Prenatal ultrasound and magnetic resonance imaging depiction of a small sublingual ranula

Prenatal diagnosis of a congenital ranula has rarely been reported. We describe the case of a small ranula depicted on prenatal sonogram and magnetic resonance imaging, in which we could confirm the intact airway. Although the size of the ranula noted in our fetus was the smallest among the cases reported in the English literature, both of these imaging modalities clearly presented typical diagnostic features present on both ultrasound and magnetic resonance imaging.

Free peritoneal cyst with histologic properties of amniotic epithelium observed in a woman pregnant with twins

We report an interesting case of a free peritoneal cyst in a woman pregnant with twins. As far as we know, a cyst with histologic properties similar to the metaplastic stratified squamous epithelium of the amnion has not been reported. A 20-year-old Japanese woman pregnant with twins underwent cesarean section at 29 weeks of gestation. A simple serous cyst 5 cm in diameter was found at excavatio vesicouterina. The cyst was not attached to the surrounding organs, and was located independent of any other tissues in the patient's abdominal cavity. Histologic examination revealed that the cyst wall was composed of three major layers (epithelium, mesenchyme and mesothelium) with no vessels. Immunohistochemical staining with human chorionic gonadotropin (HCG), cytokeratins, vimentin, placental alkaline phosphatase (PAP) and cluster of differentiation (CD) 31, showed that the cyst wall had characteristic features of the amniotic membrane. Alleles of the patient's husband were not identified when the cyst was genotyped. Some of the patient's loci were deleted and others showed a structurally heterogeneous pattern. These findings suggest that the cyst was derived not from the ovum parthenogenesis, but from the patient's somatic cells and could have been incubated by ascites.

The incidence, treatment and prognosis of cervical carcinoma in young women: a retrospective analysis of 4,975 cases in Japan

OBJECTIVE

To determine the clinical characteristics of patients (young women) with cervical carcinoma aged less than 35 years.

METHODS

Data from patients who were treated for cervical carcinomas from 1990 to 2000 in the Kinki District were retrospectively investigated for clinical stage, histologic type, treatment procedure and prognosis.

RESULTS

Of a total of 4,975 cases, 441 patients were aged less than 35 years old. The incidence of cervical carcinoma in these women was 7.9% from 1990 to 1995, 9.1% from 1996 to 2000, and 9.5% from 2001 to 2005. FIGO Stage I included 374 cases, followed by, 49 in Stage II, 11 in Stage III, and seven in Stage IV. Squamous cell carcinoma incidence was 80.7% and non-squamous cell carcinoma incidence was 19.3%. Several types of surgery were performed in patients with Stage I and II, while patients with Stage III and IV were treated with radiotherapy and/or chemotherapy without any type of surgery. In patients who underwent lymphadenectomy, 21.1% cases had nodal involvement. The 5-year survival rate was 95% for Stage I disease, 73% for Stage II, 68% for Stage III, and 19% for Stage IV.

CONCLUSION

The incidence of cervical carcinoma in young women slightly increased from 1990 to 2005. The prognosis of cervical carcinoma tends to be better in young women than in older patients, especially in Stage III disease.

The effect of zoledronic acid on serum dickkopf-1, osteoprotegerin, and RANKL in patients with Paget's disease of bone

Overexpression of dickkopf (DKK)-1 in pagetic osteoblast cultures resulted in stimulation of osteoclast proliferation and inhibition of osteoblast growth. The aim of this study was to evaluate for the first time in Paget's disease of bone (PDB): 1) the serum levels of DKK1; 2) the association of DKK-1 with receptor activator of nuclear factor kappa B (RANKL) and osteoprotegerin (OPG); and 3) the effect of zoledronic acid (ZOL) on serum DKK-1, RANKL, and OPG. The study was conducted as a prospective open-label cohort study. Eleven patients with PDB (median age 60 years) were recruited. Twelve age- gender- and body mass index (BMI)-matched healthy individuals were used as controls at baseline. Blood samples were obtained before treatment (baseline) and after 3, 6, 12, and 18 months following ZOL infusion in patients with PDB. Patients with PDB had significantly higher RANKL (p=0.002), OPG (p=0.001), and bone markers (total alkaline phosphatase and C-terminal cross-linking telopeptide of type I collagen) compared with controls at baseline. There was no difference between groups in DKK-1 at baseline. Bone markers were both significantly decreased after therapy. Serum OPG, RANKL, RANKL:OPG ratio, and DKK-1 remained unaffected throughout the study. No correlations were found between OPG, RANKL, RANKL:OPG ratio, and DKK-1 at baseline nor between their changes during the study. Although both OPG and RANKL were increased in patients with PDB, ZOL had no effect on their serum levels. Serum DKK-1 was neither increased in patients with PDB nor related to OPG and RANKL, and was unaffected by ZOL.

