The Importance of DHEA-S Levels in Cushing's Syndrome; Is There a Cut-off Value in the Differential Diagnosis?

The purpose of this study was to determine possible cut-off levels of basal DHEA-S percentile rank in the differential diagnosis of patients with Cushing's syndrome (CS) with ACTH levels in the gray zone and normal DHEA-S levels. In this retrospective study including 623 pathologically confirmed CS, the DHEA-S percentile rank was calculated in 389 patients with DHEA-S levels within reference interval. The patients were classified as group 1 (n=265 Cushing's disease; CD), group 2 (n=104 adrenal CS) and group 3 (n=20 ectopic ACTH syndrome).ROC-curve analyses were used to calculate the optimal cut-off level of DHEA-S percentile rank in the reference interval in the differential diagnosis of CS, and the effectiveness of this cut-off level in the identification of the accurate etiology of CS was assessed in patients who were in gray zone according to their ACTH levels. The DHEA-S percentile rank in the reference interval were significantly lower in group 2 compared to the other two groups (p<0.001), while group 1 and group 3 had similar levels. The optimal cut-off level of DHEA-S percentile rank in the reference interval providing differential diagnosis between group 1 and group 2 was calculated as 19.5th percentile (80.8% sensitivity, 81.5% specificity) and the level demonstrated the accurate etiology in 100% of CD and 76% of adrenal CS patients who were in the gray zone. This study showed that the cut-off value of DHEA-S level less than 20% of the reference interval could be used for differential diagnosis of CD and adrenal CS with high sensitivity and specificity, and it should be taken into the initial evaluation.

Renal complications of lipodystrophy: A closer look at the natural history of kidney disease.

OBJECTIVES: Lipodystrophy syndromes are a group of heterogeneous disorders characterized by adipose tissue loss. Proteinuria is a remarkable finding in previous reports. STUDY DESIGN: In this multicentre study, prospective follow-up data were collected from 103 subjects with non-HIV-associated lipodystrophy registered in the Turkish Lipodystrophy Study Group database to study renal complications in treatment naïve patients with lipodystrophy. METHODS: Main outcome measures included ascertainment of chronic kidney disease (CKD) by studying the level of proteinuria and the estimated glomerular filtration rate (eGFR). Kidney volume was measured. Percutaneous renal biopsies were performed in 9 patients. RESULTS: Seventeen of 37 patients with generalized and 29 of 66 patients with partial lipodystrophy had CKD characterized by proteinuria, of those 12 progressed to renal failure subsequently. The onset of renal complications was significantly earlier in patients with generalized lipodystrophy. Patients with CKD were older and more insulin resistant and had worse metabolic control. Increased kidney volume was associated with poor metabolic control and suppressed leptin levels. Renal biopsies revealed thickening of glomerular basal membranes, mesangial matrix abnormalities, podocyte injury, focal segmental sclerosis, ischaemic changes and tubular abnormalities at various levels. Lipid vacuoles were visualized in electron microscopy images. CONCLUSIONS: CKD is conspicuously frequent in patients with lipodystrophy which has an early onset. Renal involvement appears multifactorial. While poorly controlled diabetes caused by severe insulin resistance may drive the disease in some cases, inherent underlying genetic defects may also lead to cell autonomous mechanisms contributory to the pathogenesis of kidney disease.

Primary hyperparathyroidism in pregnancy: a case series and literature review.

Primary Hyperparathyroidism (PHP) in pregnancy constitutes a serious danger to mother and fetus. The diagnosis of PHP in pregnancy presents a challenge, and PHP commonly goes unidentified and untreated in pregnancy. We present four case reports about patients having PHP, which is very rare condition in pregnancy and their treatment modalities. Three patients, not to be controlled biochemically, denied the parathyroidectomy operation although they are informed about the details of their disease. They are followed up with medical therapy. The first one had no maternal or fetal complications, the second one acquired nephrolithiasis crisis in the last trimester and the third one gave birth to a premature baby who succumbed to tetany. The fourth patient who underwent parathyroidectomy operation in the second trimester had no maternal or fetal complications. PHP in pregnancy is a preventable cause of fetal and maternal mortality and morbidity. Thus, suspecting from PHP during the pregnancy and early diagnosis is critically important in terms of maternal and fetal wellness.

