[Various scenarios for billing and remuneration of preoperative management of iron deficiency anemia in the German healthcare system]

More than 30% of all patients undergoing surgery suffer from preoperative anemia. Iron deficiency anemia is the most common type of anemia. The diagnostics and treatment of iron deficiency anemia can be carried out before patients undergo surgery as an alternative to blood transfusion and is an interdisciplinary task. This article gives an overview of various billing modalities and payment arrangements for management of preoperative anemia in the German healthcare system.

Color Doppler Imaging in Uveitis

PURPOSE

To evaluate the vascular hemodynamic changes that can be detected with color Doppler imaging (CDI) in diagnosis, differential diagnosis and prognosis of uveitis with different etiologies including Behçet's disease.

METHODS

Four groups consisting of healthy volunteers, uveitis patients with different etiologies and Behçet's disease patients with and without ocular involvement were examined by CDI. Central retinal artery (CRA), posterior ciliary artery (PCA), ophthalmic artery (OA) and central retinal vein (CRV) flow velocities and vascular resistances were measured prospectively by a radiologist blinded to the presence and etiology of uveitis.

RESULTS

The peak systolic and end-diastolic velocities in CRA and PCA in Behçet's disease with ocular involvement were significantly lower than all other groups (p < 0.001). Peak systolic and end-diastolic velocities in CRA were lower than the control group in Behçet's disease patients without ocular involvement (p < 0.001) but there were no differences in PCA and OA flow velocity (p > 0.05). In the uveitis group, CRA and CRV flow velocities were significantly lower than in the control group (p < 0.001).

CONCLUSIONS

According to our results, uveitis in Behçet's disease is associated with significant reductions of CRA and PCA flow velocities when compared with other types of uveitis and healthy subjects. In cases without ocular involvement, CRA flow velocities were lower than the control group, but there were no real differences in the PCA and OA values. This suggests that vasculitic involvement of PCA is more specific to Behçet's disease and occurs later in the course of the disease. The results also suggest that it may be possible to detect and follow hemodynamic changes in Behçet's disease with CDI before clinical findings of ocular involvement become evident.

Possible association between germline methylenetetrahydrofolate reductase gene polymorphisms and psoriasis risk in a Turkish population

BACKGROUND

Psoriasis is a common chronic inflammatory skin disease caused by genetic and epigenetic factors. There are conflicting results in the literature about the association between psoriasis and the methylenetetrahydrofolate reductase gene (MTHFR), ranging from strong linkage to no association.

AIM

To investigate the association between the germline MTHFR polymorphisms C677T and A1298C with psoriasis risk in a Turkish population.

METHODS

The study enrolled 84 patients with psoriasis and 212 healthy controls (HCs) without any history of psoriasis. DNA was extracted from peripheral blood samples of patients and HCs, and real-time PCR was used for genotyping. Results were compared by Pearson χ² test and multiple logistic regression models.

RESULTS

The frequency of both the MTHFR 677TT and A1298C (homozygous) genotypes was statistically significantly different from HCs. Point mutations were detected in all patients with early-onset psoriasis (before the age of 20 years). The T allele of MTHFR 677 and the C allele of MTHFR 1298 increased psoriasis risk by 12.4- and 17.0-fold, respectively, in patients compared with HCs.

CONCLUSION

A possible association was detected betweengermline MTHFR 677 C>T and 1298 A>C genotypes and psoriasis risk in a Turkish population. These results need to be confirmed in further studies with larger sample sizes.

Assessing the Relationship Between Serum Ghrelin Levels and Metabolic Parameters and Autoimmunity in Patients with Euthyroid Hashimoto's Thyroiditis

OBJECTIVE

Hashimoto's thyroiditis (HT) may affect metabolic parameters and increase predisposition to obesity. In this study, we aimed to assess the relationships among serum ghrelin concentrations, metabolic parameters, and thyroid autoimmunity in euthyroid HT patients.

METHODS

The study included 48 euthyroid HT patients and 41 age- and sex-matched healthy controls. We assessed serum ghrelin, free triiodothyronine (T3), free thyroxine (T4), thyroid-stimulating hormone (TSH), thyroid peroxidase antibody (anti-TPO), thyroglobulin antibody (anti-Tg), fasting blood glucose (FBG), insulin, lipid levels, and homeostasis model assessment insulin resistance (HOMA-IR) in all subjects.

RESULTS

Sex distribution, mean age, and body mass index (BMI) were similar in HT patients and controls (female/male, 42/6 vs. 33/8, 46.8 ± 14.7 vs. 45 ± 12.5 years, 28.5 ± 6.1 vs. 28.4 ± 4.9 kg/m2, respectively; P>.05 for all). The mean waist circumference (WC) of the HT group was significantly higher than that of the control group (100.6 ± 14.6 vs. 93.2 ± 13.2 cm, P = .015). While FBG, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels in the HT group were significantly higher than in the control group, insulin levels and HOMA-IR were similar. Ghrelin levels were lower in HT patients compared to controls (416.9 ± 224.4 and 689.9 ± 191.6 pg/mL, respectively; P<.001). Ghrelin levels were similar in patients with low and high anti-TPO titers. Negative correlations were observed between ghrelin levels and BMI, WC, and anti-TPO levels. Regression analysis revealed that HT was the most important predictor of ghrelin levels.

CONCLUSION

Euthyroid HT is associated with a decrease in plasma ghrelin levels. Altered body fat distribution and increased anti-TPO levels do not seem to be directly involved in lower ghrelin levels in euthyroid HT patients.

Vitamin D Levels of Anesthesia Personnel, Office Workers and Outdoor Workers in Ankara, Turkey

BACKGROUND

Vitamin D deficiency or insufficiency is a highly prevalent condition worldwide. Anesthesia providers or support personnel working in operating rooms might be considered at increased risk of vitamin D deficiency. There is a small amount of information about 25(OH)D levels in people who work mainly indoors as an operating room. This study aimed to investigate whether there was a higher vitamin D insufficiency or deficiency rate among anesthesia personnel working indoors when compared with personnel working in an office or outdoors in Ankara, Turkey (39 degrees North, 32 degrees East).

METHODS

This study consisted of 125 volunteer anesthesia personnel and 60 subjects as control groups (30 outdoor workers and 30 office workers). All of the individuals completed a questionnaire. Serum levels of total 25(OH)D were measured by a chemiluminescent immunoassay method.

RESULTS

74.4% of anesthesia personnel and 76.6% of control group 1 (outdoor workers) and 76.6% of control group 2 (office workers) had serum 25(OH)D concentrations < 10 ng/mL. 20.8% of anesthesia personnel and 23.4% of control group 1 and 23.4% of control group 2 had serum 25(OH)D concentrations levels 10 - 20 ng/mL. 4.8% of anesthesia personnel had serum 25(OH)D concentration levels 21 - 30 ng/mL. There was no significant difference in the mean serum 25(OH)D level between the groups (Anesthesia group: 8.98 ± 4.89 ng/mL, Control group 1: 8.18 ± 2.39 ng/mL, Control group 2: 8.37 ± 3.01 ng/mL) (p > 0.05).