Long term follow-up of patients with adrenal incidentalomas--a single center experience and review of the literature

INTRODUCTION

Adrenal incidentalomas (AIs) constitute an emerging clinical entity due to the increased use of abdominal imaging for diagnostic purposes. Most often it consists of benign-nonfunctioning lesions and an increase in size during follow-up is reported in about 9% (0-26%), whereas their functional evolution is rare.

MATERIALS AND METHODS

Sixty-four patients (22 males and 42 females; mean age 61.6 ± 1.2 years), with AIs and follow-up of 3.1 ± 0.4 years (range 0-19) were retrospectively evaluated. The patients underwent basal and dynamic evaluation of the hypothalamic-pituitary-adrenal axis, renin-angiotensin-aldosterone system and adrenomedullary function. Mass enlargement and adrenal hyperfunction were estimated at yearly intervals.

RESULTS

Adrenalectomy was performed in 5 patients (4 benign cortical adenomas and 1 pheochromocytoma). Abnormal manifestation, based on clinical, laboratory and histological evaluation, was observed in 4 patients [1 (1.56%) with SCS, 2 (3.12%) with pheochromocytoma and 1 (1.56%) with aldosteronoma], 3 of which were diagnosed at their initial evaluation and 1 at the 3 (rd) year of follow-up. The remainders [60 patients (93.75%)] were harbouring a non-secretory mass (8 potential myelolipomas, 8 nodular hyperplasias, 3 cystic lesions). Eleven patients (17.2%) had bilateral AIs. Mass enlargement (5-13 mm) was observed in 9 patients (14%), ≥10 mm 4 (6.25%), while mass shrinkage (5-19 mm) in 3 (4.7%) during follow-up. No hormonal evolution was noticed.

CONCLUSIONS

AIs present usually as benign, non-secretory lesions. Criteria for surgical intervention were met at initial assessment for the majority of AIs. Size alterations during follow-up are uncommon and functional evolution is rare.

Persistence of FOXP3 expression is impaired in RR-MS Tregs (99.3)

Impaired Treg function may contribute to the development of Multiple Sclerosis (MS). FOXP3 is required for Treg function and its expression is maintained by the common γ-chain cytokines through phosphorylation of STAT5 (pSTAT5). We examined the pSTAT5 levels of CD4+CD25+Treg from relapsing remitting MS and control subjects in response to low-dose IL-2. We found that, despite equivalent levels of CD25, pSTAT5 was lower in RR-MS subjects (p= 0.0013), indicating a mechanism by which FOXP3 expression and Treg function may be lost in MS. To further examine the expression and persistence of FOXP3 in these subjects we generated adaptive Tregs and followed FOXP3 expression in these cells over time. We found that the initial induction of FOXP3 was similar to that of controls, but by day 10 of culture FOXP3 expression in CD4+CD25+ T cells was significantly lower (p<0.0001). FOXP3 expression could not be rescued by IL-2, IL-7 or IL-2/IL-7 in combination. In addition, cell surface expression of CD122 and CD132 is significantly decreased on RR-MS CD4+ CD25+ T cells. Taken together we conclude that the impaired persistence of FOXP3 expression in aTreg may impact the number and function of Tregs in individuals with RR-MS. This loss of FOXP3 may be due to decreased pSTAT5 in response to IL-2 and IL-7 which may be due to decreased levels of the IL-2R and IL-7R complexes. This work was supported by grants from the JDRF33-2008-398 and DFG108312-1.

