ULTRASOUND EXAMINATION OF THE ORBIT IN PATIENTS WITH THYROIDASSOCIATED ORBITOPATHY - EXAMINATION GUIDE AND RECOMMENDATIONS FOR EVERYDAY PRACTICE. A REVIEW.

The purpose of this study is to present the possibilities and benefits of ultrasonography (US) of the orbit in the diagnosis and treatment of thyroidassociated orbitopathy (TAO). Methods: US examination of the orbit is an essential addition to clinical and laboratory examination in TAO patients. Nevertheless, it is often neglected in clinical practice or indicated with delay. Based on previously published studies and our experience with the diagnosis and treatment of TAO patients, we aim to highlight the clear benefit of US examination of the orbit and oculomotor muscles, not only for correct TAO diagnosis but also in the monitoring of the disease over time. However, knowledge of the drawbacks and limitations of this method is also essential, as we shall point out. It is always necessary to remember that US examination must be evaluated in connection with the clinical findings. A detailed recommendation for US examination of the extraocular muscles and the orbit based on our experiences with diagnosing and treating TAO patients in daily practice is also included. Conclusion: According to our experience, US examination of the orbit is an excellent and irreplaceable tool for timely TAO diagnosis and further disease monitoring. However, considerable examiner experience and detailed knowledge of the clinical and ultrasound manifestations of TAO are essential.

Computed tomography and magnetic resonance imaging of the orbit in the diagnosis and treatment of thyroid-associated orbitopathy - experience from practice. A Review.

The purpose is to acquaint readers with the contribution of imaging methods (IMs) of the orbit, specifically computed tomography (CT) and magnetic resonance imaging (MRI), in the diagnosis of thyroid-associated orbitopathy (TAO). Methods: IMs of the orbit are an indispensable accessory in the clinical and laboratory examination of TAO patients. The most frequently used and probably most accessible method is an ultrasound examination of the orbit (US), which, however, has a number of limitations. Other methods are CT and MRI. Based on the published knowledge implemented in our practice and several years of experience with the diagnosis and treatment of TAO patients, we would like to point out the benefits of CT and MRI in the given indications: visualisation of the extraocular muscles, assessment of disease activity, diagnosis of dysthyroid optic neuropathy and differential diagnosis of other pathologies in the orbit. Our recommendation for an ideal MRI protocol for disease activity evaluation is also included.  Conclusion: IMs play an irreplaceable role not only in the early diagnosis of TAO, but also in the monitoring of the disease and the response to the applied treatment. When choosing a suitable IM for this diagnosis, a number of factors must always be taken into account; not only availability, cost and burden for the patient, but especially the sensitivity and specificity of the given method for the diagnosis of TAO.

Comparison of Three Methods of Tonometry in Patients with Inactive Thyroid-Associated Orbitopathy.

INTRODUCTION: Intraocular pressure (IOP) measurement in patients with thyroid-associated orbitopathy (TAO) can be difficult and misleading, particularly in patients with diplopia and eye deviation (esotropia or hypotropia). However, when measuring IOP, it is also necessary to pay sufficient attention to TAO patients without diplopia in primary gaze direction and without motility disorder that might not be readily apparent. PURPOSE: The aim of this study was to evaluate the accuracy of measurement of intraocular pressure (IOP) using three different types of tonometers: the rebound tonometer (iCARE), the Goldmann applanation tonometer (GAT) and the non-contact airpuff tonometer (NCT) in patients with inactive TAO.  Materials and Methods: A total of 98 eyes of 49 adult patients with TAO were examined. The study group included 36 females and 13 males, with an age range of 19-70 years and a median age of 55.0. All the patients had evidence of thyroid disease,  a history of mild to moderate TAO, no clinical signs or symptoms of active disease, and no diplopia in direct gaze direction. In addition to a comprehensive eye examination, all the patients underwent measurement of intraocular pressure with three tonometers: NCT, iCARE, and GAT. The measurements with these three devices were compared. RESULTS: The mean IOP was 18.1 ± 2.4 mmHg (range 13-25 mmHg) with GAT, 22.3 ±5.0 mmHg (range 13-35 mmHg) with NCT, and 18.0 ±2.4 mmHg (range 13.3-26 mmHg) with iCARE. The mean difference between the GAT and iCARE measurements (using the Bland-Altman analysis) was -0.1 ±1.16 mmHg (limits of agreement -2.4 to 2.1). The mean difference between the GAT and NCT measurements was 4.2 ±3.6 mmHg (limits of agreement -2.8 to 11.2). The mean difference between the iCARE and NCT measurements was -4.3 ±3.7 mmHg (limits of agreement -11.6 to 2.9). No significant difference was found between GAT and iCARE (p = 1.000). However, there was a significant difference between GAT and NCT (p < 0.0001), as well as between iCARE and NCT (p < 0.0001).  Conclusions: In patients with TAO, NCT significantly overestimates IOP values compared to the GAT and ICare. By contrast, the iCARE rebound tonometer provides IOP measurements comparable to the gold standard GAT in these patients.

