Treatment of recurrent malignant pheochromocytoma with a novel approach: A case report and review of literature.

INTRODUCTION: Pheochromocytomas are rare catecholamine-secreting tumors with a high potential for recurrence post-surgery, necessitating prolonged follow-up. This case highlights the diagnostic and therapeutic challenges in managing recurrent pheochromocytoma. CASE PRESENTATION: A 25-year-old female, with a history of left pheochromocytoma treated with adrenalectomy a decade earlier, presented with a right adrenal mass. Despite controlled hypertension, elevated urine metanephrines suggested recurrence. Imaging showed a right adrenal mass and suspicious left paraaortic lymph nodes, confirming the diagnosis of recurrent malignant pheochromocytoma in the left adrenal bed and right adrenal gland, with metastasis to the paraaortic lymph nodes. The patient underwent right adrenalectomy coupled with cytoreductive surgery (CRS) in the form of excision of left-sided adrenal bed recurrence and left paraaortic lymph node dissection, intraoperative radiation therapy (IORT), and hyperthermic intraperitoneal chemotherapy (HIPEC). On follow-up six years later, the patient remains free from recurrence. DISCUSSION: This case illustrates the importance of continued surveillance in pheochromocytoma patients, even those with a low-risk profile. The recurrence in this case, despite a smaller initial tumor size and no genetic predispositions, underscores the unpredictable nature of pheochromocytomas. The successful management with CRS, IORT, and HIPEC emphasizes the need for a personalized and multifaceted treatment approach. CONCLUSION: Pheochromocytoma patients, including those initially considered low risk, require long-term monitoring due to the risk of recurrence. The utilization of CRS, IORT, and HIPEC in this case was pivotal in managing the recurrent and metastatic malignant disease effectively, demonstrating the significance of a comprehensive, multidisciplinary treatment strategy in such complex cases.

Cardiovascular Risk Among Patients with Controlled and Uncontrolled Type 2 Diabetes: A Sub-Cohort Analysis from the Heart Health Promotion (HHP) Study.

Objective: This study aimed to estimate the risk of cardiovascular disease (CVD) among patients with and without diabetes mellitus (DM) using the Framingham risk score (FRS) and to investigate the effect of DM control on CVD risk. Methodology: A total of 2432 participants who had their glycosylated hemoglobin (HbA1c) measured within the last three months were included in this study. The study cohort was divided into three categories: non-diabetic, participants with controlled DM (HbA1c<7%), and uncontrolled DM (HbA1c≥7%). The World Health Organization's stepwise approach to chronic disease risk factor Surveillance-Instrument v2.1 was used in this study to collect the anthropometric and biochemical measurements. The Framingham Coronary Heart Risk Score (FRS) was used to calculate the 10-year cardiovascular risk (CVR). The groups were compared concerning the prevalence of metabolic, socioeconomic, and cardiac risks. Results: Out of 2432 participants, 149 had controlled DM (6.1%), 286 had uncontrolled DM (11.8%), and 1997 participants were normoglycemic (82.1%). Compared to healthy participants, diabetic participants showed more high-risk characteristics across all CVR parameters. Uncontrolled diabetic patients had a graver laboratory and clinical profiles compared to the controlled DM group. As measured by FRS, nearly half of patients with controlled DM (49.9%) and two-thirds of patients with uncontrolled DM (63.3%) were classified as intermediate and high-risk compared to 4.6% of the healthy participants. Compared to healthy participants, patients with controlled DM showed a threefold increased CVR (OR = 3.02, 95% C.I. = 1.41-7.24) while this risk catapulted to 13 times among those with uncontrolled DM (OR = 13.57, 95% C.I. = 6.99-26.36). Conclusion: Participants with DM are at moderate to high CVR. Individuals with uncontrolled DM showed higher CVR profiles as measured by FRS and have a higher prevalence of obesity, unhealthy diet, and physical inactivity.

Thyroid Dysfunction and Renal Function: A Crucial Relationship to Recognize.

