The efficacy of metformin compared with insulin in regulating blood glucose levels during gestational diabetes mellitus: A randomized clinical trial.

BACKGROUND: Insulin has been a conventional medication in the treatment of female patients suffering from gestational diabetes mellitus (GDM). However, the need for a large number of insulin injections in these patients causes them a lot of discomforts. Recently, an alternative medication, metformin, has received considerable attention in the treatment of GDM. The aim of this study was to compare the efficacy of metformin and insulin in regulating blood glucose levels and fetal outcomes in GDM. METHODS: This randomized clinical trial included 286 pregnant women diagnosed with positive GDM at 24-28 weeks of pregnancy. The subjects were randomly divided into two groups of 143 patients, with one group receiving insulin and the other undergoing a treatment plan using metformin. Fasting plasma glucose (FPG), 2-hr plasma glucose (PG) and glycated hemoglobin (HbA1c) were recorded twice a month until delivery. Other variables, including birth delivery method, cause of cesarean section, gestational age at the delivery time, birth trauma, Apgar score, birth weight, admission at neonatal intensive care unit (NICU), and neonatal hypoglycemia were also registered. RESULTS: Age of mother, body mass index, history of diabetes in the family, previous history of GDM, parity, FPG, 1- and 2-hr PG after meals, and 75-g glucose tolerance test before treatment were not statistically different between the two groups. FPG, PG, and HbA1c did not show significant differences between the two groups after completing the course of treatment. There was also no significant difference between two groups regarding the birth delivery method, the cause of cesarean section, birth trauma, Apgar score, birth weight, admission at NICU, and neonatal hypoglycemia. CONCLUSION: As mean FPG and 2-hr PG were not significantly different between the two groups, it seems that metformin can be recommended as an effective substitute for insulin in the treatment of GDM. However, there are still some undesirable risk factors with both treatments that may threaten the mother and the newborn.

Gastric bypass surgery in morbid obesity: Influence on thyroid function tests and insulin resistance status.

Background: There are inconsistent results about the effect of gastric bypass surgery on thyroid function tests in morbidly obese subjects. The aim of this study was to investigate the changes in thyroid function tests and insulin resistance status in euthyroid morbidly obese subjects before and three months after gastric bypass surgery (GBS). Methods: Twenty-nine subjects with morbid obesity (BMI≥40) were enrolled in this before-after study. Patients with known thyroid disorders or a history of thyroid ablative therapy, users of drugs that affect thyroid function, or fasting blood sugar and insulin were excluded. TSH, Free T4, total T3, fasting blood sugar and insulin level, and BMI were measured before and 3 months after GBS. Statistical analysis was performed with appropriate tests and p<0.05 was considered significant. Results: Body mass index (BMI), insulin sensitivity index (HOMA-IR), and total T3 significantly decreased after bypass surgery (all with p<0.001) but no significant changes were seen in TSH (P=0.203) and FreeT4 (P=0.33). There was a significant negative correlation between changes in HOMA-IR and changes in FreeT4 (P=0.038, r= -0.38). There was no statistically significant correlation between the percentage of excess BMI loss (%EBMIL) and changes in T3 (P=0.66), Free T4 (P=0.92), TSH (P= 0.27), and HOMA-IR (P=0.17). Conclusion: Although significant changes can occur in BMI, insulin sensitivity index, fasting blood sugar, and T3 in short-time follow-up after bariatric surgery, significant TSH and FreeT4 changes may need longer follow-ups.

Preoperative Vitamin.D Status and Post-Total Thyroidectomy Hypocalcemia.

Introduction: Hypocalcemia is a common complication of total thyroidectomy (TT). This study was designed to investigate the effect of preoperative vitamin.D (Vit.D) status on the occurrence of post-total thyroidectomy hypocalcemia. Materials and Methods: Patients who underwent TT without parathyroidectomy were divided into three groups based on their preoperative Serum Vit.D levels (<20 ng/ml, 20-30 ng/ml, and ≥30 ng/ml were considered deficient, insufficient, and normal Vit.D levels, respectively). Serum levels of calcium and phosphorus were measured before and 24 hours after surgery in all patients. The patients were examined for clinical symptoms and signs of hypocalcemia postoperatively. In cases with positive clinical symptoms and signs of hypocalcemia and/or calcium levels <8 mg/dl, PTH level was measured before starting calcium infusion, while serum calcium and phosphorus levels were also measured 24 hours later. Results: Among 100 patients enrolled in this study, 81% were females. The mean age was 36.60±8.32 years. Before surgery, the mean Vit.D level was 26.9±16.89 ng/ml, while 47% of cases had normal Vit.D level, 32% had insufficient vitamin levels, and 21% had Vit.D deficiency. Twenty-four hours after surgery, the calcium (P=0.356) and phosphorus (P=0.743) levels were not significantly different between the three Vit.D groups. A comparison of postoperative PTH levels between the three Vit.D groups showed no significant difference (P=0.596). Conclusions: Based on our findings, preoperative serum Vit.D levels did not affect postoperative serum calcium levels.

