The effect of COVID-19 pandemic restrictions on the management of differentiated thyroid cancer in Turkey: a single tertiary centre experience.

PURPOSE: Many countries have implemented unprecedented health measures since the World Health Organisation declared the novel coronavirus disease 2019 (COVID-19) a global pandemic. These measures have resulted in delays in the diagnosis of differentiated thyroid cancer (DTC). However, there is limited data on the impact of restrictions imposed during the pandemic on DTC management. Thus, the aim of this study is to analyse the clinicopathological and follow-up data of DTC patients diagnosed before and during the COVID-19 outbreak. METHODS: This retrospective study included 191 DTC patients that were diagnosed between December 2018 and June 2021. The patients were divided into two groups: patients diagnosed before (December 2018 to February 2020) and during (March 2020 to June 2021) the COVID-19 pandemic. The clinicopathological and follow-up data between the two groups were compared. RESULTS: Similar preoperative cytology results were obtained from the two groups. No difference with regard to tumour size, lymphovascular invasion and extrathyroidal invasion was observed between the two groups. While the American Thyroid Association risk stratification was similar between the two groups, radioactive iodine (RAI) therapy was applied less during the COVID-19 period. Although RAI therapy was administered at a lower rate during the COVID-19 period, the recurrence rates among patients after two years of follow-up were similar to those during the pre-COVID-19 period. CONCLUSION: Although the COVID-19 pandemic restrictions during the pandemic period caused difficulties in the management of DTC patients, this did not negatively affect their prognosis. These findings can confirm the applicability of active surveillance in DTC patients and may help change the real-life treatment practices in selected low-risk DTC patients.

The prevalence and associated risk factors of detectable renal morphological abnormalities in acromegaly.

PURPOSE: The aim of this study was to investigate the prevalence of simple renal cysts (SRCs) and kidney stone disease (KSD) together with laboratory data in patients with acromegaly through comparisons with healthy subjects, and to examine the possible risk factors associated with these abnormalities in acromegaly. METHODS: This retrospective, single-center study included 125 acromegaly patients (46.4 ± 11.6 years, 68 females/57 males) and 114 age-sex matched healthy individuals (45.3 ± 12.4 years, 59 females/55 males). Demographic data, clinical history, biochemical and abdominal/urinary system ultrasonographic data of the patients were reviewed. RESULTS: The SRC prevalence (28.8% vs. 8.8%, p < 0.001) and the longitudinal and transverse lengths of kidneys (p < 0.05) were significantly higher in patients with acromegaly compared to the control group. The presence of acromegaly was determined to increase the risk of SRC formation 12.8-fold. The prevalence of KSD was similar in both the patient and control groups (15.2% vs. 7.9%, p = 0.08). Patients with acromegaly with renal cysts (n = 36) compared to the group without cysts (n = 89) were older, had a higher male gender frequency, a longer pre-diagnosis symptom duration, and a higher incidence of hypertension and diabetes mellitus at the time of diagnosis. The multivariate logistic regression analysis showed that only advanced age and male gender were associated risk factors for SRCs in acromegaly patients. CONCLUSION: The results of this study showed that acromegaly disease significantly increased the prevalence of SRCs and kidney length compared to the age-sex matched healthy population, while the prevalence of KSD was similar. Advanced age and male gender were seen to be independent risk factors for SRC formation in patients with acromegaly.

Impact of Bolus/Basal Insulin Ratio on HbA1c and Lipid Profile in Adult Patients with Type 1 Diabetes Mellitus.

