symptomatology, early insomnia (HAM-D#6), work and activities (HAM-D#7), psychic anxiety (HAM-D#10), weight loss (HAM-D#16), insomnia (HAM-A#4), and cardiovascular symptoms (HAM-A#8) were significantly more frequent in the hyperthyroidism group. By Wilks lambda discriminant analysis, psychomotor agitation (HAM-D#9), weight loss (HAM-D#16), and insomnia (HAM-A#4) were found as the discriminating symptoms for the hyperthyroidism group, whereas somatic anxiety (HAM-A#11) and loss of interest (HAD#14) were distinguishing symptoms of the euthyroidism group. CONCLUSIONS: Hyperthyroidism and syndromal depression-anxiety have overlapping features that can cause misdiagnosis during acute phase. For differential diagnosis, one should follow-up patients with hyperthyroidism with specific hormonal treatment and evaluate persisting symptoms thereafter. In addition to specific symptoms of hyperthyroidism, psychomotor retardation, guilt, muscle pain, energy loss, and fatigue seem to appear more frequently in patients with comorbid depression and hyperthyroidism; thus, presence of these symptoms should be a warning sign to nonpsychiatric professionals for the need for psychiatric consultation.

Association between homocysteinemia and renal function in patients with type 2 diabetes mellitus.

Homocysteinemia is an independent risk factor for cardiovascular disease, but information on its association with type 2 diabetes and mild renal dysfunction is limited. Plasma total homocysteine (tHcy) concentration is partly determined by renal plasma clearance. Serum cystatin C (Cys C) concentration has been introduced as a marker of renal function, specifically as an indicator of glomerular filtration rate (GFR). The aim of this study was to explore the relationships among tHcy, creatinine clearance (Ccr), serum Cys C, and microalbuminuria in a population with type 2 diabetes. Fasting plasma tHcy, serum homocysteine-related vitamins (folate and vitamin B12), serum Cys C, serum creatinine, urine microalbumin, and creatinine clearance were determined in 75 type 2 diabetic patients and 40 healthy control subjects. The patients were assigned to two groups based on urinary albumin excretion (UAE): normoalbuminuric (NAU, UAE < 30 mg/24 hr, n = 35) and microalbuminuric (MAU, UAE 30-300 mg/24 hr, n = 40). Ccr was calculated using the Cockroft-Gault formula. Plasma Hcy levels were determined by HPLC with fluorescence detection and serum Cys C by automated particle enhanced immunoturbidimetry. Plasma tHcy levels were significantly higher in normoalbuminuric and microalbuminuric patients than in controls (10.64 +/- 0.53, 13.29 +/- 0.78, 6.91 +/- 0.37 mmol/L, respectively). Serum Cys C levels in microalbuminuric diabetics were higher than in normoalbuminurics and controls (1.36 +/- 0.06, 1.12 +/- 0.04, 1.10 +/- 0.06 mg/ L, respectively). Positive correlations were noted between tHcy and Cys C levels in normoalbuminuric and microalbuminuric diabetics (r = 0.72, r = 0.64, respectively). Homocysteine and creatinine concentrations were correlated in both diabetic groups (r = 0.89, r = 0.93, NAU and MAU, respectively). Elevated plasma total homocysteine concentrations in type 2 diabetics suggest an association between homocysteinemia and deterioration of renal function, evidenced by increased serum creatinine and Cys C, Ccr, and microalbuminuria. These findings implicate homocysteinemia in the relationship between diabetic nephropathy and cardiovascular complications of diabetes.