Endocrinology and Metabolism Institute

Cleveland, OH, United States

Endocrinology and Metabolism Institute

Cleveland, OH, United States
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Vest A.R.,Tufts Medical Center | Patel P.,Centennial Hospital | Schauer P.R.,Bariatric and Metabolic Institute | Satava M.E.,Quality and Patient Safety Institute | And 4 more authors.
Circulation: Heart Failure | Year: 2016

Background-Obesity is a risk factor for development of left ventricular systolic dysfunction (LVSD) and can complicate LVSD management, especially for individuals in whom cardiac transplantation is indicated. Bariatric surgery is increasingly recognized as a safe and effective intervention to achieve marked weight loss, but experience is limited in the LVSD population. Methods and Results-We retrospectively reviewed patients with obesity and left ventricular ejection fraction (LVEF) <50% who underwent bariatric surgery at a tertiary center 2004 to 2013. An analysis of outcomes and efficacy compared 42 surgical patients with LVSD to 2588 without known LVSD. The LVSD group had greater baseline prevalence of comorbidities and showed a slight excess of early postoperative heart failure and myocardial infarction. However, patients with LVSD achieved good weight loss efficacy (mean decrease 22.6%) and no excess in mortality at 1 year. An overlapping cohort of 38 patients with LVSD had both pre-and postoperative echocardiographic images available for review by 2 blinded readers. Obese nonsurgical controls were matched on age, sex, initial LVEF, and interval between echocardiograms. There was a mean pre-to postoperative LVEF improvement of +5.1% ±8.3 (P=0.0005) for surgical subjects, but not for controls (+3.4%±10.5, P=0.056). Among surgical subjects, 11 patients had an LVEF improvement of >10%, whereas only 6 improved by >10% among nonsurgical controls. Conclusions-At experienced centers, bariatric surgery may be a safe and effective intervention for obese patients with LVSD. Bariatric surgery was associated with an improvement in LVEF, although the magnitude of change was on the cusp of clinical significance. © 2016 American Heart Association, Inc.

Makin V.,Endocrinology and Metabolism Institute | Hatipoglu B.,Endocrinology and Metabolism Institute | Hamrahian A.H.,Endocrinology and Metabolism Institute | Knott P.D.,Head and Neck Institute | And 2 more authors.
American Journal of Otolaryngology - Head and Neck Medicine and Surgery | Year: 2011

Patients with acromegaly usually present with characteristic clinical features or comorbidities associated with excess insulinlike growth factor 1 (IGF-1)/growth hormone (GH) or may come to medical attention secondary to mass effects causing visual field distortions. Herein, we report a case of spontaneous cerebrospinal fluid (CSF) rhinorrhea as the presenting symptom of acromegaly. A 68-year-old man presented to an outside facility with a 2-day history of headache associated with nausea, vomiting, dizziness, and clear nasal discharge and underwent 2 attempted repairs of a sphenoid sinus CSF leak. Examination on admission to our hospital was significant for fluctuating level of consciousness. Subsequently, subtle coarse facial features were appreciated. Pituitary function testing showed thyrotropin and gonadotropin deficiencies along with an elevated age- and sex-matched IGF-1 of 285 (normal level, 59-225 ng/mL). Nadir GH during oral glucose tolerance test was 5.5 ng/mL and confirmed the diagnosis of acromegaly. Magnetic resonance imaging showed pneumocephalus, an enlarged sella with an elongated pituitary stalk, and partial erosion of the anterior wall of the sphenoid sinus. A distinct adenoma could not be identified. An endoscopic, transnasal, transsphenoidal exploration and biopsy with multilayered skull base reconstruction were performed. Histologic examination of the biopsy contents was consistent with a GH-producing adenoma. Postoperatively, the patient's fluctuating level of consciousness improved and returned to baseline after his successful skull base repair. During the follow-up period, he had an IGF-1 of 713 ng/mL and started treatment with a somatostatin analogue. To our knowledge, this is the first reported case of a GH-producing pituitary adenoma presenting with spontaneous CSF rhinorrhea. Pituitary adenomas should be considered in the differential diagnosis of patients presenting with spontaneous CSF rhinorrhea with abnormal sellar image, and these patients should undergo a thorough hormonal evaluation. © 2011 Elsevier B.V.