Levels of endothelial cell-specific molecule-1 (ESM-1) in overt hypothyroidisim.

PURPOSE: Endothelial cell-specific molecule-1, endocan, is a proteoglycan that is expressed by the vascular endothelium. Endocan can be a biomarker of endothelial dysfunction caused by endothelial cell-dependent disorders. Endothelial dysfunction is an early step of atherosclerosis and is developed in hypothyroid patients, which indicates an association between hypothyroidism and atherosclerosis. Therefore, we aimed to investigate whether circulating endocan levels are associated with endothelial dysfunction in overt hypothyroid patients. MATERIALS AND METHODS: Forty patients with hypothyroidism diagnosed in the last 5 years and 30 healthy subjects were recruited. RESULTS: The mean endocan value in all patients was 0.63 ± 0.26 pg/ml, which was higher than that in controls (0.36 ± 0.10 pg/ml, p < 0.05). When we subgrouped the patients as hypothyroid and euthyroid, all groups demonstrated significantly different endocan levels, and hypothyroid patients had the highest endocan levels. A correlation analysis demonstrated that endocan levels were positively correlated with body mass index (BMI), thyroid-stimulating hormone (TSH), anti-thyroid peroxidase, and anti-thyroglobulin and negatively correlated with free thyroid hormone 4 (FT4) and vitamin D levels. In addition, in the patient group, endocan levels were correlated with FT4 levels independently in a covariance analysis. CONCLUSIONS: The circulating endocan level increased in hypothyroid patients, suggesting that endocan levels may be an early biomarker of the development of endothelial dysfunction in patients with hypothyroidism. They may also prove useful in the prediction of cardiovascular diseases after further studies using cardiovascular disease biomarkers. In addition, targeting endocan levels to decrease cardiovascular risk may be a new treatment strategy in these patients.

Do We Care Enough About the Presence of Sexual Problems in Diabetic Patients?

Purpose: Sexual health is not only the absence of sexual dysfunction or disability, but also the presence of physical, emotional, mental, and social well-being related to sexuality. The current study aims to determine whether all adult patients who have applied for their regular health check-ups due to diabetes mellitus had ever voluntarily expressed their sexual problems to a specialist and whether they were asked about the presence of sexual dysfunction. It also aims to determine how the physicians attach importance to the issue. Patients and Methods: All patients aged 18-65 years with type 1 and type 2 diabetes mellitus, who applied to our hospital between the years of January 2021 and 2022, were questioned by filling out a questionnaire for the presence of sexual problems in addition to screening for chronic complications of diabetes mellitus (retinopathy, nephropathy, and neuropathy) and routine history and physical examination. Results: The association between the presence of sexual problems and whether patients were questioned about the relevant issue in their previous controls and gender and age factors, educational background, presence of comorbidities, duration of marriage, and microvascular complications of diabetes mellitus were examined. In a population of 595 patients, 53.78% of the patients stated that they had sexual problems; however, 9.91% had been questioned about this issue by the physician. It was observed that 6.3% of female and 15.3% of male patients had previously consulted a doctor voluntarily due to their sexual problems. Conclusion: This study presents empirical findings that shed light on the inadequacies in healthcare providers' approach to addressing sexual health concerns among individuals diagnosed with diabetes, as well as the shortcomings in patients' effective communication of these concerns.

Retinal Nerve Fiber Layer Thickness in Prediabetic Patients.

