The association of TSH-receptor antibody with the clinical and laboratory parameters in patients with newly diagnosed Graves’ hyperthyroidism: experience from a tertiary referral center including a large number of patients with TSH-receptor antibody-negative patients with Graves’ hyperthyroidism

Introduction: Although the TSH-receptor antibody (TRAb) plays a central role in the pathogenesis of Graves’ disease (GD), the association between TRAb at first diagnosis and clinical and laboratory parameters is not well known. On the other hand, a minority of patients with GD may be TRAb negative, and there is a lack of adequate evidence to demonstrate the clinical and laboratory characteristics of these patients. Therefore, we aimed to investigate the association of TRAb at the initial diagnosis of GD with the clinical and laboratory parameters in a large number of patients with GD and to compare the clinical and laboratory parameters between patients with high TRAb levels and TRAb-negative patients. Material and methods: This study included 440 patients [326 (74%) female, 114 (26%) male]. All patients were classified according to gender, age, smoking habit, and TRAb levels. Results: TRAb levels were significantly higher in male compared to female patients and in smokers compared to non-smokers. Smoking male patients had the highest TRAb levels. In regression analysis, goiter size, male gender, cigarette smoking, Graves’ orbitopathy, fT3, and anti-TPO antibody levels were independently associated with high TRAb levels, while age at diagnosis and fT4 levels were not independently associated with high TRAb levels. TRAb-negative GD was diagnosed in 80 (18%) patients. TRA-negative patients had markedly less severe clinical and laboratory hyperthyroidism compared to patients with high TRAb levels. Moreover, the smoking habit was significantly lower in patients with TRAb-negative GD. Conclusions: According to our study results, TRAb levels at the initial diagnosis of GD are differently associated with clinical and laboratory parameters. Male patients and smoking patients with GD tended to have markedly higher TRAb levels and more severe clinical hyperthyroidism. Therefore, besides other contributing factors, male gender and smoking may affect TRAb levels and consequently the severity of hyperthyroidism in patients with GD. Furthermore, male gender and smoking may have a synergistic effect on TRAb levels and consequently on the severity of hyperthyroidism in patients with GD

B-mode ultrasound assessment of carotid artery structural features in patients with normocalcaemic hyperparathyroidism

Introduction: Normocalcaemic hyperparathyroidism is a condition first defined in 2008, characterized by normal serum calcium and high parathormone levels. Although normocalcaemic hyperparathyroidism is considered to have a milder clinical picture compared to asymptomatic primary hyperparathyroidism, recent studies have shown that it may be associated with osteoporosis, insulin resistance, metabolic syndrome, and cardiovascular risk factors. Considering that normocalcaemic hyperparathyroidism may pose a cardiovascular risk in the setting of carotid atherosclerosis, we sought to examine the structural features of the carotid artery in patients with normocalcaemic hyperparathyroidism compared to a control group. Material and methods: After excluding patients with hypertension, diabetes, and dyslipidaemia (other factors contributing to atherosclerosis), 37 (32 females, 5 males) patients with normocalcaemic hyperparathyroidism with a mean age of 51.2 ± 8 (min: 32, max: 66) years and 40 controls (31 females, 9 males) with a mean age of 49.3 ± 7.5 (min: 34, max: 64) years with normal serum albumin-corrected calcium and parathyroid hormone levels were included in the study. Structural features of the carotid artery including intima-media thickness (mean and maximum), lumen diameter, and the presence of plaque were assessed using B-mode ultrasound. Results: On ANCOVA analysis corrected for atherosclerotic factors (body mass index, waist circumference, fasting plasma glucose, serum cholesterol, lipid, and blood pressure), greater mean intima-media thickness was found in patients with normocalcaemic hyperparathyroidism than in controls (0.65 mm vs. 0.59 mm, respectively) (p = 0.023). Maximum carotid intima-media thickness was also greater in patients with normocalcaemic hyperparathyroidism compared to controls (0.80 mm vs. 0.75 mm, respectively) (p = 0.044). The study groups did not show a significant difference in lumen diameter and the presence of carotid plaque. In addition, a negative correlation was found between parathormone (PTH) level and lumen diameter. Conclusion: The findings of this study show that as with asymptomatic primary hyperparathyroidism, normocalcaemic hyperparathyroidism may be associated with increased cardiovascular risk by predisposing to atherosclerosis

The effect of gender on response to antithyroid drugs and risk of relapse after discontinuation of the antithyroid drugs in patients with Graves’ hyperthyroidism: a multicentre study

