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Background Several inflammatory biomarkers, especially a high preoperative neutrophil-to-lymphocyte count ratio (NLR) and platelet-to-lymphocyte count ratio (PLR), are known to be indicator of poor prognosis in several cancers. However, very few studies have evaluated the significance of the NLR and PLR in papillary thyroid cancer (PTC). We evaluated the association of the preoperative NLR and PLR with clinicopathological characteristics in patients with PTC. Methods This study included 1,066 female patients who underwent total thyroidectomy for PTC. Patients were stratified into 4 quartiles by preoperative NLR and PLR. And the combination of preoperative NLR and PLR was calculated on the basis of data obtained value of tertile as follows: patients with both an elevated PLR and an elevated NLR were allocated a score of 2, and patients showing one or neither were allocated a score of 1 or 0, respectively. Results The preoperative NLR and PLR were significantly lower in patients aged ≥45 years and in patients with Hashimoto's thyroiditis. The PLR was significantly higher in patients with tumor size >1 cm (P=0.021).When the patients were categorized into the aforementioned four groups, the group with the higher preoperative PLR was found to have a significantly increased incidence of lateral lymph node metastasis (LNM) (P=0.018). However, there are no significant association between the combination of preoperative NLR and PLR and prognostic factors in PTC patients. Conclusion These results suggest that a preoperative high PLR were significant associated with lateral LNM in female patients with PTC.

Background We evaluated the disease profile and clinical management, including the status of both glycemic control and complications, in patients with diabetes who were transferred to referral hospitals in Korea. Methods Patients referred to 20 referral hospitals in Gyeongsangnam/Gyeongsangbuk-do and Jeollanam/Jeollabuk-do with at least a 1-year history of diabetes between January and June 2011 were retrospectively reviewed using medical records, laboratory tests, and questionnaires. Results A total of 654 patients were enrolled in the study. In total, 437 patients (67%) were transferred from clinics and 197 (30%) patients were transferred from hospitals. A total of 279 patients (43%) visited higher medical institutions without a written medical request. The main reason for the referral was glycemic control in 433 patients (66%). Seventy-three patients (11%) had received more than one session of diabetic education. Only 177 patients (27%) had been routinely self-monitoring blood glucose, and 146 patients (22%) were monitoring hemoglobin A1c. In addition, proper evaluations for diabetic complications were performed for 74 patients (11%). The most common complication was neuropathy (32%) followed by nephropathy (31%). In total, 538 patients (82%) had been taking oral hypoglycemic agents. A relatively large number of patients (44%) had been taking antihypertensive medications. Conclusion We investigated the clinical characteristics of diabetic patients and identified specific problems in diabetic management prior to the transfer. We also found several problems in the medical system, which were divided into three medical institutions having different roles in Korea. Our findings suggested that the relationships among medical institutions have to be improved, particularly for diabetes.

To the Editor, Parathyroid carcinoma is a rare disease that accounts for less than 1% of all hyperparathyroidism [1]. The incidence of parathyroid carcinoma is extremely low, although the apparent incidence of hyperparathyroidism increased after the introduction of multi-channel auto-analyzers. If increased serum calcium and parathyroid hormone (PTH) levels are sustained postoperatively, metastatic lesions should be suspected [2]. Here, we report a case in which high serum calcium and PTH levels were sustained after resection of a parathyroid carcinoma and a final diagnosis of concurrent parathyroid carcinoma and hyperplasia was made. A 74-year-old woman was referred to our hospital following loss of consciousness. She had a 4-year history of severe back pain and was diagnosed with spinal stenosis. Despite medical treatment, her back pain persisted. At presentation, she was stuporous and her blood pressure was undetectable. Mechanical ventilation was started and vasopressors administered. Laboratory results included a serum calcium of 17.7 mg/dL and PTH of 713.9 pg/mL. Computed tomography (CT) revealed a left thyroid mass. Ultrasonography revealed a left parathyroid