OBJECTIVE: Diabetic retinopathy is a leading cause of blindness. Diabetic retinopathy is not only seen in diabetic patients with the clinical diagnosis but also in prediabetic patients. The aim of this study is to evaluate the RNFL thickness in prediabetic patients. MATERIALS AND METHODS: In this study, 50 prediabetic patients and 50 healthy individuals were included. RNFL measurements were performed with SD-OCT in patients with prediabetes and healthy controls. RESULTS: The mean RNFL thickness for the prediabetic group was 94.7 ± 6.3 µm, inferior quadrant (120 ± 11.6), superior quadrant (112.3 ± 14.13), nasal quadrant (71 ± 12.9), and temporal quadrant (65.3 ± 9.2 µm). The mean RNFL thickness for the control group was 98.9 ± 7.5 µm, inferior quadrant (128 ± 14.7), superior quadrant (116.3 ± 15.12), nasal quadrant (77 ± 15.8), and temporal quadrant (71.2 ± 10.3 µm). Variance analysis demonstrated that the RNFL thickness difference between the groups was significant in all quadrants (P < .001). CONCLUSION: RNLF thinning can be seen in prediabetic patients before obvious vascular damage has occurred, and it may present in prediabetic patients not only in the temporal quadrant but also in all quadrants. The early retinal neural changes shown in this study in prediabetic patients may help to better understand the process leading to diabetic overt retinopathy.

Primary hyperparathyroidism presenting as a palatal and mandibular brown tumor.

Primary hyperparathyroidism is a fairly frequent pathologic diagnosis characterized by hypersecretion of parathyroid hormone, which results from adenomas in 80% to 85% of all cases. At clinical onset, the most common symptoms are hypercalcemia-related and some of them are pain due to kidney stones, polyuria, gastrointestinal, and neurologic disorders, whereas rarer symptoms are due to brown tumors and expansive lesions often found in fibrocystic osteitis. Brown tumors represent the terminal stage of the remodeling processes caused by an increased osteoclastic activity and fibroblastic proliferation during primary or secondary, albeit more seldom, hyperparathyroidism. The manifestation of primary hyperparathyroidism as skeletal disease has nearly disappeared in the last 2 decades. Cases are now most often diagnosed by the coincidental finding of asymptomatic hypercalcemia. Advanced screening techniques have made clinical evidence of bone disease rare. This article contains a case of brown tumor on the maxilla, palate, and mandible in addition to nephrectomy and proximal femur fracture, which are probably associated with primary hyperparathyroidism although less common nowadays. The diagnosis was suggested by the clinical history and confirmed by biochemical, radiologic, and histopathologic evidence. Excision of a parathyroid adenoma normalization of the metabolic status was then realized.

Exophthalmometric values in a normal Turkish population living in the northeastern part of Turkey.

BACKGROUND: Exophthalmometry is a simple examination procedure used for the early diagnosis of many of the orbital pathologies. The exophthalmometric measures tend to vary with age, sex, and race. Therefore, a lot of investigators conducted researches to determine the minimum, maximum, and normal values of exophthalmometric measures in their populations. OBJECTIVE: We planned this study to gather data about the normal exophthalmometric measures in our population. DESIGN: In this study, 240 male and 240 female subjects with age ranging from 3 to 80 years were included. The results of measures from both the eyes were evaluated for the study subjects. The protrusions of both the eyes were measured simultaneously in daylight via Hertel exophthalmometry. RESULTS: The minimum and maximum measures of Hertel exophthalmometry for the male subjects were found to be 8 and 20 mm, respectively, with the mean being 13.49 +/- 2.6 mm. No statistically significant difference existed either between the eyes or between the age groups for the male subjects. The minimum and maximum measures of Hertel exophthalmometry for the female subjects were 8 and 19 mm, respectively, with the mean being 13.39 +/- 2.6 mm. Similar to the males, no statistically significant difference existed either between the eyes or between the age groups for the females. When the results of Hertel measurements for male and female subjects were compared, no significant difference could be found. CONCLUSIONS: As it provides results of exophthalmometry for the Turkish population, our study is important. However, larger, nationwide, and multisite studies examining more subjects may provide more valuable data about the Turkish population.

