Subacute THYROiditis Related to SARS-CoV-2 VAccine and Covid-19 (THYROVAC Study): A Multicenter Nationwide Study.

CONTEXT: The aims of the study are to compare characteristics of subacute thyroiditis (SAT) related to different etiologies, and to identify predictors of recurrence of SAT and incident hypothyroidism. METHODS: This nationwide, multicenter, retrospective cohort study included 53 endocrinology centers in Turkey. The study participants were divided into either COVID-19-related SAT (Cov-SAT), SARS-CoV-2 vaccine-related SAT (Vac-SAT), or control SAT (Cont-SAT) groups. RESULTS: Of the 811 patients, 258 (31.8%) were included in the Vac-SAT group, 98 (12.1%) in the Cov-SAT group, and 455 (56.1%) in the Cont-SAT group. No difference was found between the groups with regard to laboratory and imaging findings. SAT etiology was not an independent predictor of recurrence or hypothyroidism. In the entire cohort, steroid therapy requirement and younger age were statistically significant predictors for SAT recurrence. C-reactive protein measured during SAT onset, female sex, absence of antithyroid peroxidase (TPO) positivity, and absence of steroid therapy were statistically significant predictors of incident (early) hypothyroidism, irrespective of SAT etiology. On the other hand, probable predictors of established hypothyroidism differed from that of incident hypothyroidism. CONCLUSION: Since there is no difference in terms of follow-up parameters and outcomes, COVID-19- and SARS-CoV-2 vaccine-related SAT can be treated and followed up like classic SATs. Recurrence was determined by younger age and steroid therapy requirement. Steroid therapy independently predicts incident hypothyroidism that may sometimes be transient in overall SAT and is also associated with a lower risk of established hypothyroidism.

Serum TSH, 25(OH) D and phosphorus levels predict weight loss in individuals with diabetes/prediabetes and morbid obesity: a single-center retrospective cohort analysis.

BACKGROUND: To evaluate the association of vitamin D and thyroid-stimulating hormone (TSH) with weight loss (WL) percentage (%) in patients with diabetes/prediabetes and Class II/III obesity. METHODS: A retrospective cohort study was designed. Data were collected from a database of a referral endocrinology clinic that is prospectively and systematically generated. After exclusion of unavailable cases, the study enrolled 285 patients (51 ± 11 years old, female/male = 208/77; diabetes/prediabetes = 159/126; no/on levothyroxine replacement = 176/109; Class II/III obesity = 184/101, respectively) who maintained euthyroidism and were followed up for ≥6 months. The data were analyzed to determine the predictors of WL%. RESULTS: Compared with baseline, in the median 22 months of follow-up, the whole study group lost 5.1% of their baseline body weight. As most obesity management trials define success as 'at least 10% of WL compared to baseline', we stratified the patients based on WL% extents. The distribution was as follow: Group 1 (n = 61) lost ≥10% body weight, Group 2 (n = 162) lost < 10% body weight, while Group 3 (n = 62) gained weight by the final visit. In groups 1 and 2 (weight losers), the serum thyroid stimulatig hormone (TSH) and parathyroid hormone (PTH) levels decreased and the free thyroxine (fT4), calcium, phosphorus, and 25-hydroxyvitamin D (25(OH)D) levels increased. In Group 3 (weight gainers), these changes were not observed (except for an increase in calcium levels). Regression analysis revealed that the final visit TSH (ß = - 0.14, p < 0.05), 25(OH) D (ß = 0.15, p < 0.05), and phosphorus (ß = 0.20, p < 0.05) levels predicted WL%. However, if patients with autoimmune thyroiditis were excluded from the analysis, the decrease in TSH levels was not statistically significant. CONCLUSIONS: Serum TSH, phosphorus, and 25(OH) D levels predict WL% in euthyroid patients with diabetes/prediabetes and morbid obesity. TSH predictivity seems to be a function of thyroid autoimmunity present with increased frequency in this cohort. Greater levels of phosphorus within the reference range and a sufficient vitamin D status are associated with a greater WL%.

Relationship between liver function tests & cardiovascular risk factors in stage 3-5 pre-dialysis chronic kidney disease.

