Cardiovascular evaluation and endothelial dysfunction in Cushing syndrome following remission: a prospective study

PURPOSE

Cushing syndrome (CS) is a well-known risk factor for cardiovascular morbidities. We aimed to evaluate endothelial and cardiovascular functions, endothelial mediators and pro-inflammatory cytokines in patients with CS before and after remission.

METHODS

Adult patients with newly diagnosed endogenous CS were included. Metabolic [body mass index (BMI), glucose, and lipid values] and cardiovascular evaluation studies [24-h ambulatory blood pressure monitoring, carotid intima-media thickness (CIMT), flow-mediated dilation (FMD), and echocardiography] were performed, and endothelial mediators [asymmetric dimethyl arginine (ADMA) and endothelin-1 (ET-1)] and pro-inflammatory cytokines [interleukin-1β (IL-1β) and tumor necrosis factor-alpha (TNF-α)] were measured. Control group was matched in terms of age, gender, and BMIs.

RESULTS

Twenty-five patients, mean age 40.60 ± 14.04 years, completed the study. Compared to controls (n = 20) mean arterial pressure (MAP) and CIMT were higher (p < 0.005 and p = 0.012, respectively), and FMD (p < 0.001) and mitral E/A ratio (p = 0.007) lower in the patients during active disease. Baseline serum ADMA, ET-1, and IL-1β were similar between the groups, while TNF-α was lower in the patients (p = 0.030). All patients were in complete remission 1 year following surgery. BMI, LDL cholesterol, serum total cholesterol, fasting plasma glucose, MAPs, and CIMT significantly decreased (p < 0.005), while there was no improvement in FMD (p = 0.11) following remission. There was no significant change in ADMA, IL-1β, and TNF-α levels, but ET-1 increased (p = 0.011).

CONCLUSIONS

Remission in CS improves some cardiovascular parameters. ADMA and ET-1 are not reliable markers for endothelial dysfunction in CS. Metabolic improvements may not directly reflect on serum concentrations of TNF-α and IL-1β following remission of CS.

The Effects of Regulating Increased Blood Glucose Levels on Plasma Endothelin-1 Levels After Severe Head Trauma in Rats

AIM

To examine the effects of regulating increased blood glucose levels on plasma ET-1 levels after severe head trauma in rats.

MATERIAL AND METHODS

Traumatic diffuse brain injury-induced rats were followed for 7 days and were randomly divided into two groups of 36 rats. Pre- and posttraumatic blood glucose and ET-1 levels were measured in group 1 (control). Posttraumatic blood glucose levels were maintained at normal levels using insulin and both blood glucose and ET-1 levels were measured at 2, 6, 12, 24, and 48 h and 7 days posttrauma in group 2. The study excluded animals that died and had skull fractures.

RESULTS

Posttraumatic plasma ET-1 levels (n=36) were significantly higher than baseline values in group 1 (p < 0.05). ET-1 levels in group 2 at the 7-day follow-up after trauma were significantly higher than baseline values (n=36) (p < 0.05). However, the increased ET-1 levels were statistically significantly lower in group 2 than in group 1 (p < 0.05).

CONCLUSION

The increased ET-1 levels were significantly prevented by keeping blood glucose levels within normal limits with insulin after severe head trauma. Thus, secondary injury to cerebral blood flow can be prevented by reducing the occurrence of vasospasm that starts in the early posttraumatic period or by stimulating the release of nitric oxide. Therefore, further studies on the role of ET-1 and insulin in developing secondary injuries after severe head trauma would be beneficial.

Dural and calvarial metastasis of thyroid follicular carcinoma mimicking Sindou type 6 parafalcine meningioma

ABSTRACT

Fifty-two years, NID type-2 diabetic female was admitted with progressive headache, enlarging, pulsatile midline mass, dizziness, and numbness of extremities. Physical examination revealed only hypoesthesia in the upper left extremity C7-dermatome. Preoperative computed tomography revealed eroded parafalcian dural mass and caused a round 7 cm calvarial defect over the superior sagittal sinus (SSS) and another left parietal 1.2 cm satellite mass. Magnetic resonance imaging revealed an extra-axial, diffuse heterogeneous gadolinium-enhanced, well-circumscribed lesion invading the SSS and Trolard veins (bilaterally). Supratotal resection 1 cm from the tumor borders was performed, histopathology suggested papillary thyroid carcinoma follicular variant. The euthyroid patient underwent total thyroidectomy, and final pathology revealed invasive TFC. 5-year follow-up was uneventful without recurrence or new metastasis. Parafalcian meningioma classification was reviewed for the best surgical approach. The definitive diagnosis of meningioma should be established with histopathological analysis. TFC should be included in the differential diagnosis in cases of extra-axial tumors.