Prenatal diagnosis of Holt-Oram syndrome: role of 3-D ultrasonography

Holt-Oram syndrome (HOS) is an autosomal dominant disorder consisting of a congenital heart defect in combination with upper limb abnormalities. This report presents the ultrasonographic follow-up of a fetus at risk for this syndrome. An abnormal four-chamber view of the heart and slight shortening of the forearm were found by prenatal ultrasound performed at 16 weeks of gestation. At 25 weeks of gestation, detailed sonographic examination clearly revealed abnormalities in the upper limbs and heart of the fetus. At 39 weeks of gestation, spontaneous labor and delivery produced a female infant weighting 2940 g. Postnatal examination of the infant confirmed the prenatal sonographic findings. 3-D ultrasound has an important role in prenatal diagnosis of HOS, which is essential for proper genetic counseling.

Effect of exogenous intermittent recombinant human PTH 1-34 administration and chronic endogenous parathyroid hormone excess on glucose homeostasis and insulin sensitivity

We aimed to evaluate the effects of exogenous intermittent teriparatide (rhPTH 1-34) administration versus the chronic exposure to excess endogenous parathyroid hormone (PTH), as in pHPT, on glucose homeostasis. Two patient groups were studied: Group 1 included 25 normocalcemic women with postmenopausal osteoporosis (age 65.2+/-1.6 years) studied before and six months after teriparatide initiation; Group 2 included 19 postmenopausal women with pHPT (age 55.2+/-2.5 years) studied before and six months after successful parathyroidectomy. Calcium - total (Ca) and corrected (CCa) - ALP, PTH, as well as glucose and insulin concentrations during an oral glucose tolerance test (OGTT) were determined before and six months after either intervention. Area under the curve for glucose (AUCglu) and insulin (AUCins) were calculated. DeltaIns30'/DeltaGlu30' was applied as an index of insulin secretion. The HOmeostasis Model of Assessment (HOMA) and Matsuda ISI (Insulin Sensitivity Index) were used to calculate insulin resistance (IR) and whole body insulin sensitivity, respectively. In Group 1 no difference was found in any OGTT-derived parameter. In Group 2 significant reductions in AUCins and DeltaIns30'/DeltaGlu30' were observed. No correlation between the change in DeltaCCa or DeltaPTH and DeltaAUCglu or DeltaAUCins was found in either group. Our data suggest that while subtle transient alterations of Ca and PTH within the normal range as in exogenous rhPTH 1-34 administration do not affect glucose homeostasis, the continuously elevated Ca and endogenous PTH levels as in pHPT affect insulin sensitivity and result in increased insulin secretion.

The use of demographic, ultrasonographic and scintigraphic data in the diagnostic approach of thyroid nodules

INTRODUCTION

Thyroid nodules are a common diagnostic challenge mainly because of the need to exclude thyroid malignancy. The aim of this study was to evaluate the usefulness of demographic, ultrasonographic and scintigraphic findings in differentiating benign from malignant thyroid lesions in patients presenting with thyroid nodules.

MATERIALS AND METHODS

941 patients, who presented with palpable thyroid nodules and underwent at least one fine-needle aspiration biopsy (FNAB), were retrospectively evaluated.

RESULTS

The thyroid was assessed by ultrasonography (US) in 796 patients and by scintigraphy (SC) in 774 patients. The final diagnostic outcome was established after surgery (n=183) or after a minimum of one-year clinical follow-up period. Higher rates of malignancy were observed in male gender (p<0.001), in patients presenting with a solitary nodule in US (p<0.001), in nodules with maximum diameter > or =4.5 cm in US (p=0.024) and in nodules detectable by SC (p=0.006). There were no statistical differences in the rates of malignancy among cystic, solid or mixed nodules in US or among "hot", "warm" or "cold" nodules in SC.

CONCLUSIONS

Male gender, solitary nodule and nodule diameter > or =4.5 cm can serve as adjuncts to FNAB in predicting the risk of thyroid malignancy in patients presenting with thyroid nodules.

