Quality of life and other patient-reported outcomes in adult Lebanese patients with type 2 diabetes during COVID-19 pandemic.

INTRODUCTION: Several studies have shown that COVID-19 pandemic has a negative impact on type 2 diabetic mellitus (T2DM) patients' quality of life (QoL). However, very few studies were performed in Middle Eastern countries. AIM: The aim of the current study was to assess, the QoL and diabetes-specific QoL, treatment satisfaction and psychological distress of Lebanese patients with T2DMs using: the Audit of Diabetes-Dependent Quality of Life (ADDQoL), Diabetes Treatment Satisfaction Questionnaire status version (DTSQs) and Kessler 10 (K10) questionnaires and to compare results to those obtained during the pre-COVID-19 period. RESULTS: 461 patients with T2DM participated in the study; 52.6% men, 47.4% women; median age 59 years old. The respective median ADDQoL and DTSQs scores were - 2.2 (interval interquartile range (IQR) - 3.9, - 0.8) (range from - 9 maximum negative impact to + 3 maximum positive impact) and 30(IQR22-36) (range from 0 maximum dissatisfaction to 36 maximum satisfaction). K10 median score was 26(IQR18-35) (range from minimum score of 10 indicating no distress to maximum score of 50 indicating severe distress). Rural dwelling, lack of exercise, current smoking, diabetic complications, injectable diabetes treatment, and previous COVID-19 infection were all associated with significantly worse ADDQoL, DTSQs, and K10 score indicating greater distress. A significant worsening of ADDQoL scores followed onset of the pandemic with no significant change in DTSQs scores. CONCLUSION: During the COVID-19 pandemic, T2DM Lebanese patients experienced more negative impact of diabetes on QoL and mental health. Those infected with COVID-19 also reported worse QoL, treatment satisfaction and mental health. This highlights the need for community and individual support.

Relationship between 25 hydroxyvitamin D and lipid profile in Lebanese school children.

PURPOSE: Limited information is available regarding the association of vitamin D and lipid profile in pediatric populations. The objective of this cross-sectional study is to determine the prevalence of vitamin D deficiency in a large sample of Lebanese schoolchildren and to evaluate the relationship between vitamin D and lipid profile. METHODS: 969 Lebanese schoolchildren (505 boys and 464 girls) aged 8-18 years were recruited from 10 schools of different socioeconomic status (SES). Non-fasting total cholesterol, triglycerides and HDL-Cholesterol (HDL-C) were measured. Non-HDL-C was calculated. RESULTS: The prevalence of 25(OH)D deficiency (level below 20 ng/ml) is 56.6% (48.1% in boys, 65.7% in girls). There is no significant relationship between 25(OH)D levels and age. 25(OH)D is inversely correlated with BMI in the total population, and in boys and girls (p < 0.0001, p = 0.001 and p = 0.001, respectively) and is higher in children from high SES schools and during the summer season (p < 0.0001 in both cases). 25(OH)D is inversely correlated with triglycerides and non-HDL-C in the total population and in boys and girls (p < 0.0001 for all), and positively correlated with HDL-C in the total population and in boys but not in girls (p = 0.001, p < 0.0001 and p = 0.1, respectively). In a multilinear regression analysis, in the overall population, 25(OH)D is independently associated with sex, season, school's SES, BMI, triglycerides and non-HDL-C. In boys, the association with BMI and season is non-significant. CONCLUSION: An independent relationship is observed between 25(OH)D and cardiometabolic risk factors in the pediatric Lebanese population Further studies are needed to evaluate the long-term consequences of this relationship.

Serum 25 hydroxyvitamin D in employees of a Middle Eastern university hospital.

BACKGROUND: The Middle East registers the highest rate of vitamin D deficiency worldwide. In Lebanon, previous studies looked at this deficiency in schoolchildren, university students, young adults and postmenopausal women. However, no previous study was performed in hospital workers. The objective of our study was to evaluate vitamin D status in a Beirut hospital center and to look at the potential factors influencing these measurements. METHODS: This cross-sectional study was performed on hospital employees who came for a regular checkup at the primary health-care department. 25(OH)D measurements were performed using the Dia-Sorin chemiluminescent assay. RESULTS: 392 subjects (318 women and 74 men) were included in the study. The mean age of the participants was 41.02 ± 11.3 years. The mean 25(OH)D level was 15.61 ± 7.91 ng/ml, with no significant difference according to gender. There were no significant correlations between 25(OH)D and both BMI and age, but 25(OH)D was significantly associated with educational level (p = 0.03). There was a significant difference in 25(OH)D levels according to season (p < 0.001) and a significant association between 25(OH)D and the reported weekly hours of sun exposure (r = 0.1, p = 0.032), but not with the reported sunscreen use. Fish consumption was positively associated with 25(OH)D levels (p = 0.018), while milk, dairy product or egg consumption did not achieve any significant relationship. In a stepwise linear regression analysis, fish consumption and season were the only independent predictors of 25(OH)D levels (p = 0.007 and p = 0.0001 respectively). CONCLUSION: Vitamin D deficiency is common among hospital workers. This finding reinforces the need for vitamin D supplementation in these high-risk populations.