Circulating MicroRNAs as Potential Biomarkers for Traumatic Brain Injury-Induced Hypopituitarism

Traumatic brain injury (TBI), a worldwide public health problem, has recently been recognized as a common cause of pituitary dysfunction. Circulating microRNAs (miRNAs) present in the sera are characteristically altered in many pathological conditions and have been used as diagnostic markers for specific diseases. It is with this goal that we planned to study miRNA expression in patients with TBI-induced hypopituitarism. Thirty-eight patients (27 male, 11 female; mean age, 43 ± 18 years) who had been admitted to the neurosurgery intensive care unit due to TBI were included in the acute phase of the study. In the chronic phase, miRNA expression profile blood samples were drawn from 25 patients who had suffered TBI 5 years ago. In the acute phase (on Days 1, 7, and 28), a substantial amount of patients (26%, 40%, and 53%; respectively) had hypopituitarism (acute adrenocorticotropic hormone deficiency). In the chronic phase eight of 25 patients (32%) had TBI-induced-hypopituitarism. Forty-seven age-gender-similar healthy controls (25 male, 22 female, mean age: 41 ± 14 years) were included in the study. In order to identify potential candidate miRNA/miRNAs whose levels had been altered in response to TBI-induced hypopituitarism, 740 miRNA expression analyses were performed in the sera of TBI patients by high throughput real-time polymerase chain reaction. Statistical analyses showed that miRNA-126-3p (miR-126-3p) and miRNA-3610 (miR-3610) were detected in the sera of patients who developed hypopituitarism on the 1st, 7th, and 28th days, and in the 5th year following TBI. In addition, miRNA-3907 showed statistically significant and constant dynamic changes on the 1st, 7th, and 28th days, and in the 5th year in the patients with TBI. Our results indicated that altered expression of miR-126-3p and miR-3610 may play an important role in the development of TBI-induced hypopituitarism.

Evaluation of peripheral blood CD34+ cell count in the acute phase of traumatic brain injury and chest trauma

AIM

To determine the impact of traumatic brain injury (TBI) and chest trauma (CT) on the number of peripheral blood (PB) stem cells in affected patients in comparison to normal controls. Additionally, the aim was to determine the relationship between CD34+ cell counts and TBI-induced hypothalamus-pituitary-adrenal axis dysfunction in the acute phase of trauma.

PATIENTS AND METHOD

Thirty patients with TBI, 12 patients with CT and 53 healthy subjects were included in the study.

RESULTS

CD34+ cell counts within the first 24-48 hours of TBI were found to be lower than those obtained on the 7(th) day of TBI and those in the healthy controls. CD34+ cell counts obtained on the 2(nd) day of CT were lower than those in the healthy group, but did not differ from those measured on the 7(th) day of CT. There was no correlation between CD34+ cell counts and serum total cortisol (STC) levels on the 2(nd) and 7(th) days in the TBI or CT groups.

CONCLUSION

An increase in CD34+ cell counts as observed on the 7(th) day in both TBI and CT groups suggested that CD34 changes were not specific to TBI. Moreover, this study showed for the first time that CD34 response was not affected by changes in cortisol levels induced by TBI and severity of TBI.

Can a glucagon stimulation test characterized by lower GH cut-off value be used for the diagnosis of growth hormone deficiency in adults?

OBJECTIVE

The aim of this study was to assess diagnostic values of insulin tolerance test (ITT), glucagon stimulation test (GST), and insulin like growth factor-I (IGF-I) level, to find optimal GH cut-off values for GST, and to evaluate efficiencies of patient age, gender, body-mass index (BMI), and additional pituitary hormone deficiencies (PHDs) in the diagnosis of growth hormone deficiency (GHD).

STUDY DESIGN

This retrospective study involved 216 patients with a pituitary disease and 26 healthy controls. Age, gender, BMI, medical histories, and hormonal data including baseline and stimulated hormone values were evaluated. Three cut-off values for peak GH responses to stimulation tests were evaluated: (a) 3.00 µg/L on ITT, (b) 3.00 µg/L on GST, and (c) 1.07 µg/L on GST.

RESULTS

According to the ITT, GST with 3.00 µg/L cut-off, and GST with 1.07 µg/L cut-off, GHD was present in 86.1, 74.5, and 54.2 % patients, respectively. Patient age, BMI, and number of PHDs, but not gender, were found to be correlated with IGF-I and peak GH concentrations. All patients with an IGF-I concentration ≤95 ng/ml or ≥3 PHD had GHD. None of the patients with adequate GH response to the GST with 1.07 µg/L cut-off, but blunted responses to ITT and GST with 3.00 µg/L cut-off, had ≥3 PHDs. 12 out of 26 (46.2 %) healthy subjects failed the GST with 3.00 µg/L cut-off, but not with 1.07 µg/L cut-off.

