What is the optimal time for measuring glucose concentration to detect steroid-induced hyperglycemia in patients with rheumatic diseases?

OBJECTIVE: Corticosteroids may cause hyperglycemia and diabetes mellitus (DM). Development of DM during long-term steroid use has been well studied; however, data regarding the short-term effects of steroid therapy are scarce. In this study, we aimed to detect the actual time of short-term steroid-induced hyperglycemia in patients without previous impaired glucose metabolism, and the ideal time (which day and in relation to meals) of glucose measurement. METHODS: The 7-point blood glucose (BG) measurements of patients who were commenced moderate to high-dose steroids (≥15 mg/day prednisolone or its equivalent) due to rheumatological diseases during the first 5 days of steroid therapy were recorded. Fasting BG ≥ 7 mmol/L (126 mg/dL) or random BG ≥ 11.1 mmol/L (200 mg/dL) were considered as overt DM in accordance with the 2016 American Diabetes Association guideline, and post-meal BG ≥10 mmol/L (180 mg/dL) was considered as steroid-induced hyperglycemia. RESULTS: Fifteen males (mean age: 44 ±â€¯16 years) and 35 females (mean age: 41 ±â€¯12 years) were recruited to the study. One thousand seven hundred fifty fasting, pre-meal, and 2-hours post-meal BG concentrations were analyzed. Twenty-one (42%) patients developed steroid-induced DM and 39 (78%) developed steroid-induced hyperglycemia. The highest glucose concentrations were detected on the 3rd day of steroid therapy and 2-h after meals (p < .0001). CONCLUSION: Intermediate to high-dose steroid therapy causes hyperglycemia after lunch and dinner on the 3rd day of treatment. This time period should be taken into consideration in the detection and treatment of steroid-induced hyperglycemia.

Oncocytic neoplasms; rare adrenocortical tumours - a report of eleven patients.

INTRODUCTION: Oncocytomas of adrenal glands are extremely rare and usually present as incidentally detected masses. We aimed to present a series of patients with adrenal oncocytomas and review the literature. MATERIAL AND METHODS: Electronic database of patients with adrenal tumours, who were admitted to the internal medicine and endocrinology and metabolism outpatient clinics of Uludag University Medical Faculty between January 2005 and November 2016, were assessed retrospectively. Those who underwent surgery and pathological diagnosis of oncocytoma (n = 11) were included to the study. The demographic, clinical, pathological, radiological, and laboratory features were evaluated. RESULTS: Of these 11 patients, 54.5% (n = 6) were female and 45.5% (n = 5) were male. They aged between 31 and 76 years (45.36 ± 13.68). Five (45.5%) of the masses showed endocrinological activity and were more frequent in women. The masses were 25-130 (57.63 ± 34.04) mm in width and 20-100 (47.82 ± 28.95) mm in length. Seven (63.6%) oncocytomas were classified as benign and the remainder as having uncertain malignant potential according to Lin-Weiss-Bisceglia criteria. Mean duration of follow-up were 24.8 (6-60) months and 38.2 (15-82) months, respectively. CONCLUSIONS: Because there are no unique clinical and imaging characteristics differentiating adrenal oncocytomas from other types of adrenal masses, it should be kept in mind in differential diagnosis of adrenal masses, especially large ones and those suspicious for adrenocortical carcinoma.

Is Parenteral Levothyroxine Therapy Safe in Intractable Hypothyroidism?

CASE: A 32-year old woman was admitted to the hospital due to intractable hypothyroidism refractory to high dose of oral l-thyroxine therapy. She underwent total thyroidectomy and radioactive iodine therapy due to papillary thyroid cancer. After excluding poor adherence to therapy and malabsorption, levothyroxine absorption test was performed. No response was detected. Transient neurologic symptoms developed during the test. She developed 3 attacks consisting of neurologic symptoms during high dose administration. The patient was considered a case of isolated l-thyroxine malabsorption. She became euthyroid after intramuscular twice weekly l-thyroxine therapy. DISCUSSION: There are a few case reports regarding isolated l-thyroxine. We report successful long term results of twice weekly administered intramuscular l-thyroxine therapy. We also draw attention to neurologic side effects of high dose l-thyroxine therapy.

