Prospective case control comparison of fetal intrapartum oxygen saturations during epidural analgesia.

BACKGROUND: The purpose of this study was to compare fetal oxygen saturation by fetal pulse oximetry in parturients with and without epidural labor analgesia in a prospective case control study. METHODS: Fetal oxygen saturation values were compared in term pregnant women who received epidural analgesia (epidural group) with those in women who did not (control group). Mode of delivery, Apgar score, fetal oxygen saturation, cord blood gas analysis and fetal outcomes were also compared. RESULTS: A total of 150 pregnant women (75 in each group) gave written consent and were enrolled. The average fetal oxygen saturation during the first stage of labor (active phase) was 45.6 +/- 8.1% for the epidural group and 45.9 +/- 7.4% for the control group (NS); saturations for the second stage of labor were 44.9 +/- 8.8% and 45.3 +/- 6.7%, respectively (NS). In the epidural group, the duration of the first stage of labor was significantly longer (565 +/- 217 min) than the control group (434 +/- 222 min; P= 0.001). Cesarean delivery rates, neonatal cord blood gas analysis, Apgar scores, and neonatal outcomes were similar in the two groups. CONCLUSIONS: Fetal oxygen saturation values are similar in the first and second stage of labor in the presence or absence of epidural labor analgesia.

Sublingual versus vaginal misoprostol for cervical ripening PRIOR TO manual vacuum aspiration under local anaesthesia: a randomized study.

OBJECTIVE: To compare the effectiveness of sublingual and vaginal misoprostol application for cervical ripening prior to manual vacuum aspiration (MVA) under local anaesthesia for voluntary termination of pregnancy between 7 and 10 weeks of gestation. MATERIALS AND METHODS: Prospective randomized study in which 72 women were randomly assigned to administration of either 400 microg vaginal misoprostol 3 hours prior to or 200 microg sublingual misoprostol 2 hours prior to the surgical procedure. We took the preoperative cervical dilatation that was achieved as the main outcome measure. The duration of the procedure, intra-operative blood loss, pain perception before and during the operation, patients' satisfaction, side effects and duration of post-operative bleeding were secondary outcome measures. RESULTS: A similar pre-operative cervical dilatation was achieved in the sublingual and the vaginal groups (6.9 +/- 1.6 mm and 6.6 +/- 1.1 mm, respectively; p = 0.3). The duration of the operation, intra-operative blood loss, and patients' satisfaction did not differ between the two groups. Pain scores were significantly higher in the sublingual group than in the vaginal group, both after administration of misoprostol (p = 0.02) and during the procedure (p = 0.02). Nausea and vaginal spotting were significantly more frequent (p = 0.01 and p = 0.003, respectively), but post-operative bleeding significantly shorter (p = 0.003) in the sublingual group. CONCLUSION: Administration of 200 microg sublingual misoprostol 2 hours before suction curettage under local anaesthesia was as effective as 400 microg vaginal misoprostol 3 hours before that procedure with regard to achieving cervical dilatation. It resulted in higher pre-operative and intra-operative pain scores without changing patients' satisfaction.

FHIT expression in neoplastic, hyperplastic, and normal endometrium.

Fragile histidine triad (FHIT), a candidate of tumor suppressor protein, expression was examined on paraffin-embedded specimens in proliferative, secretory, hyperplastic, and neoplastic human endometrium by immunohistochemistry. The results of FHIT immunoreactivity in endometrial carcinomas were compared with prognostic indicators as well as with p53 overexpression. Forty-four cases of endometrial carcinoma, 30 normal functional (15 proliferative, 15 secretory), and 24 hyperplastic endometrium (12 without atypia, 12 with atypia) specimens were studied using polyclonal FHIT antibody. The streptavidin-biotin-peroxidase detection system was used, and the intensity and the distribution of immunoreactivity were evaluated semiquantitatively. There were no significant differences in FHIT expression in the proliferative, secretory, hyperplastic, either with or without atypia, or carcinomatous endometria. No significant difference in FHIT expression of endometrial carcinomas was detected when prognostic parameters or p53 overexpression were considered. Loss or reduced FHIT expression was not found to predict disease-free or cumulative survivals. This study showed that loss or reduction in FHIT protein expression is present in normal functional and hyperplastic endometria as well as in neoplastic endometrium. FHIT protein seems not to be involved directly in endometrial carcinogenesis, but rather, it regulates cell proliferation both in physiologic and in pathologic conditions of endometrium.