BACKGROUND AND AIM: Renal function is noticeably altered in both hypothyroidism and hyperthyroidism. However, clinical studies on thyroid dysfunction and its association with renal function are scarce. The purpose of this study was to evaluate changes in biochemical parameters of renal function in subjects with thyroid dysfunction and to correlate these values with the patient's thyroid profile. The effect of changes in thyroid function during therapy on renal function was also investigated. METHODS: A prospective cohort study included 41 patients with untreated primary hypothyroidism and 16 patients with untreated hyperthyroidism. Thyroid-stimulating hormone (TSH), free thyroxine, and free triiodothyronine were assessed using immunoassay. The estimated glomerular filtration rate was calculated by the Modification of Diet in Renal Disease formula. Renal function tests were assessed in all patients at each of the two-time points: during thyroid dysfunction (hypo- or hyperthyroidism) and after attaining euthyroidism. RESULTS: Our study demonstrated a statistically significant reduction in the average serum creatinine level in the hypothyroid patients after treatment compared to before treatment whereas the mean estimated glomerular filtration rate (eGFR) significantly improved after treatment compared to before treatment. Moreover, the average serum creatinine level in the hyperthyroid patients was significantly lower before treatment compared to after treatment, whereas the mean eGFR significantly dropped after treatment. TSH had a significant positive correlation with serum creatinine and a significant negative correlation with eGFR in all patients with thyroid dysfunction. CONCLUSIONS: Thyroid dysfunction is associated with deranged kidney function. It is crucial for the clinician to be aware of the link between thyroid disorders and aberrant renal function in order to consider a thyroid function test when treating a patient whose biochemical markers of renal function are only mildly elevated. There is a need for monitoring creatinine in patients with thyroid dysfunction.

Association of serum 25-hydroxyvitamin D3 levels and insulin resistance with viral load and degree of liver fibrosis in Egyptian chronic HBV patients: a case-control study.

Aim of the study: To assess serum 25-hydroxyvitamin D3 level and insulin resistance (IR) in hepatitis B virus (HBV) patients compared with controls and to evaluate the correlation with HBV viral load, severity of liver disease and degree of liver fibrosis. Material and methods: A case-control study. Sixty HBV patients and 60 controls were enrolled. Chemiluminescence was used to determine 25-hydroxyvitamin D3 levels. Insulin resistance was evaluated using the homeostasis model assessment method. Polymerase chain reaction was used to quantify HBV viral loads. Severity of liver disease was assessed by Child-Pugh scores. Transient elastography was used to evaluate the degree of liver fibrosis. Results: 25-Hydroxyvitamin D3 deficiency is more prevalent among HBV patients compared to controls. 25-Hydroxyvitamin D3 levels declined considerably as viral load rose (p < 0.001). 25-Hydroxyvitamin D3 level declined as liver fibrosis progressed (34.0 ±0.0 ng/ml in F1 vs. 12.67 ±8.0 ng/ml in F4) and the severity of the disease increased (22.75 ±6.36 ng/ml in Child A vs. 5.50 ±0.58 ng/ml in Child C). Insulin resistance is more prevalent among HBV patients compared to controls and it appeared to deteriorate progressively with boosting of the viral load, degree of fibrosis and severity of liver disease (p < 0.001). Conclusions: HBV patients had significantly lower 25-hydroxyvitamin D3 levels compared to healthy individuals and HBV infection is associated with IR. 25-Hydroxyvitamin D3 deficiency and IR were associated with HBV viral loads, severity of liver disease, and degree of liver fibrosis.

Evaluation of adrenal function in hemodynamically stable patients with liver cirrhosis.

