Evaluation and follow-up of patients diagnosed with hypophysitis: a cohort study.

OBJECTIVE: Primary hypophysitis might be challenging to diagnose, and there is a lack of evidence regarding optimal treatment strategies due to rarity of the disease. We aim to investigate the clinical features and compare the outcomes of different management strategies of primary hypophysitis in a large group of patients recruited on a nationwide basis. DESIGN: A retrospective observational study. METHODS: The demographic, clinical, and radiologic features and follow-up data were collected in study protocol templates and analyzed. RESULTS: One hundred and thirteen patients (78.8% female, median age: 36 years) were included. Lymphocytic (46.7%) and granulomatous hypophysitis (35.6%) were the prevailing subtypes out of 45 patients diagnosed after pathologic investigations. Headache (75.8%) was the most common symptom, and central hypogonadism (49.5%) was the most common hormone insufficiency. Of the patients, 52.2% were clinically observed without interventions, 18.6% were started on glucocorticoid therapy, and 29.2% underwent surgery at presentation. Headache, suprasellar extension, and chiasmal compression were more common among glucocorticoid-treated patients than who were observed. Cox regression analysis revealed higher hormonal and radiologic improvement rates in the glucocorticoid-treated group than observation group (hazard ratio, 4.60; 95% CI, 1.62-12.84 and HR, 3.1; 95% CI, 1.40-6.68, respectively). The main indication for surgery was the inability to exclude a pituitary adenoma in the presence of compression symptoms, with a recurrence rate of 9%. CONCLUSION: The rate of spontaneous improvement might justify observation in mild cases. Glucocorticoids proved superior to observation in terms of hormonal and radiologic improvements. Surgery may not be curative and might be considered in indeterminate, treatment-resistant, or severe cases.

Impact of early versus late enteral nutrition on cell mediated immunity and its relationship with glucagon like peptide-1 in intensive care unit patients: a prospective study.

INTRODUCTION: Glucagon-like peptide-1 (GLP-1) originates from the gastrointestinal system in response to the presence of nutrition in the intestinal lumen and potentiates postprandial insulin secretion. Also, it acts as an immune-modulator which has influences on cell-mediated immunity. MATERIALS AND METHODS: The study was designed as a prospective, single-blinded study and carried out in the neurology intensive care unit (ICU) of a university hospital. Twenty-four naive patients with acute thromboembolic cerebrovascular events, with National Institute of Health (NIH) stroke scores between 12 and 16, were included. Any condition interfering with GLP-1 and immunity was regarded as exclusion criterion. Two patients died, and two dropped out of the study due to complicating conditions. RESULTS: Group 1 and Group 2 exhibited similar GLP-1 levels in the pre-feeding and post-feeding periods for both the first time and the third day of enteral feeding. Also, no significant change in pre-/post-feeding GLP-1 levels was observed within groups. T-helper and T-regulatory cells increased, T-cytotoxic cells decreased significantly in Group 1 (P=0.02; P=0.036; P=0.0019), but remained the same in Group 2 after enteral feeding. Positive but statistically insignificant clinical effects in terms of predisposition to infections (10% vs 40%) and median time of ICU stay (10 vs 15 days) were observed in Group 1. CONCLUSIONS: Depending on our findings, we propose that early enteral feeding may cause amelioration in cell-mediated immunity via factors other than GLP-1 in ICU patients with acute thromboembolic stroke. However, the possible deleterious effects of parenteral nutrition cannot be ruled out.

Clinical and demographic aspects of Paget disease of bone: A multicentric study from Turkey.