mass (Fig. 1A). A sesta technetium-99m methoxyisobutylisonitrile (99mTc-sestamibi) scintigram revealed no abnormal uptake (Fig. 2). The patient regained consciousness after intravenous hydration and calcitonin treatment. One month later, she underwent a left parathyroidectomy and hemithyroidectomy. Parathyroid carcinoma with capsular invasion was confirmed histologically (Fig. 3). Given her unstable vital signs intraoperatively, the surgeon could not explore the right thyroid gland accurately. Figure 1 Thyroid ultrasonographic-findings. (A) A 2.8 × 1.5-cm, polymorphic, ill-defined, inhomogenous, and hypoechoic mass is noted in the lower portion of the left lobe of the thyroid gland. (B) A 1.1 × 0.6-cm, oval, well-defined, inhomogenous, ... Figure 2 Technetium (99mTc)-sestamibi scan. (A) A 15-minute scan after 99mTc-sestamibi injection shows normal thyroid uptake. (B) A 2-hour scan after 99mTc-sestamibi injection shows no parathyroid uptake. Figure 3 Light microscopic findings. (A) Capsular invasion with extension into the adjacent soft tissue (H&E, × 40). (B) Trabecular growth, clear cytoplasm, an atypical nucleus with atypical mitosis are seen (H&E, × 400). (C) Monotonous ... The elevated serum calcium and PTH levels decreased after resecting the left parathyroid carcinoma, but were still elevated compared to normal. To detect remnants or metastatic lesions, f luorodeoxyglucose positron emission tomography was performed, but no abnormalities were found. Ultrasonography detected a mildly enlarged parathyroid gland on the right inferior side, which had previously been very small (Fig. 1B). She underwent surgical exploration of the right parathyroid glands 1 month later. The right superior parathyroid gland was of normal size and histology and was preserved. In contrast, the right inferior parathyroid gland was mildly enlarged with grossly normal morphology, but hyperplasia was confirmed histologically (Fig. 3C). Ultimately, three parathyroid glands were removed and the serum calcium and PTH levels dropped to 8.1 mg/dL and 14.8 pg/mL, respectively. The etiology of parathyroid carcinoma is still unknown. There have been several reports on concurrent disease in the other parathyroid glands, such as carcinoma, adenoma, or hyperplasia [3]. These reports suggest that parathyroid adenoma and hyperplasia may change into carcinoma. However, the findings are controversial due to the low incidence [4]. Primary hyperparathyroidism usually involves slightly elevated hypercalcemia (to 1 mg/dL), while parathyroid carcinoma produces much higher serum calcium levels (> 14 mg/dL) [1]. The laboratory findings suggested that our patient had a parathyroid carcinoma. The skeletal system involvement is greater in parathyroid carcinoma, and includes hyperparathyroid bone disease. In contrast, the skeletal system is involved in 5% of patients with benign hyperparathyroidism [2]. Although our patient was diagnosed with spinal stenosis before her presentation, it is possible that her back pain was induced by parathyroid carcinoma. On physical examination, a mass in the parathyroid area of the neck is an important sign for distinguishing between adenoma and carcinoma of the parathyroid gland, because it occurs in 30% to 76% of all parathyroid carcinomas. Although the laboratory results and clinical symptoms and signs can help distinguish between benign and malignant tumors, a definitive diagnosis is difficult preoperatively. Histological differences are useful for the differential diagnosis, such as the criteria for malignancy proposed by Schantz and Castleman [4]: 1) the presence of a trabecular growth pattern, mitotic figures, and capsular or vascular invasion; and 2) the presence of nodal or distant metastasis. Recently, loss of parafibromin immunostaining helped with the differential diagnosis of parathyroid carcinomas from adenomas in Asians and may serve as a prognostic marker in patients with parathyroid carcinomas [5]. In our case, the left parathyroid mass exhibited capsular invasion with extension into the adjacent soft tissue and trabeculum, clear cytoplasm, and atypical nuclei with atypical mitoses, suggesting carcinoma. In contrast, the right inferior parathyroid gland exhibited monotonous cell proliferation without atypical nuclei and capsulation, suggesting hyperplasia. The most effective treatment of parathyroid carcinoma is complete removal of the primary lesion during surgery [1,5]. If patients with benign adenomas or hyperplasia are suspected of having concurrent parathyroid carcinoma, the surgeon should explore all four parathyroid glands. If the frozen pathology suggests cancer or the quick intact