OBJECTIVE: To evaluate the existence of any relationship between the bolus/basal (B/b) insulin ratio and HbA1c and lipid profile in patients with Type 1 Diabetes mellitus (T1DM) on a basal-bolus treatment regimen. STUDY DESIGN: Retrospective observational study. Place and Duration of the Study: University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, from January 2015 to March 2020. METHODOLOGY: This retrospective-observational study included 181 adult patients with T1DM. They were divided into two groups with <1.5 and ≥1.5 B/b insulin ratios, and the parameters were compared. RESULTS: The subjects comprised 94 females and 87 males with a mean age of 30.1 ± 9.2 years. Microvascular complications and dyslipidaemia were found in 30.9% and 68.5% of the patients, respectively. B/b insulin ratio of ≥1.5 was observed in 65.1% of the patients. The HbA1c level was <58 mmol/mol in 11.6% of the patients. A positive correlation was found between the B/b insulin ratio and HbA1c level. Fasting Plasma Glucose (FPG) and HbA1c levels were higher in those with ≥1.5 B/b insulin ratio. The rate of patients who reached the optimal HbA1c level was 3.57-fold lower in those with ≥1.5 B/b ratio. CONCLUSION: A higher B/b insulin ratio was associated with higher HbA1c levels in patients with T1DM treated with intensive insulin therapy. Prospective studies are needed to define a causal relationship between the B/b insulin ratio, glycaemic parameters, and lipid profile. KEY WORDS: Bolus/basal insulin ratio, Type 1 Diabetes mellitus, HbA1c, Low-density lipoprotein, Lipid profile.

Subacute THYROiditis Related to SARS-CoV-2 VAccine and Covid-19 (THYROVAC Study): A Multicenter Nationwide Study.

CONTEXT: The aims of the study are to compare characteristics of subacute thyroiditis (SAT) related to different etiologies, and to identify predictors of recurrence of SAT and incident hypothyroidism. METHODS: This nationwide, multicenter, retrospective cohort study included 53 endocrinology centers in Turkey. The study participants were divided into either COVID-19-related SAT (Cov-SAT), SARS-CoV-2 vaccine-related SAT (Vac-SAT), or control SAT (Cont-SAT) groups. RESULTS: Of the 811 patients, 258 (31.8%) were included in the Vac-SAT group, 98 (12.1%) in the Cov-SAT group, and 455 (56.1%) in the Cont-SAT group. No difference was found between the groups with regard to laboratory and imaging findings. SAT etiology was not an independent predictor of recurrence or hypothyroidism. In the entire cohort, steroid therapy requirement and younger age were statistically significant predictors for SAT recurrence. C-reactive protein measured during SAT onset, female sex, absence of antithyroid peroxidase (TPO) positivity, and absence of steroid therapy were statistically significant predictors of incident (early) hypothyroidism, irrespective of SAT etiology. On the other hand, probable predictors of established hypothyroidism differed from that of incident hypothyroidism. CONCLUSION: Since there is no difference in terms of follow-up parameters and outcomes, COVID-19- and SARS-CoV-2 vaccine-related SAT can be treated and followed up like classic SATs. Recurrence was determined by younger age and steroid therapy requirement. Steroid therapy independently predicts incident hypothyroidism that may sometimes be transient in overall SAT and is also associated with a lower risk of established hypothyroidism.

The role of elastography in the assessment of thyroid nodules in acromegaly.

BACKGROUND: Nodular thyroid disease is a frequent finding seen in patients with acromegaly. Ultrasound-elastography (US-E) appears to be a helpful tool for the diagnosis of thyroid cancer. The aims of this study were to evaluate thyroid nodules in acromegaly and to assess the diagnostic accuracy of US-E in detecting thyroid cancer in this population. METHODS: US-E was applied to 166 nodules detected in 102 acromegalic patients and to 105 nodules found in 95 nonacromegalic subjects. The lesions were classified according to the elasticity scores (ES) as soft (ES 1-2) or hard (ES 3-4). RESULTS: : Mean age was 55.1 ± 12.47 years [59 (58%) women]. The prevalence of hard nodules (ES 3 and 4) was significantly higher in the group of acromegalic patients than in control subjects (48% to 20%, p < 0.001). Mean ES was higher in patients with acromegaly (2.45 to 2.22, p: 0.001), however, the mean strain index (SI) was similar between groups (1.53 to 1.65, p: 0.204). DISCUSSION: Thyroid nodules in acromegaly patients have a higher elasto score and the prevalence of hard nodules is higher in active disease. However, increased stiffness of nodules by US-E in patients with acromegaly does not seem to estimate the malignancy of the nodules.