Serum uric acid in relation with the metabolic syndrome components and adiponectin levels in Lebanese University students.

BACKGROUND: The relation between serum uric acid (SUA) and metabolic syndrome (MetS) parameters has never been studied in a young Middle-Eastern population. In addition, the relation between SUA and adiponectin was poorly studied. METHODS: We looked at the relation between SUA, and both adiponectin and MetS components in 381 randomly selected Lebanese university students (201 males and 180 females). RESULTS: SUA was positively correlated with body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), waist circumference (WC), fasting blood glucose (FPG), triglycerides, total and LDL-cholesterol, and homeostasis model assessment (HOMA) index (p<0.001 for all variables, p<0.01 for FPG) and inversely correlated with HDL-cholesterol and adiponectin (p<0.001 for both variables). In men, SUA was positively correlated with BMI, WC, SBP, DBP, FPG, triglycerides, total and LDL-cholesterol, and HOMA index and inversely correlated with adiponectin (p<0.001 for all variables, p<0.05 for adiponectin); these correlations persisted after BMI adjustment, for WC, FPG, triglycerides, total-cholesterol, LDL-cholesterol, and HOMA index. In women, SUA was positively correlated with total and LDL-cholesterol (p<0.001), independently of BMI. In a multiple regression analysis, SUA was independently associated with WC, triglycerides, total cholesterol, HDLcholesterol and adiponectin in the overall population while, in men, it was associated with triglycerides, total-cholesterol, and WC. CONCLUSION: Our results suggest, in young adults, a gender difference in the relation between SUA and both adiponectin and MetS parameters. In addition, we observed in both genders a strong relation of SUA with total cholesterol. Further studies are needed in larger populations in order to elucidate these findings.

Serum proteomic profiling of obese patients: correlation with liver pathology and evolution after bariatric surgery.

OBJECTIVE: Chronic liver diseases, including cirrhosis, may develop in obese patients. Steatosis and non-alcoholic steatohepatitis (NASH) are risk factors for progression to fibrosis. To date, diagnosis of steatosis and NASH relies on liver biopsy. The aim of the study was to identify serum markers of steatosis and NASH in obese patients using SELDI-TOF ProteinChip. PATIENTS: Eighty obese non-alcoholic patient candidates for bariatric surgery and devoid of hepatitis B and C infection were selected. Serum samples were collected before surgery and at 6 months after surgery for 33 of these patients. Wedge liver biopsy was performed at the time of bariatric surgery. Twenty-four serum samples from healthy blood donors served as controls. The protein profiles of each serum were assessed using SELDI-TOF ProteinChip technology and were compared according to liver histological lesions. RESULTS: Twenty-four obese patients (30%) had non-significant liver lesions, 32 (40%) had significant steatosis and 24 (30%) had NASH. Comparison of serum protein profiles according to liver lesions identified three peaks (CM10-7558.4, CM10-7924.2 and Q10-7926.9) the intensity of which significantly increased according to the severity of the liver lesions (steatosis and NASH) and returned to normal after bariatric surgery. None was correlated with either liver function tests or metabolic parameters. Identification using immunoSELDI assay characterised these peaks as the double charged ions of alpha- and beta-haemoglobin subunits. CONCLUSION: The differential proteomic method demonstrated changes in serum protein profiles in obese patients according to severity of liver lesions. Free haemoglobin subunits may serve as a serum biomarker of the severity of liver damages.

Predictors of intra-operative parathyroid hormone decline in subjects operated for primary hyperparathyroidism by minimally invasive parathyroidectomy.