The effects of ovulation induction on ovarian epithelium dysplasia scores and Ki67 expression: an experimental study on rats.

We aimed to evaluate the effects of ovulation induction on Ki67 expression and dysplasia scores of female rat ovaries. Twenty female Wistar rats were randomized either to receive 150 IU/kg human menopausal gonadotropin on estrous day 2 and 75 IU/kg human chorionic gonadotropin on the day of preestrous (induction group, n= 10) or saline as placebo on the corresponding days (control group, n= 10). After five estrous cycles bilateral oophorectomy was performed to compare the Ki67 expression and dysplasia score of the ovarian epithelium. The mean number of the cells that stained positive for Ki67 was 159.6 +/- 101.92 in the follicles, 283.4 +/- 42 in the corpus luteum, and 151 +/- 75.1 in the stroma of the study group compared to 41.8 +/- 35.6 (P= 0.03), 43.2 +/- 28.3 (P= 0.007), and 55.6 +/- 18.6 (P= 0.01), respectively, in the control group. The mean number and rate of cells that stained positive for Ki67 in the epithelium was significantly higher in the ovulation induction group (758 +/- 71 and 63 +/- 1.6%, respectively) compared to the control group (386 +/- 23, P < 0.001; and 60 +/- 1.1%, P < 0.001; respectively). The mean dysplasia score was significantly higher (9.6 +/- 1.3) in the study group compared to the control group (5.08 +/- 0.9, P < 0.001). Ovulation induction in rats resulted in increased Ki67 expression and dysplastic features in the ovarian epithelial cells.

Maternal colonisation with group B streptococcus and effectiveness of a culture-based protocol to prevent early-onset neonatal sepsis.

This study was conducted to find out the group B streptococcus colonisation of pregnant women in Kocaeli, Turkey. A culture plus individualised high-risk-based antibiotic prophylaxis was compared with high-risk-based approach alone. The screening of women was performed via vaginal and anal cultures for group B streptococcus (GBS). The maternal GBS colonisation rate was found to be 6.5%. All colonised women or preterm labours with unavailable culture results until delivery received prophylactic antibiotics. Neonatal colonisation rate and early-onset neonatal sepsis due to GBS was 1/200. The unscreened 900 women received prophylactic antibiotics due to a risk factor-based approach. The neonatal colonisation rate was 17/900 (p = 0.1), and the rate of early-onset neonatal sepsis was 3/900 (p = 0.6). A culture plus individualised high-risk-based antibiotic prophylaxis provided an insignificant change in neonatal colonisation and early-onset neonatal sepsis with GBS when compared with high-risk-based approach alone.

Magnetic resonance imaging and angiography for the prerupture diagnosis of rudimentary uterine horn pregnancy.

Magnetic resonance (MR) imaging and MR angiography were used for the differential diagnosis and preoperative planning of a 17 weeks of age rudimentary horn pregnancy. A 26-year-old primigravida was referred to our hospital with a preliminary diagnosis of abdominal pregnancy. After an inconclusive ultrasound evaluation we were able to identify a rudimentary horn pregnancy, extent of the placental invasion, and the vascular supply via MR imaging and time of flight sequence MR angiography. The obtained data were also used for preoperative planning, which resulted in an uncomplicated, prerupture laparotomy for pregnancy termination and a healthy female.

Effects of aminoguanidine and tolrestat on the development of ocular and renal structural changes in experimental diabetic rats.

Studies that researched the role of aminoguanidine and tolestat in the prevention of diabetic retinopathy and nephropathy resulted in conflicting data. We investigated the effects of these agents in the prevention of ocular and renal changes in streptozotocin (STZ)-induced diabetic rats. Diabetes was induced by intravenous injection of STZ in 30 rats. Ten rats that were not given STZ served as non-diabetic control (Group 1). Ten STZ-diabetic rats that were not given any treatment served as diabetic control (Group 2). Groups 3 and 4 were composed of STZ-induced diabetic rats (10 each) that were given tolrestat and aminoguanidine respectively. Eyes and kidneys were examined at the 24th week under electronmicroscopy. Cataract was observed in all six of the surviving rats in Groups 2 and 4, and in one of 6 surviving rats in group 3. Cataract development was lower in Group 3 than Groups 2 and 4. All retinal samples obtained from group 2 demonstrated a number of structural abnormalities, whereas there were no significant ultrastructural changes in groups 3 and 4. Groups 2 and 3 demonstrated mesangial proliferation and expansion, diffuse glomerular basement membrane (GBM) thickening, and focal GBM thickening in the bulb form. Group 4 demonstrated a normally appearing mesangial space, minimal diffuse but no focal GBM thickening. The urinary albumin excretion (UAE) was lower in Group 4 than the other groups. In conclusion, our results suggest that aminoguanidine may be an important agent for the prevention of renal changes, whereas tolrestat may be effective for the prevention of ocular changes in diabetes mellitus.