Effect of thyroid nodule size on cytology reliability and incidence of malignancy: A large cohort of 1205 patients from a single center.

OBJECTIVE: There is controversy about whether the rates of malignancy and of false-negative malignancy are greater in large nodules. The aim of this study was to determine the reliability of cytology in ≥4cm nodules and to compare malignancy rates between ≥4cm and<4cm nodules. METHODS: The study included 1205 patients who underwent biopsy and subsequent thyroidectomy with the diagnosis of nodular thyroid disease between 2014 and 2019. The patients were separated into two groups, ≥4cm and<4cm, according to the size of the index nodule on ultrasonography. RESULTS: Two hundred and eleven index nodules (17.5%) were ≥4cm. Malignancy rate on definitive pathology was 51% in<4cm nodules and 30% in ≥4cm nodules. Malignancy risk was significantly lower in ≥4cm nodules than <4cm nodules (P<0.001). When<1cm nodules were excluded and 1-4cm and ≥4cm nodules were compared, malignancy risk was also significantly lower in ≥4cm nodules (P=0.001). On definitive pathology, there were 45 false-negative results among cytologically benign nodules. There was no difference in false-negative cytology rate between<4cm and ≥4cm nodules (P=0.209). CONCLUSION: The present study found no decrease in the reliability of cytology in ≥4cm nodules, and there may not be a linear relationship between nodule size and malignancy risk. Therefore, in asymptomatic cytologically benign ≥4cm nodules, surgery may not be recommended based on nodule size alone.

Prevalence and associated risk factors of simple renal cysts in primary hyperparathyroidism.

PURPOSE: Previous studies have pointed to the role of parathormone (PTH) in the development of simple renal cysts. However, there is insufficient evidence related to simple renal cysts in primary hyperparathyroidism (PHPT). Therefore, this study aimed to evaluate the prevalence and risk factors associated with renal cysts in PHPT patients. METHODS: In this retrospective study, we included 235 patients treated surgically for PHPT and 147 control subjects. The clinical and physical examination findings, laboratory test results, and neck and urinary system ultrasonography examination findings were evaluated. Postoperative parathyroid adenoma volume and weight were also recorded. RESULTS: Simple renal cysts were found in 53 PHPT patients (22.6%) and in 15 control subjects (10.2%) (p = 0.002). Kidney stones were found in 33 PHPT patients (14%) and in only seven control subjects (4.8%) (p = 0.004). The presence of PHPT and high PTH levels independently supported the development of a simple renal cyst. Advanced age was determined as a risk factor for the development of simple renal cysts, and the presence of kidney stones was an independent predictor of simple renal cysts in PHPT patients. There was no relationship between the presence of simple renal cysts and the volume and weight of parathyroid adenoma. CONCLUSION: A diagnosis of PHPT, high PTH levels, advanced age, and kidney stones are independent risk factors for simple renal cysts in PHPT patients. These patients should be evaluated regularly for complications of renal cysts and nephrolithiasis.

Impact of the COVID-19 pandemic on the incidence, seasonal distribution, and characteristics of subacute thyroiditis.

