Cutaneous findings in patients with acromegaly and its relationship with concomitant endocrinopathies.

OBJECTIVES: Skin changes in acromegaly are often the first sign of the disease. The aim of this study was to describe the cutaneous findings in patients with acromegaly. In addition, a secondary aim was to investigate the possible association of these findings with remission status and concomitant endocrinopathies. DESIGN, PATIENTS, AND MEASUREMENTS: In this prospective multicenter study, 278 patients over the age of 18 years with acromegaly who were followed up in 14 different tertiary healthcare institutions were included. These patients, who were followed up by the Endocrinology Department, were then referred to a dermatologist for dermatological examination. The frequency of skin lesions was investigated by detailed dermatologic examination. Dermatological diagnosis is reached by clinical, dermatological and/or dermoscopic examination, and rarely skin punch biopsy examinations in suspicious cases. The possible association of the skin findings between remitted and nonremitted patients and with concomitant endocrinopathies were evaluated. RESULTS: The most common skin findings in patients with acromegaly in our study were skin tags (52.5%), cherry angiomas (47.4%), seborrhoea (37%), varicose veins (33%), acneiform lesions (28.8%), hyperhidrosis (26.9%) and hypertrichosis (18.3%). Hypertrichosis was significantly more prevalent in patients nonremitted (p: .001), while xerosis cutis was significantly more prevalent in patients remitted (p: .001). The frequency of diabetes mellitus and hypothyroidism was significantly higher in patients with varicose veins and seborrhoeic keratosis than those without. Additionally, the coexistence of hypothyroidism, hyperthyroidism and galactorrhea was significantly higher in patients with Cherry angioma than in those without Cherry angioma (p-values: .024, .034 and .027, respectively). The frequency of hypogonadism in those with xerosis cutis was significantly higher than in those without (p: .035). CONCLUSIONS: Cutaneous androgenization findings such as skin tag, seborrhoea, acne and acanthosis nigricans are common in patients with acromegaly. Clinicians should be aware that skin findings associated with insulin resistance may develop in these patients. It can be said that the remission state in acromegaly has no curative effect on cutaneous findings. Only patients in remission were less likely to have hypertrichosis. This may allow earlier review of the follow-up and treatment of acromegaly patients presenting with complaints of hypertrichosis. Additionally, it can be said that patients with skin findings such as cherry angioma may be predisposed to a second endocrinopathy, especially hypothyroidism. Including dermatology in a multidisciplinary perspective in acromegaly patient management would be beneficial to detect cutaneous findings earlier.

Test-Retest Reliability and Convergent Validity of Piezoelectric Force Plate Measures of Single-Leg Sit-to-Stand Performance in Trained Adults.

ABSTRACT: Makaraci, Y, Nas, K, Ruiz-Cárdenas, JD, Gündüz, K, Aydemir, M, and Orange, ST. Test-retest reliability and convergent validity of piezoelectric force plate measures of single-leg sit-to-stand performance in trained adults. J Strength Cond Res 37(12): 2373-2380, 2023-The single-leg sit-to-stand (STS) test has emerged as a promising method of assessing lower-limb functional strength and asymmetry. However, the reliability of its performance parameters on a force plate has not been explored. This study examined the test-retest reliability and convergent validity of the single-leg STS test performed on a piezoelectric-based force plate in trained subjects. Thirty trained male adults (age: 21.4 ± 1.7 years) performed 3 separate single-leg STS days of testing to assess both intraday and interday reliability. Performance parameters included STS time, ground reaction force (GRF), and center of pressure (CoP) sway velocity. The relationship between single-leg STS parameters and unilateral countermovement jump (CMJ) variables was assessed for convergent validity. Intraclass correlation coefficient (ICC) and coefficient of variation (CV) were calculated for reliability analyses, and convergent validity was assessed with Spearman's correlation coefficient (ρ). In the dominant leg, single-leg performance parameters showed moderate-to-excellent intraday reliability (ICC = 0.65-0.90, CV = 4.3-11.2%) and moderate interday reliability (ICC = 0.54-0.74, CV = 5.8-13.5%). In the nondominant leg, all single-leg STS performance parameters showed good intraday (ICC = 0.79-0.86, CV = 3.8-9.8%) and interday reliability (ICC = 0.75-0.82, CV = 4.6-9.7%). STS times in the dominant and nondominant legs were inversely related to unilateral CMJ velocity (ρ = -0.47 and -0.38, respectively). CoP sway velocity in the nondominant leg showed positive correlations with unilateral CMJ power and velocity (ρ = 0.38 and 0.54, respectively). In conclusion, the force plate-based single-leg STS test provides reliable measures of STS time, GRF, and CoP sway velocity in trained adults and could be used to assess lower-limb function and asymmetry.

