ACTA ENDOCRINOLOGICA (BUC)

Context. Detection of parathyroid incidentalomas (PTIs) by ultrasonography (US) generally depends on clinical experience and it can be usually confused with perithyroidal lymph nodes. Objective. We aimed to evaluate the role of US for the detection of PTIs and define clinicopathologic features of PTIs detected during routine neck US. Design. In this retrospective study, we studied PTIs in a multidisciplinary clinical approach of nuclear medicine and general surgery clinics. Subjects and Methods. US indications and reports of 41275 were reviewed retrospectively. Of these patients, PTI was suspected in 66 (0.16%) patients. Those with a pathology-confirmed diagnosis after surgery formed Group PCD and those without a pathology-confirmed diagnosis and operation Group NPCD. These groups were compared statistically according to demographic data, laboratory tests, imaging results and postoperative findings. Results. The diagnosis of PTI was confirmed pathologically in 31 operated patients. Other pathologies rather than PTI on US were multinodular goiter, thyroiditis, thyroid nodule and perithyroidal lymph node. PTH and calcium levels were significantly higher in PCD Group;anti- TPO and anti-TG levels were significantly higher in NPCD Group. Conclusions. Lesions suspected of PTI on US should be followed-up with further evaluation by laboratory tests and imaging methods and a multidisciplinary working environment should be established.

Objectives. To determine whether levonorgestrel releasing intrauterine device (LNGIUD) in association with oestradiol subdermic implant is an efficient and safe therapy for neurovegetative disturbances in climacterium, for the patients who had previous metrorrhagia in preclimax.\r\nPatients and method. We performed a prospective study on 18 menopausal patients (group A) with a mean age of 50.2 ? 1.5 years with LNG-IUD, inserted in preclimacterium for dysfunctional uterine bleeding (biopsy showed us simple endometrial hyperplasia) and 20 menopausal women with neurovegetative symptoms that refused hormonal replacement therapy (HRT) as control group B. In group A, patients had amenorrhea after 6.8 ? 1.7 months from IUD insertion. Our criteria for selection were: presence of neurovegetative disturbances, FSH >25 UI/L, no contraindication for hormonal replacement therapy. Group A patients had a subdermic implant with estradiol 25 mg every six months. All patients were regularly followed: first visit after one month, the next visits every three months for three years. At each visit we observed neurovegetative symptoms, uterine bleeding, endometrial thickness assessed by transvaginal ultrasonography. The Kupperman test of menopausal distress index was calculated at each visit.\r\nResults. All patients reported the absence of neurovegetative symptoms after 4.5 ? 1.8 months of therapy. Fifteen of them (83.33%) had no vaginal bleeding during the study, three patients presented minor uterine bleeding during the first six months of follow-up. Transvaginal ultrasonography showed endometrial thickness < 5mm in all our subjects. Four patients presented breast discomfort for a short period.\r\nConclusion. LNG-IUD in association with estradiol subdermic implant proved to be an efficient therapy in climacterium. The capacity of LNG-IUD to determine endometrial atrophy contributes to local safety of this hormonal replacement therapy.

Background. There is no immunohistochemical study to show luteinizing hormone receptor (LHR), estrogen receptor (ER) and progesterone receptor (PR) in the pregnant Fallopian tubes (FT). Objective. To study LHR, ER, PR expression in FT containing an ectopic pregnancy (EP) and during the menstrual phase. Design. Thirty FT were obtained from women diagnosed with EP and twenty FT collected by hysterectomy performed for benign diseases not affecting the tubes were included in this study. Assessment of immunohistochemical expression staining LHR, ER, PR in epithelium, smooth muscle cell and blood vessel endothelium in FT containing an EP and during the different phases of menstrual cycle. Results. In ectopic pregnancy group we found LHR expression in epithelium in 30 cases, muscle cell in 28 cases, and endothelium in 9 cases in FT. In menstrual cycle group we noted LHR expression in FT in epithelium in all cases, muscle cell in 4 cases. Conclusion. There is a significant difference in the proportions of the existence of LH receptor immunostaining in the muscle cells for ectopic pregnancy group as compared to the menstrual cycle groups (p < 0.001). Our findings may suggest that the women who have increased LH receptors on muscle cells in Fallopian tubes are at increased risk for having external pregnancy.