Introduction: The outcome of medical treatment in patients with Graves’ disease (GD) is generally difficult to predict. In this study, we examined the hypothesis that gender may affect the outcome of treatment with antithyroid drugs (ATDs). Material and methods: This is a retrospective multicentre study including 717 (514 female and 203 male) patients with the first episode of GD treated for at least 12 months. Patients were classified as relapse, poorly controlled (several episodes of hyperthyroidism followed by euthyroidism and rarely hypothyroidism, occurring after titration of ATDs), and remission. Results: During the mean follow-up time of 26.75 ± 21.25 months (between 1 and 120 months), 269 (37.5%), 176 (24.5%), and 272 (37.9%) patients experienced a relapse, a poorly controlled disease, and remained in remission, respectively. During the follow-up time, 223 (43.4%) of the female and only 49 (24%) of the male patients remained in remission. Relapse and poorly controlled disease (non-remitting GD) were more common in male compared to female patients with GD (hazard ratio 1.26, 95% CI: 1.03–1.53, p = 0.025). Graves’ disease in male patients tended to relapse earlier, and male patients tended to have larger goiter sizes at diagnosis as well. The smoking habit wasalso significantly more frequent in males compared to female patients with GD. Conclusion: Male patients with GD have a markedly higher frequency of relapse and poorly controlled disease, as compared to female patients. Larger goiter sizes and higher frequency of smoking may contribute to the higher frequency of relapse and poorly controlled disease in male patients.

The Effect of Trandolapril on Insulin Resistance is Determined by the Degree of Baseline Resistance Level

Insulin resistance (IR) is the core problem in type 2 diabetes mellitus that may lead to cardiovascular morbidity and mortality. Hypertension commonly accompanies type 2 diabetes. Antihypertensive agents improving IR may reduce the risk of cardiovascular diseases. This study was conducted to assess the effect of trandolapril on IR, glucose and lipid metabolisms in hypertensive subjects with different degrees of IR and investigate the importance of IR level in angiotensin converting enzyme inhibitor response. The subjects were nondiabetic and type 2 diabetic hypertensive patients treated with trandolapril for 12 weeks. Blood pressures (BP) and metabolic parameters were measured in all patients at baseline and after 12 weeks of trandolapril treatment and compared. Trandolapril reduced BP similarly in nondiabetic and diabetic patients. Homeostasis model assessment insulin resistance (HOMA-IR), serum glucose and hemoglobin A1C (A1C) in diabetic patients were higher than nondiabetics. HOMA-IR (from 9.0  1.0 to 6.6  0.7, p4.67 responded better. In conclusion, trandolapril improved insulin sensitivity better in type 2 diabetic hypertensive patients with higher degree of IR compared with the ones with low grade IR, being independent of its hemodynamic action. [Med-Science 2014; 3(2.000): 1140-54

A Rare Cause of Hypercalcemia: Immobilization A Case Report and Literature Review

Immobilization hypercalcemia (IH) mainly results from rapid bone turnover and may be seen after spinal cord injury or long bone fracture in particular in children and adolescents. The pathophysiology of this entity is entirely unknown. A-19 year-old, male quadriplegic adolescent was referred to our outpatient clinic by a family physician. At presentation he had some vague symptoms due to hypercalcemia including fatigue, nausea, vomiting, anorexia, constipation and dehydration. Laboratory investigations for hypercalcemia revealed low intact parathyroid hormone level, low 25-0H vitamin D, and high 24-hour urine calcium. He was diagnosed as having IH after all other causes of hypercalcemia were excluded. The pathophysiology of IH remains unclear. Treatment is directed towards lowering the serum calcium level. Up to date, intravenous hydration with isotonic saline, furosemide and salmon calcitonin have been the conventional therapies. Other treatment options include bisposphonates (such as etidronate, zoledronate or pamidronate) or, an inhibitor of receptor activator of nuclear factor kappa-B ligand (RANKL), denosumab. IH is a rare cause of hypercalcemia. Physicians should be aware of this condition when seeing patients with restricted physical activity. [Med-Science 2015; 4(3.000): 2521-7

Medicine Science 2014;3(2):1140-54 Trandolapril and insulin resistance Original Investigation The Effect of Trandolapril on Insulin Resistance is Determined by the Degree of Baseline Resistance Level Trandolapril and insulin resistance Original Investigat

Abstract Insulin resistance (IR) i

Amiodarone induced thyrotoxicosis may not respond to therapeutic plasma exchange like patients with graves disease: A report of two cases and literature review

