Novel Classification of Acromegaly in Accordance with Immunohistochemical Subtypes: Is There Really a Clinical Relevance?

According to the recent studies, immunohistochemical subtypes of growth hormone (GH) secreting adenomas have been considered as a predictive factor in determining the clinical outcomes including biochemical, radiologic, and endocrine remission. In a 20 year-of time period, acromegaly patients who were treated and followed at the Endocrinology Department of our University Hospital were screened for the study. Of total 98 patients, 65 patients who had been operated by transsphenoidal surgery and having postoperative specimens were included. Postoperative specimens of the surgery of the patients were classified into 3 groups based on the histochemical characteristics (densely, sparsely, and mixed). Parasellar extensions of pituitary tumors were classified into the five grades according to Knosp classification. The patients were investigated and evaluated for postoperative clinical progress, remission rates, comorbidities regarding with the histopathological patterns. Of total 65 patients, 31 were classified as densely granulated (group 1), 32 were classified as sparsely granulated (group 2), and 2 patients were assessed as mixed granulated (group 3). There was no difference between groups for age and gender. Pre-treatment of adenoma size in all groups was correlated with each other and the frequency of macroadenoma (1 vs. 2, 77.4 vs. 84.3%) was higher in two groups. Although mean initial GH levels in group 1 was higher than the other groups (p=0.03), IGF1 levels (age and gender matched) were similar in each group. Adenomas in all groups demonstrated noninvasive radiological characteristics (Knosp grade 0-1-2). Ki-67 proliferation index of both groups (64.5 vs. 50%) was predominantly 1%. With a similar follow-up period, the endocrine remission rates (GH<1 µg/l) in groups were 64 vs. 69%, respectively. In conclusion, classification according to immunohistochemical subtypes of growth hormone secreting adenomas may not be a qualified parameter to evaluate patients with patterns of aggressiveness, clinical outcomes, or treatment response.

Awareness of Vaccination against Respiratory Tract Diseases, Including Pneumonia, Influenza, and COVID-19 in Patients with Diabetes Mellitus.

Patients with diabetes have an increased risk of severe acute respiratory infections, and vaccination is their life-saving option. This study aimed to investigate the interest and knowledge of patients about influenza, pneumonia, and COVID-19(coronavirus disease 2019) vaccines. Materials. We handed out a questionnaire to patients with diabetes who were admitted to the endocrinology clinic between April and August 2021. The questionnaire collected information on demographic data, knowledge about respiratory tract disease vaccines, and hesitancy about vaccines. Results. Four hundred twenty-four patients (female = 256, male = 168) enrolled in the study. In this study, 148 (34.9%) participants were vaccinated against pneumonia, 155 (36.6%) against flu, and 312 (73.6%) against COVID-19. In addition, antivaccination sentiment was recorded in 8.7% of patients with diabetes. We found that participants in the study primarily rely on doctors as the source of information about vaccines (doctor (46.7%), nurse (1.2%), television (8.7%), friend/neighbour (8.7%), and others (2.6%)). The rate of vaccination was statistically higher than the presence of comorbid diseases. Conclusions. We examined the vaccine awareness of patients with diabetes and investigated factors affecting it. It was determined that vaccination awareness is affected by many factors, especially comorbid diseases and educational status. The study showed that patients primarily relied on doctors as their source of information for vaccination. Doctor-centered vaccination promotion programmes can increase the rate of vaccination.

Possible role of the receptor of advanced glycation end products (RAGE) in the clinical course of prostate neoplasia in patients with and without type 2 diabetes mellitus.

AIM: The expression of the cognate receptor of advanced glycation end products (RAGE) in malignant tissues of patients with type 2 diabetes has been suggested as a co-factor determining the clinical course and prognosis. We aimed to investigate the relationship between RAGE expression and clinicopathological features of prostate neoplasia. METHODS: Tissue samples of 197 patients, 64 (24 patients with type 2 diabetes and 40 controls) with benign prostate hyperplasia (BPH) and 133 (71 patients with type 2 diabetes and 62 controls) with localised or metastatic prostate cancer (LPCa/MetPCa) were included in the study. The expression of RAGE in prostate specimens was studied immunohistochemically. RAGE scores were determined according to the extent of immunoreactivity and staining intensity. RESULTS: RAGE expression in BPH group (patients with type 2 diabetes and controls) was negative. Patients with both LPCa and MetPCa had significantly higher scores than those with BPH (P < .001). The mean RAGE scores of patients with type 2 diabetes LPCa and MetPCa were 4.71 ± 3.14 and 4.97 ± 3.69. The mean scores of control LPCa and MetPCa were 1.52 ± 1.87 and 1.69 ± 1.58, respectively. The scores of patients with type 2 diabetes LPCa and MetPCa were significantly higher than those of control LPCa and MetPCa (P = .01 and P < .001, respectively). CONCLUSION: We found higher RAGE expression levels in malignant prostate neoplasia than in BPH. As expected, patients with diabetes had higher scores than control patients. Disease progression and survival parameters were worse in patients with high RAGE levels. RAGE expression may be a useful biomarker for the diagnosis and prognosis of prostate cancer.