CONCLUSIONS

To our knowledge the present study is the first study to investigate the comparison of vitamin D levels of anesthesia personnel with outdoor and office workers. Our findings alarmingly emphasize that vitamin D deficiency is very common at the end of winter in Ankara, regardless of being anesthesia personnel in operating room or a worker in office or an outdoor worker. Vitamin D supplementation may be suggested in all groups in Ankara.

Insulin resistance and androgen levels in eugonadic and hypogonadic women with prolactinoma

BACKGROUND

Hyperprolactinemia is the most common endocrinologic disorder in causing menstrual irregularities. Although the correlation between hyperprolactinemia and menstrual dysfunction is widely known, the etiology of menstrual cycle disorders is not profoundly understood in patients with prolactinoma. We aimed to investigate the correlation between prolactin levels and insulin resistance and hyperandrogenism in patients with prolactinoma.

METHODS

Sixty-four patients with microprolactinoma and 33 healthy women were enrolled. Thirty-six of these patients with prolactinoma (group 1) had an estradiol (E2) level under 30 pg/mL, and 28 (group 2) had an E2 level greater than 30 pg/mL. Blood samples were drawn to measure the levels of the following hormones: Follicle stimulating hormone (FSH), luteinizing hormone (LH), E2, prolactin (PRL), total testosterone (TT), androstenedione (AS) and dehydroepiandrostenedione sulphate (DHEAS). Body Mass Index (BMI of ≥30 kg/m2) was excluded from the study. Insulin resistance (IR) was calculated by the HOMA-IR.

RESULTS

BMI was higher in patients with prolactinoma than the control group (P=0.02, P=0.025, respectively). IR and glucose intolerance existence were higher in patients with prolactinoma (P=0.007, P=0.097, respectively) than the healthy women, but these differences did not exist between eugonadic and hypogonadic women with prolactinoma (P=0.020, P=0.032, respectively, Bonferroni correction). TT and AS were higher in eugonadic women with prolactinoma than the control group (P=0.004, P=0.003, Bonferroni correction, respectively).

CONCLUSIONS

Our study revealed that the relationship between hyperprolactinemia and IR/glucose intolerance is irrespective of gonadal status in women with prolactinoma. Also, the study concluded that hyperandrogenism may be a cause of menstrual dysfunction in eugonadic women with prolactinoma.

The efficacy and safety of capecitabine plus bevacizumab combination as first-line treatment in elderly metastatic colorectal cancer patients

AIM

The optimal treatment in older persons with metastatic colorectal cancer (mCRC) is complicated by a lack of general agreement. The aim of this study was to evaluate the activity of bevacizumab plus capecitabine combination in elderly mCRC patients who were not suitable for chemotherapy with irinotecan and oxaliplatin-containing regimens.

MATERIALS AND METHODS

Seventy years and older patients with metastatic colorectal carcinoma were included in this retrospective study. Bevacizumab was administered at a dose of 7.5 mg/kg on day 1 as an intravenous (IV) infusion over 30-90 min every 21 days, and capecitabine was prescribed at 1000 mg/m(2) twice daily on days 1-14 of the same 21-day schedule.

RESULTS

Eighty-two consecutive patients (47 men, 35 women) were included in the study. The mean age was 75.5 (SD 3.9, range 70-87). Half of the patients were older than 75 years. There were 55 patients (67.1 %) with a good Eastern Cooperative Oncology Group (ECOG) performance status (PS: 0-1) and the remaining 27 patients (32.9 %) had a poor ECOG performance status (PS: 2). With a median follow-up period of 18.5 months, the median progression-free survival (PFS) was 10 months (95 % CI, 7.8-12.1) and the median OS was 25 months (95 % CI, 18.6-31.3). The main toxicities recorded were non-hematological. Thirty-one patients (37 %) experienced grade 3/4 adverse events, the most common being hand-foot syndrome (9.8 %). No fatal toxicity resulting from this regimen was recorded.

CONCLUSIONS

Considering the toxicity profile and survival outcomes, the combination regimen of capecitabine and bevacizumab is a potentially feasible treatment option in elderly mCRC patients.

Higher body mass index and larger waist circumference may be predictors of thyroid carcinoma in patients with Hürthle-cell lesion/neoplasm fine-needle aspiration diagnosis

OBJECTIVE

High body mass index (BMI) has been found to be associated with raised thyroid cancer risk, particularly in women. We examined the associations for BMI and waist circumference (WC) with thyroid cancer risk among women with Hürthle-cell lesion/neoplasm (HLN) on fine-needle aspiration biopsy (FNAB) with the hypothesis that BMI and WC could guide the management of these challenging indeterminate lesions.

METHODS

This cross-sectional study included 224 women with HLN who underwent thyroidectomy. In all patients, TSH and thyroid auto-antibodies were evaluated, and thyroid nodule features were recorded. Patients were grouped according to BMI (<30 or ≥30 kg/m(2)) and WC (<88 or ≥88 cm). Relationships of thyroid cancer with BMI and WC were assessed using logistic regression analysis.

RESULTS

Mean weight, BMI (31·26 ± 5·1 vs 26·47 ± 5·9, P < 0·001), WC (98·23 ± 7·6 vs 86·18 ± 11, P = 0·001), and proportion of patients with high BMI (≥30 kg/m(2)) (65·9 vs 33·8%, P < 0·001) or large WC (≥88 cm) (84·1 vs 47·9%, P < 0·001) were significantly higher in malignant group compared to benign group. In regression analysis, BMI and WC significantly associated with existence of malignancy. Malignancy risk was 3·819-fold higher (95% CI: 2·068-7·054) in BMI≥30 kg/m(2) group compared to BMI<30 kg/m(2), which was independent of TSH and age. Large WC was also associated with increased risk (OR = 5·593, 95% CI: 2·736-11·434). Baseline tumour characteristics were similar according to BMI and WC groups.

CONCLUSIONS

A great BMI and large WC were associated with higher thyroid cancer risk in patients with FNAB diagnosis of HLN. Further studies are needed to use BMI or WC in the management of patients with HLN.

Should insulin resistance be screened in lean hirsute women?

The role of insulin resistance (IR) is well-documented in obese women with polycystic ovary syndrome (PCOS). Controversies exist concerning the presence of IR in idiopathic hirsutism (IH) or if it is a manifestation of high body mass index (BMI). We aimed to investigate the presence/absence of IR in lean hirsute women. One-hundred fifty-one lean women with hirsutism [96 PCOS (group 1) and 55 IH (group 2)] and 58 age-and BMI-matched healthy controls (group 3) were recruited in the study (mean age 25.21 ± 6.1 versus 26.26 ± 4.6years; BMI 21.79 ± 1.7 versus 22.02 ± 2.2 kg/m(2), respectively). Significantly higher insulin and HOMA-IR, and significantly lower fasting glucose insulin ratio (FGIR), quantitative insulin sensitivity check index (QUICKI), reciprocal insulin, and Raynaud index were detected in groups 1 and 2 than in group 3 (p < 0.05). These IR indices were similar between groups 1 and 2. The number of patients with IR (HOMA-IR > 2, FGIR < 7.2, or QUICKI < 0.357) was significantly higher in groups 1 and 2 than in group 3, but was similar between groups 1 and 2. A higher frequency of IR occurs in lean hirsute women regardless of they having PCOS or IH. IR may contribute to aetiopathogenesis of IH, or may cause some metabolic abnormalities in these patients.

