Sonographic Features of Atypical and Initially Missed Parathyroid Adenomas: Lessons Learned From a Single-Center Cohort.

CONTEXT: Awareness of typical and atypical ultrasonographic (US) features of parathyroid adenomas (PAs) is crucial since US is the most widely used first-line imaging modality. OBJECTIVE: The purpose of this study was to describe the atypical features of PAs on US and other possible factors leading to a false negative examination in a large single-center cohort. MATERIALS AND METHODS: The US records of 457 PAs in 445 patients with biochemically proven primary hyperparathyroidism (PHPT) were evaluated in a prospectively maintained database. Atypical size, composition, shape, echogenicity, location, and vascular pattern on US were noted. For patients who previously had at least one negative US examination in referring centers, the main possible reason was defined accordingly. RESULTS: The study group included 359 female and 86 male patients with PHPT. Typical sonographic features were observed in 231 PAs (51%), whereas 226 (49%) had at least one atypical US feature. The most common atypical features were atypical size (29%), followed by atypical echogenicity (19%), shape (8%), location (7%), and composition (7%), respectively. There were 122 initially missed PAs in all groups. The most frequent main atypical US features leading to false negative examinations were atypical size (22.1%) and atypical location (18.8%). Inexperience was third most common reason (16.3%) for false negative US examinations. CONCLUSIONS: Almost half of PAs have at least one atypical feature on US. Awareness of the high prevalence of atypical US features could increase the accuracy of US examination and potentially decrease demand for more expensive second-line imaging modalities.

Novel Anti-obesity Therapies and their Different Effects and Safety Profiles: A Critical Overview.

Obesity has become an epidemic and a worldwide problem and its treatment is ever-evolving. Apart from diet and exercise, medication and surgery are other options. After disappointing side effects of various obesity drugs, new treatments showed promising results. This review discusses the following anti-obesity drugs: liraglutide, semaglutide, tirzepatide, orlistat, as well as the phentermine/topiramate and bupropion/naltrexone combinations. These drugs have been approved by the Food and Drug Administration (FDA) for weight reduction except for tirzepatide which is still under evaluation. Efficacy and tolerable safety profiles of some of these drugs contribute to the management of obesity and reduce the complications associated with this chronic disease.

Subacute THYROiditis Related to SARS-CoV-2 VAccine and Covid-19 (THYROVAC Study): A Multicenter Nationwide Study.

CONTEXT: The aims of the study are to compare characteristics of subacute thyroiditis (SAT) related to different etiologies, and to identify predictors of recurrence of SAT and incident hypothyroidism. METHODS: This nationwide, multicenter, retrospective cohort study included 53 endocrinology centers in Turkey. The study participants were divided into either COVID-19-related SAT (Cov-SAT), SARS-CoV-2 vaccine-related SAT (Vac-SAT), or control SAT (Cont-SAT) groups. RESULTS: Of the 811 patients, 258 (31.8%) were included in the Vac-SAT group, 98 (12.1%) in the Cov-SAT group, and 455 (56.1%) in the Cont-SAT group. No difference was found between the groups with regard to laboratory and imaging findings. SAT etiology was not an independent predictor of recurrence or hypothyroidism. In the entire cohort, steroid therapy requirement and younger age were statistically significant predictors for SAT recurrence. C-reactive protein measured during SAT onset, female sex, absence of antithyroid peroxidase (TPO) positivity, and absence of steroid therapy were statistically significant predictors of incident (early) hypothyroidism, irrespective of SAT etiology. On the other hand, probable predictors of established hypothyroidism differed from that of incident hypothyroidism. CONCLUSION: Since there is no difference in terms of follow-up parameters and outcomes, COVID-19- and SARS-CoV-2 vaccine-related SAT can be treated and followed up like classic SATs. Recurrence was determined by younger age and steroid therapy requirement. Steroid therapy independently predicts incident hypothyroidism that may sometimes be transient in overall SAT and is also associated with a lower risk of established hypothyroidism.

Molecular and pro-inflammatory aspects of COVID-19: The impact on cardiometabolic health.

Obesity, type 2 diabetes (T2DM), hypertension (HTN), and Cardiovascular Disease (CVD) often cluster together as "Cardiometabolic Disease" (CMD). Just under 50% of patients with CMD increased the risk of morbidity and mortality right from the beginning of the COVID-19 pandemic as it has been reported in most countries affected by the SARS-CoV2 virus. One of the pathophysiological hallmarks of COVID-19 is the overactivation of the immune system with a prominent IL-6 response, resulting in severe and systemic damage involving also cytokines such as IL2, IL4, IL8, IL10, and interferon-gamma were considered strong predictors of COVID-19 severity. Thus, in this mini-review, we try to describe the inflammatory state, the alteration of the adipokine profile, and cytokine production in the obese state of infected and not infected patients by SARS-CoV2 with the final aim to find possible influences of COVID-19 on CMD and CVD. The immunological-based discussion of the molecular processes could inspire the study of promising targets for managing CMD patients and its complications during COVID-19.

