The correlation between adiposity and adiponectin, tumor necrosis factor alpha, interleukin-6 and high sensitivity C-reactive protein levels. Is adipocyte size associated with inflammation in adults?

OBJECTIVE

Hypertrophic obesity correlates with metabolic complications of obesity. We evaluated adipocyte volume and its relationship with tumor necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6), adiponectin and high sensitivity C-reactive protein (hs-CRP) levels.

SUBJECTS AND METHODS

Patients were divided into 4 groups; lean healthy controls [body mass index (BMI): 24.2+/-1.4 kg/m2], non-diabetic obese patients (30.2+/-2.9), obese (30.1+/-3.2) and non-obese (22.2+/-1.5) Type 2 diabetic patients. TNF-alpha, hs-CRP, adiponectin and IL-6 levels were measured preoperatively and sc fat specimens were obtained during operation. Semi-thin sections were stained with toluidine-blue and evaluated by light microscopy. Fat volumes were calculated by Goldrick's formulation.

RESULTS

Mean adipocyte volumes were higher in obese diabetic patients than in other groups (p<0.0001). Mean TNF-alpha, hs-CRP and IL-6 levels were higher in obese diabetic patients than in control subjects, obese non-diabetic and non-obese diabetic patients (p<0.0001, p<0.02 and p<0.01, respectively). Mean TNF-alpha levels of non-diabetic obese patients were higher than the control group (p<0.05). Mean IL-6 levels of diabetic and non-diabetic obese patients were higher than control subjects (p<0.02 and p<0.0001, respectively). Mean adiponectin levels of control subjects were higher than non-diabetic obese, non-obese diabetic and obese-diabetic subjects (p<0.0001). Mean adiponectin levels of obese diabetic patients were lower than non-diabetic obese subjects (p<0.008). Mean hs-CRP levels were higher in diabetic patients whether they were obese or not. There was a positive correlation between adipocyte size and TNF-alpha (p<0.01), IL-6 (p<0.03) and hs-CRP levels (p<0.004), and negative correlation between adipocyte size, adiponectin levels (p<0.0001).

CONCLUSIONS

TNF-alpha, IL-6 and hs-CRP levels were positively, adiponectin negatively correlated with adipocyte size. Therefore, adiposity may be an inflammatory condition.

Comparison of agonistic flare-up-protocol and antagonistic multiple dose protocol in ovarian stimulation of poor responders: results of a prospective randomized trial

The management of poor responders in IVF has always been a big problem. The ideal approach has yet to be formulated. In this study we aim to compare two alternative stimulation protocols. A total of 48 poor responder patients described from previous cycles were included and grouped into two: group I consisted of 24 patients in 24 cycles in which leuprolide acetate (40 microg s.c. per day) was initiated on cycle day 2 followed by exogenous gonadotrophins on cycle day 3; group II consisted of 24 patients in 24 cycles in which ovarian stimulation included gonadotrophin-releasing hormone (GnRH) antagonist (cetrorelix, 0.25 mg daily during late follicular phase) administration. While only the oestradiol concentrations on the day of HCG were lower in group II compared with group I, the clinical pregnancy and implantation rates among groups did not show any significance. The impact of these two regimens in ovarian stimulation of poor responders seem to be same and to establish these results further randomized studies with larger sample sizes are required.

