Assesment of attainment of recommended TSH levels and levothyroxine compliance in differentiated thyroid cancer patients.

OBJECTIVE: Thyroid-stimulating hormone (TSH) suppression treatment can induce signs and symptoms of hyperthyroidism and hypothyroidism due to inappropriate treatment or poor compliance to the treatment. The current study aimed to investigate TSH levels, frequency of being on target TSH, adherence to levothyroxine (LT4) suppression treatment in differentiated thyroid cancer (DTC) patients after surgery in a multicentric setting. DESIGN AND PATIENTS: This multicentric cross-sectional study was conducted at 21 medical centres from 12 cities in Turkey. DTC patients followed at least one year in the same center included in the study. Clinical data, serum TSH, free thyroxine (FT4), thyroglobulin (Tg) and anti-Tg levels were recorded during the most recent visit. Body mass index, systolic and diastolic blood pressures, pulse rate were measured. LT4 doses were recorded and doses per kilogram of bodyweight were calculated. Pill ingestion habits recorded and adherence to the therapy were evaluated using the Morisky Medication Adherence Scale and categorized as good, moderate or poor compliant based on their scores. Risk stratification forpredicting the disease persistance and/or reccurence was assessed using the American Joint Committee on Cancer-7th edition thyroid cancer staging calculator. TSH serum concentrations were classified as severe suppression (TSH < 0.01 mU/L), moderate suppression (TSH: 0.01-0.1 mU/L), mild suppression (TSHL 0.1-0.5 mU/L), euthyroid (TSH: 0.5-4 mU/L) and hypothyroid (TSH > 4 mU/L). TSH levels can also be classified as on being on target, under the target, or beyond over the target, according to the American Thyroid Association recommendations. RESULTS: A group of 1125 patients (F/M: 941/184, 50.7 ± 11.7 years) were included in the study. The mean LT4 daily dosage was 132.4 ± 39.6 mcg/day. TSH levels showed severe suppression in 99 (%8.8) patients, moderate suppression in 277 (%24.6) patients and mild suppression in 315 (%28) patients and euthyroid range in 332 (%29.5) patients and hypothyroid range in 97 (8.6%). TSH levels were in target in 29.2% of the patients 20.4% of the patients were undertreated, 50.4% overtreated. The daily LT4 dose and LT4 dose/kg were significantly higher in the severe suppression group (p < .001, p < .001). According to the Morisky scale, 564 patients (50.1%) were good compliant, 368 patients (32.7%) were moderate compliant, and 193 patients (17.1%) were noncompliant. Patients with poor compliance need a higher dose of LT4 compared to the good compliance group (p < .001). TSH levels of patients with good compliance were 0.67 ± 1.96 mU/L and TSH with poor compliance was 2.74 ± 7.47 mU/L (p < .001). TSH levels were similar in patients on fixed and alternating dosages. CONCLUSION: In 29.2% of the DTC patients, serum TSH levels were at target levels. Remaining of the study group have TSH levels under or over treatment range, exposing the patient to medication side effects. Majorty of the study group 82.8% have good or moderate adherence to LT4 therapy. Reaching TSH targets requires simplified and applicable guidelines and following the guideline recommendations.

The Importance of DHEA-S Levels in Cushing's Syndrome; Is There a Cut-off Value in the Differential Diagnosis?

The purpose of this study was to determine possible cut-off levels of basal DHEA-S percentile rank in the differential diagnosis of patients with Cushing's syndrome (CS) with ACTH levels in the gray zone and normal DHEA-S levels. In this retrospective study including 623 pathologically confirmed CS, the DHEA-S percentile rank was calculated in 389 patients with DHEA-S levels within reference interval. The patients were classified as group 1 (n=265 Cushing's disease; CD), group 2 (n=104 adrenal CS) and group 3 (n=20 ectopic ACTH syndrome).ROC-curve analyses were used to calculate the optimal cut-off level of DHEA-S percentile rank in the reference interval in the differential diagnosis of CS, and the effectiveness of this cut-off level in the identification of the accurate etiology of CS was assessed in patients who were in gray zone according to their ACTH levels. The DHEA-S percentile rank in the reference interval were significantly lower in group 2 compared to the other two groups (p<0.001), while group 1 and group 3 had similar levels. The optimal cut-off level of DHEA-S percentile rank in the reference interval providing differential diagnosis between group 1 and group 2 was calculated as 19.5th percentile (80.8% sensitivity, 81.5% specificity) and the level demonstrated the accurate etiology in 100% of CD and 76% of adrenal CS patients who were in the gray zone. This study showed that the cut-off value of DHEA-S level less than 20% of the reference interval could be used for differential diagnosis of CD and adrenal CS with high sensitivity and specificity, and it should be taken into the initial evaluation.

