Cardiac phenotype in familial partial lipodystrophy

OBJECTIVES

LMNA variants have been previously associated with cardiac abnormalities independent of lipodystrophy. We aimed to assess cardiac impact of familial partial lipodystrophy (FPLD) to understand the role of laminopathy in cardiac manifestations.

STUDY DESIGN

Retrospective cohort study.

METHODS

Clinical data from 122 patients (age range: 13-77, 101 females) with FPLD were analysed. Mature human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) from a patient with an LMNA variant were studied as proof-of-concept for future studies.

RESULTS

Subjects with LMNA variants had a higher prevalence of overall cardiac events than others. The likelihood of having an arrhythmia was significantly higher in patients with LMNA variants (OR: 3.77, 95% CI: 1.45-9.83). These patients were at higher risk for atrial fibrillation or flutter (OR: 5.78, 95% CI: 1.04-32.16). The time to the first arrhythmia was significantly shorter in the LMNA group, with a higher HR of 3.52 (95% CI: 1.34-9.27). Non-codon 482 LMNA variants were more likely to be associated with cardiac events (vs. 482 LMNA: OR: 4.74, 95% CI: 1.41-15.98 for arrhythmia; OR: 17.67, 95% CI: 2.45-127.68 for atrial fibrillation or flutter; OR: 5.71, 95% CI: 1.37-23.76 for conduction disease). LMNA mutant hiPSC-CMs showed a higher frequency of spontaneous activity and shorter action potential duration. Functional syncytia of hiPSC-CMs displayed several rhythm alterations such as early afterdepolarizations, spontaneous quiescence and spontaneous tachyarrhythmia, and significantly slower recovery in chronotropic changes induced by isoproterenol exposure.

CONCLUSIONS

Our results highlight the need for vigilant cardiac monitoring in FPLD, especially in patients with LMNA variants who have an increased risk of developing cardiac arrhythmias. In addition, hiPSC-CMs can be studied to understand the basic mechanisms for the arrhythmias in patients with lipodystrophy to understand the impact of specific mutations.

Magnetic resonance spectroscopy to assess hepatic steatosis in patients with lipodystrophy

BACKGROUND/AIMS

Lipodystrophy is a rare metabolic disorder characterized by near total or partial lack of subcutaneous adipose tissue and associated with insulin resistance. We aimed to evaluate the efficacy of magnetic resonance spectroscopy imaging (MRS) to explore the fat content of the liver in patients with lipodystrophy and to determine the relationship between the liver fat accumulation and clinical presentations of lipodystrophy.

MATERIALS AND METHODS

Between July 2014 and February 2016, 34 patients with lipodystrophy were assessed by MRS for quantification of hepatic steatosis. All patients had metabolic abnormalities associated with insulin resistance. Metabolic parameters and the MRS findings were analyzed to identify potential correlations between the liver fat content and disease severity.

RESULTS

The MRS fat ratios (MRS-FR) were markedly higher, indicating severe hepatic steatosis in lipodystrophy. Patients with generalized and partial lipodystrophy had comparable levels of MRS-FRs, although patients with generalized lipodystrophy were significantly younger. Patients with genetically based lipodystrophy had elevated MRS-FR compared to those with acquired lipodystrophy (p=0.042). The MRS-FR was positively correlated with liver enzyme alanine aminotransferase (p=0.028) and serum adiponectin (p=0.043).

CONCLUSION

Our data suggest that MRS might be an effective, noninvasive imaging method to quantify hepatic fat content in patients with lipodystrophy. Further studies are needed to validate the technique and threshold values which would allow accurate comparison of data acquired by different machines and centers.