CONCLUSIONS

Patient age, IGF-I, BMI, and number of PHDs are efficient factors associated with the diagnosis of GHD. A 4 h GST with a diagnostic GH threshold of 1.07 µg/L seems to be a good diagnostic method for GHD.

The Comparison of Hemilaminectomy and Laminoplasty Procedures in the Surgical Treatment of Cervical Spondylotic Myelopathy

AIM

To compare cervical hemilaminectomy with cervical laminoplasty to determine the prognostic significance of both methods in cervical spondylotic myelopathy (CSM). This study is first in the literature to compare the hemilaminectomy and laminoplasty procedures MATERIAL and METHODS: A total of 42 patients who underwent surgery due to CSM and followed for at least 24 months were included in the study. Thirty-four out of 42 patients were males, while 8 were females; the mean age of the patients was 63.6 years (range 41-80). The visual analog scale (VAS) was used in the evaluation of postoperative axial neck pain. Factors known to affect prognosis of CSM such as patients" age, gender, duration of symptoms, pressure level, and T2-hyperintense appearance on magnetic resonance imaging (MRI) were evaluated. Patients were compared in terms of sagittal alignment of the vertebrae (instability), anterior-posterior diameter of the spinal canal, transsectional spinal canal area, axial neck pain, and recovery rate based on the preoperative and postoperative Japanase Orthopaedic Association (JOA) scores.

RESULTS

The recovery rate in patients who underwent hemilaminectomy was 60.8%±18.8, while in patients that underwent laminoplasty it was 52.8%±11.9. The comparison of both surgical techniques in terms of postoperative recovery rates did not show any significant difference between the techniques (p > 0.05).

CONCLUSION

There were no significant differences in terms of recovery rate, preoperative and postoperative canal diameter, preoperative and postoperative spinal canal area, and postoperative sagittal alignment (p > 0.05). The VAS evaluating axial neck pain was significantly lower in patients from the hemilaminectomy group compared to patients from the laminoplasty group.

A comparison of low-dose ACTH, glucagon stimulation and insulin tolerance test in patients with pituitary disorders

CONTEXT

Diagnosis of secondary adrenal insufficiency and GH deficiency requires evaluation by dynamic stimulation tests in most cases. Although insulin tolerance test (ITT) is accepted as the gold-standard test for the evaluation of both hypothalamo-pituitary-adrenal (HPA) and (GH)-IGF-1 axes, the test is cumbersome. In clinical practice, low-dose adrenocorticotrophic hormone (ACTH) stimulation test is a sensitive, safe and easily applicable alternative to ITT. Although it takes more time, glucagon stimulation test (GST) is also a good alternative to ITT and can evaluate both axes.

OBJECTIVE

The primary aim of this study was to compare the ITT, low-dose ACTH and GSTs in the evaluation of HPA and GH-IGF-1 axes in patients with pituitary disorders and to evaluate the repeatability of all three tests.

DESIGN

ITT, low-dose ACTH and GSTs were performed in all 129 patients, and the tests were repeated in 66 of these patients.

SETTING

Erciyes University Medical School, Department of Endocrinology.

PATIENTS OR OTHER PARTICIPANTS

One hundred and twenty-nine adult patients (76 women, 53 men) with pituitary disorder were included in the study.

MAIN OUTCOME MEASURE(S)

The cortisol and GH responses of patients to dynamic tests.

RESULTS

Peak cortisol levels obtained during ITT were significantly lower than the values obtained during both low-dose ACTH and GSTs. Peak cortisol levels obtained during the GST were lower than those found during the low dose ACTH stimulation test. Peak GH responses were found to be higher in GST than in ITT. All three tests had good reproducibility.

CONCLUSIONS

Any of 3 tests can be used in the evaluation of the HPA axis and either GST or the ITT can be used in the evaluation of the GH-IGF-1 axis but cut-off levels for the insufficiency of HPA or GH-IGF-1 axis should be individualized for each test.

Growth hormone deficiency due to sports-related head trauma is associated with impaired cognitive performance in amateur boxers and kickboxers as revealed by P300 auditory event-related potentials

OBJECTIVES

It has been recently reported that boxing and kickboxing may cause pituitary dysfunction, GH deficiency in particular. The strong link between poor cognitive performance and GH deficiency due to causes other than head trauma and the improvement of cognitive function after GH replacement therapy have been previously shown. P300 auditory event-related potential (ERP) measure is widely used to evaluate cognitive performance. In this study, we investigated the relation between the GH-IGF-I axis and cognitive performance in boxers and kickboxers.

