NEW-ONSET PRIMARY ADRENAL INSUFFICIENCY AFTER COVID-19: CASE REPORT.

COVID-19 primarily affects the respiratory system. What comes after the disease is now a greater concern for the scientific world. It is remarkable for causing endocrine organ involvement, particularly in the adrenal glands. However, its effect on the adrenal gland has not been fully elucidated. A case of primary adrenal insufficiency after COVID-19. A 31-year-old female patient who presented with complaints of weakness, anorexia, nausea, recent onset of vomiting, dizziness, and low blood pressure for two months was admitted to the outpatient Department of Endocrinology and Metabolism. After discharge, the patient had routine follow-ups, and here we present the information on the first and seventh month after discharge. The patient was diagnosed with primary adrenal insufficiency with cortisol <0.054 µg/dL and adrenocorticotropic hormone >1200 pg/mL in the laboratory. In the non-contrast computed tomography taken in the adrenal protocol, the stem and leaves of both adrenal glands are significantly thinned and appear atrophic, the right adrenal gland is hardly distinguished. Hydrocortisone was started. All complaints were resolved within a week, except hyperpigmentation, which was resolved six months later after treatment. Our study support adrenal gland involvement due to COVID-19, further research is needed to obtain data on damage mechanisms.

Clinical predictors of ectopic parathyroid adenomas: experience with 421 confirmed parathyroid adenoma localizations.

PURPOSE: This study was designed to evaluate whether patients with ectopic parathyroid adenoma (EPA) have clinical predictors by comparing them with other patients operated on for primary hyperparathyroidism (PHPT) with uniglandular parathyroid adenomas in other localizations. METHODS: The data of PHPT patients who underwent parathyroidectomy in our institution were assessed retrospectively. Abnormal gland localization was confirmed by operative and pathology reports as well as normocalcemia that lasted for at least 6 months postoperatively. The relationships of biochemical and clinical findings of patients with confirmed adenoma localizations were analyzed. In order to determine independent factors that can predict EPAs, binary logistic regression was used. RESULTS: Among 421 patients (83.4% female, mean age 49 ± 13.2 years) enrolled in the study, the most common adenoma localization was the lower left parathyroid gland (36.1%; p < 0.001). Parathyroid adenomas were more common in lower localizations compared to upper localizations and were smaller in size (p < 0.001 and p = 0.004, respectively). In univariate analysis, serum intact parathyroid hormone and calcium levels were found to be higher (p = 0.004 and p = 0.002, respectively), moderate/severe hypercalcemia was more common (p = 0.024), phosphorus levels were lower (p = 0.04), and postoperative transient hypocalcemia was more common (p = 0.013) in cases of EPAs than other localizations. There was no significant difference in adenoma size between EPAs and other classical localizations. In multivariate analysis, only a high serum calcium level was an independent predictor of EPAs (OR 2.017, 95% CI 1.142-3.564, p = 0.016). Receiver-operating characteristic curve analysis yielded an optimal cutoff value of 12.25 mg/dL for serum calcium (88% sensitivity, 63% specificity, and area under the curve: 0.861). CONCLUSION: EPAs can cause a more biochemically distinct PHPT picture compared to parathyroid adenomas in classical localizations. A high calcium level at diagnosis may be a clinical predictor for EPAs and may affect the clinical approach and imaging technique choices. Due to the increased risk of transient hypocalcemia in patients with EPAs, caution should be exercised in postoperative follow-up. Furthermore, in the event of negative preoperative imaging, starting the parathyroid exploration from the lower left region may be a good option for the surgeon.

No association of anti-osteoporosis drugs with COVID-19-related outcomes in women: a nationwide cohort study.