Association of Metabolic Syndrome and Hyperuricemia in the Recipients of Kidney Transplants: A Single-Center Study.

INTRODUCTION: The prevalence of hyperuricemia shows an increasing trend among kidney transplant recipients. The association between metabolic syndrome and hyperuricemia among the recipients of kidney transplants may consequently lead to reduction in graft survival. In this regard, the present study aimed at comparing the kidney transplant recipients with and without metabolic syndrome in terms of the prevalence of hyperuricemia. METHODS: This cross-sectional study was carried out on kidney transplant recipients who were referred to the Kidney Transplant Clinic of Montaserieh Organ Transplant Hospital, Mashhad University of Medical Sciences, from 2019 to 2020. The serum uric acid, anthropometric data, renal function, glucose levels, and lipid profile of the study participants were evaluated. RESULTS: According to our findings, higher mean uric acid levels were reported in recipients with metabolic syndrome (6.9 ± 1.51 mg/dL), compared to recipients without metabolic syndrome (6.11 ± 1.47 mg/dL; P < .001). It was also found that 55.6 and 38.5% of the cases with and without metabolic syndrome had hyperuricemia, respectively (P < .05). Additionally, the results showed no significant association between hyperuricemia and the number of metabolic syndrome criteria (P > .05). A comparison between recipients with and without hyperuricemia revealed significantly lower levels of tacrolimus in the hyperuricemia group (P < .05). Regarding serum Tacrolimus levels, no significant difference was found between recipients with and without metabolic syndrome (P > .05). Moreover, there was no significant difference between recipients with and without hyperuricemia (P > .05) or metabolic syndrome (P > .05) in terms of serum cyclosporine level. CONCLUSION: The findings of the current study indicate that kidney transplant recipients suffering from metabolic syndrome have higher mean serum levels of uric acid than those without metabolic syndrome.  DOI: 10.52547/ijkd.7141.

Accuracy of fine-needle aspiration cytopathology to differentiate malignant and benign thyroid nodules with ≥4 cm diameter: A retrospective study.

BACKGROUND: Thyroid nodules (TN) are commonly present in the general population and are usually pathologically benign. An initial diagnosis with fine-needle aspiration (FNA) cytopathology could help clinical decision-making with fewer complications. As the previous studies suggest surgical procedures for >4 cm TNs, we aimed to investigate the accuracy of preoperative FNA cytology to predict malignancy risk in these nodules in a sample of the Iranian population. METHODS: Patients with ≥4 cm TNs who had preoperative FNA cytology, underwent nodulectomy and had a histopathological report were included. Each patient's preoperative demographic, ultrasonographic, and cytology data were gathered. After surgery, resected samples were assessed pathologically and diagnosed as benign or malignant. Finally, data were analyzed to evaluate the presurgical accuracy of the FNA cytology. RESULTS: We identified 41 (51.25%) patients with malignant legions among our study population (N = 80). The pathology reports were indeterminate in 3 patients with follicular neoplasm. Bethesda scores were substantially higher in patients with malignancy. The sensitivity, specificity, and false-negative rate of FNA cytology reports using the Bethesda system were 73.7%, 74.2%, and 26.3%, respectively. There was no association between malignancy and TNs' size, neither their volume nor their highest diameter. CONCLUSION: FNA cytology is not as sensitive and specific in nodules>4 cm as in smaller ones. However, it can still be used alongside other diagnostic procedures in malignancy screening. Clinicians should make more complex decisions considering various influential factors to avoid missing malignant lesions and reduce diverse probable complications of highly invasive diagnostic surgery. Further prospective research on >4 cm TNs and their multiple features' association with malignancy is required for more precise judgment.

The Prognostic Role of Corticosteroid Administration in Hospitalized Patients with Severe COVID-19: A Cross-sectional Study.

