Effects of COVID-19 infection on ECG parameters in outpatients

Objective

Covid-19 infection has been declared as a pandemic disease by the World Health Organization (WHO) and has been associated with increased morbidity and mortality. More than 400 million people diagnosed with the disease has been reported until February 2022 [1]. Covid-19 infection mostly progresses with lung involvement and pneumonia, however, its effects on the cardiovascular system are also well-known. Studies have reported that Covid 19 infection can trigger cardiac events such as acute myocardial damage, acute myocarditis, acute coronary syndrome (ACS), ventricular arrhythmias, cardiogenic shock, and cardiac arrest [2]. Electrocardiogram (ECG) is an important tool to diagnose cardiac involvement. QTc interval, QT dispersion, Tp-e interval, Tp-e/QTc ratio are defined as ventricular repolarization parameters and these parameters are associated with increased risk of ventricular arrhythmia [3,4]. In our study, we aimed to evaluate to predict ventricular arrhythmia by ECG in Covid-19 patients.

Methods

Our study is a single-center, cross-sectional study. Patients diagnosed with Covid-19 in our center between July and October 2020 were included. 408 patients with positive SARS-CoV2 PCR test were detected and the ECGs of the patients were recorded at admission and 15 days after symptomatic recovery. After the exclusion criteria, remained 91 patients were analyzed. Conduction parameters (PR and QRS durations) and repolarization parameters (QTc interval, QT dispersion, Tp-e interval and Tp-e/QTc ratio) were evaluated in 12-lead ECG recordings.

Results

Ninety-one patients with Covid-19 infection were included. The group were consisted of 47 male (52%) and 44 female (48%). The mean age was 50.4 years. As a result of the statistical analysis, no significant difference was observed between the groups in terms of PR interval (142.2±21.4 ms vs. 140.1±19.0 ms; p=0.312). QRS duration was found significantly higher during active infection (91.4±12.2 ms vs. 88.8±10.9 ms; p=0.022). The mean QTc duration was detected longer in the first ECG, but no statistically significant difference was observed between the two groups (426.1±23.6 ms vs. 422.5±26.2 ms; p=0.237). QT dispersion (35.2±7.3 ms vs. 27.7±7.8 ms; p<0.001), Tp-e interval (86.7±10.1 ms vs. 76.1±9.9 ms; p<0.001) and Tp-e/QTc ratio (0.204±0.026 vs 0.180±0.025; p<0.001) were found significantly higher during active infection

Conclusion

In our study, QRS complex, QT dispersion, Tp-e interval, Tp-e/QTc ratio were significantly higher during active infection. We considered these parameters as a contributor of the increased mortality by inducing ventricular arrhythmia and sudden death in Covid-19 patients during active infection.

Funding Acknowledgement

Type of funding sources: None.

Clinical and demographic aspects of Paget disease of bone: A multicentric study from Turkey

OBJECTIVE

Paget disease of bone (PDB) is a metabolic bone disease that has been rarely reported in the Eastern countries. This study aimed to evaluate the clinical and demographic characteristics of patients with PDB followed up at endocrinology clinics in Turkey.

METHODS

An invitation was sent to tertiary endocrinology clinics to complete a survey on the demographic, clinical, radiological, and laboratory parameters, as well as treatment modalities of patients with PDB. This study enrolled clinically and radiologically proven 185 patients with PDB from 18 endocrinology centers based in 10 cities of Turkey.

RESULTS

This cohort of PDB had female preponderance (women/men: 105/80) with a mean age, during diagnosis, of 57±10 years. Most of the patients (59.6%) were symptomatic at diagnosis. Bone pain and headache were the predominant clinical symptoms. Polyostotic disease was observed in 67.5% (n=125) of patients. Frequently affected bones were skull (41.6%), pelvis (53.5%), spine (41%), and femur (25.4%). Moreover, 17 patients with skull involvement had hearing loss. Mean serum alkaline phosphatase (ALP) level (552±652 IU/L; range: 280-5762 IU/L) was over the normal reference cutoff with normal serum calcium levels. Intravenous bisphosphonates (zoledronic acid, 5 mg; pamidronate, 60-90 mg) were the most used drugs (75%) for the treatment of PDB. Most of the patients (87.1%) treated with intravenous bisphosphonates responded well, with a decrease in serum ALP level (117±114 IU/L) in the 12th month of therapy. Furthermore, 16 patients relapsed after the second year of therapy; 3 patients did not respond to the initial intravenous bisphosphonate treatment.

CONCLUSION

The patients with PDB followed up by endocrinology clinics of Turkey exhibited polyostotic disease with classical clinical, radiological, and biochemical features and women's predominance with good response to intravenous bisphosphonate therapy.

