Adrenal incidentaloma.

Adrenal Incidentaloma is an adrenal tumor, which is unidentified before the imaging procedures conducted for an abnormality which is initially unforeseen as an adrenal disease. Symptoms and/or clinical signs of adrenal tumor do not have to be present prior to a diagnosis. Adrenal Incidentaloma can be divided into non-hypersecreting adrenal adenoma, hypersecreting tumor, primary adrenal carcinoma, other adrenal mass, and metastases. The majority of adrenal tumor is non-hypersecreting adrenal adenoma, but it is always considered as hypersecreting tumor until proven otherwise. Some conditions that can be found due to hormonal activity of adrenal incidentaloma is subclinical Cushing's syndrome, pheochromocytoma, aldosteronoma (Conn's disease), and several tumors which secrete androgen and sex hormone. Diagnostic approach of adrenal incidentaloma is focused on two main problems, which are, whether the lesion is hormonally active even though lacking characteristic clinical signs, and whether the lesion is benign or malignant; thus it needs hormonal and radiologic evaluation, even a fine needle biopsy. The management for adrenal incidentaloma includes surgical removal for hormonally active adrenal tumors, or inactive tumors with size less than 4 cm. Monitoring of tumor's hormone level and size are necessary for non-hypersecreting tumor without surgical removal.

Gestational transient thyrotoxicosis.

Gestational transient thyrotoxicosis refers to non-autoimmune hyperthyroidism in pregnant women and it is associated with hyperemesis gravidarum. During pregnancy, there are some alterations in thyroid gland, such as elevation of thyroxine binding globulin, increased iodium clearance in kidneys, and stimulation of thyroid gland by human chorionic gonadotropin. Hitherto, the pathophysiology underlying the development of gestational transient thyrotoxicosis has not been fully recognized. Studies showed that human chorionic gonadotropin, an agonist of thyroid stimulating hormone, may stimulate thyroid stimulating hormone receptor, leading to increased thyroid hormone. Diagnosis of gestational transient thyrotoxicosis is established based on inexistence history of previous hyperthyroidism, elevation of thyroid hormone, absence of hyperthyroid abnormalities signs on physical examination (such as: enlargement of thyroid gland, exophthalmia), and the absent of positive thyroid autoantibody. Generally, gestational transient thyrotoxicosis does not require medication, unless if hyperemesis gravidarum is present, thus the patient has to be hospitalized to receive intravenous rehydration, electrolyte correction and antiemetic medication. On cases with worsened or prolonged symptoms, anti-thyroid agents such as short term propiltiourasil is needed.

Isolated post-challenge hyperglycemia: concept and clinical significance.

The American Diabetes Association has strongly recommended that fasting plasma glucose should be sufficient for establishing diagnosis of diabetes mellitus; while World Health Organization supports to maintain the oral glucose tolerance test. Several epidemiological studies confirmed that postprandial hyperglycemia is a significant predictor for cardiovascular mortality and incidence. Post-challenge hyperglycemia following the oral glucose tolerance test is a condition similar to postprandial hyperglycemia. Isolated post-challenge hyperglycemia is a type of diabetes mellitus with a normal fasting plasma glucose level measured by oral glucose tolerance test. However, the glucose level following 2-hour post-challenge glucose test is >or= 200 mg/dl. Several long-term studies on population have shown that subjects with isolated post-challenge hyperglycemia have higher risk for cardiovascular events and mortality. Moreover, they also have an equal risk as those who have previously had diabetes mellitus. Therefore, it is suggested that for screening of diabetes mellitus, especially in the elderly population, oral glucose tolerance test should be performed in addition to measuring fasting plasma glucose.

Fasting insulin, adiponectin, hs-CRP levels, and the components of metabolic syndrome.

AIM: in this study we report the relationship between fasting plasma insulin, C-reactive protein, adiponectin levels and the components of metabolic syndrome. METHODS: for the diagnosis of metabolic syndrome we used the modified NCEP ATP criteria for Asian people. Complete routine physical examinations were performed to all subjects including blood pressure, waist circumference. After 12-hours fasting, blood sample was taken for fasting plasma glucose, fasting insulin, and lipid profiles. Fasting insulin was determined by RIA, adiponectin by ELISA, and hs-CRP by sensitive immunometric assay. According to NCEP ATP III, the metabolic syndrome consists of five components. Subjects fulfilling the studied criteria were divided into five groups according to the component/components they had. RESULTS: during the study, 118 adult individuals can be covered, including 88 patients (68,8%) with metabolic syndrome. They consist of 19 subjects who had only 1 component, 21 subjects had 2 components, 31 subjects with 3 components, 34 subjects with 4 components, and 23 subjects had 5 component. All subjects were overweight/obese (BMI > 23 kg/m), but patients with metabolic syndrome were significantly more obese compared to the non-metabolic syndrome (p < 0.05). There was no significant difference in age among all individuals. Fasting insulin, hs-CRP levels is increasing with the increasing number of components of metabolic syndrome, being higher among those with 3-5 components, while adiponectin is decreasing with the number of the components. Fasting insulin 3,5+1,1 uU/ml, 3,6+1,4 uU/ml, 5,9+1,8 uU/ml, 7,8+2,1 uU/ml, 7,9+2,3 uU/ml respectively, hs-CRP 2,8+1,2 mg/L, 5.6+3.4 mg/L, 7.4+4.4 mg/L, 9.0+4.7 mg/L, 9.5+3,9 mg/L, and adiponectin 9.1+3.5 ng/ml, 8.6+1.6 ng/ml, 3.4+1.2 ng/ml, 3.2+1.3 ng/ml, 2.8+0.9 ng/ml in 3,4,5 components respectively. CONCLUSION: there is a relationship between the number of components of metabolic syndrome and the increasing levels of fasting insulin, and hs-CRP, and low levels of adiponectin. These may explain in part the risk of cardiovascular events among individuals with metabolic syndrome.