Role of Vitamin D in Intima Media Thickness in Patients with Type 1 Diabetes Mellitus.

Increased carotid intima media thickness indicates subclinical atherosclerosis. We evaluated the relation between vitamin D level and intima media thickness in patients with type 1 DM. 93 patients (female/male: 48/45, aged 31.5 ± 11.9 years, A1c 9.48 ± 2.43, vitamin D [15.9 (12.1-19.2)]) with type 1 DM were included into the study. Common carotid artery IMT was measured by real time B mode ultrasonography (MyLab 70 XVG, Esaote SpA, Genoa, Italy). Vitamin D was measured using radioimmunassay. Male and female patients (n = 14, 15%) had similar rates of plaque presence (p = 0.377). IMT was similar according to gender. IMT [0.45 (0.40-0.50)] was positively correlated with age, duration of diabetes, creatinine, LDL/HDL ratio, and ALP. Median IMT was higher in current smokers, patients with retinopathy, and nephropathy, and overweight/obese patients. IMT was not different according to vitamin D status. However calcium level corrected for albumin was in positive correlation with mean IMT (r = 0.221, p = 0.033). We detected high frequency of vitamin D deficiency (78%) defined as less than 20 ng/ml. Vitamin D and diabetes control defined as A1c have no effect on intima media thickness in type 1 DM. Traditional cardiovascular risk factors including age, duration of DM, smoking, and BMI adversely affect intima media thickness.

Parathyroid hormone in washout fluid seems to be superior to cytology for localization of the lesion in MIBI-negative patients with primary hyperparathyroidism

Background/aim: Primary hyperparathyroidism (PHPT) is characterized by increased calcium (Ca) and parathyroid hormone (PTH) levels. Surgical removal of the culprit hyperfunctioning parathyroid gland is the preferred treatment. In this study, we aimed to determine whether PTH-washout or cytological examination of suspicious lesions was superior in MIBI-negative patients diagnosed with PHPT.Materials and methods: We retrospectively evaluated the medical records of 98 patients diagnosed with PHPT. Seventy-six patients who had positive parathyroid scintigraphy and who did not undergo parathyroidectomy in our center due to various reasons were excluded. We evaluated the remaining 22 patients with negative scintigraphy. Medical records including PTH levels in serum and washout fluid of fine-needle aspiration biopsy (FNAB), biochemical data, cytological results of FNAB, and histologic reports were reviewed.Results: The patients had a mean age of 50 +- 9 (31-72) years, serum Ca of 10.9 +- 0.5 (10.3-12.7) mg/dL, serum PTH of 285 +- 156 (107.2-679) pg/mL, and PTH of washout fluid of 19,523 +- 38,632 (1410-166,000) pg/mL. Cytological evaluation revealed insufficient material in 9 patients and cells of indeterminate origin in 4 patients.Conclusion: Our results showed that when evaluating ambiguous lesions on neck ultrasound, measuring the PTH level in washout fluid of FNAB is a reliable and effective method for diagnosis of parathyroid lesions and is superior to FNAB for localization.

A novel truncating AIP mutation, p.W279*, in a familial isolated pituitary adenoma (FIPA) kindred.

Familial isolated pituitary adenomas (FIPA) constitute 2-3% of pituitary tumours. AIP is the most commonly mutated gene in FIPA. We herein report a novel germline mutation of the AIP gene in a family with FIPA. We present two patients, a father and his 12-year-old daughter, diagnosed clinically and using laboratory measures with acromegaly-gigantism. Both underwent transsphenoidal hypophyseal surgery for macroadenomas. We initially detected a novel heterozygous germline AIP mutation, c.836G>A (p.W279*), in the father's DNA. We then found the same mutation in his affected daughter. Pituitary adenomas associated with AIP mutations mostly present as FIPA (68%) at an early age (78% occur at <30 years old). They are often growth hormone (GH) - or prolactin - secreting macroadenomas (88%) that have already extended beyond the sella at the time of diagnosis. Acromegalic cases are resistant to somatostatin analogues and multimodal management is frequently essential to control the disease. Our patients had normalized GH/IGF-1 values soon after surgery, although enough time may not have elapsed to reach final cure. While penetrance of the disease can be as low as 10% in FIPA, especially children and young patients with somatotropinoma and prolactinoma should be surveyed for inactivating mutations or deletions in AIP. Determining the causative mutations may be of assistance in early diagnosis, treatment success, and genetic counseling.

