Comparison of primary octreotide-lar and surgical treatment in newly diagnosed patients with acromegaly.

OBJECTIVE: The primary aim of the study was to compare the efficacy of Oct-LAR and surgery in terms of controlling IGF-1 and GH levels and tumour volumes. The second aim was to compare two primary treatment modalities in terms of side effects such as pituitary insufficiency, cholelithiasis, metabolic parameters and the effect on quality of life (QoL). DESIGN: The study was a randomized, prospective study. PATIENTS: The 22 patients were consecutively randomized to Oct-LAR and surgical treatment groups. RESULTS: Baseline serum IGF-1 level, tumour volume and GH levels were comparable in the Oct-LAR and surgery groups. No significant differences were detected between the Oct-LAR and the surgery groups in terms of IGF-1 and GH levels at the 3rd and 6th months, but at 12th month, preglucose GH was found to be lower in the surgical treatment group. IGF-1 control and complete biochemical response rates were found to be 27% and 64%, in the Oct-LAR and surgical treatment groups, respectively. The mean percentage of tumour volume reduction was found to be 26%, 30% and 31% in the Oct-LAR group vs 64%, 74% and 79% in the surgery group at the 3rd, 6th and 12th months, respectively. CONCLUSION: Primary surgical treatment seems to be slightly more effective than Oct-LAR in terms of biochemical response and IGF-1 control, besides tumour volume reduction, in patients with acromegaly with noninvasive tumours. Oct-LAR is associated with more side effects such as cholelithiasis and glucose metabolism disorders and is more expensive.

Increased micronucleus, nucleoplasmic bridge, nuclear bud frequency and oxidative DNA damage associated with prolactin levels and pituitary adenoma diameters in patients with prolactinoma.

Prolactinoma is the most common pituitary tumor. Most pituitary tumors are benign, but they often are clinically significant. We investigated cytokinesis-block micronucleus cytome (CBMN cyt) assay parameters and oxidative DNA damage in patients with prolactinoma to assess the relations among age, prolactin level, pituitary adenoma diameter and 8-hydroxy-2'-deoxyguanosine (8-OHdG) level in patients with prolactinoma. We investigated 27 patients diagnosed with prolactinoma and 20 age- and sex-matched healthy controls. We measured CBMN cyt parameters and plasma 8-OHdG levels in peripheral blood lymphocytes of patients with prolactinoma and controls. The frequencies of micronucleus (MN), nucleoplasmic bridge, nuclear bud, apoptotic and necrotic cells, and plasma 8-OHdG levels in patients with prolactinoma were significantly greater than controls. MN frequency was correlated positively with age, prolactin levels and pituitary adenoma diameters in patients with prolactinoma. The increased chromosomal and oxidative DNA damage, and the positive correlation between MN frequency, prolactin levels and pituitary adenoma diameters may be associated with increased risk of cancer in patients with prolactinoma, because increased MN frequency is a predictor of cancer risk.

Patient with Weismann-Netter and Stuhl (toxopachyosteosis) syndrome with communicant hydrocephalus and arachnoid cyst.

Weismann-Netter and Stuhl (toxopachyosteosis) syndrome is a rare bone disease, manifesting with anterior bowing of the tibiae, short stature and mild mental retardation. We report a patient with Weismann-Netter and Stuhl syndrome with an unusual manifestation communicant hydrocephalus and arachnoid cyst.

Thyroid function tests in the newborn infants of preeclamptic women.

The purpose of this study was to identify possible changes in thyroid functions in newborn infants of preeclamptic women. Fifteen neonates (nine boys and six girls) of preeclamptic women and 17 healthy neonates (nine boys and eight girls) for the control group were included in the study. Serum thyroid-stimulating hormone (TSH), total triiodothyronine (TT3) and total thyroxine (TT4) levels and thyroid gland volumes were determined in both groups. Serum TSH and TT4 levels were not statistically different between the two groups. However, serum TT3 level was 79.22 +/- 40.19 ng/dl in the study group and 40.00 +/- 15.99 ng/dl in control subjects (p < 0.01). The mean right, left and total thyroid volumes were 1.3 +/- 1.2 ml, 1.2 +/- 1.1 ml and 2.4 +/- 2.3 ml in the study group and 0.6 +/- 0.2 ml, 0.6 +/- 0.2 ml, and 1.1 +/- 0.4 ml in the control group, respectively (p < 0.05). The mean thyroid volume/body weight was 0.9 +/- 0.09 ml/kg in the study group and 0.3 +/- 0.06 ml/kg in the control group (p < 0.05). In conclusion, we would like to stress that preeclampsia might be a cause of fetal and neonatal thyroid enlargement and elevated serum TT3 level.

