Epidemiology and histology of malignant thyroid nodules in North East Region of Romania (Moldavia) before and after alimentary salt universal iodination

Research on the relationship between iodine exposure and thyroid cancer risk is limited and the findings are inconclusive.

OBJECTIVES

Given this molecular data on iodine we decided to evaluate the changes of incidence and histology of thyroid cancer in the North-Eastern region of Romania (Moldavia) after the government decision from 2004 that introduced the universal iodination of alimentary salt. After this decision values of urinary iodine increased from 50 microg/L (2001-2002) to 117 microg/L (2006 -2008).

MATERIAL AND METHODS

We compared the incidence and the histology of thyroid cancer in residents living in an area known as a mild endemic goiter region (Moldavia-Romania) between 2001-2004 with the incidence and the histology of thyroid cancer between 2005-2008 in the same region after the introduction of universal iodization of alimentary salt.

RESULTS

The number of papillary cancers increased from 125 cases (2001-2004) to 276 cases (2005-2008). The number of follicular cancer decreased from 52 cases (2001-2004) to 27 cases (2005-2008). The ratio between papillary and follicular cancers increased from 4.80 / 1 (2001-2004) at 10.61 / 1 (2005-2008). The number of medullar thyroid carcinoma increased from six cases (2001-2004) to 24 cases (2005-2008). Thyroid anaplastic carcinomas number increased from 7 cases (2001-2004) to 12 cases (2005-2008). The total number of thyroid cancer has increased dramatically after the introduction of universal iodination of alimentary salt with 178% compared to 2001-2004 (from 190 cases in 2001-2004 to 339 cases in 2005-2008), despite the fact that the number thyroidectomies decreased from 1734 (2001-2004) to 1449 (2005-2008).

CONCLUSION

After the introduction the universal iodination of alimentary salt starting from 2004 the total number of thyroid cancers increased comparative with the period before universal iodination of alimentary salt.

[Clinical profile of thyroid nodules in Iaşi, Department of Endocrinology, St. Spiridon Hospital, between 2005-2009]

Thyroid nodules are common, with up to 50% of the adult population having palpable nodules. With the use of ultrasound, up to 10 times more nodules are likely to be detected. Given this we decided to evaluate by retrospective study the incidence of thyroid nodule in the North-Eastern Region of Romania (Moldavia) between 2005-2009.

MATERIAL AND METHOD

We reviewed the records of patients admitted in the Department of Endocrinology, St. Spiridon Hospital Iaşi between 1.01.2005-31.12. 2009 (4712 patients) and with selected the cases with nodular goiter.

RESULTS

A total of 3105 cases of nodular goiter were identified. The women were most affected and highest prevalence was noticed for the patients with ages between 51-60 years. Most of the nodules were found in the right thyroidian lobe and the majority of the patients were euthyroid . The peak of incidence of nodular hyperthyroidism was different from that of diffuse hyperthyroidism.

CONCLUSIONS

Thyroid nodules are the most common endocrine problem and the increasingly frequent detection of nonpalpable thyroid nodules in asymptomatic patients requires new approaches for their management.

[Surgical treatment of hyperparathyroidism]

BACKGROUND

Hyperparathyroidism (HPT), the result of excessive secretion of the parathormone, is one of the most common endocrine disorders. In most forms of HPT, surgical parathyroidectomy is the best choice.

AIM

This paper aims to examine patients with hyperparathyroidism operated in First Surgical Unit Iaşi, in terms of indications, surgical technique and postoperative results.

MATERIAL AND METHOD

We performed a retrospective study, in First Surgical Unit Iaşi, during 2000-2008. Clinical, laboratory, intraoperative and histopathological data were included in a MS Access Office XP database. Statistical analysis was performed with the SPSS ver. 15.0 for Windows (Statistical Package for the Social Sciences, Chicago, Ilinois).