Functional characterization of AVPR2 mutants found in Turkish patients with nephrogenic diabetes insipidus

Diabetes insipidus is a rare disorder characterized by an impairment in water balance because of the inability to concentrate urine. While central diabetes insipidus is caused by mutations in the AVP, the reason for genetically determined nephrogenic diabetes insipidus can be mutations in AQP2 or AVPR2 After release of AVP from posterior pituitary into blood stream, it binds to AVPR2, which is one of the receptors for AVP and is mainly expressed in principal cells of collecting ducts of kidney. Receptor activation increases cAMP levels in principal cells, resulting in the incorporation of AQP2 into the membrane, finally increasing water reabsorption. This pathway can be altered by mutations in AVPR2 causing nephrogenic diabetes insipidus. In this study, we functionally characterize four mutations (R68W, ΔR67-G69/G107W, V162A and T273M) in AVPR2, which were found in Turkish patients. Upon AVP stimulation, R68W, ΔR67-G69/G107W and T273M showed a significantly reduced maximum in cAMP response compared to wild-type receptor. All mutant receptor proteins were expressed at the protein level; however, R68W, ΔR67-G69/G107W and T273M were partially retained in the cellular interior. Immunofluorescence studies showed that these mutant receptors were trapped in ER and Golgi apparatus. The function of V162A was indistinguishable from the indicating other defects causing disease. The results are important for understanding the influence of mutations on receptor function and cellular trafficking. Therefore, characterization of these mutations provides useful information for further studies addressing treatment of intracellularly trapped receptors with cell-permeable antagonists to restore receptor function in patients with nephrogenic diabetes insipidus.

Retro- and orthonasal olfactory function in relation to olfactory bulb volume in patients with hypogonadotrophic hypogonadism

Introduction

Idiopathic hypogonadotrophic hypogonadism with an olfactory deficit is defined as Kallmann syndrome and is distinct from normosmic idiopathic hypogonadotrophic hypogonadism.

Objective

Because olfactory perception not only consists of orthonasally gained impressions but also involves retronasal olfactory function, in this study we decided to comprehensively evaluate both retronasal and orthonasal olfaction in patients with idiopathic hypogonadotrophic hypogonadism.

Methods

This case-control study included 31 controls and 45 idiopathic hypogonadotrophic hypogonadism patients. All participants whose olfactory and taste functions were evaluated with orthonasal olfaction (discrimination, identification and threshold), retronasal olfaction, taste function and olfactory bulb volume measurement. The patients were separated into three groups according to orthonasal olfaction: anosmic idiopathic hypogonadotrophic hypogonadism, hyposmic idiopathic hypogonadotrophic hypogonadism and normosmic idiopathic hypogonadotrophic hypogonadism.

Results

Discrimination, identification and threshold scores of patients with Kallmann syndrome were significantly lower than controls. Threshold scores of patients with normosmic idiopathic hypogonadotrophic hypogonadism. were significantly lower than those of controls, but discrimination and identification scores were not significantly different. Retronasal olfaction was reduced only in the anosmic idiopathic hypogonadotrophic hypogonadism group compared to controls. Identification of bitter, sweet, sour, and salty tastes was not significantly different when compared between the anosmic, hyposmic, and normosmic idiopathic hypogonadotrophic hypogonadism groups and controls. Olfactory bulb volume was lower bilaterally in all patient groups when compared with controls. The olfactory bulb volume of both sides was found to be significantly correlated with threshold, discrimination and identification scores in idiopathic hypogonadotrophic hypogonadism patients.

Conclusion

1) There were no significant differences in gustatory function between controls and idiopathic hypogonadotrophic hypogonadism patients; 2) retronasal olfaction was reduced only in anosmic patients but not in orthonasally hyposmic participants, possibly indicating presence of effective compensatory mechanisms; 3) olfactory bulb volumes were highly correlated with olfaction scores in the hypogonadotrophic hypogonadism group. The current results indicate a continuum from anosmia to normosmia in idiopathic hypogonadotrophic hypogonadism patients.

Thyroid Hormone Replacement Therapy Improves Olfaction and Taste Sensitivity in Primary Hypothyroid Patients: A Prospective Randomised Clinical Trial

