Hirsuitism

Question 1: In the process of evaluation of a patient with hirsuitism, which statment is false:
1-Total testesterone is less than 150 ng/dl in most patients with PCO
2-LH:FSH ratio is more than 3 is diagostic in patients with PCO.
3- Adrenal CT or MRI is indicated to role out adrenal androgen-secreting tumor if serum DHEA-s is > 700 mcg/dL .
4- A transvaginal ultrasound if serum total testesterone is > 150 ng/dL, and DHA is not significantly elevated.
5- Labroscopy is indicated if testesterone level is > 200 ng/dL with negative imaging of ovaries and adrenals to look for a small ovarian tumor (likely a hilus-cell tumor) that is too small to be detected by ultrasonography.

The right answer is 2, LH:FSH ratio used to one of the criteria to diagnose PCO however due to the pulsatility of LH as well findings of same ratio in some normal women the test is not helpful.

Most patients with PCO have mildly elevated or even normal testosterone level high level of 150 or more suggests ovarian or adrenal tumors. An elevated DHEA-s will suggest to adrenal tumor while a normal a DHEA will suggest ovarian tumor in this condition.

Question -2 In treatment of women with hirsuitism which is the wrong answer:
1-BCP is added if cosmetic measures and direct hair removal methods are commonly ineffective alone.
2-BCP may take more than 6 months to show effect in hirsuitism.
3- Anti-androgens typically spironolactone is added if BCP is not effective.
4- Avandia is effective in treating hirsuitism due to PCO.
5- Metformin have been shown to be effective in hirsuitism due to PCO.
6- Vaniqa cream for short course of 6 months will cure hirsuitism.
7- Flutamide to be avoided for hepatotoxicity.

The right answer is 6. BCP (Birth Control Pills) is the drug of choice if cosmetic measures are not effective alone. If it fails anti-androgens is added on or if used alone patient has to be in highly effective way of contraception since have effect on sex organs of male fetus. Typically spironolactone is used, flutamide has high risk of hepatoxicity. Cyproterone and finasteride are two other antiadnrogens. Though avandia (rosiglitzone) is effective in decreasing hirsuitism it cause weight gain and has a cardiovascular risk. Metformin in metanalysis of 8 studies found to be ineffective in diminishing hirsuitsim. Vaniqa cream will suppress hair growth temporarily and recurrence is common unless it is continued or BCP and anti-androgens are used as well.

LDL Pearls

By: Maged Taman

1- Adults 20 years old or more should have fasting lipid profile. If normal they can retested at least once every 5 years.

2- Lipid profile is fasting Total cholesterol, triglycerides, LDL (bad cholesterol and HDL (good cholesterol).

3- Lipid profile assessment:
Total cholesterol: <200>150 normal (preferable <100>140/90 or in blood pressure medicine.
Low HDL
Family history of premature CAD: father, brother or son <55>45 years old and women >55 years old.
HDL > 60 cancells one of the above risk factors.

5- CAD equivalents: these are other astherosclerotic manifestations that lead to same risks of CAD death and nonfatal MI like that of established CAD. They are:
peripheral vascular disease
Abdominal Aortic aneurysm.
Carotid artery disease.
Diabetes Mellitus.
10-year risk> 20%

6- LDL and non HDL goals:
CAD or CAD equivalents:
LDL goal is <100>100 or even >70
Non-HDL goal (total cholesterol - HDL) <130>130
drug for LDL > 130 and 10 year risk of 10-20%
Drug for LDL >160 and 10 year risk is <10> 160
Drug for LDL > 190
Non-HDL goal <190

7- Statins are the drug of choice for above patients decreases LDL 20-60%, resins 15-30 %, nicotinc acid 10-25 %, fibrates 5-20%, cholesterol absorption blocker Zetia 17%.

8- Patients with premature CAD and normal lipid profile: check LP (a), apo B and homocysteine.