Clinical predictors of incipient vertebral fractures and bone mineral density in kidney transplant patients.

PURPOSE: Kidney transplant recipients are prone to metabolic bone diseases and consequent fractures. This study aimed to evaluate the incidence of incipient vertebral fractures, osteopenia, osteoporosis, and the clinical factors associated with incipient vertebral fractures in a group of kidney transplant patients. METHODS: Two hundred sixty-four patients (F/M 124/140, 45.3 ± 13 years) who had undergone kidney transplantation in tertiary care centers were included. Vertebral fractures were assessed semiquantitatively using conventional thoracolumbar lateral radiography in 202 of the patients. RESULTS: Vertebral fractures were observed in 56.4% (n = 114) of the study group. The frequency of osteoporosis was 20.0% (53 of 264 patients), and osteopenia was 35.6% (94 of 264 patients). Bone mineral density (BMD) levels were in the normal range in 40.3% (n = 46) of the subjects with vertebral fractures. It was in the osteoporotic range in 20.1% (n = 23) and the osteopenic range in 40.3% (n = 46). Vertebral fractures were associated with age, duration of hemodialysis, BMI, and femoral neck Z score (R2 37.8%, p = 0.027). CONCLUSION: As incipient vertebral fractures can be observed in patients with normal BMD levels in kidney transplant recipients, conventional X-ray screening for vertebral fractures may be beneficial for a proper therapy decision of metabolic bone disease in kidney transplant recipients.

Assessment of right ventricular functions in acromegaly: comparison of active disease with remission.

Aim    Cardiac involvement in acromegaly is defined as acromegalic cardiomyopathy, an insidious and chronic disease. Previous research on acromegalic cardiomyopathy was largely focused on morphological and functional assessment of the left heart. Since the literature data regarding right heart function in acromegalic patients are limited, we aimed to evaluate the structure and function of the right heart in such patients.Material and Methods    We included 43 adult participants as the acromegaly group and 42 individuals as the control group. All patients underwent echocardiographic evaluation. The results were compared between acromegaly and control groups and between active and controlled acromegaly groups.Results    The acromegaly group had increased interventricular septum thickness, right ventricular (RV) free wall thickness, right atrium (RA) minor diameter, RV basal and longitudinal diameters, RV end-diastolic and end-systolic areas, E / E' ratio, isovolumetric relaxation time, and RV ejection time. The E / A ratio and E' velocity were reduced. GH and IGF-1 were positively correlated with RV longitudinal diameter, indexed RA minor-axis dimension, and indexed RV end-diastolic area. Patients with active acromegaly had increased RV index of myocardial performance (RVIMP) and isovolumetric contraction time and shortened RV ejection time compared to patients in remission. A RVIMP value of 0.435 predicted active acromegaly with a sensitivity and specificity of 0.83 and 0.64, respectively (p=0.002).Conclusions    Increases in the size and diameters of the right heart chambers along with RV free wall thickness may be attributed to acromegalic cardiomyopathy. RVIMP, isovolumetric contraction time, and ejection time are parameters that can be used in the evaluation of active acromegaly disease.

Visfatin Levels May be an Early Marker of Atherosclerosis in Patients with Acromegaly.