An extremely rare case of hypoglycemia with a novel mutation and review of the literature: fructose-1,6 bisphosphatase deficiency in an adult man.

Hypoglycemia is an uncommon clinical problem among non-diabetic patients. It requires systematic evaluation to determine the etiology. It may be related to critical illness, hepatic insufficiency, renal insufficiency, cardiac insufficiency, drugs, alcohol, cortisol insufficiency, growth hormone insufficiency, insulinoma, gastric bypass surgery, and paraneoplastic (insulin-like growth factor-2-related) immune-mediated or inherited metabolic disorders. We aimed to summarize the literature and present a case who suffered from hypoglycemia throughout his life and was diagnosed with fructose-1, 6 bisphosphatase deficiency in adulthood to attract attention to the rare causes of hypoglycemia in adulthood.

An aggressive Cushing's syndrome originating from a rare thymic neuroendocrine tumor, controlled successfully with fluconazole and octreotide therapy before surgery.

ABSTRACT: Cushing's syndromes (CSs) due to the thymic neuroendocrine tumors are rarely seen. Here, a case of ectopic CS originating from an atypical neuroendocrine tumor has been presented. A 49-year-old woman was hospitalized with symptoms of fatigue, chest pressure, dyspnea, muscle weakness, and resistant hypertension. There was marked hyperpigmentation in the whole-body surface suggestive of adrenocorticotropic hormone (ACTH) excess and there were physical features of CS. There was deep hypokalemia. Basal hormone profile, dexamethasone suppression tests, midnight cortisol, and 24-hour urine cortisol levels were suggestive of ectopic CS. The pituitary magnetic resonance imaging revealed a 5 mm cystic lesion and the patient refused inferior petrosal sinus sampling. Thorax computerized tomography showed an anterior mediastinal mass. A fluorodeoxyglucose-positron emission tomography showed the same mediastinal lesion (suvmax: 11.4), and no other tumor focus was detected. There was an aggressive cortisol excess causing acute respiratory distress syndrome, making it difficult to perform the surgery. We immediately started fluconazole and octreotide therapy and were successful in lowering the cortisol level. Then a complete resection of the tumor had been able to be surgically performed and tumor cells showed strong cytoplasmic immunopositivity with ACTH. A definitive diagnosis of "ACTH secreting atypical thymic carcinoid tumor" was rendered based on the histopathological and immunohistochemical features. There was only surrounding vessel invasion, and no lymphoid or other organ metastases were detected. As there were surrounding vessel invasions, a two-cycle regimen cisplatin-etoposide chemotherapy and radiotherapy were employed. After surgical and medical therapy, the cortisol and ACTH levels turned to normal. The patient is in biochemical and clinical remission and has no tumor recurrence yet. Ectopic ACTH-producing thymic carcinoids are rare but life-threatening tumors because of the underlying malignancy and severe hypercortisolemia. It is important to consider this disease and perform appropriate treatment at the right time. Today, surgery is the standard therapeutic modality if it is possible to perform, but there is not a clear and constant recommendation for nonsurgical therapeutic modalities. Further studies are needed for the optimal treatment strategies.

Head to head comparison of diagnostic performance of three non-mydriatic cameras for diabetic retinopathy screening with artificial intelligence.