Addition of GnRH antagonist in cycles of poor responders undergoing IVF

Concern about the use of gonadotrophin-releasing hormone (GnRH) agonists in ovarian stimulation of poor responder IVF patients has arisen from the claim that GnRH agonists might have a direct deleterious effect through their receptors on the ovary. In this study, we compared two ovarian stimulation protocols in which no GnRH agonists were used. In all, 40 patients with a poor response in previous treatment cycles were included. They were divided into two groups: group I (n = 20) received ovarian stimulation for 20 cycles, without the addition of either GnRH agonist or antagonist; while group II (n = 20) patients received ovarian stimulation for 20 cycles, including the administration of a GnRH antagonist (Cetrorelix, 0.25 mg daily) during the late follicular phase. There was no statistically significant difference between the groups for mean age, duration of infertility, baseline FSH concentration, cancellation rate, number of ampoules of gonadotrophin used, number of mature oocytes retrieved, oestradiol concentrations on the day of injection of human chorionic gonadotrophin (HCG), fertilization rate and number of embryos transferred. The clinical pregnancy and implantation rates in group II appeared higher than in group I, but were not significantly different (20 and 13.33% compared with 6.25 and 3.44% respectively). The addition of GnRH antagonists to ovarian stimulation protocols might be a new hope for poor responder IVF patients, but this report is preliminary and further controlled randomized prospective studies with larger sample sizes are required.

Insulin sensitivity and hyperprolactinemia

It has been shown that prolactin (PRL) induces glucose intolerance, hyperinsulinemia and insulin resistance in several animal species. In women with microprolactinomas, the sensitivity to insulin is lower in hyperprolactinemia than in normoprolactinemia. Thirty non-obese women with hyperprolactinemia and 30 healthy non-obese women were included into the study. Age, body weight (bw), height, body mass index (BMI), waist circumference, hip circumference and waist to hip ratio of both patients with hyperprolactinemia and control subjects were not different. Mean serum prolactin level was higher in hyperprolactinemic patients than in control group (84.5 +/- 51.1 ng/ml and 13.8 +/- 5.3 ng/ml respectively, p<0.002). Mean HOMA-(%B) index of hyperprolactinemic patients was higher than in control subjects (121 +/- 49 and 84 +/- 38, respectively, p<0.02). Mean HOMA-(%S) index was lower in hyperprolactinemic patients (56 +/- 39 and 105 +/- 55, respectively, p<0.006). Serum total testosterone, free testosterone, androstenedione, estradiol, cortisol, sex hormone binding globulin and DHEA-S levels in both hyperprolactinemic women and healthy subjects, statistically did not show any difference between the two groups. The present data indicate that hyperprolactinemia is associated with an insulin-resistant state. This resistant state may not be a result of obesity, androgenic hormones, and SHBG or pregnancy. It may be the result of serum free fatty acids (FFA) levels, decrement in the number of insulin receptors (by a down-regulation of insulin receptors) or post-binding defect in insulin action or more.

The effect of high-fat diet on the development of obesity and serum leptin level in rats

Ten male Wistar-albino rats were overfed with high-fat diet (margarine at the dose 40 g/kg body weight/day in addition to standard rat diet) during six months from the age of between 8-12 weeks. Ten male rats received a standard chow for the same period. The body weights of the overfed rats increased time dependently (basal 171.5 +/- 5, at sixth month 268 +/- 19 g), whereas those of the rats fed with standard chow did not increase significantly (basal 177 +/- 6.4, at sixth month 220 +/- 10 g). At the sixth month, mean body fat percentages were 36.3 +/- 6.7% and 24.2 +/- 5.4% respectively. Both total cholesterol-triglyceride levels and mean serum leptin levels were also higher than in the overfed rats (p < 0.01 and p < 0.05 respectively). The livers of all rats were histopathologically normal.

CONCLUSION

High-fat diet resulting in an increased body fat percentage in rats is associated with hyperleptinemia, hypercholesterolemia and hypertriglyceridemia.

Is hyperprolactinemia associated with insulin resistance in non-obese patients with polycystic ovary syndrome?