DESIGN AND PATIENTS

Forty-one actively competing or retired male boxers (n: 27) and kickboxers (n: 14) with a mean age of 29·04 ± 9·30 year and 14 age- and education-matched healthy male controls were included in the study. For neuropsychological tests, the mini-mental state examination (MMSE) and Quality of Life Assessment of GH Deficiency in Adults (QoL-AGHDA) questionnaires were administered. Moreover, cognitive performance was evaluated according to P300 ERPs.

RESULTS

Nine of 41 (21·9%) athletes had GH deficiency. P300 amplitudes were lower at all electrode sites in the GH-deficient group than in controls, and the differences were statistically significant at Fz and Oz electrode sites (P < 0·05). When GH-deficient athletes were compared with GH-sufficient athletes, the P300 amplitudes were lower at all electrode sites in the GH-deficient group; these differences were statistically significant at Fz, Pz and Cz electrode sites (P < 0·05). In all athletes, there were significant negative correlations between IGF-I levels vs P300 latencies, and there were significant positive correlations between IGF-I levels vs P300 amplitudes (P < 0·05).

CONCLUSION

This study provides the first electrophysiological evidence for the close relation between the P300 ERPs and the GH-IGF-I axis in boxers and kickboxers.

Three years prospective investigation of pituitary functions following subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) is known to be related to pituitary dysfuntion in retrospective and short-term prospective studies. We aimed to investigate pituitary functions in patients with SAH in longer follow-up periods to demonstrate if pituitary hormone deficiencies recover, persist or new hormone deficiencies occur. Twenty patients with SAH, who were followed up for 3 years, were included in the present study. Patients were evaluated with basal hormone levels and glucagon stimulation test (GST).Serum basal cortisol and adrenocorticotropic hormone (ACTH) levels were found to be significantly elevated at 3rd year of SAH compared to 1st year. Other basal hormone levels at 3rd year did not show a significant change from the levels found at 1st year. One of the patients had ACTH deficiency at 1st year of SAH and recovered at 3rd year. Growth hormone (GH) deficiency, according to GST,was diagnosed in 4 patients. One patient with GH deficiency at first year was still deficient, 3 of them recovered and 3 patients were found to have new-onset GH deficiency 3 years after SAH. SAH is associated with anterior pituitary dysfunction and GH is the most frequently found deficient hormone in the patients. Although one year after SAH seems to be an appropriate time for the evaluation of pituitary functions, further follow-up may be required at least in some cases due to recovered and new-onset hormone deficiencies at 3rd year of SAH.

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.

Can basal cortisol measurement be an alternative to the insulin tolerance test in the assessment of the hypothalamic-pituitary-adrenal axis before and after pituitary surgery?

BACKGROUND

The aims of this study were to evaluate the validity of preoperative basal serum cortisol levels measured in predicting preoperative adrenal insufficiency and also the validity of basal serum cortisol levels and early postoperative insulin tolerance test (ITT) in predicting postoperative adrenal insufficiency.

METHODS

The study was prospectively designed and included 64 patients who underwent pituitary surgery for conditions other than Cushing's disease. An ITT was performed preoperatively, on the 6th postoperative day and at the 1st postoperative month. Basal serum cortisol levels were measured on the 2nd, 3rd, 4th, 5th, and 6th postoperative days.

RESULTS

Patients with a preoperative basal cortisol level of <165 nmol/l (6 microg/dl) showed insufficient cortisol response and those with levels higher than 500 nmol/l (18 microg/dl) had sufficient cortisol response to the preoperative ITT. The positive predictive value of the ITT performed on the 6th postoperative day was 69.7%, and the negative predictive value in predicting adrenal insufficiency at the 1st postoperative month was 58%. Patients were considered to have an insufficient cortisol response to ITT at the 1st postoperative month if their basal cortisol levels were <193 nmol/l (7 microg/dl) or 220 nmol/l (8 microg/dl) or 193 nmol/l (7 microg/dl) or 165 nmol/l (6 microg/dl) or 83 nmol/l (3 microg/dl) on the 2nd-6th postoperative days respectively.

CONCLUSION

Serum basal cortisol levels may be used as the first-line test in the assessment of the hypothalamic-pituitary-adrenal axis both preoperatively and postoperatively. Dynamic testing should be limited to the patients with indeterminate basal cortisol levels.

Investigation of antihypothalamus and antipituitary antibodies in amateur boxers: is chronic repetitive head trauma-induced pituitary dysfunction associated with autoimmunity?