BACKGROUND: Diabetic Retinopathy (DR) is a leading cause of blindness worldwide, affecting people with diabetes. The timely diagnosis and treatment of DR are essential in preventing vision loss. Non-mydriatic fundus cameras and artificial intelligence (AI) software have been shown to improve DR screening efficiency. However, few studies have compared the diagnostic performance of different non-mydriatic cameras and AI software. METHODS: This clinical study was conducted at the endocrinology clinic of Akdeniz University with 900 volunteer patients that were previously diagnosed with diabetes but not with diabetic retinopathy. Fundus images of each patient were taken using three non-mydriatic fundus cameras and EyeCheckup AI software was used to diagnose more than mild diabetic retinopathy, vision-threatening diabetic retinopathy, and clinically significant diabetic macular oedema using images from all three cameras. Then patients underwent dilation and 4 wide-field fundus photography. Three retina specialists graded the 4 wide-field fundus images according to the diabetic retinopathy treatment preferred practice patterns of the American Academy of Ophthalmology. The study was pre-registered on clinicaltrials.gov with the ClinicalTrials.gov Identifier: NCT04805541. RESULTS: The Canon CR2 AF AF camera had a sensitivity and specificity of 95.65% / 95.92% for diagnosing more than mild DR, the Topcon TRC-NW400 had 95.19% / 96.46%, and the Optomed Aurora had 90.48% / 97.21%. For vision threatening diabetic retinopathy, the Canon CR2 AF had a sensitivity and specificity of 96.00% / 96.34%, the Topcon TRC-NW400 had 98.52% / 95.93%, and the Optomed Aurora had 95.12% / 98.82%. For clinically significant diabetic macular oedema, the Canon CR2 AF had a sensitivity and specificity of 95.83% / 96.83%, the Topcon TRC-NW400 had 98.50% / 96.52%, and the Optomed Aurora had 94.93% / 98.95%. CONCLUSION: The study demonstrates the potential of using non-mydriatic fundus cameras combined with artificial intelligence software in detecting diabetic retinopathy. Several cameras were tested and, notably, each camera exhibited varying but adequate levels of sensitivity and specificity. The Canon CR2 AF emerged with the highest accuracy in identifying both more than mild diabetic retinopathy and vision-threatening cases, while the Topcon TRC-NW400 excelled in detecting clinically significant diabetic macular oedema. The findings from this study emphasize the importance of considering a non mydriatic camera and artificial intelligence software for diabetic retinopathy screening. However, further research is imperative to explore additional factors influencing the efficiency of diabetic retinopathy screening using AI and non mydriatic cameras such as costs involved and effects of screening using and on an ethnically diverse population.

Comparative evaluation of clinical outcomes of dapagliflozin and empagliflozin in type-2 diabetes mellitus.

BACKGROUND: Sodium-glucose transporter 2 (SGLT-2) inhibitors provide additional benefits besides glycemic control. AIM: This study aims to compare the clinical outcomes of dapagliflozin and empagliflozin. METHODS: This retrospective study evaluated data retrieved from medical records of patients who were under follow-up with the diagnosis of type 2 diabetes mellitus (T2DM) and were started on dapagliflozin or empagliflozin treatment between January 1, 2017, and June 1, 2020. Demographic features, comorbidities, clinical features, duration of diabetes, baseline, and follow-up laboratory test results were recorded. The significance level was set at p < 0.05. RESULTS: This study comprised 342 patients who are on the treatment with dapagliflozin (n = 228) or empagliflozin (n = 114). The glycosylated hemoglobin a1c (HBA1C) level was significantly decreased in both the dapagliflozin (8.18-7.59, p < 0.001) and empagliflozin (8.35-7.58, p < 0.001) groups. The urine albumin-to-creatinine ratio (ACR) was also decreased in both groups. A decrease in urine ACR was observed independent of using a renin-angiotensin-aldosterone system (RAAS) blocker both in the whole group and in patients with diabetic nephropathy. The time to addition of a new anti-diabetic agent to the treatment was shorter in the dapagliflozin group (14.4 months vs 17.7 months, p = 0.041, respectively). CONCLUSION: Dapagliflozin and empagliflozin are the drugs to choose for renoprotection in diabetics independent of the use of a RAAS blocker. Even the time to addition of a new anti-diabetic agent is longer in the empagliflozin group, head-to-head comparative trials are needed to asess the potential differences in this regard.

Diagnostic value of thyroglobulin washout in fine-needle aspiration samples for diagnosis and follow-up of differentiated thyroid cancer.