BACKGROUND AND OBJECTIVE: The COVID-19 pandemic is a recent global issue with no established consensus on treatments. Therefore, the aim of this study was to assess the impact of corticosteroid (CS) pulses on the prognosis of COVID-19 patients admitted to hospitals. METHODS: In this retrospective single-center cross-sectional study, we used hospital records of all consecutive patients aged 18 years or older admitted to the hospital from July 23rd to September 23rd, 2021. All patients included in the study had confirmed SARS-CoV-2 infection using polymerase chain reaction (PCR) testing and required hospitalization. Demographic and clinical information, as well as patient outcomes, were collected. Treatment details, including the type(s), cumulative doses, and duration of administered corticosteroids, were also recorded. CS pulse therapy was defined as the daily administration of 24 mg or more of dexamethasone or its equivalents. RESULTS: A total of 500 patients with COVID-19 were included in this study, comprising 122 patients who received CS pulse therapy and 378 patients who did not. A higher mortality rate was observed in patients receiving CS pulse therapy (42.6%) compared to the other group (28%) (p =0.04). Additionally, logistic regression analysis showed an increased mortality risk in patients receiving CS pulse therapy in the crude model (OR=1.54, 95% CI: 1.01-2.27, p <0.01). However, after adjusting for confounding factors, such as mechanical ventilation and ICU admission, the results were reversed (OR=0.21, 95% CI: 0.07-0.62, p <0.01). ; Conclusion: In the findings of the current study, treatment with CS pulses was shown to significantly enhance recovery in patients with non-severe COVID-19.

Xanthogranulomatous hypophysitis: A rare presentation in a young female patient.

Hypophysitis is a rare inflammatory condition that may present both clinically and radiologically as a neoplastic lesion. Xanthogranulomas are rare intracranial lesions with controversial etiology. Here, we report a clinical case of histologically confirmed xanthogranulomatosis hypophysitis in a young female with type I diabetes mellitus and hypothyroidism.

The Effect of Levothyroxine in Comparison with Placebo on Serum Osteocalcin Levels in Patients with Subclinical Hypothyroidism.

BACKGROUND AND OBJECTIVE: Subclinical hypothyroidism can potentially develop into overt hypothyroidism. Thyroid hormones have substantial roles in metabolism and glucose homeostasis and thus, are closely related to determinant factors of metabolic syndromes, such as obesity and insulin resistance. Osteocalcin is considered a predictor of metabolic conditions in thyroid diseases. This study aimed to investigate the effect of levothyroxine vs. placebo on serum osteocalcin levels in patients with subclinical hypothyroidism. METHODS: This randomized clinical trial was performed on 30 patients with subclinical hypothyroidism, who were referred to the endocrine clinics of Ghaem and Imam Reza hospitals in Mashhad, Iran. After giving informed consent, patients were randomly divided into intervention (50 µg/- day levothyroxine for 2 months) and control (placebo) groups. Serum levels of osteocalcin, thyroid hormones, lipid profile, insulin, and fasting glucose, as well as other clinical and anthropometric data, were measured at baseline and at the end of the study. SPSS was used to analyze the data, and p < 0.05 was considered significant. RESULTS: Mean age in the intervention and control groups was 35.07 ± 9.94 and 31.30 ± 4.30, respectively (p = 0.20). There was no significant difference between osteocalcin levels before and after the intervention in either of the groups (p = 0.54). TSH level was significantly decreased in the levothyroxine group after the intervention (p < 0.01). T4 level was significantly increased in the intervention group (p = 0.02). CONCLUSION: Levothyroxine had no significant effect on the increasing levels of serum osteocalcin in patients with subclinical hypothyroidism.

The Prognostic Role of Metabolic and Endocrine Parameters for the Clinical Severity of COVID-19.

OBJECTIVE: An outbreak of coronavirus disease-19 (COVID-19) began in December 2019 and spread globally, overwhelming the entire world. COVID-19 is a public health emergency of international concern. Due to its high morbidity and mortality rate, recognition of its risk and prognostic factors is important. We aimed to understand the relationship between metabolic and endocrine parameters and the prognosis of COVID-19. METHODS AND MATERIALS: This was a cross-sectional clinical study. A total of 70 patients with severe COVID-19 were enrolled. Laboratory results at the first admission time (including complete blood count, C-reactive protein, lactate dehydrogenase, blood glucose, calcium, phosphate, albumin, creatinine, magnesium, lipid profiles, liver enzymes, thyroid hormones, cortisol, and vitamin D) and outcome data were recorded. We divided patients into (1) intensive care unit- (ICU-) admitted and non-ICU-admitted and (2) survivors and nonsurvivors for estimation of severity and prognosis. We determined the risk factors associated with critical illness and poor prognosis. RESULTS: Patients with higher white blood cell (WBC) count and phosphate levels had significantly higher ICU admission rates. According to univariate analysis, serum levels of T3, phosphate, and WBC as well as the duration of hospitalization were associated with mortality. Multivariate analysis revealed that only WBC and duration of hospitalization were independent predictors for mortality rate in COVID-19 patients. CONCLUSION: Our findings suggest that longer duration of hospitalization and higher WBC count are associated with poor outcomes in patients with COVID-19.

