Retrosternal goitre is defined as a goitre with a portion of its mass ≥ 50% located in the mediastinum. Surgical removal is the treatment of choice and, in most cases, the goitre can be removed via a cervical approach. Aim of this retrospective study was to analyse personal experience in the surgical management of retrosternal goitres, defining, in particular, the features requiring sternotomy. Over a 5-year period (2004-2008), 986 patients underwent thyroidectomy in the ENT Department of the University Hospital of Udine, Italy; in 53 patients, 37 females, 16 males (mean age: 64 years, range: 35-85), thyroidectomy was performed for a retrosternal goitre, which extended, at computed tomography at least 3 cm below the cervico-thoracic isthmus. Retrosternal goitres were removed via a cervical approach in 49 patients; a sternotomy was necessary in 4 patients (7.5%), due to an ectopic intra-thoracic thyroid in one patient, and a very large thyroid reaching the main bronchial bifurcation in the other 3 (mean weight of goitres: 883 g, range: 520-1600). Histo-pathological studies revealed a benign lesion in 50 patients and a carcinoma in 2 (3.7%). The incidence of transient and permanent hypoparathyroidism was 13% and 3.7%, respectively. Transient recurrent laryngeal nerve palsy occurred in one patient (1.8%), post-operative bleeding in 3 patients (5.6%) and respiratory complications, requiring a tracheotomy in one case, in 2 patients (3.7%). Surgical removal of a retrosternal goitre is a challenging procedure; it can be performed safely, in most cases, via a cervical approach, with a complication rate slightly higher than the average rate for cervical goitre thyroidectomy, especially concerning hypoparathyroidism and post-operative bleeding. The most significant criteria for selecting patients requiring sternotomy are computed tomography features, in particular the presence of an ectopic goitre, the thyroid gland volume and the extent of the goitre to or below the tracheae carina. In conclusion, if retrosternal goitre thyroidectomy is performed by a skilled surgical team, familiar with its unique pitfalls, the assistance of a thoracic surgeon may be required only in a few selected cases.
Thyroid; Retrosternal goitre; Surgical treatment; Sternotomy; Complications
“Forgotten” goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy.
PRESENTATION OF CASE
We report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves’ disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures.
In the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter.
Retrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.
Forgotten goiter; Retrosternal goiter; Substernal goiter; Total thyroidectomy
Most retrosternal goiters are situated in the anterior mediastinal compartment, but according to the literature, 10–15% are located in the posterior mediastinum. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a huge posterior mediastinal goiter extending from the neck retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side and ending at the level of the lower part of the left cardiac atrium, nearly reaching the diaphragm. Surgical removal is the treatment of choice in such cases. We performed an operation using a transcervical and right thoracotomy approach. Histopathological examination confirmed the diagnosis of the large goiter. The patient recovered well and was discharged in 1 week.
Retrosternal goiter; Transcervical; Thoracotomy
Objective: To summarize the experience in the peri-operative treatment of giant nodular goiter.
Methods: A total of 123 patients with giant nodular goiter sized 6~20 cm were admitted into our hospital from 1990 to 2011 and the clinical data were retrospectively analyzed. These patients underwent total or subtotal thyroidectomy.
Results: All patients underwent surgical intervention. Unilateral subtotal thyroidectomy was performed in 40 patients, unilateral total thyroidectomy in 1 patient, bilateral subtotal thyroidectomy in 79 patients, and unilateral total thyroidectomy, removal of entire isthmus and contralateral subtotal thyroidectomy in 3 patients. Nodular goiter was pathologically proven post-operatively. No short-term complications such as dyspnea or thyroid storm were found postoperatively. Post-operative follow up was done for 9 months to 6 years and no recurrence was observed.
Conclusion: Comprehensive pre-operative preparation, pre-operative evaluation, complete exposure of the operative field, meticulous operation, effective control and prevention of hemorrhage and prevention against damage to superior and recurrent laryngeal nerves are crucial for the successful surgical intervention of giant nodular goiter.
nodular goiter; peri-operative treatment; surgical intervention.