SUN-556 Cardiac Phenotype in Familial Partial Lipodystrophy

Background Pathogenic variants in Lamin A/C (LMNA) gene are the most common monogenic etiology in Familial Partial Lipodystrophy (FPLD) causing FPLD2. LMNA pathogenic variants have been previously associated with cardiomyopathy, familial arrhythmias or conduction system abnormalities independent of lipodystrophy. We aimed to assess cardiac impacts of FPLD, and to explore the extent of overlap between cardiolaminopathies and FPLD. Methods We conducted a retrospective review of an established cohort of 122 patients (age range: 13-77, M/F 21/101) with FPLD from Michigan (n = 83) and Turkey (n = 39) with an accessible cardiac evaluation. Also, functional syncytia of mature human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) from a FLPD2 patient was studied for assessment of autonomous rhythm and action potential duration with optical mapping using a voltage sensitive dye. Results In the whole study cohort, 95 (78%) patients had cardiac alterations (25% ischemic heart disease, 36% arrhythmia, 16% conduction abnormality, 20% prolonged QT interval, 11% cardiomyopathy, and 15% congestive heart failure). The likelihood of having an arrhythmia (OR; 3.95, 95% CI: 1.49-10.49) and conduction disease (OR: 3.324, 95% CI: 1.33-8.31) was significantly higher in patients with LMNA pathogenic variants. Patients with LMNA pathogenic variants were at high risk for atrial fibrillation/flutter (OR: 6.77, 95% CI: 1.27- 39.18). The time to first arrhythmia was significantly shorter in the LMNA group with a higher hazard rate of 3.04 (95% CI: 1.29-7.17, p = 0.032). Non-482 LMNA pathogenic variants were more likely to be associated with cardiac events (vs. 482 LMNA: OR: 4.74, 95% CI: 1.41- 15.98 for arrhythmia; OR: 17.67, 95% CI: 2.44- 127.68 for atrial fibrillation/flutter; OR: 5.71, 95% CI: 1.37- 23.76 for conduction disease. hiPSC-CMs from a FPLD2 patient had higher frequency of autonomous activity, and shorter Fridericia corrected action potential duration at 80% repolarization compared to control cardiomyocytes. Furthermore, FPLD2 functional syncytia of mature hiPSC-CMs presented several rhythm alterations such as early after-depolarizations, spontaneous quiescence and spontaneous tachyarrhythmia; none of those were observed in the control cell lines. Finally, FPLD2 hiPSC-CMs presented significantly slower recovery in chronotropic changes induced by isoproterenol exposure; which indicates disrupted beta-adrenergic response. Conclusion Our results suggest the need for vigilant cardiac monitoring in FPLD, especially in patients with FPLD2 who have an increased risk to develop cardiac arrhythmias and conduction system diseases. In addition, study of human induced pluripotent stem cell-derived cardiomyocytes may prove useful to understand the mechanism of cardiac disease and arrhythmias and to create precision therapy opportunities in the future.

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

OBJECTIVES

Lipodystrophy syndromes are a group of heterogeneous disorders characterized by adipose tissue loss. Proteinuria is a remarkable finding in previous reports.

STUDY DESIGN

In this multicentre study, prospective follow-up data were collected from 103 subjects with non-HIV-associated lipodystrophy registered in the Turkish Lipodystrophy Study Group database to study renal complications in treatment naïve patients with lipodystrophy.

METHODS

Main outcome measures included ascertainment of chronic kidney disease (CKD) by studying the level of proteinuria and the estimated glomerular filtration rate (eGFR). Kidney volume was measured. Percutaneous renal biopsies were performed in 9 patients.

RESULTS

Seventeen of 37 patients with generalized and 29 of 66 patients with partial lipodystrophy had CKD characterized by proteinuria, of those 12 progressed to renal failure subsequently. The onset of renal complications was significantly earlier in patients with generalized lipodystrophy. Patients with CKD were older and more insulin resistant and had worse metabolic control. Increased kidney volume was associated with poor metabolic control and suppressed leptin levels. Renal biopsies revealed thickening of glomerular basal membranes, mesangial matrix abnormalities, podocyte injury, focal segmental sclerosis, ischaemic changes and tubular abnormalities at various levels. Lipid vacuoles were visualized in electron microscopy images.

CONCLUSIONS

CKD is conspicuously frequent in patients with lipodystrophy which has an early onset. Renal involvement appears multifactorial. While poorly controlled diabetes caused by severe insulin resistance may drive the disease in some cases, inherent underlying genetic defects may also lead to cell autonomous mechanisms contributory to the pathogenesis of kidney disease.