Bronchial Carcinoid Tumors

All are true about bronchial carcinoids except:

1- arises from Kulchitsky cells one type of the neuroendocrine cells APUD.
2- Serum chromogranin A mild elevated.
3- Causes carinoid syndrome in less than 5%.
4- Causes acromegaly due to releasing GHRH.
5- Can cause Cushing second to the release of ectopic ACTH.
6- Silver stain is the gold standard to identify the tumors histologically.
7- CT lung will identify most of the tumors. MR with gado will show enhancement of T2 if CT can not distinguish them from vessels. Octreotide scan will show metastasis however these are rare and the scan picks up other tumors and granuloma.
8- In bronchoscopy the tumor have characteristic appearance.
9- Central carcionids are diagnosed by biopsy through bronchoscopy.
10- peripheral carcinoids are diagnosed by CT-guided transthoracic needle aspiration.
11- Treatment of choice is surgical excision with mediastinal lymph node resection.
12- Liver is the most common site of metastasis that are better image by MRI, resection would prolong survival.
13- In patient with more advanced disease the treatment of choice is somatostatin analogue.

All are correct except silver stain it used to be the common stain used in the past now the confirmatory immunohistochemical stain in diagnosing Carcinoids are NSE, synaptophysin and chromogranin. The tumors are commonly locally malignant and slowly growing with 10 years survival is over 80% atypical carinoids however tends to have worse prognosis. MRI of the liver will identify metastasis to the liver. Though carcinoids rarely metastasis less than 5%. The liver is the main site of their metastasis.

Glucagonoma

All of the following are true about glucagnoma except:

1- The tumore arises from the alpha cells of the pancreas.
2- The tumor most often arise from the tail of the pancrease.
3- Necrolytic migratory erythema rash is specific to glucagonoma.
4- Glucagon level > 1000pg/ml is diagnostic.
5- CT abdomen with contrast is intial study for localization.
6- Endoscopic US of pancreas will help both the localization and obtaining biopsy of the tumor.
7- It is among endocrine tumors that is uniquely associated with venous thromboembolism.

All are true except 3, this rash can occur in other conditions, however it is commonly the clue to this rare diagnosis. Weight loss and diabetes mellitus are common as well. Neuropsychiatric symptoms are common. The diagnosis is usally established late after the tumor have metastasized. The diagnosis is usually made after the skin rash occured and glucagon level is commonly quite elevated > 500 the normal is 100 level can be at high normal in few patients. CT is usually the test ordered to localize the tumor and potential metastasis which are commonly to the liver. Octreotoide scan will also show the tumor and metastasis however rarely needed since the CT will visualize the tumor in most cases. The second study is usually through endoscopic US that can identify tumors and as well allow needle biopsy of the tumors in the pancreas. In the early cases with no metastasis surgical removal of the tumor is done. In hepatic predominant disease from metastasis resection of hepatic metastasis or hepatic artery embolization may be effective in slowing the disease. Octretoide is quite effective in controlling the symptoms however regress of tumor is not clearly shown. Alpha interferon and chemotherapy are other options. Disease is monitored regularly with serum glucagon and CT. It is not uncoomon to have 5 year survival of 50% in metastatic slowly progressing disease.

Glucocorticoid-Remediable Aldosteronism

In Glucocorticoid-Remediable Aldosteronism (GRA) all are true except:

1- It is an autosomal dominant condition.
2- Patients commonly present before age of 21 years old with hypertension.
3- Family history may be obtained of GRA, brain aneurysms or intracranial hemorrhage.
4- It is due to increase production of ACTH-sensitive aldosterone in the zona fasciulata.
5- Aldosterone:renin ratio and hypokalemia are not as significant as in primary hyperaldosteronism.
6- It is primarily diagnosed with dexamthazone suppression test and the presence of elevated 18 hydroxycortisol and 18 oxocortisol.
7- It is well treatable with glucocorticoid or aldosterone receptor antagonist.

All are true except 6 the primary diagnosis now is with demonstration of the chimeric gene. It should be considered in patients with early hypertension, family history or early strokes <40>

Craniopharyngioma

All are true about Craniopharyngioma except:
1- Arises from remnants of Rhathke pouch.
2- A cystic calcified lesion in CT is very suggestive of the tumor.
3- Is malignant with metastasis in 20%.
4- Primary treatment is surgery.
5- Edema along optic tract is common finding in MRI.
6- Both anterior and posterior pituitary can be affected.