Objective. Gestational diabetes mellitus (GDM) is defined as glucose intolerance that\r\nis detected for the first time during pregnancy. Normal pregnancy induces insulin resistance\r\nthrough the diabetogenic effects of placental hormones. Glucose tolerance test results in\r\ntwin and singleton pregnancies were compared in this study.\r\nSubjects and Methods. A total of 360 pregnant women were studied. 200 women\r\n(mean age 31.60?2.10 yr) had singleton pregnancies (Group I) and 160 women (mean age\r\n28.20?2.70 yr) had twin pregnancies (Group II). 50- g, 1- hour glucose tolerance test was\r\nconducted on the first prenatal visit. An abnormal glucose screen defined as glucose > 140\r\nmg/dL was followed by a 100g, 3-hour glucose tolerance test. Gestational diabetes was\r\ndefined as the presence of two or more abnormal values during the 3-hour test.\r\nResults. Gestational diabetes was found in 4 of the 200 (2%) singleton pregnant\r\nwomen and 8 of the 160 (5%) twin pregnant women. Group I (Singleton) was further\r\ndivided into two subgroups according to whether the 1-hr plasma glucose level was < 140\r\nmg/dl (Group Ia) or >140 mg/dL (Group Ib). Likewise, Group II pregnancies was also\r\ndivided into two subgoups on the same basis. Mean screening test glucose levels were found\r\nto be 127.8?14.94 mg/dL in Group Ia and 150.8 ? 18.1 mg/dL in Group Ib women. Mean\r\nscreening test glucose levels of Group IIa subjects was 92.80 ? 18.30 mg/dL while that of\r\nGroup IIb subjects was 154.8 ? 27.0 mg/dL. Mean 1st h glucose levels of 100-g glucose\r\ntolerance test was found to be 131.4 ? 32.58 mg/dL in Group I, and 112.5 ? 39.6 mg/dL in\r\nGroup II. Mean 2nd h glucose tolerance test values were 133.2 ? 28.8 mg/dL in Group I and\r\n100.6?28.8 mg/dL in Group II. Mean 3rd h glucose tolerance test values were 107.6 ? 23.58\r\nmg/dl in Group I and 72?16.9 mg/dL in Group II.\r\nConclusion: Glucose screening results and 100-g, 3- hour glucose tolerance test\r\nvalues have been found to be lower in twin pregnancies than in singleton pregnancies.\r\nTherefore, we suggest that these findings be taken into account in developing diagnostic\r\ncriteria for gestational diabetes in twin or more pregnancies.

Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) plays an important role in the regulation of cellular energy metabolism, and it is involved in obesity and type 2 diabetes mellitus (T2DM). Its expression is elevated in the liver of T2DM mouse models. Literature reports show that chronic β2 stimulation improved insulin sensitivity in T2DM. Objectives. We aimed to test the hypotheses that chronic β2 stimulation-induced improvement in insulin sensitivity involves changes in the expression of PGC-1α and glucose transporter 4 (GLUT4). Animals and Methods. We fed a locally inbred, 8 months old mice, a high fat diet (HFD) to induce diabetes. These mice gained weight and became insulin resistant. The β2 agonist salbutamol had a beneficial effect on both glucose tolerance and insulin sensitivity after 4 weeks. Results. Salbutamol beneficial effect persisted after 4 weeks of its discontinuation. HFD caused an up regulation of the hepatic PGC-1 α expression by 5.23 folds (P< 0.041) and salbutamol reversed this effect and caused a down regulation by 30.3 folds (P< 0.0001). PGC-1 α and GLUT4 expression in the muscle was not affected by salbutamol (P> 0.05). Conclusion. Down regulation of the liver’s PGC- 1 α contributes to the beneficial effect of the chronic β2 stimulation on glucose tolerance and insulin sensitivity in T2DM mice.

Context. Endothelial dysfunction and diabetic cardiomyopathy are critical complications of diabetes. Gallic acid (GA) plays a significant role in cardiovascular disorders resulted from diabetes. In addition, increased plasma miR-24, miR-126 associated with endothelial dysfunction. Aim. The current study was designed to assess the effects of GA on plasma miR-24, miR-126 levels in the diabetic rats. Animals and Methods. Adult male Sprague-Dawley rats were divided into three groups (n=8): control (C), diabetic (D) and diabetic group treated with GA (D+G, 25 mg/kg, by gavage) for eight weeks. The blood glucose level, body weight, lipid profile, blood pressure, plasma miR-24 and miR-126 levels, antioxidant and inflammatory biomarkers were measured. Results. The plasma levels of miR-24, miR-126, body weight, high-density lipoprotein cholesterol (HDL-c), total anti-oxidant capacity (TAC) and the systolic blood pressure significantly reduced and blood glucose, total cholesterol (TC), triglycerides (TG), very low-density lipoprotein cholesterol (VLDL-c), malondialdehyde (MDA), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α) and low-density lipoprotein cholesterol (LDL-c) significantly elevated among the diabetic rats compared with the control group. However, GA restored body weight, blood pressure, TC, TG, VLDL-c, TNF-α, miR- 126, blood glucose, HDL-c, MDA, TAC, miR-24 and IL-6 among the GA treated rats compared with the diabetic group. Conclusion. GA improves inflammation, oxidative stress and hypotension result from diabetes. These protective effects are probably mediated via increasing plasma miR-24 and miR-126 levels.