Effects of granulocyte-colony stimulating factor in the treatment of diabetic foot infection.

AIMS: Foot infections and the subsequent amputation of a lower extremity are the most common cause of hospitalization among patients with diabetes mellitus. Although there are several reasons for susceptibility to infection in diabetic patients, white blood cell dysfunction is considered to be an important cause for this tendency. Granulocyte-colony stimulating factor (G-CSF) increases the release of neutrophils from the bone marrow and improves neutrophil functions. Based on this knowledge, the aim of the present study was to investigate the effects of addition of G-CSF to the treatment of foot infections in diabetic patients. METHODS: Thirty diabetic patients with foot infection were included in the study. Fifteen of the patients received standard treatment consisting of local wound care and antibiotics (standard group), and the other 15 patients received G-CSF besides standard treatment (G-CSF group). The objectives of this study were to determine the time to resolution of infection, time to hospital discharge, need for surgical intervention, and the effects of G-CSF on phagocytosis and respiratory burst of neutrophils. RESULTS: Treatment with G-CSF led to significantly higher neutrophil counts on the 5th and 10th days, and at the end of treatment in the G-CSF treated group compared to the standard group. Respiratory burst of neutrophils increased significantly in both the G-CSF group (from 1.6 +/- 0.3 to 2.3 +/- 0.5, p = 0.001) and the standard group (from 2.0 +/- 0.4 to 2.3 +/- 0.4, p = 0.02) with treatment. But, while phagocytosis of neutrophils increased significantly in the G-CSF group (from 70.4 +/- 2.0 to 74.5 +/- 1.9, p = 0.004), it did not change significantly in the standard group (from 68.1 +/- 0.2 to 69.4 +/- 1.9, p = 0.3) with treatment. Duration of hospitalization (26.9 +/- 2.0 vs. 28.3 days, p < 0.05), duration of parenteral antibiotic administration (22.9 +/- 2.0 vs. 23.3 +/- 1.9 days, p < 0.05), time to resolution of infection (23.6 +/- 1.8 vs. 22.3 +/- 1.7 days, p < 0.05), and need for amputation (13.3% vs. 20%, p > 0.05) were similar between the G-CSF and the standard groups. CONCLUSIONS: Although G-CSF improves neutrophil function as well as increasing the absolute numbers, this improvement is not associated with shortening of duration of antibiotic administration, duration of hospital stay or need for amputation in diabetic foot infection.

Insulin resistance in nonobese patients with polycystic ovary syndrome.

OBJECTIVES: Most patients with polycystic ovary syndrome (PCOS) are obese and known to have insulin resistance. Obesity per se is a cause of insulin resistance. This study was performed to determine whether insulin resistance occurs in patients with PCOS in the absence of obesity and acanthosis nigricans. METHOD: For this purpose, an euglycemic hyperinsulinemic clamp study was performed in 12 nonobese patients with PCOS and in 10 healthy control subjects matched for age and weight. RESULTS: The mean serum testosterone and luteinizing hormone (LH) levels were significantly elevated (4.09 +/- 1.32 vs. 1.18 +/- 0.53 pg/ml, p < 0.001, and 11.63 +/- 5.37 vs. 4.98 +/- 2.73 mIU/ml, p < 0.001, respectively), and the serum sex hormone binding globulin level was significantly reduced (40.96 +/- 14.94 vs. 73.98 +/- 30.40 nmol/l, p < 0.001) in patients with PCOS as compared with the values in control subjects. The mean serum insulin level was also elevated in patients with PCOS as compared with control subjects (32.33 +/- 4.98 vs. 19.56 +/- 2.21 microU/ml, p < 0.05). The insulin sensitivity was lower in patients with PCOS as compared with the control subjects (200 +/- 27.8 vs. 427.8 +/- 88.9 micromol x kg(-1) x min(-1), p < 0.001). In patients with PCOS, the serum levels of free testosterone (r = -0.89, p < 0.001) and LH were inversely correlated with the insulin sensitivity (r = -0.63, p < 0.05). Serum follicle-stimulating hormone, prolactin, and dehydroepiandrosterone sulfate levels were similar in both groups. CONCLUSIONS: These results indicate that a significant degree of insulin resistance exists in nonobese patients with PCOS and that this insulin resistance is significantly related to serum LH and free testosterone levels. Thus, measures to decrease insulin resistance may have to be considered earlier to decrease the potential risks of developing diabetes mellitus and coronary artery disease at later ages of life in these patients.