Background & objectives: Cardiovascular disease (CVD) remains the leading cause of mortality among patients with chronic kidney disease (CKD). Liver function tests (LFTs) have emerged as markers of CVD risk in some population-based studies. Hence, in the present study the relation between LFTs and biochemical cardiovascular risk factors (CRFs) were evaluated in CKD patients. Methods: A total of 246 patients with stage 3-5 pre-dialysis CKD were enrolled. Demographics, LFTs [alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyltransferase (GGT)] and biochemical CRFs were recorded retrospectively. Glomerular filtration rate (GFR) was calculated using CKD-EPI equation. Results: ALT was positively correlated with GFR, albumin, triglyceride and 25-hydroxyvitamin D and negatively correlated with CRP and intact parathyroid hormone (iPTH); AST was positively correlated with GFR, albumin, high-density lipoprotein cholesterol (HDL-C) and 25-hydroxyvitamin D and negatively correlated with CRP and iPTH; GGT was positively correlated with GFR, CRP and triglyceride and negatively correlated with HDL-C. In diabetic patients, ALT correlated positively with GFR; AST correlated positively with GFR and HDL-C, but correlated negatively with iPTH. In the correlation analysis between GFR and CRF, GFR was positively correlated with albumin, triglyceride and 25-hydroxyvitamin D and negatively correlated with CRP, iPTH and albuminuria in both total study population and diabetic group. A partial correlation analysis revealed no correlation between LFTs and CRFs after being controlled for GFR. Interpretation & conclusions: The results of the present study suggest that the relationship between LFTs and biochemical CRFs seems to be a function of impaired GFR.

Occult Adrenal Insufficiency in Renal Amyloidosis Patients.

OBJECTIVE: Systemic amyloidosis may affect many organs, and may cause endocrinologic problems which may result in adrenal insufficiency. However, assessment of adrenocortical reserve is challenging in amyloidosis patients with renal involvement. We aimed to evaluate adrenocortical reserve with various methods of cortisol measurement to determine any occult clinical condition. METHODS: Patients with renal amyloidosis and healthy subjects were evaluated in this cross-sectional study. Basal cortisol, corticosteroid-binding globulin (CBG), and albumin levels were measured. Serum free cortisol (cFC) level was calculated. Cortisol response tests performed after ACTH stimulation test (250 µg, intravenously) were evaluated, and free cortisol index (FCI) was calculated. RESULTS: Twenty renal amyloidosis patients, and 25 healthy control subjects were included in the study. Patients and control subjects had similar median serum baseline cortisol levels [258 (126-423) vs 350 (314-391) nmol/L, p=0.169)] whereas patients' stimulated cortisol levels at the 60th minute were lower [624 (497-685) vs 743 (674-781) nmol/L, p=0.011)]. The 60th-minute total cortisol levels of 8 of the 20 (40%) amyloidosis patients were <500 nmol/L, but only three of these 8 patients had stimulated FCI <12 nmol/mg suggesting an adrenal insufficiency (15%). CONCLUSION: ACTH stimulation test and cortisol measurements should be considered in renal amyloidosis patients with severe proteinuria to avoid false positive results if only ACTH stimulation test is used. It will be appropriate to evaluate this group of patients together with estimated measurements as FCI.

Utilization of statins and LDL-cholesterol target attainment in Turkish patients with type 2 diabetes - a nationwide cross-sectional study (TEMD dyslipidemia study).