Context. It is a challenge to determine the origin of Cushing syndrome (CS), especially in patients with low-normal adrenocorticotropic hormone (ACTH) concentrations. Objective. To evaluate the reliability of the corticotropin-releasing hormone (CRH) stimulation test in patients with CS whose origin of disease was not clearly identified using ACTH values, the high-dose dexamethasone suppression test (HDDST), and imaging in a single tertiary referral center. Design and Methods. Twenty-one patients with CS who were admitted to the endocrinology-metabolism clinic between 2004 and 2016 whose ACTH concentrations were 5-20 pg/mL and needed CRH stimulation test were retrospectively assessed. Results. Nine out of 21 patients were diagnosed as having Cushing’s disease (CD) and 12/21 had adrenal CS. The CRH stimulation test had a sensitivity and specificity of 100% and 8%, and positive and negative predictive values of 100% and 45% according to the current diagnostic criteria, respectively. An increase in ACTH ≥115% at 15 minutes and cortisol ≥86% at 60 minutes after CRH were associated with the highest likelihood ratio. The sensitivity and specificity of ACTH was 67% and 83% (AUC=0.75±0.12, 95% CI: [0.5-0.9]; p=0.03), and for cortisol it was 75% and 78% (AUC=0.71±0.15, 95% CI: [0.5-0.9]; p=0.03). Cortisol suppression of more than 64% from basal level in the HDDST suggested CD with the highest likelihood ratio. When these cut-off values were used together, both tests were negative in the patients with CD. Conclusion. The CRH stimulation test has low specificity to localize CS in patients with ACTH concentrations of 5-20 pg/mL according to the current diagnostic criteria. Different diagnostic criteria may be used in the CRH stimulation test and also in the HDDST in this group of patients.

Context. Anti-Mullerian hormone (AMH) assay is becoming the best indicator of successful IVF treatment response to fertility drugs and could be a useful marker of embryo implantation potential. Various protocols are being used for controlled ovarian stimulation (COS), but there is an uncertainty regarding the implementation of the best protocol for endometriosis patients and also little evidence is available concerning the clinical value of AMH levels in endometriosis. Objective. This study aimed to evaluate the prognostic value of serum AMH levels for pregnancy in COS using GnRH-agonist(GnRH-a) and GnRHantagonist( GnRH-ant) protocols in endometriosis patients. Design. This is a cross-sectional study between March 2012 and November 2015. Subjects and Methods. Data were collected from 249 COS cycles of endometriosis patients, including 129 cycles with GnRH-a and 120 cycles with GnRH-ant. Patients in each group were classified into three subgroups based on their serum AMH levels. The outcomes of ICSI program were evaluated. Results. The ROC curve analysis showed that embryo and oocyte counts and AMH were equally predictive for pregnancy, as demonstrated by a similar area under the curve (AUC) of 0.69, 0.66 and 0.64, respectively. The sensitivity and specificity for prediction of positive pregnancy were 70.91% and 67.01% for embryo counts, 70.91% and 67.53% for oocyte counts at the cutoff values of 5 and 7, respectively, and 83.64% and 52.58% for AMH levels at the cutoff values of 1.3ng/mL. Conclusions. This study demonstrates that AMH as a single test has substantial accuracy in the prediction of pregnancy using the GnRH antagonist protocol for patients with endometriosis. In other words, AMH assay prior to ovarian stimulation initiation guides the clinicians to choose the antagonist stimulation protocol for the patients with two extreme AMH levels. AMH levels can be used to individualize control ovarian stimulation in endometriosis patients.

abdominal cystic lesions should include investigation of cystic pheochromocytomas. To date only a few cases of purely cystic pheochromocytoma have been reported in the English literature. Aim. To present the management in four cases of silent pheochromocytomas patients who presented with pure or partially cystic abdominal lesions with benign (n:3) and malignant characteristics (nonspecific neuroendocrine tumor) (n:1) in histological evaluation. Results. Resection of the tumor is considered the primary treatment option in the management of pheochromocytoma, and preoperative preparation with alpha and beta antagonists is crucial in order to avoid precipitation of hypertensive crisis during surgical procedures. The absence of clinical symptoms and lack of typical radiological features may complicate the diagnosis of pheochromocytoma resulting with increased mortality and morbidity during surgery. Conclusion. Asymptomatic pheochromocytomas are rare and they are responsible for approximately 5% of adrenal incidentalomas. These lesions may be referred to surgery as clinically nonfunctional adrenal adenomas.

We present the case of severe hypocalcaemia in a 5 weeks old baby, secondary to pre and postnatal vitamin D deficiency. The symptomatic hypocalcaemia led to several life threatening episodes of seizures. Following initial calcium gluconate infusion, multiple phospho-calcic deposits in the soft tissue and cerebral tissue were observed. A multifactorial etiology of calcinosis cutis was suggested by the association between infusion of high and repeated doses of calcium gluconate in a severely hypocalcaemic baby, with a low 25- hydroxyvitamin D3 level, associated to a renal and bone relative resistance to the high level of PTH. The aim of this report is to raise pediatric health care professionals awareness on the relatively rare entity known as calcinosis cutis.