Smell and taste are known to be influenced by thyroid function changes. However, many hypothyroid patients and physicians are unaware of their dysosmia and dysgeusia. The present study was performed to shed more light on the relation between hypothyroidism and olfactory loss. 32 primary hypothyroid patients and 31 controls enrolled in the prospective randomized interventional study. Newly diagnosed Primary hypothyroid patients were treated with L-thyroxine for 3-6 months. The control group was selected on the basis of the biochemical evidence of a normal thyroid function. Psychophysiological olfactory testing was performed using odor dispensers similar to felt-tip pens ("Sniffin' Sticks", Burghart, Wedel, Germany). Taste function tests were made using "Taste Strips" (Burghart, Wedel, Germany) which are basically tastant adsorbed filter paper strip. Smell identification, threshold, discrimination, TDI scores, bitter and sweet taste scores were significantly lower in untreated hypothyroid patients compared to controls (12.31±1.09 vs. 14.03±1.05, p<0.001; 7.09±1.15 vs. 8.89±1.12, p<0.001; 11.47±0.95 vs. 13.06±0.85, p<0.001; 30.90±2.70 vs. 35.89±2.07, p<0.001; 4.88±1.6 vs. 6.64±0.96, p<0.001; and 5.5±2.22 vs. 6.58±1.28, p=0.021) respectively. Comparison of scores at the third month of treatment and before treatment of hypothyroid patients revealed significant improvement in smell and taste functions in terms of identification, threshold, discrimination, TDI scores, bitter, sweet and salty tastes (12.31±1.09 vs. 13.84±1.22, p<0.001; 7.09±1.15 vs. 8.02±1.16, p<0.001; 11.47±0.95 vs. 12.41±1.21, p<0.001; 30.90±2.70 vs. 34.27±3.25, p<0.001; 4.88±1.6 vs. 6.06±1.4, p<0.001; 5.5±2.22 vs. 6.38±1.28, p<0.001; and 6.12±2.32 vs. 6.62±1.48, p=0.044) respectively. On correlation analysis, there was a negative correlation between TPO-Ab levels and discrimination, identification and TDI scores (r=-0.409, p=0.02; r=-0.424, p=0.016; r=-0.532, p=0.002), and also between Tg-Ab levels and identification, TDI, and bitter scores (r=-0.423, p=0.016; r=-0.468, p=0.007; r=-0.409, p=0.02) respectively. Primary hypothyroidism was found to have a negative effect on smell and taste. RAI treatment was found to be most destructive on smell and taste compared to surgical and autoimmune hypothyroidism. Treatment of hypothyroidism was positively correlated with an improvement of both senses. Thus, the future workup of patients with smell/taste loss should include investigations for thyroid functions.

The value of combined elevation of D-dimer and neopterin as a predictive parameter for early stage acute mesenteric ischemia: An experimental study

Background

The diagnosis of acute mesenteric ischemia is variable. Early diagnosis is important for reducing the mortality and morbidity rates.

Aim

This experimental study aims to investigate the diagnostic utility of D-dimer and neopterin as a marker for the early stage of acute mesenteric ischemia caused by occlusion of superior mesenteric artery.

Methods

The levels of D-dimer and neopterin were measured using an animal acute mesenteric ischemia model in 21 male rabbits. Superior mesenteric artery occlusion (Group 1, n = 14) and control (Group 2, n = 7) groups were identified. Blood samples at different times are collected from each rabbits. Blood samples from superior mesenteric artery occlusion group were taken 30 min after anesthesia but before laparotomy, 1, 2, and 3 h after superior mesenteric artery ligation. Blood samples from control group were taken 1 h before, 1 and 3 h after anesthesia and laparotomy. The D-dimer and neopterin levels of each blood sample were measured.

Results

The probability of acute mesenteric ischemia was found to be 36 times higher when the D-dimer level was over 0.125 ng/L, whereas the probability was 19.2 times higher when the neopterin level was over 1.25 nmol/L.

Conclusions

In this experimental study, the combined elevation of two significant markers, D-dimer and neopterin, may be helpful for the early diagnosis of acute mesenteric ischemia.

Is There Any Effect on Smell and Taste Functions with Levothyroxine Treatment in Subclinical Hypothyroidism?