RESULTS

There were examined 34 patients with HPT: 32 cases were primary HPT (94.12%), and two cases with secondary HPT (patients with renal failure). The men/women ratio was 6/28 and mean age was 50.09 +/- 2.23 years old. Clinical presentation was variable: the dominant symptoms were osteoarticular (67.6%) followed by neuropsychological (64.7%), digestive (17.6%) and renal (11.8%). Associated diseases were recorded at 47.06% of patients: arterial hypertension--32.4%, coronary heart disease--23.5%, heart rhythm disorders--17.6%, diabetes--11.8%, biliary lithiasis--5.9%, renal lithiasis--8.8% and thyroid hypertrophy--55.9%. In 8 cases, primary hyperparathyroidism was associated with other diseases of the endocrine glands: 4 cases with Multiple Endocrine Neoplasia (MEN) type 1; a patient with von Recklinghausen disease; a patient with associated hypothyroidism and diabetes; two cases that with papillary thyroid carcinoma. Positive diagnosis was supported by determining serum calcium, phosphorus and serum concentration of the parathormone (PTH). All patients were evaluated by ultrasound exam; the sensitivity of the investigation was 88.23%. 99Tc-sestamibi scintigraphy was performed in 32.35% of patients with a sensitivity of 72.72%. Parathyroidectomy was performed by Kocher's incision in 88.23% and minimally-invasive open approach in 11.76%. The following types of interventions have been performed: tumor resections (73.53%), subtotal parathyroidectomies (17.6%), total parathyroidectomies (8.82%). In patients with associated thyroid disease total thyroidectomies (26.5%) and subtotal thyroidectomies were done (11.8%). The postoperative morbidity rate was 2.9% (transient hypocalcemia). Histopathological examination revealed the presence of parathyroidian adenoma in 67.6% of patients (N=23), parathyroidian hyperplasia in 26.5% (N=9) and parathyroidian carcinoma in the others 5.9% (N=2).

CONCLUSIONS

The diagnosis of HPT involves positive determination of calcium and PTH. The most useful imaging techniques, are 99Tc-sestamibi scintigraphy and ultrasonography, which locates in most cases, the parathyroid pathological glands. Surgical treatment is the only curative treatment of HPT, with medical treatment only role in preoperative preparation. The precise site of the parathyroidian lesion facilitates minimally-invasive approach. The postoperative follow-up is mandatory because of the increased potential for recurrence and for diagnosis of other endocrine tumors (in patients with MEN).

[Parathyroid glands involvement in multiple endocrine neoplasia]

Multiple endocrine neoplasias are syndromes characterized by the involvement of at least two endocrine glands. Parathyroid gland involvement is usually noted in Multiple Endocrine Neoplasia (MEN) type I and type II. Parathyroid glands tumor associated with endocrine pancreatic tumor, as well as pituitary tumors is the typical pattern of MEN I. The parathyroid gland is the most frequent abnormality in MEN I.

CASES REPORTS

We presented five cases with MEN I and parathyroid glands involvement. In three cases with young ages (28-33 years old) and familial setting, the MEN I syndrome was "complete" (parathyroid adenoma, gastrinoma or insulinoma and pituitary adenoma--prolactinoma or GH-secreting tumors), and, in the other two cases, with 57 and 68 years old respectively, the MEN I syndrome was "incomplete" with parathyroid glands and pituitary gland involvement. The cases with gastrinomas were operated in emergency for complication of peptic ulcer (perforation associated with peritonitis and gastro-intestinal bleeding); then the pancreatic tumors were diagnosed and left pancreatectomy with spleen preservation and respectively, tumor resection have been performed. Hyperparathyrodism was then diagnosed and subtotal parathyroidectomy has been performed in both cases. Unfortunately one patients died due to severe endocrine disorder. During the necropsy, the pituitary adenoma has been diagnosed. The third case with "complete" MEN was a women of 33 years old, admitted for severe hypoglycemia. The imagistic and laboratory test diagnosed a tumor situated into the pancreatic body, and an parathyroid adenoma. The resection of pancreatic tumor associated with resection of the parathyroid adenoma, in the same time, were performed. The other two cases with "incomplete" MEN were older then the first patients, and were diagnosed with hyperparathyrodism and pituitary gland tumor. The resection of parathyroid gland adenoma has been performed in both cases, with uneventful postoperative course. The literature data was also discussed.

CONCLUSIONS

The parathyroid glands involvement in MEN is common. There are two kinds of MEN associated with parathyroid gland involvement: the "complete" form, especially in young patients, with diffuse involvement of the parathyroid glands, and the subtotal parathyroidy is the best choice, and the "incomplete" form, especially in elderly, with the involvement of a single parathyroid gland; in this way, the resection of the adenoma associated with biopsy from the other parathyroid gland is the best approach. The presence of gastrinomas, complicate the disease prognosis and the surgical approach. The treatment of these patients is challenging and has to be done in multidisciplinary team.

[Compliance with bread fortified with vitamin D and calcium in elderly]

AIMS

The bakery products fortifying is an option for vitamin D daily intake supplementation. Our study has proposed the evaluation of the community-based elderly compliance to the daily administration of vitamin D fortified bread.

MATERIAL

A group of 33 subjects between 58 to 89 years of age (71 +/- 6.9 years) who were living in a nursing home for elderly people, from Iaşi, Romania. DIET: The patients have received daily 100 g bund enriched with 125 mg (5000 UI) D3 vitamin and with calcium carbonate (320 mg of elemental calcium) during 12 months.

METHOD

We had used 22 items questioner for evaluation of the Vitamin D supplementation compliance to the daily administration of the vitamin D fortified bread at the institutionalized patients.