Utilization of statins and LDL-cholesterol target attainment in Turkish patients with type 2 diabetes - a nationwide cross-sectional study (TEMD dyslipidemia study).

BACKGROUND: Attaining acceptable levels of LDL Cholesterol (LDL-C) significantly improves cardiovascular (CV) outcomes in patients with type 2 diabetes mellitus (T2DM). The LDL-C target attainment and the characteristics of patients attaining these targets were investigated in this study. Furthermore, the reasons for not choosing statins and the physicians' attitudes on the treatment of diabetic dyslipidemia were also examined. METHODS: A nationwide, cross-sectional survey was conducted in tertiary centers for diabetes management. Adult patients with T2DM, who were under follow-up for at least a year in outpatient clinics, were consecutively enrolled for the study. LDL-C goals were defined as below 70 mg/dL for patients with macrovascular complications or diabetic nephropathy, and below 100 mg/dL for other patients. Data about lipid-lowering medications were self-reported. RESULTS: A total of 4504 patients (female: 58.6%) were enrolled for the study. The mean HbA1c and diabetes duration was 7.73 ± 1.74% and 10.9 ± 7.5 years, respectively. The need for statin treatment was 94.9% (n = 4262); however, only 42.4% (n = 1807) of these patients were under treatment, and only 24.8% (n = 448) of these patients achieved LDL-C targets. The main reason for statin discontinuation was negative media coverage (87.5%), while only a minority of patients (12.5%) mentioned side effects. Physicians initiated lipid-lowering therapy in only 20.3% of patients with high LDL-C levels. It was observed that the female gender was a significant independent predictor of not attaining LDL-C goals (OR: 0.70, 95% CI: 0.59-0.83). CONCLUSIONS: Less than 50 % of patients with T2DM who need statins were under treatment, and only a quarter of them attained their LDL-C targets. There exists a significant gap between the guideline recommendations and the real-world evidence in the treatment of dyslipidemia in T2DM.

Markers of Metabolic Syndrome in Patients with Pituitary Adenoma: A Case Series of 303 Patients.

To assess the demographic characteristics and hormonal status of patients who presented to our clinic with pituitary adenoma and to demonstrate the presence, prevalence, and relationship of metabolic syndrome parameters in these patients. The study included 303 patients with known or newly diagnosed pituitary adenoma and 52 age- and sex-matched healthy controls. The patients were classified into 3 groups; acromegaly (ACRO) (n=54),prolactinoma (PRLoma) (n=163), and non-functional adenoma (NFA) (n=86). in 55.6% (n=172) and 52% (n=163) of the patients, respectively. The waist circumference of all patients (p<0.001) and body mass index (BMI) of patients with PRLoma (p=0.03) and ACRO (p<0.001) were found to be significantly higher than in the controls. The HbA1c, insulin and HOMA-IR values were significantly higher in the ACRO and PRLoma groups, whereas the insulin and HOMA-IR values were significantly higher in the NFA group compared with the control group (p<0.001 and p<0.001, respectively). When the 3 patient groups were compared, waist circumference and BMI were significantly higher in the ACRO group than in the PRLoma group (p=0.04 and p=0.03, respectively). In patients developing pituitary failure after treatment, age, waist circumference, plasma glucose, low-density lipoproteins and triglyceride values were significantly increased when compared with those without pituitary failure after treatment (p<0.001). In our study, it was found that there was increased metabolic and cardiovascular risk in functional pituitary adenoma and NFA.

An international survey on hypoglycemia among insulin-treated type I and type II diabetes patients: Turkey cohort of the non-interventional IO HAT study.