Subclinical hypothyroidism has been accused for coronary heart disease, lipid metabolism disorders, neuropsychiatric disorders, infertility or pregnancy related problems with various strength of evidence. Currently there is insufficient knowledge about olfaction and taste functions in subclinical hypothyroidism. Aim of the present study is to investigate the degree of smell and taste dysfunction in patients with subclinical hypothyroidism. 28 subclinical hypothyroid patients, and 31 controls enrolled in the prospective study in Istanbul, Turkey. Subclinical hypothyroid patients were treated with L-thyroxine for 3 months. Psychophysiological olfactory testing was performed using odor dispensers similar to felt-tip pens (“Sniffin’ Sticks”, Burghart, Wedel, Germany). Taste function tests were made using "Taste Strips" (Burghart, Wedel, Germany) which are basically tastant adsorbed filter paper strip. Patients scored lower on psychophysical olfactory tests than controls (odor thresholds:8.1±1.0 vs 8.9±1.1, p = 0.007; odor discrimination:12.4±1.3 vs 13.1±0.9, p = 0.016; odor identification:13.1±0.9 vs 14.0±1.1, p = 0.001; TDI score: 33.8±2.4 vs 36.9±2.1, p = 0.001). In contrast, results from psychophysical gustatory tests showed only a decreased score for “bitter” in patients, but not for other tastes (5.9±1.8 vs 6.6±1.0, p = 0.045). Three month after onset of treatment olfactory test scores already indicated improvement (odor thresholds:8.1±1.0 vs 8.6±0.6, p<0.001; odor discrimination:12.4±1.31 vs 12.9±0.8, p = 0.011; odor identification:13.1±0.9 vs 13.9±0.8, p<0.001; TDI scores:33.8±2.4 vs 35.5±1.7, p<0.001) respectively. Taste functions did not differ between groups for sweet, salty and, sour tastes but bitter taste was improved after 3 months of thyroxin substitution (patients:5.9±1.8 vs 6.6±1.2, p = 0.045). Correlation of changes in smell and taste, with thyroid function test were also evaluated. TSH, fT4 were found have no correlation with smell and taste changes with treatment. However bitter taste found positively correlated with T3 with treatment(r: 0.445, p: 0.018). Subclinical hypothyroid patients exhibited a significantly decreased olfactory sensitivity; in addition, bitter taste was significantly affected. Most importantly, these deficits can be remedied on average within 3 months with adequate treatment.

Evaluation of electrocardiographic parameters in patients with diabetes insipidus

BACKGROUND

There is limited data regarding the effect of altered serum osmolality on cardiac electrical activity. The aim of the present study is to evaluate the electrocardiographic (ECG) effects of diabetes insipidus (DI) and any related hyperosmolality in a population of young patients with DI and without any known cardiovascular disease or risk factors.

METHODS

Twelve-lead ECG's of 44 consecutive untreated young male patients (age: 21.8 ± 2.9 years) who had been referred to endocrinology clinic and diagnosed as DI based on water deprivation test were retrospectively evaluated. A total of 30 age-matched (21.9 ± 2.4 years) healthy males were selected as control group and ECG's of these controls were obtained for comparison with ECG's of DI patients. All ECG parameters were measured and compared.

RESULTS

Duration of QRS complex was significantly shorter in patients with DI compared with controls (85.2 ± 12.0 vs. 94.0 ± 10.6 ms, p: 0.001). P wave dispersion (PWD) of patients with DI was significantly higher compared with controls (31.9 ± 9.9 vs. 26.5 ± 10.6 ms, p: 0.03) and it was significantly correlated with serum osmolality and serum sodium level (r = - 0.36, p: 0.02 and r: - 0.35, p: 0.02, respectively).

CONCLUSIONS

DI patients without any cardiovascular disease or risk factors displayed significantly shorter QRS duration and increased p wave dispersion compared with controls.

Identification of a Novel Deletion in AVP-NPII Gene in a Patient with Central Diabetes Insipidus

Central Diabetes Insipidus (CDI) is caused by a deficiency of antidiuretic hormone and characterized by polyuria, polydipsia and inability to concentrate urine. Our objective was to present the results of the molecular analyses of AVP-neurophysin II (AVP-NPII) gene in a large familial neurohypophyseal (central) DI pedigree. A male patient and his family members were analyzed and the prospective clinical data were collected. The proband applied to hospital for eligibility to be a recruit in Armed Forces. The patient had severe polyuria (20 L/day), polydipsia (20.5 L/day), fatique, and deep thirstiness. CDI was confirmed with the water deprivation-desmopressin test according to an increase in urine osmolality from 162 mOsm/kg to 432 mOsm/kg after desmopressin acetate injection. To evaluate the coding regions of AVP-NPII gene, polymerase chain reactions were performed and amplified regions were submitted to direct sequence analysis. We detected a heterozygous three base pair deletion at codon 69-70 (207_209delGGC) in exon 2, which lead to a deletion of the amino acid alanine. A three-dimensional protein structure prediction was shown for the deleted AVP-NPII and compared with the wild type. The three base pair deletion may yield an abnormal AVP precursor in neurophysin moiety, but further functional analyses are needed to understand the function of the deleted protein.