Clinical presentations, metabolic abnormalities and end-organ complications in patients with familial partial lipodystrophy

OBJECTIVE

Familial partial lipodystrophy (FPLD) is a rare genetic disorder characterized by partial lack of subcutaneous fat.

METHODS

This multicenter prospective observational study included data from 56 subjects with FPLD (18 independent Turkish families). Thirty healthy controls were enrolled for comparison.

RESULTS

Pathogenic variants of the LMNA gene were determined in nine families. Of those, typical exon 8 codon 482 pathogenic variants were identified in four families. Analysis of the LMNA gene also revealed exon 1 codon 47, exon 5 codon 306, exon 6 codon 349, exon 9 codon 528, and exon 11 codon 582 pathogenic variants. Analysis of the PPARG gene revealed exon 3 p.Y151C pathogenic variant in two families and exon 7 p.H477L pathogenic variant in one family. A non-pathogenic exon 5 p.R215Q variant of the LMNB2 gene was detected in another family. Five other families harbored no mutation in any of the genes sequenced. MRI studies showed slightly different fat distribution patterns among subjects with different point mutations, though it was strikingly different in subjects with LMNA p.R349W pathogenic variant. Subjects with pathogenic variants of the PPARG gene were associated with less prominent fat loss and relatively higher levels of leptin compared to those with pathogenic variants in the LMNA gene. Various metabolic abnormalities associated with insulin resistance were detected in all subjects. End-organ complications were observed.

CONCLUSION

We have identified various pathogenic variants scattered throughout the LMNA and PPARG genes in Turkish patients with FPLD. Phenotypic heterogeneity is remarkable in patients with LMNA pathogenic variants related to the site of missense mutations. FPLD, caused by pathogenic variants either in LMNA or PPARG is associated with metabolic abnormalities associated with insulin resistance that lead to increased morbidity.

Effects of Hypericum perforatum on an Experimentally Induced Diabetic Wound in a Rat Model

OBJECTIVE

The aim of this study was to investigate the probable effects of Hypericum perforatum (HP) on wound healing in diabetic rats.

MATERIALS AND METHODS

Thirty-five male Wistar rats were divided evenly into 5 groups. Diabetes formation was induced by intraperitoneal streptozotocin (60 mg/kg) administration for groups 1 (HP extract in olive oil), 2 (HP extract in ethanol), 3 (povidone-iodine application), and 4 (diabetic rats without any applied medication); group 5 was the control. Dorsal dermoepidermal incision was performed on each rat after 48 hours. The aforementioned solutions were applied only to groups 1, 2, and 3; groups 4 and 5 did not receive solution applications. At the end of the 7-day period, the cutaneous tissue was resected from the center of the incised and sutured region and divided into 3 pieces for biomechanical, biochemical, and histopathological assessments.

RESULTS

Ultimate stress and toughness significantly decreased in groups 3, 4, and 5 compared to group 1. There was a significant difference between groups 2 and 3 for the same parameters (P < .05). Compared with group 4, tissue malondialdehyde levels were found to be lower in the HP groups (P < .05). Histopathological evaluation revealed the fibroblast count was reduced considerably in the HP-applied rats compared with other groups (P < .05).

CONCLUSION

Application of HP may be recommended as effective on wound healing in diabetic rats, but further investigation is needed to adapt the findings for clinical use.

Metastatic Papillary Thyroid Cancer Diagnosed and Treated during Pregnancy

Physiological changes of the thyroid gland encountered during pregnancy can cause previously diagnosed thyroid nodules to grow or new nodules to form. Surgery of the slowly growing, localized, non-metastatic, well-differentiated, thyroid cancers diagnosed during pregnancy can be delayed to after delivery, whereas rapidly growing and metastatic cancers with compressive symptoms may be a candidate for surgery during pregnancy. In this case report, we present a case of cervical metastatic papillary thyroid cancer diagnosed and treated by total thyroidectomy and right functional neck dissection during pregnancy in a 22-year-old pregnant woman at 23-week pregnancy. In this case report, the optimal treatment for papillary thyroid cancer diagnosed during pregnancy is discussed under the light of current endocrine guidelines and previous case reports and series.