OBJECTIVE: Paget disease of bone (PDB) is a metabolic bone disease that has been rarely reported in the Eastern countries. This study aimed to evaluate the clinical and demographic characteristics of patients with PDB followed up at endocrinology clinics in Turkey. METHODS: An invitation was sent to tertiary endocrinology clinics to complete a survey on the demographic, clinical, radiological, and laboratory parameters, as well as treatment modalities of patients with PDB. This study enrolled clinically and radiologically proven 185 patients with PDB from 18 endocrinology centers based in 10 cities of Turkey. RESULTS: This cohort of PDB had female preponderance (women/men: 105/80) with a mean age, during diagnosis, of 57±10 years. Most of the patients (59.6%) were symptomatic at diagnosis. Bone pain and headache were the predominant clinical symptoms. Polyostotic disease was observed in 67.5% (n=125) of patients. Frequently affected bones were skull (41.6%), pelvis (53.5%), spine (41%), and femur (25.4%). Moreover, 17 patients with skull involvement had hearing loss. Mean serum alkaline phosphatase (ALP) level (552±652 IU/L; range: 280-5762 IU/L) was over the normal reference cutoff with normal serum calcium levels. Intravenous bisphosphonates (zoledronic acid, 5 mg; pamidronate, 60-90 mg) were the most used drugs (75%) for the treatment of PDB. Most of the patients (87.1%) treated with intravenous bisphosphonates responded well, with a decrease in serum ALP level (117±114 IU/L) in the 12th month of therapy. Furthermore, 16 patients relapsed after the second year of therapy; 3 patients did not respond to the initial intravenous bisphosphonate treatment. CONCLUSION: The patients with PDB followed up by endocrinology clinics of Turkey exhibited polyostotic disease with classical clinical, radiological, and biochemical features and women's predominance with good response to intravenous bisphosphonate therapy.

Plasma fetuin-A levels are reduced in patients with hypothyroidism.

OBJECTIVE: To determine plasma fetuin-A levels in hypothyroid patients before and after treatment with l-thyroxine (T4) and to determine the relation between plasma fetuin-A levels with cardiovascular risk factors. DESIGN: A prospective, controlled, single-blind study. METHODS: Forty-four treatment-naive female patients diagnosed with hypothyroidism and 39 age- and sex-matched control subjects were enrolled. Anthropometric measurements, blood pressure, plasma TSH, fetuin-A, free T4, LDL-cholesterol, triglyceride, C-reactive protein, fibrinogen levels, and brachial artery flow-mediated dilatation were measured. All measurements were repeated after 3 months in the control group and 3 months after the attainment of euthyroidism with l-T4 replacement in the hypothyroid group. Baseline data were compared between the two groups. Posttreatment plasma fetuin-A levels of hypothyroid patients were compared with baseline levels of both groups. The relationship between plasma fetuin-A, TSH levels, and other cardiovascular risk factors was evaluated. RESULTS: Plasma fetuin-A levels were ∼20% lower in hypothyroid female patients compared with the controls (P=0.0001). Fetuin-A levels increased by ∼20% in hypothyroid patients after achievement of euthyroidism (P=0.0001) and were no longer different compared with controls (P=0.38). There was a negative correlation between plasma TSH and fetuin-A levels (r=-0.79; P=0.001). There was no significant correlation between plasma fetuin-A levels and cardiovascular risk factors within or between groups. The fetuin-A levels were normalized with thyroid hormone treatment. CONCLUSION: Plasma fetuin-A levels are reduced in female patients with hypothyroidism, which are restored to normal during restoration of euthyroidism. There was no relation with cardiovascular risk factors.

Are plasma thyroid-stimulating hormone levels associated with degree of obesity and metabolic syndrome in euthyroid obese patients? A Turkish cohort study.

We aimed to observe the association between degree of obesity and metabolic syndrome and plasma thyrotropin levels in obese, euthyroid Turkish patients. 947 obese and overweight patients who admitted to our outpatient clinic were assessed retrospectively. 150 healthy euthyroid cases were also recruited as the control group. Cases with metabolic syndrome were determined. Patients were divided into various subgroups as overweight, obese, morbid obese, men, and women. No statistical significance was determined when all the patients' and subgroups' plasma thyrotropin levels were compared to normal weight control group. No association was shown between the presence of metabolic syndrome and plasma thyrotropin levels for both all patients and subgroups. Also there was not any association between each component of metabolic syndrome and plasma thyrotropin levels. In conclusion, we did not found any significant association between plasma thyrotropin levels and obesity and metabolic syndrome in our euthyroid subjects.

Risk Factors That can Predict Antenatal Insulin Need in Gestational Diabetes.