Mon S.Y.,Medicine Institute | Alkabbani A.,Endocrinology and Metabolism Institute | Hamrahian A.,Endocrinology and Metabolism Institute | Thorton J.N.,Cleveland Clinic | And 6 more authors.
Pituitary | Year: 2013

Prolactin has been proposed as a potent coactivator of platelet aggregation, possibly contributing to thromboembolic events. The objective of the study was to evaluate the relationship between prolactinoma and deep vein thrombosis (DVT), pulmonary embolism (PE), and cerebrovascular accident (CVA). Subjects were identified from a prospectively maintained pituitary database at the Cleveland Clinic. We retrospectively reviewed the charts of 544 subjects: 347 patients with prolactinomas (prolactinoma group) and 197 patients with nonfunctional pituitary adenomas (control group). Main outcome measures were DVT, PE and CVA. We found that 19 (5.5 %) patients in the prolactinoma group and five (2.5 %) patients in the control group had documented DVT, PE, or CVA, but this difference was not significant (p = 0.109). However, the mean initial prolactin level was higher at the time of diagnosis among prolactinoma patients than among controls (815.23 ng/ml vs. 15.90 ng/ml; p < 0.001). Among prolactinoma patients, 15 (5.5 %) of 275 patients who underwent medical treatment (with cabergoline, bromocriptine, pergolide and/or other drug) and 4 (5.6 %) of 72 patients who underwent transsphenoidal surgery had documented DVT, PE, or CVA, which suggests that dopaminergic therapy did not influence the risk of thromboembolic events. Hyperprolactinemia per se does not appear to predispose to a hypercoagulable state. © 2012 Springer Science+Business Media New York.

Karabulut K.,Endocrinology and Metabolism Institute | Aucejo F.,Cleveland Clinic | Akyildiz H.Y.,Endocrinology and Metabolism Institute | Siperstein A.,Endocrinology and Metabolism Institute | Berber E.,Endocrinology and Metabolism Institute
Surgical Endoscopy and Other Interventional Techniques | Year: 2012

Background We have been utilizing both resection and laparoscopic radiofrequency ablation (RFA) to treat hepatocellular carcinoma (HCC). The aim of this study is to describe patient characteristics and outcome for each treatment modality from a single institution. Methods Medical records of HCC patients who underwent resection (n = 92) or laparoscopic (RFA) (n = 92) between 1997 and 2010 were reviewed. Univariate Kaplan- Meier and multivariate Cox proportional-hazards model were used to analyze survival. Results Patients with normal liver function and larger tumors were resected, and those with liver dysfunction, portal hypertension, and multiple tumors were ablated. Tumor size was larger in the Resection group, whereas number of tumors was higher in the RFA group. Child class and Barcelona Clinic Liver Cancer (BCLC) staging were more advanced in the RFA group. Hospital stay was longer, and morbidity and mortality higher in the Resection versus the RFA group. There was no difference in diseasefree survival, but the 5-year actual survival was significantly higher (40% versus 21%) in the Resection group. On univariate analysis, number of tumors, tumor size, platelet count, BCLC stage, Child class, and type of surgery were predictors of overall survival. On multivariate analysis, Child class and number of tumors were independent predictors of overall survival. Conclusions To our knowledge, this is the largest North American series reporting on RFA and resection for HCC from a single institution. Herein, we describe the perioperative and oncologic outcomes to be expected when these modalities are used in a certain treatment algorithm. © Springer Science+Business Media, LLC 2011.