Effect of Laparoscopic Sleeve Gastrectomy on Serum Adipokine Levels.

Bariatric procedures are considered to be the most effective treatment options for obesity. One of them is laparoscopic sleeve gastrectomy (LSG), which is nowadays very popular and widely used. LSG leads to weight loss and metabolic improvement and also changes adipokine levels, although it is just a restrictive operation. We describe changes in pro-inflammatory (leptin, resistin, visfatin and chemerin) and anti-inflammatory adipokines (adiponectin, omentin), with adiponectin and leptin being most studied. Their levels are markedly changed after LSG and this may partially explain the weight loss seen after LSG. Adipokines are closely connected to insulin resistance and chronic inflammation both being positively influenced after LSG. Leptin regulates amount of body fat, appetite, thermogenesis and metabolic rate and its levels are positively correlated with both weight and BMI changes after operation. Resistin influences insulin sensitivity, modulates body cholesterol trafficking and its changes after operation correlate with BMI, waist circumference, fat mass, LDL cholesterol and C-reactive protein. Chemerin, an important component of immune system, decreases after bariatric surgery and its levels correlate with BMI, triglyceride levels, and blood glucose. On the other hand, pro-inflammatory adipokine adiponectin, which influences fatty acid oxidation, browning of fat tissue and energy metabolism, is declining after LSG. This decline explains improvement of glucose status after bariatric surgery in patients with diabetes and is correlated with BMI loss, waist circumference and LDL cholesterol level. Effect of LSG goes beyond calory restriction and the changes of adipokines have a great impact on health status of the bariatric patients.

COMPUTER TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING OF THE ORBIT IN THE DIAGNOSIS AND TREATMENT OF THYROID-ASSOCIATED ORBITOPATHY - EXPERIENCE FROM PRACTICE. A REVIEW.

The purpose is to acquaint readers with the contribution of imaging methods (IMs) of the orbit, specifically computer tomography (CT) and magnetic resonance imaging (MRI), in the diagnosis of thyroid-associated orbitopathy (TAO). Methods: IMs of the orbit are an indispensable accessory in the clinical and laboratory examination of TAO patients. The most frequently used and probably most accessible method is an ultrasound examination of the orbit (US), which, however, has a number of limitations. Other methods are CT and MRI. Based on the published knowledge implemented in our practice and several years of experience with the diagnosis and treatment of TAO patients, we would like to point out the benefits of CT and MRI in the given indications: visualisation of the extraocular muscles, assessment of disease activity, diagnosis of dysthyroid optic neuropathy and differential diagnosis of other pathologies in the orbit. Our recommendation for an ideal MRI protocol for disease activity evaluation is also included. Conclusion: IMs play an irreplaceable role not only in the early diagnosis of TAO, but also in the monitoring of the disease and the response to the applied treatment. When choosing a suitable IM for this diagnosis, a number of factors must always be taken into account; not only availability, cost and burden for the patient, but especially the sensitivity and specificity of the given method for the diagnosis of TAO.

Erratum for: Pregnancy lipid profile and different lipid patterns of gestational diabetes treated by diet itself.

List of changes Authors and affiliation: Lubica CIBICKOVA1,3, Katerina LANGOVA2, Jan SCHOVANEK1,3, Dominika MACAKOVA1,3, Ondrej KRYSTYNIK1,3, David KARASEK1,3 1Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic, 2Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic, 3Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, University Hospital Olomouc, Olomouc, Czech Republic Acknowledgement: Supported by the grants: MH CZ - DRO (FNOl, 00098892); AZV NV18-01-00139.

MRI in the assessment of thyroid-associated orbitopathy activity.

Management of patients with thyroid-associated orbitopathy (also called Graves' disease) is dependent on the assessment of the disease activity. Evaluation of disease activity is based on ophthalmological examination. Magnetic resonance imaging (MRI) is an auxiliary method that may help quantify the activity and is also helpful in obtaining anatomical information concerning muscle thickness, exophthalmos, or optic neuropathy. We present a review of MRI techniques of the orbits with emphasis on the evaluation of disease activity. The most convincing seems to be the group of T2-weighted techniques such as conventional T2 weighting, T2 relaxometry, and T2 mapping. Dynamic contrast-enhanced MRI is another promising method.

Pregnancy lipid profile and different lipid patterns of gestational diabetes treated by diet itself.