BACKGROUND: Attaining acceptable levels of LDL Cholesterol (LDL-C) significantly improves cardiovascular (CV) outcomes in patients with type 2 diabetes mellitus (T2DM). The LDL-C target attainment and the characteristics of patients attaining these targets were investigated in this study. Furthermore, the reasons for not choosing statins and the physicians' attitudes on the treatment of diabetic dyslipidemia were also examined. METHODS: A nationwide, cross-sectional survey was conducted in tertiary centers for diabetes management. Adult patients with T2DM, who were under follow-up for at least a year in outpatient clinics, were consecutively enrolled for the study. LDL-C goals were defined as below 70 mg/dL for patients with macrovascular complications or diabetic nephropathy, and below 100 mg/dL for other patients. Data about lipid-lowering medications were self-reported. RESULTS: A total of 4504 patients (female: 58.6%) were enrolled for the study. The mean HbA1c and diabetes duration was 7.73 ± 1.74% and 10.9 ± 7.5 years, respectively. The need for statin treatment was 94.9% (n = 4262); however, only 42.4% (n = 1807) of these patients were under treatment, and only 24.8% (n = 448) of these patients achieved LDL-C targets. The main reason for statin discontinuation was negative media coverage (87.5%), while only a minority of patients (12.5%) mentioned side effects. Physicians initiated lipid-lowering therapy in only 20.3% of patients with high LDL-C levels. It was observed that the female gender was a significant independent predictor of not attaining LDL-C goals (OR: 0.70, 95% CI: 0.59-0.83). CONCLUSIONS: Less than 50 % of patients with T2DM who need statins were under treatment, and only a quarter of them attained their LDL-C targets. There exists a significant gap between the guideline recommendations and the real-world evidence in the treatment of dyslipidemia in T2DM.

DISCORDANCE BETWEEN GH AND IGF-1 LEVELS IN TURKISH ACROMEGALIC PATIENTS.

OBJECTIVE: Discordance between insulin-like growth factor-1 (IGF-1) and growth hormone (GH) levels is an important problem in the follow-up of patients diagnosed with acromegaly. Our aims were to evaluate the discordance between IGF-1 and GH levels and compare the performance of different cut-off levels for the nadir in GH (GHn) in acromegalic patients. METHODS: The study included 63 acromegalic patients in a follow-up at a tertiary care university hospital facility. Levels of IGF-1, IGF binding protein-3 (IGFBP-3), and GH were investigated. The baseline GH and GHn levels were evaluated after an oral glucose tolerance test (cut-offs of 0.4 and 1 ng/mL, respectively). The discordance rates between GHn and IGF-1 levels, and IGF-1/IGFBP-3 ratios were determined. RESULTS: We first adopted a GHn cut-off value of 1 ng/mL and found that 27 patients (42.9%) exhibited biochemical remission (BR) (IGF-1 <95th percentile, GH <1), and 25 patients (39.7%) had no BR (NBR) (IGF-1 ≥95th percentile, GH >1). Discordance in the presence of normal IGF-1 and nonsuppressed GH (DC1) occurred in 2 of 63 (3.2%) patients; discordance in the presence of high IGF-1 and suppressed GH (DC2) occurred in 9 of 63 (14.3%) patients. If the GHn cut-off value adopted was 0.4 ng/mL, the distributions were 17 of 63 (27.0%) patients in BR, 29 of 63 (46.0%) patients in NBR, 12 of 63 (19.0%) in DC1, and 5 of 63 (7.9%) patients in DC2. If only the baseline GH values were considered, the distributions were very similar to those with a GHn cut-off value of 0.4 ng/mL. The IGF-1/IGFBP-3 ratio was lowest in the BR group. CONCLUSION: Adopting a GHn cut-off value of 0.4 ng/mL did not increase the test performance compared with baseline GH only. In contrast, in the follow-up of acromegalic patients, the IGF-1/IGFBP-3 ratio might be a useful measurement when discordance between IGF-1 and GH levels occurs. We propose that these values be considered in clinical practice. ABBREVIATIONS: BR = biochemical remission DC1 = discordance group 1 DC2 = discordance group 2 DM = diabetes mellitus GH = growth hormone GHn = nadir in GH IGF-1 = insulin-like growth factor-1 IGFBP-3 = IGF binding protein-3 LAR = long-acting release NBR = not in biochemical remission OGTT = oral glucose tolerance test.

Unknown aspect of the old disease: does dyslipidemia in systemic AA amyloidosis differ from the dyslipidemia in primary glomerulonephritis?

