Treatment of sialorrhea with botulinum toxin A injection in children

Aims

We aimed to evaluate the effectivity and safety of botulinum toxin A (BT-A) to reduce sialorrhea in children with hypersalivation due to neurological diseases.

Methods

Patients who had a complaint of severe sialorrhea were included in the study. Drooling severity of the patients was evaluated using the classification of Thomas-Stonell and Greenberg. The frequency of aspiration before and after the procedure was recorded. The 24-hour saliva amount and mean duration of two consecutive aspirations were recorded. BT-A was injected into the bilateral parotid and submandibular glands by a otorhinolaryngologist under the guidance of ultrasound guidance (USG).

Results

When patients' mean drooling severity scores, drooling frequency scores, mean duration of two consecutive aspirations, and amount of saliva collected before and after procedure were compared, a statistical significance was observed. One-year hospital records before after and injection were examined and it was observed that after BT-A injection, hospital visits were statistically significantly low (P = 0.017).

Conclusion

BT-A injection into salivary glands is well tolerated, is minimally invasive, has low complication rates and should be performed into both parotid and submandibular glands under USG. Although there is still no consensus on the ideal dose and frequency of injections, it is thought that a dose of 1U/kg/gland can be used with safety in pediatric age groups and the dimensions of the salivary glands and quantitative measurements of the amount of saliva should be utilized. Larger studies involving more patients are required in order to constitute a standard injection protocol.

The association between the lymphocyte-to-monocyte ratio and coronary artery disease severity in patients with stable coronary artery disease

OBJECTIVE

Inflammation plays an important role in the pathogenesis of atherosclerosis. The lymphocyte-to-monocyte ratio (LMR) may reflect a systemic inflammatory status. We investigated the association between the LMR and coronary artery disease (CAD) in patients with stable angina pectoris.

PATIENTS AND METHODS

A total of 221 consecutive patients who had been routinely referred for coronary angiography, for stable angina pectoris and 72 patients with normal coronary arteries were included in the present study. We analyzed the relation between the LMR and the angiographic severity of CAD. The SYNTAX score (SxS) was used for assessing the severity of coronary atherosclerosis.

RESULTS

The neutrophil-to-lymphocyte ratio (N/L ratio), platelet size distribution width (PDW), neutrophil and uric acid levels were significantly higher in the stable angina pectoris group than in the control group. The LMR was significantly lower in the stable angina pectoris group than in the control group (4.5±3.2 vs. 6±2.9, p < 0.001). The MPV/L ratios were similar in both groups. Patients with elevated SYNTAX scores (>32) had lower LMR values (3.2±1.5 vs. 4.6±3, p = 0.002). The monocyte count/HDL-C ratio (MHR) was significantly higher in patients with stable CAD than in the control group (0.015±0.008 vs 0.009±0.004, p < 0.001); however, it was similar in the higher SYNTAX score (>32) and lower SYNTAX score groups (0.018±0.007 vs. 0.014±0.008, p = 0.056). Using multivariate logistic regression analysis, we found that only the LMR was an independent predictor of the high SYNTAX scores in patients with stable angina pectoris.

CONCLUSIONS

 The LMR, an inexpensive and easily measurable laboratory variable, is significantly associated with the presence of CAD and high SYNTAX scores in patients with stable angina pectoris.

A randomized study to evaluate post-dural puncture headache after cesarean section: Comparison with median and paramedian approaches

Background

Although the most popular anesthesia technique for cesarean is spinal anesthesia, its most common complication is post-dural puncture headache (PDPH).

Aim

We aimed to determine the effect of median and paramedian approaches during spinal anesthesia on PDPH in patients undergoing cesarean section.

Subjects and Methods

200 pregnant women between the ages of 19-45 years, ASA physical status II, scheduled to undergo elective cesarean section under spinal anesthesia, were studied. The patients were randomized into two groups: Group M; (n = 100) spinal anesthesia with the median approach, Group PM; (n = 100) spinal anesthesia with paramedian approach. The patients were questioned for the possible occurrence of PDPH on the first, third and seventh postoperative days. A telephone follow-up call was used if the hospital stay was shorter than seven days. Post-dural puncture headache was evaluated according to the International Classification of Headache Disorders (ICHD-III) diagnostic criteria. Normally distributed data were summarized using mean and standard deviation. Skewed data were summarized using median (range).

Results

A total of 200 patients completed the study. There were no statistically different between the groups by comparing the incidence and characteristics of PDPH (32% vs. 28%, P = 0.548). Most patients rated their pain intensity during PDPH as mild to moderate in both groups (p = 0.721). PDPH onset time was 2 (1-4) days in Group PM versus 3 (1-7) days in Group M (p = 0.173). No patient needed for epidural blood patch in both groups.