The purpose of the study was to compare serum visfatin levels between patients with acromegaly and healthy controls and to evaluate the relationships between visfatin levels and epicardial fat thickness (EFT), carotid intima media thickness (cIMT), and ankle brachial index (ABI). We conducted a cross-sectional case-control study of 54 patients with acromegaly (37 females and 17 males) and 34 healthy controls (22 females and 12 males). Serum visfatin was measured by ELISA. Acromegalic and control participants and those with active or controlled acromegaly were compared with respect to their serum visfatin, clinical and metabolic parameters, EFT, cIMT, and ABI. Linear correlation was used to identify associations between these parameters and visfatin in all participants. Serum visfatin and glycated hemoglobin (HbA1c) were higher in the acromegaly group than in the control group (p<0.001 and p=0.007, respectively). There was no difference in visfatin between the active and controlled acromegaly groups, but HbA1c was higher in the active than the controlled acromegaly group (p<0.04). EFT, cIMT, and ABI were similar between the acromegaly and control groups and between the active and controlled acromegaly groups. Serum visfatin positively correlated with HbA1c, growth hormone (GH), and insulin-like growth factor-1 (IGF-1)/upper limit of normal ratio (r=0.245, p=0.024; r=0.259, p=0.017; and r=0.282, p=0.009, respectively). This study has revealed that a high visfatin level is associated with glycemic dysregulation and higher levels of GH and IGF-1 in acromegalic patients.

Macula halo syndrome.

INTRODUCTION: Niemann-Pick disease (NPD) is a hereditary lysosomal storage disorder in which mutations in the sphingomyelin phosphodiesterase gene leads to partial or complete deficiency of the sphingomyelinase enzyme. Niemann-Pick Type B is the intermediate form associated with hepatosplenomegaly, foam cells in the bone marrow, hyperlipidemia and diffuse pulmonary infiltrates, which is generally diagnosed in late adolescence. Central nervous system is not affected, and some cases may display macular halo. CASE: A 45-year-old female seen in ophthalmology clinic for the examination of the eyes. Extraocular motility was normal bilaterally, and the visual acuity was 20/25 for both eyes. Biomicroscopic examination revealed faint corneal haze bilaterally, Circular pale granular depositions were detected in the parafoveal retina on both eyes. Optical coherence tomography (OCT) revealed thin hyperreflective band corresponding to depositions located in the parafoveolar inner retina. Microperimeter showed slight depression in retinal sensitivity, which was more pronounced particularly on perifovea rather than parafovea. CONCLUSIONS: Challenge to identify the NPD subtype of this case is associated with phenotypic characteristics on a wider spectrum that overlap the currently described subtypes.

Comparison of serum paraoxonase and arylesterase activities between iron deficiency anemia patients and chronic kidney disease patients with anemia.

OBJECTIVE: Altered paraoxonase (PON) and arylesterase (ARE) activities have been shown in anemic chronic kidney disease (CKD) patients and in iron deficiency anemia (IDA) patients. Whether accompanying anemia alone is responsible for this diminished PON and ARE activities in CKD patients or an additive factor for this is not well studied. Therefore, we tried to clarify this issue here. METHODS: A total of 82 subjects that consisted of 19 patients with IDA (group 1), 23 anemic CKD patients (group 2), and 40 age and sex matched healthy subjects (group 3) were enrolled. Carotid intima media thickness (CIMT), serum total thiol (-SH), PON, and ARE activities of the participants were analyzed. RESULTS: Group 2 patients had significantly lowest serum levels of Total -SH, PON and ARE. Further comparison showed that total -SH, PON and ARE levels were lower in group 1 than group 3 (p = 0.0001 in both). Regarding comparison of group 1 and 2, only serum ARE levels were significantly lower in group 2 (p = 0.001). PON activity was not different between group 1 and group 2 whereas ARE activity was lower in group 2 than groups 1 and 3. In addition, correlation analysis showed that CIMT was negatively correlated with PON and ARE. CONCLUSIONS: This markedly decreased ARE activity in CKD patients, which could not be explained by the anemia alone, may have a role in the pathogenesis of increased atherosclerosis in such patients. Still further studies are needed to certain this.

The early results of our initial experience with robotic adrenalectomy.