RESULTS

Patients compliance was very good, 75% of these eating daily the fortified buns, 18% one at two days and the rest of the patients two days in a week. 76% of the patients have consumed the entire bun, 9% of the patients 3/4, 12% of the patient half bun and 3 % of the patients a quarter bun. For 79% of the patients the taste of the bread was good and 21% has complained some deficiencies. By the declaration of the 60% of the patients, the general health status was better at the end of the study.

CONCLUSION

Alimentary supplementation through vitamin D and calcium bread fortification is a practical possibility for prevention of the population vitamin D deficit.

[Thyroid ultrasonography. Interobserver and intraobserver variations]

Thyroid ultrasonography is a simple diagnostic method for assessing the prevalence of goitre in children, parameter useful in the estimation of iodine supply. The normal limits recommended by WHO and ICCIDD (following the ThyroMobil study) have been debated by studies which found smaller values, even in regions included in the ThyroMobil study.

AIM

To assess the importance of the inter- and intra-observer differences in the determination of thyroid volume in children.

MATERIAL AND METHODS

Thyroid volume in 30 children was estimated using the rotating ellipsoid formula by 3 different observers. One of them determined twice the volume in 25 children.

RESULTS

Mean interobserver variations were 9.51 +/- 8.8%. More important differences were between observer 1 and 3. The differences between every diameter were between 12 and 16%, more important for the longitudinal one. The intraobserver differences were 6.29 +/- 6.12%. We did not find a relation between the value of the thyroid volume and the interobserver (r2 = 0.13, p > 0.05) or intraobserver (r2 = 0.15, p > 0.05) differences.

CONCLUSIONS

Interobserver variation may be important, and can partially explain the disagreements on thyroid volume in children. Intraobserver differences, although present, are less calculated. It is important to establish standards for each geographical area and, as much as possible, by the same person. In order to obtain comparable data the techniques of the ultrasound volume evaluation should be harmonized.

[The role of fine needle aspiration biopsy in differentiated thyroid carcinoma]

Fine needle aspiration biopsy (FNAB) in evaluation of nodular goiter generated a true revolution. It is generally assumed that the use of FNAB reduces the number of surgical procedures by 50%, while doubles the proportion of carcinoma in surgically treated patients. The aim of the study was to demonstrate the utility of FNAB in preoperative diagnosis of thyroid carcinoma.

MATERIAL AND METHOD

We have investigated 3240 patients with nodular goiter by FNAB (MGG stain and morphometrical analysis), followed by morphological examination in those who underwent surgery.

RESULTS

Globally, FNAB had a good sensitivity (77%) and specificity (95%), which made an accuracy of 92%, proving its diagnostic value. In follicular carcinoma (FC), where the cytological diagnostic cannot be certain, morphometry helped the diagnostic: mean cells diameter was significantly higher (p < 0.001) in FC (9.5 mm) vs. thyroid adenoma (8.6 mm).

CONCLUSION

With good statistical value, FNAB remain a useful preoperative diagnostic method.

[Oxidative stress and immune response in eumenorrheic underweight patients]

Malnutrition is known to induce a state of immunodeficiency and a predisposition to death from infectious diseases. During fasting or starvation, it appears that oxidative stress is decreased. The goal of our study was to assess the interrelation between nutritional factors, oxidative stress and immune response. The malondialdehyde (MDA)-marker of lipid peroxidation, white blood cell count, differential count and hormonal status (FSH, LH, and cortisol) were followed in eumenorrheic underweight patients. MDA was significantly lower and lymphocyte count was significantly increased in eumenorrheic underweight patients as compared to normal weight patients. Gonadal and adrenal axes were found normal in eumenorrheic underweight patients. Body mass index was positively correlated with MDA and negatively correlated with lymphocyte count. Low levels of lipid peroxidation and non-suppressed immune function in underweight patients may be explained by an increased sensitivity to leptin but further studies are requested.

Osteoporosis in liver cirrhosis--overview

Osteoporosis can occur as a result of liver cirrhosis. The pathogenesis of reduced bone mineral density in liver cirrhosis is multifactorial. It can be caused by alterations in calcium and vitamin D homeostasis, as well as nutritional and dietary factors. Dual-energy X-ray absorptiometry (DXA) has become the gold standard in assessing bone mineral density in patients with liver cirrhosis. In such cases, patients can be treated with calcium and vitamin D supplements, bisphosphonates and hormonal replacement therapy (HRT).

[Lipids profile in a group of hypothyroid patients vs. treated hypothyroid patients]

Hypothyroidism, like obesity, is one of the pathological conditions most frequently associated to disorders of the lipid metabolism. Hypercholesterolemia is favored, due to the hormone deficit and to the decreased activity of the lipoprotein lipase.