The development of gestational diabetes mellitus (GDM) affects lipid metabolism during pregnancy. However, the magnitude of changes in lipid parameters is unclear. In addition, the patterns of these changes may vary based on the criteria selected for making the diagnosis of GDM. Thus, our aim was to compare the anthropometric and laboratory profiles of GDM-associated vs. GDM-free gestation with those of healthy non-pregnant women. We designed a cross-sectional study involving a group of females affected by GDM, a group of healthy pregnant controls and a group of healthy non-pregnant counterparts. GDM patients were divided into 3 subgroups according to the fulfilled diagnostic criteria, that is, those presenting with high fasting plasma glucose in the first trimester (subgroup 1), high fasting plasma glucose in the second trimester (subgroup 2) and high plasma glucose following oral glucose load in the second trimester (subgroup 3). The anthropometric and metabolic profiles of GDM subjects resembled the facets of metabolic syndrome (highest body mass index, waist circumference, C-peptide level, triglycerides) significantly more than the respective profiles of healthy non-pregnant women (p<0.0001). While total cholesterol (TC) (together with LDL-C and non-HDL-C) in pregnant women with GDM and without GDM did not differ, both groups had significantly higher levels of triglycerides (TG) than non-pregnant women (p<0.0001). Subgroup 1 had the highest fasting glucose level in the second trimester whereas subgroup 3 had the lowest fasting glucose level (p=0.019). Concentration of TG increased, being the lowest in subgroup 1 and the highest in subgroup 3 (p=0.006). Women with GDM had more pronounced features of metabolic syndrome than pregnant women without GDM. Both groups reached higher levels of TC (LDL-C, non-HDL-C) than non-pregnant controls and did not differ from each other. We found differences in TG and fasting glucose levels among different types of GDM.

Association of pigment epithelium derived factor with von Willebrand factor and plasminogen activator inhibitor 1 in patients with type 2 diabetes.

To compare circulating pigment epithelium derived factor (PEDF) levels in type 2 diabetes patients (T2D) with and without metabolic syndrome (MetS+/-) to healthy controls and assess PEDF association with plasminogen activator inhibitor-1 (PAI-1) and von Willebrand factor (vWF) as markers of endothelial dysfunction. Fifty T2D individuals and forty healthy controls were included. PEDF, PAI-1, vWF, anthropological parameters, lipids, and markers of insulin resistance were investigated in all subjects. Compared to controls only MetS+ diabetics had higher PEDF levels [14.2 (10.2-16.0) mg/l vs. 11.1 (8.6-14.4) mg/l; p<0.05]. PEDF significantly correlated: positively with body mass index (rho=0.25), smoking (rho=0.21), C-reactive protein (rho=0.22), triglycerides (rho=0.38), non-HDL-cholesterol (rho=0.39), apolipoprotein B (rho=0.38), fasting glucose (rho=0.22), glycated hemoglobin (rho=0.24), C-peptide (rho=0.28), insulin (rho=0.26); and negatively with HDL-cholesterol (rho=-0.42) and apolipoprotein A1 (rho=-0.27). Independent association of PEDF with vWF in T2DMetS- subjects was found. Significantly elevated PEDF in T2DMet+ patients and its association with adverse metabolic profile confirmed PEDF as a marker of insulin resistance. Negative independent association of PEDF with vWF in T2DMetS- patients may reveal its angio-protective role.

OVARIAN GOITER AS A RARE CAUSE OF HYPERTHYROIDISM.

INTRODUCTION: Thyroid tissue ectopically located in the ovary can be reported accidentally after adnexectomy, but as a primary cause of hyperthyroidism this diagnosis is rare. The clinical search for a functional ectopic thyroid tissue requires intense clinical focus and a multidisciplinary approach. CASE DESCRIPTION: This case report demonstrates a patient with a history of Graves' disease who had undergone thyroidectomy combined with postoperative 131I radioablation. Despite the previous treatment, she developed an outburst of hyperthyroidism ten years later. Only very close follow-up enabled us to disclose the right condition. The ovarian source of thyroid hormone production was removed by laparoscopic adnexectomy and a right sided benign ovarian struma was confirmed. CONCLUSION: Most patients treated by thyroidectomy and radioiodine do not require extended periods of follow-up or postoperative investigations, but when the clinical or laboratory signs change, clinicians should be prepared to perform the necessary re-evaluation in order to provide the best care.

ULTRASOUND-GUIDED PERCUTANEOUS ETHANOL INJECTION THERAPY IN A 92 YEAR-OLD PATIENT WITH PARATHYROID ADENOMA AND WITH A HISTORY OF TOTAL THYROIDECTOMY FOR PAPILLARY THYROID CARCINOMA.

Percutaneous Ethanol Injection Therapy (PEIT) of parathyroid adenoma under ultrasound guidance is individually used as an alternative procedure in management of primary hyperparathyroidism in polymorbid elderly patients with increased surgical risk. The treatment is also suitable for patients who already underwent surgery of the thyroid gland, and any other surgery is associated with a higher risk of postsurgical complications. We present a case of a 92-year-old male patient, who underwent thyroidectomy for papillary thyroid carcinoma three years ago. Part of the regular annual follow-up visits was also ultrasonography, which showed a solitary parathyroid adenoma at the site of the removed thyroid gland. Given the underlying condition, polymorbidity and age of the patient, the PEIT method was successfully used in the therapy. The coincidence of adenoma and papillary thyroid carcinoma is also interesting.