This study was performed to evaluate whether the use of drugs in the treatment of osteoporosis in women is associated with COVID-19 outcomes. The results showed that the risk of hospitalization, intensive care unit admission, and mortality was not altered in individuals taking anti-osteoporosis drugs, suggesting no safety issues during a COVID-19 infection. INTRODUCTION: Whether patients with COVID-19 receiving anti-osteoporosis drugs have lower risk of worse outcomes has not been reported yet. The aim of this study was to evaluate the association of anti-osteoporosis drug use with COVID-19 outcomes in women. METHODS: Data obtained from a nationwide, multicenter, retrospective cohort of patients diagnosed with COVID-19 from March 11th to May 30th, 2020 was retrieved from the Turkish Ministry of Health Database. Women 50 years or older with confirmed COVID-19 who were receiving anti-osteoporosis drugs were compared with a 1:1 propensity score-matched COVID-19 positive women who were not receiving these drugs. The primary outcomes were hospitalization, ICU (intensive care unit) admission, and mortality. RESULTS: A total of 1997 women on anti-osteoporosis drugs and 1997 control patients were analyzed. In the treatment group, 1787 (89.5%) women were receiving bisphosphonates, 197 (9.9%) denosumab, and 17 (0.9%) teriparatide for the last 12 months. Hospitalization and mortality rates were similar between the treatment and control groups. ICU admission rate was lower in the treatment group (23.0% vs 27.0%, p = 0.013). However, multivariate analysis showed that anti-osteoporosis drug use was not an independent associate of any outcome. Hospitalization, ICU admission, and mortality rates were similar among bisphosphonate, denosumab, or teriparatide users. CONCLUSION: Results of this nationwide study showed that preexisting use of anti-osteoporosis drugs in women did not alter the COVID-19-related risk of hospitalization, ICU admission, and mortality. These results do not suggest discontinuation of these drugs during a COVID-19 infection.

A phase I trial of the trifunctional anti Her2 × anti CD3 antibody ertumaxomab in patients with advanced solid tumors.

BACKGROUND: Ertumaxomab (ertu) is a bispecific, trifunctional antibody targeting Her2/neu, CD3 and the Fcγ-receptors I, IIa, and III forming a tri-cell complex between tumor cell, T cell and accessory cells. METHODS: Patients (pts) with Her2/neu (1+/SISH positive, 2+ and 3+) expressing tumors progressing after standard therapy were treated to investigate safety, tolerability and preliminary efficacy. In this study, ertu was applied i.v. in 2 cycles following a predefined dose escalating scheme. Each cycle consisted of five ascending doses (10-500 µg) applied weekly within 28 days with a 21 day treatment-free interval. If 2 pts experienced a dose limiting toxicity (DLT) at a given dose level, the maximum tolerated dose (MTD) had been exceeded. RESULTS: Fourteen heavily pretreated pts (e.g. breast, rectal, gastric cancer) were enrolled in the four main cohorts. Three (21 %) pts had to be replaced. Two serious adverse events (SAE) with possible relation to the investigational drug were seen, both fully reversible. A DLT was not detected. Consequently, the MTD could not be determined. All adverse events (AE) were transient and completely reversible. Most frequent AEs were fatigue (14/14), pain (13/14), cephalgia (12/14), chills (11/14), nausea (8/14), fever (7/14), emesis (7/14) and diarrhea (5/14). Single doses up to 300 µg were well tolerated (total dose up to 800 µg per cycle). We observed one partial remission and two disease stabilizations after first treatment cycle. CONCLUSIONS: Single doses up to 300 µg could be safely administered in an escalating dose scheme. Immunological responses and clinical activity warrant further evaluation in patients with Her2 over expressing tumors. TRIAL REGISTRATION: EudraCT number: 2011-003201-14; ClinicalTrials.gov identifier: NCT01569412.

[Estrogen Receptors and their Impact for Prognosis and Therapy of Lung Cancer - New Insights to an Underestimated Mechanism]. / Östrogenrezeptoren und ihre Bedeutung für die Prognose und Therapie des Lungenkarzinoms - neue Erkenntnisse zu einem bisher unterschätzten Mechanismus.

Though tobacco smoking is the leading cause of lung cancer, during the last decades the prevalence increased in never smoking patients, especially in women. Sex steroid hormones and particularly the estrogen receptors (ERs) seem to play an important but still underestimated role in non-small cell lung cancer (NSCLC). Beside long existing hints that hormone replacement therapy (HRT) increases the risk of lung tumors recent analyses on cell lines, xenografts and human tumors of both sexes gave clear evidence of ER expression and proliferation in NSCLC. Most recently, the expression of ERs apparently has prognostic and predictive value. Recently, an intracellular "cross-talk" between the ER and the epithelial growth factor receptor (EGFR) could be demonstrated. EGFR are important targets of approved tyrosinkinases (TKIs), like gefitinib, erlotinib or afatinib. Currently, clinical studies are enrolling lung tumor patients for combination treatment with EGFR TKI and antihormonal drugs, e. g. fulvestrant.

