Images Combined With Surgical Procedures and Pathological Identification to Distinguish a Reactive Histiocytosis With Organized Hematoma From a Malignant Peripheral Nerve Sheath Tumor.

BACKGROUND/AIM: Malignant peripheral nerve sheath tumors (MPNST) are rare soft tissue malignant tumors. To the best of our knowledge, there have been no previous reports of benign reactive histiocytosis with hematoma that mimics MPNST on medical images. CASE REPORT: A 57-year-old female with past history of hypertension came to our clinic due to low back pain with radiculopathy which was diagnosed with a tumor arising from L2 neuroforamen with L2 pedical erosion. Initial tentative diagnosis on the images was MPNST. However, after surgical resection, the pathologic report revealed no evidence of malignancy but only an organized hematoma with reactive histiocytosis. CONCLUSION: Images cannot provide enough diagnostic evidence for distinguishing a reactive histiocytosis from MPNST. Proper surgical procedures and expert pathological identification can correct the mistaking of the ambiguous identification as MPNST. Images can only provide precise and personalized medication accompanied by proper surgical procedures and expert pathological identification.

Surgical interventions for Bertolotti's syndrome: case report and review of unsatisfactory cases in the literature.

BACKGROUND: Bertolotti's syndrome (BS) is characterized by the enlargement of transverse processes in caudal lumbar segments, causing chronic and persistent low back pain or sciatica. The present study aimed to describe our surgical technique for BS treatment and to review existing literature describing unsatisfactory outcomes. CASE PRESENTATION: We report a patient who complained of lower back pain and soreness that intermittently radiated to his left leg for longer than 10 years. Based on an examination of his symptoms and signs, including imaging and electrical physiology assessments, in addition to the report of temporary pain relief after a local steroid injection to a diagnostic trigger site (articulation between the transverse process and the sacral ala or iliac crest), the patient was diagnosed with BS. The applied surgical techniques included minimally invasive, three-dimensional C-arm guidance, a tubing approach, and microscopic and bone cavitron ultrasonic surgical aspirator-assisted operations. After surgery, improvements were reported on the visual analog scale (from 8 to 2 points on a 10-point scale) and the straight leg raising test for the left leg (20° to 90°) within 3 days. The patient gained an ordinary life and returned to work within one week of surgery, with no observed postoperative complications. CONCLUSIONS: Minimally invasive tubular microscopic decompression and disarticulation is an effective method for treating BS. However, to achieve a successful outcome, it is recommended to use physician-proficient techniques that are in line with the patient's diagnosis.

Correlates of Nocturia and Relationships of Nocturia With Sleep Quality and Glycemic Control in Women With Type 2 Diabetes.

PURPOSES: To explore correlates of nocturia, compare sleep quality and glycemic control for women with and without nocturia, and examine relationships of nocturia with sleep quality and glycemic control in women with diabetes. DESIGN: This study was a cross-sectional, correlational study with data collected from 275 women with type 2 diabetes. METHODS: Data were collected using a structured questionnaire. Multivariate logistic regression analyses were used to identify correlates. Chi-squared tests were used to identify candidate variables for the first logistic regression model. A one-way analysis of variance was used to compare sleep quality and glycemic control for women with and those without nocturia. Pearson correlations were used to examine the relationships of nocturia with sleep quality and glycemic control. FINDINGS: Of the 275 participants, 124 (45.1%) had experienced nocturia (at least two voids per night). Waist circumference, parity, time since diagnosis of diabetes, sleep quality, and increased daytime urinary frequency were correlated with nocturia after adjusting for age. Compared to women without nocturia, women who had nocturia reported poorer sleep quality. A significant correlation was found between the number of nocturnal episodes and sleep quality. CONCLUSIONS: Nocturia and poor sleep are common among women with diabetes. The multifactorial nature of nocturia supports the delivered management and treatments being targeted to underlying etiologies in order to optimize women's symptom management. Interventions aimed at modifiable correlates may include maintaining a normal body weight and regular physical exercise for maintaining a normal waist circumference, and decreasing caffeine consumption, implementing feasible modifications in sleeping environments and maintaining sleep hygiene to improve sleep quality. CLINICAL RELEVANCE: Healthcare professionals should screen for nocturia and poor sleep and offer appropriate nonpharmacological lifestyle management, behavioral interventions, or pharmacotherapy for women with diabetes.