OBJECTIVE

Current data clearly demonstrate that sports-related chronic repetitive head trauma due to boxing might result in hypopituitarism. However, the mechanism of sports-related traumatic brain injury-induced pituitary dysfunction is still unclear. In order to understand whether autoimmune mechanisms could play a role in the pituitary dysfunction due to sports-related head trauma, we investigated the presence of antipituitary antibodies (APAs) and antihypothalamus antibodies (AHAs) in amateur boxers.

PATIENTS AND DESIGN

Sixty-one actively competing (n=44) or retired (n=17) male boxers (mean age, 26 years; range, 17-53) who had been evaluated regarding pituitary functions previously were included in the study. In all boxers and in 60 age/sex-similar normal controls, AHAs and APAs were investigated by an indirect immunofluorescence method.

RESULTS

AHAs were detected in 13 of 61 boxers (21.3%), and APAs were detected in 14 of 61 boxers (22.9%), but in none of the normal controls. Pituitary dysfunction was significantly higher in AHA-positive boxers (46.2%) than in AHA-negative boxers (10.4%) (P=0.003). There was a significant association between AHA positivity and hypopituitarism due to boxing (odds ratio: 7.37, 95% confidence interval 1.8-30.8). There was no significant association between APA positivity and hypopituitarism.

CONCLUSIONS

This study demonstrates for the first time the presence of AHAs and APAs in boxers who were exposed to sports-related head trauma. Moreover, the present investigation provides preliminary evidence that AHAs are associated with the development of pituitary dysfunction in boxers, thus suggesting that autoimmunity may have a role in the pathogenesis.

Apolipoprotein E3/E3 genotype decreases the risk of pituitary dysfunction after traumatic brain injury due to various causes: preliminary data

Traumatic brain injury (TBI) is a devastating public health problem which may result in hypopituitarism. However, the mechanisms and the risk factors responsible for hypothalamo-pituitary dysfunction due to TBI are still unclear. Although APO E is one of the most abundant protein in hypothalamo-pituitary region, there is no study investigating the relation between APO E polymorphism and TBI-induced hypopituitarism. This study was undertaken to determine whether APO E genotypes modulate the pituitary dysfunction risk after TBI due to various causes, including traffic accident, boxing, and kickboxing. Ninety-three patients with TBI (mean age, 30.61 +/- 1.25 years) and 27 healthy controls (mean age, 29.03 +/- 1.70 years) were included in the study. Pituitary functions were evaluated, and APO E genotypes (E2/E2; E3/E3; E4/E4; E2/E3; E2/E4; E3/E4) were screened. Twenty-four of 93 subjects (25.8%) had pituitary dysfunction after TBI. The ratio of pituitary dysfunction was significantly lower in subjects with APO E3/E3 (17.7%) than the subjects without APO E3/E3 genotype (41.9%; p = 0.01), and the corresponding odds ratio was 0.29 (95% confidence interval [CI], 0.11-0.78). In conclusion, this study provides strong evidence for the first time that APO E polymorphism is associated with the development of TBI-induced pituitary dysfunction. Present data demonstrated that APO E3/E3 genotype decreases the risk of hypopituitarism after TBI. The demonstration of the association between the APO E polymorphism and TBI may provide a new point of view in this field and promote further studies.

Antipituitary antibodies after traumatic brain injury: is head trauma-induced pituitary dysfunction associated with autoimmunity?

OBJECTIVE

Traumatic brain injury (TBI) is a devastating public health problem that may result in hypopituitarism. However, the mechanisms responsible for hypothalamic-pituitary dysfunction due to TBI are still unclear. Although the antibodies against neurons have been demonstrated in injured animal studies, investigations regarding the occurrence of antipituitary antibodies (APAs) in patients with TBI are lacking in the literature. In order to investigate whether autoimmune mechanisms could play a role in the pituitary dysfunction after TBI, we have planned this study aimed at investigating the presence of APA at the third year of TBI and association between the TBI-induced hypopituitarism and APA.

PATIENTS AND DESIGN

Twenty-nine (25 males and 4 females; age 36.5+/-2.3 years) patients who had completed a 3-year follow-up after TBI were included in the present study. APA and pituitary function were evaluated in all the patients 3 years after TBI; moreover, APAs were tested also in sera of 60 age-/sex-matched normal controls. The APAs were investigated by an indirect immunofluorescence method. Results APAs were detected in 13 out of the 29 TBI patients (44.8%), but in none of the normal controls. Pituitary dysfunction development ratio was significantly higher in APA-positive patients (46.2%) when compared with APA-negative ones (12.5%; P=0.04). There was a significant association between APA positivity and hypopituitarism due to TBI (odds ratio: 2.25, 95% confidence intervals 1.1-4.6). Moreover, there was a significant positive correlation (r=0.74, P=0.004) between APA titer ratio and peak GH response to GHRH+GH related peptide (GHRP)-6 test, suggesting that high APA titers were associated with low GH response to GHRH+GHRP-6 test.