MATERIALS AND METHOD

We observed the determination of the serum concentrations of TSH, of the total cholesterol level, of the triglycerides, HDL, LDL, VLDL and BMI as well.

RESULTS AND DISCUSSIONS

We observed the predominance of the female hypothyroid patients, ages 40 through 60 and BMI > 30kg/m2. The presence of the heart condition in the studied group was the predominance of the cases of ischemic heart disease. The cholesterol levels varied depending on the TSH levels. There are multiple mechanisms of the dyslipemic syndrome, its intensity depending on the degree of the thyroid insufficiency, however, not influenced being by its cause. It can be considered an indicator of the disease evolution or of the efficiency of the substitution treatment strategy. The absence of the total normalization of the lipid metabolism, under the conditions of a correct treatment strategy, may raise suspicions regarding a possible associated primitive hyperlipidemia, who need typical therapy.

[Determination of urinary iodine as a marker of iodine deficiency]

PURPOSE

Determination of ioduria in order to establish the actual degree of iodine deficiency in school-age children from 4 counties in Moldavia.

MATERIALS AND METHODS

Urinary iodine was determined in 927 school-children aged 7-14 years from 4 counties: Suceava, Iaşi, Neamţ and Botoşani. The determination was made by cerium-arsenate method and by a semi-quantitative method.

RESULTS

The median value of ioduria was 3 micrograms/dL in Suceava, 8.8 micrograms/dL in Iaşi, 7.1 micrograms/dL in Botoşani. In Roman-Neamţ 93.75% of all samples had a value of ioduria below 10 micrograms/dL. From this point of view, Suceava and Roman are with moderate iodine deficiency; Iaşi and Botoşani are with mild iodine deficiency.

CONCLUSIONS

Despite the existence of a program of iodine prophylaxis, there are still many regions in Moldavia with iodine deficiency, so it is important to have more measures of sanitary education and prophylaxis in these regions.

[Hyperprolactinemia and pregnancy]

Prolactin is a polipeptidic hormone secreted by the anterior pituitary gland, whose main role consists in the stimulation of lactation in the postpartum period. The increasing of prolactin secretion can be physiological (pregnancy and lactation) or pathological (hypothalamic and pituitary diseases, iatrogenic, etc.). The suppression of the hypothalamic-pituitary-gonadal axis and the resistivity of the ovary and gonadotropin action are induced in hyperprolactinemia, the amenorrhea and lack of ovulation being the result. Infertility associated with hyperprolactinemia is reversible with treatment, irrespectively to the type of treatment (radical or medical). Lowering of prolactin levels to normal or near normal is often necessary to permit ovulation. Dopamine-like drogs, as bromocriptine, appear to be safe for the developing fetus, at lest when the treatment is interrupted in the first trimester of pregnancy.

[Contribution of ultrasonography in the evaluation of subacute thyroiditis]

Ultrasonography is a useful tool in diagnosing and monitoring thyroid pathology. The aim of this study was to evaluate the value of thyroid ultrasonography in the follow-up of subacute thyroiditis (SAT). The study group included 48 subjects with clinical and biological diagnosis of subacute thyroiditis. All patients were evaluated by ultrasonography and followed-up for a mean period of 12 months. The evaluation protocol included biological data (TSH, T4, erythrocyte sedimentation rate--ESR) and ultrasonography, performed at 1, 2, 3, 6, and 12 months. Initially, all patients had an enlarged thyroid volume (median = 30.5 ml, range 23-90) and a low echogenicity, with an inhomogeneous aspect in 54.1% cases. After a mean period of 3 months thyroid volume had a significant reduction (median volume = 20.2 ml, range 7-36, p < 0.0001). Echogenicity was also significantly improved, with a decrement, on a semi-quantitative scale of 4 degrees (1 = normal, 4 = intense hypoechogenicity), from 3.25 to 2.48 (p < 0.0001). Almost half of the patients (45.8%) presented persistent (although slighter) hypoechoic/inhomogeneous pattern. Ultrasonographic abnormalities were not correlated with the intensity of the inflammatory syndrome and/or the thyroid status. Recurrence appeared in 10 (20.8%) patients. All patients presented a new thyroid enlargement (from a median = 16.1 ml to 31.5 ml, p = 0.056) and an extension of hypoechoic regions. The risk of recurrence could not be correlated with thyroid function, inflammatory syndrome or ultrasonographic aspect. There were not significant differences between the subgroups of patients with and without recurrence concerning the initial thyroid volume (p = 0.889), echogenicity (p = 0.735), TSH (p = 0.321) or ESR (p = 0.1332). Thyroid ultrasonography is useful not only for the initial diagnosis but also for the follow-up of patients with subacute thyroiditis. Remission and recurrence can be appreciated and monitored by the ultrasonographic pattern of the thyroid.