The role of diffusion-weighted magnetic resonance imaging in intracranial cystic lesions.

We aimed to define the diffusion-weighted magnetic resonance (MR) imaging features of intracranial cystic lesions and to investigate possible special features for the differential diagnosis. One hundred and twenty patients with intracranial cystic lesions were included in the study. There were 29 arachnoid cysts, eight epidermoid cysts, 34 primary tumors, 18 abscesses, 29 metastases and two hydatid cysts. Echo-planar diffusion-weighted MR imaging was obtained in addition to conventional cranial MR scans. The morphologic features of the cystic portion and the wall of the cyst and signal intensities on diffusion-weighted images were evaluated. All abscesses and epidermoid cysts were hyperintense on diffusion-weighted images. Arachnoid cysts, hydatid cysts, primary tumors, and metastases were hypointense except five cystic tumors. These five primary or metastatic necrotic tumors showed high signal intensity on diffusion-weighted images due to hemorrhage or superinfection. The walls of the cystic tumors were usually hyperintense on diffusion-weighted images in contrast to the wall of the abscesses, which were iso-hypointense. This was a statistically significant finding for the differentiation between tumors and abscesses (p<0.05). Diffusion-weighted MR imaging is a useful technique for the evaluation of the intracranial cystic lesions and provides additional beneficial information to conventional MR imaging. However, the presence of hemorrhage and superinfection of the tumors may cause a signal increase that results in misinterpretetations. In these cases, the appearance of tumor wall may be useful for differentiating abscesses from tumors.

Evaluation of the hypothalamic-pituitary-adrenal axis in untreated patients with polymyalgia rheumatica and healthy controls.

OBJECTIVE: To explore the hypothalamic-pituitary-adrenal (HPA) axis in polymyalgia rheumatica (PMR). SUBJECTS AND METHODS: This study was carried out on 13 female patients with PMR who were diagnosed according to the criteria of Chuang et al (Ann Intern Med 1982;97:672-80) and 10 healthy female subjects in the Department of Physical Medicine and Rehabilitation, Erciyes University Medical School. In the patient and control groups, basal cortisol, adrenocorticotrophic hormone (ACTH), 17alpha-hydroxyprogesterone (17-OHP), 11-deoxycortisol (11-S), dehydroepiandrosterone sulfate (DHEAS), androstenedione (A), prolactin (PRL), and thyroid stimulating hormone (TSH) levels were measured. Cortisol, 17-OHP, 11-S and A responses after the low-dose (1 microg) ACTH stimulation test and cortisol and DHEAS responses after the dexamethasone suppression test were detected. We also measured acute phase reactants including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). RESULTS: Age and sex characteristics were similar in both patient and control groups. The levels of basal hormones including cortisol, ACTH, 17-OHP, 11-S, DHEAS, A, prolactin and TSH and cortisol and DHEAS levels after the low-dose dexamethasone suppression test were not significantly different between the patient and control groups. However, cortisol/CRP and ACTH/CRP ratios were significantly lower in the patient group. Cortisol and DHEAS responses after the low-dose dexamethasone suppression test were not significantly different between the patient and control groups. Cortisol response after the 1 microg ACTH stimulation test was significantly lower in the patients than in the control group, but there were no significant differences in 17-OHP, 11-S and A responses between the patients and controls. Correlation analysis showed that there was a negative correlation between peak cortisol levels after the ACTH stimulation test and disease duration, and also a positive correlation between cortisol levels after the low-dose dexamethasone suppression test and acute phase reactants including CRP and ESR. CONCLUSION: A significant low cortisol response to ACTH stimulation was detected in the patients with PMR. In addition, a negative correlation after the 1 microg ACTH stimulation test between peak cortisol levels and disease duration was detected. These findings may indicate hypoactivation in the HPA axis.

Successful surgical excision of juvenile-type spinal arteriovenous malformation in two stages following partial embolization.

The case of a 24-year-old man with a juvenile-type spinal arteriovenous malformation is reported. Spinal angiography and magnetic resonance image revealed a juvenile (Type III) AVM at the cervical spine. This spinal malformation was successfully resected with a posterior and anterior surgical approach in two stages following partial embolization.

Magnetic resonance imaging findings in chronic carbon monoxide intoxication.