The achievement of euthyroid state has been suggested in patients with thyrotoxicosis undergoing surgery to reduce the risk of thyroid storm. However, euthyroid state could not always be achieved by antithyroid drugs. Therefore, therapeutic plasma exchange (TPE) is an option in this condition. A 58-year-old male patient with a history of type-2 diabetes using 200 mg amiodarone per day, admitted for diabetic ketoacidosis (DKA), induced by thyrotoxicosis. with palpitation, sweating, polyuria, and polydipsia. Euthyroid state could not be achieved, despite all apropriate treatments for thyrotoxicosis. Therefore, preparation with TPE followed by total thyroidectomy was planned. A 35% decrease in fT3 (free T3) and fT4 (free T4) levels were achieved, after two sessions of TPE. A 74-year-old male patient, admitted for acute anterior myocardial infarction (AMI) induced by thyrotoxicosis due to Graves disease. Multiple vessel disease was detected on primer percutanous coronary angiography, and an emergency coronary artery bypass grafting (CABG) was planned. Therefore, preperation with TPE was planned before surgery. A substential decrease in fT4 and fT3 levels (45% and 72%, respectively) levels were achieved, after one session of TPE. Most of the studies evaluating the efficacy of TPE in patients with thyrotoxicosis are including patients with Graves disease and toxic multinodular goiter, and TPE was indicated as an effective option for preparation of these patients for surgery. However, as presented in case 1, TPE may not be effective in amiodarone induced thyrotoxicosis (AIT) as in cases with thyrotoxicosis due to Graves disease. [Med-Science 2019; 8(1.000): 233-6

Cytoplasmic Pattern Anti-neutrophil Cytoplasmic Antibody (cANCA)-positive Cutaneous Leukocytoclastic Vasculitis Induced by Propylthiouracil: A Case Report

Propylthiouracil (PTU) is a medication commonly used to treat hyperthyroidism, but it has various rare side effects such as anti-neutrophil cytoplasmic antibodies (ANCA)- associated vasculitis (AAV). In the last decades, multiple cases of PTU-induced AAV have been reported, some being fatal. While AAV is primarily related to perinuclear-staining ANCA/anti-myeloperoxidase (pANCA/anti-MPO), it can occur to a lesser extent in association with cytoplasmic staining ANCA/ proteinase 3 (cANCA/PR3). A case is presented of a 62-year-old female with a history of hyperthyroidism due to toxic multinodular goiter treated with a standard dose of PTU. Approximately 3 years after starting therapy, she noticed formation of skin ulcerations on both of her ear lobes, nose and bilateral limbs. Detailed hospital work-up detected cANCA positivity. Biopsy of the affected skin revealed leukocytoclastic vasculitis and additional tests excluded systemic vasculitis. The patient was diagnosed as PTU-induced vasculitis, a form of drug-induced vasculitis. Although clinical manifestations improved slightly after total thyroidectomy, the patient could not be saved because of the fulminant course of infected and disseminated skin ulcers. Conclusion: PTU is one of the causes of AAV. However, the presence of cANCA positivity when pANCA is negative in PTU-induced AAV is extremely rare. Here, we present a rather unusual case of PTU-induced AAV associated with cANCA. [Med-Science 2016; 5(2.000): 645-54

Peripheral Blood CD34+ Cell Counts in Patients With Severe Sepsis

Objectives: This study aims to determine the impact of severe sepsis (SS) on CD34(+) cell counts in the peripheral blood and to compare these counts with those of healthy subjects

Ultrasound Guided-Fine Needle Aspiration Biopsy of Thyroid Nodules: 18 Months Retrospective Review of One Center Experience

The objective of this study is to elucidate the use of ultrasonography guided fine-needle aspiration biopsies (UG-FNAB) in the evaluation of thyroid nodules. The study population consisted of 790 UG-FNAB in 719 patients whom were admitted to the our endocrinology clinic. The cytological results were classified as benign, follicular lesion or suspicious for malignancy, malignant and non-diagnostic. The results of 790 UG-FNAB of 719 patients were as follows: 567 (71.77%) benign, 97 (12.28%) non-diagnostic cytology, 43 (5.44%) atypia with undetermined significance, 81 (10.25%) follicular lesion or suspicious for malignancy, 2 (0.25%) malignant. In our study, thyroid carcinoma rate was found to be lower than current literature. Of the malignant nodules which were reported as papillary thyroid carcinoma by UG-FNAB cytology, both were female, euthyroid and have single nodule in their thyroid gland. One of the patient (39 years old) had a micro nodule (< 1 cm in diameter) that it had an isoechoic pattern with regular margin on thyroid ultrasonography; whereas the other one (79 years old) had macro nodule (>1 cm diameter) that it had, hypoechoic pattern with irregular margin. None of them have calcifications in their nodules. Multidisciplinary approach including endocrinologists, radiologists and pathologists is essential for the management of patients with thyroid nodules to avoid missestimation of the risk of thyroid cancer. [Med-Science 2014; 3(2.000): 1249-61