AIM: To investigate the nature of dyslipidemia and its diversity in patients with systemic AA amyloidosis. METHODS: The reports of the kidney biopsies performed due to nephrotic proteinuria (>3.5 g/day/1.73 m(2)) with preserved renal function [glomerular filtration rate (GFR) >60 mL/min/1.73 m(2)] were reviewed. Clinical and laboratory data of the patients with systemic AA amyloidosis and primary glomerulonephritis (PG) were analyzed. RESULTS: A total of 104 (systemic AA amyloidosis: 43, PG: 61) patients were included in the study. Proteinuria and GFR levels were similar in both the groups. Patients with systemic AA amyloidosis group had lower serum albumin (p = 0.002), lower hemoglobin levels (p = 0.001), higher platelet counts (p = 0.002) and higher C-reactive protein levels (p = 0.001) compared to patients in PG group. Although the frequency of dyslipidemia was similar in the groups (86.0 vs. 93.4%), patients with systemic amyloidosis had both lower values of LDL-C (4.56 ± 2.05 vs. 5.49 ± 2.23 mmol/L, p = 0.028) and HDL-C (1.19 ± 0.36 vs. 1.35 ± 0.39 mmol/L, p = 0.035). Serum lipid levels were correlated with serum total protein, albumin and proteinuria levels in PG group. However, in the systemic amyloidosis group, only one clear correlation between serum lipid and hemoglobin levels was estimated. A multivariate analysis demonstrated that LDL-C was independently associated with the etiology of nephrotic proteinuria, serum total protein, serum albumin (inversely) and hemoglobin levels. CONCLUSIONS: Although dyslipidemia is closely associated with serum total protein, albumin and proteinuria in patients with PG, there is no clear such association in patients with systemic amyloidosis. Correlation between serum lipid and hemoglobin levels in this group and other findings point out that probably complex mechanisms take place in dyslipidemia of nephrotic syndrome caused by systemic AA amyloidosis.

Obesity with and without metabolic syndrome: do vitamin D and thyroid autoimmunity have a role?

AIMS: To investigate serum levels of thyroid stimulating hormone (TSH), anti-thyroid peroxidase antibody (TPO), and 25(OH)D in the presence or absence of metabolic syndrome in an obese population. METHODS: Data from a prospectively generated "Obesity Polyclinic" database that includes socio-demographic characteristics, anthropometric, and laboratory measurements of obese subjects were retrospectively analyzed. Subjects with body-mass index (BMI) ≥30kg/m(2) were eligible. After detailed analysis and exclusion of unavailable cases, subjects diagnosed with and without metabolic syndrome were compared for TSH, anti-TPO, and 25(OH)D. RESULTS: Of the study participants (n=548; men/women, 64/484), 277 were diagnosed with metabolic syndrome [Met-S (+)]. Met-S (+) patients had a higher mean BMI (36.4 vs. 32.3kg/m(2), p<.001) and percentage body fat (PBF) (39.2 vs. 35.3%, p<.001), but similar TSH (2.1 vs. 2.2mIU/mL, p=.759), anti-TPO (12 vs. 13IU/mL, p=.483), 25(OH)D (13.2 vs. 12.6ng/mL, p=.409), and calcium-phosphorus product (28.7 vs. 29.5mg/dL, p=0.275), compared to Met-S (-) subjects. When serum TSH, anti-TPO, and 25(OH)D levels were analyzed according to tertiles for comparisons of fasting plasma glucose, triglycerides, high-density lipoprotein cholesterol, BMI, and PBF, only 25(OH)D levels were negatively correlated with BMI and PBF. CONCLUSIONS: Although decreased 25(OH)D levels were related to the degree of obesity in obese subjects, serum 25(OH)D levels per se did not seem to be associated with metabolic syndrome. The prevalence of thyroid autoimmunity and hypothyroidism were high in this obese sample; however, neither serum TSH nor anti-TPO levels correlated with metabolic syndrome. Our findings did not support the hypothesis that thyroid autoimmunity and/or vitamin D status have a role in the development of metabolic disturbances in the obese population.

Adrenocortical reserves in hyperthyroidism.