Conclusions

Spinal anesthesia with a median or paramedian approach at cesarean section has no effect on the incidence of PDPH, but we believe that there has been a need for further studies with larger or different patient populations.

Serum leptin levels and GHR-d3/fl gene polymorphism in acromegalic patients with thyroid nodules

BACKGROUND

Acromegaly is a rare and serious syndrome that is commonly associated with pituitary neoplasms. Thyroid multinodular disease is a common finding in acromegaly. Leptin is a polypeptide hormone, and studies have shown that it can increase cell proliferation and inhibit apoptosis.

OBJECTIVES

The aim of the study was to determine the relationship of serum leptin levels with certain blood parameters and determine if growth hormone receptor (GHR)-d3/fl gene polymorphism is associated with thyroid nodules in acromegalic patients.

MATERIAL AND METHODS

A total of 24 acromegalic patients with or without thyroid nodules were included in the study. Gene polymorphisms and blood parameters were examined.

RESULTS

A marked increase was observed in serum leptin concentration in acromegalic patients with thyroid nodules compared to patients without them (p < 0.05). GH levels were lower in patients without nodules than in patients with nodules (p < 0.05). Blood glucose levels were higher in patients with nodules compared to those without them (p < 0.05), and the presence of thyroid nodules was associated with decreased blood low-density lipoprotein (LDL) levels compared to patients without nodules (p < 0.05). A significant relationship was observed between growth hormone receptor (GHR)-d3/fl gene polymorphism and leptin levels in acromegalic patients with thyroid nodules (p < 0.001).

CONCLUSIONS

These data from acromegalic patients indicate that thyroid nodules are associated with increased serum leptin, GH and blood glucose levels and with decreased LDL levels. GHR-d3/fl gene polymorphism status was strongly related to higher leptin levels.

Vitamin-D Receptor (VDR) Gene Polymorphisms (TaqI, FokI) in Turkish Patients with Hashimoto's Thyroiditis: Relationship to the Levels of Vit-D and Cytokines

BACKGROUND

Hashimoto's thyroiditis (HT) is a common autoimmune disease. Vitamin D is an important regulator of immune system. It has been shown in several studies that vitamin D prevents the development of lots of autoimmune diseases. There are some studies that prove vitamin D receptor (VDR) gene polymorphism increases the risk of Hashimoto's thyroiditis. In this study, we aimed to investigate the association between HT and level of 25(OH)D3, IL-2, IL-4, IL-5, TNF-α and IFN-γ and VDR FokI and TaqI gene polymorphism. Moreover, to find out whether low levels of vitamin D affect HT pathogenesis over inflammatory parameters.

METHODS

We performed a case-control study that included 136 cases with HT (49 euthyroid, 49 subclinical hypothyroid, 38 hypothyroid patients) and 50 healthy control. Serum levels of 25(OH)D3, glucose, insulin, parathyroid hormone, calcium, phosphorus, alkaline phosphatase were measured and IL-4, IL-5, TNF-α, IFN-γ analysis were performed with ELISA kits in all 186 subjects. Genetic analysis for VDR FokI and TaqI gene polymorphisms were done by RFLP in all subjects.

RESULTS

Mean serum 25(OH)D levels were 14.88±8.23 ng/ml in patient with HT and 15.52±1.34 ng/ml in healthy controls. There were no statically significant differences between the groups in terms of vitamin D levels (P=0.977). Prevalence of vitamin D insufficiency in HT cases was significantly higher than controls (p=0.02). Although serum IL-2, IL-4, TNF-α and IFN-γ were significantly higher in HT patients, there were no significant differences regarding IL-5 levels. Significant differences were observed between the groups regarding the genotype of TaqI but no differences regarding FokI genotype.

CONCLUSION

Vitamin D insufficiency is associated with HT. There is a relationship between VDR TaqI gene polymorphism and HT. Although vitamin D levels are low in both patient and control group, detection of high level of inflammatory parameters in HT group makes us think that low level of vitamin D does not affect HT pathogenesis over these parameters.

Adiponectin and Cardiac Hypertrophy in Acromegaly

BACKGROUND

Adiponectin is an adipocytes-derived hormone which has been shown to possess insulin-sensitizing, antiatherogenic, and anti-inflammatory properties. In acromegaly, the data on adiponectin is contradictory. The relationship between adiponectin levels and cardiac parameters has not been studied.