Retrospective comparison of cabergoline and bromocriptine effects in hyperprolactinemia: a single center experience

INTRODUCTION

Patients with hyperprolactinemia who require medical therapy are typically treated with dopamine agonists (DAs). In most cases, DAs normalize prolactin levels, control symptoms, and substantially decrease tumor size. Here, we aimed to compare the efficacy of cabergoline (CAB) and bromocriptine (BRC) in patients with hyperprolactinemia at a single center.

METHODS

Retrospective analysis of the clinical records of 498 patients with hyperprolactinemia [mean age 33.3 ± 10.8 years (range 16-66), 450 women, and 48 men] who had received either CAB (n = 450) or BRC (n = 48) was performed.

RESULTS

The mean age, gender distribution, and treatment duration were similar between the CAB and BRC groups (33.2 ± 11 vs. 34.1 ± 9.6 years, male/female 44/406 vs. 4/44, 18.7 ± 12.1 vs. 17.8 ± 6.0 months, respectively; p > 0.05 for all). Mean dosage was 1.5 ± 1.6 mg/week for CAB and 3.8 ± 2.7 mg/day for BRC. Baseline prolactin levels, frequency of galactorrhea, amenorrhea, oligomenorrhea, erectile dysfunction, infertility, and visual impairment were similar between the two groups, whereas the baseline tumor volume was higher in the CAB group. The prolactin normalization rate (87.4 vs. 41.4 %, p = 0.029) and tumor volume shrinkage (79.8 ± 39.1 vs. 54.1 ± 55.3 %, p = 0.015) were significantly higher in the CAB-treated patients than in the BRC-treated patients, while the tumor cure rates were similar. Symptom relief was higher in the CAB group than in the BRC group. More side effects were recorded in patients who took BRC (29.1 vs. 5.3 %, p < 0.001).

CONCLUSION

Our data revealed that CAB was more effective than BRC in controlling symptoms associated with hormone excess, normalizing serum prolactin levels, and shrinking prolactinomas.

High prevalence of Hashimoto's thyroiditis in patients with polycystic ovary syndrome: does the imbalance between estradiol and progesterone play a role?

OBJECTIVE

Some similar factors, such as genetic susceptibility and subinflammation/autoimmunity, contribute to development of both polycystic ovary syndrome (PCOS) and Hashimoto's thyroiditis (HT), suggesting a potential pathogenic link between the two common disorders. In this study, we investigated the relationship between PCOS and HT, considering the possible effect of PCOS-related hormonal and metabolic factors on thyroid autoimmunity.

METHODS

Eighty-six reproductive-age women diagnosed with PCOS according to Rotterdam criteria and 60 age-BMI matched control women were included in the study. All subjects had thyroid function tests, thyroid peroxidase anti-body (anti-TPO), thyroglobulin anti-body (anti-Tg), LH, FSH, estradiol, progesterone, androgens, fasting glucose, insulin, lipid, homeostasis model assessment insulin resistance (HOMA-IR) levels, thyroid and pelvic ultrasounds.

RESULTS

TSH, anti-TPO (p = 0.017), anti-Tg (p = 0.014), LH, DHEAS, testosterone, and HOMA-IR levels were significantly higher and progesterone were lower in PCOS women than in controls. Free T4, free T3, FSH, estradiol levels and thyroid volume were similar between the two groups. A higher percentage of PCOS patients had elevated TSH (26.7 and 5%; p = 0.001), anti-TPO (26.7 and 6.6%; p = 0.002), and anti-Tg (16.2 and 5%; p = 0.039). HT was more common in PCOS patients compared to controls (22.1 and 5%; p = 0.004). Estradiol (p = 0.003) were higher in anti-TPO positive PCOS women than anti-TPO negative ones. Anti-TPO was correlated positively with estradiol, estradiol/progesterone ratio, and TSH.

CONCLUSIONS

This study demonstrated a higher prevalence of HT, elevated TSH, anti-TPO, and anti-Tg levels in PCOS patients. Increased estrogen and estrogen/progesterone ratio seem to be directly involved in high anti-TPO levels in PCOS patients.

Acetylsalicylic Acid resistance in patients with type 2 diabetes mellitus, prediabetes & non-diabetic coronary artery disease

Objective : Several studies have demonstrated the beneficial role of antiplatelet therapy with acetylsalicylic acid (ASA) at atherosclerotic vascular disease. Antiaggregant effect of ASA is not uniform in all patients. Purpose of the present study is to evaluate the prevalence of ASA resistance in patients with type 2 diabetes mellitus (T2DM), pre-diabetes and non-diabetic coronary artery disease (CAD).

METHODS

Effect of ASA was assessed using the platelet function analyzer (PFA-100) system. Resistance to ASA was defined as a normal collagen/epinephrine induced closure time after one week of ASA therapy. Patients with non-diabetic CAD, pre-diabetes and T2DM were compared.

RESULTS

ASA resistance was found in 26 (37.1%), 6 (17.6%) and 41 (26.5%) patients in the groups, respectively (p=0.154). ASA resistance was found to be significantly higher in men, smokers and insulin users, besides this it was found to be significantly lower in beta blocker (BB) users, angiotensin converting enzyme inhibitor (ACEI) users with univariate analysis. However insulin usage was found to be the single effective parameter on ASA resistance in multivariate analysis.

CONCLUSION

There was no difference with regard to ASA resistance between groups. While ASA resistance was higher in men, smokers and insulin users, it was lower in patients using BBs and ACEIs.

The frequency of malignancy and the relationship between malignancy and ultrasonographic features of thyroid nodules with indeterminate cytology

Various approaches are available for the management of nodules that are evaluated to be indeterminate according to the results of thyroid fine needle aspiration biopsy. The present study aimed to determine the rate of malignancy and the ultrasonographic features that could be used as predictor of malignant pathologies at the nodules with indeterminate cytology. A total of 201 patients who underwent total thyroidectomy and whose fine needle aspiration biopsy results were evaluated to be Hurthle cell lesion (n = 99), follicular neoplasm (n = 61) and [corrected] suspicious for malignancy (n = 41) were enrolled in this study. Of these patients, 178 were females (88.6 %) and 23 were males (11.4 %). The rates of malignancy were found to be 33.3 % in the Hurthle cell lesion group, 23.0 % in the follicular neoplasm group and 53.7 % in the suspicious for malignancy group (p = 0.006). The comparison of the ultrasonographic characteristics of the malignant and benign nodules revealed hypoechogenicity and microcalcification to be more common in malignant nodules (34.3 vs. 16.9 %, p = 0.005; 27.1 vs. 13.1 %, p = 0.014; respectively). While 92.3 % of the malignant nodules were ≥1 cm, 82.9 % of the benign nodules were ≥1 cm (p = 0.042). We believe that as the patients at Hurthle cell lesion group have higher risk of malignancy than the patients with Follicular Neoplasia so total thyroidectomy will be suitable for these patients. [corrected]. In addition, microcalcification and hypoechoic nodules at patients with indeterminate cytology can be related with increased risk of malignancy. [corrected].