A randomised multicentre phase II study with cisplatin/docetaxel vs oxaliplatin/docetaxel as first-line therapy in patients with advanced or metastatic non-small cell lung cancer.

BACKGROUND: This study was designed to compare cisplatin/docetaxel with oxaliplatin/docetaxel in patients with advanced and metastatic non-small lung cancer as a first-line treatment. METHODS: Patients were randomly assigned to receive either cisplatin 75 mg m(-2) and docetaxel 75 mg m(-2) every 3 weeks or oxaliplatin 85 mg m(-2) and docetaxel 50 mg m(-2) every 2 weeks. The primary end point was response rate, and secondary end points were toxicity, time to progression and overall survival. RESULTS: A total of 88 patients (median age: 65 (39-86) years; stage IV: 93%) were randomly assigned. Response rate (complete and partial response) was 47% (95% CI: 33-61%) in the cisplatin/docetaxel arm and 28% (95% CI: 17-43%) in the oxaliplatin/docetaxel arm (P=0.118). There was no significant difference in time to progression (6.3 vs 4.9 months, P=0.111) and median overall survival (11.6 vs 7.0 months, P=0.102) with cisplatin/docetaxel vs oxaliplatin/docetaxel, although slight trends favouring cisplatin were seen. Oxaliplatin/docetaxel was associated with significantly less (any grade) renal toxicity (56% vs 11%), any grade fatigue (81% vs 59%), complete alopecia (76% vs 27%), any grade leukopenia (84% vs 61%) and grade 3/4 leukopenia (44% vs 14%) and neutropenia (56% vs 27%). CONCLUSION: Oxaliplatin/docetaxel has activity in metastatic non-small cell lung cancer, but it seems to be inferior to cisplatin/docetaxel.

Quality of life is impaired not only in vitamin D deficient but also in vitamin D-insufficient pre-menopausal women.

BACKGROUND: Vitamin D deficiency may be more common in pre-menopausal women than previously thought and it may impair quality of life (QoL). AIM: The aim of this study is to evaluate QoL in pre-menopausal women with vitamin D deficiency and insufficiency. SUBJECTS AND METHODS: This is a cross-sectional study in which subjects were enrolled between September 1st and November 30th, 2011. Healthy premenopausal women with weakness, fatigue and non-specific pain were assigned into three groups according to their 25- hydroxyvitamin D (25-OHD) levels: ≤20 ng/ml (vitamin D deficient, no.=30), 21-29 ng/ml (vitamin D insufficient, no.=30) and ≥30 ng/ml (vitamin D sufficient, no.=20). Short form-36 (SF- 36) scores, age, calcium (Ca), phosphorus (P), and PTH levels were compared among the groups and correlations of SF-36 scores with age, serum 25-OHD, Ca, P, and PTH were done. RESULTS: There were significant differences among the groups with regard to PTH (p=0.008), physical component score (p=0.02), mental component score (p=0.035), physical functioning score (p=0.0001), and vitality score (p=0.05). Apart from PTH and physical functioning score, the results were significant when vitamin D-insufficient and -sufficient women were compared. Serum 25-OHD, but not PTH was correlated with some of the scales of SF-36. CONCLUSIONS: Some components of QoL are impaired not only in vitamin D deficient but also in insufficient pre-menopausal women, and impairment is related to 25-OHD rather than PTH levels.

Assessment of balance performance and fear of falling in acromegalic patients: a comparative study.

BACKGROUND: Acromegaly may lead to balance disturbances and fear of falling due to changes in body composition and co-morbidities. AIM: The aim of this study was to evaluate balance and fear of falling in acromegalic patients and their relation with disease characteristics. MATERIALS AND METHODS: Forty-eight acromegalic patients and 41 age- and gender-matched controls were enrolled in the study. The median ages of the patients and controls were 48 (25-75) and 50 (25-67) yr, respectively. Berg Balance Scale (BBS) and one-leg stance test (OLST) were used to compare dynamic and static balance respectively, 50 meters walking test was used to compare functional capacity and falls efficacy scale-international (FES-I) was used to compare fear of falling between the groups. RESULTS: Balance tests (BBS and 50 meter walking test) and fear of falling (FES-I) were significantly disturbed in patients compared with controls. There was no significant difference in OLST. BBS and OLST were negatively and FES-I was positively correlated with age. FES-I was negatively correlated with BBS and OLST was positively correlated with 50 meters walking test. Only OLST was negatively correlated with disease duration. Logistic regression analysis revealed that balance was not affected by the presence of co-morbidities, postoperative vision loss and disease control. CONCLUSIONS: This is the first study showing that balance is disturbed in acromegalic patients. This disturbance is not related to disease control and co-morbidities but somewhat to disease duration.