BACKGROUND: The predictors of intra-operative PTH (IOPTH) decline during minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism have been but poorly studied. MATERIALS AND METHODS: This retrospective study included 108 patients who underwent MIP for a single adenoma. Serum calcium and phosphorus were measured before surgery and 1 day post-operatively. IOPTH was measured before (intra-operative preincision or PTHt0) and 10 min after removal of the adenoma (PTHt10). The Modification of Diet in Renal Disease (MDRD) equation was used to estimate the glomerular filtration rate. The weight of the adenoma was assessed in all the subjects. RESULTS: The sex ratio female/male was 5.37 with a mean age of 57.3 yr. The mean pre- and postoperative values were for calcium 2.80 and 2.19 mmol/l, respectively (p<0.0001) and for phosphorus 0.90 and 1.16 mmol/l, respectively (p<0.0001). The PTH dropped from a mean value of 184.8 to 50.8 pg/ml 10 min after adenoma resection with a mean drop of 69.7%. Thirteen patients (12%) did not achieve a PTH fall of more than 50%. In a bivariate analysis, age, an MDRD<60 ml/min and weight of adenoma were inversely associated with IOPTH fall (p=0.009, p=0.004, and p<0.001, respectively) while gender, body mass index, hypertension, diabetes, pre-operative phosphorus and calcium had no significant effects. In the multivariate analysis, age, weight of adenoma, and MDRD were still independent negative predictors of the IOPTH fall (p=0.01, p=0.018, and p<0.001, respectively). CONCLUSION: Our results suggest that during MIP the presence of a parathyroid adenoma with a high weight, in an elderly subject or in a subject with altered renal function, will result in a lesser degree of IOPTH fall.

Use of desmopressin as an alternative to corticotropin-releasing hormone during inferior petrosal sinus sampling in a child with Cushing's disease.

Cushing's syndrome (CS) is rare in children. Information on bilateral inferior petrosal sinus sampling (BIPSS) in children with CS is limited. In the procedure CRH is always used to stimulate ACTH values. In addition, growth failure is the main complication of pediatric CS, mainly due to a profound GH suppression that persists for a few months after cure of the disease. Early treatment with recombinant GH after CS cure may partly reverse this phenomenon. We report herein a case of Cushing's disease (CD) in a 7-yr-old child, presenting with severe growth failure. No pituitary adenoma was shown on magnetic resonance imaging and a BIPSS using desmopressin allowed the identification of a central to peripheral (C/P) gradient; however transphenoidal surgery (TSS) did not cure the disease thus requiring the performance of bilateral adrenalectomy. After cure of the disease, a partial catch up of the growth delay occurred without any GH treatment. Our case reinforces the fact that BIPSS can be performed safely in very young children with CD. It also suggests for the first time that the use of desmopressin during the procedure gives the same information as CRH, as well as confirming the fact that the success of TSS is poor in very young children. Finally, it suggests that growth failure in children with CS can be partially reversed after surgical cure of the disease without any GH treatment and that the high IGF-I observed during corticosteroid replacement therapy is due to a state of IGF-I resistance.

Middle East and North Africa consensus on osteoporosis.

With the increasing life expectancy, osteoporosis is becoming a major worldwide health problem. The magnitude of the disease may become larger in developing countries, more particularly in the Middle East region where the prevalence of low bone mass is higher than in western countries. Although several local organizations and countries have developed guidelines for osteoporosis, no previous regional guidelines have been developed encompassing all Middle-Eastern and North African countries. The present document reviews all the regional published data on bone mineral density, risk factors, fracture prevalence and vitamin D status. It also gives simple recommendations applicable to all these countries. This document was endorsed by leading members of all the different regional countries including, Iran, Egypt, Tunisia, Jordan, Palestine, Syria, Iraq, Libya, Oman, Kuwait, Saudi Arabia and Bahrain.

Hypovitaminosis D in a sunny country: relation to lifestyle and bone markers.