Effect of obesity on TAFI in postmenopausal period.

AIM: The aim of the study was to evaluate how obesity effects the coagulation and fibrinolytic system in the postmenopausal period. METHOD: Forty-eight obese (body mass index (BMI) ≥30 kg/m(2)) and 38 nonobese (BMI < 30 kg/m(2)) postmenopausal women were enrolled in the study. Fat mass and insulin resistance were calculated. Plasma levels of plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA), d-dimer, thrombomodulin, and thrombin activatable fibrinolysis inhibitor (TAFI) antigen were determined by ELISA method. TAFI activity was measured using the chromogenic assay. RESULTS: Obese subjects had higher PAI-1 (73.5 ± 35.7 ng/mL vs. 57.1 ± 34.2 ng/mL, p < 0.05) levels but lower tPA/PAI-1 ratio (0.59 ± 0.50 vs. 38 ± 0.21, p < 0.05) than their nonobese counterparts. Obesity was not statistically significant for other haemostatic variables. BMI and fat mass were positively correlated with PAI-1 (r = 0.312, p = 0.003; r = 0.381, p = 0.005, respectively) and negatively correlated with tPA/PAI-1 ratio (r = -0.273, p = 0.01; r = -0.545, p = 0.01, respectively). HOMA scores were also positively correlated with PAI-1 levels (r = 0.236, p = 0.04). CONCLUSION: We found that tendency to hypercoagulability in the postmenopausal women was due to increased PAI-1 rather than TAFI levels, which may contribute to adverse cardiovascular outcomes in this cohort. Further studies should be undertaken to evaluate effects of weight loss on the coagulation and fibrinolytic system.

Migraine in metabolic syndrome.

OBJECTIVES: Recent studies suggest that insulin resistance is more common in patients with migraine. Insulin resistance underlies the pathogenesis of obesity, diabetes, and hypertension that are components of metabolic syndrome. As migraine is associated with an increased risk of vascular disorders, such as stroke, and migraine patients have higher diastolic blood pressure than healthy individuals, we aimed to investigate the 1-year prevalence of migraine in metabolic syndrome. METHODS: Two hundred ten patients with metabolic syndrome were enrolled in the study. Migraine was diagnosed according to International Classification of Headache Disorders-II criteria. RESULTS: Migraine prevalence was estimated as 11.9% in men and 22.5% in women with metabolic syndrome. Of the metabolic syndrome components, diabetes, increased waist circumference, and body mass index were significantly more frequent in patients with migraine in contrast to those without migraine (P<0.05). Hypertension and dyslipidemia frequencies showed no difference between 2 groups. CONCLUSIONS: Our results demonstrate that migraine prevalence in metabolic syndrome was higher than in the general population.

Serum insulin like growth factor-1 (IGF-1) and insulin like growth factor binding protein-3 (IGFBP-3) levels in liver cirrhosis.