A rare presentation of subclinical Cushing's syndrome as a pubic fracture

Osteoporosis and bone fractures are commonly seen in patients with Cushing's syndrome (CS). Fractures usually occur in the vertebrae and ribs whereas pubic fractures are less common. Similar to obvious hypercortisolemia, subclinical hypercortisolemia can increase the risk of fractures. However, in subclinical cases, bone fractures are very rarely seen as the presenting symptom. We herein report the case of a 62-year-old postmenopausal woman who was presented with a pubic fracture. During the evaluation of the fracture, thoracoabdominal magnetic resonance imaging of the patient demonstrated an adrenal mass. Although the patient did not show any signs of overt hypercortisolism, an endocrinologic evaluation revealed hypercortisolism due to an adrenal tumor. Adrenalectomy was performed, which resulted in a cure of the disease. During the orthopedic follow-up, the patient's pubic area pain gradually improved, and the pubic fracture healed without any accompanying new bone fractures. One year after the surgery, a remarkable improvement was detected in the patient's bone density in spite of the lack of administration of any medications for osteoporosis. Subclinical CS can present as a pubic fracture, and awareness of this relationship can help physicians to diagnose the disease.

Relationship between thyroid nodules and non-functioning adrenal incidentalomas and their association with insulin resistance

OBJECTIVE

The relationship between insulin resistance and thyroid nodules in patients with non-functional adrenal incidentalomas (AI) is not clearly understood. The aim of this study was to determine the frequency of thyroid nodules in AI patients, as well as to evaluate any possible associations with disorders of insulin resistance.

METHODS

Patients diagnosed with a non-functional AI were approached for inclusion in the study. Insulin resistance was evaluated using homeostasis model assessment (HOMA-IR). All participants were screened for the presence of thyroid nodule by ultrasonography, and fine needle aspiration biopsies were obtained from consenting subjects.

RESULTS

One-hundred-thirteen patients with AI and 152 age-, BMI- and gender-matched healthy controls were enrolled. AI patients had higher waist circumference and waist/hip ratio than the control group. Metabolic syndrome, hypertension and type 2 diabetes mellitus rates were significantly higher in AI patients. HOMA-IR was similar between the groups. At least one thyroid nodule was observed in 42 (27.6%) of the controls compared to 55 (48.7%) of AI patients (p < 0.001). The mean number of thyroid nodules in AI patients was significantly higher than the control subjects (2.4 ± 0.9 versus 1.7 ± 1.0, p = 0.008). Mean nodule volume was similar between AI patients and the controls. A correlation could not be established between adrenal tumor/thyroid nodule volumes and the number of thyroid nodules, HOMA-IR, waist circumference, waist/hip ratio, BMI and thyroid function tests.

CONCLUSION

A higher prevalence of thyroid nodule and a higher number of thyroid nodules were determined in patients with AI compared to healthy controls.

Comparison of alendronate and raloxifene for the management of primary hyperparathyroidism

AIM

To evaluate and compare the efficacy of alendronate sodium (ALN) and raloxifene (RLX) for the management of primary hyperparathyroidism (PHPT) in postmenopausal female patients (pts) with osteoporosis.

METHODS

Twenty-four postmenopausal women with osteoporosis who were diagnosed with PHPT, but refused the option of surgery, were enrolled. Participants were sequentially randomized into two groups: an ALN-group of 12 pts (70 mg/week) and a RLX-group of 12 pts (60 mg/day). The control group consisted of 10 pts with PHPT who did not have any indications for surgery.

RESULTS

The decrease in ionized calcium levels was significantly more pronounced in the ALN group compared to the RLX and control groups (p<0.001). In terms of difference from baseline in bone mineral density (BMD) of the lumbar area in percentages over a period of 12 months, pts in the ALN and RLX groups both showed statistically significant improvements compared to pts in the control group (control vs ALN, p<0.001; control vs RLX, p<0.001). BMD measurements of the femoral and radial areas were comparable in all three groups.

CONCLUSIONS

ALN and RLX may improve bone density in the lumbar area of osteoporotic post-menopausal women with PHPT. The more significant decrease in serum calcium levels which was observed in the ALN group compared to both RLX and control groups, suggests that ALN could be used for the short-term control of calcium levels in patients awaiting surgery.

Comparison of octreotide LAR and lanreotide autogel as post-operative medical treatment in acromegaly

Long-acting somatostatin analogs are frequently used as adjuvant treatment of acromegaly patients after noncurative surgery. This sudy aims to compare the efficacy of octreotide long-acting release (OCT) and lanreotide Autogel (LAN) in acromegaly patients. Sixty-eight patients not cured by transsphenoidal endoscopic or microscopic pituitary surgery between 2003 and 2009 were retrospectively analyzed (25 men; 43 women; mean age 41.1 ± 10.9 years [range 18-65 years]). The patients were assigned randomly to OCT (n = 36) and LAN (n = 32) groups. Evaluations included insulin-like growth factor I (IGF-I) and growth hormone (GH) after oral glucose tolerance test (OGTT) 3, 6, 12 and 18 months after starting medical treatment; pituitary magnetic resonance imaging was performed before treatment and after 3 and 12 months. Patients achieving IGF-I levels within the age and gender normal range and GH level <1 μg/l following OGTT were considered a 'biochemical cure'. Mean IGF-I and GH values and tumor volumes (cm(3)) in the LAN and OCT groups were similar in the post-operative period before initiation of medical treatment. A statistically significant decrease in GH and IGF-I levels was obtained for both treatment groups at each follow-up visit compared to the previous value. Tumor shrinkage after 12 months of treatment was statistically significant in both groups but the percentage tumor shrinkage (28.5% vs. 34.9%, P = 0.166) and rate of patients achieving biochemical cure (63.9 and 78.1%, P = 0.454) were similar between OCT and LAN groups, respectively. OCT and LAN treatment options have similar efficacy for ensuring biochemical cure and tumor shrinkage in acromegaly patients who had noncurative surgery.

Reverse tissue expansion by liposuction deflation adopted for harvest of large sheet of full-thickness skin graft

Full-thickness skingraft is a valid option to release burn scar contractures with the main purpose of correcting the induced limitation in function and improve the disfiguring appearance of the scar. The main pitfall remains the limited availability of these grafts, especially when large sheets are needed. We present an application of a previously described technique known as reverse tissue expansion, which permits the harvesting of a large sheet of full thickness skin graft when needed. This method was adopted to release a burn scar contracture in a 32-yr-old man who sustained a 65% TBSA burn secondary to a gasoline tank explosion at the age of 7 yr followed by multiple reconstructive procedures. The patient presented with a disfiguring anterior neck contracture coupled to limited range of motion. Improvement of neck extension was contemplated using full-thickness skin graft harvested following reverse tissue expansion achieved by deflation liposuction of the donor site.