Asymptomatic diabetes: the difference between population-based and office-based screening.

AIM: To compare the results between population-based and office-based diabetes screening. METHODS: In 1997, a population-based screening was performed on a group of government employees and retired subjects in the Makassar Municipality. Since the year 2000, we performed screening at the clinic. For clinical-based screening, we focused the screening on those with high risks for developing diabetes mellitus, i.e. all subjects aged > or =45 or those aged < 45 with one or more of the following abnormalities: obese (BMI > 25 kg/m2), elevated blood pressure (> or =140/90 mmHg in adults), family history of diabetes, previous identified IFG or IGT, HDL-cholesterol < or =35 mg/dl and/or triglyceride > or =250 mg/dL, and history of gestational diabetes mellitus or delivery of babies > or =4000 gram. For population-based screening, the criteria for diabetes mellitus was based on a single test 2-hours post load (75 gram glucose), while for office-based screening, the WHO l999 was used i.e. fasting and 2-hours post 75 gram glucose load (OGTT). RESULTS: During the screening in the population, 941 subjects were screened, 290 women and 651 men. There were 51 diabetic subjects, or a prevalence of 5.42%, 21 women or 7.24% of all women, and 30 men or 4.60% of all men. At the clinical setting, 907 were screened, 483 women and 424 men. Among these subjects, 155 fulfilled the diabetes criteria, with a prevalence of 17.1%. There were 78 diabetic women or 16.1% of all women, and 77 men or 18.2% of all men. If the diagnosis of diabetes mellitus in the clinical setting is based only on 2 hours post load (the same as for population-based) only 70 patients can be detected, for a prevalence of 7.7%, which is still higher compared to the results of the population-based screening. All figures obtained from the office-based screening were higher as compared to the population-based results. CONCLUSION: These results show that office-based screening detected more asymptomatic diabetes compared to population-based screening. It is suggested that early detection of asymptomatic diabetes is performed at the clinic, either at the hospital or doctor's private office.

Comparison of The World Health Organization (WHO) two-step strategy and OGTT for diabetes mellitus screening.

The new diagnostic criteria recommended by the American Diabetes Association (ADA) will only detect diabetic patients with fasting hyperglycemia, and leave patients with isolated post-challenge hyperglycemia (IPCH) and imparied glucose tolerance (IGT) unidentified. The WHO recommends that all those with abnormal fasting glucose should undergo the oral glucose tolerance test (OGTT) to exclude the diagnosis of diabetes (two-step strategy). This two-step strategy will leave out subjects with normal fasting glucose (<109 mg/dl). The aim of this study is to compare the WHO two-step strategy and the gold standard OGTT for all subjects. We re-analyzed the results of 907 high-risk patients who have been screened for diabetes mellitus and impaired glucose tolerance. All subjects were screened with an OGTT containing a 75-gram glucose load after fasting for 12 hours. The results were classified into three categories: the ADA criteria, the two-step strategy, and the OGTT. Using the ADA criteria, these 907 subjects can be classified has having normal fasting glucose (fasting plasma glucose - FPG < 109 mg/dl) in 715 subjects (78.9%), abnormal fasting glucose (FPG 110 - 125 mg/dl) in 107 subjects (11.8%), and diabetes mellitus (FPG > 126 mg/dl) in 85 subjects (9.4%). The WHO two-step strategy performed in 107 IFG subjects identified another 30 diabetic patients (FPG < 109 mg/dl and 2 hour post load > 200 mg/dl = IPCH) or 3.3%, and 49 patients with IGT, or 5.4% from all subjects. If the OGTT was performed on the 715 normal fasting glucose, it could identify another 40 diabetic patients or 4.4%, and another 178 IGT patients, or 19.6% of all subjects. This means that without OGTT to all subjects, 40 diabetic patients or 25.8% of all diabetic patients and 178 patients or 78.4% from all IGT subjects would have remained unidentified. From this study we can conclude that applying the WHO two-step strategy in subjects with IFG would fail to detect 25.8% of diabetic patients and 78.4% of IGT subjects. It is recommended that the old strategy of screening--the gold standard OGTT--should be used instead of the two-step strategy, at least in high-risk groups.