OBJECTIVES

The aim of this study was to find out how adiponectin levels were affected in acromegalic patients and the relationship between adiponectin levels and cardiac parameters.

MATERIAL AND METHODS

We included 30 subjects (15 male, 15 female), diagnosed with acromegaly and 30 healthy (10 male, 20 female) subjects. Serum glucose, insulin, GH, IGF-1 and adiponectin levels were obtained and the insulin resistance of the subjects was calculated. Echocardiographic studies of the subjects were performed.

RESULTS

We determined that adiponectin levels were significantly higher in the acromegalic group than the control group. In the acromegalic group, there was no statistically significant relation between serum adiponectin and growth hormone (GH), or insulin-like growth factor-1 (IGF-1) levels (p = 0.3, p = 0.1). We demonstrated that cardiac function and structure are affected by acromegaly. IVST, PWT, LVMI, E/A ratio, DT, ET, IVRT, VPR, and LVESV values were increased and the results were statistically significant. In the acromegalic group, adiponectin levels were positively related with left ventricle mass index (LVMI) but this correlation was found to be statistically weak (p = 0.03). In our study, there was a positive correlation between VAI and LVM. We also could not find any correlation between VAI and adiponectin levels.

CONCLUSIONS

Although insulin resistance and high insulin levels occur in active acromegaly patients, adiponectin levels were higher in our study as a consequence of GH lowering therapies. Our study showed that adiponectin levels may be an indicator of the cardiac involvement acromegaly. However, the usage of serum adiponectin levels in acromegalic patients as an indicator of cardiac involvement should be supported with other, wide, multi-centered studies.

Impact of QRS morphology on heart rate turbulence and heart rate variability after cardiac resynchronization therapy in patients with heart failure

OBJECTIVE

Impairment of heart rate turbulence (HRT) and heart rate variability (HRV) are associated with poor prognosis in chronic heart failure (CHF). Although previous studies have demonstrated that patients with a left bundle branch block (LBBB) have a better outcome with cardiac resynchronization therapy (CRT), the effect of QRS morphology on HRV and HRT is not known. We aimed to evaluate the effect of QRS morphology on HRV and HRT after CRT implantation in patients with CHF.

PATIENTS AND METHODS

Patients who had been implanted a CRT device with cardioversion-defibrillation feature were included to the study. Forty-three patients with LBBB (group 1) were compared with 21 patients without LBBB (group 2). HRV and HRT parameters were compared before and one month after CRT implantation.

RESULTS

We compared the echocardiographic and electrocardiographic changes in both groups after CRT. Cardiac output (CO) was found to be significantly much more increased in group 1 (1.1 ± 0.4 vs. 0.6 ± 0.4, p = 0.001). Similarly, except SDNN and LF, all HRT and HRV parameters were significantly changed in the patients with LBBB (TO 1.4 ± 0.3 vs. 1.2 ± 0.2, p = 0.001; TS -1.8 ± 0.7 vs. -0.9 ± 0.7, p = 0.001; RMSSD -15.7 ± 9.9 vs. -6.3 ± 6.2, p = 0.001; PNN50 -7.0 ± 4.6 vs. -1.7 ± 1.1, p = 0.001; HF -13.3 ± 6.7 vs. -4.3 ± 3.5, p = 0.001; LF/HF 1.9 ± 0.4 vs. 1.5 ± 0.2, p = 0.001) compared to those without LBBB. Lineer regression analysis showed that the CO (β = 0.2, t = 2.8, p = 0.007) and QRS configuration (β = 0.6, t = 0.5, p = 0.001) were independent parameters affecting TO.

CONCLUSIONS

HRV and HRT are improved after CRT but these improvements are more remarkable in patients with LBBB. CO, QRS configuration (but not duration) were two independent parameters affecting TO, LF and LF/HF ratio after CRT.

Real-life safety and efficacy of vildagliptin as add-on to metformin in patients with type 2 diabetes in Turkey--GALATA study

OBJECTIVE

To evaluate tolerability/safety and the efficacy of the combination of vildagliptin plus metformin in a real-life population of patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

This multicenter, single-arm, 6 month, observational, prospective cohort study was conducted at 39 centers across Turkey. T2DM patients on vildagliptin and metformin for ≤4 weeks were enrolled regardless of their previous antidiabetic therapy.

MAIN OUTCOME MEASURES

Efficacy was evaluated by measuring hemoglobin A1c (HbA1c) levels. Tolerability/safety parameters evaluated included hypoglycemic events, gastrointestinal events, peripheral edema and weight gain.