The intrathoracic (substernal) goiter (1-15% of all thyroidectomies) is usually benign; but it can be malignant in 3-17%. There is history of thyroid surgery in 13-30% of patients. Intrathoracic goiters cause adjacent structure compression more frequently than the cervical goiters, due to the limited space of the thoracic cage. Compression of trachea, oesophagus, vascular and neural structures may cause dyspnoea, dysphagia, superior vena cava syndrome, subclavian vein thrombosis, dysphonia, and Horner’s syndrome. There is usually progressive deterioration, but acute exacerbation may occur. We present successful surgical management of a gigantic benign intrathoracic goiter, causing severe respiratory distress.
Patients and methods
A 63 year old male with history of subtotal thyroidectomy 2 years ago, presented with progressively increasing dyspnoea and inspiratory stridor. A large cervical, and prespinal superior and posterior mediastinal mass was revealed on computed tomography. Two retrovascular, pre- para- and retro-tracheal lobes were displacing the aortic arch, the anonymous vein, and the trachea, descending to the carina, severely compressing the trachea at the level of the aortic arch. Two lobes [maximum length: 12 cm (right), 14 cm (left), total weight: 290 gr] were resected en block through a cervical collar incision and a median sternotomy. Histology revealed multinodular goiter without malignancy.
The operation and the postoperative course were uneventful, without: bleeding, infection, recurrent laryngeal nerve palsy, cardiorespiratory, endocrine, or wound complications. Airway stenosis was immediately relieved, although a minor degree of stenosis, attributed to tracheomalacia due to chronic compression, remained. No intervention was required, and improvement was noted at follow-up.
Thoracic goiter (>50% of the mass below the thoracic inlet) is per se an indication for resection. Tracheal compression by (cervical or thoracic) goiter is also an indication for resection; early tracheal decompression is recommended particularly in symptomatic patients. In severe respiratory distress, intubation and semi-urgent operation may be required. With early intervention, most intrathoracic goiters (91-99%) can be removed through a cervical approach, while tracheomalacia is avoided. Re-operation and resection of a goiter descending to the carina, adjacent to the aortic arch, the descending aorta and the thoracic spine required a median sternotomy that was not associated with morbidity.
Hashimoto’s thyroiditis (HT) is usually treated conservatively with thyroxine. Its incidence is higher in Iodine sufficient areas and may require surgery for associated nodularity or complications. A retrospective study on surgically treated HT cases was conducted in a teritiary care teaching hospital in an Iodine sufficient area of Southern India. 34 cases of goiter with associated HT, who underwent thyroidectomy between 2007 and 2010 were analysed for indications of surgery. Minimum follow-up period was 6 months. F:M ratio was 31:3 with mean age of 41.3 years. Goiter was diffuse in 41% and nodular in 59%. 16 (47%) of patients were hypothyroid. Autoimmune association was found in 35%. Commonest surgery done was hemithyroidectomy in 12 (35%) followed by subtotal thyroidectomy in 10 cases. Most frequent indication for surgery was nodular goiter in 12 (35%) followed by associated malignancy, persistent goiter, pressure symptoms and painful thyroiditis. Histopathology showed diffuse HT alone in 12 (35%) and rest of the cases had HT as a component synchronous with other pathologies. Associated pathologies were benign multinodular goiter (6), colloid nodule (6), papillary cancer (5), follicular adenoma (4), cyst (1). Surgery for HT is primarily indicated for associated pathologies like dominant nodule, suspicious or proven malignancy, persistent goiter, painful thyroiditis, pressure symptoms and rarely for HT perse. Rate of surgery for HT associated goiter appears to be higher in Iodine sufficient areas, the cause of which needs to be studied further.