The role of negative pressure wound therapy in the treatment of fourth-degree burns. Trends and new horizons

The term "fourth-degree burn" is not very often found in the literature because it is often associated with lethal injury. These injuries are characterized by exposure of viable tissue such as tendon or bone and are associated with challenging wound closure. The goal of reconstruction is to provide adequate soft tissue coverage and restoration of function. Several treatment modalities have been used to serve this purpose. We present four male patients with fourth-degree burns of the extremities, treated with negative pressure wound therapy. The patients' age ranged from 15 to 49 yr (mean, 28 yr). The total body surface area burned ranged from 3 to 60% (mean, 34.25%). Negative pressure wound therapy was applied for 16-30 days (mean, 23.75 days). Three split-thickness skin grafts and one bipedicled local flap were performed. Wound closure was completed in 28 to 50 days. The results were satisfactory for both physicians and patients. Our longest follow-up was three years. The results achieved in this group of patients revealed the negative pressure wound therapy was a reliable alternative method in the treatment of fourthdegree burns.

Clinical and radiological findings in macroprolactinemia

Hyperprolactinemia is the most common abnormality of the hypothalamic-pituitary axis. The aim of this study was to investigate the clinical and radiological features of patients with macroprolactinemia. The study population consisted of patients with elevated serum prolactin (PRL) concentrations who presented to our Endocrinology outpatient clinic. Detection of macroprolactin (macroPRL) was performed using the polyethylene glycol precipitation method. Patients in which macroPRL made up more than 60% of total PRL levels were stratified into the macroPRL group, while the remaining patients were placed in the monomeric prolactin (monoPRL) group. A total of 337 patients were enrolled with a mean age of 33.8 ± 10.8 (16-66) years and a male/female ratio of 29/308. Eighty-eight of the patients (26.1%) had an elevated macroPRL level. The mean age in the monoPRL group was higher than in the macroPRL group (35.0 ± 10.1 vs. 30.7 ± 9.8, P = 0.016). The mean PRL levels (ng/ml) in the macroPRL and monoPRL groups were similar (168.0 ± 347.0 vs. 238.8 ± 584.9, P = 0.239). Frequency of amenorrhea, infertility, irregular menses, gynecomastia, and erectile dysfunction were also similar in both groups. More patients in the macroPRL group were asymptomatic compared to the monoPRL group (30.2 vs. 12.0%, P = 0.006). Compared to the macroPRL group, the monoPRL group had a higher frequency of galactorrhea (39.2 vs. 57.1%, P = 0.04) and abnormal magnetic resonance imaging findings (65.3 vs. 81.1%, P = 0.02). Elevated macroPRL levels should be considered a pathological biochemical variant of hyperprolactinemia that may present with any of the conventional symptoms and radiological findings generally associated with elevated PRL levels.

A comparative study of pre-operative imaging methods in patients with primary hyperparathyroidism: ultrasonography, 99mTc sestamibi, single photon emission computed tomography, and magnetic resonance imaging

AIM

This study compares the accuracy rates achieved in ultrasonography (US), 99mTc-sestamibi (MIBI), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI) as imaging methods used in the pre-operative localization of the enlarged parathyroid glands.

SUBJECTS AND METHODS

For the purposes of this study, US, MIBI, SPECT, and MRI were performed on 98 patients with primary hyperparathyroidism (pHPT). All patients underwent parathyroidectomy.

RESULTS

Pre-operative localization of an abnormal parathyroid gland was successfully performed in 82 of the cases scanned with US (83.7%), while the result was 66 in the cases scanned with MIBI (67.3%), 71 of the cases were successfully localized with SPECT (72.4%), while MRI revealed the diseased gland in only 60 of the total cases (61.2%). In MIBI-positive and -negative patients there was a statistically significant difference among cases in terms of adenoma volume (1.30±1.51 vs 0.58±0.91, p<0.05). Sensitivity, specificity and diagnostic accuracy values were 87.2%, 25.0%, and 83.0%; 70.2%, 50.0%, and 69.4%; 75.5%, 50.0%, and 74.5%; 63.8%, 50.0%, and 63.3% for US, MIBI, SPECT, and MRI, respectively. The respective values for sensitivity, specificity, and diagnostic accuracy were 94.9%, 25.0%, and 91.1% when US was combined with MIBI.

CONCLUSIONS

Combining US and MIBI as imaging methods for pre-operative imaging of pHPT often produces more satisfactory results. While the accuracy of US is relatively low in the ectopic localizations, the size of the lesion can be an important factor in the accuracy achieved with MIBI.

Impaired gallbladder motility and the effect of metformin therapy in patients with polycystic ovary syndrome

OBJECTIVE

  Impaired gallbladder (GB) emptying is a well-documented contributor to gallstone formation. The aim of this study was to evaluate GB motility in patients with polycystic ovary syndrome (PCOS).

METHODS

  The study population consisted of 36 PCOS patients and 20 healthy controls. GB volume was calculated using the ellipsoid formula (π/6 × L × D × W) after three-dimensional measurements were made by ultrasound [length (L), width (W) and depth (D)]. Following the determination of fasting GB volume (V0), patients were given a standard liquid meal. GB volume measurement was then repeated after 10, 20, 30, 40, 50, 60, 75 and 90 min. Gallbladder ejection fraction (GBEF) was calculated after each measurement. PCOS patients were re-evaluated after a 12-week course of metformin therapy at a dose of 1000 mg/day.

RESULTS

  Mean baseline GB volume (V0) was significantly higher in the patient group compared to the control group (27·2 ± 12·5 cm(3) vs 13·3 ± 7·0 cm(3) , P < 0·001). While baseline GBEF values were similar between groups, increases in GBEF were significantly lower in the PCOS group starting from 20 min after consumption of a standard test meal. A 12-week course of metformin therapy resulted in significant improvements in GB volume and GBEF values with a reversal of metabolic and hormonal abnormalities.

CONCLUSION

  For the first time in the literature, we managed to demonstrate impaired GB motility in patients with PCOS. Metformin therapy not only improves the metabolic and hormonal imbalances associated with PCOS but also has a positive influence on GB motility.

Evaluation of hearing loss in patients with Graves' disease

Hearing loss has commonly been reported in association with thyroid disorders and during treatment with propylthiouracil. The relationship between hyperthyroidism and the auditory system has not been previously investigated. The aim of this cross-sectional, case-control study was to investigate hearing loss in patients with Graves' disease (GD). The study population consisted of patients with newly diagnosed GD and healthy controls. Pure tone audiometry at frequencies of 250, 500, 1000, 2000, 4000 and 8000 Hz, along with immittance measures including tympanometry and acoustic reflex tests, were performed in all participants. Twenty-two GD patients and 22 healthy controls consented to inclusion in the study. The differences between groups with regards to age and gender distribution were statistically insignificant (P = 0.567 and P = 0.757, respectively). The hearing thresholds of right and left ears were also similar in both groups (P > 0.05). When single-ear evaluations were taken into account (total of 44 ears for both groups), hearing thresholds in the GD group were significantly higher than healthy controls at all frequencies (P < 0.05). Following testing at the designated frequencies, the only significant effect of thyrotoxicosis was observed with frequencies of 4000 and 8000 Hz. The odds ratio for having hearing loss at a frequency of 8000 HZ associated with GD was 14.97 (95% confidence interval 4.03-55.64). In patients with GD, right and left pure tone audiometric findings at a frequency of 8000 Hz correlated positively with FT3, FT4 and negatively with TSH. Our results are highly suggestive of a decrease in hearing ability in patients with GD, particularly at high frequencies. Further studies are needed to help elucidate the mechanisms behind hearing loss which develops in association with GD.