Flechner S.M.,Glickman Urological and Kidney Institute | Berber E.,Endocrinology and Metabolism Institute | Askar M.,Cleveland Clinic | Stephany B.,Glickman Urological and Kidney Institute | And 2 more authors.
American Journal of Transplantation | Year: 2010

We report the successful allotransplantation of cryopreserved parathyroid tissue to reverse hypocalcemia in a kidney transplant recipient. A 36-year-old male received a second deceased donor kidney transplant, and 6 weeks later developed severe bilateral leg numbness and weakness, inability to walk, acute pain in the left knee and wrist tetany. His total calcium was 2.6 mg/dL and parathormone level 5 pg/mL (normal 10-60 pg/mL). He underwent allotransplantation of parathyroid tissue cryopreserved for 8 months into his left brachioradialis muscle. Immunosuppression included tacrolimus (target C0 10-12 ng/mL), mycophenolate mofetil and steroids. Within 2 weeks, the left knee pain, leg weakness and numbness resolved, and by 1 month he could walk normally. After a peak at month 2, his parathyroid hormone (PTH) level fell to <10 pg/mL; therefore at month 3 he received a second parathyroid transplant from the same donor. Eight months later (11 months after initial graft) he has a total calcium of 9.3 mg/dL, PTH level 15 pg/mL and is clinically asymptomatic. The amount of parathyroid tissue needed to render a patient normocalcemic is not known. In our case, the need for second transplant suggests that the amount of tissue transferred for an allograft may need to be substantially greater than for an autograft. © 2010 The American Society of Transplantation and the American Society of Transplant Surgeons.

Jarrar A.M.,Digestive Disease Institute | Jarrar A.M.,Md Center For Hereditary Colorectal Neoplasia | Milas M.,Endocrinology and Metabolism Institute | Mitchell J.,Endocrinology and Metabolism Institute | And 8 more authors.
Annals of Surgery | Year: 2011

Objective: Clarify the incidence of thyroid cancer in patients with Familial adenomatous polyposis (FAP) in a prospective study of thyroid neck US screening. Background: FAP is a hereditary disease predisposing to cancer in multiple organs, including the thyroid. However, routine thyroid screening for FAP patients is not generally practiced in the United States. Here, we report the initial results of a prospective thyroid cancer screening program in patients with FAP. Methods: At the time of yearly gastrointestinal follow-up, every FAP patient in our registry was offered thyroid ultrasound (US) performed by experienced endocrine surgeons. Clinical findings related to thyroid disease were analyzed for those patients who completed screening from August 2008 to December 2009. Results:: Of 192 screened FAP patients, 72 (38%) had thyroid nodules and 5 (2.6%) had thyroid cancer. Three of 5 patients with FAP and thyroid cancer were women. Four of 5 patients had the multifocal papillary type with mean size 15 mm. Clinical history and neck exam did not detect any of the 5 cancers. Conclusion:: The incidence of thyroid cancer among FAP patients is high. Medical history and exam are inadequate to identify patients with thyroid cancer, thus thyroid screening with US is warranted. Copyright © 2011 by Lippincott Williams & Wilkins.

Shiber-Ofer S.,Rabin Medical Center | Shiber-Ofer S.,Tel Aviv University | Shohat Z.,Tel Aviv University | Shohat Z.,Bio statistical Institute | And 2 more authors.
Journal of Clinical Hypertension | Year: 2015

Elevated blood pressure (BP) is reported in many individuals without hypertension presenting to the emergency department (ED). Whether this condition represents a transient state or is predictive for the development of future hypertension is unknown. This observational prospective study investigated patients admitted to an ED without a diagnosis of hypertension in whom BP values were ≥140/90 mm Hg. The primary outcome was development of hypertension during follow-up. Overall, 195 patients were recruited and at the end of follow-up (average 30.14±15.96 months), 142 patients were diagnosed with hypertension (73%). The mean age (50±12.25 vs 48.31±13.9, P=419) and sex distribution (78 men/64 women vs 24 men/20 women, respectively; P=148) were similar in both groups. There were significant differences in systolic and diastolic BP between those who developed hypertension on follow-up and those who did not (177.6 mm Hg±22.6/106.1 mm Hg±16.9 vs 168.6 mm Hg±18/95.2 mm Hg±12.2; P=011 for systolic BP, P<001 for diastolic BP). In multivariate analysis the only significant predictive factor for the development of hypertension was diastolic hypertension recorded in the ED (P=03). Elevated diastolic, but not systolic, BP among patients presenting to the ED is associated with future development of hypertension in previously normotensive individuals. © 2015 Wiley Periodicals, Inc.