Hashimoto’s thyroiditis; Thyroxine; Surgery
This study was carried out to evaluate the clinical presentation, surgical treatment, complications, and risk of malignancy for large substernal goiter. From March 2010 to December 2012, 12 patients with large substernal thyroid goiter who underwent surgery in our Department were enrolled in the study. Their medical records were retrospectively analyzed. Collar-shaped incision was adequate for resection of the lesions in 10 (83%) patients, while two (17%) patients required combined cervical-thoracic incision. In addition, one case was subjected to postoperative tracheotomy. Transient hypocalcaemia occurred in one case. The incidence of transient hoarseness, tracheomalacia and hypothyroidism was 8.3%. There was no perioperative bleeding, thyroid storm as well as other serious complications. All patients were clinically cured. Therefore, cervical collar incision is nearly always adequate for most cases of larger substernal goiter, and sternotomy can be avoided. Furthermore, the application of intraoperative ultrasonic knife can effectively reduce intraoperative and postoperative complications. Aggressive perioperative management is crucial for the successful removal of large substernal goiter.
Substernal goiter; operative approach; ultrasonic knife; complications
To investigate the accuracy of a dual-projection respiratory self-gating (DP-RSG) technique in dynamic heart position measurement and its feasibility for free-breathing whole-heart coronary MR angiography (MRA).
Materials and Methods
A DP-RSG method is proposed to enable accurate direct measurement of heart position by acquiring two whole-heart projections. On 14 volunteers, we quantitatively evaluated the efficacy of DP-RSG by comparison with diaphragmatic navigator (NAV) and single-projection-based respiratory self-gating (SP-RSG) methods. For DP-RSG, we also compared center-of-mass and two profile-matching algorithms in deriving heart motion. Coronary imaging was conducted on 8 volunteers based on retrospective gating to preliminarily validate the effectiveness of DP-RSG for whole-heart coronary MRA. Comparison of vessel delineation was performed between images reconstructed using different gating methods.
The quantitative evaluation shows that DP-RSG more accurately tracks heart motion than NAV with all gating window (GW) values and SP-RSG approaches with GW ≥2.5mm and profile-matching algorithms are more reliable for motion derivation than center-of-mass calculations with GW ≥1.0mm. Whole-heart coronary MRA studies demonstrate the feasibility of using DP-RSG to improve overall delineation of the coronary arteries.
DP-RSG is a promising approach to better resolve respiratory motion for whole-heart coronary MRA compared to conventional NAV and SP-RSG.
coronary MRA; respiratory gating; motion correction; self-navigation
Rosiglitazone (RSG) is an insulin-sensitizing drug used to treat type 2 diabetes mellitus. The A Diabetes Outcome Progression Trial (ADOPT) shows that women taking RSG experienced more fractures than patients taking other type 2 diabetes drugs. These were not osteoporotic vertebral fractures but, rather, occurred in the limbs. The purpose of this study was to investigate how RSG treatment alters bone quality, which leads to fracture risk, using the Zucker fatty rat as a model.
RESEARCH DESIGN AND METHODS
A total of 61 female 4-month-old rats were divided into six groups. One Sham group was a control and another was administered oral RSG 10 mg/kg/day. Four ovariectomized (OVX) groups were dosed as follows: controls, RSG 10 mg/kg, alendronate (ALN, injected at 0.7 mg/kg/week), and RSG 10 mg/kg plus ALN. After 12 weeks of treatment, bone quality was evaluated by mechanical testing. Microarchitecture, bone mineral density (BMD), cortical bone porosity, and bone remodeling were also measured.
OVX RSG 10 mg/kg rats had lower vertebral BMD and compromised trabecular architecture versus OVX controls. Increased cortical bone porosity and decreased mechanical properties occurred in these rats. ALN treatment prevented decreased BMD and architectural and mechanical properties in the OVX model. Reduced bone formation, increased marrow adiposity, and excess bone resorption were observed in RSG-treated rats.
RSG decreases bone quality. An unusual finding was an increase in cortical bone porosity induced by RSG, consistent with its effect on long bones of women. ALN, an inhibitor of bone resorption, enhanced mechanical strength and may provide an approach to partially counter the deleterious skeletal effects of RSG.