Aim of the study: To estimate the prevalence of adrenal insufficiency (AI) in hemodynamically stable cirrhotic patients and to evaluate the potential association with patients' clinical characteristics, cirrhosis etiology and liver disease severity. Material and methods: The cross-sectional study included 132 stable liver cirrhosis patients. Severity of liver disease was graded using the Child-Pugh classification and Model for End-stage Liver Disease (MELD) score. The adrenal function was evaluated by measuring basal and peak cortisol after 60 minutes following the short Synacthen test (SST). Differences in terms of demographic data, clinical information and liver disease severity were compared between cirrhotic patients with and without AI. Results: Out of 132 cirrhotic patients, 86 patients had evidence of AI based on the peak serum cortisol value while the prevalence was lower (67 patients out of 132) when basal cortisol level was taken as the basis. A total of 82 patients were classified as Child-Pugh class C, with an average MELD score of 20 ±7.1. Most patients with AI had Child-Pugh class C. Patients with AI had a higher prevalence of ascites, gastrointestinal hemorrhage, and hepatic encephalopathy, a higher MELD score and a lower serum sodium level compared to patients with normal adrenal function. AI was not related to the etiology of cirrhosis but was related to the severity of liver disease and the degree of hyponatremia. Conclusions: Adrenal insufficiency is common among hemodynamically stable patients with cirrhosis. It is related to the severity of liver disease and the degree of hyponatremia.

Potential relationships between COVID-19 and the thyroid gland: an update.

In this review, I aim to provide a complete overview of recent advances in knowledge regarding severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2)-induced thyroid dysfunction. I discuss the findings regarding the role of SARS-CoV-2 in the development of thyroid dysfunction, including subacute thyroiditis, Graves' disease, non-thyroidal illness, thyrotoxicosis and Hashimoto's thyroiditis during and subsequent to coronavirus disease 2019 (COVID-19). The thyroid gland and the entire hypothalamic-pituitary-thyroid (HPT) axis may represent key targets of SARS-CoV-2. Thyroid dysfunction during and subsequent to COVID-19 has been documented in clinical studies and is usually reversible. Most of the thyroid disorders, including Graves' disease, euthyroid sick syndrome, Hashimoto's thyroiditis and subacute thyroiditis, have been documented as sequelae to COVID-19, and the SARS-CoV-2 virus has been implicated in the aetiology of each. COVID-19 has been suggested to trigger the activation of pre-existing thyroid disease or autoimmunity. Furthermore, patients with uncontrolled thyrotoxicosis are at risk of SARS-CoV-2 infection-related consequences. Because of the neutropenia caused by antithyroid medications, which may obscure the signs of COVID-19, this group of patients should receive special attention. It is suggested that thyroid dysfunction during COVID-19 is caused by direct infection of the thyroid or "cytokine storm"-mediated autoimmune effects on the thyroid.

Huge Right Retroperitoneal Paraganglioma With a High Risk of Surgical Excision Treated Conservatively for 14 Years.

Paraganglioma is an uncommon type of neuroendocrine tumor capable of secreting neuropeptides and catecholamines. Retroperitoneal paragangliomas are rare neoplasms that originate from chromaffin cells that secrete catecholamines in the sympathetic ganglia. Tumor reduction and management of excessive catecholamine secretion are the key treatment goals. Surgery is the choice of treatment modality when tumors are amenable to resection because of their malignant potential. Currently, high-dose metaiodobenzylguanidine (MIBG) radiation and chemotherapy are adjuvant therapy to surgery. This case is reported to demonstrate a good prognosis in a conservatively managed, huge, non-functional retroperitoneal paraganglioma for 14 years. This provides alternative options to the traditional surgical treatment in patients who refuse, are unfit for surgery, or have complex surgery, which carries a high mortality rate with analysis of follow-up modalities. Meanwhile, a review of the relevant literature was conducted in order to figure out the prognosis.

Serum Ghrelin Concentration in Patients With Primary Biliary Cirrhosis (PBC).