[Fertility in prolactinomas--considerations concerning some clinical cases]

Prolactinoma is a frequent endocrine cause of infertility in both man and women. The aim of this study was to evaluate female fertility in association with hyperprolactinemia. The study is a retrospective one, based on the cases monitored in the Endocrinology Department of Iaşi. From the 113 cases of prolactinoma in women we have selected 83 women aged between 18-45 years (fertile age). The diagnosis was suspected on clinical bases: endocrine (amenorrhea-galactorrhea, associated or isolated, spaniomenorrhea, infertility), and tumoral (headache, visual disturbances) syndromes and confirmed by biological (PRL dosage) and morphological (pituitary CT) tests. We classified the found associations between prolactinoma and fertility in: no correlation (previous pregnancies with no desire for another child--76 patients = 75.2%); prolactinoma diagnosed immediately after a pregnancy by persistency of galactorrhea, lack of menses reapparition, headache (16 cases = 15.8%); prolactinoma diagnosed before pregnancy, which was obtained thanks to the hyperprolactinemia treatment (9 patients = 8.9%). All 9 patients of the last group were in remission at the moment of pregnancy apparition and had a normal pregnancy, giving birth to normal children. Infertility associated with prolactinoma is reversible with treatment. Lowering of prolactin levels to normal is often necessary to permit ovulation. Bromocriptine used by pregnant women appears to be safe for the developing fetus, at least in our study where the treatment was interrupted in most cases in the first trimester of pregnancy.

[The influence of body weight upon the function of ovarian axis]

The relationship between the body weight and the function of hypothalamopituitary-ovarian axis was longtime studied. Frisch and Ravell (1971) have proposed the hypothesis that the onset of menarche is strong related to the achievement of a critical body weight. These authors observed that, despite the decrease in the last 120 years of the menarche age from 16.5 to 12.5 year-old, the body weight at which the menarche appears remains unchanged, 47.5 +/- 0.5 Kg. Many studies show the importance of both, body weight and fat mass percentage, in the appearance of menarche at puberty, or in the restoration of menses after the weight loss amenorrhea. Primary or secondary underweight amenorrhea can be associated to an eating disorder (anorexia nervosa, bulimia nervosa, or the alternation of these to clinical conditions), to severe exercise (athletes, gymnasts, dancers) or to malnutrition. The connected signal between metabolic status and reproductive function may be represented by the substances like: insulin, amino acids, IGFPB-I, leptin. The low levels of leptin were found in underweight female with oligo or amenorrhea. By the other hand, obesity is not a primary factor causing chronic anovulation. However, obesity may aggravate an already existing subtle defect in some women and result in amenorrhea.

[Thyroxine therapy in benign thyroid nodules]

Levothyroxine (LT4) treatment in benign thyroid nodules is a controversial management. The favorable response varies between 10-60%, being, in some studies, comparable between treated and untreated groups. The aim of this study was to evaluate the response of uninodular goiter at the LT4 treatment, in comparison with untreated patients. The study group (S) included 53 patients diagnosed with nodular goiter, treated with LT4 for 1 year. 26 patients with nodular goiter, age and sex-matched, untreated, constituted the control group (C). All patients were from a minor iodine deficient area. The including criteria were euthyroidism, single nodule, solid (ultrasonography), cold (Scintigraphy), and benign (FNAB). After 1 year mean nodular volume had a significant decrement in both groups, higher in group S (35%: from 7.8 to 5.2 mL, p = 0.0098) than in group C (25%: from 8.4 to 5.9 mL, p = 0.026). Linear regression showed a slight correlation between the nodular decrement and the initial volume (r = 0.23): the responders percentage was higher in nodules with a volume < 5 ml than in those with volume > 5 ml (51.5% vs o 19.6%, p < 0.0001). The evolution of treated nodules seamed to be better than of the untreated ones, but the differences were only slightly significant. We believe that the evolution of thyroid nodules under LT4 treatment can be influenced by the iodine supply, since in most of the studies from minor iodine deficiency regions (Europe, South America) the response is better than in regions with sufficient iodine supply (North America). Knowing the potential side effects of LT4 therapy, this kind of management of benign thyroid nodules should be reserved to selected cases.

Barraquer-Simons syndrome. Report of a case and review of the literature

Among lipodystrophies, the Barraquer-Simons syndrome or "parital lipodystrophy of the cephalothoracic type" is a rare condition of unknown origin characterized by a progressive atrophy of the subcutaneous fat of the upper part of the body. We report a 34-year-old woman with progressive loss of subcutaneous fat during 20 years, first affecting the face and spreading to the upper part of the body, equally presenting hypertrophy of the lower body fatty tissue. An overview of this rare syndrome is made.