RESULTS

This study enrolled 665 patients with a mean ± standard deviation (SD) age of 55.1 ± 10.2 years and female predominance (n = 394, 59.2%). Safety was assessed in all enrolled patients. Hypoglycemia was reported in 10 (1.5%) patients (95% confidence interval = 0.8-2.7%). Efficacy was assessed in 289 (43.5%) patients treated for 6 ± 1 months; these patients showed a mean decrease in HbA1c of 0.8% from baseline value of 7.8% (p < 0.001). The percentages of patients who achieved HbA1c targets of ≤6.5% and ≤7.0% were significantly increased, from 10.7% to 33.6% and from 22.1% to 52.6%, respectively (p < 0.001 each). The decrease in HbA1c was independent of baseline HbA1c (≤8% vs. 8-10% vs. ≥10%), age (≤65 vs. >65 years) and body mass index (<30 vs. ≥30 kg/m(2)) (p < 0.001 each). In total, 136 adverse events (AEs) were observed in 71 (10.7%) patients; 10 (1.5%) patients experienced hypoglycemia and gastrointestinal AEs were most commonly reported (n = 29, 4.4%).

CONCLUSIONS

In a 'real-life' setting, the vildagliptin and metformin combination was associated with significant improvements in reaching target HbA1c levels, even in elderly and obese patients with T2DM. Moreover, vildagliptin and metformin demonstrated a good overall tolerability/safety profile.

Relationship of apelin, procalcitonin, and fetuin-A concentrations with carotid intima-media thickness in acromegaly

Background

Acromegaly is characterized by excess growth hormone and insulin-like growth factor-1 concentrations. There is conflicting evidence as to whether acromegaly is associated with an increased risk of atherosclerosis. Apelin is an adipose tissue-derived peptide that may be associated with hyperinsulinemia. Fetuin-A is a hepatocyte produced plasma glycoprotein that has an important role as a calcification inhibitor. The aim of this study was to examine apelin, fetuin-A, and procalcitonin concentrations and to assess their relationship with carotid intima medial thickness (cIMT) in subjects with acromegaly.

Methods

Apelin, fetuin-A, and procalcitonin serum concentrations were measured in 37 (20 inactive and 17 active) subjects with acromegaly and 30 control subjects, along with carotid intima medial thickness.

Results

The concentrations of apelin, fetuin-A, and procalcitonin were increased in subjects with acromegaly. There were significant correlations between apelin, fetuin-A, and procalcitonin in subjects with acromegaly. Carotid intima medial thickness values were similar between control subjects and subjects with acromegaly.

Conclusions

Carotid intima medial thickness was not increased in subjects with acromegaly. It is possible that the increased apelin and fetuin-A concentrations observed play a protective role against the development of atherosclerosis in subjects with acromegaly.

Significance of IMP3, Nucleophosmin, and Ki-67 Expression in Papillary Thyroid Carcinoma

The purpose of our study was to investigate the diagnostic value of expression of IMP3, nucleophosmin, and correlation of these markers with Ki-67 proliferation index in papillary thyroid carcinoma and benign neoplasms of thyroid gland. The aim was also to investigate whether there is a difference between papillary and micropapillary carcinomas with regard to clinicopathologic parameters beside IMP3, nucleophosmin, and Ki-67 proliferation index. It was concluded that IMP3 and nucleophosmin cannot be a routine diagnostic marker for discrimination of papillary carcinomas and benign lesions. IMP3 positive staining was quite scarce in IMP3 positive papillary carcinomas although specifity of IMP3 is 100%. A statistically significant correlation was not detected between nucleophosmin, IMP-3, and Ki-67 proliferation index. A statistically significant correlation was found between tumor size, lymphovascular embolism, and Ki-67 proliferation index. There was also significant correlation between tumor size and lymphovascular embolism.

Dehydroepiandrosterone sulfate levels in Turkish obese patients

PURPOSE

Obesity is well known to be linked to higher morbidity and mortality. Elevated plasma levels of free dehydroepiandrosterone (DHEA) are associated with reduced obesity and more limited accumulation of abdominal body fat. In contrast, the relationship between the DHEA sulfate ester (DHEAS) and adiposity is inconsistent and contradictory.

METHODS

The aim of this study was to compare DHEAS levels in obese Turkish individuals, 37 men and 246 women. A variety of fatness, hormone, and blood parameters were measured.

RESULTS

Statistically significant differences were found between male and female individuals with respect to weight, waist circumference, fat %, insulin, and DHEAS levels.

CONCLUSIONS

We found that in the Turkish population, while a correlation between obesity parameters and DHEAS levels exists in both female and male individuals, DHEAS levels are significantly higher in obese male individuals than in obese female individuals.