Insulin resistance is common in polycystic ovary syndrome (PCOS). Moderate elevations in serum PRL concentration may contribute to insulin resistance in PCOS. The aim of this study was to determine PRL on development of insulin resistance in non-obese hyperprolactinemic patients with PCOS. Ninety-eight non-obese subjects with PCOS and 100 non-obese healthy control were accepted in the study. Serum glucose, lipids, androgens, free androgen index (FAI), gonadotropins, fat mass and percentage, SHBG, and insulin levels were measured. Homeostasis model assessment (HOMA) was used as index of pancreatic beta-cell function and tissue insulin sensitivity. Independent t-test was used in comparison of results. In patients with PCOS, FAI and mean HOMA-(%B) level were higher than in the control group (p<0.0001), whereas mean HOMA-(%S) in subjects with PCOS was lower than in the control group (p<0.0001). Patients with PCOS were divided into subgroups according to their serum prolactin level (< 24 or > or = 24 ng/ml). Although FAI was not different, mean insulin and HOMA-(%B) levels in hyperprolactinemic patients were higher than in normoprolactinemic subjects (p<0.001). HOMA-(%S) in hyperprolactinemic patients with PCOS was lower than in normoprolactinemic patients (p<0.002). In conclusion, PCOS is associated with insulin resistance; non-obese hyperprolactinemic PCOS patients may be more insulin-resistant than normoprolactinemics and there may be an association between hyperprolactinemia and insulin resistance in PCOS.

Is serum C-reactive protein concentration correlated with HbA1c and insulin resistance in Type 2 diabetic men with or without coronary heart disease?

BACKGROUND AND AIMS

C-reactive protein (CRP) is an inflammatory marker that predicts coronary heart disease (CHD) risk. Diabetes mellitus (DM) counts as a CHD risk equivalent. We aimed to compare serum high sensitivity CRP (hs-CRP) levels in Type 2 diabetic (T2DM) men without CHD, non-diabetic CHD patients and T2DM patients with CHD.

SUBJECTS AND METHODS

Four groups were formed; Group 1 [DM(+), CHD(-), no.=25], Group 2 [DM(-), CHD(+) no.=25], Group 3 [DM(+), CHD(+), no.=25], and Group 4 (controls, no.=30). Serum hs-CRP, insulin, glucose, total, HDL-, LDL- and VLDL-cholesterol, triglyceride levels and homeostasis model assessment for insulin resistance (HOMA-IR) index were determined.

RESULTS

Mean hs-CRP level of Group 1 (0.6+/-0.29) was not different statistically from Group 2 (1.44+/-0.97). Mean hs-CRP levels were higher in men with CHD, whether they were diabetic (Group 3; 3.83+/-2.01 mg/dl) or non-diabetic (Group 4), than in control subjects (0.16+/-0.15; p=0.0001 and p<0.004, respectively). Mean hs-CRP level of Group 3 was also higher than Group 2 (p=0.0001). There was a positive correlation between serum hs-CRP and glycated hemoglobin (HbA1c; r=0.277, p<0.01), fasting insulin (r=0.336, p<0.02) and HOMA-IR (r=0.348, p<0.02) in T2DM men with or without CHD.

CONCLUSIONS

T2DM men without CHD had similar CRP levels with non-diabetic CHD patients, whereas CRP levels of T2DM men with CHD were higher than non-diabetic men with CHD. Because of a positive correlation between serum hs-CRP and HbA1c, fasting insulin and HOMA-IR, inflammation, insulin resistance and hyperglycemia jointly contribute to the cardiovascular risk in T2DM men.

The comparison of insulin sensitivity in non-diabetic hemodialysis patients treated with and without recombinant human erythropoietin

BACKGROUND

Patients with end-stage renal disease (ESRD) are known to have insulin resistance. Treatment with EPO is associated with improvement in insulin sensitivity in uremic patients. The aim of this study was to compare insulin sensitivity and pancreatic B cell function in adult non-diabetic uremic hemodialysis patients treated with or without rHuEPO.

SUBJECTS AND METHODS

Three groups of subjects were included to the study: hemodialysis patients treated with rHuEPO [EPO(+) group] or without rHuEPO [EPO(-) group], and healthy controls. Anthropometrical parameters, lipid levels, fasting glucose and insulin levels were measured in all subjects. Homeostasis Model Assessment (HOMA) was used to compare insulin sensitivity. ANOVA, independent t-test, and Pearson correlation were used for statistical analysis.