PURPOSE: To define the cranial magnetic resonance imaging (MRI) features of the chronic stage of carbon monoxide (CO) poisoning in patients with and without neuropsychiatric sequelae. MATERIAL AND METHODS: Eight patients who had neither symptoms nor neurological sequelae and eight patients with neuropsychiatric sequelae were included in the study. Patients aged between 9 to 57 (mean 32.2 years). All patients had been comatose at initial admittance and awoke after normobaric 100% oxygen therapy within 1-7 days. In this study, the patients were being examined with routine cranial MRI between 1 and 10 years (mean 3.4 years) after exposure to CO. RESULTS: The most common finding was bilateral symmetric hyperintensity of the white matter, which was more significant in the centrum semiovale, with relative sparing of the temporal lobes and anterior parts of the frontal lobes on T2-weighted and FLAIR images in all patients. Cerebral cortical atrophy was seen in 10 patients; mild atrophy of cerebellar hemispheres in 8; and vermian atrophy in 11. Corpus callosum was atrophic in one patient. Bilateral globus pallidus lesions were seen in three patients. The lesions were hypointense on T1-weighted images and hyperintense on T2-weighted and FLAIR images. CONCLUSION: Patients with severe CO intoxication may develop persistent cerebral changes independently of their neuropsychiatric findings in the chronic stage. They may present with characteristic MRI findings as described here, even if asymptomatic. The history of CO exposure is therefore helpful for recognizing and interpreting the MRI findings of chronic stage CO intoxication.

Changes in the size of adrenal glands in acute pulmonary tuberculosis with therapy.

Adrenal glands may be involved during both acute and chronic tuberculosis. They are enlarged in acute pulmonary tuberculosis. We aimed to investigate the changes in adrenal size in acute pulmonary tuberculosis before and after therapy in a prospective study. Eleven hospitalized patients with newly diagnosed sputum positive pulmonary tuberculosis were studied. Basal cortisol levels were measured in the patients before and after the therapy. Cortisol levels were also measured 30 and 60 min after Synacthen (250 micrograms i.v.) injection in the patients before the therapy. The size of the adrenal glands was measured by computerized tomography. The maximum width perpendicular to the long axis of the body of the gland, maximum width of the medial and lateral limbs and the length of the adrenals were measured. All measurements were done before and after the eight-month anti-tuberculosis therapy. All 11 patients had an intact adrenal cortisol reserve. Both the width and length of the right and left adrenal glands were significantly greater before the therapy than after the therapy. We conclude that adrenal enlargement demonstrated by computerized tomography in acute pulmonary tuberculosis is reduced after appropriate therapy.

Mesenteric, omental, and retroperitoneal cysts in children.

OBJECTIVE: To report our experience in the management of mesenteric, omental, and retroperitoneal cysts. DESIGN: Retrospective study. SETTING: University department of paediatric surgery, Turkey. SUBJECTS: 10 children with mesenteric, omental, and retroperitoneal cysts. INTERVENTIONS: Laparotomy in all cases. MAIN OUTCOME MEASURES: Mode of presentation, imaging techniques, surgical intervention, histological examination, morbidity, and recurrence. RESULTS: The main presenting symptoms were abdominal distension and pain. A palpable abdominal mass was detected in 4 patients. Preoperative ultrasonography was done in 8 patients and showed a cystic mass in 7. All patients underwent laparotomy-6 as emergencies because of acute abdominal findings. The cysts were located in the small bowel mesentery in 6, in the retroperitoneum in 2, and in the omentum and the mesosigmoid in another 2. Operations included complete excision of the cyst in 5 and complete excision with intestinal resection in the other 5. There was only one recurrence of a retroperitoneal cyst that needed a second operation. CONCLUSION: Early recognition and appropriate treatment of these cysts are associated with a good prognosis, but long term follow-up is advisable because of the possibility of recurrence.

Renal hydatid cysts and the evaluation of their radiologic images.