INTRODUCTION: The appetite-modulating hormone ghrelin may have a role in the etiology of anorexia which is a serious concern in patients with primary biliary cirrhosis (PBC). This study aims to assess the difference in ghrelin level between cases of PBC and healthy controls matched for age and gender, and to evaluate the level of ghrelin in relation to clinical and laboratory findings among cases. METHODS: Twenty patients with primary biliary cirrhosis and 30 healthy controls matched by gender and age were recruited. The severity of liver disease was determined using the Child-Pugh grading system. Clinical comorbidities such as a history of ascites, gastrointestinal bleeding, and encephalopathy were evaluated. A commercial enzyme-linked immunosorbent assay was used to measure total ghrelin.  Results: PBC cases had a significantly higher average level of ghrelin (2305.3 ± 639.4) pg/mL compared to controls (682 ± 197.3) pg/mL. Furthermore, the minimum reported level in cases was 1258 pg/mL compared to 326 pg/mL in controls, while the maximum level nearly tripled the control's maximum level. In PBC patients, plasma levels of total ghrelin showed a weak positive correlation with age, an inverse correlation with body mass index, and were not associated with gender. The level was significantly higher than those in the controls. Ghrelin was associated with the severity of cirrhosis. Levels of serum ghrelin were higher in patients with associated comorbidities such as a history of ascites, gastrointestinal bleeding, and encephalopathy. CONCLUSIONS: Our study demonstrated elevated serum ghrelin levels in patients with primary biliary cirrhosis. Serum ghrelin was associated with the degree of severity and the presence of related comorbidities. Patients with primary biliary cirrhosis remain anorexic and catabolic despite elevated ghrelin levels, suggesting tissue resistance to this anabolic peptide which could be crucial to understanding anorexia and cachexia in primary biliary cirrhosis.

Evaluation of Serum Levels of Insulin-Like Growth Factor 1 and Insulin-Like Growth Factor-Binding Protein 3 in Patients With Colorectal Cancer: A Case-Control Study.

BACKGROUND/AIM: Limited information is available about the relationship between colorectal cancer (CRC) and serum concentration of insulin-like growth factor 1 (IGF1) and insulin-like growth factor-binding protein 3 (IGFBP3). This study aims to compare the serum levels of IGF1and IGFBP3 in colorectal cancer cases and controls and to assess the relationship between their level and the demographic and histopathological characteristics. METHODS: A case-control study in which 50 patients with colorectal cancer and 50 controls matched by gender and age were compared regarding the demographic characteristics and the level of both IGF1 and IGFBP3. The correlation with different clinicopathological features was assessed. RESULTS: Levels of IGF1 were significantly higher while levels of IGFBP3 were significantly lower among cases compared to control. IGF1 was significantly higher among patients with liver metastasis, lymph node (LN) spread, and lymphovenous invasions and did not show significant association with gender, smoking status, family history, or primary site of colorectal cancer. Lower IGFBP3 was significantly high among patients with liver and lymph node metastasis, lymphovenous invasion, and patients with positive family history. This significant negative correlation was also detected between IGFBP3 levels and the size of the tumor. CONCLUSIONS: High IGF1 levels and low concentrations of IGFBP3 are related to colorectal cancer and were significantly associated with liver metastasis, lymph node spread, and lymphovenous invasions. Further research is recommended to investigate if circulating IGF1 and IGFBP3 levels can be used to identify people at high risk of colorectal cancer and to investigate potential lifestyle or pharmaceutical ways to lower IGF1 bioactivity as a risk reduction strategy.

Evaluation of thyroid function and thyroid autoimmune disease in patients with non-alcoholic fatty liver disease.

Aim of the study: Evaluation of thyroid function and thyroid autoimmunity in patients with non-alcoholic fatty liver disease (NAFLD). Material and methods: A case control study. Fifty patients with NAFLD and 50 control subjects matched by gender and age were recruited. Serum thyroid stimulating hormone (TSH) and free thyroxine (FT4) were measured to assess thyroid function. Thyroid autoimmune disease was evaluated by measuring thyroid peroxidase antibody (TPOAb) and anti-thyroglobulin antibodies (TgAb). The FIB-4 score and the APRI score were calculated to assess the degree of fibrosis. The association between thyroid parameters and NAFLD was explored. Results: About one quarter of patients with NAFLD had hypothyroidism compared to 10% of the control group whilst 6% of NAFLD patients had hyperthyroidism compared to 2% of the controls. NAFLD cases showed substantially higher TSH and lower FT4 compared to controls; meanwhile, levels of fibrosis indices (FIB-4 and APRI score) were significantly higher among hypothyroid patients in both cases and controls. TSH had a positive strong correlation with FIB-4 and APRI score, whereas FT4 had a negative significant correlation with both fibrosis indicators, and this clinical relationship was similar in NAFLD cases and controls. Conclusions: Hypothyroidism is more prevalent among patients with NAFLD compared to controls and high levels of TSH with low FT4 might be a risk factor for NAFLD and may impact the development of liver fibrosis. The role of thyroid autoimmunity in NAFLD needs further assessment. NAFLD patients should be monitored by yearly TSH and FT4 testing.