Evaluation of ovarian reserve based on hormonal parameters, ovarian volume, and antral follicle count in women with type 2 diabetes mellitus

OBJECTIVE

The aim of this study was to evaluate ovarian reserve of women with type 2 diabetes mellitus (T2DM).

METHODOLOGY

Eighty-nine women with T2DM and 73 healthy controls were enrolled and divided into three age groups [group 1 (20-29 yr), seven diabetics and 18 healthy controls; group 2 (30-39 yr): 35 diabetics and 35 healthy controls; and group 3 (40-49 yr): 47 diabetics and 20 healthy controls]. All participants were subjected to transvaginal ultrasonographic examination on the third day of their menstrual periods for the determination of ovarian volume and total antral follicle count (AFC).

RESULTS

A significant difference in mean FSH levels (international units per liter) was observed between women with diabetes and healthy controls in all age groups (group 1, 7.8 ± 0.9 vs. 5.0 ± 1.0; group 2, 8.2 ± 1.1 vs. 7.2 ± 1.8; group 3, 9.5 ± 3.2 vs. 6.4 ± 2.4; P < 0.001 for all). Similarly, mean AFC was significantly lower in patients with T2DM than in healthy controls in all age groups (group 1, 21.1 ± 4.8 vs. 25.0 ± 9.1; group 2, 10.4 ± 5.2 vs. 23.0 ± 9.5; group 3, 6.0 ± 3.5 vs. 21.7 ± 2.1; P < 0.001 for all). A statistically significant difference in total ovarian volume was only observed in group 1 (9.7 ± 3.0 in T2DM patients vs. 6.8 ± 2.7 in healthy controls; P = 0.002). AFC was found to be negatively correlated with FSH (r = -0.406, P < 0.001), age (r = -0.618, P < 0.001), glycolized hemoglobin (r = -0.505, P < 0.001), and fasting blood glucose (r = -0.687, P < 0.001).

CONCLUSION

In this pioneer study, the first to evaluate ovarian reserve in T2DM patients, we managed to demonstrate lower ovarian reserves in women with diabetes compared with healthy controls.

Serum transforming growth factor-beta levels in patients with vitamin D deficiency

BACKGROUND

Transforming growth factor-beta 1 (TGF-β1) contributes to tissue repair by promoting tissue fibrosis, and elevations have been reported in patients with bone marrow fibrosis. The aim of this study was to evaluate the relationship between TGF-β1 levels and vitamin D deficiency.

METHODS

All patients presenting to the outpatient Endocrinology and Metabolic Diseases clinic between June and September of 2008 were approached, and consenting patients who were deemed suitable candidates were enrolled. Hematological parameters were measured, along with serum levels of total and ionized calcium, phosphorus, parathyroid hormone, iron, folic acid vitamin B12 levels, 25 OH vitamin D3 (25OHD(3)) and TGF-β1.

RESULTS

A total of 132 patients were included in the study. Patients were divided into 4 groups based on levels of 25OHD(3) [group 1 (<5 ng/ml), 20 patients; group 2 (5-15 ng/ml), 38 patients; group 3 (16-30 ng/ml); and group 4 (>30 ng/ml), 28 patients]. TGF-β1 levels were higher in patients in group 1 compared to the other groups. Transforming growth factor-beta levels correlated negatively with vitamin D3 and positively with leukocyte count, platelet count, of MCV and MCH. Multiple regression analyses revealed TGF-β1 levels to be associated with 25OHD(3) as well as with platelet count.

CONCLUSIONS

Results of this study are suggestive of the presence of a significant relationship between TGF-β and vitamin D deficiency. Increased TGF-β1 and platelet count may be an early indicator of bone marrow fibrosis in patients with vitamin D deficiency.

Gestational diabetes and subclinical inflammation: evaluation of first year postpartum outcomes

AIM

The aim of this study was to evaluate the relationship between sublinical inflammation and glycemic status in patients with gestational diabetes mellitus (GDM).

METHODS

Sixty-one patients with GDM and 40 healthy pregnant women were included in the study. Fasting blood glucose (FBG), insulin, high sensitivity C-reactive protein (hsCRP), lipid parameters and carotid artery intima-media thickness (CIMT) were measured. Fifty-five of the patients with GDM returned for a follow-up visit scheduled at 1-year post-partum. These patients were subjected to 75 g oral glucose tolerance test (OGTT) followed by an evaluation of metabolic and subclinical inflammatory parameters were evaluated.

RESULTS

The mean FBG, insulin, homeostasis model assessment insulin resistance (HOMA-IR), triglyceride (TG), hsCRP levels and CIMT in the women with GDM were significantly higher than those in the control group. C-reactive protein and CIMT were positively correlated with insulin, HOMA-IR, glucose value at the time of the OGTT 50, prepregnancy body mass index, TG and FBG. Multivariate logistic regression analysis on patients with sustained hyperglycemia one-year postpartum revealed elevated hsCRP levels to be independent risk factors for the development of dysglycemia.

CONCLUSIONS

Elevated hsCRP levels could be predictors of progression to T2DM later in life in patients with GDM.

Thyrotropin secreting pituitary adenoma accompanying a silent somatotropinoma

Thyroid stimulating hormone (TSH) secreting pituitary adenomas are rare tumors manifested as hyperthyroidism with goiter in the presence of elevated TSH. We present a case with pituitary adenoma secreting both TSH and growth hormone (GH) with the prominent clinical findings of hyperthyroidism but without clinical findings of acromegaly. Pituitary magnetic resonance imaging revealed a macroadenoma. Transsphenoidal surgery was performed twice. The immunohistochemical staining showed that tumor cells were strongly reactive to GH and relatively mildly reactive to TSH. Control pituitary imaging revealed a residual macroadenoma, and long acting octreotide treatment was administered. After two years of the treatment, tumor size remained the same while thyroid function tests and insulin-like growth factor 1 (IGF-I) values returned to normal ranges. In conclusion, we always recommend hormonal examinations for all patients who have pituitary adenoma without signs and symptoms of acromegaly.