OBJECTIVE: Robotic adrenalectomy is one of the minimally invasive surgical methods gaining wide acceptance due to the three-dimensional imaging system and ergonomics of the equipment. We aimed to present the early data on patients who underwent robotic adrenalectomy due to adrenal masses in our hospital. MATERIAL AND METHODS: The records of eight cases, in which a unilateral robotic trans-peritoneal adrenalectomy was conducted due to an adrenal mass between 2011 and 2013, have been evaluated. Demographic characteristics of cases, body mass index (BMI), American Society of Anesthesiologists (ASA) score, preoperative diagnosis, diameter and localization of the adrenal mass, operative time, blood loss, conversion rate to open surgery, morbidity and mortality rates, length of hospital stay, total hospital charges and postoperative pathologic results were considered. RESULTS: The female to male ratio was 6:2, the median age was 49.5 (26-71) and the median BMI was 29.7 (21.7-38.5). An adrenalectomy was performed in six cases for a right adrenal mass and in two cases for a left adrenal mass. The mean tumor diameter was 53.6 mm (20-90). The average surgical time (including docking) was 98 min. (55-175 min.) and the average blood loss was 50 mL. The only complication was a diaphragm injury which was repaired robotically. There were no conversions to traditional laparoscopic or open surgery and there have not been any mortality in the series. The median length of hospital stay was 4.1 days (range 2-11) and the average cost was 3617.12 TL ($1808.56). CONCLUSION: Robotic adrenalectomy is an effective and safe surgical alternative to laparoscopic adrenalectomy. However its high cost has emerged as its main disadvantage.

Medium and Long-Term Data from a Series of 96 Endoscopic Transsphenoidal Surgeries for Cushing Disease.

OBJECTIVE: Postoperative data on Cushing's disease (CD) are equivocal in the literature. These discrepancies may be attributed to different series with different criteria for remission and variable follow-up durations. Additional data from experienced centers may address these discrepancies. In this study, we present the results obtained from 96 endoscopic transsphenoidal surgeries (ETSSs) for CD conducted in a well-experienced center. METHODS: Pre- and postoperative data of 96 ETSS in 87 patients with CD were included. All cases were handled by the same neurosurgical team between 2014 and 2022. We obtained data on remission status 3-6 months postoperatively (medium-term) and during the latest follow-up (long-term). Additionally, magnetic resonance imaging (MRI) and pathology results were obtained for each case. RESULTS: The mean follow-up duration was 39.5±3.2 months. Medium and long-term remission rates were 77% and 82%, respectively. When only first-time operations were considered, the medium- and long-term remission rates were 78% and 82%, respectively. The recurrence rate in this series was 2.5%. Patients who showed remission between 3-6 months had higher longterm remission rates than did those without initial remission. Tumors >2 cm and extended tumor invasion of the cavernous sinus (Knosp 4) were associated with lower postoperative remission rates. CONCLUSION: Adenoma size and the presence/absence of cavernous sinus invasion on preopera-tive MRI may predict long-term postoperative remission. A tumor size of 2 cm may be a supporting criterion for predicting remission in Knosp 4 tumors. Further studies with larger patient populations are necessary to support this finding.

The significance of forearm bone mineral density evaluation in determining surgical indications in primary hyperparathyroidism.

PURPOSE: Forearm osteoporosis is a well-known complication of primary hyperparathyroidism (PHPT). However, measuring forearm bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) at the distal radius is often neglected in clinical practice despite the fact that osteoporosis at any site is a criterion indicating surgery. We aimed to evaluate the importance and priority of forearm BMD and to determine its association with biochemical parameters. MATERIAL AND METHODS: Three hundred fourteen patients (272 females, 42 males) with PHPT who had BMD measurements at 3 sites were recruited for this retrospective study. The effect on surgical indications of osteoporosis only in the forearm was evaluated. Group 1 (n=151) with forearm osteoporosis and group 2 (n=163) without were compared in terms of biochemical and clinical parameters. RESULTS: In the overall study population, 165 of the 314 patients had osteoporosis in at least 1 site. Twenty seven percent (n=86/314) had osteoporosis only in the forearm, while the other 2 sites (lumbar spine and femoral neck) were normal or osteopenic. Surgery was indicated based on osteoporosis only in the forearm in 10% of patients (n=30/314). Corrected calcium and parathyroid hormone levels were significantly higher in group 1 than group 2 (p=0.001 and p<0.001, respectively) and were also negatively correlated with distal radius BMD, T-score and Z-score in the whole study group. CONCLUSION: Including the distal radius in BMD measurement increased the number of patients diagnosed with osteoporosis and for whom surgery was indicated. Calcium and PTH were also more frequently elevated in patients with forearm osteoporosis. These results show that distal radius BMD is relevant to the management of PHPT.

The effect of COVID-19 process on patients with endocrinological disease in a pandemic hospital: What happened to the others?