CONCLUSIONS

This study shows for the first time the presence of the APA in TBI patients 3 years after head trauma. Moreover, present investigation indicates preliminary evidence that APA may be associated with the development of TBI-induced pituitary dysfunction, thus suggesting that autoimmunity may contribute in the development of TBI-induced hypopituitarism. The presence of the association between APA and TBI-induced hypopituitarism may provide a new point of view in this field and promote further clinical and experimental studies.

Brief communication: pituitary volume and function in competing and retired male boxers

BACKGROUND

Pituitary consequences of chronic head trauma in boxing have not been investigated in detail.

OBJECTIVE

To investigate the pituitary function in retired or active amateur boxers.

DESIGN

Cross-sectional, observational study.

SETTING

Turkey.

PARTICIPANTS

61 actively competing (n = 44) or retired (n = 17) male boxers of the Turkish National Boxing Team.

MEASUREMENTS

Body composition variables, pituitary volume (in 38 of 61 boxers), and pituitary function.

RESULTS

9 of 61 boxers (15%) had growth hormone (GH) deficiency and 5 of 61 boxers (8%) had adrenocorticotropic hormone deficiency. All boxers with GH deficiency except 1 were retired from boxing. Of 17 retired boxers, 8 (47%) had GH deficiency. Retired boxers with GH deficiency had significantly lower pituitary volume than retired boxers with normal GH.

LIMITATION

Pituitary volume was measured in only 38 of 61 boxers, and the study had no comparison group.

CONCLUSION

This study suggests that retired boxers have a high rate of pituitary dysfunction. Therefore, investigation of pituitary function in boxers, particularly retired ones, is recommended.

Three years prospective investigation of anterior pituitary function after traumatic brain injury: a pilot study

OBJECTIVE

It has been recently demonstrated that traumatic brain injury (TBI)-mediated hypopituitarism could be more frequent than previously known. However, most of the previous data were obtained from retrospective studies, and the natural history of the hypopituitarism due to TBI is still unclear. So far no study has been reported in which the pituitary function of the same patients has been investigated more than 1 year after TBI. Therefore, we report the results of 3 years prospective follow-up of anterior pituitary function in patients with mild, moderate and severe TBI.

PATIENTS AND DESIGN

Thirty patients (25 males, 5 females; age 37.2 +/- 2.4 years) with TBI were included in the study. Pituitary function was evaluated at 1 and 3 years after TBI.

RESULTS

After individual evaluation of GH deficiency from 1 year to 3 years after TBI, 7 of 13 (53.8%) GH-deficient patients at 1st year recovered after 3 years of TBI, and GH deficiency detected at 3 years in one patient was new onset. Additionally, five of six (83.3%) ACTH-deficient patients at 1st year recovered after 3 years of TBI, and ACTH deficiency detected at 3 years in one patient was new onset.

CONCLUSIONS

GH deficiency is the most common pituitary deficit 1 and 3 years after TBI. In patients with mild and moderate TBI, pituitary function improves over time in a considerable number of patients, but it may also worsen rarely over the 3-year period. In patients with severe TBI, ACTH and GH deficiencies at 1st year evaluation persist at 3rd year.

Pituitary functions in the acute phase of traumatic brain injury: are they related to severity of the injury or mortality?

PRIMARY OBJECTIVE

There are only limited data regarding pituitary functions in the acute phase of traumatic brain injury (TBI) and previous studies have been conducted in only small cohorts of subjects. Therefore we have investigated the pituitary functions in the early acute phase, within 24 hours of trauma, in 104 patients with TBI. Additionally, the relationships between basal pituitary hormones, severity of the trauma and mortality due to trauma were also investigated.

METHODS AND PROCEDURES

One hundred and four TBI patients were included in the study consecutively. All patients underwent basal hormonal evaluation within the first 24 hours of admission. Twenty of 104 patients died during the acute phase.

MAIN OUTCOMES

Prolactin levels were negatively correlated with the Glasgow coma scale (GCS), cortisol levels were positively correlated with the GCS and cortisol levels were positively correlated with ACTH levels. Additionally there was a significant positive correlation between the total testosterone levels and the GCS in males. Logistic regression analysis revealed that mortality after TBI was unrelated to basal pituitary hormone levels. However age and GCS were significantly related to the mortality. The percentages of pituitary hormone deficiencies were as follows: 3.8% had TSH deficiency, 40.0% had gonadotrophin deficiency, 8.8% had ACTH deficiency and 20.0% had GH deficiency.