Assessment of the elasticity properties of the ascending aorta in patients with subclinical hypothyroidism by tissue Doppler imaging

OBJECTIVE: We aimed to investigate whether aortic elastic properties were affected in subclinical hypothyroidism (SCH) by using tissue Doppler imaging (TDI). SUBJECTS AND METHODS: Forty-three patients with newly diagnosed SCH and forty-eight healthy controls were included to the study. Systolic and diastolic diameters of the ascending aorta were measured by M-mode transthoracic echocardiography, and the upper wall velocities of ascending aorta and mitral annulus velocities were measured by TDI. Aortic stiffness index (ASI) and aortic distensibility were computed using the formulas accepted in literature. RESULTS: The clinical and demographic features of both groups were comparable. Aortic distensibility was significantly lower, and ASI was significantly higher in SCH patients than in controls. Systolic aortic upper wall velocity (Sao) was also significantly lower in SCH patients. Early (Eao) and late diastolic aortic upper wall (Aao) velocities did not differ between the two groups. Mitral annulus (Sm, Em, and Am) velocities were also similar between the groups. Sao was negatively correlated with ASI, and positively correlated with aortic distensibility. TSH level was positively correlated with ASI, total cholesterol and low-density lipoprotein-cholesterol, and negatively correlated with aortic distensibility and Sao. CONCLUSIONS: In this study, our results showed that SCH is associated with impaired elasticity of the ascending aorta. Elastic properties of the ascending aorta can be directly evaluated by the reproducibly measurement of the upper wall movements of the ascending aorta by TDI in SCH patients.

Insulin receptor substrate-2 gene polymorphism: is it associated with endometrial cancer?

OBJECTIVE

The G1057D polymorphism in the insulin receptor substrate-2 (IRS-2) gene has been reported to be associated with insulin resistance, obesity and type 2 diabetes. However little is known about its possible association with cancer. To investigate this association, we determined the distribution of its genotypes and frequency of alleles in endometrial cancer patients.

METHODS

The study population consisted of 184 subjects: 44 patients with endometrial cancer and 140 controls without cancer. All the patients were primarily treated with surgical intervention. DNA was extracted from the leucocytes by high pure polymerase chain reaction (PCR) template preparation kit. Genetic polymorphism of IRS-2 G1057D was detected by using PCR-based restriction fragment-length polymorphism.

RESULTS

For IRS-2 G1057D polymorphism, there was a significant difference in genotype distribution and allele frequency between endometrial cancer patients and controls (p < 0.001). The risk for endometrial cancer was 4.87 times higher in the individuals with the IRS-2 DD genotype compared to the GG genotype [95% confidence interval (CI): 1.74-13.63 p = 0.003]. Also individuals with the IRS-2 D allele had a significantly higher risk of endometrium cancer compared with individuals with the IRS-2 G allele, with a relative risk of 2.23 (95% CI: 1.36-3.67, p = 0.001) for cases compared with population controls.

CONCLUSION

These results suggest that IRS-2 G1057D polymorphism may be associated with endometrial cancer.

P-wave dispersion in endogenous and exogenous subclinical hyperthyroidism

BACKGROUND

The aim of this study was to measure maximum P wave duration (Pmax) and P wave dispersion (PWD), which can be indicators for the risk of paroxysmal atrial fibrillation when increased, and to reveal their relationship with thyroid hormone levels in patients with endogenous and exogenous subclinical hyperthyroidism.

METHODS

Seventy-one patients with sublinical thyrotoxicosis (34 endogenous, 37 exogenous) and 69 healthy individuals were enrolled in the study. Pmax and minimum P wave duration (Pmin) on electrocardiogram recordings were measured and PWD was calculated as Pmax-Pmin.

RESULTS

Pmax (p<0.001) and PWD (p<0.001) values were significantly higher in patients with endogenous subclinical hyperthyroidism compared with the control group. Pmax (p<0.001) and PWD (p<0.001) values were significantly higher in patients with exogenous subclinical thyrotoxicosis compared with the control group. Pmax (p=0.710) and PWD (p=0.127) were not significantly different in patients with endogenous subclinical hyperthyroidism compared with exogenous subclinical hyperthyroid patients. Pmax and PWD negatively associated with TSH in endogenous and exogenous subclinical hyperthyroidism.