Benign cervical goiters rarely cause acute airway obstruction.
We report the case of a 64-year-old woman of African descent who presented with acute shortness of breath. She required immediate intubation and later a total thyroidectomy for a benign cervical multi-nodular goiter with no retrosternal tracheal compression.
Benign multi-nodular goiters are commonly left untreated once euthyroid. Peak inspiratory flow rates should be measured via spirometry in all goiters to assess the degree of tracheal compression. Once tracheal compression is identified, an elective total thyroidectomy should be performed to prevent morbidity and mortality from acute airway obstruction.
Surgical brain injury (SBI) is unavoidable during many neurosurgical procedures. This inevitable brain injury can result in postoperative complications including brain edema, blood-brain barrier disruption (BBB) and cell death in susceptible areas. Rosiglitazone (RSG), a PPAR-γ agonist, has been shown to reduce inflammation and provide neuroprotection in experimental models of ischemia and intracerebral hemorrhage. This study was designed to evaluate the neuroprotective effects of RSG in a rodent model of SBI.
65 adult male Sprague-Dawley rats were randomly divided into sham, vehicle and treatment groups. RSG was administered intraperitoneally in two dosages (1mg/kg/dose, 6mg/kg/dose) 30 minutes before surgery, and 30 minutes and 4 hours after surgery. Animals were euthanized 24 hrs following neurological evaluation to assess brain edema and BBB permeability by IgG staining. Inflammation was examined using myeloperoxidase (MPO) assay and double-labeling fluorescent immunohistochemical analysis of IL-1β and TNF-α.
Localized brain edema was observed in tissue surrounding the surgical injury. This brain edema was significantly higher in rats subjected to SBI than sham animals. Increased IgG staining was present in affected brain tissue; however, RSG reduced neither IgG staining nor brain edema. RSG also did not improve neurological status observed after SBI. RSG, however, significantly attenuated MPO activity and qualitatively decreased IL-1β and TNF-α expression compared to vehicle-treated group.
SBI causes increased brain edema, BBB disruption and inflammation localized along the periphery of the site of surgical resection. RSG attenuated inflammatory changes, however, did not improve brain edema, BBB disruption and neurological outcomes after SBI.
Rosiglitazone; surgical brain injury; inflammation; brain edema; blood brain barrier; myeloperoxidase
Patients treated with peroxisome proliferator-activated receptor-γ (PPAR-γ) agonist manifest favorable metabolic profiles associated with increased plasma adiponectin (APN). However, whether increased APN production as a result of PPAR-γ agonist treatment is an epiphenomenon or is causatively related to PPAR-γ’s cardioprotective actions remains completely unknown.
To determine the role of APN in rosiglitazone (RSG) cardioprotection against ischemic heart injury.
Methods and Results
Adult male wild type (WT) and APN knockdown/knockout (APN+/− and APN−/−) mice were treated with vehicle or rosiglitazone (RSG, 20 mg/kg/day), and subjected to coronary artery ligation 3 days after beginning treatment. In WT mice, RSG (7 days) significantly increased adipocyte APN expression, elevated plasma APN levels (2.6-fold), reduced infarct size (17% reduction), decreased apoptosis (0.23±0.02% vs. 0.47±0.04% TUNEL positive in remote non-ischemia area), attenuated oxidative stress (48.5% reduction), and improved cardiac function (P<0.01). RSG-induced APN production and cardioprotection were significantly blunted (P<0.05 vs. WT) in APN+/−, and completely lost in APN−/− (P>0.05 vs. vehicle-treated APN−/− mice). Moreover, treatment with RSG for up to 14 days significantly improved the post-ischemic survival rate of WT mice (P<0.05 vs. vehicle group), but not APN knockdown/knockout mice.
PPAR-γ agonists’ cardioprotective effects are critically dependent on its APN stimulatory action, suggesting that under pathologic conditions where APN expression is impaired (such as advanced type-2 diabetes), the harmful cardiovascular effects of PPAR-γ agonists may outweigh its cardioprotective benefits.