CONCLUSIONS

Present data clearly demonstrate that pituitary function is disturbed in TBI and the most frequently deficient pituitary hormones were gonadotrophins in the early acute phase of TBI. Basal hormone levels including cortisol, prolactin and total testosterone were related to the severity of the trauma. However there was no relation between basal hormones and mortality due to TBI. Age and GCS were significantly related to mortality.

Complete surgical resolution of bilateral total opthalmoplegia without visual field defect in an acromegalic patient presented with pituitary apoplexy

Pituitary apoplexy (PA), which is one of the most serious life-threatening complications of pituitary adenoma, is characterized by abrupt onset of headache, nausea, vomiting, visual disturbances and oculomotor paresis. Combination of oculomotor cranial nerve paralysis with normal visual fields is very rare in PA. We report a 60-year-old acromegalic man presented with panhypopituitarism and bilateral total opthalmoplegia without a visual field defect. At initial evaluation his clinical findings were compatible with adrenal crisis and eye examination revealed total opthalmoplegia, bilateral ptosis and normal vision. MRI showed a large heterogeneous mass in the pituitary fossa. Although clinical findings due to adrenal crisis improved after glucocorticoid therapy there was no improvement in opthalmoplegia and ptosis. The patient underwent transsphenoidal excision of the pituitary mass. Histological examination revealed an adenoma with large areas of hemorrhagic infarction and most of the cells were positive for GH in immunohistochemical analysis. Although opthalmoplegia was severe at presentation, total recovery was achieved 3 months after transsphenoidal surgery. Therefore the presented case clearly demonstrates that opthalmoplegia without a visual field defect due to PA has a good prognosis and early diagnosis and treatment including surgical decompression are crucially important.

High risk of pituitary dysfunction due to aneurysmal subarachnoid haemorrhage: a prospective investigation of anterior pituitary function in the acute phase and 12 months after the event

OBJECTIVE

Recent investigations have provided evidence for a high prevalence of pituitary dysfunction in patients with subarachnoid haemorrhage (SAH). However, apart from one study, all of the previous data were obtained from retrospective studies. To our knowledge there is no previously reported study in which pituitary function was investigated in the same patients immediately after SAH and 12 months later. The aim of this study was to understand the prevalence and progression of anterior pituitary hormone deficiencies both in the acute phase of SAH and 12 months after the event.

PATIENTS AND DESIGN

Twenty-two SAH patients (11 men, 11 women) were included in the study. Pituitary function was evaluated in the early acute phase (within 24 h of admission) and after 12 months.

RESULTS

Pituitary hormone deficiencies in the acute phase were as follows: 31.8% had gonadotrophin, 22.7% had ACTH and 22.7% had GH deficiencies. At 12 months after SAH: 0.0% had gonadotrophin, 13.6% had ACTH and 36.4% had GH deficiencies. Overall, after 12 months, pituitary hormone deficiencies recovered in 15 (68.2%) patients and new-onset pituitary hormone deficiencies were present in nine (40.9%) patients.

CONCLUSIONS

GH deficiency (GHD) was the most common pituitary deficit at 12 months after SAH and the majority of the patients (87.5%) had isolated GHD. During the 12-month follow-up, pituitary function was found to either improve or worsen in a considerable number of patients.

Transient hypogonadotropic hypogonadism in an amateur kickboxer after head trauma

Traumatic brain injury (TBI) is a frequent health problem and increased prevalence of neurendocrine dysfunction in patients with TBI has been reported. Sports injuries and particularly boxing may result in pituitary dysfunction. However, transient hypogonadotropic hypogonadism after an acute head trauma due to boxing and/or kickboxing has not been defined yet. We describe the case of a 20-yr-old male amateur kickboxer who was admitted to hospital complaining of decreased libido and impotence 2 weeks after an intensive bout. Basal hormone levels were compatible with mild hyperprolactinemia and hypogonadotpopic hypogonadism. GH axis was evaluated by GHRH+GHRP-6 test and peak GH level was within normal reference range. Three months later his complaints improved and abnormalities in basal hormone levels normalized. He was also re-evaluated 9 months after the first evaluation; basal hormone levels were within normal ranges and he had no complaints. In conclusion acute head trauma due to kickboxing may cause transient gonadotropin deficiency. Therefore, screening the pituitary functions of sportsmen dealing with combative sports is crucial.

High risk of hypopituitarism after traumatic brain injury: a prospective investigation of anterior pituitary function in the acute phase and 12 months after trauma

CONTEXT

Recent data have demonstrated that traumatic brain injury (TBI)-mediated hypopituitarism could be more frequent than previously known. However, most previous data were obtained from retrospective studies.