Does the intrauterine device carry the risk of immunity to sperm?

Intrauterine devices (IUDs) are the second most commonly used contraceptive method in the world. A number of mechanisms have been proposed by which IUDs could interfere with reproductive processes. In this study, the relationship between intrauterine devices and the risk of antisperm antibody (ASA) production in the absence of prior sensitization was investigated. Sixty-two IUD users (group 1) and 42 women with no contraceptive use as a control group (group 2) were included in the study. Six months after the IUD insertion, 4 women in group 1 and 2 women in group 2 with lower genital tract infections were excluded from the study. The sera of the remaining 58 women in group 1 and 40 women in group 2 were evaluated again for the presence of ASA. Twelve patients (20.7%) in group 1 and 12 patients (30.0%) in group 2 had ASA positivity. When we compared the ASA levels in the IUD group with those in the control group, there was no statistically significant difference (p>0.05). In summary, our data proved that copper-containing intrauterine devices in the absence of prior sensitization do not significantly affect immunity to sperm in sera of women.

The effects of thyroid status on plasma leptin levels in women.

Leptin, the product of the adipose specific ob gene, regulates food intake and energy expenditure. However, little is known about the effects of thyroid status on plasma leptin levels in women. We determined fasting plasma leptin levels before and 1 month after restoration of euthyroidism in 20 female patients with hypothyroidism, 20 female patients with hyperthyroidism and 20 age and BMI-matched female controls. To restore the normal thyroid function patients with hypothyroidism were treated with levothyroxine, whereas patients with hyperthyroidism were treated with propylthiouracil. Plasma leptin levels were measured by a RIA method with a sensitivity of 0.5 microgram/l. Leptin levels were significantly lower in patients with hypothyroidism before treatment (4.17 +/- 2.58 micrograms/l) than in patients with hyperthyroidism (6.80 +/- 4.3 micrograms/l; z = -2.06, p = 0.037). Leptin levels were significantly higher in hyperthyroid patients than in the control group (3.71 +/- 1.69 micrograms/l, z = -2.44, p = 0.014) whereas leptin levels in the hypothyroid patients were not significantly different from those in control subjects (z = -0.16, p = 0.87). Restoration of euthyroid state was not associated with a significant change in leptin levels either in the hypothyroid (from 4.17 +/- 2.58 to 5.22 +/- 3.4 micrograms/l; z = -1.74, p = 0.08) or in the hyperthyroid group (from 6.80 +/- 4.37 micrograms/l to 7.93 +/- 6.25 micrograms/l z = -0.89, p = 0.37), although a tendency for leptin to increase was observed in both groups. There was no correlation between plasma leptin and FT3, FT4, TSH, or BMI either before or after therapy in both groups. Leptin levels were significantly correlated with BMI in the control group (r = -0.53, p = 0.018). We conclude that plasma leptin levels are increased in hyperthyroidism and unchanged in hypothyroidism. Furthermore, our study demonstrates that mean plasma leptin levels are not influenced by short term restoration of euthyroidism in both hypothyroidism and hyperthyroidism, although an effect of long-term treatment may not be excluded.

The effects of human amniotic membrane and fibrin sealant in the prevention of postoperative adhesion formation in the rabbit ovary model.