Diabetes; Myocardial infarction; Adipocytokine; Signaling
Fine-needle aspiration (FNA) is a useful method for evaluating multinodular goiter; however, its role is still controversial. The aim of this study was to assess the utility of ultrasound-guided thyroid FNA in detecting malignancy in patients with multinodular goiter in Oman.
Materials and Methods:
This was a retrospective study where all patients with multinodular goiter seen at the Sultan Qaboos University Hospital endocrinology clinic in Oman in 2005 were evaluated. The thyroid FNA results were grouped into either malignancy (positive result) or others (negative result). They were compared to those of final histopathological examination in order to calculate the value of the test in diagnosing malignancy. Analyses were evaluated using descriptive statistics.
A total of 272 patients were included in the study. The mean age was 3913 years with an age range from 5 to 85 years. The majority of the patients were females (n=236; 87%). The results of thyroid FNA revealed that 6% (n=15) of the patients had malignancies while histopathological results showed that the proportion of subjects with malignancies was 18% (n=49). Out of the 15 cases identified to have malignances by thyroid FNA, only 53% (n=8) of the subjects were confirmed to have malignancy by biopsy. Overall, the results of the tests were poor, revealing a sensitivity of 16%, specificity of 97% and a diagnostic accuracy of 82%, with a positive predictive value of 53% and a negative predictive value of 84%.
Thyroid FNA is not a useful test in differentiating multinodular goiter from malignancy, as more than 80% of the malignancies go unnoticed.
Fine-needle aspiration; malignancy; multinodular goiter
Clinical studies suggest that rosiglitazone (RSG) treatment may increase the incidence of heart failure in diabetic patients. In this study, we examined whether a high corn oil diet with RSG treatment in insulin resistant aging mice exerted metabolic and pro-inflammatory effects that stimulate cardiac dysfunction. We also evaluated whether fish oil attenuated these effects. Female C57BL/6J mice (13 months old) were divided into 5 groups: (1) lean control (LC), (2) corn oil, (3) fish oil, (4) corn oil + RSG and (5) fish oil + RSG. Mice fed a corn oil enriched diet and RSG developed hypertrophy of the left ventricle (LV) and decreased fractional shortening, despite a significant increase in total body lean mass. In contrast, LV hypertrophy was prevented in RSG treated mice fed a fish oil enriched diet. Importantly, hyperglycemia was controlled in both RSG groups. Further, fish oil + RSG decreased LV expression of atrial and brain natriuretic peptides, fibronectin and the pro-inflammatory cytokines interleukin-6 and tumor necrosis factor-α, concomitant with increased interleukin-10 and adiponectin levels compared to the corn oil + RSG group. Fish oil + RSG treatment suppressed inflammation, increased serum adiponectin, and improved fractional shortening, attenuating the cardiac remodeling seen in the corn oil + RSG diet fed C57BL/6J insulin resistant aging mice. Our results suggest that RSG treatment has context-dependent effects on cardiac remodeling and serves a negative cardiac role when given with a corn oil enriched diet.
Aging; Corn oil; Fish oil; Cardiac remodeling; Inflammation; Left ventricle hypertrophy; Rosiglitazone
The intrathoracic (or substernal) goiter is more often benign; but it can be malignant in 2-22% of patients. There is history of prior thyroid surgery in 10% to more than 30% of patients. Intrathoracic goiters cause adjacent structure compression more frequently than the cervical goiters, due to the limited space of the thoracic cage. Compression of trachea, oesophagus, vascular and neural structures may cause dyspnoea, dysphagia, superior vena cava syndrome, subclavian vein thrombosis, hoarseness, and Horner’s syndrome. There is usually progressive deterioration, but acute exacerbation may occur. The presence of a thoracic goiter (>50% of the mass below the thoracic inlet) is per se an indication for resection. Tracheal compression by (cervical or thoracic) goiter is also an indication for resection; early tracheal decompression is recommended particularly in symptomatic patients. In severe respiratory distress, intubation and semi-urgent operation may be required. With early intervention, most intrathoracic goiters can be removed through a cervical approach, while tracheomalacia is avoided. We hereby present successful and uncomplicated total thyroidectomy, through a median sternotomy, of a benign, gigantic, bilateral, retrovascular, posterior mediastinal, intrathoracic goiter, encircling the trachea, and causing severe respiratory distress in a 63 year old man with history of previous subtotal thyroidectomy.
