Low libido despite high normal testosterone levels in a male with an FSH-secreting pituitary macroadenoma.

Summary: Functioning gonadotroph adenomas with clinical manifestations are extremely rare and the majority of these are FSH-secreting macroadenomas. Clinical symptoms are due to excess gonadotrophins and sex hormones, and these may be present for a long time before the diagnosis of pituitary adenoma is made. We present the case of a 37-year-old Caucasian male with clinical manifestations of an FSH-secreting pituitary macroadenoma. He had sexual dysfunction for a year followed by bilateral testicular pain and enlargement which was initially treated as suspected recurrent epididymitis, but his symptoms did not resolve. He presented a year later with headaches and bilateral superior temporal visual field defects. Brain imaging confirmed a pituitary macroadenoma with optic chiasm compression. Pituitary profile demonstrated an unusually high FSH with high normal LH and normal testosterone level. The patient successfully underwent transsphenoidal hypophysectomy and histology confirmed gonadotroph differentiation and immunoreactivity predominantly with FSH. Gonadotrophin levels and testosterone dropped significantly after surgery, and he was started on testosterone replacement. MR imaging, 2 years post surgery, showed no recurrence of pituitary adenoma. In conclusion, testicular enlargement and hypogonadal symptoms associated with low testosterone levels are recognised features in FSH-secreting pituitary adenomas. Our patient had hypogonadal symptoms but consistently high normal testosterone levels prior to surgery. The reason for low libido despite high testosterone is unclear. Our case highlights the need to suspect such rare underlying pituitary pathology when dealing with unusual combinations of hypogonadal symptoms, testicular enlargement with low or normal testosterone levels. Learning points: Functioning pituitary adenomas that secrete excess follicle-stimulating hormone (FSH) are very rare and often present with symptoms related to pituitary mass effect. Testicular enlargement alongside sexual dysfunction are commonly reported symptoms amongst male patients. Pituitary profile results demonstrate a raised FSH level with either a low, normal, or even high testosterone level which may not always correlate to clinical symptoms. Pituitary pathology should be considered in males presenting with unusual combinations of testicular enlargement and hypogonadal symptoms even with normal testosterone levels.

Cardiac Autonomic Neuropathy in Type 1 and 2 Diabetes: Epidemiology, Pathophysiology, and Management.

PURPOSE: Cardiac autonomic neuropathy (CAN) is a serious complication of type 1 and type 2 diabetes and is independently associated with major cardiovascular events, morbidity, and mortality. This narrative review examines the epidemiology, pathophysiology, and management and identifies areas of future research to address the challenge posed by CAN. METHODS: We conducted a comprehensive literature search using a range of sources, including the electronic databases PubMed Central, Google Scholar, OVID, and Open Athens, to search for studies on CAN, diabetes mellitus, lifestyle intervention, and cardiovascular risk. We set inclusion criteria to consider review articles or original research published in peer-reviewed journals that examined CAN in diabetes. FINDINGS: Epidemiologic data indicate a varied prevalence of CAN in type 1 and 2 diabetes, with prevalences of 17% to 73%) depending on clinical and demographic factors. Indeed, duration of diabetes and hyperglycemia are the strongest risk factors for CAN development in type 1 diabetes. However, in type 2 diabetes, multifactorial risk factors, including obesity, hypertension, and hyperlipidemia, are associated with the development of CAN. Insulin resistance, which underpins type 2 diabetes and metabolic syndrome, has a direct role in the pathogenesis of CAN. Lifestyle interventions, including dietary measures and tailored exercise programs, have been beneficial in improving cardiac autonomic function primarily measured through heart rate variability. In addition, weight loss through bariatric surgery also improves heart rate variability and may prevent or reduce CAN progression in people living with obesity and concomitant type 2 diabetes. For optimization in type 2 diabetes, both lifestyle and targeted pharmacologic interventions are required to achieve glycemic/metabolic targets, and weight loss is required to prevent or reverse early CAN or prevent the progression to definite and severe CAN. IMPLICATIONS: The focused use of diagnostic testing for CAN, including cardiac autonomic reflex testing in those at high risk of CAN, will enable earlier diagnosis. This testing will allow timely interventions at a reversible stage. Future research should examine targeted early diagnostic testing with subsequent intervention with a combination of lifestyle measures and newer pharmacotherapeutics (eg, sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists), which have produced significant cardiovascular benefit in diabetes.

A Comparative Study on Suitability of Model-Free and Model-Fitting Kinetic Methods to Non-Isothermal Degradation of Lignocellulosic Materials.