BACKGROUND/AIMS: Impaired growth hormone-insulin like growth factor system in hepatic cirrhosis leads to cirrhosis-related complications. In this study, we aimed to investigate whether serum levels of insulin like growth factor-1 and insulin like growth factor binding protein-3 are related to the level of hepatic dysfunction, clinical grade, and etiologic factors of the disease in patients with liver cirrhosis. METHODS: Forty-two patients with liver cirrhosis who were diagnosed by means of clinical findings, endoscopy, imaging studies, or histopathology were enrolled in the study. An age- and sex-matched control group was comprised of 37 healthy controls with no signs of liver disease by clinical or laboratory findings. The demographic features (age, sex, height, and weight) and serum levels of liver function tests, urea, creatinine, sodium, potassium, insulin like growth factor-1, and insulin like growth factor binding protein- 3 and hemogram values were recorded for each individual. The patients were grouped according to Child Pugh classification and etiology. RESULTS: Insulin like growth factor-1 and insulin like growth factor binding protein-3 levels were significantly lower in the cirrhotic group in comparison to the control group (p<0.005). A statistically significant decrease in levels of insulin like growth factor-1 and insulin like growth factor binding protein-3 was correlated with the degree of liver dysfunction, namely, lowest decrease in Child Pugh class A and highest decrease in class C. With respect to etiology, insulin like growth factor- 1 levels of alcohol-related liver cirrhosis were significantly lower than those of hepatitis B- related cirrhosis. There was no relation between insulin like growth factor binding protein-3 level and etiology. In the cirrhotic group, insulin like growth factor- 1 level was positively correlated with serum albumin and negatively correlated with serum creatinine and sodium levels and spleen size. Likewise, insulin like growth factor binding protein-3 level was positively correlated with serum albumin. There was a negative correlation between insulin like growth factor binding protein-3 level and serum bilirubin and spleen size. CONCLUSIONS: Insulin like growth factor-1 and insulin like growth factor binding protein-3 levels are related to the level of clinical impairment and were independent of the etiology. They may serve as novel markers of hepatocellular dysfunction.

Safety of biopsy in liver hemangiomas.

Hemangiomas are the most common tumors of the liver. Almost all cases are easily detected by ultrasonography, computed tomography, magnetic resonance imaging, and erythrocyte-tagged technetium-99m scintigraphy. In case of inconclusive radiologic features and a history of malignancy or underlying liver disease, liver biopsy is indicated. Bleeding is the most feared complication of biopsy of hemangiomas due to its highly vascular structure. In our clinic, we biopsied seven patients with suspected masses and they were diagnosed histopathologically afterwards as having hemangiomas. We did not observe any complication including bleeding during or after the procedure. Although the case number is too small to reach a definite conclusion, we think that our report deserves attention in showing that concerns about bleeding during biopsy of hemangiomas may be overstated.

Comparison of cefotaxime and ofloxacin in treatment of spontaneous bacterial peritonitis.

BACKGROUND/AIMS: Gold-standard treatment of spontaneous bacterial peritonitis currently involves 3rd generation cephalosporins. To evaluate the efficacy of ofloxacin in this infection, we compared a combined therapy with intravenous and oral ofloxacin to intravenous cefotaxime. METHODS: Thirty cirrhotic patients with spontaneous bacterial peritonitis were assigned to receive either intravenous (1 g/12 h) cefotaxime for 7 days (n=17) or intravenous (200 mg/12 h) ofloxacin for 2 days followed by oral (200 mg/12 h) ofloxacin for 5 days (n=13). All cases had community-acquired spontaneous bacterial peritonitis. RESULTS: The infection resolution rate on the 7th day of therapy was 82.4% in the cefotaxime group and 92.3% in the ofloxacin group. Hospital survival rates were 82.4% and 100%, respectively. CONCLUSIONS: Oral ofloxacin after a short course of intravenous ofloxacin is effective in the treatment of uncomplicated spontaneous bacterial peritonitis. This regimen may allow physicians to treat these patients as outpatients as soon as their intravenous therapy is completed.

B-Cell Lymphoma Presenting with Extensive Cutaneous Involvement.

Cutaneous lymphomas tend to be of T-cell origin, less commonly of B-cell origin. We report a 68-year-old male patient suffering from extensive cutaneous nodules which were found to be B-cell large cell lymphoma in nature. Our case is a good example to unexpected cutaneous involvement of diffuse large cell lymphomas. It may be debated whether it is a primary cutaneous lymphoma or cutaneous involvement of a systemic lymphoma. The case differs from other primary cutaneous lymphomas in the clinical course and in the pathologic and immunohistochemical features. Systemic B-cell lymphomas may also involve the skin. We think that our case demands attention because systemic B-cell lymphomas with such a great skin involvement is not reported in the literature before.