The study group consisted of 29 female, white New Zealand rabbits. The rabbits were randomized into 3 groups and a midline laparotomy was performed in order to make a 4-5 mm long lesion using a scalpel in both ovaries. In Group 1, both of the ovaries were left uncovered. In Group 2, the right ovaries were covered by human amniotic membrane graft. In Group 3, 0.1-0.2 mL of Tisseel solution was applied to the lesion in the right ovaries. No medication was applied to the left ovaries in any of the groups and thus this ovary acted as an individual control. After 2 weeks the adhesion scores were graded by relaparotomy in a blind manner. Fibrin sealant showed a significant reduction in postoperative adhesion formation compared with the amniotic membrane graft and control groups (p<0.001). Therefore, it can be concluded that fibrin sealant can be used as an adjuvant during reproductive surgery.

The effects of thyroid status on serum apolipoprotein A-I-containing lipoprotein particles.

Alterations of lipid profile are a well-known phenomenon in thyroid dysfunction. However, little is known about the influence of thyroid hormone on Lp A-I and LpA-I:A-II particles. We have, therefore, studied LpA-I and LpAI:A-II concentrations in a group of 20 patients with hyperthyroidism and in a group of 15 patients with hypothyroidism before and one month after attainment of euthyroidism. In hypothyroid patients, LDL-cholesterol and apo B concentrations decrease significantly after L-T4 replacement treatment (from 4.49+/-2.51 to 2.76+/-0.70 mmol/ L, P=0.036 and from 89.4+/-16.1 to 78.3+/-13.3 mg/dL, P=0.05, respectively), whereas no significant change was observed in the total cholesterol, HDL-C, LpA-I, LpA-I:A-II and apo A-I concentrations. In hyperthyroid patients, total cholesterol (from 3.58+/-0.72 to 4.74+/-1.39mmol/L, P=0.0025), HDL-C (from 1.19+/-0.23 to 1.41+/-0.27mmol/L, P=0.0084), LDL-C (from 1.83+/-0.69 to 2.96+/-1.20 mmol/l, P=0.0025), apo A-I (from 85.6+/-12.5 to 91.7+/-18.1 mg/dL, P=0.05) and apo B (from 52.7+/-8.2 to 65.6+/-16.5 mg/dL, P=0.0013) increased after restoration of euthyroidism while triglycerides, LpA-I and LpA-I: A-II concentrations were unchanged. LpA-I and LpA-I:A-II concentrations were not related to thyroid hormones in both groups. Our study suggests that LpA-I and LpA-I:A-II particles are not under the direct control of thyroid hormones.

A trial of reducing adhesion formation in a uterine horn model.

For the prevention of postoperative adhesion formation, one of the most common causes of infertility, none of the adjuvants had been proven uniformly effective. In this study we evaluated the effectiveness of sodium carboxymethylcellulose (SCMC) and disodium cromoglycate (DSCG) in postoperative adhesion prevention in a rat uterine horn model. Thirty female Sprague-Dawley rats were used. After uterine horn abrasion, in 10 rats 10 ml 0.9% saline, in 10 rats 10 ml of 2% SCMC, and in 10 rats 10 ml DSCG were administered intraperitoneally. Two weeks later, all animals were sacrificed and adhesion formation was assessed. All the pieces of the peritoneum biopsies were stained with Luna's mast cell stain to assess the mast cell degranulation. The mean adhesion scores were 2.1, 2.0 and 1.5 for saline, SCMC and DSCG groups respectively. There were no significant differences among all groups. In the pathologic examination, mast cell degranulation was less in the DSCG group than the other groups.

A case of Noonan's syndrome with numerous cardiac abnormalities.

OBJECTIVE: To report a case of Noonan's syndrome in a patient with numerous cardiac abnormalities. METHODS: We present a case report of a patient with Noonan's syndrome, including clinical, laboratory, and radiologic findings, and discuss the characteristic features of this condition. RESULTS: A 19-year-old male patient had most of the typical clinical findings of Noonan's syndrome-dysmorphic face, short stature, ear abnormalities, cryptorchidism, webbed neck, and high palate. In addition, mitral valve prolapse, secondary mitral insufficiency, left ventricular hypertrophy, and secondary tricuspid insufficiency were diagnosed. Although some cardiac abnormalities have been reported in patients with this syndrome, a case with numerous cardiac abnormalities has not been described previously. CONCLUSION: Noonan's syndrome is a rare disorder with characteristic clinical features and cardiac abnormalities. Although previously reported cases have described cardiovascular anomalies, on review of the literature we found no other case with numerous cardiac abnormalities.