The clinical and biochemical characteristics associated with insulin resistance in non-obese young women.

AIM: The aim of this study was to investigate the biomarkers of insulin resistance in non-obese women. DESIGN: This was a retrospective study. PATIENTS: A total 229 non-obese women (Body mass index: BMI < 25) were evaluated. MAIN OUTCOME MEASURE(S): Serum levels of various androgens, cardiovascular risk and metabolic components. RESULTS: There were no significant differences in the prevalence of polycystic ovary syndrome (PCOS), hyperprolactinemia, or premature ovarian failure (POF) between the non-obese women with and without insulin resistance. Non-obese women with insulin had significantly higher serum thyroid stimulation hormone (TSH) levels and resistin and lower serum adiponectin levels than non-obese women without insulin resistance; however, the inflammatory biomarkers and serum androgen levels did not differ between the two groups. Furthermore, using step-wise multivariate regression analysis applied by the risk factors listed above, TSH was the only predictive factor for insulin resistance in non-obese reproductive-aged women. CONCLUSIONS: Thyroid function should play an important role in developing insulin resistance for non-obese women. Serum androgens and inflammation might not contribute to insulin resistance in these women.

Potential of vitamin D in treating diabetic cardiomyopathy.

Cardiovascular disease is the leading cause of morbidity and mortality in patients with diabetes mellitus (DM), and patients with DM frequently develop diabetic cardiomyopathy. Currently, effective treatments for diabetic cardiomyopathy are limited. Vitamin D exerts pleiotropic effects on the cardiovascular system and is associated with DM. The purpose of this review was to evaluate published research on vitamin D in diabetic cardiomyopathy by searching PubMed databases. Herein, we reviewed vitamin D metabolism; evaluated the molecular, cellular, and neuroendocrine effects in native and bioactive vitamin D; and evaluated the role of vitamin D in treating cardiovascular disease and DM. Some evidence suggests that vitamin D may improve cardiovascular outcomes in diabetes through anti-inflammatory, antioxidative, antihypertrophic, antifibrotic, and antiatherosclerotic activities and by regulating advanced glycation end-product signaling, the renin-angiotensin system, and cardiac metabolism. This clinical and laboratory evidence suggests that vitamin D may be a potential agent in treating diabetic cardiomyopathy. However, using vitamin D entails possible adverse risks of hypercalcemia, hyperphosphatemia, and vascular calcifications. Therefore, future studies should be conducted that clarify the potential benefits of vitamin D through large-scale randomized clinical trials in well-defined groups of diabetic patients.

Cancer risk in HBV patients with statin and metformin use: a population-based cohort study.