Single-incision laparoscopic adrenalectomy in a patient with acute hypokalemic paralysis due to primary hyperaldosteronism.

Acute hypokalemic paralysis is a relatively rare cause of acute weakness. It may resolve spontaneously; however, it may be a potential life-threatening condition. Hypertension may be considered the most important finding in combination with hypokalemic paralysis for raising the suspicion of primary hyperaldosteronism (PHA). A 55-year-old hypertensive Mexican woman was admitted to the Emergency Unit with a sudden onset of generalized paralysis. An endocrinological workup and an abdominal magnetic resonance imaging revealed PHA with a 1.5 cm left adrenal tumor. After preoperative medication, left adrenalectomy was performed with single-incision laparoscopic surgery (SILS). The duration of the surgery was 45 min, and no postoperative complication was encountered. The patient was discharged after 24 h. Hypokalemic paralysis may be due to different conditions, but it may raise the suspicion of PHA in combination with a history of generally mild hypertension. Laparoscopic adrenalectomy is the preferred operation for unilateral adrenal adenomas that cause PHA. Single-incision laparoscopic surgery is a step-forward technique that improves the cosmesis, decreases access-related morbidity, and increases the postoperative recovery. We report a case with acute hypokalemic paralysis due to PHA and treated with SILS.

Low- and high-density lipoprotein subclasses in subjects with nonalcoholic fatty liver disease.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is associated with increased cardiometabolic risk. Although dyslipidemia represents a key factor in this disease, its impact on serum levels of distinct lipoprotein subfractions is largely unknown. OBJECTIVE: To assess the full low-density lipoprotein (LDL) and high-density lipoprotein (HDL) profiles in patients with NAFLD. METHODS: Seven LDL and 10 HDL subfractions were assessed by gel electrophoresis (Lipoprint, Quantimetrix Corporation, USA) in men with biopsy proven NAFLD (simple steatosis [n = 17, age, 34 ± 7 years] and nonalcoholic steatohepatitis [NASH; n = 24, age, 32 ± 6 years]). Exclusion criteria included robust alcohol consumption, infection with hepatitis B or C virus, body mass index ≥ 40 kg/m(2), diabetes mellitus, and hypertension. RESULTS: Compared with simple steatosis, NASH patients had similar body mass index, homeostasis model assessment of insulin resistance index and plasma lipids, with increased levels of both aspartate aminotransferase and alanine transaminase. NASH subjects had lower levels of larger LDL1 (10 ± 4 vs 13 ± 4%, P = .010) and increased smaller LDL3 and LDL4 particles (9 ± 5 vs 5 ± 5%, P = .017 and 3 ± 3 vs 1 ± 2%, P = .012, respectively). No changes were found in the HDL subclass profile. By multiple regression analysis, we found that NASH was associated only with increased levels of LDL3 (P = .0470). CONCLUSIONS: The increased levels of small, dense LDL3 and LDL4 in NASH may help to at least partly explain the increased risk for atherosclerosis and cardiovascular diseases in these patients.

Role of cytological characteristics of benign thyroid nodules on effectiveness of their treatment with levothyroxine.

INTRODUCTION: Levothyroxine (LT4) therapy has been used for the treatment of euthyroid nodular goiter, but there are controversial results about its usefulness. We aimed to evaluate the possible role of benign nodules' cytological characteristics in response to LT4 therapy. MATERIAL AND METHODS: In total, 93 patients with 128 nodules were included in the study; 74 of the nodules were treated with LT4 (group 1), and 54 of them had no medication (group 2). The subgroups consisted of adenomatous nodules, colloid nodules and cystic nodules. RESULTS: In group 1, mean thyroid volume and mean nodule volume were reduced significantly (p = 0.002 and p = 0.022, respectively) with low-normal level thyrotropin (TSH) suppression (between 0.3 mIU/ml and 1.0 mIU/ml), while there were no significant changes in group 2. When we evaluated changes of the initial and last nodule volumes in cytological subgroups, only colloid nodules in group 1 had significant reduction (p = 0.040) and the others had no significant changes. By omitting the colloid nodules, when the other nodules were revaluated, there were no significant changes in either group. CONCLUSIONS: On the basis of these results, obtained from a large sample of Anatolian patients, it is possible that LT4 therapy leads to significant reductions of both thyroid volume and nodule size in colloid nodules, but not in other kinds of benign nodules.

Cardiac autonomic function and global left ventricular performance in autoimmune eauthyroid chronic thyroiditis: is treatment necessary at the euthyroid stage?