Explicit data regarding the changes in adrenocortical reserves during hyperthyroidism do not exist. We aimed to document the capability (response) of adrenal gland to secrete cortisol and DHEA-S during hyperthyroidism compared to euthyroidism, and to describe factors associated with these responses. A standard-dose (0.25 mg/i.v.) ACTH stimulation test was performed to the same patients before hyperthyroidism treatment, and after attainment of euthyroidism. Baseline cortisol (Cor(0)), DHEA-S (DHEA-S(0)), cortisol binding globulin (CBG), ACTH, calculated free cortisol (by Coolen's equation = CFC), free cortisol index (FCI), 60-min cortisol (Cor(60)), and DHEA-S (DHEA-S(60)), delta cortisol (ΔCor), delta DHEA-S (ΔDHEA-S) responses were evaluated. Forty-one patients [22 females, 49.5 ± 15.2 years old, 32 Graves disease, nine toxic nodular goiter] had similar Cor(0), DHEA-S(0), CFC, FCI, and DHEA-S(60) in hyperthyroid and euthyroid states. Cor(60), ΔCor, and ΔDHEA-S were lower in hyperthyroidism. In four (10 %) patients the peak ACTH-stimulated cortisol values were lower than 18 µg/dL. When the test repeated after attainment of euthyroidism, all of the patients had normal cortisol response. Regression analysis demonstrated an independent association of Cor(60) with free T3 in hyperthyroidism. However, the predictors of CFC, FCI, and DHEA-S levels were serum creatinine levels in hyperthyroidism, and both creatinine and transaminase levels in euthyroidism. ACTH-stimulated peak cortisol, delta cortisol, and delta DHEA-S levels are decreased during hyperthyroidism, probably due to increased turnover. Since about 10 % of the subjects with hyperthyroidism are at risk for adrenal insufficiency, clinicians dealing with Graves' disease should be alert to the possibility of adrenal insufficiency during hyperthyroid stage.

Circulating glucagon to ghrelin ratio as a determinant of insulin resistance in hyperthyroidism.

Due to stimulated overall metabolism, a state of nutritional inadequacy often ensues, during thyrotoxicosis. We aimed to investigate circulating levels of some major components of the system that regulates energy stores, glucose, and fat metabolism, during thyrotoxicosis compared to euthyroidism. Fasting serum ghrelin, leptin, adiponectin, insulin, glucagon, glucose, as well as body fat composition were analyzed during thyrotoxicosis in 40 hyperthyroid patients (50.5 ± 15.2 years old, 22 females, 31 with Graves disease, and 9 with toxic nodular goiter). The same measurements were repeated an average 3 months later, when all patients achieved euthyroidism. Compared to euthyroidism, in thyrotoxicosis, patients had lower ghrelin and fat mass; had comparable insulin, HOMA-IR, glucagon, and leptin levels; higher levels of circulating adiponectin. Fasting serum glucose tended to be higher during thyrotoxicosis. The unique correlation of HOMA-IR was with the-glucagon to ghrelin ratio-(r = 0.801, p < 0.001) in hyperthyrodism, and with glucagon itself in euthyroidism (r = -0.844, p < 0.001). Circulating levels of ghrelin are decreased; leptin, insulin, glucagon are unchanged; adiponectin are increased during hyperthyroidism. The fasting HOMA-IR tends to be higher, despite the decreased adiposity in hyperthyroidism. The-glucagon to ghrelin ratio-strongly correlates with fasting HOMA-IR in hyperthyroidism.

An uninvestigated risk factor for contrast-induced nephropathy in chronic kidney disease: proteinuria.

BACKGROUND: Contrast-induced nephropathy (CIN) is one of the most frequent causes of acute renal failure in hospitalized patients with the incremental use of contrast media. We aimed to investigate whether proteinuria may act as a risk factor for CIN in patients with chronic kidney disease. METHODS: Seventy hospitalized patients (37 men, 33 women) with chronic kidney disease, proteinuria, and/or estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2, who were exposed to contrast media were investigated prospectively. Thirty patients were diabetic. All patients received prophylaxis against CIN with acetylcysteine and 0.9% intravenous saline. CIN is defined as either a 25% higher increase in serum creatinine (sCr) from the baseline levels or a 0.5 mg/dL increase in sCr at 72 h after contrast media exposure. RESULTS: CIN was detected in 26 (37.1%) patients. Advanced age, diabetes, heart failure, anemia, baseline sCr of >1.5 mg/dL, baseline eGFR of <60 mL/min/1.73 m(2), proteinuria of ≥1 g/day, hypoalbuminemia, and the volume of contrast media of ≥100 mL correlated significantly with CIN. The frequency of CIN was significantly higher in patients with proteinuria of ≥1 g/day compared to patients with proteinuria of <1 g/day (p = 0.009). CONCLUSION: Proteinuria may be a new risk factor for the development of CIN in patients with chronic kidney disease.

