Adrenal Abscesses: A Systematic Review of the Literature.

Objective: To summarize the existing knowledge about adrenal gland abscesses, including etiology, clinical presentation, common laboratory and imaging findings, management and overall morbidity and mortality. Design: Systematic literature review. Methods: We performed a search in the PubMed database using search terms: 'abscess and adrenal glands', 'adrenalitis', 'infection and adrenal gland', 'adrenal abscess', 'adrenal infection' and 'infectious adrenalitis'. Articles from 2017 to 2022 were included. We found total of 116 articles, and after applying exclusion criteria, data from 73 articles was included in the final statistical analysis. Results: Of 84 patients included in this review, 68 were male (81%), with a mean age of 55 years (range: 29 to 85 years). Weight loss was the most frequent symptom reported in 58.3% patients, followed by fever in 49%. Mean duration of symptoms was 4.5 months. The most common laboratory findings were low cortisol (51.9%), elevated ACTH (43.2%), hyponatremia (88.2%) and anemia (83.3%). Adrenal cultures were positive in 86.4% cases, with Histoplasma capsulatum (37.3%) being the leading causative agent. Blood cultures were positive in 30% of patients. The majority of the adrenal infections occurred through secondary dissemination from other infectious foci and abscesses were more commonly bilateral (70%). A total of 46.4% of patients developed long-term adrenal insufficiency requiring treatment. Abscess drainage was performed in 7 patients (8.3%) and adrenalectomy was performed in 18 (21.4%) patients. The survival rate was 92.9%. Multivariate analysis showed that the only independent risk factor for mortality was thrombocytopenia (p = 0.048). Conclusion: Our review shows that adrenal abscesses are usually caused by fungal pathogens, and among these, Histoplasma capsulatum is the most common. The adrenal glands are usually involved in a bilateral fashion and become infected through dissemination from other primary sources of infection. Long-term adrenal insufficiency develops in 46% of patients, which is more common than what is observed in non-infectious etiology of adrenal gland disorders. Mortality is about 7%, and the presence of thrombocytopenia is associated with worse prognosis. Further prospective studies are needed to better characterize optimal testing and treatment duration in patients with this relatively rare but challenging disorder.

Uso de membrana de colágeno y placa de protección mecánica como instrumento de conservación alveolar / Use of collagen membrane and mechanical protective plate as an instrument for alveolar preservation

Luego de una extracción dental ocurren inevitablemente procesos de reabsorción y remodelación ósea, donde la dimensión y morfología de la cresta alveolar se ve modificada, representando un problema para la rehabilitación de la zona. Estudios clínicos han documentado un promedio de 4,0 a 4,5 mm de reabsorción ósea horizontal luego de una exodoncia, como así también cambios dimensionales significativos en los alrededores del hueso alveolar. El propósito fue evaluar y comparar clínica y tomográficamente los procesos de reparación y conservación del reborde alveolar post-extracción de paredes intactas, con y sin la utilización de esponjas de colágeno intraalveolar como relleno y placa termoformada como barrera física, durante el proceso de cicatrización. Se seleccionaron pacientes con indicación de exodoncia de elementos dentarios normalmente implantados y clínicamente aceptables, aplicando los criterios de exclusión, se realiza toma de impresión del terreno para la confección de una placa de protección rígida 0,8 termoformada para ser colocada posterior a la extracción durante la masticación por un período de 30 días. Se indica tomografía cone-beam post operatoria inmediata y a los tres meses para analizar, medir y comparar alto y ancho de crestas alveolares residuales. En la evaluación clínica y tomográfica de los casos estudiados, el grupo control donde se usó únicamente placa de protección alveolar arrojó mejores resultados que el grupo donde se colocaron esponja de colágeno en el interior del alvéolo. Palabras clave: Regeneración ósea, esponja de colágeno, cicatrización ósea, alvéolo postextracción, placa de protección alveolar (AU)

After a tooth extraction, bone resorption and remodeling processes inevitably occurs, where size and morphology of the alveolar crest is modified, representing a problem for the rehabilitation of the area. Clinical studies have documented an average of 4.0 to 4.5 mm of horizontal bone resorption after an extraction, us well us substantial dimensional changes around the alveolar bone. The purpose was to evaluate and compare clinical and tomographically both repair and preservation of post extraction alveolar ridge of intact walls processes, with and without the use of intraalveolar collagen sponges as filler and a thermoformed protective plaque, us physica? barrier, during healing process. Patients with normally implanted and clinically acceptable tooth with extraction indication were selected, applying the exclusion criteria, impression of the field is taken to build a 0.8 rigid thermoformed protective plaque in order to be placed after extraction and used during chewing for a period of 30 days. Immediate and three months post-operative cone beam tomography are indicated to analyze, measure and compare height and width of residual alveolar crests. In the clinical and tomographic evaluation of the cases treated, control group where only alveolar protective plaque was used, showed better results than the group with intraalveolar collagen sponge (AU)

Altered Daytime Fluctuation Pattern of Plasminogen Activator Inhibitor 1 in Type 2 Diabetes Patients with Coronary Artery Disease: A Strong Association with Persistently Elevated Plasma Insulin, Increased Insulin Resistance, and Abdominal Obesity.