OBJECTIVE: Autoimmune chronic thyroiditis (ACT) is characterized by lymphocyte infiltration in the thyroid gland and the presence of antithyroid antibodies in serum. Medical treatment does not affect antibody levels and treatment decision is not definite yet for the euthyroid patients. We aimed to evaluate cardiac autonomic function and global left ventricular performance in autoimmune euthyroid chronic thyroiditis and determine the need for medical treatment. METHOD: We studied 30 ACT patients and 25 healthy control subjects. Cardiac autonomic function is evaluated by heart rate recovery (HRR). Global left ventricular performance is evaluated by two-dimensional echocardiography and pulsed-wave tissue Doppler echocardiography. RESULTS: There was no difference between patients and controls with respect to clinical and biochemical parameters except hemoglobin (13.67 ± 1.25 g/dL, 14.51 ± 1.35 g/dL, p:0.047) and low density lipoprotein (120.71 ± 24.91 mg/dL, 100.55 ± 14.73 mg/dL, p: 0.003). Tei index was significantly higher in ACT group (0.521 ± 0.074, 0.434 ± 0.034, P < 0.0001). E'/A' was found to be significantly lower (1.234 ± 0.42, 1.750 ± 0.291, P < 0.0001) and E/E' was found to be higher than the controls (8.482 ± 0.449, 6.039 ± 0.209, P < 0.0001). HRR was significantly lower than the controls (20 ± 4 BPM, 30 ± 8 BPM, P < 0.0001). CONCLUSION: Although left ventricular performance is found to be normal by conventional echocardiographic methods, it is found to be impaired when Tei index and tissue Doppler parameters are used. Cardiac autonomic function is also impaired in ACT patients. As a result of these cardiac changes, medical treatment may be considered earlier, even at the euthyroid stage.

An update on the relationships between rheumatoid arthritis and atherosclerosis.

Rheumatoid arthritis is a chronic inflammatory disease. Cardiovascular events are the most important cause of mortality and morbidity in patients with rheumatoid arthritis. Beyond the traditional cardiovascular risk factors, chronic systemic inflammation has been shown to be a crucial factor in atherosclerosis development and progression from endothelial dysfunction to plaque rupture and thrombosis. Many studies have shown that atherosclerosis is not a passive event like accumulation of lipids in the vessel walls; by contrast, it represents an active inflammation of the vessels. Inflammatory cells such as macrophages, monocytes and T cells play important roles in the development of both rheumatoid arthritis and atherosclerosis. In this article we analyse the relationships between rheumatoid arthritis and atherosclerosis.

Comparative effects of atorvastatin and simvastatin on the plasma total homocysteine levels in women with polycystic ovary syndrome: a prospective randomized study.

OBJECTIVE: To test the hypothesis that statins improve hyperhomocysteinemia in women with polycystic ovary syndrome (PCOS). DESIGN: A prospective randomized study. SETTING: University Hospital. PATIENT(S): Fifty-two women with PCOS and 52 women matched for age and body mass index as controls. INTERVENTION(S): Patients were randomly divided into two groups for treatment: group 1, atorvastatin, 20 mg daily (n = 26), and group 2, simvastatin, 20 mg daily (n = 26). Blood samples were obtained before and after treatment. MAIN OUTCOME MEASURE(S): Serum homocysteine levels. RESULT(S): After 12 weeks of treatment, serum homocysteine levels in group 1 had decreased from 14.3 +/- 2.9 to 10.6 +/- 1.7 micromol/L; in group 2, the levels decreased from 13.6 +/- 2.1 to 11.1 +/- 1.9 micromol/L. Both two groups, free testosterone and total testosterone declined statistically significantly (38.3% and 36.5%; and 40.6% and 46.0%, respectively). In group 1, vitamin B(12) increased from 362.1 +/- 107 to 478.7 +/- 267 pg/mL; in group 2, it increased from 391.3 +/- 107 to 466 +/- 211 pg/mL, but the change did not reach statistical significance. There was a considerable decline in the homeostatic model assessment index in group 1 (40.0% to 32.1%). CONCLUSION(S): Treatment with statins in women with PCOS leads to decreases in serum homocysteine levels.

Hypokalemic paralysis is not just a hypokalemic paralysis.

OBJECTIVE: Although the commonest form of hypokalemic paralysis is the hereditary variety, some patients during course of thyrotoxicosis or with chronic potassium depletion, may exhibit episodic weakness. Approach to the patient with hypokalemic paralysis should be a careful search for the etiology and potassium replacement therapy. METHODS: In this report, two hypokalemic paralysis cases are described. RESULTS: Case 1 is a 29-year-old Caucasian male who developed thyrotoxic periodic paralysis. Case 2 is a 50-year-old female who experienced hypokalemic paralysis due to primary aldosteronism. CONCLUSION: Hypokalemic paralysis usually carries an underlying secret problem. Emergency department workers should give importance to etiological differentiation.