Changes in inflammatory and metabolic parameters after periodontal treatment in patients with and without obesity.

BACKGROUND: Non-surgical periodontal treatment decreases serum levels of inflammatory cytokines in patients with and without obesity. However, the changes in metabolic parameters in association with these decreases in levels of inflammatory markers by periodontal treatment have not been evaluated in patients with obesity. The aim of this study is to evaluate the short-term changes in systemic inflammatory, lipid, and glucose parameters in the presence of obesity after periodontal treatment. METHODS: The study included 22 dyslipemic patients with obesity and 24 healthy individuals without obesity with generalized chronic periodontitis. The periodontal parameters, anthropometric measurements, and serum levels of triglyceride, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and lipoprotein-a, high-sensitive C-reactive protein, fasting blood glucose, insulin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and leptin were measured. A homeostasis model assessment of the insulin resistance (HOMA-IR) score was calculated before and 3 months after non-surgical periodontal treatment. RESULTS: Both groups responded well to the periodontal treatment in terms of periodontal parameters. The treatment was also associated with a decrease in serum TNF-α and IL-6 levels and HOMA-IR scores in individuals with obesity and with a decrease in IL-6 levels in patients without obesity. Conversely, there were insignificant decreases in lipid profiles and serum fasting glucose of patients with obesity. CONCLUSION: The non-surgical periodontal treatment causes a decrease in the levels of some circulating proinflammatory cytokines and may be associated with a decrease in insulin resistance in the obese population.

High frequency of aspirin resistance in patients with nephrotic syndrome.

BACKGROUND: Aspirin has a beneficial role in prevention of cardiovascular and thromboembolic events. Patients may experience thromboembolic events despite aspirin treatment, a phenomenon called aspirin resistance. We evaluated the frequency of aspirin resistance and its correlation with clinical and biochemical parameters among patients with nephrotic syndrome (NS). METHODS: A total of 83 patients (50 males, 33 females, age range 18-79 years) with NS using aspirin 100 mg/day were included in the study. Demographic information and aetiology of NS based on the histology of a renal biopsy were recorded for each patient. Blood samples were drawn to investigate the association of aspirin resistance with inflammation and thrombotic risk factors. Aspirin resistance was defined as a normal collagen/epinephrine closure time<159 s using a platelet function analyzer (PFA-100). RESULTS: Aspirin resistance was determined in 51 patients (61.4%). The number of patients exposed to azathioprine therapy was significantly higher in the aspirin-sensitive group (P=0.043), whereas patients exposed to cyclosporine therapy were significantly higher in the aspirin-resistant group (P=0.017). More patients in the aspirin-resistant group were on angiotensin-converting enzyme inhibitor therapy compared with the aspirin-sensitive group (P=0.024). The aspirin-resistant group showed significantly higher serum low-density lipoprotein cholesterol (LDL-C) (151±47 versus 104±21 mg/dL; P<0.001), triglyceride levels (192±116 versus 134±82 mg/dL; P=0.015) and glomerular filtration rates (91.8±43.0 versus 74.0±35.6 mL/min/1.73 m2; P=0.044) compared with the aspirin-sensitive group. In multivariate analysis, LDL-C was the only parameter associated independently with aspirin resistance [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02-1.06; P=0.004]. CONCLUSIONS: A significant number of patients with NS are resistant to aspirin therapy. Serum LDL-C level is closely associated with aspirin resistance in NS.

Hypotension, Syncope, and Fever in Systemic Mastocytosis without Skin Infiltration and Rapid Response to Corticosteroid and Cyclosporin: A Case Report.