Development of energy efficient design proposals for air conditioned mosques: Temperate humid climate case.

Mosques, which are types of religious buildings, are large buildings where many people pray at the same time. The diversity of the user type and density and the variability of the usage schedule make it difficult to establish the homogeneous thermal comfort of these large-volume public buildings. At the same time, the energy consumption in the buildings should be minimal in nowadays when the conventional energy sources decrease. The aim of this study is to evaluate created design strategies for designers and users in order to minimize energy consumption by determining the passive design criteria and choosing the type of air conditioning equipment while providing an acceptable thermal comfort level in mosques. According to the method created for the aim, the scenarios of mosques were compared in terms of thermal comfort and energy consumption in the temperate humid climate conditions. This method includes the analysis of scenarios created from the change of design parameters of mosques (plan, size, roof type of the mosques) with a simulation software which was validated with actual utility data. The suggestions were presented for the selection and design of the mechanical system as a result of the implementation of the created method. When the design scenarios of mosques are compared, the air conditioning of the indoor with radiant method consumed less energy than HVAC equipment with fan system. In accordance with the plan schemes (square, rectangle, circular), the least energy consumption per unit area was in the circular plan scheme and hemispherical design. Compared to the roof types (single dome, multi dome, pyramidal roof, flat roof), the most energy consumption per unit area was generally in the multi dome design. According to the average energy consumption values of the HVAC systems, there was 23 % less energy consumption in the flat plan type (105.06 kWh/m2) compared to the rectangular plan type (129.2 kWh/m2). In the intermittent use schedule of the HVAC system, 8 % more energy was consumed than in the continuous use schedule. According to the air changes per hour in the mosques, there was 5.93 % more energy consumption in 2 ach conditions compared to 0.5 ach conditions.

A soluble LAG-3 protein (eftilagimod alpha) and an anti-PD-L1 antibody (avelumab) tested in a phase I trial: a new combination in immuno-oncology.

BACKGROUND: Eftilagimod alpha (efti) is a major histocompatibility complex class II agonist activating antigen-presenting cells which leads to greater systemic type 1 T helper response and more cytotoxic CD8+ T-cell activation. This phase I trial evaluated the administration of efti, a soluble lymphocyte activation gene-3 (LAG-3) protein, combined with the anti-programmed death-ligand 1 (PD-L1) antibody avelumab in advanced solid tumors. PATIENTS AND METHODS: Patients with heavily pretreated metastatic solid tumors received intravenous avelumab (800 mg) combined with subcutaneously administered efti (6 or 30 mg) for up to 12 cycles, followed by avelumab monotherapy. The primary endpoint was the assessment of the recommended phase II dose (RP2D) of efti in combination with avelumab. RESULTS: Twelve patients with different tumor entities were enrolled (six patients in each cohort). During treatment, no dose-limiting toxicities occurred, and the severity of most adverse events was grade 1 or 2. In total, nine serious adverse events were documented, resulting in a fatal outcome in two cases, but none of them were assessed to be treatment related. Five patients (42%) achieved partial response. The median progression-free survival was 1.96 months and the median overall survival was not reached, with a 12-month survival rate of 75%. CONCLUSION: Subcutaneously administered efti plus avelumab was well tolerated, and efti of 30 mg was determined to be RP2D. The activity is promising and warrants further investigation in future phase II trials.

The validation of matrix metalloproteinase-9 mRNA gene expression as a predictor of outcome in patients with metastatic gastric cancer.