Knowledge, attitude, and practice regarding diabetic dermopathy among physicians in Riyadh, Saudi Arabia.

CONTEXT: Type 2 diabetes mellitus (T2DM) is expanding at an epidemic rate. Diabetes and the prediabetes are associated with a number of skin manifestations which are seen in a minimum of 30% of diabetics as first sign or during the course of their illness. To the best of our knowledge, this is the first study in Saudi Arabia that assess physicians' knowledge, attitude and practice regarding this common problem. AIMS: To assess the level of knowledge, attitude, and practice (KAP) about diabetic dermopathy among a representative sample of physicians in Saudi Arabia; and to identify determinants of good KAP. SETTINGS AND DESIGN: A cross-sectional study was conducted among physicians at university and governmental hospitals in Riyadh, KSA. MATERIALS AND METHODS: 112 physicians from different specialties and experiences were interviewed using an English self-administered questionnaire. STATISTICAL ANALYSIS USED: Data was analyzed using IBM SPSS Statistics for Windows, version 20, with appropriate statistical test. P value < 0.05 was considered significant. RESULTS: It included 112 physicians in which 43.8%, Family medicine, 31.3% endocrinologist/Internal Medicine, and 25.0% GPs/Interns. Physicians above 35 year-old, master/PhD holders, consultants, endocrinologist/Internal Medicine, and those in practice for more than 10 years scored the highest in the overall knowledge. However, only 47% were confident to diagnose diabetic dermopathy. Moreover, majority of physicians regardless of the specialty, had educated their patients, examined them for other lesions, and followed conservative protocols. As much as 74.3% of endocrinologists seek for dermatologists' consultation. CONCLUSIONS: Physicians' knowledge regarding diabetic dermopathy is suboptimal, this may impact quality of diabetes care.

Awareness, experience, and practice of physicians regarding adult gastroesophageal reflux disease (GERD) in Riyadh, Saudi Arabia.

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) was frequently managed by residents as they are the first physician who encounter the patient. This study was conducted to explore the knowledge and practice of physicians in the treatment of GERD and to compare between residents and consultants regarding their knowledge and practice. METHODOLOGY: A cross-sectional study, self-administered questionnaire. RESULTS: Esophagogastroduodenoscopy (EGD) was the most commonly used method to screen for Barrett's esophagus for symptoms for 5 or more years. The most frequent guideline used was the American College of Gastroenterology (ACG) guideline. The most commonly used diagnostic tool for evaluating uncomplicated reflux disease was upper endoscopy with biopsy. Empiric trial with acid suppression was the most commonly used and proton pump inhibitors (PPIs) was the first-line treatment. The most common combination with PPI was prokinetic drugs, most often domperidone. The preferred maintenance strategy was the 'on demand' maintenance mode. Step-down strategy was commonly recommended. A total of 26% of residents and 37% of consultants could achieve a score of good knowledge. Overall patterns of knowledge and practice of GERD diagnosis and management were comparable between residents and consultants with only minor controversy in their knowledge and practice. CONCLUSION: The overall patterns of knowledge and practice of GERD diagnosis and management are comparable among residents and consultants but still there are areas of controversy and confusion. A good knowledge score was found among only a quarter of residents and 37% of consultants. RECOMMENDATIONS: The public health implications of deviations from evidence-based practice should be studied and implementing evidence-based practice should be emphasized.