All are true except 3 it is a benign tumor but has high recurrence rate that it is dealt with as locally malignant tumor. Histologically it can be cystic epithelia, epithelial islands with degenerative cysts or epithelial humps like the enamel of developing teeth. It rarely metastasizes. Surgery is commonly incomplete and is followed by radiation. Attempt of total or subtotal excision using microsurgery decreases recurrence but has high operative mortality and morbidity rates. Cyst aspiration or intracystic radiation or chemotherapy may be used for recreant cysts. Patients commonly present in childhood with delay growth and in adult age with sexual dysfunction of amenorrhea in females and erectile dysfunction in males. hypothyroidism, adrenal insufficiency increase prolactin and central DI can also occur. Headaches and change in vision due to pressure in the optic chiasma can also occur.

Resolving the Coronary Artery Disease Epidemic through Plant-Based Nutrition

By: Caldwell B. Esselstyn, Jr., MD
From the Cleveland Clinic Foundation, Cleveland, Ohio

Taking the Offensive

Figure 4--Coronary angiograms of right coronary artery before (left) and showing 30% improvement (right) following approximately 60 months of a plant-based diet and cholesterol-lowering medication.As I have reported earlier,28,29 a plant-based diet in conjunction with cholesterol-reducing medication eliminated progression of coronary artery disease over a 12-year period in patients with triple-vessel disease. Most of the 18 patients had experienced an earlier failed intervention of bypass surgery or angioplasty. All patients who maintained the diet achieved the cholesterol goal of less than 150 mg/dL and had no recurrent coronary events during the 12 years. At 5 years, angiography was repeated in most cases. By analysis of the stenosis percentage none had progression of disease, and 70% had selective regression.28 These data are compelling when one considers that the same group had experienced more than 49 coronary events during the 8 years before this study.28

The recent case of a colleague is particularly telling. During September and October of 1996, a 44-year-old surgical colleague experienced occasional chest discomfort, yet neither electrocardiogram, stress echocardiography, or thallium scanning found evidence of disease. While eating the typical American diet, he had a total cholesterol of 156 mg/dL and an LDL of 97 mg/dL. He was lean, non-diabetic, and normotensive, did not smoke, and had no family history of coronary disease. His lipoprotein (a) and homocysteine levels were normal. On November 18, 1996, after his surgical duties, he became acutely ill with pain in the left arm, jaw, and chest. Immediate coronary catheterization found all vessels to be normal except for the left anterior descending artery, the distal third of which was diseased. Enzymes confirmed a myocardial infarction. However, no intervention was deemed appropriate.

This patient was aware of my ongoing study and was curious for more information. He and his wife consulted me for an in-depth review of the plant-based diet and techniques of this arrest and reversal study. He became the personification of commitment to the plant-based diet. Over the next 32 months, without cholesterol-lowering drugs, he maintained a mean total cholesterol of 89 mg/dL and an LDL of 38 mg/dL. The repeat angiogram 32 months after his infarction showed that the disease was completely reversed. (Fig.1)

Even though many people might find a plant-based diet initially difficult to follow, every patient with the diagnosis of coronary artery disease should at the least be offered the option of this potentially curative arrest and reversal approach. As this young surgeon's case illustrates, our plant-based diet approach can achieve total disease arrest and selective regression even in advanced cases. This approach is particularly compelling because patients can take control over the disease that was destroying them. If traditional interventional cardiology is a rear-guard action, our arrest and reversal therapy can be likened to a military offensive against atherosclerosis.

Limitations of this study are its modest number of participants and lack of comparable controls. Nevertheless, its size permitted the caregiver an opportunity for frequent patient encounters. These interactions enabled 75% of participants to achieve profound lipid reduction, dietary goals, and relief of symptoms which continued to improve throughout the study's 12-year duration. Patients essentially served as their own controls often achieving profound angiographic reversal of disease as reviewed in the angiographic core laboratory. Fig. 1-4

In addition, Dr. Dean Ornish has reported both 1- and 5-year data that support a plant-based approach to control coronary artery disease.16

Above is a portion copied from the author article.