OBJECTIVES

The aim of this study was to determine 1) the prevalence of anterior pituitary hormone deficiencies in the acute phase of TBI and after 12 months, 2) whether severity of trauma correlated with basal hormone levels, and 3) whether initial hormone deficiencies predicted medium-term hormonal status.

DESIGN AND PATIENTS

Fifty-two TBI patients (43 men and nine women) were included in the prospective study. Pituitary function was evaluated within 24 h of admission and after 1 yr.

RESULTS

Some 5.8% of the patients had TSH deficiency, 41.6% had gonadotropin deficiency, 9.8% had ACTH deficiency, and 20.4% had GH deficiency (GHD). Twelve months after TBI, 5.8% had TSH deficiency, 7.7% had gonadotropin deficiency, 19.2% had ACTH deficiency, and 37.7% had GHD. Twenty-six patients (50.9%) had at least one anterior pituitary hormone deficiency, 21 patients (41.2%) had isolated hormone deficiencies, and five patients (9.7%) had combined hormone deficiencies. Overall, the pituitary hormone deficiencies recovered in 30 (57.7%) patients after 1 yr, and new pituitary hormone deficiencies were present in 27 (51.9%) patients after 1 yr.

CONCLUSIONS

GHD is the most common pituitary deficit 12 months after TBI, and 50.9% of the patients had at least one anterior pituitary hormone deficiency. Pituitary function may improve or worsen in a considerable number of patients over 12 months.

Boxing as a sport activity associated with isolated GH deficiency

Traumatic brain injury (TBI) has long been known as a cause of hypopituitarism, and it is characterized by a high prevalence of neuroendocrine abnormalities. Boxing, one of the most common combative sports, may also result in TBI. As far as we know, pituitary functions including GH status have not been investigated in boxers. Therefore, in this preliminary study, we have assessed the pituitary functions in boxers. Eleven actively competing or retired male boxers with a mean age of 38.0 +/- 3.6 yr and 7 age-, sex- and BMI-matched healthy non-boxing controls were included in the study. Biochemical and basal hormonal parameters including IGF-I levels were measured. To assess GH secretory status in boxers and healthy controls, GHRH (1 microg/kg)+GHRP-6 (1 microg/kg) test was performed. After GHRH+GHRP-6 test, mean peak GH level in boxers and in controls were 10.9 +/- 1.7 and 41.4 +/- 6.7 microg/l, respectively (p < 0.05). Peak GH levels in 5 (45%) boxers were found to be lower than 10 microg/l and considered as severe GH deficient. In the control group, mean IGF-1 levels (367 +/- 18.8 ng/ml) were significantly higher than that obtained in boxers (237 +/- 23.3 ng/dl) (p < 0.01). All the other pituitary hormones were normal including ADH as no signs and symptoms of diabetes insipidus. There was a significant negative correlation between peak GH levels and boxing duration, and between peak GH levels and number of bouts. In conclusion, we think that boxing is a cause of TBI, and GH deficiency is very common among boxers. Further studies including large number of boxers, both professional and amateur, are needed to clarify pituitary dysfunction in boxers.

Polymicrobial ventriculitis and evaluation of an outbreak in a surgical intensive care unit due to inadequate sterilization

At the end of 1999, a case of polymicrobial ventriculitis in the Department of Neurosurgery followed by an outbreak of Serratia marcescens mediastinitis in the intensive care unit of cardiovascular surgery occurred. These nosocomial surgical infections were considered to be the result of contamination of surgical sites with inadequately sterilized instruments or theatre linen. An epidemiological survey was focused on the central sterilization unit of the hospital. The microbiological results of this survey proved that the cause of the outbreak was the use of inadequately decontaminated theatre linen. This study indicates that strict infection control measures including the control of sterilization procedures and a well-organized infection control team are necessary to prevent nosocomial surgical infections.

Postoperative mutism after the clipping of a distal anterior cerebral artery aneurysm. A case report

A 40-year-old man with mutism developed after clipping a left distal anterior cerebral artery aneurysm is presented. The most characteristic presenting symptom was complete absence of speech with unimpaired consciousness which occurred on the fourth day after operation. The patient recovered spontaneously within three weeks. In this paper we discuss the possible pathogenesis and anatomical location of mutism related to a distal anterior cerebral aneurysm in view of the literature.

Ganglioglioma of conus medullaris: a case report

A case of a ganglioglioma of the conus medullaris extending between T-12 and L2 segments is reported. The tumor was successfully removed by third stage operation. Ganglioglioma located in the conus medullaris is extremely rare. The best treatment of spinal cord ganglioglioma is totally tumor excision even when multiple stage operations are necessary.