Cardiogenic Shock Due to Aluminum Phosphide Poisoning Treated with Intra-aortic Balloon Pump: A Report of Two Cases.

The mortality rate from aluminum phosphide (AlP) poisoning is as high as 70-100%, with refractory hypotension and severe metabolic acidosis being the two most common presentations in this poisoning. As this poisoning has no specific antidote, treatments revolve around supportive care. Cardiogenic shock created by toxic myocarditis is considered the main cause of mortality in these patients. Meanwhile, the intra-aortic balloon pump (IABP) has been suggested for the treatment of cardiogenic shock. This article reports the successful treatment of cardiogenic shock caused by AlP poisoning in a 17-year-old man and a 21-year-old woman using the IABP procedure.

Methadone associated long term hearing loss and nephrotoxicity; a case report and literature review.

BACKGROUND: Methadone is a long-acting opioid receptor agonist. Reported adverse effects of methadone include constipation, respiratory depression, dizziness, nausea, vomiting, itching, sweating, rhabdomyolysis, QT prolongation, and orthostatic hypotension. Hearing loss has been rarely reported following methadone use, and when reported, long term follow-up is rare. Herein we report a case of methadone poisoning with rhabdomyolysis, acute kidney injury, and persistent hearing loss documented by a 2 year follow up. CASE PRESENTATION: The patient was a 34 years old male who presented with a reduced level of consciousness and acute hearing loss after suicidal ingestion of 40 mg of methadone while experiencing family-related stresses. He had no prior history of methadone use, abuse, or addiction. Initial laboratory testing was significant for a serum creatinine concentration of 4.1 mg/dl, a mixed metabolic and respiratory acidosis, thrombocytopenia, abnormal hepatic transaminases, and coagulation tests. The patient then developed severe rhabdomyolysis. Also, audiometry showed a bilateral sensorineural hearing loss. The patient required hemodialysis for 11 days while his metabolic abnormalities gradually resolved. However, his hearing loss was persistent, as demonstrated by 2 years of follow up. CONCLUSION: Our patient simultaneously had kidney failure, rhabdomyolysis, and permanent hearing loss following methadone poisoning. Although rare, ototoxicity and permanent hearing loss may happen in cases of methadone poisoning. While opioid-induced hearing loss is uncommon, methadone toxicity should be taken into account for any previously healthy patient presenting with acute hearing loss with or without rhabdomyolysis.

The association between serum irisin levels and cardiovascular disease in diabetic patients.

BACKGROUND: Cardiovascular disease is the most common cause of mortality and morbidity in diabetic patients. Insulin resistance has been shown to be reduced by the secretion of irisin from muscle and adipose tissues. This study was aimed at determining the relationship between serum irisin levels and angiographically defined coronary artery disease (CAD) in type II diabetic patients. METHODS: In this case-control study, 30 diabetic subjects with angiographically defined CAD were compared with 30 age- and sex-matched diabetic subjects without CAD in terms of clinical and laboratory parameters including serum irisin levels. RESULTS: Serum levels of Irisin were significantly higher in the diabetic group without CAD compared with the group with CAD (P = 0.048). Serum irisin levels showed a significant positive correlation with BMI (r = 0.374, P = 0.004) and fasting insulin (r = 0.303, P = 0.021), and a significant negative correlation with diabetes duration (r = -0.384, P = 0.002). Based on the results of the binary logistic regression model, circulating levels of irisin were associated with the presence of CAD in diabetes (p = 0.038) after adjusting for potential confounders. CONCLUSION: Serum irisin levels were lower in the diabetic patients with cardiovascular complication compared with the uncomplicated diabetic patients. Therefore, additional larger scale studies are needed to determine the role of irisin in monitoring CAD in diabetic patients.

Topical propolis improves wound healing in patients with diabetic foot ulcer: a randomized controlled trial.