Neuropad indicator test for diagnosis of sudomotor dysfunction in type 2 diabetes.

Neuropad is a new indicator test used to diagnose sudomotor dysfunction, a component of autonomic neuropathy. In this cross-sectional study, Neuropad is evaluated and compared with corrected QT (QT c), another test used in the diagnosis of autonomic neuropathy. The indicator test measures sweat production on the basis of a color change of cobalt (II) chloride solution from blue to pink upon absorption of water. This study involved 105 patients (43 men, 62 women) with type 2 diabetes with a mean age of 56.2+/-11.5 y and a mean disease duration of 10.0+/-6.3 y. Age, sex, disease duration, glycosylated hemoglobin, and QT c were compared between patients with normal and abnormal test results. The QT c interval was measured and the new indicator test was applied in all patients. The 2 tests were compared, and the sensitivity, specificity, positive predictive value, and negative predictive value for the indicator test were calculated. Autonomic neuropathy was diagnosed in 40 patients (38.1%) with QT c interval measurement and in 72 patients (68.6%) with the new indicator test (P=.001). The sensitivity, specificity, positive predictive value, and negative predictive value for the indicator test were 87.5%, 43.1%, 48.6%, and 84.8%, respectively. Patients with abnormal test outcomes had longer QT c than those whose test results were normal (0.433 vs 0.398 s; P=.002). Study results suggest that the new indicator test has an acceptable sensitivity but a low specificity and is not superior to other tests in the diagnosis of sudomotor dysfunction.

Conjunctival flora in patients with type 1 or type 2 diabetes mellitus.

Patients with diabetes mellitus (DM) are prone to infection because glucose in the skin, urine, mucous membranes, and tears promotes growth of microorganisms. Conjunctival flora develops soon after birth, and some saprophytic conjunctival flora play a pathogenic role when immune function is compromised, which can lead to serious infection. DM is one condition that may compromise immune status. In lacrimal function tests of DM patients, a decrease in breakup time (BUT) of lacrimal film and a decrease in Schirmer's test results were seen. In the present study, conjunctival flora in patients with DM was compared with that in controls with regard to type and duration of diabetes and results of lacrimal function tests. Seventeen patients with type 1 DM (n=34 eyes), 66 patients with type 2 DM (n=132 eyes), and 50 control subjects (n=100 eyes) were included. The control group consisted of age-matched patients with no ophthalmologic problems other than refractive error. Glycosylated hemoglobin values were measured with highpressure liquid chromatography with the Hi-AUTOA1c analyzer (Kyoto Daiichi Kagatu Co., Ltd., Kyoto, Japan). Type and duration of diabetes and demographic data were recorded, and routine ophthalmologic examinations were performed; the BUT of lacrimal film was determined, and the results of Schirmer's test were assessed. Microbiologic sampling was performed twice for both eyes with sterile cotton swabs. One sample was incubated in 2 mL of brain-heart infusion broth agar; the other was incubated for the presence of fungi in Sabouraud dextrose agar. Colony morphology, hemolysis, and Gram's stain, as well as catalase, oxidase, and coagulase tests were performed. No growth was observed in 12 of 17 patients (35.4%) with type 1 DM, 28 of 66 patients (21.2%) with type 2 DM, and 25 of 50 control subjects (50%). Staphylococcus epidermidis (11.79%) and Staphylococcus aureus (11.7%) were the most frequently isolated organisms in the type 1 DM group, and S epidermidis (24.2%) and S aureus (21.2%) were the predominant organisms in the type 2 DM group. In control subjects, S epidermidis (22%), S aureus (12%), and Corynebacterium spp (10%) were the most frequently isolated organisms, and the number of eyes with growth of S aureus was significantly higher in the type 2 DM group than in the other groups (P<.01). Patients with diabetes are more prone to postoperative endophthalmitis than are nondiabetics, and preoperative application of antiseptic or antimicrobial agents to the conjunctiva may not sterilize the area. Impaired integrity of the posterior capsule may also increase the risk of endophthalmitis. Postoperative endophthalmitis is usually associated with gram-positive organisms (75%-80%); gram-negative organisms (15%-29%) and fungi (3%-13%) account for a smaller number of cases. A high rate of resistance to penicillin, ampicillin, and tetracycline was observed in S aureus isolates, although resistance to vancomycin was absent, rendering this molecule the most effective therapeutic option. In this study, S epidermidis and S aureus were the 2 most frequently isolated organisms in patients with DM. It is concluded that the conjunctival flora in diabetic subjects differs from that in nondiabetic subjects. This should be considered preoperatively and postoperatively, and prophylactic and postoperative treatment should be administered accordingly to diabetic patients.