Airway obstruction/etiology; airway obstruction/surgery; thyroidectomy; goiter; substernal/surgery; goiter/intrathoracic
Multinodular goiter in lingual thyroid is quite rare. Surgical removal is indicated in symptomatic patients and when cancer is suspected. An external approach is most often used, but is associated with morbidity and sequelae. In this study, we present for the first time the technique of transoral robotic surgery (TORS) for removal of a massive lingual goiter. Prospective patient data were collected, including demographics, medical history, symptoms, comorbidities and drugs prescribed. The da Vinci Surgical System was used for a transoral approach to the oropharynx. The technique was validated in a 31-year-old woman with signs and symptoms of multinodular goiter presenting since childhood. The procedure required 115 min, with intervals as follows: tracheotomy, 25 min; robot setting time, 20 min; and console time, 70 min. TOR S is feasible in cases of multinodular goiter in a lingual thyroid. The procedure appears to be safe, with quick recovery of swallowing and speech.
Lingual thyroid goiter; Transoral robotic surgery; Thyroid ectopias
Intrathoracic goiters are divided into two categories: primary and secondary. Intrathoracic goiters (IG) can cause upper airway obstruction. The presence of obstructive symptoms secondary to increased thyroid growth and tracheal compression is major indication for surgery; however, goiters do not always require immediate surgical attention. In addition, although some diagnostic tests indicate upper airway obstruction, many patients remain asymptomatic. Surgeries to remove IG are performed routinely however, they are not without risk. In some cases, intrathoracic goiters present as thyroid cancers. Very rare cancers such as Hürthle cell carcinoma (HCC) can create a challenge for the surgeon when surgical intervention is vital.
Anesthetic management of patients with mediastinal masses remains challenging as acute cardiorespiratory decompensation may follow induction of anesthesia. We describe a 57 year old lady with massive retrosternal goiter and severe intrathoracic tracheal compression who had a total thyroidectomy. Comprehensive contingency plans were an essential prerequisite for successful management of difficult airway, including multidisciplinary involvement of otorhinolaryngologic and cardiothoracic surgeons preparing for rigid bronchoscopy and cardiopulmonary bypass. Awake oral fiberoptic intubation was performed under dexmedetomidine sedation. Severe tracheal narrowing necessitated usage of a 5.0 mm uncuffed flexometallic endotracheal tube. Anesthesia was maintained with sevoflurane and dexmedetomidine infusion with target controlled infusion of remifentanil as analgesia. No muscle relaxant was given. Surgical manipulation led to intermittent total tracheal compression and inadequate ventilation. The tumor was successfully removed via the cervical approach. A close working relationship between anesthesiologists and surgeons was the key to the safe use of anesthesia and uneventful recovery of this patient.
Awake fiberoptic intubation; Dexmedetomidine; Difficult airway; Mediastinal mass
During the 26-year period, January 1, 1950 to December 31, 1975, inclusively, there were 680 thyroidectomies for clinical evidence of primary thyroid disease performed at the Howard University Hospital (0.6 percent of routine surgicals). There were 595 female and 85 male patients (ratio 7:1). All of the patients were black. In the 680 cases, the incidence of carcinoma was 4.6 percent, adenoma 11.3 percent, nodular goiter 51.9 percent, diffuse hyperplasia 21.3 percent, various thyroiditis 7.1 percent, and miscellaneous conditions 3.8 percent. A statistical analysis, together with a brief review of the literature on each entity, will be presented.