Objective: To evaluate the effects of the pandemic process on those with an endocrinological disease that will require close follow-up from the last visit before the pandemic. Materials and Methods: Patients of 3,903 with thyroid, calcium-bone metabolism, adrenal gland, pituitary diseases, and neuroendocrine tumor (NET) were retrospectively scanned. The remaining 855 (656 females and 199 males) patients with active disease or who still needed multidisciplinary approaches were included. The number of patients who continued the disease-related medical procedures and could complete these procedures on time in the pandemic period was determined, and medical deprivation rate (MDR) was calculated. Results: The prepandemic period of our patients with thyroid disease (n = 594), calcium-bone metabolism disorder (n = 130), adrenal disease (n = 85), pituitary disease, and NET (n = 46) had MDRs of 85%, 56%, 81%, and 89%, respectively. For each subgroup of patients, the lowest MDR (67%) was in medullary thyroid carcinoma, the highest MDR (89%) was in differentiated thyroid carcinoma; the lowest MDR (6%) was in osteoporosis, the highest MDR (100%) was in the active Paget's disease; the lowest MDR (0%) was in primary adrenocortical insufficiency, the highest MDR (100%) was in hyperfunctional adrenal adenomas; the lowest MDR (81%) was in pituitary nonfunctional adenomas, and the highest MDR (100%) was in Cushing's disease, active prolactinoma, TSHoma, and NET, respectively. Conclusion: This study showed that not only those who had COVID-19 but also those who had medical deprivation due to their current endocrinological disease were not to be underestimated during the pandemic period.

A hyperparathyroid case with pulmonary edema: can hypercalcemia trigger pulmonary edema?

Most cases of pulmonary edema presenting with hypercalcemia are associated with malignant hypercalcemia and related with metastatic calcification. Most patients have predisposing factors such as hematological and solid organ malignancies and chronic renal failure. Pulmonary edema, induced by moderate hypercalcemia, which is associated with primary hyperparathyroidism, has not been reported previously. A 72-year-old female patient was admitted to the emergency service with pulmonary edema and moderate hypercalcemia because of primary hyperparathyroidism. In this presented case, we have discussed the 72-year-old female patient admitted with acute pulmonary edema who had primary hyperparathyroidism.

The prevalence of fibromyalgia syndrome in a group of patients with diabetes mellitus.

We have studied the prevalence of fibromyalgia syndrome (FMS) in patients with type 1 and type 2 diabetes mellitus (DM). Relationship with disease control of DM and the presence of FMS was also evaluated. We have studied 93 consecutive patients with DM (85 with type 2 DM and 8 patients with type 1 DM) followed in Diabetes Center. Single researcher took the history and did physical examination including manual tender point examination according to Manual Tender Point Survey instructions. For the diagnosis of FMS, 1990 American College of Rheumatology Classification Criteria for FMS was used. We measured patients' fasting blood sugar levels and HbA1c levels around the same time period. Patients were excluded from the study if they had any other serious disease, and if there was any history of drug use that interferes with the symptoms of FMS. Patients with rheumatoid arthritis (RA) were accepted as controls. FMS was found in 18% of patients with DM type 2 (no patients with FMS in type 1 DM group), in 34% of patients with RA. Female patients with DM type 2 had significantly higher FMS rates. Mean fasting blood sugar levels and mean HbA1c levels were not significantly different between type 2 DM patients with FMS and DM patients without FMS. In RA group, in RA patients without FMS, the use of steroids was significantly higher. We have found an increased prevalence rate of FMS in patients with DM type 2 and RA. There was no correlation between the prevalence rate of FMS and good DM disease control.

Ubiquitin-specific Protease 8 Gene Expression in Sporadic Pituitary Adenomas.

OBJECTIVES: In sporadic pituitary adenomas, the role of Ubiquitin-specific protease 8 (USP8) is not clearly defined. Mutations in USP8 gene are known to influence formation of the corticotroph adenomas. However, it has not been clarified whether changes in expression of USP8 have an impact on other pituitary adenomas or not. In this study we addressed the changes in USP8 gene expression levels in pituitary adenomas (PA) relative to non-adenomatous brain tissue. MATERIAL AND METHODS: USP8 gene expression analysis was performed on a total of 43 tissue samples from human pituitary adenomas and on 16 tissue samples from non-pituitary brain tissues (control group). Adenomatous tissues and control tissues were assessed for quantification of RNA expression of USP8.The levels of USP8 gene expression were determined relative to those in control group. RESULTS: Overall, the USP8 gene expression levels in PA were 3.7 times higher than the control brain tissues (CBT) (p=0.002). However, after stratification, only the USP8 in the secretory PA were higher than CBT(p=0.002). CONCLUSIONS: Present findings support that USP8 gene expression levels may contribute to pitutary tumorigenesis and hormonogenesis..