PTH levels do not decrease significantly after mass removal, all lesions on the same side of the thyroid lobe and any suspicious tissues around the lesions should be removed. In our patient, all lesions on the left side were removed, but the right side was explored later because CT, ultrasonography, and 99mTc-sestamibi scintigraphy revealed that the right parathyroid gland was normal and the surgeon could not continue the operation as the patient's vital signs deteriorated. Serum calcium and PTH levels are useful for postoperative follow-up because normal levels indicate successful surgery. If patients have elevated serum calcium and PTH levels, additional action should be taken to localize remnant or metastatic lesions. 99mTc-sestamibi scintigraphy may be useful for localizing parathyroid tumors, including benign and malignant lesions, although no abnormal uptake was detected with both the parathyroid carcinoma and hyperplasia in our patient. Parathyroid carcinoma is rare and its concurrence with different pathologies in the other parathyroid glands is extremely rare. Because the elevated postoperative serum calcium and PTH levels suggested remnant or metastatic lesions, additional action was taken. In our patient, the elevated serum levels returned to normal after surgical removal of another parathyroid gland. Parathyroid hyperplasia was confirmed histologically. In this case, we were unable to evaluate the other parathyroid glands during the first operation; nevertheless, no abnormal findings appeared during either the first-look operation or during subsequent imaging studies, including CT, 99mTc-sestamibi scintigraphy, and ultrasonography. We believe that the postoperative serum calcium and PTH levels are very useful for detecting not only remnant or metastatic parathyroid lesions, but also concurrent parathyroid hyperplasia or adenoma.

Thyrotoxic periodic paralysis (TPP) is a rare manifestation of hyperthyroidism characterized by muscle weakness and hypokalemia. All ethnicities can be affected, but TPP typically presents in men of Asian descent. The most common cause of TPP in thyrotoxicosis is Graves' disease. However, TPP can occur with any form of thyrotoxicosis. Up to our knowledge, very few cases ever reported the relationship between TPP and painless thyroiditis. We herein report a 25-yr-old Korean man who suffered from flaccid paralysis of the lower extremities and numbness of hands. The patient was subsequently diagnosed as having TPP associated with transient thyrotoxicosis due to painless thyroiditis. The paralytic attack did not recur after improving the thyroid function. Therefore, it is necessary that early diagnosis of TPP due to transient thyrotoxicosis is made to administer definite treatment and prevent recurrent paralysis.

BackgroundA previous study on the genetic association between single nucleotide polymorphisms in FGFR1OP2/wit3.0 and the long term atrophy of edentulous mandible hypothesized that the excessive jawbone atrophy after dental extraction may be associated with abnormal oral mucosa contraction induced by the FGFR1OP2/wit 3.0 gene. It was reported that the minor allele of rs840869 or rs859024 in FGFR1OP2/wit3.0 was associated with the excessive atrophy of edentulous mandible. The present study represents an attempt to replicate the results of this previous study and to examine the genetic association between polymorphisms in FGFR1OP2 and residual ridge resorption of mandible in a Korean population.Methodology/principal findings134 subjects (70.46 ± 9.02 years) with partially or completely edentulous mandible were recruited. The mandibular bone height was measured following the protocol of the American College of Prosthodontists (ACP). From 24 subjects, seven variants in FGFR1OP2 were discovered and four of them were novel. Selected SNPs that are not in high LD at r2 threshold of 0.8 were genotyped for the remaining population. There was no frequency of the minor allele of SNP rs859024 in Korean population. SNP rs840869 was not associated with residual ridge resorption (p = 0.479). The bone height of the subject with the ss518063493 minor allele (8.52 mm) was shorter than that of those subjects with major alleles (18.96 ± 5.33 mm, p = 0.053).Conclusions/significanceThe patient with minor allele of ss518063493 may be associated with excessive atrophy of edentulous mandible whereas the patients with that of rs840869 are not associated in Korean population. The result from this study may assist in developing a novel genetic diagnostic test and be useful in identifying Koreans susceptible to developing excessive jawbone atrophy after dental extraction.