The Role of Sex Hormones in Multiple Sclerosis.

Multiple sclerosis (MS) is a chronic inflammatory demyelination disorder with an immune-mediated pathophysiology that affects the central nervous system (CNS). Like other autoimmune conditions, it has a predilection for female gender. This suggests a gender bias and a possible hormonal association. Inflammation and demyelination are hallmarks of MS. Oligodendrocytes are the myelinating cells of the CNS and these continue to be generated by oligodendrocyte precursor cells (OPCs). The process of remyelination represents a major form of plasticity in the developing adult CNS. Remyelination does occur in MS, but the process is largely inadequate and/or incomplete. Current treatment strategies primarily focus on reducing inflammation or immunosuppression, but there is a need for more extensive research on re-myelination as a possible mechanism of treatment. Previous studies have shown that pregnancy leads to an increase in OPC proliferation, oligodendrocyte generation and the number of myelinated axons in the maternal CNS. Studies have also suggested that this remyelination is possibly mediated by estriol. Sex hormones in particular have been shown to have an immuno-protective effect in TH1-driven autoimmunity diseases. The aim of our article is to review the available research on sex hormone-specific immune modulatory effects, assess its remyelination potential in MS, and suggest a future path for more extensive research on sex hormone as a target for therapeutics in MS.

Vitamin D status and monitoring in female veterans.

An increasing number of women are serving in the military. We initiated a retrospective study to evaluate vitamin D status and monitoring in female veterans, and to examine the potential link between vitamin D status, age, race, post-traumatic stress disorder (PTSD), health care costs, and utilization. Approximately 44 percent of the 3,608 female veterans evaluated between 2001 and 2010 were vitamin D deficient (25(OH)D < 20 ng/ml), a rate substantially higher than that of the general population. While younger (<55 years) and older (55+ years) women did not differ significantly in initial vitamin D status, older women had significantly more vitamin D monitoring and follow-up testing than younger women. Approximately 44 percent of vitamin D deficient women did not receive follow-up vitamin D testing. Minority female veterans were most likely to be vitamin D deficient. Female veterans with PTSD did not differ from others regarding their initial vitamin D status; those that were initially deficient were significantly more likely to receive follow-up testing and were more likely to achieve a replete state. Vitamin D deficiency in female veterans was also associated with increased health-care costs. Appropriate monitoring and replacement of vitamin D should be offered to all female veterans.

Does melatonin have therapeutic use in tinnitus?

Melatonin, a hormone produced by the pineal gland, may be a promising treatment option for tinnitus. The primary functions of this hormone are believed to be the initiation and maintenance of sleep because its secretions coincide with circadian rhythms. Some investigators have noted that melatonin may alleviate subjective symptoms of tinnitus. Moreover, melatonin may have properties protective against ototoxic drugs such as amikacin, gentamicin, or cancer therapeutic agents that are dose dependent. In vitro, melatonin has demonstrated antioxidative properties and it has been postulated that these antioxidative properties contribute to the alleviation of tinnitus. Melatonin levels used to obtain these findings in vitro, however, are at supraphysiologic levels; therefore, it is more likely that the benefits from taking supplemental melatonin occur from minimal antioxidative properties, sleep enhancement, or other potential methods of action that are not yet understood. Melatonin offers minimal risk of toxicity with modest daily doses such as 1 to 3 mg, as well as a low cost and favorable adverse effect profile for older adults. In addition to potential benefits in the treatment of tinnitus, melatonin also may have beneficial neurogenerative properties. We recommend that melatonin be considered for use in patients with significant tinnitus.

Glucose monitoring as an impediment to Improving glycemic control: a case report.

Diabetes mellitus is increasing in frequency and is associated with disabling acute and chronic complications. There is evidence to indicate that excellent glucose control may retard the development and/or progression of these complications. In order to optimize diabetic control, patients are encouraged to monitor their glucose frequently We describe a patient who provided inaccurate glucose monitoring results, delaying effective management of his progressively increasing glycosylated hemoglobin level. The diagnostic clue to his erroneous glucose monitoring results was the lack of intra-day variation in this patient on insulin therapy. Moreover, glucose records within the patient's glucometer pointed to a much less frequent glucose monitoring than the written data provided by the patient. The glucometer was accurate when used by the patient under direct observation. It remains unclear whether this patient deliberately misled his providers or if the erroneous data reflected underlying cognitive dysfunction. Providers are encouraged to approximate average blood sugars based on glycosylated hemoglobin values and compare this to home monitoring results provided by the patient. Primary providers should also expect a certain degree of variability when reviewing home blood sugar values with their patients (on insulin therapy) and consider further investigation should the numbers lack such variation. Clinicians are urged to inspect the actual glucose readings on the patient's glucometer as well as inspecting written glucose records. Observing the patient's technique and accuracy when using their personal glucometer should also be considered.