Cost analysis of acute burn patients treated in a burn centre: the Gulhane experience

Even if calculating the exact cost of burn treatment is a very hard task, the study of cost analysis provides financial perspective. We performed a cost analysis study in our burn centre to respond to questions about total patient treatment cost and the length of hospital stay. We reviewed all patients admitted to the Gulhane Military Medical Academy Burn Centre in Ankara, Turkey, between March 2005 and August 2008. Forty-three patients with major burns were identified on the basis of the study criteria. The data regarding total treatment cost and the length of hospital stay for each type of burn (flame, scald, electric) were collected at the end of the study. The average total body surface area burned was 36 ± 7%.. The average duration of hospital stay was 73 ± 33 days. Patients with electrical burns stayed longer in hospital than patients with other types of burn injuries. Each one per cent of burn corresponded to a mean hospital stay of two days. The overall mean total cost was $US 15,250. The mean total cost of electrical burns was the highest, with $US 22,501 ± 24,039. Even if the costs associated with burn injury are higher than some other well-known health-related problems, they have not been much studied. Reports have produced different results, but it should be kept in mind that although the results of cost analysis studies may vary they must be performed in all newly established burn centres in order to form a financial overview.

Prevalence of incidental thyroid cancer and its ultrasonographic features in subcentimeter thyroid nodules of patients with hyperthyroidism

In patients, who undergo surgery for hyperthyroidism, many cases of incidental thyroid cancer (ITC) have been detected. In the literature, there is no study about ITC in subcentimeter nodules in these patients. We performed this study to determine the frequency of ITC in subcentimeter nodules and ultrasonographic features that can predict malignancy in the patients with hyperthyroidism. We retrospectively reviewed our database about 3114 patients, who underwent thyroidectomy in our hospital. Among 869 patients (27.9%), who were operated because of hyperthyroidism, we enrolled 337 patients, who underwent total thyroidectomy and had subcentimeter nodule [59 Graves’ disease (GD) 98 subcentimeter nodule; 278 toxic multinodular goitre (TMNG), 359 subcentimeter nodule], in this study. Twenty-five nodules with ITC and 432 benign nodules have been detected and compared for ultrasonographic (US) features. Incidental thyroid cancer detection ratio was 5.4% [10.2% (10/98) in subcentimeter thyroid nodules in individuals with GD, and 4.1% (15/359) in individuals with TMNG, P = 0.018)]. Significant differences have been observed between the groups in terms of microcalcification in US examination of malign and benign subcentimeter thyroid nodules and the ratio of anterioposterior diameter to transverse diameter (A/T) ≥1 [(OR = 5.172; 95% CI: 1.495–17.886, P = 0.015), and (OR = 5.930; 95% CI: 1.531–22.971, P = 0.007), respectively]. We detected a higher incidence of ITC in subcentimeter thyroid nodules in GD compared to TMNG. US examination of subcentimeter nodules in hyperthyroid individuals has indicated that microcalcification and ratio of A/T ≥1 are the parameters that predict malignancy.

Comparison of the prevalence and sonographic features of thyroid nodules accompanying autoimmune thyroid diseases

INTRODUCTION

The coexistence of thyroid nodules and autoimmune thyroid disease (ATD) has been widely reported. The aim of our study was to retrospectively evaluate the prevalence and sonographic features of malignancy of thyroid nodules in ATD patients.

MATERIAL AND METHODS

We retrospectively analysed data from 500 patients with ATD in our hospital. We recorded ultrasonographic, histopathological and laboratory features of these patients. Thyroid ultrasonography was performed on all the patients, as well as fine needle aspiration biopsy (FNAB) of the thyroid nodule, when required. Patients underwent operations depending on the result of the FNAB.

RESULTS

Of the 500 with ATD (400 female and 100 male; mean age = 42.4 years), 300 (60%) had Hashimoto's thyroiditis (HT) and 200 (40%) presented with Graves' disease (GD). The frequency of thyroid nodules was statistically significantly higher in those with GD (37.8%) than in those with HT (24.3%) (p 〈 0.001). One hundred and forty-nine nodules underwent FNAB (37.8%, 76 out of 200 had GD and 24.3%; 73 out of 300 had HT). The results of the cytological examination were: non-diagnostic cytology, benign, malignant and indeterminate in 19.4%, 73.8%, 2% and 4.5% of the nodules, respectively. When 55 GD and 32 HT patients, on whom total thyroidectomy had been carried out, were evaluated, the incidence of thyroid carcinoma was similar between patients with GD (n = 3, 5.5%) and HT (n = 2, 6.3%) (p 〉 0.05).

CONCLUSIONS

We observed that the prevalence of thyroid nodules in patients with GD was higher than patients with HT. However, in general, the characteristics of the nodules and FNAB results were similar in both ATDs.

A report of ten patients with thyroid hemiagenesis: ultrasound screening in patients with thyroid disease

BACKGROUND

Thyroid hemiagenesis (TH) is a rare congenital abnormality of the thyroid gland, characterised by the absence of one lobe. The true prevalence of this congenital abnormality is not known because the absence of one thyroid lobe usually does not cause clinical symptoms by itself. This study aims to identify the frequency of TH and associated diseases in outpatients referred to our clinic for the first time.

SUBJECTS AND METHODS

6242 outpatients, who were referred to our thyroid clinic between January 2008 and March 2009 and underwent thyroid ultrasonography, were retrospectively analysed. For patients with TH, demographic data, family history of thyroid disorders, drugs administered, thyroid function parameters, thyroid autoantibodies were examined and thyroid sonography was carried out. Tc99m pertechnetate scintigraphy was performed to confirm the diagnosis of hemiagenesis and to rule out coexisting ectopic thyroid tissue.

RESULTS

We identified 10 cases of TH in 6242 outpatients with various thyroid disorders, 8 women and 2 men (ratio 4:1), age 21-63 years, indicating a prevalence of 0.16%. Associated thyroid disease in these patients included: 1 patient with nodular Graves' disease, 1 with Hashimoto's thyroiditis, 4 with euthyroid nodular goiters and 2 with euthyroid multinodular goiters. Nine patients were clinically asymptomatic. However, the patient with nodular Graves' disease presented thyrotoxicosis.

CONCLUSIONS

TH is a rare congenital anomaly and prevalence of TH in thyroid patients is 0.16%. In our study, the most frequently seen thyroid disease accompanying thyroid hemiagenesis was nodular goiter.

Somatotropin adenoma and resistance to thyroid hormone

Resistance to thyroid hormone (RTH) is a rare disease characterized by non-suppressed TSH in spite of high free thyroid hormone levels. Up to date, in the literature, there are more than 600 RTH cases, but co-incidental hypophyseal adenoma was reported in only 1 case. In the literature, despite reported cases with thyrotropinoma accompanying RTH, we could not find a case with somatotropinoma accompanying RTH. Here, we report a 34-yr-old male patient, who was admitted to the hospital with complaints of dyspnea, chest pain, and palpitation in 2003. His alpha- subunit value was normal and the alpha-subunit/TSH molar ratio was <1. His response to TRH stimulation test was normal. His TSH level was suppressed in the T3 suppression test. Hypophyseal magnetic resonance imaging showed a 6-mm hypophyseal microadenoma. Levels of all anterior hypophyseal hormones, including GH and IGF-I, were normal. Oral glucose tolerance test (OGTT)-GH suppression test was normal. The patient was followed with the diagnosis of RTH and incidental hypophyseal adenoma. After 3 yr, because of high levels of IGF-I: 901 ng/ml (68-324), the OGTT-GH suppression test was reported and no suppression was detected. Thus, the patient was referred to surgery with the pre-diagnosis of RTH and acromegaly. Immunohistochemistry was showed as strong GH staining with low Ki 67 index while TSH and other anterior hypophyseal hormones stainings were negative. Post-operative thyroid hormones were still high.