RESULTS

Mean insulin level of control group (20.04 +/- 7.2 pmol/l) was significantly lower than EPO(+) group (p < 0.04) and EPO(-) group (p < 0.0001). HOMA-(%B) levels in the EPO(+) group were significantly lower than in the EPO(-) group (106 +/- 42, 140 +/- 63 respectively, p < 0.02). HOMA-(%B) levels in the control group (66 +/- 17) were significantly lower than in the EPO(+) and EPO(-) group (p < 0.005 and p < 0.0001 respectively). HOMA-(%S) levels in the EPO(+) groups was significantly higher than in the EPO(-) group (91 +/- 40, 56 +/- 26, respectively; p < 0.01). HOMA-(%S) levels of control group (125 +/- 24 ) was significantly higher than EPO(+) and EPO(-) groups (p < 0.02, p < 0.0001 respectively). We found a positive correlation between duration of erythropoietin treatment and insulin sensitivity (r = 0.484, p < 0.002).

CONCLUSIONS

Firstly, patients treated with EPO are insulin sensitive compared to patients not treated with EPO. Secondly, duration of erythropoietin treatment is positively correlated with insulin sensitivity in hemodialysis patients.

Necrotizing (malignant) otitis externa: An unusual localization of mucormycosis

Malignant otitis externa (MOE) is a severe infection of external auditory canal and skull base. A 17-year-old diabetic girl was admitted with diabetic ketoacidosis. Cellulitis of her right ear occurred on the second day of hospitalization and a black necrotic scar in the same region appeared on the next day. The lesion rapidly invaded to right side of neck and surrounding tissue of the patient. Therefore, antimycotic therapy was started. Unfortunately the patient died on seventh day of hospitalization because of probably extensive fungal invasion. Physicians should suspect MOE connected to mucormycosis especially in patients with cutaneous lesions of ear unresponsive to antibiotic therapy.

A simple way to estimate mean plasma glucose and to identify Type 2 diabetic subjects with poor glycaemic control when a standardized HbA1c assay is not available

AIMS

To evaluate the relationship between HbA(1c) and fasting plasma glucose (FPG) and postprandial plasma glucose (PPG) levels, and to estimate the mean plasma glucose (mPG) derived from FPG and PPG that would predict Type 2 diabetic subjects with poor glycaemic control.

METHODS

FPG, PPG and HbA(1c) values from 565 Type 2 diabetic patients (247 men and 318 women) were recorded. Linear regression analysis and Pearson's correlation was used to determine the relationship between HbA(1c), FPG and PPG. FPG and PPG were included as explanatory variables of HbA(1c) in linear regression analysis.

RESULTS

The American Diabetes Association's objective of achieving an HbA(1c) level < 7.0% was obtained in 26.2% of the patients. The coefficients of FPG and PPG which determined HbA(1c) were similar. Therefore, mPG was calculated using the equation (FPG + PPG)/2. Pearson's correlation coefficient for HbA(1c) and FPG, PPG and mPG were 0.723 (P < 0.0001), 0.734 and 0.761 (P < 0.0001), respectively. A mPG cut-off value of 10 mmol/l predicted an HbA(1c) > 7% in the whole population, with a sensitivity of 84.2% and specificity of 80.4%. The area was high (0.90) in receiver-operating characteristic (ROC) curve analysis performed to examine the performance of mPG to predict HbA(1c) > 7%.

CONCLUSIONS

The mPG derived from FPG and PPG correlates strongly with HbA(1c). We therefore suggest that using a cut-off of 10 mmol/l for mPG may be appropriate in diabetes management in the primary-care setting, where most management of Type 2 diabetes occurs.

Serum prostate specific antigen levels in women with polycystic ovary syndrome and the effect of flutamide+desogestrel/ethinyl estradiol combination

BACKGROUND

Prostate-specific antigen (PSA) is expressed in many female tissues and its concentrations were higher in hirsute subjects. We aimed to determine serum PSA level in hirsute women and evaluate the effect of flutamide+desogestrel/ethynil estradiol combination.