Clinical spectra of neuromuscular manifestations in patients with lipodystrophy: A multicenter study.

Lipodystrophy is a heterogeneous group of disorders characterized by loss of adipose tissue. Here, we report on clinical spectra of neuromuscular manifestations of Turkish patients with lipodystrophy. Seventy-four patients with lipodystrophy and 20 healthy controls were included. Peripheral sensorimotor neuropathy was a common finding (67.4%) in lipodystrophic patients with diabetes. Neuropathic foot ulcers were observed in 4 patients. Drop foot developed in 1 patient with congenital generalized lipodystrophy type 1. Muscle symptoms and hypertrophy were consistent findings in congenital generalized lipodystrophy (21/21) and familial partial lipodystrophy (25/34); on the other hand, overt myopathy with elevated creatine kinase activity was a distinctive characteristic of congenital generalized lipodystrophy type 4. Muscle biopsies revealed myopathic changes at different levels. Accumulation of triglycerides was observed which contributes to insulin resistance. All patients with congenital generalized lipodystrophy suffered from tight Achilles tendons at various levels. Scoliosis was observed in congenital generalized lipodystrophy type 4 (2/2) and familial partial lipodystrophy type 2 (2/17). Atlantoaxial instability was unique to congenital generalized lipodystrophy type 4 (2/2). Bone cysts were detected in congenital generalized lipodystrophy type 1 (7/10) and congenital generalized lipodystrophy type 2 (2/8). Our study suggests that lipodystrophies are associated with a wide spectrum of neuromuscular abnormalities.

Natural History of Congenital Generalized Lipodystrophy: A Nationwide Study From Turkey.

CONTEXT: Congenital generalized lipodystrophy (CGL) is a rare autosomal recessive disorder characterized by near-total lack of body fat. OBJECTIVE: We aimed to study natural history and disease burden of various subtypes of CGL. DESIGN: We attempted to ascertain nearly all patients with CGL in Turkey. SETTING: This was a nationwide study. PATIENTS OR OTHER PARTICIPANTS: Participants included 33 patients (22 families) with CGL and 30 healthy controls. MAIN OUTCOME MEASURE(S): We wanted to ascertain genotypes by sequencing of the known genes. Whole-body magnetic resonance imaging was used to investigate the extent of fat loss. Metabolic abnormalities and end-organ complications were measured on prospective follow-up. RESULTS: Analysis of the AGPAT2 gene revealed four previously reported and four novel mutations (CGL1; c.144C>A, c.667_705delinsCTGCG, c.268delC, and c.316+1G>T). Analysis of the BSCL2 gene revealed four different homozygous and one compound heterozygous possible disease-causing mutations (CGL2), including four novel mutations (c.280C>T, c.631delG, c.62A>T, and c.465-468delGACT). Two homozygous PTRF mutations (c.481-482insGTGA and c.259C>T) were identified (CGL4). Patients with CGL1 had preservation of adipose tissue in the palms, soles, scalp, and orbital region, and had relatively lower serum adiponectin levels as compared to CGL2 patients. CGL4 patients had myopathy and other distinct clinical features. All patients developed various metabolic abnormalities associated with insulin resistance. Hepatic involvement was more severe in CGL2. End-organ complications were observed at young ages. Two patients died at age 62 years from cardiovascular events. CONCLUSIONS: CGL patients from Turkey had both previously reported and novel mutations of the AGPAT2, BSCL2, and PTRF genes. Our study highlights the early onset of severe metabolic abnormalities and increased risk of end-organ complications in patients with CGL.