BACKGROUND: This study was undertaken to assess the association between insulin need in gestational diabetes mellitus (GDM) and clinical features and laboratory parameters. Factors that can predict insulin need are also identified. METHODS: Cases with GDM were included retrospectively from records. Cases which failed to achieve target blood glucose levels with medical nutrition therapy (MNT) and need insulin treatment were recorded. Risk factors which can predict antenatal insulin treatment (AIT) were identified as follows; the presence of diabetes in a first degree relative, body mass index prior to pregnancy, number of parity, history of GDM, macrosomic baby delivery (> 4,000 g), age, gestational week at time of diagnosis, body mass index during diagnosis, weight gain untill diagnosis, mean systolic and diastolic blood pressure, HbA1C level during diagnosis, and fasting plasma glucose on diagnostic oral glucose tolerance test. Presence of a statistical significance between those patient features and AIT was assessed. Independent predictors for AIT were evaluated. RESULTS: A total of 300 cases were recruited from records, 190 cases (63.3%) were followed only with MNT until delivery and 110 cases (36.7%) were initiated AIT. The association between AIT and patient factors like presence of diabetes in the pedigree, week of gestation at which GDM was diagnosed, BMI during diagnosis, HbA1C levels, and fasting plasma glucose during diagnosis was found (P = 0.03; 0.008; 0.049; 0.001 and 0.001respectively). Multivariant analysis showed that fasting plasma glucose levels during diagnosis and HbA1C levels were independent risk factors for AIT. Fasting plasma glucose values that can predict AIT were identified > 89.5 mg/dL with 72.7% sensitivity and 62.6% spesifity (P < 0.001). Positive predictive value was 73% (P < 0.001). Also, HbA1C levels that can predict AIT was found to be > 5.485% with 65.3% sensitivity and 66.7% spesifitiy(P < 0.001) with a positive predictive value 68% (P < 0.001). CONCLUSIONS: Independent predictors for AIT were found as fasting plasma glucose on OGTT and HbA1c levels during diagnosis in GDM. Cases with fasting plasma glucose ≥ 89.5 mg/dL or HbA1C ≥ 5.485% should be closely followed for AIT in specified centers.

A case of inoperable malignant insulinoma with resistant hypoglycemia who experienced the most significant clinical improvement with everolimus.

Metastatic insulinomas may sometimes present with recurrent life-threatening hypoglycemia episodes. Such patients usually fail to respond to various therapeutic agents which causes constant dextrose infusion requirement. Herein, we present a resistant case of inoperable malignant insulinoma who was treated with many therapeutic agents and interventions including somatostatin analogues, Yttrium-90 radioembolization, everolimus, radiotherapy, and chemoembolization. Close blood sugar monitorization during these therapies showed the most favourable response with everolimus. Everolimus treatment resulted in rapid improvement of hypoglycemia episodes, letting us discontinue dextrose infusion and discharge the patient. However, experience with everolimus in such patients is still limited, and more precise data can be obtained with the increasing use of this agent for neuroendocrine tumours.

Successful management of a giant pituitary lactosomatotroph adenoma only with cabergoline.

Although advances in endocrinologic and neuroradiologic research allow easier recognition of pituitary adenomas, giant pituitary tumours are relatively rare. In the literature, the term "giant" is generally used when a pituitary tumour becomes larger than 4 cm in diameter. Cabergoline is a potent and long-acting inhibitor of prolactin secretion, which exhibits high specificity and affinity for dopamine D2 receptor. Herein, we report a 46-year-old woman with a giant lactosomatotroph pituitary adenoma, sized 6 × 5 × 5.5 cm, who is treated successfully only with cabergoline. The patient showed dramatic response to cabergoline treatment by means of clinical, biochemical and radiological imaging findings. Cabergoline seems to be safe and effective in the treatment of prolactin and growth hormone cosecreting pituitary adenomas as well as prolactinomas. However, surgical or more aggressive approach must be considered where indicated.

The effects of hypothyroidism on strength-duration properties of peripheral nerve.

Axonal injury and/or demyelination commonly result in peripheral mononeuropathy, polyneuropathy or entrapment neuropathies in hypothyroidism. In this study, we aimed to measure the strength-duration time constants (SDTC) of motor and sensory fibres in patients with primary hypothyroidism before and after hormone replacement treatment. The motor and sensory SDTC and rheobase of 14 patients with overt hypothyroidism (TSH>10mg/ml, free T4