Long-term outcomes of ultra-thin porous polyethylene implants used for reconstruction of orbital floor defects

PURPOSE

The objective of this article is to present the long-term outcomes of ultra-thin polyethylene implants used for orbital floor reconstruction in facial trauma patients.

MATERIALS AND METHODS

From 1998 to 2004, 38 patients underwent orbital floor reconstruction with porous polyethylene implants with a mean follow-up of 4 years. A subciliary incision and preexisting facial wounds or scars were used. The boundaries of the maxillofacial injury and the orbital volumes of both orbits were assessed by computed tomography images obtained pre- and postoperatively. In all patients, ultra-thin porous polyethylene implants in various sizes were used to reconstruct the orbital floor defect.

RESULTS

None of the patients needed removal of the implants during the follow-up. The volume increase of the traumatized orbits ranged from 0.04 to 6.18 (average 3.12 +/- 1.48) mL compared with the intact orbit (P < 0.01). This difference was not significant postoperatively (P > 0.01). Postoperative ectropion in three cases was corrected under local anesthesia. Persistence of complications were as follows: enophthalmos, 3 in 28; diplopia, 1 in 16; dystopia, 1 in 4; and infraorbital nerve hypoesthesia, 3 in 31. One patient underwent late enucleation of the globe because of initial penetrating trauma.

CONCLUSIONS

We recommend the use of ultra-thin porous polyethylene implants in the reconstruction of the orbital floor defects in facial trauma patients. The implants are durable in the long-term and mimic the anatomy of the thin orbital floor and avoid the morbidity of autogenous bone grafts.

Imaging meningiomas: Is there a need for post-contrast FLAIR?

AIM

The aim of this study was to compare post-contrast fluid-attenuated inversion recovery (FLAIR) imaging with post-contrast T1-weighted images (T1WI) in depicting meningiomas.

MATERIALS AND METHODS

Twenty-nine patients with 46 meningiomas were included in this study. FLAIR and T1WI were obtained before and after intravenous administration of gadopentetate dimeglumine. The contrast enhancement degree, contrast enhancement pattern, lesion conspicuity, and the detection of the dural sign were compared between post-contrast FLAIR images and post-contrast T1WI.

RESULTS

The enhencement degree on FLAIR was equal or less than T1WI for all meningiomas. Among 46 meningiomas 38 (83%) enhanced homogeneously and eight (17%) inhomogeneously on T1WI. On contrast-enhanced FLAIR images, of the total 46 meningiomas 22 (48%) enhanced homogeneously, eight (17%) inhomogeneously, whereas 14 (30%) meningiomas showed a peripheral rim enhancement not observed on T1WI. Two (5%) meningiomas showed no contrast enhancement on post-contrast FLAIR images. Among the 14 meningiomas showing rim enhancement using FLAIR imaging, 12 (85%) were measured to be 2 cm or more in diameter. A dural tail sign was found in 16 (35%) and 23 (50%) meningiomas on post-contrast T1WI and FLAIR images, respectively.

CONCLUSION

In contrast to other extra-axial diseases, post-contrast FLAIR sequence was not found to be a valuable adjunct to contrast-enhanced T1WI in the depiction of meningiomas.

High incidence of antinuclear antibodies that recognize the matrix attachment region

The matrix attachment region (MAR) is a distinctive genomic DNA involved in a variety of nuclear processes through association with the nuclear matrix. Recent studies suggest that nuclear matrix is altered in the process of apoptosis and presented to the immune system, leading to the production of autoantibodies against its protein components. To see whether MARs are also recognized by autoantibodies, a collection of human sera containing antinuclear antibodies was screened for the presence of binding activities against cloned MARs. We found that MAR-binding activities are quite common in these sera. There was a positive correlation among the MAR-binding titers for three different MAR probes. As expected, the MAR-binding activity was copurified with serum IgG, and subclass analysis with affinity-purified IgG on MAR-Sepharose showed a predominance of IgG2 isotype. Several lines of evidence implied that the anti-MAR antibodies detected here is distinct from the ordinary anti-DNA antibodies that are reactive to bulk DNA.

Lower extremity salvage using a free flap associated with the Ilizarov method in patients with massive combat injuries

Nine patients with massive combat injuries of the lower extremities were treated with Ilizarov bone transport in conjunction with free muscle flap coverage. In 4 patients soft-tissue coverage was applied first, and distraction osteogenesis was initiated 4 to 6 weeks later. In 3 patients both methods were applied simultaneously, and in 2 patients soft-tissue coverage occurred after distraction. The bones healed well, and all flaps survived. The segmental defects ranged from 8 to 16.5 cm in greatest dimension. The total disability time from initial injury ranged from 16 to 25.5 months. In all patients, full union of the tibia was achieved, and no osteomyelitis occurred. However, in 2 patients the applied flap became depressed, necessitating another flap operation. Despite late treatment in all 9 patients, successful results were obtained. Maintaining the original length of the tibia and providing timely, definitive treatment offer the best outcome for repair of massive injuries of the lower extremities. The Ilizarov transport method, used in combination with muscle flap coverage, represents an effective therapy for repair of massive injury of the lower extremities.

Magnetic resonance imaging and morphometric histologic analysis of prostate tissue composition in predicting the clinical outcome of terazosin therapy in benign prostatic hyperplasia

PURPOSE

To determine whether magnetic resonance imaging (MRI) or quantitative color-imaged morphometric analysis (MA) of the prostate gland are related to the clinical response to terazosin.

METHODS

Thirty-six male patients with symptomatic benign prostatic hyperplasia (BPH) with a serum prostate-specific antigen level of 4-10 ng/mL underwent MRI with body coil, transrectal prostate ultrasonography and biopsy prior to terazosin therapy. For MRI-determined stromal and non-stromal BPH, the ratio of the signal intensity of the inner gland to the obturator internus muscle was evaluated. Histologic sections were stained with hematoxylin and eosin. The MA of the specimens was performed by Samba 2000. Results of the two techniques were interpreted according to the terazosin therapy results.

RESULTS

The mean stromal percentage was 60.5 +/- 18.0%. No statistically significant relationship was found between the clinical outcome of terazosin and the MRI findings. The MA results showed a significant relationship between the percentage of stroma and the percent change of the peak urinary flow rate, but not with the percent change of the international prostate symptom score after terazosin therapy (P < 0.05).

CONCLUSION

Magnetic resonance imaging alone is not sufficient in predicting the response to terazosin therapy. Morphometric analysis of BPH tissue composition can be used in predicting the clinical outcome of terazosin therapy but it is suitable only in patients for whom prostatic biopsy is necessary in order to rule out prostate cancer.