Noninvasive indicators of atherosclerosis in subclinical hypothyroidism

INTRODUCTION

Cardiovascular system is rich in thyroid hormone receptors and is one of the major sites of action for thyroid hormones. However, the effect of subclinical hypothyroidism (SCH) on atherosclerosis has not been cleared yet.

MATERIALS AND METHODS

SCH is defined as high thyroid-stimulating hormone (TSH) levels in the presence of normal serum T4 and T3 levels. A total of 32 patients with SCH and 29 controls were included in the study. Carotid intima-media thickness, flow-mediated dilatation, and aortic distensibility were compared between the groups.

RESULTS

FMD was lower in patients with SCH than in controls. GTN-induced vasodilatation was similar in the patients with SCH and controls. There was no statistically significant difference between the patients with SCH and controls with respect to CIMT and aortic distensibility.

CONCLUSION

SCH is associated with endothelial dysfunction as established by FMD. Inconsistent results of CIMT and aortic stiffness can be explained by these parameters being measures of structural changes whereas FMD is a dynamic measure that reflects the impact of both acute and chronic influences on endothelial function.

Resistin and leptin levels in acromegaly: lack of correlation with echocardiographic findings

PURPOSE

To find out how resistin and leptin levels were affected in patients with acromegaly and whether there is a relation between resistin levels and cardiac parameters. We also aimed to investigate whether resistin and leptin may be a link between insulin resistance and cardiac functions as well as these affected cardiac functions in the patients with acromegaly.

METHODS

We included 30 subjects (15 men and 15 women) who had a diagnosis of acromegaly and 30 healthy (10 men and 20 women) subjects. Serum glucose, insulin, growth hormone, insulinlike growth factor 1 (IGF-1), resistin, and leptin levels were obtained, and insulin resistance of subjects were calculated. Echocardiographic studies of the subjects were performed.

RESULTS

Resistin levels of the patients with acromegaly were found lower than controls. This difference was statistically significant (P = 0.001). Leptin levels were lower in the patients with acromegaly than in the controls, but this difference was not statistically significant. Resistin and leptin levels were not correlated with growth hormone, IGF-1, and with insulin-like growth factor binding protein 3 levels. Homeostasis model assessment of insulin resistance was positively correlated with resistin levels. (P = 0.03; r = 0.531) but not correlated with leptin levels. There was a positive correlation between body mass index and leptin levels in the patients with acromegaly (P = 0.007; r = 0.482). Interventricular septum thickness, posterior wall thickness, left ventricle mass index, peak early mitral inflow velocity-peak late mitral inflow velocity ratio, deceleration time, ejection time, isovolumetric relaxation time, velocity propagation, and left ventricular end-systolic volume values were significantly greater in the patients with acromegaly. Leptin levels in the acromegalic patients were not correlated with any of them.

CONCLUSIONS

We found biventricular hypertrophy and impairment of diastolic and systolic function in the patients with acromegaly. We conclude that changes in resistin and leptin levels are unlikely to account for the insulin resistance of acromegaly. They do not also seem to be contributing factors of cardiovascular changes in patients with acromegaly.

Prevalence and risk factors for methicillin-resistant Staphylococcus aureus colonization in a diabetic outpatient population: a prospective cohort study

BACKGROUND

Diabetes mellitus is a risk factor for methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection. We attempted to determine the prevalence and risk factors for MRSA colonization in a population of outpatients with diabetes.

METHODS

This prospective cohort study enrolled patients with diabetes. Anterior nares cultures were obtained from patients with diabetes admitted to outpatient endocrinology and metabolism clinics, and risk factors for MRSA colonization were analyzed.

RESULTS

Out of the 304 patients evaluated, 127 (41.9%) were colonized with S aureus and 30 (9.9%) were colonized with MRSA. Overall, 23.6% of all S aureus isolates were MRSA. In multivariate analysis, factors independently associated with an increased risk of MRSA colonization included the presence of connective tissue disease (odds ratio, 7.075; 95% confidence interval, 2.157-23.209; P = .001) and insulin therapy (odds ratio, 3.910; 95% confidence interval, 1.652-9.251; P = .002).

CONCLUSIONS

The prevalence of MRSA colonization in our sample of diabetic outpatients was 9.9%. Independent risk factors for MRSA colonization were the presence of connective tissue disease and insulin use. A better understanding of the epidemiology and risk factors for nasal MRSA colonization in the persons with diabetes may have significant implications for the treatment and prevention of MRSA infections.