Patients with type 2 diabetes mellitus (T2DM) have a higher risk of cardiovascular disease (CVD). Peroxisome proliferator-activated receptors (PPARs) play an important role in the regulation of energy homeostasis. Therefore, we aimed to observe the effects of combined PPARα/γ agonists on T2DM patients with coronary artery disease (CAD). Patients were randomly divided into a rosiglitazone (RSG) group (n=20), a bezafibrate (BEZ) group (n=20), a combination of RSG and BEZ group (n=20) and a control group (n=20). Plasma C-reactive protein (CRP) and monocyte chemoattractant protein-1 (MCP-1) were measured by enzyme-linked immunosorbent assay before and 12 weeks after treatment. Fasting blood glucose (FBG), fasting insulin, insulin resistance index (IRI), hemoglobin A1c (HbA1c), lipid levels and body mass index were also investigated. At the end of the treatment, FBG, insulin, IRI, HbA1c and triglyceride levels decreased and the level of high-density lipoprotein cholesterol increased in the RSG, BEZ and combination groups. A decrease in low-density lipoprotein cholesterol was only observed in the combination group. Although the total cholesterol levels in all groups decreased, no significant difference was noted. The levels of CRP and MCP-1 were reduced in patients in the RSG, BEZ and combination groups. In addition, RSG, BEZ and the combination of RSG and BEZ also inhibited MCP-1 secretion. The combination of RSG and BEZ was more efficient than RSG or BEZ alone in downregulating cytokines. In conclusion, our results suggest that a combination of RSG and BEZ may be more efficient than RSG or BEZ alone in the treatment of T2DM patients with CAD.
diabetes mellitus; coronary heart disease; peroxisome proliferator-activated receptor α; peroxisome proliferator-activated receptor γ; inflammatory cytokine
Triple transgenic (3xTg-AD) mice harboring the presenilin 1, amyloid precursor protein, and tau transgenes (Oddo et al., 2003) display prominent levels of amyloid-beta (Aβ) immunoreactivity in forebrain regions. The Aβ immunoreactivity is first seen intracellularly in neurons and later as extracellular plaque deposits. The present study examined Aβ immunoreactivity that occurs in layer III of the granular division of retrosplenial cortex (RSg). This pattern of Aβ immunoreactivity in layer III of RSg develops relatively late, and is seen in animals older than 14 mo. The appearance of the Aβ immunoreactivity is similar to an axonal terminal field and thus may offer a unique opportunity to study the relationship between afferent projections and the formation of Aβ deposits. Axonal tract tracing techniques demonstrated that the pattern of axon terminal labeling in layer III of RSg, following placement of DiI in medial septum, is remarkably similar to the pattern of cholinergic axons in RSg, as detected by acetylcholinesterase histochemical staining, choline acetyltransferase immunoreactivity, or p75 receptor immunoreactivity; this pattern also is strikingly similar to the band of Aβ immunoreactivity. In animals sustaining early damage to the medial septal nucleus (prior to the advent of Aβ immunoreactivity), the band of Aβ in layer III of RSg does not develop; the corresponding band of cholinergic markers also is eliminated. In older animals (after the appearance of the Aβ immunoreactivity) damage to cholinergic afferents by electrolytic lesions, immunotoxin lesions, or cutting the cingulate bundle, result in a rapid loss of the cholinergic markers and a slower reduction of Aβ immunoreactivity. These results suggest that the septal cholinergic axonal projections transport Aβ or APP to layer III of RSg.