BACKGROUND: Limited real-world data are currently available on hypoglycemia in diabetes patients. The International Operations Hypoglycemia Assessment Tool (IO HAT) study was designed to estimate hypoglycemia in insulin-treated type I (T1DM) and type II (T2DM) diabetes mellitus patients from 9 countries. The data from Turkey cohort are presented here. METHODS: A non-interventional study to determine the hypoglycemia incidence, retrospectively and prospectively, in Turkish T1DM and T2DM patients using a 2-part self-assessment questionnaire. RESULTS: Overall, 2348 patients were enrolled in the Turkey cohort (T1DM = 306 patients, T2DM = 2042 patients). In T1DM patients, 96.8% patients reported hypoglycemic events (Incidence rate [IR]: 68.6 events per patient-year [ppy]), prospectively, while 74.0% patients reported hypoglycemic events (IR: 51.7 events ppy), retrospectively. In T2DM patients, 95.9% patients (IR: 28.3 events ppy) reported hypoglycemic events, prospectively, while 53.6% patients (IR: 23.0 events ppy) reported hypoglycemic events, retrospectively. Nearly all patients reported hypoglycemia during the prospective period. CONCLUSIONS: This is a first patient-reported dataset on hypoglycemia in Turkish, insulin-treated diabetes patients. A high incidence of patient-reported hypoglycemia confirms that hypoglycemia remains under-estimated. Hypoglycemia increased healthcare utilization impacting patients' quality of life. Hypoglycemia remains a common side effect with insulin-treatment and strategies to optimize therapy and reduce hypoglycemia occurrence in diabetes patients are required. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02306681 (Date of registration: 12 Nov 2014; retrospectively registered).

Carotid Intima-Media Thickness as the Cardiometabolic Risk Indicator in Patients with Nonfunctional Adrenal Mass and Metabolic Syndrome Screening.

BACKGROUND: Our purpose was to show the association of adrenal incidentaloma and metabolic syndrome in consideration of the studies and to detect the increase in the carotid intima-media thickness which is regarded as the precessor of atherosclerosis. MATERIAL/METHODS: Eighty-one patients who were diagnosed with adrenal mass were included in the study. Hormonal evaluation, insulin rezistance measurement with the HOMA-IR and 1-mg DST were performed of all patients. The patients were classified as follows: mass size <3 cm (K1) and mass size of at least 3 cm (K2). Echocardiography and carotid intima-media thickness of the patients were measured using B-mode ultrasound. Thirty-three healthy individuals were enrolled as the control group. RESULTS: Mass size of 64.19% K1, while mass size of the remainder (35.81%) K2 was calculated. Five of the patients with adrenal mass were detected to have subclinical Cushing syndrome. The remaining 76 patients were accepted as nonfunctional. It was seen with regard to metabolic and biochemical parameters that plasma glucose (p=0.01), insulin (p=0.00) and triglyceride (p=0.012) values of all patients were significantly high compared to those of the control group. It was detected that measured heart rate (p=0.00), end-diastolic diameter (p=0.02), end-systolic diameter (p=0.014) and carotid intima-media thickness (p=0.00) values of the patients with adrenal mass were significantly higher than those of the healthy control group. CONCLUSIONS: We found that the increased insulin resistance, increased risk of cardiovascular disease with the increase in the thickness of carotid intima-media and diastolic disfunction parameters, although the patients with adrenal incidentaloma are nonfunctional.

Troponin T and NT ProBNP Levels in Gestational, Type 1 and Type 2 Diabetic Mothers and Macrosomic Infants.