A large deletion of the AVPR2 gene causing severe nephrogenic diabetes insipidus in a Turkish family

X-linked nephrogenic diabetes insipidus (NDI) is a rare hereditary disease caused by mutations in arginine vasopressin type 2 receptor (AVPR2) and characterized by the production of large amounts of urine and an inability to concentrate urine in response to the antidiuretic hormone vasopressin. We have identified a novel 388 bp deletion starting in intron 1 and ending in exon 2 in the AVPR2 gene in a patient with NDI and in his family. We have revealed that this mutation is a de novo mutation for the mother of the proband patient. Prospective clinical data were collected for all family members. The water deprivation test confirmed the diagnosis of diabetes insipidus. The patient has severe symptoms like deep polyuria nocturia, polydipsia, and fatigue. He was given arginine vasopressin treatment while he was a child. However, he could not get well due to his nephrogenic type of illness. Both of his nephews have the same complains in addition to failure to grow. We have sequenced all exons and intron-exon boundaries of the AVPR2 gene of all family members. The analyses of bioinformatics and comparative genomics of the deletion were done via considering the DNA level damage. AVPR2 gene mutation results in the absence of the three transmembrane domains, two extracellular domains, and one cytoplasmic domain. Three-dimensional protein structure prediction was shown. We concluded that X-linked NDI and severity of illness in this family is caused by a novel 388 bp deletion in the AVPR2 gene that is predicted to truncate the receptor protein, and also this deletion may lead to dysfunctioning in protein activity and inefficient or inadequate binding abilities.

Effects of valsartan treatment on serum ghrelin level and left ventricular mass index in patients with untreated primary hypertension

OBJECTIVE

In the present study, left ventricular hypertrophy and serum ghrelin concentration in patients with primary hypertension and effects of angiotensin receptor blocker valsartan on these parameters were determined.

METHODS

Thirty-seven patients and 30 age and body mass index matched healthy controls were followed up prospectively. Serum ghrelin level was measured by enzyme immunoassay (EIA). Left ventricular mass was determined by transthoracic echocardiography. Left ventricular mass index (LVMI) was calculated by dividing the left ventricular mass to body surface area. All patients were started treatment with oral valsartan 80 mg. Follow-up visits were performed every 4 weeks, and the dosage was doubled in subjects with insufficient blood pressure reduction. At the end of the 12th week all measurements were repeated in the patient group. All data were recorded in the computer using SPSS for Windows software. Mann-Whitney U, Student t, Wilcoxon and t tests were used for statistical analyses.

RESULTS

At baseline, mean serum ghrelin level was significantly lower in the patients group (14.9 ng/mL) compared to healthy controls (42.1 ng/mL) (p<0.05). After a 12-week antihypertensive treatment of patients, serum ghrelin concentration increased while LVMI decreased (p<0.05, for both). No significant correlation was found between Δ-ghrelin level and Δ-LVMI (r=0.155, p=0.368).

CONCLUSION

Low circulating level of ghrelin in patients with hypertension and its increase after antihypertensive treatment suggest that this peptide need to be explored in the mechanism and complications of hypertension.

Adrenocortical carcinoma: clinical outcomes and prognosis of 330 patients at a tertiary care center

OBJECTIVE

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Herein, we describe the clinical features and outcomes for a large series of ACC patients.

DESIGN AND METHODS

Retrospective review of ACC patients seen at The University of Texas MD Anderson Cancer Center from 1998 through 2011.

RESULTS

A total of 330 patients with median age at diagnosis of 48.5 years; 12 (3.6%) patients were under 18 years. Hormonally functioning tumors represented 41.8% (n=138) of all cases. Surgical resection for the primary tumor was done in 275 (83.3%) patients (45 at MD Anderson (16.4%)). For those who had surgical resection, the median local-recurrence-free time was 1.04 years. Factors associated with local recurrence included positive surgical margins (P=0.007) and advanced disease stage (P=0.026). Median overall survival time for all patients was 3.21 years. Median survival times were 24.1, 6.08, 3.47, and 0.89 years for stages I, II, III, and IV respectively. In multivariable analysis, older age, functioning tumors, and higher disease stage remained significant prognostic factors associated with poor survival.

CONCLUSION

ACC prognosis remains poor with the use of currently available treatments. Older age, functioning tumors, and incomplete resections are clinical factors associated with poor survival. Surgical expertise is important to achieve complete resections and to improve outcome.

A retrospective cohort analysis of the efficacy of adjuvant radiotherapy after primary surgical resection in patients with adrenocortical carcinoma

CONTEXT

Adrenocortical carcinoma (ACC) is a rare malignancy with high recurrence and mortality rates. The role of adjuvant radiation therapy (RT) to improve outcome remains unclear.

OBJECTIVE

The aim of this study was to evaluate the impact of adjuvant RT on overall survival and recurrence rates of ACC patients.

DESIGN

We conducted a retrospective cohort study of select ACC patients who were seen at The University of Texas MD Anderson Cancer Center (MDACC) between 1998 and 2011. All patients in this study underwent primary tumor resection and received adjuvant RT within 3 months of primary surgical resection prior to referral to the MDACC. We compared patients who had surgery and adjuvant RT with patients who had surgery alone.