Chronic infection with hepatitis B virus (HBV) often causes chronic inflammation of the liver with an increased incidence of hepatocellular carcinoma (HCC). HBV-infected individuals may also have an increased incidence of nonliver cancers. Taking statin or metformin may decrease inflammation and infiltration, which may, as a result, reduce the risk of liver cancer or other major cancers in patients with HBV infection. The purpose of this study was to evaluate the hypothesis that statin and metformin could reduce the incidence of liver cancer (HCC) or nonliver cancers in patients with HBV.Using the Taiwan Longitudinal Health Insurance Database 2000 to 2008, this cohort study comprised patients with a recorded diagnosis of HBV (N = 71,847) between January 1, 2000 and December 31, 2008. Each patient was followed-up until the end of 2008. The occurrence of HCC or a nonliver cancer was evaluated in patients who either were or were not taking statin or metformin. Cox proportional hazard regressions were used to evaluate the cancer incidence after adjusting for known confounding factors.In total, 71,824 HBV-infected patients comprised the study cohort. Our study showed that either metformin or statin use was associated with a reduction in the incidence of cancer. This was most prominent in patients taking both statin and metformin. The adjusted hazard ratios (HRs) for patients using only statin were 0.52 (95% confidence interval [CI], 0.48-0.57) for all cancers, 0.28 (95% CI, 0.23-0.35) for liver cancer, and 0.63 (95% CI, 0.57-0.70) for nonliver cancers. Patients taking only metformin had risk-adjusted HRs of 0.82 (95% CI, 0.75-0.90) for all cancers, 0.97 (95% CI, 0.84-1.14) for liver cancer, and 0.75 (95% CI, 0.67-0.84) for nonliver cancers. A dose-dependent effect of statin use for chemoprevention was observed for all cancers, including both liver cancer and nonliver cancers. A dose-dependent effect of metformin was also seen in liver cancer and nonliver cancers without stratification into different cumulative daily doses of statin use.This population-based cohort study investigated the protective effect of statin and metformin against cancer events in patients with HBV infection. Our study demonstrated that either statin or metformin served as independent chemopreventive agents with a dose-response effect in reducing the incidence of cancer with a dose-response effect of the agents and an additive or synergistic effect of combining statin and metformin use in reducing the incidence of many cancers.

Psychometric testing of a Mandarin Chinese Version of the Clinically Useful Depression Outcome Scale for patients diagnosed with type 2 diabetes mellitus.

BACKGROUND: The Clinically Useful Depression Outcome Scale (CUDOS) is a self-report instrument that assesses symptoms and the severity of depression, but its psychometric properties in patients with type 2 diabetes mellitus in Chinese-Speaking populations are unknown. OBJECTIVES: To examine the psychometric properties of the Mandarin Chinese version of the CUDOS (CUDOS-Chinese). DESIGN: A methodological research design. SETTING: Endocrinology and metabolism outpatient clinics at 2 university-affiliated hospitals in northern Taiwan. PARTICIPANTS: Two-hundred and fourteen type 2 diabetic patients with the mean age of 62.6 years were enrolled, and two-hundred and twelve of them completed the study. METHODS: Internal consistency, test-retest reliability, concurrent, and contrasted-groups validity were assessed. A receiver operating characteristic curve analysis was performed to assess sensitivity and specificity. Construct validity by means of confirmatory factor analysis was conducted. RESULTS: Internal consistency (Cronbach α of total scale and four subscales=0.93, 0.80, 0.66, 0.80, and 0.83, respectively), test-retest reliability (intra-class correlation coefficients of total scale and four subscales=0.92, 0.89, 0.94, 0.89, and 0.91, respectively), and strong correlations with the Beck Depression Inventory-II (r=0.87) suggested good reliability and validity. The confirmatory factor analysis supported a four-factor model. A cut-off score of 19/20 yielded 77.8% sensitivity and 75.6% specificity. CONCLUSIONS: The CUDOS-Chinese demonstrated satisfactory validity and reliability for detecting depression in type 2 diabetic patients in Taiwan.

Calcitriol modulates receptor for advanced glycation end products (RAGE) in diabetic hearts.