SUBJECTS AND STUDY DESIGN

Thirty patients with polycystic ovary syndrome (PCOS) and 30 healthy controls were studied. Hirsutism was defined by modified Ferriman-Gallwey score (FGS). Free androgen index (FAI) was used for hyperandrogenism. Patients received flutamide (500 mg/d) and oral contraceptive (desogestrel+ethinyl estradiol) for 9 months.

RESULTS

Mean FGS (p<0.0001), insulin (p<0.01), FAI (0.0001), androstenedione (p<0.0001), LH (p<0.05), and free testosterone (p<0.003) levels of patients with PCOS were higher than the control group. Mean serum total and free PSA level of PCOS patients were higher than the control group (p<0.0001 and p<0.0001). We found a positive correlation between total PSA levels and FGS (r=0.568, p<0.001), FAI and FGS (r=0.456 and p<0.01). There was also a positive correlation between FAI and total PSA (r=0.503 and p<0.005). At the end of treatment, FGS, androstenedione, free and total testosterone, FAI, serum PSA and LH levels decreased significantly [serum total PSA was 0.0208 +/- 0.0178 ng/ml at baseline and 0.0061 +/- 0.0044 ng/ml after treatment (p<0.0001)].

CONCLUSIONS

1. Serum prostate specific antigen level is higher in patients with PCOS; 2. There is a positive correlation among FGS, FAI and PSA levels; 3. Serum PSA levels decrease with antiandrogen treatment; 4. Serum PSA measurement might be a marker for hirsutism.

The results of cytogenetic analysis with regard to intracytoplasmic sperm injection in males, females and fetuses

OBJECTIVES

To determine the incidence of chromosome abnormalities among couples for whom intracytoplasmic sperm injection (ICSI) treatment was indicated and fetuses conceived through the ICSI procedure.

METHODS

All cytogenetic results were evaluated retrospectively. Patients undergoing ICSI (n = 508) were classified according to the referring indications as: (1) males with severe infertility (87 azoospermia and 34 oligoasthenoteratozoospermia, OAT), (2) prior to ICSI (56 males and 61 females), and (3) following an unsuccessful ICSI procedure (132 males and 138 females). Fetuses conceived through ICSI (n = 475) were also classified into 4 groups according to the additional risk factors for chromosome abnormalities: ICSI (n = 185), ICSI + advanced maternal age (AMA, n = 215), ICSI + positive triple test result (TT, n = 50), and ICSI + abnormal ultrasound findings (USG, n = 25).

RESULTS

An abnormal karyotype was found in 31.03% of males with azoospermia and 14.71% of males with OAT, in 3.57% of males and 1.64% of females in the group prior to ICSI, and in 5.30 and 5.07%, respectively, in the group following unsuccessful ICSI treatment. Gonosomal aneuploidies were predominant in males with azoospermia and autosomal rearrangements in males with OAT, while low-level sex chromosome mosaicism was found in females. The overall frequency of chromosome abnormalities in fetuses was 4.42% and varied in the different groups from 1.62% in ICSI, 2.79% in ICSI + AMA, 10.0% in ICSI + TT to 28.0% in ICSI + USG. The frequencies of the different types of chromosome abnormalities were as follows: balanced 1.05%, unbalanced 3.37%, familial 0.84%, de novo 3.37%, autosomal 3.58%, gonosomal 0.84%, numerical 1.89%, structural abnormalities 2.53%, and mosaicism 1.26%.

CONCLUSION

Our results indicate that cytogenetic investigations of the ICSI parents and fetuses are essential for the families, genetic counselors and also reproductive centers. In fetal karyotyping, de novo structural chromosome abnormalities and mosaicism should be taken into consideration.