Primary adrenal lymphoma presenting as Addison's disease. Case report and review of the literature

Primary Adrenal Lymphoma (PAL) is a very rare clinical entity. Adrenal insufficiency is a common complication of this pathology. Most patients present with clinical and laboratory findings of adrenal insufficiency and bilateral enlargement of the adrenal glands. We present a 78-year-old woman admitted to our institution with typical clinical and laboratory findings of adrenal insufficiency. Computerized tomography (CT) of the abdomen revealed bilateral enlargement of the adrenal glands. The patient was eventually diagnosed with a diffuse large B-cell lymphoma after a CT-guided needle adrenal biopsy and treated with combined immuno-chemotherapy (R-LPD-COP). Twenty months after the initial evaluation, she is in good condition, with no signs of adrenal insufficiency.

Associations of obesity with modifiable risk factors for the development of cardiovascular disease in patients with rheumatoid arthritis

OBJECTIVES

To assess the association of body mass index (BMI) with modifiable cardiovascular disease (CVD) risk factors in patients with rheumatoid arthritis (RA).

METHODS

BMI, disease activity, selected CVD risk factors and CVD medication were assessed in 378 (276 women) patients with RA. Patients exceeding accepted thresholds in >or=3 CVD risk factors were classified as having the metabolic syndrome (MetS).

RESULTS

BMI independently associated with hypertension (OR = 1.28 (95% CI = 1.22 to 1.34); p = 0.001), high-density lipoprotein (OR = 1.10 (95% CI = 1.06 to 1.15); p = 0.025), insulin resistance (OR = 1.13 (95% CI = 1.08 to 1.18); p = 0.000) and MetS (OR = 1.15 (95% CI = 1.08 to 1.21); p = 0.000). In multivariable analyses, BMI had the strongest associations with CVD risk factors (F(1-354) = 8.663, p = 0.000), and this was followed by lipid-lowering treatment (F(1-354) = 7.651, p = 0.000), age (F(1-354) = 7.541, p = 0.000), antihypertensive treatment (F(1-354) = 4.997, p = 0.000) and gender (F(1-354) = 4.707, p = 0.000). Prevalence of hypertension (p = 0.004), insulin resistance (p = 0.005) and MetS (p = 0.000) was significantly different between patients with RA who were normal, overweight and obese, and BMI differed significantly according to the number of risk factors present (p = 0.000).

CONCLUSIONS

Increasing BMI associates with increased CVD risk independently of many confounders. RA-specific BMI cut-off points better identify patients with RA at increased CVD risk. Weight-loss regimens should be developed and applied in order to reduce CVD in patients with RA.

Head-to-head comparison of risedronate vs. teriparatide on bone turnover markers in women with postmenopausal osteoporosis: a randomised trial

AIMS

We aimed to compare the effect of risedronate (RIS) and teriparatide (TPTD) (recombinant human parathyroid hormone 1-34) on bone turnover markers in women with postmenopausal osteoporosis.

METHODS

Forty-four Caucasian women (age 65.1 +/- 1.6 years) with postmenopausal osteoporosis were randomly assigned to receive either RIS 35 mg once weekly (n = 22) or TPTD 20 microg once daily (n = 22) for 12 months. Serum N-terminal propeptide of type 1 collagen (P1NP), C-terminal telopeptide of type 1 collagen (CTx), total alkaline phosphatase (ALP) and intact parathyroid hormone (iPTH) were obtained from all women before, 3 and 6 months after treatment initiation. Lumbar spine bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry before and 12 months after treatment initiation.

RESULTS

P1NP, CTx and total ALP levels decreased in RIS group (p < 0.001) and increased in TPTD group (p < 0.001) throughout the treatment. iPTH increased significantly in RIS group (p < 0.05) and decreased in TPTD group (p < 0.001). Finally, lumbar spine BMD increased significantly in both RIS (p = 0.003) and TPTD groups (p < 0.001) without significant differences between them.

CONCLUSIONS

Our data suggest that both serum P1NP and CTx are reliable markers of RIS and TPTD action in women with postmenopausal osteoporosis. In a similar way, serum total ALP can be used as an alternative marker for monitoring both RIS and TPTD action, while iPTH can be used only for TPTD-treated women. The increase in P1NP and CTx after 3 months of treatment with RIS or TPTD can predict the increase in BMD after 12 months of treatment.