This study was aimed at investigating daily fluctuation of PAI-1 levels in relation to insulin resistance (IR) and daily profile of plasma insulin and glucose levels in 26 type 2 diabetic (T2D) patients with coronary artery disease (CAD) (group A), 10 T2D patients without CAD (group B), 12 nondiabetics with CAD (group C), and 12 healthy controls (group D). The percentage of PAI-1 decrease was lower in group A versus group B (4.4 ± 2.7 versus 35.0 ± 5.4%; P < 0.05) and in C versus D (14.0 ± 5.8 versus 44.7 ± 3.1%; P < 0.001). HOMA-IR was higher in group A versus group B (P < 0.05) and in C versus D (P < 0.01). Simultaneously, AUCs of PAI-1 and insulin were higher in group A versus group B (P < 0.05) and in C versus D (P < 0.01), while AUC of glucose did not differ between groups. In multiple regression analysis waist-to-hip ratio and AUC of insulin were independent determinants of decrease in PAI-1. The altered diurnal fluctuation of PAI-1, especially in T2D with CAD, might be strongly influenced by a prolonged exposure to hyperinsulinemia in the settings of increased IR and abdominal obesity, facilitating altogether an accelerated atherosclerosis.

Indirect estimation of age-related reference limits of thyroid parameters: a cross-sectional study of outpatients' results.

OBJECTIVES: Defining adequate reference limits (RLs) for thyroid hormones is an important task for support monitoring and the treatment of subclinical thyroid disease. We determined whether there are age-related RLs for thyroid parameters in male and female outpatients free of overt thyroid disease. DESIGN: We analyzed 22,860 results (11,440 male and 11,420 female outpatients above the age of 18) for thyrotropin (TSH), free thyroxine (fT4) and total triiodothyronine (T3) that were stored in our laboratory information system between 2008 and 2011. We calculated the 2.5th and 97.5th centiles for the analyzed thyroid parameters. RESULTS: Our results indicate higher TSH levels with ageing, with a significant difference (p < 0.05) between the 97.5th centiles for males and females older than 70 (5.07 mIU/L and 4.10 mIU/L), but also a significant difference between male and female fT4 from 31 to 40 and from 41 to 50 years old (18.4 vs 14.9 pmol/L and 19.0 vs 15.9 pmol/L, p < 0.05), respectively. Overall indirect estimates of the 97.5th centiles for TSH for males and females were not significantly different and were below the generally recommended upper limit (4.01 mIU/L and 4.20 mIU/L, respectively). In addition, we found no statistically significant change in mean T3 values in the analyzed population. CONCLUSIONS: This cross-sectional study indicates change in TSH and fT4 levels with ageing and gender-related upper limits. This suggests that by using indirect estimation a laboratory could provide clinicians with more accurate gender- and age-specific RLs for thyroid parameters.

Relationship between obesity, adipocytokines and inflammatory markers in type 2 diabetes: relevance for cardiovascular risk prevention.

This study aimed to analyse the impact of obesity in type 2 diabetes (T2D) on adipocytokines (adiponectin, leptin and resistin) and inflammatory markers (TNF-α, IL-6 and hsCRP) as cardiovascular risk factors. A cross-sectional study comparing the basal levels of adipocytokines and inflammatory markers was done in 18 obese (BMI ≥ 30 kg/m²) (group A), 21 overweight (25 kg/m² ≤ BMI < 30 kg/m²) (group B), 25 non-obese T2D patients (group C) and 15 non-obese controls (group D). The lowest levels of adiponectin and the highest levels of leptin, resistin, TNF-α, IL-6 and hsCRP were found in group A. Adiponectin levels were significantly lower, and resistin, TNF-α, and hsCRP levels were elevated in group C vs. D. However, leptin and IL-6 levels differed significantly between groups A and B, but not between groups C and D. Moreover, we found a significant negative correlation between adiponectin and TNF-α, but not with other markers, which was independent of the presence of obesity. In contrast, leptin and resistin correlated with the inflammatory markers, and this correlation was obesity-dependent. Our results suggest that obesity influences cardiovascular risk primarily through changes in leptin and resistin and less efficiently at the level of adiponectin.

Asymptomatic cardiovascular manifestations in diabetes mellitus: left ventricular diastolic dysfunction and silent myocardial ischemia.