RESULTS

Baseline characteristics and adjuvant mitotane use were not significantly different between the adjuvant RT group (n = 16) and the non-RT group (n = 32). Local recurrence occurred in seven patients (43.8%) who received RT and 10 patients (31.3%) in the control group. At 5 yr, the estimated local recurrence-free rate (95% confidence interval) was 53% (32-87%) in the RT group and 67% (52-86%) in the non-RT group (P = 0.53). The distributions of time to distant recurrence and recurrence-free survival were not significantly different between the two groups. Using a multivariate Cox proportional hazards model for overall survival, the hazard ratio for RT use was 1.593 (95% confidence interval, 0.707-3.589; P = 0.26) after adjusting for stage and adjuvant mitotane therapy.

CONCLUSIONS

ACC has high rates of recurrence. In our study, RT did not improve clinical outcomes in patients who received their initial care in the community. We believe there is a need for a collaborative, multicenter, prospective randomized trial to evaluate the role of adjuvant treatments (both mitotane and RT) to assess their impact on recurrence patterns and survival.

Mitotane-induced hyperlipidemia: a retrospective cohort study

Limited data are available about mitotane-nduced hyperlipidemia. We retrospectively analyzed lipid data in 38 patients with adrenocortical carcinoma (ACC) who received mitotane therapy with emphasis on HDL cholesterol (HDL-c) and clinical predictors of lipid changes. At baseline, the mean levels of HDL-c, LDL-c, and triglycerides were 53.3 mg/dL, 114.4 mg/dL, and 149 mg/dL, respectively. HDL-c, LDL-c, and triglyceride concentrations significantly increased with mitotane therapy to a mean HDL peak (HDL-P) of 86.3 mg/dL (P < 0.001), a mean LDL peak of 160.1 mg/dL (P < 0.001), and a mean triglyceride peak (Tg-P) of 216.7 mg/dL (P = 0.042). HDL-P positively correlated with mitotane concentration (r = 0.52, P < 0.001), while LDL-P levels and Tg-P did not. Gender, body mass index, cortisol overproduction, baseline levels of HDL-c, and triglyceride did not predict change in HDL-c. Similar changes were noticed in subgroup analysis after excluding patients who were using lipid-lowering agents. In conclusion, in ACC patients, mitotane caused significant increases in HDL-c that may counteract the deleterious atherosclerotic effects of LDL-c and Tg rise. Understanding the mechanism of HDL change may lead to the discovery of novel HDL-c-elevating drugs.

Mutations in the AVPR2, AVP-NPII, and AQP2 genes in Turkish patients with diabetes insipidus

The aim of this study was to identify mutations in three different genes, the arginine-vasopressin-neurophysin II (AVP-NPII) gene, the arginine-vasopressin receptor 2 (AVPR2) gene, and the vasopressin-sensitive water channel aquaporin-2 (AQP2) gene in Turkish patients affected by central diabetes insipidus or nephrogenic diabetes insipidus. This study included 15 patients from unrelated families. Prospective clinical data were collected for all patients including the patients underwent a water deprivation-desmopressin test. The coding regions of the AVPR2, AQP2, and AVP-NPII genes were amplified by polymerase chain reaction and submitted to direct sequence analysis. Of the 15 patients with diabetes insipidus referred to Gulhane Military Medical Academy, Department of Endocrinology and Metabolism, eight patients have AVPR2 mutations, five patients have AQP2 mutations and two patients have AVP-NPII mutations. Of the patients, which have AVPR2 mutations, one is compound heterozygous for AVPR2 gene. Seven of these mutations are novel. Comparison of the clinical outcomes of these mutations may facilitate in understanding the functions of AVP-NPII, AQP2, and AVPR2 genes in future studies.

Adjuvant radiotherapy after primary surgical resection in patients with adrenocortical carcinoma: Retrospective cohort analysis

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Background: Adrenocortical carcinoma (ACC) is a rare malignancy with high recurrence and mortality rates. The role of adjuvant radiotherapy (RT) to improve outcome remains unclear. Considering the rarity of ACC, we conducted a historical cohort study to ascertain the effect of adjuvant RT on overall survival and recurrence rates. Methods: Patients were selected from the MD Anderson Cancer Center (MDACC) ACC registry (1998- 2011) who had primary tumor resection with no evidence of distant metastasis at the time of initial diagnosis and a minimum follow-up of 6-months. The adjuvant RT group included patients who received adjuvant RT within 3 months of diagnosis. Control group included patients who did not receive RT and matched based on resection margin status and stage at diagnosis. Results: There were no significant differences between the adjuvant RT group (n=15) and comparison group (n =45) in gender distribution, age, tumor size, functional status, and use of adjuvant mitotane therapy. On multivariate Cox proportional hazard model for overall survival, the adjuvant RT group had hazard ratio of 1.981(95% confidence interval [CI] 0.894-4.391, p=0.0922) compared to the control group. The differences in median time to local recurrence, distant recurrence and of recurrence free survival were not significant between the two groups. In subgroup analysis including only the patients whose initial treatments were from outside of MDACC, RT group (n=15) had hazard ratio of overall survival of 1.604 (95% CI 0.712- 3.613, p=0.2543) compared to group without adjuvant RT (n= 32). Median times to local recurrence, distant recurrence, or of recurrence free survival were also not significantly different between the two groups. Conclusions: To our knowledge, this is the largest single institution report about adjuvant RT use in ACC. In our study, RT did not appear to cause a significant difference in overall survival, recurrence rate, or time to recurrence. However, it is still possible that patients offered adjuvant RT and control groups may have been inherently different. Hence, a prospective study is needed to clarify the role of adjuvant RT in patients with resectable ACC.