PURPOSE: An increasing number of cases of subacute thyroiditis (SAT) related to the coronavirus disease 2019 (COVID-19) and its vaccines continue to be published. The aim of this study was to investigate any change in the incidence and characteristics of SAT by comparing the pre-pandemic and pandemic periods. METHODS: This retrospective, single-center study included 432 newly-diagnosed SAT patients between January 2018 and December 2021. The annual frequency of SAT was calculated as the number of newly-diagnosed SAT cases divided by the total number of outpatients that year. RESULTS: The frequencies of newly-diagnosed SAT were 0.136% in 2018, 0.127% in 2019, 0.157% in 2020, and 0.114% in 2021 (p = 0.19). While SAT patients were clustered in the autumn (35.1%) in 2018 and 2019, it was found that this cluster shifted to the winter (33.0%) in 2020 and 2021, in parallel with COVID-19 case peaks (p = 0.017). The patients were separated into two groups as pre-COVID-19 pandemic SAT (n = 272) and COVID-19 pandemic SAT (n = 160). The mean ages of the groups were similar. There were more male patients in the COVID-19 pandemic SAT group than in the pre-pandemic group (30.6% vs. 18.7%, p = 0.005). Frequencies of overt hyperthyroidism and median free-thyroxine levels were significantly higher in the COVID-19 pandemic SAT group (p = 0.029, p = 0.001). Treatment modalities, recurrence rates, and permanent hypothyroidism were similar in both groups. CONCLUSION: With the COVID-19 pandemic, although there was a change in seasonal variation of SAT and an increase in the number of male patients, there was no change in the incidence and clinical course of SAT.

Co-existence of Papillary and Medullary Thyroid Carcinoma: Reports of Three Cases.

Medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) are two different types of thyroid carcinoma. They have different features in terms of cellular origin, histopathology, clinical features, prevalence, and prognosis. PTC originates from follicular cells, while MTC from parafollicular cells. MTC and PTC co-existence is a rare phenomenon and occurs in less than 1% of all thyroid tumors. We report three cases with coexistent MTC and PTC in the same thyroid. The papillary component was dominant in two cases and the medullary in one case. While the first case was given radioactive iodine therapy, the third was treated with vandetanib. The second case was followed up postoperatively and did not receive treatment other than levothyroxine replacement. The co-existence of these tumors requires a different clinical approach in treatment and follow-up, depending on which type is dominant. Key Words: Mixed thyroid carcinoma, Papillary thyroid carcinoma, Medullary thyroid carcinoma.

Paradoxical GH increase during oral glucose load may predict overall remission in acromegalic patients.

BACKGROUND: The nadir growth hormone (nGH) during the oral glucose tolerance test (OGTT) is the gold standard method for diagnosing acromegaly. A paradoxical growth hormone (GH) response to oral glucose (OG) in acromegaly can be observed. The role of the paradoxical GH response on how the patients with acromegaly respond to the treatment has been addressed in few studies. The aim of this study was to investigate the association between glucose-dependent growth hormone results and and the responses of acromegalic patients to surgical and/or medical therapy following surgery. MATERIAL AND METHODS: This retrospective cohort study included patients with acromegaly who underwent surgery (n = 189) or received primary medical treatment (n = 9). The mean age was 50.44 ± 12.81 years (M/F: 84/114). The patients were grouped into paradoxical (GH-P) and non-paradoxical (GH-nP) according to GH response to OG and were compared in terms of clinical and pathological features, pituitary tumor size, invasiveness, biochemical profiles, and how they responded to the treatment. RESULTS: The mean age, gender distribution, and basal tumor diameter were all similar in both groups (p > 0.05). The GH-P group had a higher remission rate in response to medical therapy followed by surgery (83% vs. 55%; p = 0.026). Although a higher surgical remission rate in favor of GH-P was observed, it did not reach statistical significance (63% vs. 48%; p = 0.059). Overall treatment response rates were also higher in the GH-P group compared to the GH-nP group (89% vs. 71%; p = 0.005). CONCLUSION: A paradoxical GH response to OG load may help to predict the response to medical treatment in patients with acromegaly.

Evaluation of the diagnostic features and clinical course of COVID-19 vaccine-associated subacute thyroiditis.