[Body composition in amenorrheic and eumenorrheic underweight patients]

Relationship between weight and hypothalamic-pituitary-ovarian axis has been long time studied. Underweight female patients can have or not disturbances of gonadal system and the importance of the weight or body composition in the mechanisms of these abnormalities is not clear. In our study, we have investigated body composition in 15 underweight female patients. Five patients have had anorexia nervosa, with amenorrhea (group AN), and other 10 patients were eumenorrheic, but with low body weight (hypoanabolic syndrome--group HA). Bioelectrical impedance method was used to investigate body composition. Total body water (TBW), lean mass (LM), and fat mass (FM) were determined. Nutritional status was also assessed using body mass index (BMI). The mean body weight was significantly decreased (p = 0.05, 36.6 +/- 4.68 Kg versus 44.1 +/- 4.67 Kg) in group AN as compared to group HA. Fat mass was very low in group AN (9.45% of body weight versus 11.3% of body weight in group HA), but there was not significant difference. Lean mass was significantly decreased in group AN (33.24 +/- 2.37 Kg) in comparison with group HA (39.3 +/- 4.06 Kg). Correlations between anthropometric indices were studied. Positive significant correlations were obtained between body weight and lean mass, total body water and basal metabolism in both groups. In conclusion, our study reveals that body weight has a relative importance in ovarian axis dysfunction, and the most important of body compartments seems to be lean mass.

[A statistical analysis of the variation in the cephalometric measures of acromegaly patients]

Acromegaly represents the endocrine disease which includes the somatic and metabolic disorders secondly resulting to the augmentation of the Growth Hormone secretion after the growth cartilages closing (in adult). In this study we want to describe the craniofacial cephalometric qualitative and quantitative disorders and to emphasize their implications in the onset and the evolution of the stomatognathic system dysfunctional syndrome. For proving this things, we made a statistical study using a statistics function named "standard deviation" which is a measure of how widely values are dispersed from the average value.

[Changes in the craniomandibular relations of acromegaly patients]

The dishomeostazical theory (etiopathogenic integrative concept) allows an ample and complex vue on the stomatognathic system dysfunctional syndrome, because it begins from the perception of the stomatognathic system (SS) as a whole in which the alteration of each element can induce the disfunction of the entire system. The purpose of this study is to demonstrate that the neuroendocrine suprasystemic factor (STH hypersecretion on adult organism) disturbs every element of the SS and induces an important alteration of the fundamental cranio-mandibular relations.

[The correlations between the electromyographic display and the aspects involved with masticatory muscle contraction and phosphorus-calcium metabolism]

The neuromuscular activity at the level of the stomatognathic system has a specific complexity, due to the multiple systemic functions, realizing the statistical and dynamical mandibular positions and the integration of the stomatognathic system at the level of the human body. Knowing that the neuroendocrine system represents an important factor for the over-systemic coordination of the stomatognathic muscular activity, we want to establish the implication and the neuroendocrine correlation in the stomatognathic muscular dysfunctions determined by some endocrine diseases.

[An analysis of the evolution of body compartments in anorexia nervosa--the bioelectrical impedance method]

Body compartments can be assessed by means of bioelectrical impedance, a non-invasive, cost saving and simple physical method. The purpose of this study was to estimate the body compartments in anorexic patients, in the under-nutrition phase (group BMI < 17 kg/m2) and after weight restoration (BMI > 17 kg/m2). Total body water, intracellular and extracellular water have significantly decreased after weight restoration. The fat mass significantly (p < 0.001) increased in group BMI > 17 kg/m2 compared with group BMI < 17 kg/m2, and we have found a positive correlation between body mass index (BMI) and fat mass (r = 0.73, p < 0.0001). The assessment of free fat mass can provide information about the under-nutrition degree and the quality of re-feeding. The increase of free fat mass was significant (p < 0.001) in the group BMI > 17 kg/m2 as compare with the group BMI < 17 kg/m2). We have found a positive correlation between free fat mass and BMI (r = 0.73, p < 0.0001).

[The Wermer syndrome]

The difficult diagnostic and therapeutic management of patients having gastrinoma with multiple endocrine neoplasia type I (MEN I) has been discussed by reference to the literature and a personal experience of 2 patients with Wermer syndrome. The syndrome is often familial and might be inherited as an autosomal dominant trait with a high but variable degree of penetrance. Pancreatic islets, parathyroid glands and adenohypophyseal [correction of antehypophyseal] cells are the three localization main for endocrine involvement in MEN I syndrome.