Color flow Doppler sonography for the etiologic diagnosis of hyperthyroidism.

Color flow Doppler sonography (CFDS) is gaining importance for the functional evaluation of the thyroid disorders. We aimed to determine the value of CFDS for the etiological diagnosis of hyperthyroidism. Fifty-five patients with hyperthyroidism (29 Graves' disease [GD] and 26 toxic adenoma [TA]), 24 patients with Hashimoto's thyroiditis (HT), and 39 euthyroid controls were included. Etiological diagnoses were carried out using standard methods. Conventional gray scale sonography was performed, followed by CFDS. Doppler patterns of the glands were scored and peak systolic velocity (PSV) measurements were obtained from intrathyroidal, perithyroidal, and perinodular vasculature. Vascular patterns were significantly more prominent, and the mean PSV values were significantly higher in the GD patients compared to the HT patients ( p < 0.001) and controls ( p < 0.001). Perinodular and intranodular signals and the mean perinodular PSV values were significantly higher in TAs compared to controls. CFDS could differentiate the untreated GD from the HT, which had similar gray scale findings. Hot nodules could also be differentiated from cold nodules with more prominent vascular patterns and significantly higher PSV values. As an inexpensive, fast, and noninvasive imaging procedure, CFDS could be helpful in the initial clinical evaluation and may avoid scintigraphy in a substantial number of thyrotoxic patients.

New-onset acute heart failure after intravenous glucocorticoid pulse therapy in a patient with Graves' ophthalmopathy.

A 53-yr-old previously healthy man was admitted to our hospital for thyrotoxicosis without ophthalmopathy. Initial therapy with propylthiouracil caused an acute elevation of liver enzymes. Then, he received a first course of 131I therapy (20 mCi). At the end of 6-mo follow-up after 131I, he was still thyrotoxic and developed moderately severe ophthalmopathy. The patient refused thyroid surgery and decided to undergo second course of 131I therapy (30 mCi). Concomitantly with the 131I, we opted to give high-dose pulse glucocorticoid therapy (PGT) to prevent further deterioration of GO. The patient was started on intravenous methylprednisolone pulse therapy 1 g daily in a cycle (one cycle every 2 wk, each cycle comprising two infusions on alternate days). After the end of the second day of PGT administration, he suddenly developed onset of acute pulmonary edema and hypertension. There was no previous history of cardiac disorder or conditions predisposing to cardiac failure other than thyrotoxicosis. A presumptive diagnosis of fluid overload and/or hypertension- induced acute heart failure was made. After prompt investigations excluding cardiogenic causes, we thought that this condition was triggered by PGT that was superimposed on thyrotoxicosis-related hemodynamic instability. Graves' patients with uncontrolled thyrotoxicosis should be under careful surveillance when PGT is planned. To our knowledge, this is the first reported case of life-threatening acute pulmonary edema caused by PGT in GO.

Comparison of palpation-guided fine-needle aspiration biopsy to ultrasound-guided fine-needle aspiration biopsy in the evaluation of thyroid nodules.

OBJECTIVE: Although fine-needle aspiration biopsy (FNAB) of thyroid nodules is a reliable and simple method, the diagnostic value may be limited by inadequate and false-negative results. In this prospective study, we compared palpation-guided FNAB (PGFNAB) with ultrasound-guided FNAB (UGFNAB) to establish the rates of inadequate material and cost-effectiveness. DESIGN: A total of 285 thyroid nodules in 215 patients were included in the study. Palpable nodules with the greatest diameter between 1 and 2.5 cm were included in the study. PGFNAB and UGFNAB techniques were applied to the same nodule by the same operator. Cytologic evaluations were performed by the same cytologist in a blinded fashion. To provide cost analysis, the prices obtained from different hospitals were evaluated. MAIN OUTCOME: The rates of inadequate material for PGFNAB and UGFNAB were significantly different as 32.3% and 21.4%, respectively (p = 0.004). There was significantly higher inadequate material rate in PGFNAB group for small-sized nodules (greatest nodule diameter between 10 and 15 mm) (p = 0.009), despite inadequate material rate was not significant for both procedures for larger sized nodules. False-negative results were 15.8% for PGFNAB and 5.6% for UGFNAB. Regarding cost analysis, the difference between the two methods was 20 dollars on average for each patient. CONCLUSIONS: We consider UGFNAB to be superior to PGFNAB for obtaining adequate material especially for small-sized nodules, as well as providing more accurate cytologic evaluation. Indeed, the difference between the costs of two procedures might be acceptable.