OBJECTIVE: This study aimed to identify cases of coronavirus disease 2019 (COVID-19) vaccine-associated subacute thyroiditis (SAT) during the active vaccination period of the pandemic, analyze the characteristics of these cases, and compare them with cases of non-vaccine associated SAT diagnosed in the same period. METHODS: A total of 55 patients diagnosed with SAT in our outpatient clinic between February and October, 2021, were included in this retrospective single-center study. RESULTS: Of the study population, 16 (29.1%) were diagnosed with COVID-19 vaccine-associated SAT (10 with CoronaVac® and six with Pfizer-BioNTech® vaccine), with a median time to onset of symptoms after vaccination of 6.5 (range, 2-20) days. There was no statistically significant difference between the vaccine-associated (VA) and non-vaccine associated (NVA) groups in terms of age, gender, time to diagnosis, thyroid volumes, thyroid function tests, and acute phase reactants. Seven (43.8%) and 25 (64.1%) patients were treated with methylprednisolone in the VA group and NVA group, respectively (p = 0.16). Follow-up data of 45 patients (16/16 for VA and 29/39 for NVA) were available. The mean follow-up of these patients was 47.4 ± 19.4 days, and the follow-up periods of the VA group and NVA group were comparable (p = 0.24). There was no difference between the two groups in terms of the frequency of euthyroidism at the follow-up visit (12/16 vs.14/29, p = 0.08). CONCLUSION: With the increase in COVID-19 vaccination rates during the current pandemic, VA SAT cases are seen more frequently. The present study demonstrated that these cases have similar diagnostic features and clinical course to that of classic forms of SAT. In addition, most patients with VA SAT had a mild clinical course that improved with non-steroidal anti-inflammatory drugs.

Relapsed and newly diagnosed Graves' disease due to immunization against COVID-19: A case series and review of the literature.

In addition to genetic factors, environmental factors such as viruses are thought to be triggers in the development of autoimmune thyroid diseases (AITD) such as Graves' disease (GD). In this context, AITD cases that may be associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or immunization have begun to be reported in increasing numbers. Although it is not clear by which pathogenetic mechanisms immunization against coronavirus disease 2019 (COVID-19) triggers the development of AITD, both the potential effect of the adjuvants in the vaccines and the cross-reactivity that can be generated by the molecular similarity of viral particles with mammalian proteins seem to be possible mechanisms. In this article, 7 GD patients consisting of relapsed and newly diagnosed cases following the COVID-19 vaccination were presented. Of these 7 cases, 5 (71.4%) were female, and the median age of the patients was 47 years (range, 31-53). One of the patients was associated with the inactivated COVID-19 vaccine, while the others were associated with the mRNA COVID-19 vaccine. The median post-vaccination symptom onset was 7 days (range, 4-30). Three of the patients had a history of GD and one had a history of Hashimoto's thyroiditis. Rapidly developing Graves' ophthalmopathy was detected in one patient. These cases are cautionary that GD and its extrathyroidal manifestations may develop in a short period after COVID-19 vaccination. When considered together with the literature review, the history of AITD in approximately half of the patients suggests that more attention should be paid to these patients in the post-vaccination period. Nevertheless, multicenter, prospective studies are needed to better understand this possible causal relationship.

The predictive value of hematologic parameters in the risk of thyroid malignancy in cases with atypia/follicular lesion of undetermined significance.