Polyglandular autoimmune syndrome type III accompanied by common variable immunodeficiency

We identified polyglandular autoimmune (PGA) syndrome type III in a 24-year-old nurse with common variable immunodeficiency (CVID). An immune-mediated disorder, membranoproliferative glomerulonephritis, was diagnosed when she was 15 years old. Clinical examination and laboratory findings revealed a PGA syndrome due to the presence of hypergonadotropic hypogonadism, insufficient growth hormone response and thyroid autoimmunity. The patient had neither adrenal disease nor hypoparathyroidism. Therefore we concluded that this patient has PGA syndrome type III. This is an interesting case, because we could not find any previous report of such coexistence between PGA type III and CVID in a Medline search. Coexistence of these two entities may be a result of autoimmunity and the association of both conditions with human leukocyte antigen.

A case series of Bardet-Biedl syndrome in a large Turkish family and review of the literature

BACKGROUND AND AIM

Bardet-Biedl syndrome (BBS) is a rare autosomal recessive genetic disorder. We aimed to report a case series of Bardet-Biedl syndrome in a Turkish family and review the literature.

PATIENTS AND METHODS

This family had 3 females and 4 males, totally 7 alive; 2 children (1 female and 1 male) had died. Parents were consanguineous. The first was a birth of twins and female sibling of these twins had congenital anal atresia and died when she was three-month old. Third (30 yr), 4th (28 yr) and 9th (19 yr) alive siblings were obese, blind and diabetic. We detected truncal obesity, postaxial polydactyly, cognitive impairment and hypogonadism. Rod-cone dystrophy was detected in ophthalmic examination. With these typical clinical findings, BBS was diagnosed. There was also a male member of the family which shared the same features of his affected brothers but he had died while he was eight months old. Marked glycosuria was determined and urine density was 1021 g/cm3. There was not any further endocrinological abnormality. Fasting blood glucose levels were changing between 290 and 452 mg/dl and the last glycated hemoglobine levels (A1c) were 9.3%, 11.2% and 12.8%, respectively. Diabetes mellitus and obesity were treated with diet, exercise, multiple daily insulin injections and metformine at the dose of 2000 mg/d.

CONCLUSIONS

Although it is an infrequent condition due to autosomal recessive transmission, consanguineous marriage may increase the risk of emergence of BBS. Genetic counseling is a very important issue in the family of patients with BBS, in order to prevent new cases.

N-terminal pro-brain natriuretic peptide in newly diagnosed acromegaly

INTRODUCTION AND AIM

The mechanisms of acromegalic cardiomyopathy are not clearly understood. Brain natriuretic peptide (BNP) and N-terminal fragment of its pro-hormone (NT-proBNP) are released by the cardiac ventricles and increase in heart failure. In the present study, we aimed to evaluate serum NT-proBNP levels in acromegalic patients and determine a relationship between NT-proBNP levels and echocardiographic parameters.

SUBJECTS AND METHODS

Twenty-two newly diagnosed acromegalic patients [mean age 38.85 ± 11.06 yr; body mass index (BMI): 28.51 ± 3.48 kg/m2] and 26 age- and BMI-matched healthy control subjects (mean age 32.9 ± 12.6 yr; BMI: 26.2 ± 5.3 kg/m2) were included in the study. Standard oral glucose tolerance test (OGTT) was performed. Serum NT-proBNP and GH were measured at the beginning of the OGTT (0 min). Body fat analyses were measured by bioelectrical impedance. Echocardiography was used in cardiac evaluations.

RESULTS

The mean NT-proBNP level in the acromegalic group was not significantly different from the control subjects (55.89 ± 46.64 pg/ml in acromegaly vs 28.76 ± 22.13 pg/ml in control subjects). There were no correlations between the serum NTproBNP, GH, and IGF-I levels. Echocardiography revealed significantly increased left ventricular end-diastolic diameter (p=0.008), interventricular septum thickness (p=0.009), left atrium (p=0.029), and right ventricle diameter (p=0.027) in the acromegalic group.

CONCLUSION

NT-proBNP levels were found to be slightly higher in acromegalic patients as an indicator of heart failure, but the increase was not statistically significant. Although these cardiac structural changes in newly diagnosed acromegalic patients are present, the normal level of NT-proBNP shows that NT-proBNP may not be a good indicator in acromegaly.