Robenshtok E.,Sloan Kettering Cancer Center | Robenshtok E.,Endocrinology and Metabolism Institute | Robenshtok E.,Tel Aviv University | Grewal R.K.,Sloan Kettering Cancer Center | And 3 more authors.
Thyroid | Year: 2013

Background: Postsurgical thyrotropin (TSH)-stimulated serum thyroglobulin (Tg) level can be used to predict the likelihood of finding radioactive iodine (RAI) avid metastatic foci on postablation scanning. However, there is little data regarding the predictive value of a nonstimulated postoperative Tg obtained on levothyroxine therapy in patients being considered for recombinant human TSH (rhTSH)-Assisted remnant ablation. Methods: The study included 290 intermediate-risk differentiated thyroid cancer (DTC) patients with a postsurgical nonstimulated Tg<10 ng/mL prior to rhTSH-Assisted remnant ablation. Patients were stratified into four groups based on the postsurgical nonstimulated Tg value: Tg<0.6 ng/mL (n=146), Tg 0.6-0.9 ng/mL (n=76), Tg 1-5 ng/mL (n=51), and Tg>5-10 ng/mL (n=17). RAI avid metastatic foci were identified using post-therapy scanning with SPECT/CT (single photon emission computed tomography). Results: RAI avid metastases were identified in 16% (46/290) of patients, including 12% (17/146) with Tg<0.6 ng/mL, 14% (11/76) with Tg 0.6-0.9 ng/mL, 25% (13/51) with Tg 1-5 ng/mL, and 29% (5/17) with Tg>5-10 ng/mL (p=0.02). While 99% of the RAI avid foci were located in the neck, lung uptake was seen in one patient with Tg<0.6 ng/mL (0.7%, 1/146), one patient with Tg 0.6-0.9 ng/mL (1.3%, 1/76), and 2 patients with Tg>5-10 ng/mL (11%, 2/17 patients). Conclusions: A postoperative nonstimulated Tg<0.6 ng/mL does not exclude identification of RAI avid metastatic foci on postablation SPECT/CT scanning in intermediate-risk DTC patients. Therefore, patient selection for RAI ablation in the intermediate-risk group must be based on an integration of multiple risk factors rather than any single clinicopathologic risk factor. © Copyright 2013, Mary Ann Liebert, Inc. 2013.

Berber E.,Endocrinology and Metabolism Institute | Heiden K.,Endocrinology and Metabolism Institute | Akyildiz H.,Endocrinology and Metabolism Institute | Milas M.,Endocrinology and Metabolism Institute | And 2 more authors.
Surgical Laparoscopy, Endoscopy and Percutaneous Techniques | Year: 2010

Various techniques for minimally invasive thyroid surgery have been described over the last decade. These techniques have significant limitations owing to 2-dimensional view and awkward endoscopic instrumentation. Robotic surgical technology was developed to overcome these limitations. In this case report, we are describing our first 2 thyroid procedures using this technology: a total thyroidectomy in a 66-year old, and a thyroid lobectomy in a 43-year old. We found that robotic resection avoids a neck scar and offers quality 3-dimensional vision with dexterity similar to the human hand. Copyright © 2010 by Lippincott Williams & Wilkins.

Taskin H.E.,Endocrinology and Metabolism Institute | Arslan N.C.,Endocrinology and Metabolism Institute | Aliyev S.,Endocrinology and Metabolism Institute | Berber E.,Endocrinology and Metabolism Institute
World Journal of Surgery | Year: 2013

Over the last decade, developments in technology have led a rapid progress in robotic endocrine surgery applications. Robotics is attractive to the surgeon because of the three-dimensional image quality, articulating instruments, and stable surgical platform. Safety and effectiveness of robotic adrenalectomy and thyroidectomy have been shown in many studies. While these robotic procedures offer better ergonomics for the surgeon, they provide similar outcomes compared to the laparoscopic approach for adrenalectomy and better cosmetic results versus the conventional option for thyroidectomy. Recently, while the robotic approach for adrenalectomy has been popularized, enthusiasm for robotic thyroidectomy has decreased. In the present review we aim to describe emerging robotic procedures and review the literature regarding outcomes. © 2013 Société Internationale de Chirurgie.

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