Management of endocrine surgical disorders during COVID-19 pandemic: expert opinion for non-surgical options.

PURPOSE: The COVID-19 pandemic brought unprecedented conditions for overall health care systems by restricting resources for non-COVID-19 patients. As the burden of the disease escalates, routine elective surgeries are being cancelled. The aim of this paper was to provide a guideline for management of endocrine surgical disorders during a pandemic. METHODS: We used Delphi method with a nine-scale Likert scale on two rounds of voting involving 64 experienced eminent surgeons and endocrinologists who had the necessary experience to provide insight on endocrine disorder management. All voting was done by email using a standard questionnaire. RESULTS: Overall, 37 recommendations were voted on. In two rounds, all recommendations reached an agreement and were either endorsed or rejected. Endorsed statements include dietary change in primary hyperparathyroidism, Cinacalcet treatment in secondary hyperparathyroidism, alpha-blocker administration for pheochromocytoma, methimazole ± ß-blocker combination for Graves' disease, and follow-up for fine-needle aspiration results of thyroid nodules indicated as Bethesda 3-4 cytological results and papillary microcarcinoma. CONCLUSION: This survey summarizes expert opinion for the management of endocrine surgical conditions during unprecedented times when access to surgical treatment is severely disrupted. The statements are not applicable in circumstances in which surgical treatment is possible.

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.

Clearance of the high intestinal (18)F-FDG uptake associated with metformin after stopping the drug.

PURPOSE: This study was done to determine whether interruption of metformin before (18)F-FDG PET/CT imaging could prevent the increased (18)F-FDG uptake in the intestine caused by this drug. METHODS: Included in the study were 41 patients with known type 2 diabetes mellitus who were referred to our department for evaluation of various neoplastic diseases. Patients underwent two (18)F-FDG PET/CT scans, the first while they were on metformin and the second after they had stopped metformin. They stopped metformin and did not take any other oral antidiabetic medication starting 3 days before the second study and their blood glucose level was regulated with insulin when necessary to keep it within the range 5.55-8.33 mmol/l. FDG uptake was graded visually according to a four-point scale and semiquantitatively by recording the maximum standardized uptake value (SUVmax) in different bowel segments. A paired-samples t-test method was used to determine whether there was a significant difference between SUVmax measurements and visual analysis scores of the metabolic activity of the bowel in the PET/CT scans before and after stopping metformin. RESULTS: Diffuse and intense (18)F-FDG uptake was observed in bowel segments of patients, and the activity in the colon was significantly decreased both visually and semiquantitatively in PET/CT scans performed after patients stopped metformin (p<0.05). There was a statistically significant decrease in activity in the small intestine on visual analysis (p<0.05), but semiquantitative measurements did not show a significant decrease in the SUVmax values in the duodenum or jejunum (p>0.05). CONCLUSION: Metformin causes an increase in (18)F-FDG uptake in the bowel and stopping metformin before PET/CT study significantly decreased this unwanted uptake, especially in the colon, facilitating the interpretation of images obtained from the abdomen and preventing the obliteration of lesions.

Transperitoneal laparoscopic surgery in large adrenal masses.