Magnetic resonance imaging of posterior pituitary for evaluation of the neurohypophyseal function in idiopathic and autosomal dominant neurohypophyseal diabetes insipidus.

We investigated the role of MR imaging for evaluation of the functional status of the neurohypophyseal system in both idiopathic central diabetes insipidus (DI) and familial autosomal dominant neurohypophyseal DI. The patients and family with DI were analyzed retrospectively for the presence or absence of posterior pituitary gland hyperintense signal on MR images. A total of 19 adult patients with idiopathic central DI, 7 members of a family with autosomal dominant DI and 20 control subjects were included in the study. Diagnosis of idiopathic DI was based on the presence of central DI in the absence of any alteration that is known to be responsible for DI. The patients were studied retrospectively and the morphology and intensity of the posterior lobe by MR imaging was assessed by blinded reading. In all patients with idiopathic central DI and the affected members of the family, the posterior bright signal was absent while the stalk was normal on MR images. In contrast, normal posterior pituitary bright signal and stalk were found in unaffected members of the family and all control subjects. We conclude that MR imaging of the posterior pituitary lobe can be used to evaluate the functional status of the neurohypophyseal system in idiopathic central DI and familial autosomal dominant DI.

Fluoxetine in the treatment of premenstrual syndrome.

BACKGROUND: Premenstrual syndrome (PMS) is defined as the disabling and cyclic occurrence of emotional and behavioral symptom complex during the latter half of the menstrual cycle. Although its etiology is unknown, it has been speculated that premenstrual syndrome is linked to a deficiency of central serotoninergic activity. METHOD: The study consisted of a double-blind, placebo controlled trial of fluoxetine at a dose of 20 mg/day or placebo for three menstrual cycles. The 440 women who appeared to meet the eligibility criteria were instructed to record the 'Calendar of Premenstrual Experiences' (CPE) scale for two complete menstrual cycles. Of 410 women who successfully completed two cycles of recording their symptoms daily only 35 met the criteria for PMS. These criteria included psychiatric interviews which were made before treatment. Thirty-five PMS patients were randomized into placebo or fluoxetine treatment groups. RESULTS: Our study suggests that fluoxetine at a dose of 20 mg per day was significantly superior to placebo in alleviating the symptoms of PMS. The most common side effects were gastrointestinal irritability (15%), insomnia (11%) and sexual dysfunction (8.5%). CONCLUSION: Fluoxetine is an effective and well-tolerated drug and appears to have considerable promise in treating a range of symptoms in women with PMS.

A case of thyrotropin-secreting pituitary microadenoma with normal thyrotropin alpha-subunit level.

We present a 32-year-old male with a thyrotropin (TSH)-secreting pituitary microadenoma with normal alpha-subunit (SU) and/or alpha-SU/TSH molar ratio. An interesting feature of this patient is that the size of the pituitary tumor remained unchanged during a 6-year follow-up without treatment. The tumor was clearly visualized with somatostatin receptor imaging, indicating that it was somatostatin receptor-positive. Subcutaneous injection of 100 microg octreotide acetate three times daily resulted in significant reduction of TSH and free thyroid hormones 6 weeks after initiation of treatment. However, tumor size was not changed 3 months after initiation of octreotide therapy and thyroid hormones, but not TSH level, eventually increased in spite of increasing the octreotide dosage up to 600 microg/day. This led to discontinuation of treatment. The patient responded only temporarily to octreotide in spite of somatostatin receptors. This case further demonstrates that a normal alpha-SU and/or alpha-SU/TSH molar ratio cannot exclude the possibility of a TSH-secreting pituitary adenoma.

A case of Addison's disease associated with the Lambert-Eaton myasthenic syndrome.

Nonneoplastic Lambert-Eaton Myasthenic Syndrome (LEMS) is rare. A 27-year-old man as initially having the diagnosis of Addison's disease was admitted to the hospital because of fatigue, dry-mouthness and proximal limb weakness for 1 year. A diagnosis of LEMS was made from electrophysiological studies. Clinical and laboratory studies revealed no malignancy. We report the first case of Addison's disease associated with non-neoplastic LEMS. It is possible that subclinical LEMS might be present in patients with Addison's disease more frequently than currently believed, since the prominent symptoms of LEMS may be confused with symptoms of Addison's disease.