acetylcholinesterase; axonal transport; basal forebrain; lesions; synaptic drive
Rosiglitazone (RSG), developed for the treatment of type 2 diabetes mellitus, is known to have potent effects on carbohydrate and lipid metabolism leading to the improvement of insulin sensitivity in target tissues. To further assess the capacity of RSG to normalize gene expression in insulin-sensitive tissues, we compared groups of 18-day-treated db/db mice with increasing oral doses of RSG (10, 30, and 100 mg/kg/d) with untreated non-diabetic littermates (db/+). For this aim, transcriptional changes were measured in liver, inguinal adipose tissue (IAT) and soleus muscle using microarrays and real-time PCR. In parallel, targeted metabolomic assessment of lipids (triglycerides (TGs) and free fatty acids (FFAs)) in plasma and tissues was performed by UPLC-MS methods. Multivariate analyses revealed a relationship between the differential gene expressions in liver and liver trioleate content and between blood glucose levels and a combination of differentially expressed genes measured in liver, IAT, and muscle. In summary, we have integrated gene expression and targeted metabolomic data to present a comprehensive overview of RSG-induced changes in a diabetes mouse model and improved the molecular understanding of how RSG ameliorates diabetes through its effect on the major insulin-sensitive tissues.
Hyperglycemia is the main determinant of long term diabetic complications mainly through induction of oxidative stress responsible for secondary defects including cancer, infertility etc. Thiazolidinediones (TZDs) are known to posses the antioxidant potential against the reactive oxygen species. The ability of clinically used TZDs like Rosiglitazone (RSG) and Pioglitazone (PIO) in diabetic complications is still need to be studied extensively in the literature. In this study, the role of RSG and PIO on the frequency of nuclear and germinal cell damage was studied using bone marrow micronucleus (MN) test, sperm shape abnormality and sperm count in normal animals. The drugs were tested in the three doses (1, 10 and 100 mg/kg) after acute (48 hrs and 72 hrs) and chronic (4 weeks) treatment. The results indicated that RSG has produced significant (p < 0.01) decrease in P/N (polychromatic and normochromatic erythrocytes) ratio at 10 and 100 mg/kg without affecting the frequency of micronucleated erythrocytes, sperm shape morphology and sperm count. PIO in the tested doses did not induce any change in P/N ratio and sperm count but the higher dose (100 mg/kg) showed suppression of MN in normochromatic erythrocytes and % sperm shape abnormality compared to the control group.
rosiglitazone; pioglitazone; micronucleus test; sperm shape morphology
From 1996 to 2001, 393 thyroidectomies were performed and 25 (6.4%) patients underwent reoperative thyroid surgery at Hospital Universiti Sains Malaysia. All reoperated patients had undergone one prior thyroid operation. All were females with an average age of 39.1 years (18–61 years). The most frequent indication for reoperation was cancer in resected specimen of an originally misdiagnosed carcinoma treated by partial thyroid resection. Final histological diagnosis of 25 reoperations showed thyroid carcinoma in 22 (88%) cases and multinodular goiter in 3 cases. The overall interval between the initial and the reoperative procedures ranged from 3 weeks to 15 years. There was no post-operative mortality after reoperation. Post-operative complications were discovered in 5 patients, as 3 (12%) of whom had transient hypocalcaemia, one (4%) had wound breakdown and one (4%) had permanent recurrent laryngeal nerve palsy. Reoperative thyroid surgery is an uncommon operation with high complication rate.
Reoperative thyroid surgery; hypocalcaemia; recurrent laryngeal nerve palsy
Thyroid gland is an important endocrine organ because of its functions. Although the morbidity and mortality of thyroid surgery have decreased markedly, serious complications may still occur. The aim of this retrospective study was to identify the factors influencing the complications in benign nodular thyroid surgery. A total of 332 patients who underwent thyroid surgery between April 2004 and May 2008 were evaluated retrospectively to identify the factors influencing the complications. We found that in surgery lasting more than 90 minutes the risk of permanent recurrent laryngeal nerve (RLN) injury was high, daily drainage more than 50 cc increases the risk of seroma formation, retrosternal goiter surgery have higher risk for bleeding. The flap edema rates were high found in the operations made by resident surgeon and patients with size 3–4 thyroid glands. Low complication rates can be achieved after thyroidectomy with better knowledge of the surgical anatomy of the neck, thyroid pathology and required surgical treatment.
Thyroidectomy; Complications; Influencing factors