BACKGROUND: Receptor for advanced glycation end products (RAGE) signaling pathway plays a vital role in diabetic cardiovascular complications. Calcitriol has been shown to exert various beneficial cardiovascular effects. The purpose of this study is to determine whether calcitriol can modulate RAGE expression, and study the potential mechanisms in diabetic hearts. METHODS: Streptozotocin (65 mg/kg, intraperitoneal injection once) induced diabetic rats were treated with or without subcutaneous injections of calcitriol at a dose of 150 ng/kg/day for 4 weeks. Western blot was used to evaluate protein expressions of myocardial RAGE, TNF-α, p65 subunit of NF-κB (p65), α subunit of inhibitor of κB (IκBα), subunits of NADPH oxidase (NOX4 and p22(phox)), angiotensin II type 1 receptor (AT1R), TGF-ß1, TGF-ß receptor I, total and phosphorylated SMAD2/3 and ERK, matrix metalloproteinases 2 (MMP2), tissue inhibitors of metalloproteinases 2 (TIMP2) and procollagen I. RESULTS: As compared to control, diabetic rats had increased expressions of cardiac RAGE, TNF-α, p22(phox), AT1R, and TGF-ß1, which were significantly attenuated in the diabetic rats treated with calcitriol. Calcitriol-treated diabetic hearts also had lesser expressions of p-SMAD2/3 and p-ERK signaling than those of diabetic hearts. Moreover, diabetic hearts had increased expressions of MMP2 and procollagen I and decreased TIMP2. However, calcitriol reverted the diabetic effects in procollagen I but not in MMP2 or TIMP2. CONCLUSIONS: Calcitriol decreased diabetic effects on RAGE and fibrosis, which may be caused by its modulation on AT1R and the anti-inflammatory and antioxidative potentials. Therefore, calcitriol may attenuate diabetic cardiomyopathy.

Pheochromocytoma mimicking both acute coronary syndrome and sepsis: a case report.

OBJECTIVE: To present an atypical manifestation in a patient with pheochromocytoma. CLINICAL PRESENTATION AND INTERVENTION: A 48-year-old man presented with chest pain, fever and leukocytosis. Elevated cardiac biomarkers and diffuse ST-T abnormalities on electrocardiography suggested myocardial infarction. However, coronary angiography showed normal coronary arteries. Abdominal computed tomography revealed a left adrenal tumor of 6.7 × 6.8 cm. Paroxysmal fluctuation of blood pressure raised the suspicion of pheochromocytoma, which was further supported by elevated urine catecholamine levels. He underwent left adrenalectomy and pathological findings confirmed the diagnosis. CONCLUSION: Pheochromocytoma should be considered as part of the differential diagnosis in a patient with symptoms suggestive of both acute coronary syndrome and sepsis.

Successful preoperative treatment of a Graves' disease patient with agranulocytosis and hemophagocytosis using double filtration plasmapheresis.

Agranulocytosis is an uncommon but serious complication of Graves' disease under thionamide therapy. In some patients removal of circulating thyroid hormones and thyroid antibodies by plasmapheresis is an effective adjunctive therapeutic option. In perioperative settings, however, plasmapheresis may cause excess bleeding intraoperatively due to coagulation factor depletion unless fresh frozen plasma (FFP) products are used in the replacement fluid mix. Double filtration plasmapheresis (DFPP) in which only a small amount of albumin supplementation is used may be a potential alternative to conventional apheresis interventions where clotting factor depletion is problematic. We report a case of a patient with Graves' disease complicated with intravenous immunoglobulin responsive methimazole-induced agranulocytosis/hemophagocytosis who underwent successful preoperative DFPP treatment in preparation for thyriodectomy. In addition to conventional apheresis using FFP replacement, DFPP may offer an effective adjunct option in the management of hyperthyroid patients needing emergent surgical interventions.

Ameliorative effects of stabilized rice bran on type 2 diabetes patients.

BACKGROUND/AIM: While it has been demonstrated that rice bran might lower the cholesterol level in hypercholesterolemic individuals, its effects on the levels of adiponectin and glycated hemoglobin (HbA1c) in patients with type 2 diabetes mellitus remain unknown. METHODS: Twenty-eight volunteers with type 2 diabetes were randomly divided into 2 groups, one of which received a dietary supplement of 20 g of stabilized rice bran and the other placebo once daily for 12 weeks. Parameters such as the level of HbA1c, glucose, insulin, homeostasis model assessment for estimation of relative insulin resistance, high-density and low-density lipoprotein (LDL) cholesterol and adiponectin were evaluated. RESULTS: At the end of the study period, postprandial glucose and the area under the glucose curve of the rice bran group were significantly lower than baseline levels by 14.4 and 15.7%, respectively. Compared to baseline, the HbA1c values in the rice bran group were also significantly lower. Serum total cholesterol and LDL cholesterol concentrations in the rice bran group were 9.2 and 13.7% lower, respectively, than in the placebo group. The plasma free fatty acid and adiponectin concentrations were 20% lower and 40% higher in the rice bran group compared to the placebo group. CONCLUSIONS: This study demonstrated that stabilized rice bran can lower the level of HbA1c and blood lipids and increase blood adiponectin concentrations in type 2 diabetic subjects. In light of this, we conclude that stabilized rice bran may represent an important functional nutrient to ameliorate lipid and glycemic anomalies in type 2 diabetic subjects.