Retinal Nerve Fiber Layer Thickness in Early-Stage Diabetic Retinopathy With Vitamin D Deficiency.

PURPOSE: To evaluate retinal nerve fiber layer (RNFL) thickness in early-stage diabetic retinopathy (DR) patients with and without vitamin D deficiency (VDD). METHODS: This study compared 50 early-stage DR patients with VDD (group 1) and 50 early-stage DR patients without VDD (group 2). All patients were examined by the same ophthalmologist. Mean RNFL thickness was determined by optical coherence tomography (OCT) performed by the two independent ophthalmologists for all subjects. Vitamin D levels were measured by using a radioimmunoassay. Vitamin D deficiency was defined, in accordance with the general standards, as a 25-hydroxyvitamin D (25(OH)D) level lower than 20 ng/mL. RESULTS: There were no significant differences between the groups in terms of age and sex distribution (P > 0.05). The mean serum 25(OH)D concentration of group 1 was significantly lower than that of group 2 (P < 0.001). The mean RNFL thickness of group 1 was significantly reduced compared to that of group 2 (P < 0.001). A significant relationship between the mean RNFL thickness and serum 25(OH)D concentrations was observed in group 1 (P < 0.001). CONCLUSIONS: The results indicate that vitamin D functions as a neuroprotective component for optic nerves. Low serum 25(OH)D concentrations contribute to RNLF thinning in early-stage DR patients with VDD.

Unusually high prolactin level for medication-induced hyperprolactinemia: a case report.

Hyperprolactinemia has a number of etiologies, including physiological, pathological and pharmacological causes. Hyperprolactinemia is frequently associated with the use of certain medications. Patients using medications known to cause hyperprolactinemia generally develop a mild form of the condition, and the prolactin level rarely exceeds 100 ng/mL in these cases. We report a case of a 43-year-old woman with an extremely high prolactin level in medication-induced hyperprolactinemia caused by a combination of an antipsychotic (sulpirid) and an antidepressant (paroxetine).

Tissue damage and oxidant/antioxidant balance.

The oxidant/antioxidant balance in healthy tissues is maintained with a predominance of antioxidants. Various factors that can lead to tissue damage disrupt the oxidant/antioxidant balance in favor of oxidants. In this study, disruptions of the oxidant/antioxidant balance in favor of oxidants were found to be a consequence of the over-consumption of antioxidants. For this reason, antioxidants are considered to be of importance in the prevention and treatment of various types of tissue damage that are aggravated by stress.

The role of carnitine on ovariectomy and inflammation-induced osteoporosis in rats.

This study was carried out to assess the protective bone-sparing effect of carnitine with anti-inflammatory properties on chronic inflammation-induced bone loss in ovariectomised (OVX) rats. A total of 64 rats were divided into eight groups. Sixteen rats were sham-operated (SH) while the others were ovariectomised (OVX). (1) SH, (2) sham + inflammation (SHinf), (3) OVX, (4) ovariectomy + inflammation (OVXinf), (5) OVX + CAR1, (6) OVX + CAR2, (7) OVXinf + CAR1, (8) OVXinf + CAR2. After the ovariectomy surgery, all the groups (3, 4, 5, 6, 7, and 8) were allowed to recover for two months. Sixty days after the OVX, inflammation was induced by subcutaneous injections of talc in groups 2, 4, 7, and 8. Group 5 and 7 were given 50 mg/kg CAR; Group 6 and 8 were given 100 mg/kg CAR from the 60th to the 80th day. Serum levels of TNF-α, IL-1, IL-6, OP, and OC were assessed to determine inflammation and to evaluate osteoblastic activity. Bone mineral density (BMD) was assessed by dual energy X-ray absorptiometry in femur bones of rats. Carnitine administration was able to restore BMD up to values measured in both the OVX and the SH animals. The serum levels of TNF-α, IL-1ß, and IL-6 were increased significantly in the OVXinf rats compared with the SH group. In OVX rats, inflammation which is evaluated by serum cytokine levels exacerbated this bone loss, as supported by values of BMD of the total femur. The two different doses of carnitine reduced bone loss and improved inflammatory biomarkers.