INTRODUCTION: Several cardiovascular manifestations in patients with diabetes may be asymptomatic. Left ventricular diastolic dysfunction (LVDD) is considered to be the earliest metabolic myocardial lesion in these patients, and can be diagnosed with tissue Doppler echocardiography. Silent myocardial ischemia (SMI) is a characteristic and frequently described form of ischemic heart disease in patients with diabetes. Objective The aim of the study was to assess the prevalence of LVDD and SMI in patients with type 2 diabetes, as well as to compare demographic, clinical, and metabolic data among defined groups (patients with LVDD, patients with SMI and patients with type 2 diabetes, without LVDD and SMI). METHODS: We investigated 104 type 2 diabetic patients (mean age 55.4 +/- 9.1 years, 64.4% males) with normal blood pressure, prehypertension and arterial hypertension stage I. Study design included basic laboratory assessment and cardiological workup (transthoracic echocardiography and tissue Doppler, as well as the exercise stress echocardiography). RESULTS: LVDD was diagnosed in twelve patients (11.5%), while SMI was revealed in six patients (5.8%). Less patients with LVDD were using metformin, in comparison to other two groups (chi2 =12.152; p=0.002). Values of HDL cholesterol (F=4.515; p=0.013) and apolipoprotein A1 (F=5.128; p= 0.008) were significantly higher in patients with LVDD. CONCLUSION: The study confirmed asymptomatic cardiovascular complications in 17.3% patients with type 2 diabetes.

Significant association of antiphospholipid antibodies and TNF-alpha: marker of severe atherogenic profile of patients with type II diabetes mellitus without micro and/or macrovascular complications.

OBJECTIVE: In vitro, stimulation of monocytes with antiphospholipid (aPL) antibodies resulted in increased secretion of TNF-alpha, but association of aPL with features of diabetes mellitus is not clarified yet. Therefore, we investigated the distribution of anticardiolipin (aCL), anti-ß2gpI (aß2gpI), anti-annexin A5 (aannxA5), and anti-oxLDL (aoxLDL) antibodies, and TNF-alpha in well-formed group of 78 patients with type II diabetes mellitus without vascular complications. METHODS: Investigated antibodies and TNF-alpha concentrations were measured by ELISA. RESULTS: Antiphospholipid antibodies were in positive correlation with TNF-alpha concentrations: aCL IgG (r=0.303, p=0.007), aCL IgM (r=0.386, p=0.000), aß2gpI IgG (r=0.499, p=0.000), aß2gpI IgM (r=0.462, p=0.000), aanxA5 IgG (r=0.479, p=0.000), aanxA5 IgM (r=0.641, p=0.000), aoxLDL (IgG+IgM, r=0.279, p=0.000). Anticardiolipin-positive and aCL-negative subgroups differed in TNF-alpha concentrations (Mann-Whitney, p=0.032). Significantly elevated LDL concentrations were noticed in aCL-positive patients with disease duration 10-15 years (χ(2)=15.000, p=0.000) and apoB concentrations were elevated in aoxLDL-positive patients with disease duration 7-10 years (χ(2)=3.938, p=0.047). CONCLUSION: Significant association of antiphospholipid antibodies and TNF-alpha might be a marker of severe atherogenic profile (suggested by increased levels of lipids in aPL-positive subgroups) and should be used for the stratification of patients with an increased risk for future deterioration of the disease.

Oxidized LDL, anti-oxidized LDL and anti-annexin A5 antibodies in primary antiphospholipid syndrome.

The aim of this study was to compare whether oxidized LDL (oxLDL), anti-oxLDL and anti-annexin (anx) A5 antibodies are associated with clinical features of primary antiphospholipid syndrome (PAPS), and to compare these to well-defined groups of non-PAPS myocardial infarction survivors (non-PAPS MI) and to non-PAPS patients with pulmonary emboli (non-PAPS PE). All parameters investigated were analyzed by ELISA using commercial reagents. PAPS patients with MI, in comparison to the group of non-PAPS MI survivors, had significantly elevated concentrations of oxLDL (p = 0.003) and anti-oxLDL antibodies (p = 0.024). Anti-anxA5 antibodies of the IgG isotype were associated with recurrent abortions (OR = 4.788, p = 0.036, 95% CI: 1.104 - 20.762). OxLDL and anti-oxLDL antibodies represent additional risk factors which, together with other factors, might lead to complications of arterial thromboses, such as myocardial infarctions in PAPS, while association of IgG anti-anxA5 antibodies with recurrent abortions is a reflection of the small number of patients with this feature involved in the study and should therefore be investigated further.

Lipoprotein (a) and apolipoprotein (a) in primary antiphospholipid syndrome.

OBJECTIVE: To investigate whether lipoprotein (a) (Lp(a)) and/or apolipoprotein (a) (apo(a)) may be markers for clinical features of 37 patients with primary antiphospholipid syndrome (PAPS) and to compare with 37 age- and sex-matched controls. METHODS: Apo(a) and Lp(a) concentrations were determined by ELISA and immunonephelometry, respectively. RESULTS: Only elevated apo(a) concentrations were significant predictor for cerebrovascular insults (OR=14.399, p=0.005, 95% CI: 2.224-93.230). CONCLUSION: Considering the fact that PAPS patients with cerebrovascular insults had recurrence of cerebrovascular episodes, measurement of apo(a) concentrations will help in the follow-up of those patients and thus in the prediction of future episodes. This finding should be further investigated in a larger study in order to provide adequate therapeutic intervention.