BACKGROUND: The prognostic role of matrix metalloproteinase-9 (MMP-9) in metastatic gastric cancer has not been validated. PATIENTS AND METHODS: We carried out a molecular analysis in 222 metastatic gastric cancer patients obtained from clinical trials. We assessed the messenger RNA (mRNA) expression of MMP-9, vascular endothelial growth factor receptor-A, and epidermal growth factor receptor in a training cohort of 130 patients and conducted an independent validation in 92 patients. Automated RNA extraction from paraffin and RT-quantitative PCR was used. Immunohistochemistry for MMP-9 and diverse immune cell infiltrates was conducted. RESULTS: In the training cohort, only MMP-9 significantly correlated with patient's survival. At the cut-off with the highest predictive value, 19% of patients had MMP-9 expression above this cut-off and these showed a median survival of 3.6 months compared with 10.5 months (P=1.7e(-6)) in patients with lower expression. Corresponding 1- and 2-year survivals were 9% and 44% and 0 and 21%, respectively. The application of this cut-off to the validation cohort revealed similar distributions of overall survival according to MMP-9 expression on uni- (P<0.001) and multivariate analyses (P<0.001). No differences in survival according to MMP-9 below best cut-off were found. MMP-9 protein assessed by immunohistochemistry was not prognostic. CONCLUSION: MMP-9 mRNA expression above a certain cut-off level is associated with dismal survival.

Phase II study of bendamustine in combination with rituximab as first-line treatment in patients 80 years or older with aggressive B-cell lymphomas.

BACKGROUND: Rituximab plus combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is widely recommended for the treatment of aggressive B-cell lymphomas. However, there is very little information regarding the management of elderly patients. PATIENTS AND METHODS: We initiated a phase II study of first-line treatment with rituximab and bendamustine in elderly patients (≥80 years) with aggressive B-cell lymphomas who were not eligible for R-CHOP or who did not agree to aggressive treatment. The treatment decision on eligibility for R-CHOP was left to discretion of the physicians. RESULTS: Fourteen patients with a median age of 85 years (range 80-95 years) were included. The age-adjusted international prognostic index was zero in five patients, one in three patients, and two in six patients. Thirteen patients were assessable for response. Seven patients (54%) had a complete response, two (15%) a partial response, and four (31%) progressive disease. The median overall survival was 7.7 months, and the median progression-free survival 7.7 months; however, six patients (43%) were alive without disease at 20-72 months from the start of treatment. Major toxicity was neutropenia (17% grade 3 and 6% grade 4). All other grade 3 and 4 hematotoxicities and non-hematological toxic effects ranged between 2% and 11% CONCLUSIONS: Because of its efficacy and low toxicity, bendamustine in combination with rituximab may be an alternative treatment for aggressive lymphomas in old patients not eligible for R-CHOP. These results, however, need to be confirmed in larger studies.

Biweekly fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) for patients with metastatic adenocarcinoma of the stomach or esophagogastric junction: a phase II trial of the Arbeitsgemeinschaft Internistische Onkologie.

BACKGROUND: The combination of docetaxel (Taxotere), cisplatin, and fluorouracil improved efficacy in gastric cancer, but was associated with substantial toxicity. This study was designed to incorporate docetaxel into a tolerable biweekly (once every 2 weeks) oxaliplatin-based chemotherapy regimen. PATIENTS AND METHODS: Patients with measurable, metastatic adenocarcinoma of the stomach or esophagogastric junction and no prior chemotherapy received oxaliplatin 85 mg/m(2), leucovorin 200 mg/m(2), and fluorouracil 2600 mg/m(2) as a 24-h infusion in combination with docetaxel 50 mg/m(2) (FLOT) on day 1 every 2 weeks. Prophylactic growth factors were not administered. RESULTS: Fifty-nine patients were enrolled; 54 received treatment. Patients had a median age of 60 years (range 29-76) and most (93%) of them had metastatic disease. Objective responses were observed in 57.7% of patients with a median time to treatment response of 1.54 months. Median progression-free survival (PFS) and overall survival were 5.2 and 11.1 months, respectively. Twenty-five percent of patients experienced prolonged (>12 months) PFS. Frequent (>10%) grade 3 or 4 toxic effects included neutropenia in 26 (48.1%), leukopenia in 15 (27.8%), diarrhea in 8 (14.8%), and fatigue in 6 (11.1%) patients. Complicated neutropenia was observed in two (3.8%) patients, only. CONCLUSIONS: Biweekly FLOT is active and has a favorable safety profile.