[A rare form of osteopoikilosis]

The authors report a typical case of osteopoikilosis striata Voorhoeve in a 51-years-old female. In connection with case they make some consideration concerning the diagnostic of this very infrequent sclerotic bone dysplasia.

[The use of echography in the diagnosis of autoimmune thyropathies]

Ultrasonography is a first line method in thyroid imaging. The aim of this study was to evaluate the usefulness of thyroid ultrasonography in the diagnosis of thyroid autoimmune diseases (TAD): Graves' disease (GD) and autoimmune thyroiditis (AT)--Hashimoto's and atrophic thyroiditis. Ultrasonography was performed with a 7.5 MHz transducer in 1033 consecutive patients. The excluding criteria was nodular goiter, irrespective of its function. Thyroid volume was calculated using the formula of a rotating ellipsoid. Hypoechogenicity was appreciated using a qualitative scale: 1 = absent, 2 = mild, 3 = moderate, 4 = marked. In patients with TAD thyroid hypoechogenicity was significantly higher than in normal subjects (2.5 +/- 1 in GD and 2.7 +/- 1 in AT, vs. 1.2 +/- 0.6 in normal subjects, p < 0.0001). The specificity of the test in identifying TAD was 91.4%, the sensitivity was 68.6% for GD and 80.8% for AT, positive predictive value was 91.5%, and negative predictive value 91.5%. Ultrasonography is useful in identifying patients with probable autoimmune thyroid diseases, being useful in epidemiological studies and having an important contribution in confirmation of the diagnosis.

[Cephalometric changes in acromegaly]

Acromegaly represents the endocrine disease which includes the somatic and metabolic disorders secondly resulting to the augmentation of the Growth Hormone secretion after the growth cartilages closing (in adult). In this case we can find very important troubles which characterize all the specific elements of the stomatognathic system. The cranio-facial skeleton has a specific configuration, the mandible is developed in excess and the relationships between the maxilla, the mandible and the skull are strongly modified. These and the structural bony troubles, the bony asymmetries involve periodontal, muscular and articular disturbances. In this study we want to describe the craniofacial cephalometric qualitative and quantitative disorders and to emphasize their implications in the onset and the evolution of the stomatognathic system dysfunctional syndrome.

[The surgical treatment of parathyroid hyperfunction; comments on 16 cases]

16 cases of primary (13 cases) or secondary (3 cases) parathyroid hyperfunction are presented. The diagnostic circumstances are described: the tumor were incidentally discovered in patients with skeletal or urinary symptoms and following the artificial dialysis in patients with send failure. The treatment consisted in 12 adenoma excision and 3 subtotal paratyroidectomies (in 3 patients with hyperparathyroidism of renal origin. Associated operations on the thyroid gland (tactical or for removing thyroid nodules) and the operations for urinary lithiasis or skeletal disease were also presented. There was no postoperative morbidity or mortality.

[Therapy with large doses of methylprednisolone in Basedow's ophthalmopathy]

Up to now there is no satisfactory therapeutical method in Graves' ophthalmopathy (GO). Recently, several authors have published the results of the so-called "pulse" method of corticotherapy, using intravenous methylprednisolone (MP) 1 g dissolved in 200 ml isotonic NaCl solution. We have treated with this method 4 patients (3 women and 1 man, aged between 35-62 years) with severe GO (III-V class after AMT Classification). Although the number of perfusions varied between 1 (2 patients) and 8, the results are encouraging: 3 improvements, 1 stationary evolution (after a single "pulse"). We have not noticed important side-effects. In conclusion we consider that the "pulse" method have proved its efficiency, recommendable in severe GO.

[Thyroid cancers]

We have analysed factors that influenced on the patient survival in 195 cases of thyroid cancer. The survival is essentially influenced by the histology, the papillary forms (survival after 15 years: 83.1-93%) and follicular cancers (survival after 15 years: 84-94%) having an excellent evolution. The non-differentiated and mixed cancers have a very severe prognosis that is independent of the complex therapy that have been used (survival after 5 years: 17.1% in non-differentiated forms and 32.5% in mixed ones). The prognosis is better in subjects under the age of 45 and in female subjects. The cancers in the 1-st and 2-nd stage of tumor extension have a better evolution that those in the 3-rd stage. In differentiated cancers, the total or subtotal thyroidectomy followed by radioiodine administration determine the best survival.

[Thyroid actinomycosis (actinobacteriosis)]

An extremely rare case (the 15th case reported in the literature, according to our knowledge) of the infection with Actinomyces Israeli localized at the level of thyroid gland is presented. Although the clinical and imaging data, the fine needle aspiration biopsy, and the intraoperative aspect clearly suggested the diagnosis of thyroid cancer, the microscopic examination surprisingly identified "sulfur granules", specific to actinomycosis, so that treatment and prognosis were reconsidered.