Mast cell disorders are defined by an abnormal accumulation of tissue mast cells in one or more organ systems. In systemic mastocytosis, at least one extracutaneous organ is involved by definition. Although, systemic mastocytosis usually represents with skin lesion called urticaria pigmentosa, in a small proportion, there is extracutaneous involvement without skin infiltration. Other manifestations are flushing, tachycardia, dyspepsia, diarrhea, hypotension, syncope, and rarely fever. Various medications have been used but there is not a definite cure for systemic mastocytosis. The principles of treatment include control of symptoms with measures aimed to decrease mast cell activation. We describe a case of systemic mastocytosis presenting with hypotension, syncope attacks, fever, and local flushing. In bone marrow biopsy, increased mast cell infiltration was demonstrated. She had no skin infiltration. A good clinicopathological response was obtained acutely with combination therapy of glucocorticoid and cyclosporine.

Circulating adiponectin represents a biomarker of the association between adiposity and bone mineral density.

An association exists between adiposity, insulin resistance, and osteoporosis; however, the mechanism of this relationship remains enigmatic. We aimed to determine whether the insulin resistance index (HOMA-IR), serum adiponectin, or leptin levels are associated with bone mineral density (BMD). A cross-sectional, observational study was designed. Eighty-four postmenopausal ambulant women [52.5 (50.0-58.0) years; body mass index (BMI): 29.4 (25.9-33.8) kg/m(2)] referred for osteoporosis screening were enrolled. Anthropometric measures, fasting serum adiponectin and leptin levels, and the HOMA-IR were determined. The relationships between these variables and lumbar, hip, and forearm BMD measured by dual-energy X-ray absorptiometry (DXA) were analyzed. Considering all 84 participants, the HOMA-IR index was 1.82 (1.17-2.86), serum adiponectin was 13.25 (10.49-16.88) microg/ml, and serum leptin was 19.26 (14.94-24.90) ng/ml. BMI, waist circumference, and leptin positively correlated with hip and lumbar BMD, whereas adiponectin negatively correlated. Multivariate analysis confirmed an inverse relation between serum adiponectin level and femoral neck and lumbar BMD measurements. In total hip and forearm areas, there was no independent association of adipocytokines with BMD measurements. Instead, waist circumference was independently associated with BMD measurements. In conclusion, adiponectin may represent a biomarker in the relationship between visceral fat mass and BMD. However, this association is probably confounded by the specific body composition parameters (i.e., waist circumference, BMI) in postmenopausal women.

Centers for Disease Control and Prevention guidelines for preventing central venous catheter-related infection: results of a knowledge test among 3405 European intensive care nurses.

OBJECTIVE: To determine European intensive care unit (ICU) nurses' knowledge of guidelines for preventing central venous catheter-related infection from the Centers for Disease Control and Prevention. DESIGN: Multicountry survey (October 2006-March 2007). SETTING: Twenty-two European countries. PARTICIPANTS: ICU nurses. MEASUREMENTS AND MAIN RESULTS: Using a validated multiple-choice test, knowledge of ten recommendations for central venous catheter-related infection prevention was evaluated (one point per question) and assessed in relation to participants' gender, ICU experience, number of ICU beds, and acquisition of a specialized ICU qualification. We collected 3405 questionnaires (70.9% response rate); mean test score was 44.4%. Fifty-six percent knew that central venous catheters should be replaced on indication only, and 74% knew this also concerns replacement over a guidewire. Replacing pressure transducers and tubing every 4 days, and using coated devices in patients requiring a central venous catheter >5 days in settings with high infection rates only were recognized as recommended by 53% and 31%, respectively. Central venous catheters dressings in general are known to be changed on indication and at least once weekly by 43%, and 26% recognized that both polyurethane and gauze dressings are recommended. Only 14% checked 2% aqueous chlorhexidine as the recommended disinfection solution; 30% knew antibiotic ointments are not recommended because they trigger resistance. Replacing administration sets within 24 hrs after administering lipid emulsions was recognized as recommended by 90%, but only 26% knew sets should be replaced every 96 hrs when administering neither lipid emulsions nor blood products. Professional seniority and number of ICU beds showed to be independently associated with better test scores. CONCLUSIONS: Opportunities exist to optimize knowledge of central venous catheter-related infection prevention among European ICU nurses. We recommend including central venous catheter-related infection prevention guidelines in educational curricula and continuing refresher education programs.