CONCLUSION

In the present study, we observed that Pmax and PWD were longer in patients with endogenous and exogenous subclinical hyperthyroidism. Lack of a difference in Pmax and PWD between patients with endogenous and exogenous subclinical hyperthyroidism seems to support the idea that hormone levels rather than the etiology of thyrotoxicosis affect the heart.

Plasma visfatin level in lean women with PCOS: relation to proinflammatory markers and insulin resistance

OBJECTIVES

The present study was undertaken to investigate the association between plasma visfatin concentrations and inflammatory markers such as interleukin-6 (IL-6) and high-sensitive C-reactive protein (hsCRP) in company with several metabolic parameters in lean women with polycystic ovary syndrome (PCOS).

METHODS

The study group consisted of 21 lean women with PCOS (BMI 20.74 +/- 1.74 kg/m(2)) and 15 healthy, normally menstruating women (BMI 20.85 +/- 2.08 kg/m(2) control group). PCOS was defined according to the Rotterdam criteria. Visfatin, IL-6, hsCRP, hyperandrogenism markers and metabolic markers were examined in all PCOS and control women.

RESULTS

Plasma visfatin level in the PCOS group was higher than that in the control group. Plasma hsCRP and IL-6 levels in PCOS group were similar with the control group. Plasma visfatin levels were positively associated with total cholesterol, high density lipoprotein, hirsutism score, total testosterone and FAI. Plasma visfatin level was negatively associated with SHBG. However, there were no correlation between plasma visfatin level and IL-6 and hsCRP. In multivariate regression analyses, only FAI and high density lipoprotein-cholesterol (HDL-C) showed a significant association with serum visfatin.

CONCLUSION

Our data indicates that plasma visfatin levels are associated with HDL-C and markers of hyperandrogenism, but it is not associated with proinflammatory markers and insulin resistance in lean women with PCOS.

Effect of very low LDL-cholesterol on cortisol synthesis

BACKGROUND

Cardiovascular disease is the most common cause of mortality around the world. The relationship between coronary artery disease and serum LDL-cholesterol levels has become obvious in recent years and statin treatment has been used more commonly. However, influence of intensive statin treatment on steroidal hormonal functions has remained unclear. In this paper, we evaluated the effect of very low LDL levels (<70 mg/dl) on serum cortisol concentrations, which is mainly synthesized from cholesterol.

SUBJECTS AND METHODS

Forty-one patients with serum LDL-cholesterol levels below 70 mg/dl were included in the study. The control group consisted of 38 healthy people. Adrenal axis was evaluated by means of cortisol response to 1 microg ACTH test.

RESULTS

The mean age of patients was 52.45+/-10.74 yr. Of 41 patients, 19 (46.9%) were female. There were statistically significant differences between the study and control group according to their serum cholesterol and LDL levels. Main serum LDL levels were 58+/-11.4 mg/dl and 131+/-25.8 mg/dl in the study and control group, respectively. There were no statistically significant differences in response to 1 microg ACTH stimulation test at basal, 30 min and 60 min among both study and control group. Atorvastatin treatment was generally well tolerated.

CONCLUSIONS

Our data reflect that having serum LDL-cholesterol levels below 70 mg/dl did not affect the adrenal axis function in terms of cortisol.

Cushing Syndrome Caused by Topical Corticosteroid: A Case Report

Development of iatrogenic Cushing syndrome from topical steroid therapy is very rare in adults. A 48-year-old woman with a diagnosis of Cushing syndrome caused by long-term topical clobetasol propionate application was presented. Laboratory studies were consistent with adrenal suppression that improved after discontinuation of the use of topical glucocorticoids. Patients who will take treatment with steroids, even with topical steroids, should be offered information about the dose, duration, and type of the treatment and its systemic side-effects.

Risk factors for infection of the diabetic foot with multi-antibiotic resistant microorganisms

AIM

To investigate the risk factors for infection of the diabetic foot with multidrug resistant microorganisms.