This study compares NT proBNP and troponin T levels in umbilical cord arterial blood and postnatal echocardiographic findings for infants of gestational and pregestational diabetic mothers and macrosomic infants. Twenty-seven infants of pregestational diabetic mothers, 61 infants of gestational diabetic mothers and 37 macrosomic infants of nondiabetic mothers were prospectively enrolled in this study along with a control group of 58 healthy infants of mothers without any pregestational or gestational disorders as the control group. All enrollees were born after 34 weeks of gestation. For this study, umbilical cord blood was drawn during delivery to determine NT proBNP and troponin T levels. Echocardiography was performed 24-72 h after the delivery. Umbilical cord troponin T and NT proBNP levels were found to be higher in the diabetic and macrosomic groups than in the control group (all of them p < 0.001). NT proBNP levels were positively correlated with interventricular septum thickness in the pregestational and gestational infants of diabetic mothers groups (r = 0.564 and r = 0.560, respectively, p < 0.01). Both pregestational and gestational diabetic mothers were divided into two groups according to HbA1c levels in the third trimester as good (<6.1 %) and suboptimal (>6.1 %) metabolic control. In the good and suboptimal metabolic control diabetic groups, NT proBNP levels were also positively correlated with interventricular septum thickness (r = 0.536 and r = 0.576, respectively, p < 0.01). In the suboptimal metabolic control diabetic group, NT proBNP was only found to be positively correlated with the left ventricular mass index (r = 0.586, p < 0.01). While there was no correlation in the myocardial performance index between infants of diabetic mothers and the control group, the myocardial performance index of macrosomic infants was lower than that of the control group (p = 0.017). Cardiac biomarkers (NT proBNP and troponin T) were elevated in infants of diabetic mothers and macrosomic infants. While there was a positive correlation between NT proBNP levels and cardiac structure in infants of pregestational and gestational diabetic mothers, there was no relationship between NT proBNP levels and cardiac function.

Tinea pedis and onychomycosis frequency in diabetes mellitus patients and diabetic foot ulcers. A cross sectional - observational study.

OBJECTIVE: Impaired cellular immunity and reduced phagocytic function of polymorphonuclear leukocytes facilitate the development of skin fungal and bacterial infections due to uncontrolled hyperglycemia in diabetic patients. In our study, we aimed to assess onychomycosis and/or tinea pedis frequency in diabetic patients, and effects on the development of chronic complications, particularly foot ulcer. METHODS: We included 227 diabetic patients in the study. Forty-three patients had diabetic foot ulcer. We screened and recorded demographic characteristics, HbA1c levels of patients, and presence of complications We examined patients dermatologically, and collected samples by scalpel from skin between toes, and from sole, toe nail, and area surrounding nails from suspected to have fungal infection. RESULTS: Native positivity between toes was higher in men compared to women (p<0.05). We obtained significant relation between HbA1c elevation and native positivity between toes (p<0.05). Fungal infection between toes, at sole and toe nail significantly increased in patients with diabetic foot ulcer compared to patients without diabetic foot ulcer (p<0.05). Moreover, native positivity in patients with diabetic foot ulcer correlated with presence of fungal infection examination findings (p<0.05). CONCLUSION: Fungal infections were more frequently observed in the presence of poor glycemic control and peripheral vascular disease in diabetic patients in compliance with the literature, and the presence of fungal infection may also responsible for the development of foot ulcers.

Clinical experiences and success rates of acromegaly treatment: the single center results of 62 patients.

BACKGROUND: This study aimed to report the clinical and outcome data from a large cohort of patients diagnosed with acromegaly and treated at our institution over a 20-year period. METHODS: Sixty-two acromegaly patients (32 women and 30 men) treated and monitored at the endocrinology polyclinic between 1984 and 2013 were enrolled in this retrospective study. Clinical features and patients' treatment outcomes were evaluated. A level of growth hormone (GH) of <2.5 ng/ml was considered as the criterion for remission, and the normal insulin-like growth factor (IGF) range was based on gender and age. RESULTS: The mean age at the time of diagnosis was 38.8 ± 1.4 years, the time to diagnosis was 4.5 ± 0.3 years, and the follow-up duration was 7.3 ± 0.8 years. Among patients' symptoms, growth in hands and feet and typical facial dysmorphism were the most prominent (92%). The number of patients with diabetes mellitus, hypertension and hyperprolactinemia were 22 (35%), 13 (21%) and 13 (21%), respectively. Microadenomas and macroadenomas were found in eight and 54 patients, respectively. A significant correlation was found between the initial tumor diameters and GH levels (p = 0.002). The mean GH and IGF-1 levels were 39.18 ± 6.1 ng/ml and 993.5 ± 79 ng/ml, respectively. Visual field defect was found in 16 patients (32%). Thirty-one patients were treated by transsphenoidal surgery. Four of these were cured, 10 patients developed postoperative anterior pituitary hormone deficiency, and one patient developed diabetes insipidus. Twenty patients were treated by transcranial surgery, of which two were cured, while 17 patients developed postoperative anterior pituitary hormone deficiency. In total, five of the patients who were not cured after surgery were given conventional radiotherapy, of which two were cured. Four of 15 patients, on whom Gamma Knife radiosurgery was performed, were cured. Biochemical remission was achieved in 32 of 52 patients who received octreotide treatment, and in two of five patients who received lanreotide treatment. CONCLUSIONS: The rate of surgical success in our patients was found to be low. This could be explained by an absence of experienced pituitary surgical centers or surgeons in our region, and the fact that most patients presented late at the macroadenoma stage.