Familial Mediterranean fever.

BACKGROUND: The pathogenesis of familial Mediterranean fever (FMF) is unknown, and since no specific laboratory test is yet available, the diagnosis of FMF remains clinical. The purpose of this study was to review clinical characteristics of patients with FMF. METHODS: A total of 96 patients with FMF were evaluated either retrospectively (for those diagnosed before 1997) or prospectively (for those after 1997). RESULTS: The records of 54 male and 42 female patients were studied. All patients were Turks. Family history was positive in 72 patients (75%). Involved site was peritoneum in 73 (76%), joints in 65 (68%), and pleura in 16 (17%). Febrile myalgia occurred in 3 patients (3%), and erysipelas-like skin lesions were observed in 2 (2%). Fever was found in 93 patients (97%). Reactive systemic (AA) amyloidosis was found in 38 patients (40%). CONCLUSIONS: Diagnostic problems persist despite increased understanding of the pathogenesis of FMF. Amyloidosis, the most important complication of FMF, is often seen.

The effects of calcitonin on bone resorption in hyperthyroidism: a placebo-controlled clinical study.

The effects of intranasal calcitonin on bone metabolism were investigated in patients with hyperthyroidism. Urinary deoxypyridinoline (uDPD) levels were measured as a bone turnover marker and lumbar spine (L2) bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA) in 7 patients who were given only antithyroid drug (group 1), in 10 patients who were given antithyroid drug plus intranasal calcitonin (group 2), and in 10 healthy subjects who were given placebo (group 3) at the beginning and at the end of the study. The study continued until the patients with hyperthyroidism became euthyroidic according to the laboratory values. This period was approximately 3 months in groups 1 and 2. At the beginning of the study, uDPD was 21.5 +/- 2.6 nM DPD/mM creatinine in group 1, 23.3 +/- 3.6 nM DPD/mM creatinine in group 2, and 4.3 +/- 1.2 nM DPD/mM creatinine in group 3. uDPD levels measured in groups 1 and 2 were significantly higher than those in group 3 ( P << 0.001). Area BMD Z scores of the patients in groups 1 and 2 were significantly lower than the healthy controls ( P << 0.01, for both). At the end of the study, uDPD was 11.5 +/- 1.6 nM DPD/mM creatinine in group 1, 5.3 +/- 0.6 nM DPD/mM creatinine in group 2, and 4.4 +/- 1.3 nM DPD/mM creatinine in group 3. The levels of uDPD obtained in group 1 were significantly higher than those obtained in groups 2 and 3 ( P << 0.05, for both). The difference between groups 2 and 3 was not significant. Area BMD Z scores measured at the end of the study were found to be increased in groups 1 and 2 compared to early values, but the values were slightly lower than the normal values. In comparison of early and late uDPD values, the decrease in late period was statistically significant in groups 1 ( P << 0.05) and 2 ( P << 0.001). We concluded that bone turnover is high in hyperthyroidism. The treatment of hyperthyroidism decreases the rate of bone turnover, but it is not sufficient to prevent the degradation of bone in hyperthyroidism. The addition of intranasal calcitonin to the treatment of hyperthyroidism prevents the degradation of bone.