Follow-up of pregnancy in acromegalic women: different presentations and outcomes.

Pregnancy in acromegaly is a rather rare event since the fertility is reduced in acromegalic women. Besides, metabolic complications of acromegaly are harmful to both mother and fetus. Little is known about the outcome of pregnancy in acromegalic women. Here, we report seven cases of pregnancy out of 48 acromegalic women followed for 16 years. At diagnosis, five patients had macroadenoma, one patient had microadenoma and the size of the tumor was not documented in one patient. In one patient, acromegaly was initially diagnosed during pregnancy at 29 weeks. When she was 33 weeks, she developed pituitary apoplexy and had an emergency transsphenoidal resection of her macroadenoma during which she also had a cesarian section and delivered a healthy baby girl. In the remaining six patients, pregnancy occurred 6 to 64.5 months after the adenoma resection. Three patients received radiotherapy before getting pregnant. In three patients, pregnancy occurred during bromocriptine treatment and the drug was withdrawn. In one patient, pregnancy occurred during chronic octreotide treatment and therapeutic abortion was performed. In another patient, therapeutic abortion was performed because of uncontrolled disease. In the remaining four patients, there were neither worsening of symptoms nor tumor growth. All four patients gave birth to full-term healthy infants. Out of our seven patients, two developed gestational diabetes mellitus which was controlled with diet. None of the patients had coronary artery disease, hypertension or dyslipidemia. These cases show that pregnancy might be uneventful in acromegalic women when the disease is controlled with prior surgery and radiotherapy.

Hyperprolactinemia of pregnancy is not associated with increased in vivo platelet activity and shortened in vitro bleeding times.

The aim of the study is to investigate whether platelet activity is increased by hyperprolactinemia during pregnancy as reflected by beta-thromboglobulin level. Forty-eight healthy, pregnant, and 30 healthy, non-pregnant women were investigated with respect to platelet count, collagen/ADP and collagen/epinephrine closure times, beta-thromboglobulin and prolactin levels. The comparison of the variables between the two groups was made by Mann-Whitney U test. The correlation analyses were performed by Spearman's rank correlation test. Our results revealed that platelet counts, collagen/ADP and collagen/epinephrine closure times and beta-thromboglobulin showed no statistically significant differences between pregnant and non-pregnant women. We found no significant correlation between prolactin and collagen/ADP closure time (r = 0.175), between prolactin and collagen/epinephrine closure time (r = -0.112) and between prolactin and beta-thromboglobulin (r = 0.220) in pregnant women. Our findings suggest that platelet activity is comparable during pregnant and non-pregnant states and there is no significant effect of prolactin on platelet function in vivo as reflected by beta-thromboglobulin level.

Synergistic effects of valproic acid and mitomycin C in adenocarcinoma cell lines and fresh tumor cells of patients with colon cancer.

Valproic acid has been demonstrated to mediate cytotoxic effects against tumor cells by acting as a histone-deacetylase inhibitor. However, to date, there are only limited data on the effects of valproic acid in colon cancer. Moreover, information regarding combinations of the drug with chemotherapeutic agents is very limited. The latter is of interest as there is increasing evidence for synergism between so-called "molecular targeting drugs" and chemotherapy. We first demonstrated that valproic acid dose-dependently reduced the viability of adenocarcimona cell lines. After co-incubation with a variety of chemotherapeutic agents, only valproic acid in combination with mitomycin C consistently induced synergistic growth inhibition in all cell lines. To confirm these results in an ex vivo situation, five samples of fresh colon cancer cells were studied. Again, the effect of valproic acid on the viability of the fresh tumor cells was dose dependent. In four of five samples of freshly isolated colon cancer cells, the synergistic effect of valproic acid and mitomycin C on the inhibition of cell growth was confirmed by calculation of the combination index by multiple drug effect analysis. In conclusion, this is the first demonstration that valproic acid as a model substance for histone-deacetylase inhibitors is effective in tumor cells freshly isolated from patients with colon cancer and that the combination of mitomycin C and valproic acid synergistically decreases viability of colon cancer cells.

Risk factors associated with malignancy and with triage to surgery in thyroid nodules classified as Bethesda category III (AUS/FLUS).