Serum osteoprotegerin and RANKL are not specifically altered in women with postmenopausal osteoporosis treated with teriparatide or risedronate: a randomized, controlled trial

Risedronate and teriparatide have opposite actions on the osteoblast-osteoclast dipole and are expected to influence the RANK/RANKL/osteoprotegerin (OPG) system. We aimed to evaluate changes in serum OPG and RANKL after risedronate or teriparatide administration in postmenopausal osteoporotic women. Seventy-four postmenopausal Caucasian women (age 64.1+/-1.0 years) were studied. Women with osteopenia served as controls (group 1, n=30). Women with osteoporosis were randomly assigned to either risedronate 35 mg once weekly (group 2, n=21) or teriparatide 20 microg once daily (group 3, n=23) for six months. Blood samples for serum RANKL, OPG, N-terminal propeptide of type 1 collagen (P1NP), and C-terminal telopeptide of type 1 collagen (CTx) were obtained before treatment and three and six months after treatment. P1NP and CTx levels remained unchanged in group 1, decreased in group 2 (p<0.001), and increased in group 3 women (p<0.001) throughout the treatment. OPG levels remained unchanged while RANKL decreased gradually in all groups (p<0.001). There was no correlation between OPG or RANKL and P1NP or CTx. Our data suggest that neither antiresorptive nor osteoanabolic therapy causes specific alterations of serum OPG/RANKL levels; therefore, these cytokines cannot substitute for the established markers of bone turnover in the monitoring of response to osteoporosis treatment.

Epidemiologic analysis of thyroid fine needle aspiration biopsies over a period of 18 years (1987-2004)

INTRODUCTION

Fine Needle Aspiration Biopsy (FNA) is a method widely used in the assessment of thyroid nodules. The main aim of this 18-year retrospective study was the investigation of the diagnostic value of FNA cytology in thyroid malignancy.

SUBJECTS AND METHODS

We retrospectively reviewed 1376 patients who underwent 1938 FNAs from 1987 to 2004 in the Department of Endocrinology, "Hippokration" General Hospital, Thessaloniki, Greece. Of them 178 subsequently underwent total or subtotal thyroid resection and a pathology report was available.

RESULTS

FNA cytology shows a sensitivity of 76.2% and a specificity of 90.5% for thyroid malignancy, with a significant agreement between FNA cytology and the histology following resection surgery (Cohen's method, p<0.05). There was a considerable improvement in the diagnostic value of FNA cytology during the sub-period 1996-2004 as compared to the sub-period 1987-1995.

CONCLUSIONS

1) FNA is a reliable diagnostic method in the assessment of thyroid malignancy, 2) a non-diagnostic FNA should always be repeated, 3) meticulous follow-up is mandatory, even after a cytological result of benign hyperplasia and 4) increased experience can improve the diagnostic value of FNA in thyroid malignancy.

New resting energy expenditure prediction equations for patients with rheumatoid arthritis

OBJECTIVES

Resting energy expenditure (REE), one of the main components of total energy expenditure, can be measured via indirect calorimetry and/or predicted from equations. The latter may be misleading in RA, as they do not take into account the metabolic alterations occurring in RA. The objectives of this study are to evaluate the accuracy of widely used REE-predictive equations in RA patients against measured REE and to develop RA-specific equations.

METHODS

We assessed REE (via indirect calorimetry and several predictive equations), fat-free mass (FFM; via bioelectrical impedance) and disease activity (CRP) in RA patients and healthy controls. Data from 60 RA patients (experimental group) were used to assess the accuracy of existing REE equations and to develop new equations. The new equations were validated in an independent cross-validation group of 22 RA patients. These two groups were merged and two final equations were developed.

RESULTS

All equations significantly under-predicted measured REE (from 15% to 18.2%, all at P < 0.001) in the RA experimental group, but not in the control group. After both equations demonstrated a high validity in the cross-validation group, the new final REE prediction equations developed from the total RA sample (n = 82) were: Model 1: REE (kcal/day) = 126.1 x FFM(0.638) x CRP(0.045) (R(2) = 0.70) and Model 2: REE (kcal/day) = 598.8 x weight(0.47) x age(-0.29) x CRP(0.066) (R(2) = 0.62).

CONCLUSION

The new equations provide an accurate prediction of REE in RA patients and could be used for clinical monitoring of resting metabolism of these patients without the requirement for specialized personnel.