The thermal kinetic modeling is crucial for development of sustainable processes where lignocellulosic fuels are a part of chemical system and their thermal degradation eventuates. In this paper, thermal decomposition of three lignocellulosic materials (bagasse, rice husk, and wheat straw) was obtained by the thermogravimetric (TG) technique and kinetics was analyzed by both model-fitting and isoconversional (model-free) methods to compare their effectiveness. Two models selected from each class include Arrhenius and Coats-Redfern (model-fitting), and Kissinger-Akahira-Sunose (KAS) and Flynn-Wall-Ozawa (FWO) (model-free). The formal model-fitting approach simulating the thermal decomposition of solids by assuming a fixed mechanism was found to be unduly facile. However, activation energy (E) values calculated from two model-fitting techniques were considerably different from each other with a percentage difference in the range of 1.36% to 7.65%. Particularly, both model-fitting methods predicted different reaction mechanism for thermal disintegration of lignocellulosic materials (two-dimensional diffusion (D2) by Arrhenius and one-dimensional diffusion (D1) by Coat-Redfern method). Conversely, the model-free routine offers a transformation of mechanism and activation energy values throughout reaction and is, therefore, more authentic to illustrate the complexity of thermal disintegration of lignocellulosic particles. Based on the model-free kinetic analysis, the lignocellulosic materials may be devised in following order of activation energy: rice husk > bagasse > wheat straw, by both KAS and FWO methods with a percentage difference no more than 0.84% for fractional conversion up to 0.7. Isoconversional approach could be recommended as more realistic and precise for modeling non-isothermal kinetics of lignocellulosic residues compared to model-fitting approach.

Molecular characterization and genetic diversity of cutaneous leishmaniasis from North Eastern Pakistan.

The genetic diversity of Leishmania spp. in North Eastern Pakistan remains undetermined despite increased cases of cutaneous leishmaniasis (CL). This study was designed to decipher the molecular characterization and genetic diversity of Leishmania spp. in North Eastern Pakistan. Out of 13761 CL suspected cases, 567 cases were microscopically positive and confirmed as Leishmania spp. by internal transcribed spacer (ITS) gene amplification through the PCR- RFLP technique. Further, isolates were directly sequenced to conduct phylogenetic analysis for genetic diversity. Among suspected CL cases, Mirpur showed the highest proportion of CL infection with 4.85% (118/2431) of the cases, while the Neelum district showed the lowest percentage at 3.29% (9/273). The slide positivity rate, annual blood examination rate, and annual parasite incidence rate were 3.84, 0.27, and 0.01% respectively, and the incidence of CL in the age group 1-20 years old was higher in males (50.92%) than females (25.75%). The RFLP analysis and sequencing confirmed the occurrence of Leishmania tropica, Leishmania major, and Leishmania infantum. Leishmania tropica (p = 0.02) confirmed significantly higher nucleotides variation than L. major (p = 0.05). Current findings confirmed the prior assumption that anthroponotic CL is the primary CL form present in North Eastern Pakistan. Moreover, this is the first report based on molecular identification of L. major, and L. infantum from North Eastern Pakistan. This remarkable heterogeneity in the Leishmania spp. is the leading cause of treatment failure and emergence of new haplotypes. Therefore more extensive investigations are recommended from all geographical regions of North Eastern Pakistan, especially those using a large sample size.

Identification of risk factors for hepatitis B and C in Peshawar, Pakistan.

BACKGROUND: Hepatitis B and C need immediate worldwide attention as the infection rates are too high. More than 240 million people have chronic (long-term) liver infections. Every year, about 600,000 people die globally due to the acute or chronic consequences of hepatitis B and more than 350,000 people die from hepatitis C-related liver diseases. METHODS: Our study was designed as a case-control, descriptive study. It was conducted through formal interviews by using structured questionnaires. A total of 100 cases were included, with four controls for each case. RESULTS: This study confirms household contact, history of dental work, history of surgery, sexual contact, and history of transfusion (blood and its components) as the main risk factors which are responsible for the increased prevalence of hepatitis. CONCLUSION: The important risk factors, responsible for the high prevalence of hepatitis B and C in our society are household contact, history of dental work, history of surgery, sexual contact, and history of transfusion (blood and its components). The odds ratio of probability for these risk factors are: 4.2 for household contact history, 4.1 for history of dental work, 3.9 for sexual contact, 2.7 for history of surgery, and 2.1 for history of transfusion. Associations of other predictor variables (diabetes status, education level, profession, contact sports, intravenous drug abuse, residence, immunosuppression, and skin tattoos) were not statistically significant.