BACKGROUND: Selection of nodules for surgery diagnosed as Bethesda category III [atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) category] is very important. We aimed at to define the predictive factors for malignancy and factors associated with triage to surgery. METHODS: The records of all patients with nodules who underwent fine needle aspiration biopsy (FNAB) and classified by Bethesda reporting system as AUS/FLUS between 2011 and 2015 at our institution were reviewed. Univariate and multivariate analysis were performed to select independent factors associated with thyroid cancer and with triage to surgery. Using independent risk factors for malignancy predictive index categories were created. RESULTS: Of the 485 patients who were classified as AUS/FLUS on initial FNAB, 153 underwent surgery with the associated malignancy rate of 22.8%. The malignancy rates for AUS/FLUS patients with and without repeat FNAB were 37.5% and 16.2%, respectively. Multivariate logistic regression analysis revealed that solid structure, microcalcification, hypoechogenicity, increased vascularization, and irregular margin were found to be significant and independent risk factors associated for malignancy, and solid structure, microcalcifications, increased nodule size (≥2 cm) and younger patient age (<65 years) were associated with triage to surgery. CONCLUSIONS: Our findings showed that using predictive factors for malignancy in AUS/FLUS category as risk indices, an important proportion of patients (35%) who had nodules without any risk factors could be spared unnecessary surgery. We suggest that predictive indices should be considered for selection of the patients to triage to surgery.

Lipoatrophy induced by subcutaneous administration of octreotide in the treatment of acromegaly.

Octreotide is the first somatostatin analogue to become available for clinical use in the treatment of acromegaly. To our knowledge, there are no reports describing lipoatrophy in patients treated with octreotide. Here, we report three patients who developed lipoatrophy after treatment with subcutaneous octreotide. Three patients (all women; 36, 43, and 50 years of age) with diagnosis of acromegaly due to pituitary macroadenoma who had undergone transsphenoidal surgery and radiotherapy received subcutaneos octreotide because of uncontrolled disease. The dose of octreotide was increased gradually in all patients. Lipoatrophy was noticed around the injection sites after about 6 years, 30 months, and 4 years of subcutaneous octreotide treatment in all patients. Thereafter, subcutaneous octreotide treatment was changed to intramuscular octreotide-LAR injection in all patients. In two of them, lipoatrophy around all injection sites did not regress after about 8 and 12 months of octreotide-LAR treatment, respectively. In the third patient, lipoatrophy around the injection sites regressed after 12 months of octreotide-LAR treatment. These cases highlight a potential for subcutaneous octreotide to induce lipoatrophy. The underlying mechanism is unknown but an immunological mechanism which is seen in lipoatrophy induced by insulin may be involved in the pathogenesis. Besides; simple trauma, personal susceptibility, mistakes in the administration of the drug, a problem in drug pH, or an idiosyncratic reaction of adipocytes to octreotide or additives in the drug may have caused lipoatrophy in our patients. Lipoatrophy in these cases was observed on long-term subcutaneous octreotide administration. Although intramuscular octreotide-LAR has largely replaced subcutaneous octreotide, we suggest close clinical follow-up for lipoatrophy in patients who are still on subcutaneous octreotide.

Clinical management of hydatid disease of the urinary tract.

This study reviews urinary hydatid disease in seven males and three females (mean age, 32.1 +/- 17.7 years; range, 7-67 years). Cysts were located in the kidney in six cases (one also involved the liver), the paravesical and retrovesical region in two cases (one coexisted with a bladder tumour), the adrenal gland (one case) and in the right parapelvic region (one case). Investigations included urinalysis, eosinophil count, Casoni skin test, indirect haemagglutination test (IHA), abdominal ultrasonography, intravenous urography and computed tomography (CT). All patients underwent surgery and were followed for an average of 5.6 years. Lumbar or abdominal pain was the most common symptom. Eosinophilia was seen in five patients (50%), IHA positivity occurred in four patients (40%) and the Casoni skin test was positive in four patients (40%). Abdominal CT was the most useful diagnostic method of radiological investigation (100%). No complications or recurrences were seen on follow-up. Urinary hydatid disease is uncommon and is likely to cause considerable diagnostic difficulties, and should therefore be considered in the differential diagnosis of space-occupying lesions of the urinary tract.