Our goal was to assess the effectiveness of fine-needle aspiration thyroglobulin (FNA-Tg) in detecting malignant lymph nodes (LNs) in patients with differentiated thyroid cancer (DTC). We also aimed to determine the factors that affect the accuracy of FNA-Tg. We conducted a retrospective cohort study using the laboratory, ultrasonographic, histopathological, FNA cytology (FNA-C), and FNA-Tg results of 176 DTC patients. We used receiver operating characteristic analysis to identify the cutoff value of FNA-Tg, and binary regression analysis to compare FNA-Tg with other diagnostic parameters. Spearman correlation was utilized to identify factors that influence FNA-Tg. Our study revealed that a cutoff value of 3.14 ng/mL for FNA-Tg had a sensitivity of 91.8% and a specificity of 96.6% in detecting malignant LNs in the entire group. In the subgroup with thyroid tissue, the optimal cutoff value for FNA-Tg was determined to be 15.5 ng/mL. Additionally, FNA-C had a sensitivity of 82.4% and a specificity of 99.4% for the entire group. The combined use of FNA-Tg and FNA-C yielded a sensitivity of 100% and a specificity of 96%, which was found to be more effective than using either test alone. Serum Tg positivity and serum thyroid-stimulating hormone were positively correlated with FNA-Tg levels in detecting malignant LNs. Our study demonstrated that FNA-Tg is a reliable method for detecting LN metastases in DTC patients, with a 3.14 ng/mL cutoff value. However, each center should take into account factors such as serum thyroid-stimulating hormone, serum Tg, and the presence of thyroid tissue when interpreting FNA-Tg results and determining the appropriate cutoff level.

Intraoperative Parathyroid Hormone Monitoring-Guided Subtotal Parathyroidectomy is an Effective and Valid Surgical Procedure for Secondary Hyperparathyroidism.

Objectives: Secondary hyperparathyroidism (sHPT) is a prevalent complication of end stage renal disease in which serious morbid conditions and mortality can be encountered. Although the best solution of this severe problem is renal transplantation, because of the huge demand and limited resources, this cannot be possible most of the time. Initial treatment alternative is medical treatment in patients with sHPT and parathyroidectomy (PTX) should be applied if does not help. Subtotal PTX, total PTX and total PTX together with autotransplantation are the current surgical options preferred for sHPT. Intraoperative parathyroid hormone (IO PTH) monitoring can increase surgical success in sHPT. We aimed to determine the ideal surgical technique and relation of IO PTH monitoring with surgical success in patients with sHPT through our study. Methods: We analyzed all the data of the 35 patients who had PTX and follow up between January 2001 and December 2021 because of sHPT at General Surgery Department of Akdeniz University Medical Faculty Hospital in retrospective manner. Results: Twenty-seven of the patients had been applied subtotal PTX while six of the cases had experienced limited surgery and two of them had undergone total PTX. Persistance happened to be present in the follow-up of nine patients and recurrence in one of them. Four persistant and one recurrent cases were present in 23 patients with IO PTH monitoring (78.3% surgical success), while there were persistences in each of the three patients with no IO PTH monitoring (0% success of surgery) (p=0.022). IO PTH monitoring data of nine patients could not be reached. In this study, 20 patients had IO PTH decline of 80% or more (90% surgical success) and three patients had IO PTH decline below 80% (0% surgical success) (p=0.006). Subtotal PTX was applied to 17 (94.1% surgical success) of these 20 patients. Conclusion: In surgical treatment of patients with sHPT, IO PTH monitoring should be maintained and operation should not be finished until 80% or more decline in IO PTH level had been detected. Among the surgical alternatives for sHPT, subtotal PTX appears as an effective and valid method when performed together with IO PTH monitoring, provided that there is a decline in PTH level of 80% or more.

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.

Management of diabetic foot ulcers and the challenging points: An endocrine view.

Diabetic foot ulcers (DFU) are one of the most challenging complications of diabetes. Up to one-third of patients with diabetes mellitus (DM) may suffer from DFUs during their life. DFU is one of the leading causes of morbidity in patients with DM. The treatment period is challenging, and the recurrence rate of DFUs is high. Hence, establishing prevention strategies is the most important point to be emphasized. A multidisciplinary approach is necessary in the prevention and treatment of DFUs. Patients at risk should be identified, and prevention measures should be taken based on the risk category. Once a DFU is formed, the appropriate classification and evidence-based treatment interventions should be executed. Glycemic control, diagnosis and treatment of vascular disease, local wound care, diagnosis, and treatment of infection should be addressed along with the proper evaluation and management of general health status.

Relationships among postural stability, physical fitness, and shooting accuracy in Olympic female goalball players.