Inadequate gonadal replacement in patients with Turner syndrome may result in pituitary volume enlargement.

OBJECTIVES: Patients with Turner syndrome need hormone replacement therapy for puberty induction. However, it is not known whether inadequate hormone replacement therapy affects the pituitary. DESIGN AND PATIENTS: Patients with Turner syndrome (n=35) and healthy control (n=20) (age/gender matched) subjects were included. MRI imaging of the pituitary was used to calculate pituitary volumes. According to the estradiol regimen, patients were divided into two groups; (i) those treated with low-dose conjugated oestrogen (CE, 0.625 mg) and (ii) those treated with combination therapy (ethinyl estradiol+sipropterone acetate; 35 mcg/2 mg). Pituitary measurements were calculated according to pituitary borders and their distances to each other via pituitary MRI. RESULTS: Pituitary hyperplasia (0.58±0.15 cm3 vs. 0.40±0.17 cm3) was determined in patients with low dose conjugated estrogen compared to the other patients or healthy control subjects (0.42±0.16 cm3) (p=0.005). Serum FSH levels of the patients treated with low dose CE were also higher compared to the patients who received combination therapy (p=0.001). CONCLUSION: Inadequate hormone replacement therapy can cause devastating effects on the bones and uterine health and disrupts the pituitary structure.

Capecitabine-induced hypertriglyceridemia and hyperglycemia: two cases.

Capecitabine has shown significant antitumor activity against anthracycline/taxane refractory breast cancer and advanced colorectal carcinoma. The main drug-related adverse effects are palmar-plantar erythrodysesthesia (hand-foot syndrome), diarrhea and stomatitis. Dyslipidemia is a rare but important side effect of this drug. The mechanism of capecitabine-induced hypertriglyceridemia (CI-HTG) is unclear. It may be due to the decreased activities of lipoprotein lipase and hepatic triglyceride lipase. This report is associated with 2 patients who developed severe HTG when receiving capecitabine. Capecitabine was discountinued and antilipemic treatments were given and both cases are in follow-up with normal lipid levels. This report describes CI-HTG and possible pathogenetic mechanisms and the literature is reviewed.

Is it Possible to Assess the Functional Status of Hormone Secretion or Non- Secretion of Adrenal Masses Through Their Magnetic Resonance Imaging (MRI) Characteristics?

BACKGROUND: Diagnostic imaging techniques, including magnetic resonance imaging (MRI) should be performed on all patients with incidentalomas. However, limited number of studies on whether the quantitative measurements (signal intensity index, adrenal to spleen ratio) in MRI could predict the functional status of adrenal adenomas are available. METHODS: Between 2015-2020, 404 patients (265 females, 139 males) with adrenal mass who were referred to the university hospital for further investigation were included. After detailed diagnostic hormonal evaluation, all patients were examined with the MRI 1.5 T device (Signa, GE Medical Systems; Milwaukee, USA). The signal intensities of the adrenal lesions on T2W images were qualitatively evaluated and noted as homogenous or heterogeneous in comparison with the liver signal intensity (SI). A chemical-shift SI index and chemical shift adrenal-to-spleen SI ratio were also calculated. RESULTS: While 331(81.9%) of the patients had nonfunctional adrenal mass, the rest (n=73, 18.1%) were patients with functional (autonomous cortisol secretion-ACS, Cushing syndrome-CS, pheochromocytoma, primary hyperaldosteronism-PA) adrenal masses. In phase vs. phase values of patients with NFAI, Pheo(n=17), ACS (n=30), CS (n=11), and PA (n=15) were 474.04±126.7 vs. 226.6±132.4, 495.3±182.8 vs. 282.17±189.1, 445.2±134.8 vs. 203.3±76.2, 506.8±126.5 vs. 212.2±73.6 and 496.2±147.5 vs. 246.6±102.1, respectively. Mean signal intensity index (SII) and adrenal to spleen ratio (ASR) of all groups (NFAI, Pheo, ACS, CS, PA) were 52.0±24.8 and 0.51, 44.9±22.5 and 0.55, 49.5±24.5 and 0.53, 56.2±16.4 and 0.43, 47.6±25.1 and 0.54, respectively. Based on the currently accepted measurements in the case of ASR and SII, all lesions were similar and observed as fat rich adenomas (p*= 0.552, p** = 0.45). CONCLUSION: The quantitative assessment (SII, ASR) of intracellular lipids in an incidentally discovered adrenal tumor could only help distinguish adrenal masses in the case of adenomas or non-adenomas. As an initial diagnostic evaluation, clinical and laboratory assessment to distinguish hormone secretion should be done for all patients with adrenal incidentalomas.