Response to copper and sodium chloride excess in Spirulina sp. (cyanobacteria)

Physiological responses of the cyanobacterium, Spirulina sp., were evaluated following exposure to copper (0.1 and 1.0 mg/L) and sodium chloride (0.2 and 0.4 mol/L) for 7 days. Growth and chlorophyll a content exhibited decreases at most exposure levels, while increases occurred for malondialdehyde at all exposure levels. Proline content was increased at the higher exposure levels. Carotenoid levels of Spirulina sp. were not significantly changed. Increased amounts of malondialdehyde were indicative of free radical formation in Spirulina sp. under the stress, while increasing levels of proline pointed to the occurrence of a scavenging mechanism. Concentrations of copper in Spirulina sp. decreased with increasing concentrations of NaCl.

Effects of short-term propylthiouracil treatment on p wave duration and p wave dispersion in patients with overt hypertyroidism

BACKGROUND

P-wave duration is defined as the time measured from the onset to the offset of the P-wave in surface electrocardiogram (ECG). Prolonged P wave duration and increased P wave dispersion (PWD) have been reported to carry an increased risk for atrial fibrillation.

AIM

Our aim was to evaluate the role of hyperthyroidism on P wave duration and dispersion, to investigate the effect of anti-thyroid therapy on P wave duration and dispersion.

MATERIAL AND METHODS

A total of 44 consecutive subjects (22 patients with newly diagnosed overt hyperthyroidism and 22 randomly selected euthyroid healthy subjects) were enrolled in the study. Transthoracic echocardiography, 12 lead surface ECG and thyroid hormone levels were studied at the time of enrollment, in the first and third months of the 6-8 mg/kg/day propylthiouracil therapy. Patients were followed-up for 3 months.

RESULTS

Patient and control groups were consisted of age and sex matched subjects. Baseline left atrial diameter was similar between the patient and control groups (3.4+/-0.3 cm and 3.4+/-0.3 cm respectively, p=0.813). The maximum P-wave duration (P maximum) was 113.1+/-6.6 and 105.7+/-4.1 ms in patient and control groups (p=0.001). PWD was 31.5+/-9.5 and 25.2+/-5.9 ms in patient and control groups respectively (p=0.015). At the third month of propylthiouracil treatment P maximum and PWD were decreased in the patient group at statistically significant level and returned back in normal limits (p<0.001 and p=0.001).

CONCLUSION

P wave duration and PWD are found prolonged in hyperthyroid patients and propylthiouracil treatment decreased them effectively. This mechanism may establish how the anti-thyroid treatment may prevent the development of atrial fibrillation in hyperthyroid patients.

Association of metabolic syndrome with impaired heart rate recovery and low exercise capacity in young male adults

BACKGROUND

Impaired heart rate recovery (HRR) is a powerful predictor of overall mortality.

AIM

The aim of the present study is to assess HRR in young adult males with metabolic syndrome and to compare HRR with those of obese patients who do not meet the criteria for metabolic syndrome.

PATIENTS AND METHODS

Sixty-four newly diagnosed and untreated young male subjects (24 +/- 3 years) with metabolic syndrome and 40 age and sex matched obese or overweight control subjects (ages 23 +/- 3 years) were enrolled in the study. All subjects performed a symptom limited exercise stress test under the standard Bruce protocol. HRR was calculated in the first, second and third minutes of the recovery period. The relationship between metabolic syndrome and HRR was evaluated via logistic regression analysis and a P-value < 0.05 was accepted as significant.

RESULTS

Body mass index (BMI) was 38.6 +/- 3.68 and 32.22 +/- 2.99 kg/m(2) in the study and control groups, respectively (P < 0.001). Total cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, systolic and diastolic blood pressures and fasting glucose levels were significantly higher in the study group. HRR in the first minute of the recovery period and mean exercise capacity were significantly lower in the study-group patients with metabolic syndrome (P < 0.001 and P = 0.012, respectively).