BACKGROUND: Atypia/follicular lesion of undetermined significance (AUS/FLUS) is still the most challenging category in the Bethesda System for Reporting Thyroid Cytopathology. Therefore, the aim of the current study was to investigate the value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume (MPV) in predicting malignancy in cases with AUS/FLUS nodules. METHODS: A total of 200 patients with AUS/FLUS nodules who underwent thyroidectomy were included in this study. Preoperative hemogram parameters, ultrasonographic findings, fine-needle aspiration results, and postoperative final histopathological diagnoses of the patients were recorded retrospectively. RESULTS: Thyroid malignancies were detected in 122 of the patients (61.0%). Patients in the benign group (BG) were older than those in the malignancy group (MG) (52.0 ± 11.3 vs. 45.9 ± 12.3 years, p < 0.001). The median TSH values of the two groups were comparable. Statistically significant differences were obtained between the two groups in respect of mean WBC of 7.53 ± 1.44 in MG and 6.87 ± 1.35 (103/mm3) in BG, mean neutrophil of 4.65 ± 1.12 in MG and 3.95 ± 0.99 (103/mm3) in BG, and median NLR of 2.18 (0.71-4.57) in MG and 1.75 (0.80-3.42) in BG (p < 0.001). The median PLR and MPV values of the two groups were similar. When NLR cut-off point was designated as 2.24, the accuracy of NLR in distinguishing malignancy from the benign condition was 0.65 in ROC analysis (area under the curve, 0.665; specificity, 0.808; sensitivity, 0.492). CONCLUSION: High NLR values may provide limited help in predicting thyroid malignancy in the AUS/FLUS nodule population, while PLR and MPV are not reliable parameters.

Evaluation of NAFLD fibrosis, FIB-4 and APRI score in diabetic patients receiving exenatide treatment for non-alcoholic fatty liver disease.

There is a closely relationship between the development and progression of nonalcoholic fatty liver disease (NAFLD) or metabolic associated fatty liver disease (MAFLD) and obesity and diabetes. NAFLD fibrosis scores should be routinely used to rule out patients with advanced fibrosis. High scores may help identify patients at higher risk of all causes andliverrelated morbidity and mortality. The aim of this study was to investigate the association between exenatide and fibrosis scores. The effect of exenatide treatment on fibrosis scores was evaluated in type 2 diabetes mellitus (DM) patients with MAFLD. Evaluation was made of 50 patients with type 2 DM and MAFLD. The NFS, FIB4 and APRI scores were calculated before and after 6 months of treatment. After 6 months of exenatide treatment, the NFS and APRI scores were determined to have decreased significantly. Exenatide was observed to control blood glucose, reduce body weight and improve fibrosis scores in MAFLD patients with type 2 diabetes.

Cushing's syndrome due to adrenocorticotropic hormone-secreting metastatic neuroendocrine tumor of unknown primary origin: a case report and literature review.

BACKGROUND: In this article, we present a case of neuroendocrine neoplasm of unknown primary origin (UPO NEN), which is a rare cause of ectopic Cushing's syndrome (ECS) presenting numerous challenges, together with a literature review. CASE REPORT: A 43-year-old male patient presented with clinical features consistent with Cushing's syndrome (CS) and adrenocorticotropic hormone (ACTH)-dependent hypercortisolemia. Despite a suspicious lesion on pituitary MRI, the high-dose dexamethasone suppression test and bilateral inferior petrosal sinus sampling results were not compatible with Cushing's disease. Bilateral non-homogeneous opacities were observed in the thorax CT of the patient, who also had a history of COVID-19 infection, but no tumoral lesion was detected. When 68Ga-SSTR PET/CT and 18FDG-PET/CT were performed, multiple metastatic foci were detected in mediastinal and hilar lymph nodes and the axial skeleton. Paratracheal-subcarinal lymph nodes were excised mediastinoscopically, and the diagnosis of NEN was made. Histopathological findings indicated that the possible origin was an atypical pulmonary carcinoid with a low Ki-67 labeling index. After controlling hypercortisolemia, a regimen of somatostatin analogs and capecitabine plus temozolomide was decided upon as treatment by a multidisciplinary council. CONCLUSION: This is a challenging case of UPO NEN presenting with ECS and confounding factors, such as previous infection and incidental lesions, during the diagnosis process. The case in question highlighted the fact that atypical pulmonary carcinoid with a low proliferation index may cause visible metastases even when radiologically undetectable.