Which predictors could effect on remission of type 2 diabetes mellitus after the metabolic surgery: A general perspective of current studies?

BACKGROUND: The alarming rise in the worldwide prevalence of obesity is paralleled by an increasing burden of type 2 diabetes mellitus (T2DM). Metabolic surgery is the most effective means of obtaining substantial and durable weight loss in individual obese patients with T2DM. There are randomized trials that justify the inclusion of metabolic surgery into the treatment algorithm for patients with T2DM, but remission rates of T2DM after metabolic surgery can display great variability. AIM: To discuss the most commonly used surgical options including vertical sleeve gastrectomy, adjustable gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. METHODS: We also report from observational and randomized controlled studies on rate of remission of T2DM after the surgical procedures. RESULTS: In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patient with T2DM, but further studies are needed to clarify better the rate of diabetes remission. CONCLUSION: In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patients with T2DM, but further studies are needed to clarify better the rate of diabetes remission.

HbA1c level decreases in iron deficiency anemia.

BACKGROUND: Hemoglobin A1c (HbA1c) is the major form of glycosylated hemoglobin. There are conflicting data on changes in HbA1c levels in patients with iron deficiency anemia (IDA). The present study aimed to investigate the effects of HbA1c levels in the presence of IDA, the effects of iron treatment on HbA1c levels, as well as the relationship between the severity of anemia and HbA1c levels in patients without diabetes. DESIGN AND METHODS: A total of 263 patients without diabetes mellitus (DM) who were admitted to Cukurova University, Faculty of Medicine, Department of Endocrinology and Hematology or who were followed up in this clinic and diagnosed as having IDA were included in the study. A total of 131 patients had IDA. The control group comprised 132 age-matched and sex-matched healthy individuals. RESULTS: The mean HbA1c level was significantly lower in the group with IDA (5.4%) than in the healthy control group (5.9%; p < 0.05). When the patients were divided into three groups according to the severity of anemia through Hb levels, HbA1c levels were observed to decrease as the severity of the anemia increased (5.5%, 5.4%, and 5%, respectively; p > 0.05). The HbA1c levels of the patients with IDA were higher after iron therapy (from 5.4 ± 0.5 to 5.5 ± 0.3; p = 0.057). The mean hemoglobin (Hb), hematocrit (Hct), mean cell volume (MCV), mean corpusculer hemoglobin (MCH), and ferritin values also increased after iron therapy (p < 0.05). CONCLUSION: The study results showed that IDA was associated with low HbA1c levels, and increased after iron therapy. Based on the study findings, it is necessary to consider the possible effects of IDA on HbA1c levels.

Hospitalization costs associated with diabetic foot ulcers treated by a multidisciplinary team in clinical practice. A retrospective study from southern Turkey.

PURPOSE: Diabetic foot ulceration (DFU) is a common problem throughout the world and results in major economic consequences for the patients and country. We aim to describe the estimated cost of illness in patients with DFU in southern Turkey. METHODS: A total of 148 (F=55, M=93) patients with DFU were included in this retrospective study. Patients characteristics, duration time of hospitalisations, biochemical parameters and the presence of diabetic retinopathy, nephropathy, neuropathy, coronary artery disease and peripheral artery disease were recorded from our database. The cost of each patient was recorded from financial affairs and the billing department unit of our hospital. RESULTS: The average unit cost of each patient was £ 730.90±664.9. The major component in the total cost were medication (£ 258.8±360.9) and hospitalisation fees (£ 76.58±56.3). One hundred and fifteen (77.7%) of the patients had peripheral arterial diseases. While we could not determine significant correlations between the patients' demographical features (age, gender, p>0.05), biochemical parameters (plasma glucose, hemoglobin A1c % (HbA1c %)) and year of diagnoses with diabetes mellitus , the length of hospitalisation, presence of peripheral artery diseases and whether amputation (minor or major) was performed were significantly correlated with the total expenses. CONCLUSION: The study revealed that the cost of DFU could show variability in relation to countries' level of development. We highlighted similar studies in other countries; the major factors of total expenses were length of hospitalisation, medication prescription and use of surgery. KEY WORDS: Costs, Diabetic foot, Multidisciplinary team.