This study aims to examine the relationship between postural perfor-mance, physical fitness level, and shooting performance in Olympic fe-male goalball players. Eight Olympic-level goalball players (age: 20.63± 4.37 years) were recruited from the Turkish National Women's Goalball Team. Postural stability, physical fitness, and shooting performance of the players were measured. The postural stability was determined us-ing body sway measurements during parallel and single-leg stances on a force plate. The physical fitness level of the players is evaluated by curl-up, isometric push-up, trunk lift, and grip strength (dominant hand) tests. A goalball-specific shooting accuracy test was used for shooting performance. Independent sample t-test and Pearson correlation were used for statistical processing. No statistical difference was observed in body sway parameters between open eyes and closed eyes condi-tions except for the anteroposterior sway area. Some of the body sway parameters performed under different stances positively correlated with all physical fitness tests (P<0.05). There was a positive correlation between the shooting accuracy and trunk lift score (r=0.767). Right leg sway area anterior-posterior and ellipse area negatively correlated with shooting accuracy (r=-0.629 and r=-0.692 respectively). It is necessary to attach importance to the improvement of the physical fitness level specific to core strength to maintain postural stability for visually im-paired athletes. In our study, some factors affecting shooting accuracy were identified, but it is necessary not to restrict a complex structure such as shooting accuracy within certain concepts.

Sodium tungstate administration ameliorated diabetes-induced electrical and contractile remodeling of rat heart without normalization of hyperglycemia.

Recently, sodium tungstate was suggested to improve cardiac performance of diabetic rats in perfused hearts based on its insulinomimetic activity. In this study, we aimed to investigate the cellular and molecular mechanisms underlying this beneficial effect of sodium tungstate. Tungstate was administered (100 mg/kg/day) to diabetic and control rats intragastrically for 6 weeks. Blood glucose levels increased, whereas body weight, heart weight and plasma insulin levels decreased significantly in diabetic animals. Interestingly, none of these parameters was changed by tungstate treatment. On the other hand, fractional shortening and accompanying intracellular Ca(2+) [Ca(2+)](i) transients of isolated ventricular myocytes were measured, and sodium tungstate was found to improve the peak shortening and the amplitude of [Ca(2+)](i) transients in diabetic cardiomyocytes. Potassium and L-type Ca(2+) currents were also recorded in isolated ventricular cells. Significant restoration of suppressed I (to) and I (ss) was achieved by tungstate administration. Nevertheless, L-type calcium currents did not change either in untreated or treated diabetic rats. Tissue biochemical parameters including TBARS, protein carbonyl content, xanthine oxidase (XO) and xanthine dehydogenase (XDH) were also determined, and diabetes revealed a marked increase in TBARS and carbonyl content which were decreased significantly by tungstate treatment. Conversely, although XO and XDH activities didn't change in untreated diabetic rats, a remarkable but insignificant decrease was detected in treated animals. In conclusion, tungstate treatment improved diabetes-induced contractile abnormalities via restoration of dysregulated [Ca(2+)](i) and altered ionic currents. This beneficial effect is due to antioxidant property of sodium tungstate rather than normalization of hyperglycemia.

Levels of plasma fibrinogen and D-dimer in subjects with subclinical hyperthyroidism.

BACKGROUND: During the last 15 years, several risk markers for atherosclerosis, such as fibrinogen and D-dimer, have been identified. The role of elevated fibrinogen levels as an independent risk factor for coronary, cerebral, and peripheral vascular disease is well established on the basis of clinical and epidemiological studies. Increased D-dimer levels are associated with increased risk of future myocardial infarction, stroke, and peripheral vascular disease. The aim of this study was to evaluate the alterations in fibrinogen and D-dimer, which indicates overall thrombotic activity, in subjects with subclinical hyperthyroidism. MATERIAL/METHODS: Thirty-six subclinical hyperthyroidic subjects and 36 euthyroidic control subjects matched for age, gender, and body mass index were selected. The levels of plasma fibrinogen and D-dimer in all subjects were measured. RESULTS: The level of fibrinogen was significantly higher in the subclinical hyperthyroidic group than in the euthyroidic group (296.9+/-74.3 mg/dl vs. 255.0+/-41.7 mg/dl, p<0.001). The level of D-dimer was significantly higher in the subclinical hyperthyroidic group than in the euthyroidic group (261.9+/-47.8 mg/dl vs. 216.4+/-32.1 mg/dl, p<0.000). CONCLUSIONS: The results suggest that subjects with subclinical hyperthyroidism present a relatively hypercoagulable state. This state could contribute to increased thromboembolic risk in subclinical hyperthyroidism.