The value of routine measurement of serum calcitonin on insufficient, indeterminate, and suspicious thyroid nodule cytology.

Routine calcitonin measurement in patients with nodular thyroid disease is rather controversial. The aim of this study was to evaluate the contribution of serum calcitonin measurement in the diagnostic evaluation of thyroid nodules with insufficient, indeterminate, or suspicious cytology. Out of 1668 patients who underwent thyroidectomy with the diagnosis of nodular thyroid disease and were screened, 873 patients with insufficient, indeterminate, or suspicious fine needle aspiration biopsy results were included in the study. From the total number of patients in this study, 10 (1.1%) were diagnosed as medullary thyroid cancer (MTC) using histopathology. The calcitonin level was detected to be above the assay-specific cut-off in 23 (2.6%) patients ranging between 6.5 - 4450 pg/mL. While hypercalcitoninemia was detected in all 10 MTC patients, a false positive elevation of serum calcitonin was detected in 13 patients (1.5%). Of the MTC group, 7 patients had cytology results that were suspicious for malignancy (Bethesda V), one patient's cytology showed atypia of undetermined significance (Bethesda III) and two patient's cytology results were suspicious for follicular neoplasm (Bethesda IV). Among the cases with non-diagnostic cytology (Bethesda I), none of the patients were diagnosed with MTC. In conclusion, routine serum calcitonin measurement can be performed in selected cases rather than in all nodular thyroid patients. While it is reasonable to perform routine calcitonin measurement in patients with Bethesda IV and Bethesda V, this measurement was not useful in Bethesda I patients. In Bethesda III patients, patient-based decisions can be made according to their calcitonin measurement.

Effect of Exenatide Therapy on Platelet Function in Type 2 Diabetes Mellitus.

OBJECTIVE: The purpose of the present study was to determine the effects of exenatide treatment on platelet function in type 2 diabetes mellitus (DM) patients. STUDY DESIGN: Case-control observational study. PLACE AND DURATION OF STUDY: University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara from October 2016 to October 2018. METHODOLOGY: This study included 50 patients with type 2 DM, who had started exenatide therapy; and age-gender matched 54 control subjects. The biochemical data and BMI of the patients were analysed at the time of admission and after six months of exenatide treatment. RESULTS: PDW (platelet distribution width) and MPV (mean platelet volume) were higher in the diabetic patient group than in the control group (p <0.01 and p=0.036, respectively). Significant positive correlations were determined between PDW and BMI (p<0.001), FPG (p <0.001), and HbA1c (p<0.001). After six months of exenatide treatment, PDW (p = 0.015) values and platelet count (p = 0.003) were significantly decreased. CONCLUSIONS: Exenatide causes a decrease in PDW value and platelet count independent of its positive effect on lipid profile, glycemic regulation, and weight loss, which contributes to explain the effect of treatment on the cardiovascular system through a different mechanism. Key Words: Exenatide, Type 2 diabetes mellitus, Platelet count, Platelet distribution width, Mean platelet volume.

Two Important Issues in Subacute Thyroiditis Management: Delayed Diagnosis and Inappropriate Use of Antibiotics.