Clinical Relevance and Immunohistochemical Patterns of Silent Pituitary Adenomas: 10 Years of Single-centre Experience.

BACKGROUND: Silent pituitary adenomas are clinically non-functional (i.e., without clinically evident pituitary hormone production). INTRODUCTION: The aim of this study was to investigate subjects with silent pituitary adenomas for possible variations in their clinical status. METHODS: A total of 102 patients who had undergone surgery for pituitary adenoma and had been diagnosed with silent pituitary adenoma was included in the study. The patients' preoperative and postoperative hormonal parameters and magnetic resonance imaging (MRI) features were collected, and pathological specimens were re-evaluated. RESULTS: Immunohistochemistry results of the 102 patients were as follows: hormone-negative adenomas (n=35) 35.5%; FSH+LH-positivity (n=32) 31.3%; ACTH-positivity (n=11) 10.7%; α-subunit- positivity (n= 9) 8.8%; prolactin-positivity (n=8) 7.8%; GH-positivity (n=6) 5.4%; and plurihormonal adenoma (n=1). The mean sizes of SGA, SGHA, and SCA were 28.0±12.7, 30.0±16.0, and 27.7±8.9mm (p>0.05), respectively. With the exception of silent gonadotroph adenomas (SGAs), female gender dominance was shown in patients with silent growth hormone adenoma (SGHA) and silent corticotroph adenoma (SCA). Although no clinical relevance was observed in relation to hormonal excess, preoperative GH (4.21±4.6, vs. 0.27±0.36 p=0.00) was slightly more elevated in SGHA than in GH-negative adenomas. Additionally, preoperative basal ACTH values (47.3±28.7 vs. 23.9±14.4, p=0.003) were also higher in SCA compared to the other types. Our findings revealed SCAs to be of more aggressive behaviour than SGHAs and SGAs due to invasiveness in radiological imaging, their elevated re-operation, and postoperative ACTH values. CONCLUSION: Silent pituitary adenomas represent a challenging diagnostic tumour group. Careful initial evaluation of patients with pituitary adenomas should consider any mild signs and symptoms of functionality, particularly in cases of GH- and ACTH-secreting adenomas.

Pituitary Volume in Patients with Primary Empty Sella and Clinical Relevance to Pituitary Hormone Secretion: A Retrospective Single Center Study.

BACKGROUND: According to neuroradiological findings, empty sella seems to be deprived of pituitary tissue in sella turcica. Changing size of the pituitary volume is closely related to the occurrence of primary empty sella. The aim of the study is to determine pituitary dysfunction in patients with partial or total primary empty sella and the significance of pituitary volume measurements in these patients. METHODS: This study was designed retrospectively. 67 patients (55 females, 12 males) diagnosed with primary empty sella syndrome between the years of 2015-2019 were included in the study. Patients were divided into two groups: partial (PES) and total (TES) empty sella by magnetic resonance imaging (MRI). Basal anterior pituitary and its hormones were assessed. We also included 26 healthy control subjects (19 females, 7 males) to compare the differences in pituitary volumes. Volumes were measured by using Osirix Dicom Viewer (Pixmeo SARL, Geneve, Swiss) in 3.0 Tesla scanner MRI. RESULTS: 82.1% (n=55) of all patients were PES and the others were (n=12) TES. Hypopituitarism, known as one or more pituitary hormones deficiency, was found in 12 patients (17.9%). While 9 of them had total PES, the others had partial PES. Secondary adrenal insufficiency and gonadotropin deficiency were more prevalent in patients with TES. Mean volume measurements of patients with TES, PES and healthy subjects were 0.23±0.17, 0.35±0.15, 0.54±0.17 cm3, respectively. Except for IGF1 values (p=0.026), there was not any significant correlation found between the anterior pituitary hormones and volume measurements. CONCLUSION: Although volume measurement has helped in the diagnosis of pituitary empty sella (partial or total), it does not seem to have any significant correlation with pituitary secretory function.

Outcomes of surgical and/or medical treatment in patients with prolactinomas during long-term follow-up: a retrospective single-centre study.