Transfusion-associated graft-versus-host disease in immunocompetent patients: case series and review of the literature.

BACKGROUND: Transfusion-associated graft-versus-host disease (TA-GVHD) is a fatal complication of transfusion of blood products that usually affects immunocompromised patients. Articles reporting this condition in immunocompetent recipients are usually from countries that still have problems in irradiation of blood products. CASE REPORTS: This report presents fatal TA-GVHD in four immunocompetent patients referred from rural areas where blood irradiation is still not the routine procedure to our tertiary-care center between July 2004 and July 2005. A similar history and chronological order of events were observed: fresh whole-blood transfusion from relatives, fever, rash, liver dysfunction, diarrhea, and pancytopenia. Skin biopsies demonstrated Grade II to III GVHD involvement. Marrow biopsies showed hypoplasia. In two cases, HLA typing studies were performed. Donors were homozygous for a shared HLA haplotype in the patients. All cases were admitted to the intensive care unit within 3 weeks after transfusions with the diagnosis of sepsis, which rapidly progressed to septic shock and multiorgan failure. Another common observation was Candida albicans growth in blood cultures. Unfortunately, all died despite prompt and appropriate sepsis treatment, along with immunomodulatory therapy. CONCLUSION: TA-GVHD is probably more prevalent than reported in the literature. It must be considered in the differential diagnosis, if the patient with a recent transfusion history admits with fever, skin rash, abnormal liver function tests, and pancytopenia associated with hypoplastic marrow. In rural areas where gamma irradiation is not possible, the overall policy of transfusion (e.g., restriction of transfusion indications and alternative methods for pathogen inactivation) should be reassessed.

Bacteremia in patients with ventilator-associated pneumonia is associated with increased mortality: A study comparing bacteremic vs. nonbacteremic ventilator-associated pneumonia.

OBJECTIVE: To assess whether bacteremic ventilator-associated pneumonia (B-VAP) differs in terms of risk factors, organisms, and outcomes from nonbacteremic VAP (NB-VAP). DESIGN: A retrospective, single-center, observational, cohort study. SETTING: Multidisciplinary teaching intensive care unit. PATIENTS: Adult patients requiring mechanical ventilation, identified as having VAP in a 44-month prospective surveillance database. INTERVENTIONS: Each B-VAP patient was matched with two controls with VAP and negative blood cultures based on the microbial etiology responsible for VAP, Acute Physiology and Chronic Health Evaluation II score on admission (+/-3 points), diagnostic category, and length of stay before pneumonia onset. MEASUREMENTS AND MAIN RESULTS: B-VAP was documented in 35 (17.6%) of 199 microbiologically confirmed VAP episodes. B-VAP developed later (median 8 vs. 5 days, p = .03) and was more frequent in previously hospitalized patients (34.3% vs. 11.0%, p < .01) and in older patients (57.4 +/- 15.2 vs. 49.5 +/- 19.3 yrs, p = .02). B-VAP was more often caused by methicillin-resistant Staphylococcus aureus (12 [20.7%] vs. 13 [5.1%] episodes, p < .01), whereas Haemophilus influenzae was associated with NB-VAP (52 [20.4%] vs. 0, p < .01). Multivariate analysis confirmed an association between B-VAP and both methicillin-resistant S. aureus (odds ratio 3.18; 95% confidence interval 1.15-8.76, p < .01) and prior hospitalization (odds ratio 2.56; 95% confidence interval 1.01-6.54, p = .05). After adjustment for potential confounders, B-VAP (hazard ratio for death 2.55; 95% confidence interval 1.25-5.23, p = .01) and vasopressor use (hazard ratio 2.43; 95% confidence interval 1.23-4.82, p = .01) remained associated with mortality. The estimated relative risk of death for bacteremic cases was 2.86 (95% confidence interval 1.09-7.51), since mortality for cases and matched NB-VAP controls was 40.6% (13 of 32) and 19.3% (11 of 57), respectively. CONCLUSIONS: B-VAP occurs later during intensive care unit stay, is more frequent in previously hospitalized patients, is more often caused by methicillin-resistant S. aureus, and is independently associated with increased intensive care unit mortality.