Study of bodyweight and eating attitude among female university members in the Kingdom of Saudi Arabia: A comparison between different methods of weight assessment.

BACKGROUND: The economic transition in Saudi Arabia imposed negative consequences leading to an increase in the prevalence of obesity and its sequelae. Despite the commitment of high authorities in KSA to combat obesity, so far 25% of Saudis are still obese. The association between obesity, disordered eating attitude, and body image needs to be addressed. AIM: To explore the relationship between obesity, eating attitude, and body image satisfaction among students and employees at Princess Nourah University (PNU) and to compare the different modalities of assessing body weight. METHODS: A cross-sectional study using a convenient sampling technique comprised of 550 participants. Obesity was assessed by anthropometric measurements and body composition monitor (BF511). Eating attitude test (EAT26) was used to determine eating attitude while body image satisfaction score was determined using body shape questionnaire (BSQ). RESULTS: Around 382 (69.5%) students and 168 employees participated in the study. Obesity was significantly higher among employees (48.2%) vs students (27.7%) (P < 0.001). Body fat composition showed significant positive correlations ranging from weak-to-moderate (0.13 to 0.44) with other body measurements for students and employees. The disordered eating attitude was maximized among obese compared to other BMI groups (P < 0.05). Percentage of disordered eating attitude score correlated positively with BMI: 35.2% vs 52.3% among underweight and obese, respectively (P = 0.001). There was no statistical difference in eating attitudes between students and employees. BSQ score correlates positively with BMI (P < 0.001), it was 36.73 ± 18.68 vs 57.92 ± 18.50 for underweight and obese, respectively. The effect of BMI on body image score was 19.1%. DISCUSSION AND CONCLUSION: Obesity remains a significant health problem among Saudi females. Increased BMI is associated with increased disordered food attitude and the effect of BMI on body image score was minimal.

Clinical Significance of Hepatocyte Growth Factor and Transforming Growth Factor-Beta-1 Levels in Assessing Disease Activity in Inflammatory Bowel Disease.

Background. Transforming growth factor-beta (TGF-ß) and hepatocyte growth factor (HGF) are inflammatory cytokines which function as key regulators of immunological homeostasis and inflammatory responses. They have been linked to inflammatory bowel diseases (IBD). In this study, we aim to assess the levels of TGF-ß and HGF and other inflammatory markers in patients with IBD and correlate them with the disease activity. Study Design. A cross-sectional study involving 100 patients with ulcerative colitis (UC) and 100 patients with Crohn's disease (CD) and 50 control subjects. TGF-ß and HGF levels were measured and correlated with disease activity. Results and Conclusion. Serum levels of TGF-ß and HGF were significantly higher in IBD patients compared with the control group. In the UC group, the levels of HGF and TGF-ß were significantly higher than in the CD group. Levels of TGF-ß and HGF correlate with the activity of IBD.

Awareness about Stroke and Proper Actions to Be Taken; A room for Improvement.

OBJECTIVE: To assess the awareness level about stroke's risk factors, warning signs, and proper actions to be taken. METHOD: A cross-sectional study of 600 adults was conducted using a validated questionnaire. Participants who were able to recognize at least 5 risk factors, 3 warning signs, and defined calling the ambulance in the first 3 hours of a suspected incident were considered knowledgeable. RESULTS: The average age was (27.7 ± 11.5) with a female predominance. The majority (59.3%) were able to correctly define 5 or more risk factors, 68.3% of participants were able to identify at least 3 warning signs of stroke whilst 9.5% were not able to identify any warning signs. More than 70% of participants were willing to call ambulance within 3 hours while 86.2% preferred counseling doctors within 24 hours. Participants who intended to call the ambulance in the first 3 hours were significantly younger (76.1%), mainly students (45.4%) and were able to identify at least 5 risk factors (64.5%) and 3 warning signs of stroke (74.1%). CONCLUSIONS: Despite reporting a relatively higher level of public's knowledge regarding stroke, there is a persistent gap in their knowledge of stroke risk factors, and the importance of seeking emergency medical care.