OBJECTIVES: Prolactinoma is the most common cause of pituitary tumours. Current medical guidelines recommend dopamine agonists (cabergoline or bromocriptine) as the initial therapy for prolactinoma. However, surgical removal can also be considered in selected cases, such as patients with macroadenomas with local complications (bleeding or optic chiasm pressure) or those not responding to medical treatment. METHODS: The present retrospective study included patients with prolactinomas (n=43; female, 24; male, 19) who were primarily managed with medical (n=32) or surgical (n=11) treatment. RESULTS: Macroadenoma (n=29.67%) was commonly detected in both genders (female, 54%; male, 84%). Moreover, the mean pre-treatment prolactin levels were similar in both genders (female, 683.3 ± 1347 ng/mL; male, 685.4 ± 805 ng/mL; p=0.226). Surgically treated patients had a greater reduction in tumour size (27.7 ± 17.9 mm pre-treatment vs. 8.72 ± 14.2 mm post-treatment) than non-surgically treated ones (12.5 ± 7.5 mm pre-treatment vs. 4.1 ± 4.2 mm post-treatment; p=0.00). However, the decrease in prolactin levels was similar between the two patient groups (p=0.108). During the follow-up period (10.6 ± 7.0 years), the average cabergoline dose of the patients was 1.42 ± 1.47 mcg/week. CONCLUSIONS: Although a surgical approach was considered for selected cases of prolactinoma, the average dose used for medical treatment was highly inadequate for the patients in the present study.

Adipocytokines in Non-functional Adrenal Incidentalomas and Relation with Insulin Resistance Parameters.

OBJECTIVE: Adrenal incidentalomas are diagnosed incidentally during radiological screenings and require endocrinological investigations for hormonal activity and malignancy. In certain studies, it has been reported that non-functional incidentalomas can be associated with high adipocytokines levels affecting the insulin resistance just like the adipose tissue with metabolic syndrome. Here, we studied serum adipocytokine levels including leptin, resistin, visfatin, omentin 1 and adiponectin in subjects with non-functional adrenal incidentaloma. METHODS: Seventy-seven (77) patients (Female 57; Male 20) with non-functional adrenal incidentaloma (NFAI) were enrolled in the study. All patients' past medical history, physical examination including Body Mass Index (BMI) and waist circumference were performed. The patients' demographic, radiologic, hormonal and biochemical parameters were recorded. To compare the parameters, a control group (CG) (n=30) was formed from healthy volunteers. Both groups were matched for age, gender, waist circumference and BMI. Serum adipocytokines including leptin, resistin, visfatin, omentin 1 and adiponectin were measured quantitatively by ELISA. Fasting plasma glucose, insulin, sodium, potassium, cortisol, adrenocorticotropic hormone (ACTH), lipid profiles, and dehidroepiandrostenedion sulphate (DHEAS) were measured. RESULTS: Mean age of the patients was 52.2±10.4 years. BMI and waist circumference of NFAI patients were 26.2±3.28 kg/m2 and 90.2 ±7.5cm, respectively. The mean age of the control group was 48.0±8.16. BMI and waist circumference values for the control group were 25.3±3.5 kg/m2 and 88.3±9.6 cm, respectively. When both groups were compared for age, gender, BMI and waist circumference were non-significant (p>0.05). Serum fasting insulin, total cholesterol, LDL, triglyceride levels of the NFAI group were significantly higher than CG (p<0.05). The insulin resistance index (HOMAIR) values of the NFAI subjects were found to be higher than CG (2.5±1.37, 1.1±0.3 p=0.00). Resistin level of NFAI group was also found to be higher than CG [286.6 ng/L vs. 197 ng/L; (P=0,00)], respectively. Leptin levels of NFAI were significantly higher than CG [441.1 ng/mL vs. 186.5 ng/mL; (P=0.00)] respectively. Adiponectin levels were significantly reduced in the NFAI group than in the CG [10.7 mg/L vs. 30.8 mg/L; (P=0.00)]. Comparision of visfatin and omentin levels was nonsignificant. CONCLUSION: In this study on subjects with non-functional adrenal incidentaloma, we found not only significantly decreased serum adiponectin levels but also increased leptin, resistin levels as well as dyslipidemia, hypertension and high insulin resistance index. All of which could affect insulin resistance and cardiovascular risk factors. The underlying mechanisms of these findings are unknown, hence further studies are needed.