METHODS

Amongst 102 diabetic patients with evidence of soft tissue infection of the foot who presented to our health center over a three year period, we investigated risk factors that might be predictive of multi-antibiotic resistance of the infecting organism.

RESULTS

Of 102 patients with a diabetic foot wound, bacteria were cultured from 73, yielding a total of 104 isolates. The number of multidrug resistant isolates was 42 from 36 cases and the number of isolates other than multidrug resistant ones was 62 from 37 cases. Previous antibiotic therapy (p=0.002) and its duration (p=0.0001), frequency of hospitalization for the same wound (p=0.000), duration of hospital stay (p=0.000) and osteomyelitis (p=0.001) were significant risk factors for infections with multidrug resistant microorganisms.

CONCLUSION

In conclusion, an appropriate antibiotic should be initiated promptly, wound perfusion should be effective, duration of hospital stay should be as short as possible and optimum hygiene should be provided during wound care to prevent infections of diabetic foot wound with multidrug resistant microorganisms.

Effects of terlipressin on systolic pulmonary artery pressure of patients with liver cirrhosis: An echocardiographic assessment

AIM: Portopulmonary hypertension is a serious complication of chronic liver disease. Our aim was to search into the effect of terlipressin on systolic pulmonary artery pressure among cirrhotic patients.

METHODS: Twelve patients (6 males and 6 females) with liver cirrhosis were recruited in the study. Arterial blood gas samples were obtained in sitting position at rest. Contrast enhanced echocardiography and measurements of systolic pulmonary artery pressure were performed before and after the intravenous injection of 2 mg terlipressin.

RESULTS: Of 12 patients studied, the contrast enhanced echocardiography was positive in 5, and the positive findings in contrast enhanced echocardiography were reversed to normal in two after terlipressin injection. The mean systolic pulmonary artery pressure was 25.5 ± 3.6 mmHg before terlipressin injection, and was 22.5 ± 2.5 mmHg after terlipressin (P = 0.003). The systolic pulmonary artery pressure was above 25 mmHg in seven of these 12 patients. After the terlipressin injection, systolic pulmonary artery pressure was < 25 mmHg in four of these cases (58.3% vs 25%, P = 0.04).

CONCLUSION: Terlipressin can decrease the systolic pulmonary artery pressure in patients with liver cirrhosis.

Systolic pulmonary artery pressure and serum uric acid levels in patients with hyperthyroidism

BACKGROUND

The aim of this study was to investigate systolic pulmonary artery pressure (SPAP) and serum uric acid (SUA) levels in patients with hyperthyroidism and after euthyroid state was reached.

METHODS

Twenty five (10 male, 15 female, mean age 49.8 +/- 11.6 years) consecutive patients with hyperthyroidism (18 due to toxic nodular goiter, seven to Graves' disease) and 25 (eight male, 17 female, mean age 48.7 +/- 8.7 years) healthy controls were included in the study. Thyroid hormones, SUA, glucose, urea, creatinine, and transthoracic echocardiography were performed in all patients. All tests were repeated after treatment of hyperthyroidism.

RESULTS

Mean SPAP and SUA levels in patients with hyperthyroidism were significantly higher than in controls (30.4 +/- 8.5 vs. 22 +/- 3.7 mmHg, p <0.0001, and 5.1 +/- 1.1 vs. 4.3 +/- 0.5 mg/dL, p = 0.004, respectively). Elevated SPAP and SUA levels in patients with hyperthyroidism decreased significantly after treatment to levels comparable with controls (24.4 +/- 5.4 mmHg, p = 0.001 and 4.6 +/- 0.9 mg/dL, p = 0.002, respectively). Correlation between SPAP and SUA levels, however, was not significant in hyperthyroid population and after euthyroid stage was reached (r = 0.34, p = 0.097, and r = 0.256, p = 0.216, respectively), possibly due to relatively low number of patients (overall correlation of SPAPs and SUAs was r = 0.4, p <0.0001).

CONCLUSIONS

Hyperthyroidism should be included in differential diagnosis of pulmonary arterial hypertension. However, further investigations are needed to determine the exact mechanism between hyperthyroidism and pulmonary hypertension.