CONCLUSION

We determined that HRR was impaired in young adult males with metabolic syndrome compared with obese ones who do not meet the criteria of metabolic syndrome. This decreased HRR may have prognostic value in the prediction of vascular events in patients with metabolic syndrome.

Pathergy reaction in different body areas in Behçet's disease

Behçet's disease (BD) is a chronic inflammatory multisystemic disorder characterized mainly by vasculitis. Although the pathergy reaction (PR) has been accepted as one of the major criteria in this disease, there is a lack of a standardized method to measure PR. The aim of this study was to evaluate results of PR in different body areas and the effect on the positive rate of PR of application of numerous needle pricks. The pathergy test was performed using simultaneous 16 needle pricks with 20G disposable needles on different body areas of 56 patients with BD, 49 patients with recurrent aphthous stomatitis (RAS) and 17 healthy subjects. No positive PR was found in healthy controls, but was observed in nine patients with RAS (18.3%). It was detected in 48 of 56 patients with BD, a positive rate of 85.7%. The site most frequently positive for PR was the forearm, while the least frequent was the abdomen. Multiple needle pricks could play an important role in increasing the positive rate of PR in BD, and it may be important in the investigation of aetiological factors in RAS.

The vitamin D receptor fokI start codon polymorphism and bone mineral density in male hypogonadotrophic hypogonadism

The genetic factors determining bone mineral density (BMD) are not well characterized. Many studies have investigated the relationship between the fokI polymorphism of vitamin D receptor (VDR) gene in diverse populations and gender, resulting in conflicting outcomes. Because peak bone mass in men is closely related to sufficient androgen release, the contribution of VDR gene on BMD might have been masked by hormonal status of adulthood. We therefore investigated the relationship between the fokI polymorphism of VDR and BMD in male patients with idiopathic hypogonadotrophic hypogonadism (IHH). Sixty-five untreated male patients with IHH and 39 healthy matched controls were evaluated. fokI polymorphism ("f" allele) was detected by polymerase chain reaction (PCR)-restriction fragment length polymorphism using restriction endonuclease fokI, and BMD was measured by dual Energy X-ray absorpsiometry in lumbar spine, femur and radius. The distribution of FF, Ff, and ff alleles in patients with IHH and controls were not different (patients; 46%, 51%, 3% and controls; 51.3%, 46.1%, 2.6%, respectively). BMD levels in patients with IHH were significantly lower than controls. We categorized patients and control subjects in subgroups according to whether they had homozygous FF and heterozygous Ff genotype. No differences in BMD were seen between control subgroups, but total femur and femoral neck BMD were significantly lower in patients bearing heterozygous Ff genotype with IHH than homozygous FF ones (p=0.017 and p=0.009, respectively). Ff genotype might run down the BMD in cortical bone of femur, which needs to be proved in further studies.

Increased abnormal pituitary findings on magnetic resonance in patients with male idiopathic hypogonadotrophic hypogonadism

Idiopathic hypogonadotropic hypogonadism (IHH) is a well-known disorder apart from its pathogenesis, which is still mostly unclear, even though a diverse subgroup of patients with hypogonadotropic hypogonadism and hyposmia/anosmia--the Kallman syndrome--have been partly linked to a mutated gene, known as kal-1 gene. In this study, we aimed to evaluate the sellar region of patients with IHH on magnetic resonance (MR). Pituitary MR of 120 male patients with IHH, diagnosed by a thorough endocrinologic assessment, were compared with pituitary MR of 49 healthy cases selected randomly who underwent detailed endocrinologic and neurologic evaluation and were assessed as healthy. Patients with IHH were diagnosed with microadenomas and irregularly contrasting pituitary (ICP), 18.2 and 10.7%, respectively. Although some anatomic variations were seen in healthy controls, microadenomas and ICP had solely been observed in patients with IHH and none in controls. Intact appearence of hypophysis in patients with IHH was significantly lower than in randomly selected healthy male subjects (p = 0.021). Mean infundibulum width of hypophysis and transverse diameter of posterior hypophysis were significantly broader in patients with IHH than in controls (both having p < 0.001), while mean hypophysis height and volume did not differ between groups. Results showed unusual incidence of pituitary abnormalities on pituitary MR in male patients with IHH. In conclusion, MR imaging is particularly useful in defining the morphological aspects of the hypothalamo - pituitary region in some endocrine disorders and other researchers might want to bear our findings in mind when performing MR evaluation of similar patient subgroups.

[Adenocarcinoma of the kidney in children]

Renal adenocarcinoma in infancy is a rare tumour. The presence of a case in our service has encouraged us to submit it and to carry out a review of the literature available.