INTRODUCTION: The laparoscopic adrenalectomy (LA) has become the gold standard since the transperitoneal laparoscopic approach was first reported. AIM: To evaluate the applicability, safety and short-term results of laparoscopic surgery in adrenal masses over 6 cm. MATERIAL AND METHODS: Demographic data, hormonal activities, imaging modalities, operative findings, operation time, conversion rates, complications, duration of hospital stay and histopathologic results of 128 patients who underwent laparoscopic adrenalectomy were evaluated retrospectively. Patients included in the learning curve (n = 23), robotic surgery cases (n = 15) and patients with suspected metastasis (n = 4) were excluded from the study. Six cm mass size was taken as a reference and two groups were formed (group 1: < 6 cm, group 2: ≥ 6 cm). The results of the two groups were compared. RESULTS: There were 64 cases in group 1 and 22 cases in group 2. Functional mass ratio and mass sides were similar between the groups (p = 0.30 and p = 0.17, respectively). The mean mass size in group 1 was 36.4 ±11.2 mm and in group 2 82.4 ±15.5 mm. The conversion rate was similar between the two groups (p = 0.18). The duration of surgery was 135.5 ±8.29 min in group 1, 177.0 ±14.9 min in group 2 (p = 0.014). Morbidity and lengths of hospital stay were similar (p = 0.76, p = 0.34 respectively). Adrenocortical carcinoma was detected in three cases in group 1, which were completed laparoscopically, and in two cases in group 2, which were converted to open surgery (p = 0.46). CONCLUSIONS: Although open surgery is still recommended in the guidelines, studies are now being carried out to ensure that laparoscopy can be safely performed on masses over 6 cm. There was no difference between short-term follow-up and histopathologic results in our study.

Evaluation of factors affecting sexual dysfunction in female patients with diabetes mellitus.

OBJECTIVE: Our objective in this study was to evaluate the factors predicting female sexual dysfunction (FSD) in patients with diabetes mellitus (DM). SUBJECTS AND METHODS: The study included 149 women with DM. Sexual function was evaluated with the Female Sexual Function Index (FSFI) questionnaire, in which total scores under 26.55 characterized the occurrence of FSD (Group 1 > 26.55, Group 2 < 26.55). We recorded the patients' demographic, metabolic, and hormonal data. Ophthalmologic, neurologic, and renal complications were also evaluated. The antioxidant status of the patients in both groups was determined by measuring the activity of the enzymes paraoxonase-1 (PON-1) and arylesterase (ARE). RESULTS: Based on the FSFI scores, 60 patients were allocated to Group 1 (26.6 ± 12.3) and 89 to Group 2 (22.6 ± 9.5). Group 2 compared with Group 1 had significantly (p < 0.05) higher mean concentrations of glycated hemoglobin (HbA1c), glucose, triglycerides, and insulin, along with higher rates of metformin use, smoking, retinopathy, and nephropathy. The mean serum ARE concentrations were significantly lower in Group 2 compared with Group 1 (p = 0.000), but the mean serum PON-1 concentrations were similar between both groups (p = 0.218). On multivariable regression analysis, age, ARE activity, Beck Depression Inventory (BDI) score, and menopause were significant independent predictors of FSD (p < 0.05). CONCLUSIONS: In this study, we evaluated the predictive factors determining FSD caused by DM. Despite the significant results found in our study, future randomized controlled studies with a long follow-up and a larger number of patients are required to determine how DM affects FSD.

The role of selective venous sampling in patients with non-localized primary hyperparathyroidism.

OBJECTIVES: The aim of this observational clinical study was to evaluate the success of angiographic selective venous sampling (ASVS) in locating parathyroid adenoma in patients with primary hyperparathyroidism (PHPT), in whom the other imaging modalities have failed, and and to evaluate its possible contribution to the applicability of minimal invasive surgery. MATERIAL AND METHODS: Fifty-five patients who were admitted to our hospital's General Surgery department between January 2012 and January 2015 for PHPT in whom ultrasound and sestamibi scintigraphy have failed to localize the diseased gland were included to the study. Patients were divided into two groups: those who underwent ASVS and those who did not. The outcomes of patients were reviewed retrospectively. RESULTS: Among 55 patients, 20 underwent ASVS. ASVS successfully lateralized the diseased gland in 17 (85%) patients, and minimally invasive parathyroidectomy could be performed in 14 (70%) patients. The cut-off value of parathormon gradient was considered 10% for lateralization and the accuracy of ASVS in lateralization was 94.1%. In 11 (59%) patients, the superior-inferior discrimination could be achieved in addition to lateralization. CONCLUSION: ASVS has a high sensitivity in locating the diseased gland in patients with PHPT in whom ultrasound and sestamibi scan have failed, and thereby, rendering the performance of minimally invasive surgery possible. Further studies may reveal the role of ASVS in providing useful information about not only lateralization but also the superior-inferior discrimination.