In this randomized controlled trial, diabetic patients with foot ulcers (Wagner grades 1 and 2) were randomly assigned to conventional therapies for diabetic foot ulcer plus topical propolis ointment (5%; twice daily) or conventional therapies alone. The process of ulcer healing was observed during 4 weeks and compared between the two groups regarding the size, erythema, exudates, white blood cell (WBC) count and erythrocyte sedimentation rate (ESR). The process of ulcer size reduction during the four-week period of study was significantly different between the groups. However, this difference was not significant between the third and fourth weeks. There was no significant difference between two groups regarding erythema and exudate reduction as well as WBC count and ESR. Administration of topical propolis ointment in addition to the conventional treatments of diabetic foot ulcer could reduce the size of ulcers with Wagner grades 1 and 2.

The relationship between serum levels of fibroblast growth factor 21 and diabetic retinopathy.

Fibroblast growth factor 21 (FGF21) is a major metabolic regulator that has been shown to be elevated in a number of metabolic disturbances including type 2 diabetes mellitus (T2DM) and the metabolic syndrome, but few studies about the relationship between serum FGF21 and the complications of diabetes have been done. Since the association between FGF21 and diabetic retinopathy is not clear, this study was conducted to investigate this relationship. In this cross-sectional study, 61 subjects (14 healthy controls, 22 diabetic patients without retinopathy, and 25 patients with diabetic retinopathy) were evaluated. All patients in the study were examined for the presence of diabetic retinopathy. Various clinical and biochemical parameters including FGF21 were evaluated and analyzed and compared between the study groups. Serum levels of FGF21 showed a significant difference between the three groups (P=0.003) but the difference between diabetic patients with and without retinopathy was not significant (P=0.122). Regression model was used to evaluate the role of FGF21 in predicting diabetic retinopathy. In the multivariate logistic regression model after adjustment of systolic blood pressure and fasting blood glucose, the level of FGF21 was not associated with diabetic retinopathy. In the multivariate model, only fasting blood glucose was associated with diabetic retinopathy (P=0.009). According to the results of this study, serum levels of FGF21 in diabetic patients was higher than the control group but these raised levels could not predict the presence of diabetic retinopathy.

The relationship between serology of hepatitis E virus with liver and kidney function in kidney transplant patients.

Although hepatitis E virus (HEV) is well known to cause acute hepatitis, there are reports showing that HEV may also be responsible for progression of acute to chronic hepatitis and liver cirrhosis in patients receiving organ transplantation. In this study, we aimed to evaluate the prevalence of HEV in patients with kidney transplantation. In this study, 110 patients with kidney transplantation were recruited, and anti-HEV IgG, creatinine, alanine transaminase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and estimated glomerular filtration rate (eGFR) in the first, third and sixth months after renal transplantation were measured. The mean serum anti-HEV IgG titers in the study participants was 1.36 (range 0.23 to 6.3). Twenty-three patients were found to be seropositive for HEV Ab defined as anti-HEV IgG titer > 1.1. The difference in liver and renal function tests (creatinine, eGFR, AST, ALT and ALP) at different intervals was not significant between patients with HEV Ab titers higher and lower than 1.1 (p > 0.05). However, an inverse correlation was observed between HEV Ab and eGFR values in the first (p = 0.047, r = -0.21), third (p = 0.04, r = -0.20) and sixth (p = 0.04, r = -0.22) months after renal transplantation in patients with HEV Ab < 1.1 but not in the subgroup with HEV Ab > 1.1. Also, a significant correlation between age and HEV Ab levels was found in the entire study population (p = 0.001, r = 0.33). Our findings showed a high prevalence of seropositivity for anti-HEV IgG in patients receiving renal transplants. However, liver and renal functions were not found to be significantly different seropositive and seronegative patients by up to 6 months post-transplantation.

Prevalence and risk factors for diabetic retinopathy: an Iranian eye study.

PURPOSE: The aim of this study was to determine the prevalence of diabetic retinopathy among diabetic patients in Iran and its association with some predisposing factors. METHODS: All diabetic patients who attended the diabetes clinic underwent ocular examination, including slit-lamp biomicroscopy. The blood pressure and blood biochemical parameters were then measured. RESULTS: The prevalence of diabetic retinopathy among 1022 diabetic participants was 23.6% (241 cases). This study showed that there is a statistically significant relation between diabetic retinopathy and mean blood pressure, fasting blood sugar, blood urea nitrogen, and level of HbA1c. There was no difference in lipid profile between patients with and without retinopathy. The duration of diabetes was a predicting factor for retinopathy as well as presence of renal and cardiovascular diseases and fasting glucose >126 as independent variables. CONCLUSIONS: The duration of diabetes was the most important risk factor for progression of retinopathy.