[The cardiac manifestations in hyperthyroidism. The surgical implications]

In a statistics including 954 patients with hyperthyroidism [correction of Huprotoncoses] treated between 1966-1989, the authors found 522 cases (54) with various associated cardiac disorders. Of these cases, 199 presented rhythm disturbances: extrasystolic arrhythmia, auricular fibrillation and flutter to which 34 postoperative arrhythmias are added. Cardiac insufficiency present in 46 cases was the main complication and end point of the various myocardial conditions. Ischemic cardiopathy (181 cases), arterial hypertension (98 cases) and rheumatic valvulopathies (9 cases), either isolated or dominating the clinical picture, complete the nosological spectrum of these disturbances. The frequency of associated conditions and the absence of some specific morphologic lesions suggest that thyrotoxicosis is rather an aggravating factor although in many cases the presence of a previous cardiac disease is excluded. The two objectives in the management of thyrocardiac diseases are the amelioration of cardiac condition and an endocrine balance. In the conditions of a careful selection and preoperative preparation, surgery gave good results consisting, in this series, in over 70% cures and ameliorations.

[Hyperthyroidism in the elderly. The clinical forms. The incidence of signs and symptoms. The evolutionary features]

The last 15 years, 1939 patients suffering from different clinical forms of hyperthyroidism were hospitalised in the Clinic of Endocrinology of Iaşi. The frequency of the disease increases with age, especially for the toxic nodular goitre. In older patients we have noted a non-typical clinical course of the disease, with prevailing cardiovascular signs and weight loss. The clinical course is also particular especially because of the associated pathology. We have made some theoretical considerations concerning the possible explanations of these phenomena.

[Differentiated thyroid cancer]

In the interval 1979-1988, out of 1070 operated goiters 77 malignant thyroid tumors were recorded, 60 of them being differentiated: papillary--32 (53.4%), vesicular--12 (20%), mixed forms--16 (26.7%). The differentiated thyroid carcinomas had peculiar clinical biological and prognostic features and were framed: stage I--60%, stage II--23.4% and state III-IV--16.6%. Only 15 cases presented lymph node metastases. In 16 cases the thyroid tumor was associated with another thyropathy: Hashimoto's thyroiditis--5 cases, Basedow's disease--1 case. The surgical intervention was performed in two times: first total lobectomy or total lobo-isthmectomy [correction of lobioistectomy] with contralateral subtotal exeresis, then total thyroidectomy. It is insisted upon a careful surveillance of postoperative evolution (clinical, biological, scintigraphy) in order to detect the recurrence and apply a proper treatment.

[The "cold" thyroid nodule]

The main problem posed by an (apparent) solitary thyroid nodule is cancer identification, present in about 10% of the nodules excised surgically. This percent might increase to 25-30% in the cold scintigraphic nodules. Therefore, a combination of all the methods for nodule assessment is necessary: anamnesis, physical examination, functional tests, therapeutic test with tyrosine and thyroid imaging, but mainly the intensive active exploration including puncture-biopsy with a fine needle and exeresis with extemporaneous and paraffin morphological checking. Starting from a two decades' experience of a group of endocrinologists, surgeons, anatomo-pathologists and specialists in nuclear medicine, in 2,289 thyropathies operated--of whom 1691 (poly)nodular goitres and 1,190 non-capturing nodules--the authors suggest an investigation algorithm for achieving a differentiated surgery in terms of the pre- and intraoperative morphological findings. This attitude permitted both the improvement of the surgeries of thyroid cancers and the exeresis of benign nodules under low-risk surgical conditions or avoidance of a "non-necessary" surgery.

[Cases of thyroid cancer irradiated at the Iaşi Radiology-Oncology Clinic (1984-1988)]

The study is based on 35 cases of thyroid cancer treated by external radiotherapy. The analysis of these cases and especially their grouping on clinical stages according to the recent TNM classification reveal the prognostic importance of such factors as the patients' age, histopathological form and the loco-regional and at distance spread.

[The incidence of conjugal sterility of endocrine origin]

During a 14-year interval, 27,000 patients were admitted to the Endocrinological Clinic of Iaşi, of whom 337 (207 women and 130 men) for sterility. The endocrine disturbances that may induce sterility are reviewed.

Cystic parathyroid cancer. Case report

A patient hospitalized for the assessment of a "thyroid nodule" is presented. Scintigraphically the nodule was cold. Thin needle aspiration biopsy by which 50 ml of a clear fluid was drawn, proved the nodule to be of cystic nature. Phospho-calcium findings allowed the diagnosis of primary hyperparathyroidism though the patient presented no subjective complaints. Histologic examination of the tissue removed intraoperatively revealed a cystic parathyroid neoplasm.