BACKGROUND: Subacute thyroiditis (SAT) is a rare inflammatory disease of the thyroid gland. It has been noticed that patients with a diagnosis of SAT visit more other clinics and receive antibiotics unnecessarily. Therefore, the aim of this study was to reveal the degree of delay in the diagnosis of SAT, prediagnosis antibiotic use rates, and the awareness of clinics for the diagnosis of SAT. METHODS: A total of 121 patients with SAT were enrolled in the study. A retrospective analysis was made of the history of patient symptoms during the diagnosis, which physicians they visited, antibiotic use, laboratory test results, and ultrasonographic findings. RESULTS: The median age of the patients was 41 years. Neck pain radiating to the jaw/ear was seen in most patients (71.1%). The median time from symptom onset to a diagnosis of SAT was 23 days (range, 6-70 days). Antibiotics were erroneously prescribed to 71 patients (58.7%) before the diagnosis. The median time to diagnosis was 28 days in patients using antibiotics and 20 days in the group not using antibiotics (p < 0.001). Two or more physicians had been visited before SAT diagnosis by 89 (73.6%) patients, and more antibiotics were prescribed to these patients than the group who visited fewer physicians (p < 0.05). The frequency of prescribing antibiotics by physicians was 73.7% by emergency physicians, 53.1% by family doctors, 51.1% by ENT specialists, and 35.4% by internal medicine specialists. CONCLUSION: The diagnosis of SAT is often delayed, and misdiagnosis leads to erroneous antibiotic overuse. Physicians should increase their awareness of the diagnosis of SAT in patients with neck pain.

The Effects of Chronic Lymphocytic Thyroiditis on Clinicopathologic Factors in Papillary Thyroid Cancer.

OBJECTIVE: This study evaluated the impact of chronic lymphocytic thyroiditis (CLT) on clinicopathologic parameters, prognostic outcome, and initial treatment responses in patients with papillary thyroid cancer (PTC). METHODS: A retrospective review was conducted of 1409 patients with PTC, comprising 443 patients with pathology-proven PTC with CLT and 447 patients with PTC without CLT. RESULTS: The median follow-up time was 58 months (range, 8-380 months), and the median age at the time of diagnosis was 43 years. The age at diagnosis was significantly lower in patients with CLT than in those without CLT (42 years vs 45 years, respectively; P = .001). The preoperative thyroid-stimulating hormone level was found to be significantly higher in patients with CLT than in those without CLT (1.71 mIU/L vs 1.28 mIU/L, respectively; P < .001). Multifocality and capsular, lymphovascular, and perineural invasion were detected at a higher rate in the group with CLT than in the group without CLT (P = .015, P = .024, P = .004, and P = .039, respectively). No difference was found between the 2 groups in terms of tumor size, bilaterality, extrathyroidal invasion, lymph node metastasis, disease stage, or response to treatment (P > .05). CONCLUSION: The results of the present study demonstrated that the coexistence of PTC and CLT is very frequent. Patients with the coexistence of PTC and CLT were diagnosed at a younger age, and the thyroid-stimulating hormone level was higher in these patients. Contrary to previous studies, no positive effect of the CLT and PTC combination was detected on any clinicopathologic factor. In addition, lymphovascular and perineural invasions, which had negative effects on prognosis, were more common in the group with CLT.

Fatty acid-binding protein-4 as a biomarker predicting acromegaly-associated diabetes mellitus.

BACKGROUND: The known pathogenesis of diabetes mellitus (DM) in acromegaly is mainly based on growth hormone (GH) and insulin-like growth factor-1 (IGF-1) excess. Fatty acid-binding protein 4 (FABP-4), a novel adipokine, is found to induce insulin resistance and type 2 DM. We aimed to investigate the possible effect of FABP-4 on glucose metabolism in patients with acromegaly. METHODS: This case-control study included 28 patients newly diagnosed with acromegaly and 57 healthy volunteers. The patients with acromegaly were classified according to their glycemic status as with DM, prediabetes, and normal glucose tolerance. Anthropometric measurements, laboratory test results, and FABP-4 levels of the subjects were evaluated. RESULTS: Although no difference was observed in FABP-4 levels between acromegaly and control groups, the FABP-4 level was higher in the patients with acromegaly having DM compared to the patients with acromegaly having prediabetes and NGT, and the control group (p = 0.004, p = 0.001, p = 0.004, respectively). Logistic regression analysis suggested that the FABP-4 is an independent predictor of DM in acromegaly (ß = 7.382, OR = 38.96, 95% CI: 1.52-5.76, p = 0.018). DISCUSSION: The FABP-4 may be a helpful predictor of acromegaly-associated DM.