OBJECTIVE: We present our experience with the various sonographic and CT findings observed in patients with hydatid disease involving the kidney. The imaging characteristics of various echinococcal cysts were evaluated comparatively to offer a diagnostically better explanation for the radiologic images and to assist the urologist in defining the nature of the cyst and its content preoperatively. Renal involvement is extremely rare in patients with hydatid disease. METHODS: The clinical and radiological features in 17 patients with renal hydatid disease are described. Two patients (4 and 28 years old) had renal colic with passage of debris in urine (hydatiduria). Five males and twelve females were 4-61 years old (mean 37 years). Their histories, physical findings and imaging procedures were evaluated. Plain abdominal radiographs were taken in 17 patients. RESULTS: Plain film showed calcified mass compressing the pelvicalyceal system and/or ureter in 10 cases. Sonography showed typical features of echinococcal cysts in 14 cases, especially in the liver and spleen. CONCLUSIONS: Sonography demonstrates the internal cystic content better. When daughter cysts are present, CT establishes the diagnosis. CT scan provides further information on the affected organ and involvement of other organs, calcification of the cyst wall and density. The diagnosis was suggested preoperatively in all patients, and confirmed surgically in 12 patients. Eight total nephrectomies and four partial nephrectomies were performed. The others are being followed up.

The hormonal and radiological evaluation of adrenal glands, and the determination of the usefulness of low dose ACTH test in patients with renal amyloidosis.

Amyloidosis is a multisystem disease which may cause organ loss. Renal involvement is the most common clinical problem in amyloidosis, however involvement of endocrin organs is possible. In this study to assess adrenocortical function and to evaluate the usefulness of low dose ACTH test in patients with renal amyloidosis, we determined cortisol, 17-hydroxyprogesteron (17-OHP) and 11-deoxycortisol (11-DOC) responses to both 1 microg and 250 microg Synacthen. We also determined the size of adrenal glands radiologically by using computerized tomography. Twenty one patients with renal amyloidosis and 16 healthy subjects for hormonal evaluation, and 20 patients with renal amyloidosis and 22 healthy subjects for radiologic evaluation were included in the study. In four patients (19%) peak serum cortisol levels following stimulation with the low dose of Synacthen were less than 20 microg/dL (550 nmol/L). Two of them had also subnormal cortisol response to the 250 microg Synacthen stimulation test. Basal and stimulated levels of 11-DOC were lower than those of control values (p=0.000 and p<0.01 respectively). The mean 11-DOC responses to stimulation with 1 microg Synacthen were also significantly lower than the values obtained after the simulation with 250 microg Synacthen (p<0.01 and p=0.000). Cortisol responses to the stimulation with 250 microg Synacthen were also lower than the control responses (p<0.05). 17-OHP responses were similar to the control values in both tests. In the radiological evaluation the mean maximum width of right adrenal glands and the mean anterior and maximum width of left adrenal glands were significantly greater in the patient group (p<0.01). In conclusion, adrenal involvement and adrenal insufficiency is common in amyloidosis. Low 11-DOC levels in amyloidosis is a new finding and further detailed studies is required to explain its cause.

Investigation of the hypothalamo-pituitary-adrenal axis (HPA) by 1 microg ACTH test and metyrapone test in patients with primary fibromyalgia syndrome.

Primary fibromyalgia syndrome (PFS) is characterized by widespread chronic pain that affects the musculoskeletal system, fatigue, anxiety, sleep disturbance, headache and postural hypotension. The pathophysiology of PFS is unknown. The hypothalamic-pituitary-adrenal (HPA) axis seems to play an important role in PFS. Both hyperactivity and hypoactivity of the HPA axis have been reported in patients with PFS. In this study we assessed the HPA axis by 1 microg ACTH stimulation test and metyrapone test in 22 patients with PFS and in 15 age-, sex-, and body mass index (BMI)- matched controls. Metyrapone (30 mg/kg) was administered orally at 23:00 h and blood was sampled at 08:30 h the following morning for 11-deoxycortisol. ACTH stimulation test was carried out by using 1 microg (iv) ACTH as a bolus injection after an overnight fast, and blood samples were drawn at 0, 30 and 60 min. Peak cortisol level (659.4 +/- 207.2 nmol/l) was lower in the patients with PFS than peak cortisol level (838.7 +/- 129.6 nmol/l) in the control subjects (p < 0.05). Ten patients (45%) with PFS had peak cortisol responses to 1 microg ACTH test lower than the lowest peak cortisol detected in healthy controls. After metyrapone test 11-deoxycortisol level was 123.7 +/- 26 nmol/l in patients with PFS and 184.2 +/- 17.3 nmol/l in the controls (p < 0.05). Ninety five percent of the patients with PFS had lower 11-deoxycortisol level after metyrapone than the lowest 11-deoxycortisol level after metyrapone detected in healthy controls. We also compared the adrenal size of the patients with that of the healthy subjects and we found that the adrenal size between the groups was similar. This study clearly shows that HPA axis is underactivated in PFS, rather than overactivated.