Effects of glucose and alpha-tocopherol on low-density lipoprotein oxidation and glycation.

Glycation of blood proteins is considered to be a major contributor to hyperglycemic complications in diabetes mellitus patients. In this study, we demonstrate the efficacy of alpha-tocopherol in reducing low-density lipoprotein (LDL) oxidation and glycation in vitro. Native LDL isolated from healthy subjects was exposed to various concentrations of glucose and malondialdehyde (MDA) with or without alpha-tocopherol enrichment for 7 days in sealed vacuum ampoules. The degree of glycation, copper-induced lag time, content of thiobarbituric acid-reactive substances (TBARS), and alpha-tocopherol levels in LDL were then assessed. LDL lag time was significantly reduced with high levels of glucose and MDA. Alpha-tocopherol enrichment dramatically inhibited the oxidation of LDL in the lag-time assay. However, the length of incubation time was inversely related to the LDL lag time. Longer incubation time resulted in shorter LDL lag time, with or without alpha-tocopherol enrichment. The level of TBARS associated with LDL oxidation was highest in native, MDA-supplemented, and high-glucose samples. The alpha-tocopherol levels were inversely related to glucose levels and incubation times. In conclusion, high-glucose concentrations heightened the oxidative susceptibility of LDL. Alpha-tocopherol enrichment reduced this trend and prevented LDL from undergoing architectural modification.

Advanced glycosylation end products induce inducible nitric oxide synthase (iNOS) expression via a p38 MAPK-dependent pathway.

BACKGROUND: Advanced glycosylation end products (AGEs) accumulation in tissue has been implicated in diabetic related complications, including diabetic nephropathy. Activation of peroxisome proliferator activated receptor-gamma (PPAR-gamma) ameliorates diabetic nephropathy. METHODS: In the present study, we investigated the effects of AGEs on inducible nitric oxide synthase (iNOS) expression and nitric oxide production, and the effects of rosiglitazone, an activator of PPAR-gamma, on AGE-induced iNOS expression and nitrite release in glomerular mesangial cells. RESULTS: AGEs caused a dose- and time-dependent increase of iNOS induction and nitrite accumulation in mesangial cells. A protein tyrosine kinase inhibitor (genistein), or a p38 mitogen-activated protein kinase (MAPK) inhibitor (SB203580) suppressed AGE-induced iNOS expression and nitrite release from mesangial cells. Addition of bovine serum albumin (BSA)-AGEs to mesangial cells increased p38 MAPK activities. Activation of PPAR-gamma by rosiglitazone inhibited AGE-induced iNOS expression, nitrite release, and p38 MAPK activation in mesangial cells. AGE-stimulated nitrite release was attenuated by pretreatment with anti-tumor necrosis factor-alpha (TNF-alpha) and anti-transforming growth factor-beta (TGF-beta) antibodies. AGE-induced iNOS expression was inhibited by treatment with a nuclear factor-kappaB (NF-kappaB) inhibitor, pyrrolidone dithiocarbamate. Addition of BSA-AGEs to mesangial cells stimulated p65 NF-kappaB translocation from the cytosol to the nucleus. CONCLUSION: These data suggest that cytokine release, NF-kappaB and p38 MAPK-dependent pathways may play a role in AGE-induced iNOS expression and subsequent nitric oxide production in mesangial cells. Rosiglitazone may prevent AGE-induced iNOS expression by interfering with p38 MAPK activity.