Blockade of tumour necrosis factor-alpha in rheumatoid arthritis: effects on components of rheumatoid cachexia

OBJECTIVES

Rheumatoid arthritis (RA) is accompanied by increased resting energy expenditure (REE) and decreased fat-free mass (FFM). This is referred to as rheumatoid cachexia and is attributed to high levels of tumour necrosis factor-alpha (TNF-alpha). This study aimed to investigate the effects of anti-TNF-alpha therapy on REE, body composition, physical activity and protein intake in RA patients.

METHODS

Twenty RA patients [50% female; age: (mean +/- s.d.) 61.1 +/- 6.8 yrs; body mass index (BMI): 28.3 +/- 3.7 kg/m2] and 12 age-sex-BMI-matched healthy controls were assessed. REE (indirect calorimetry), body composition (bioelectrical impedance), the International Physical Activity Questionnaire (IPAQ), diet, Health Assessment Questionnaire (HAQ), disease activity [disease activity score 28 (DAS28), erythrocyte sedimentation rate (ESR), C-reactive protein] and serum TNF-alpha were measured before (Baseline) as well as 2 weeks (Time-1) and 12 weeks (Time-2) after initiation of anti-TNF-alpha treatment. Controls were only assessed at Baseline.

RESULTS

RA patients had significantly higher REE than controls at Baseline (1799.4 +/- 292.0 vs 1502.9 +/- 114.5 kcal/day, P = 0.002). Within the RA group, REE increased significantly between Time-1 and Time-2 (P = 0.001) but not between Baseline and Time-2. Sustained significant increases were observed in IPAQ (P = 0.001) and protein intake (P = 0.001). There were no significant changes in FFM or body fat. ESR (P = 0.002), DAS28 (P < 0.001), HAQ (P < 0.001) and TNF-alpha (P = 0.024) improved significantly. Physical activity (P = 0.001) and protein intake (P = 0.024) were significant between-subject factors for the elevation of REE.

CONCLUSIONS

After 12 weeks of anti-TNF-alpha therapy, there were significant improvements in disease activity and physical function, as well as physical activity and protein intake, but no significant changes in REE or FFM. There is a need for longer-term studies in this field.

Kisspeptins: a multifunctional peptide system with a role in reproduction, cancer and the cardiovascular system

The pairing of the kisspeptins (KP) with the KISS1 (GPR54) receptor has received growing attention since the description of the receptor as a molecular switch for puberty. The role of KP and its receptor, GPR54, in puberty is the most exciting finding made in the field of reproductive biology since the discovery of Gonadotropin Releasing Hormone (GnRH) in 1970s. A significant body of evidence across several species now suggests that KISS1 (GPR54) activation is a critical point in the commencement of puberty, although further investigation is required to characterize the interaction between KP and GnRH cascade. Given such pivotal roles of kisspeptins and GPR54 as gatekeepers of reproductive function, and the proven ability of sex steroids to physiologically regulate this system, it is plausible that environmental compounds with ability to interfere oestrogen and/or androgen signaling (agonists or antagonists) may target the hypothalamic kiss-1/GPR54 system, thereby inducing functional alterations of the hypothalamic-pituitary-gonadal axis. Synthetic agonists targeting KISS1 (GPR54) may represent novel therapeutic agents for the treatment of hypogonadotrophic hypogonadism in some affected individuals. The diverse multifunctional nature of the KP is beginning to unravel. The unexpected role of these peptides in puberty has raised a number of important questions that remain to be answered.

Is the Y chromosome all that is required for sex determination?

The gender identity of a person is the final result of genetic, hormonal and morphologic sex. Over a long period sex determination, and, specifically, male sex determination, has been correlated to the presence of the Y chromosome, which in turn has been the karyotype signal of the testes. However, research has provided data to convince that this theory is only part of the truth. In addition to the Y chromosome, a multitude of other genes influence sex determination and are able to cause male to female sex-reversal and vice versa. It is of great interest that these genes are located in more than one autosomal chromosomes or even in the X chromosome. It has become obvious that sex determination, according to the genetic sex, is a complicated matter that not only requires the presence of Y chromosome. This fact triggered extensive research of the Y chromosome and led to great insight into its structure, origin, evolution and eventual fate in humans.