Relationship of vitamin D monitoring and status to bladder cancer survival in veterans.

OBJECTIVES: Veterans of the armed forces, like most population groups, have a high prevalence of vitamin D deficiency, which may be associated with adverse outcomes in several types of cancer. Ultraviolet irradiation is inversely linked with the risk of bladder cancer, presumably through enhanced vitamin D synthesis. We hypothesized that variations in vitamin D status and monitoring predict adverse outcomes in bladder cancer among veterans. METHODS: A retrospective analysis of data in the Veterans Integrated Service Network-9 (southeastern United States) was performed for patients diagnosed between October 1, 1999 and February 29, 2008. Age, tobacco exposure, body mass index, and latitude and seasonality of sampling were included as variables in addition to serum vitamin 25(OH)D levels. RESULTS: Monitoring of vitamin D and vitamin D levels and status were closely linked to survival in bladder cancer. Both the chances of survival and longevity improved with enhanced vitamin D status and monitoring. Veterans with bladder cancer had better outcomes if the initial vitamin D level was higher and had more monitoring of the vitamin. Initial vitamin D levels were more strongly related to outcomes than follow-up levels. The link between vitamin D and outcomes remained after adjusting for background variables such as age, body mass index, latitude, seasonality, and tobacco exposure. CONCLUSIONS: Findings suggest that adequate vitamin D levels early in the course of the disease provide the best opportunity to improve outcomes. Ensuring that veterans with bladder cancer have adequate vitamin D reserves with appropriate monitoring may play a role in improving outcomes in bladder cancer.

Glucose monitoring as an impediment to improving glycemic control: a case report.

Diabetes mellitus is increasing in frequency and is associated with disabling acute and chronic complications. There is evidence to indicate that excellent glucose control may retard the development and/or progression of these complications. In order to optimize diabetic control, patients are encouraged to monitor their glucose frequently. We describe a patient who provided inaccurate glucose monitoring results, delaying effective management of hisprogressively increasing glycosylated hemoglobin level. The diagnostic due to his erroneous glucose monitoring results was the lack of intra-day variation in this patient on insulin therapy. Moreover, glucose records within the patient's glucometer pointed to a much less frequent glucose monitoring than the written data provided by the patient. The glucometer was accurate when used by the patient under direct observation. It remains unclear whether this patient deliberately misled his providers or if the erroneous data reflected underlying cognitive dysfunction. Providers are encouraged to approximate average blood sugars based on glycosylated hemoglobin values and compare this to home monitoring results provided by the patient. Primary providers should also expect a certain degree of variability when reviewing home blood sugar values with their patients (on insulin therapy) and consider further investigation should the numbers lack such variation. Clinicians are urged to inspect the actual glucose readings on the patient's glucometer as well as inspecting written glucoserecords. Observing the patient's technique and accuracy when using their personal glucometer should also be considered.

Secondary hyperparathyroidism: benign bystander or culpable contributor to adverse health outcomes?

Elevation in serum parathyroid hormone (PTH) often accompanies vitamin D deficiency and renal impairment. PTH elevation in renal failure is viewed as an unfavorable development. Evidence is increasing that PTH elevation may be associated with increased morbidity and mortality. In many instances these PTH effects appear to be independent of vitamin D status. PTH mediates its effects through the ubiquitous type 1 PTH/PTH-related peptide receptor, which is notably present in the cardiovascular system. Increased PTH may promote cardiovascular disease through diminished cardiac contractility, enhanced coronary risk, and cardiac valvular and vascular calcification. High PTH levels appear to be linked to the metabolic syndrome and are aligned with hyperlipidemia, decreased insulin sensitivity, and, perhaps, decreased insulin secretion. Increased PTH also is associated with neuroendocrine activation, increased sympathetic activity, and endothelial stress. The relation between PTH and vitamin D is complex and may show significant threshold variations, especially when calcium intake, age, and race are considered. Moreover, evidence is increasing that fragments of PTH may not only be hormonally active but also may have opposing effects to PTH. Despite these caveats, PTH values provide useful clinical diagnostic and prognostic information in monitoring many chronic ailments such as heart and renal failure and multiple sclerosis.