Hypovitaminosis D is associated with poor dietary intake and inadequate sunshine exposure. It is common worldwide, particularly in European elderly people. Information about vitamin D status in young adult populations from the Middle East is scarce. Furthermore, the relationship between hypovitaminosis D and some lifestyle factors such as style of clothing and dwelling location is not well defined. We assessed vitamin D intake and measured serum calcium, phosphorus, albumin, alkaline phosphatase, 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), osteocalcin, and urinary-free deoxypyridinoline (DPD) in 316 Lebanese volunteers (99 men and 217 women) aged 30-50 years; 156 were recruited from rural areas and 160 from urban areas. Fifty-one women from each area were veiled. The average daily vitamin D intake was 100.3 +/- 67.9 IU and was found to be higher in men compared with women, in urban subjects compared with rural ones and in nonveiled women compared with veiled ones. The mean level of 25(OH)D was 9.71 +/- 7.07 ng/ml. Hypovitaminosis D [25(OH)D < 12 ng/ml] affected 72.8% of our population. It was more common in women than in men (83.9% vs. 48.5%). Severe hypovitaminosis D [25(OH)D < 5 ng/ml] was observed in 30.7% of our subjects and was more prevalent in women (41.5%), particularly in the veiled ones (61.8%). 25(OH)D levels were the lowest in veiled women, and in women living in rural areas. Rural men had the highest 25(OH)D levels despite their very low vitamin D intake. In a multivariate model, inadequate vitamin D intake, urban dwelling, veil wearing, and high parity in women were independent predictors of hypovitaminosis D. 25(OH)D was related inversely to PTH and free DPD whereas osteocalcin achieved only a weak positive correlation with 25(OH)D. In the absence of information regarding time spent outdoors, our results show that hypovitaminosis D is common among young Lebanese people and is related mostly to low vitamin D intake. This should emphasize the need for more vitamin D in our population.

[Blood and leukocyte glutathione and glutathione S-transferase: relationship to cholesterolemia in healthy volunteers]. / Glutathion et glutathion S-transférase sanguins et leucocytaires: relation avec la cholestérolémie chez des volontaires sains.

Hypercholesterolemia increases the oxidation of low density lipoprotein (LDL) which subsequently leads to atherogenesis. The oxidized LDL are also known to increase in vitro macrophage synthesis of glutathione. The purpose of this study was to investigate the relationship between lipid parameters and the glutathione system (glutathione, glutathione S-transferase) in total blood and within leukocytes. The glutathione and glutathione S-transferase were evaluated by spectrophotometric methods in sixty-two healthy volunteers (32 women, 30 men, mean age 39.9 +/- 7.7). No correlation was found between the level of blood cholesterol and the values of the blood glutathione system. However, a positive correlation between the values of glutathione and glutathione S-transferase in leukocytes and the blood cholesterol level was only found in women (r = 0.55 and r = 0.50 respectively, p < 0.01). We also found in men a positive correlation between body mass index and glutathione S-transferase in total blood and within leukocytes (r = 0.38, p < 0.05, r = 0.5, p < 0.01 respectively). No correlation was found between age, smoking and the values of the glutathione system. Our results suggest that the glutathione system in leukocytes is related to blood cholesterol levels. The fact that this positive correlation was only observed in women points to a possible role of estrogens in the regulation of the glutathione system which merits to be further studied.

[Hypovitaminosis D: a major worldwide public health problem]. / L'hypovitaminose D, problème mondial majeur de santé publique.

PHYSIOLOGY: Vitamin D increases intestinal absorption of calcium favoring the microenvironment necessary for bone mineralization. In addition, vitamin D prevents hypocalcemia via its osteoclastic action. Severe hypovitaminosis leads to rickets in children and its equivalent in adults, osteomalacia. Mild to moderate hypovitaminosis D causes secondary hyperparathyroidism increasing the risk of fracture, particularly femoral neck fracture. Vitamin D would also have an antiinflammatory and anticancer effect. WORLDWIDE: Hypovitaminosis D is frequently observed in Europe in the elderly, particularly in the institutionalized population, but is also seen in otherwise healthy younger adults. An estimated 40% of the young European population has some degree of hypovitaminosis D. Surprisingly, it is more frequent in sunny Mediterranean countries than in certain northern countries such as Norway. The lower incidence observed in the United States is probably related to the vitamin D supplementation of the American diet. Hypovitaminosis D in Africa and the Middle-East is also an important problem, being considered to be one of the 5 most prevalent childhood diseases in developing countries. ENVIRONMENTAL FACTORS: The limited quantity of vitamin D in food and multiple environmental factors contribute to hypovitaminosis D. These factors include insufficient sun exposure and urban lifestyle with a high degree of pollution. In addition, cutaneous photosynthesis of vitamin D is limited by hyperpigmentation in black people, wearing traditional veils that limit sun exposure, and use of sun lotions, further contributing to vitamin D deficiency. CONCLUSIONS AND RECOMMENDATIONS: The very high prevalence of hypovitaminosis D in the world, and particularly in Europe, Africa and the Middle-East, points to the need for public health measures in these countries. While waiting for these measures to be implemented, vitamin D supplementation (for example in tablet form) should be encouraged in order to meet minimum requirements. Finally, the beneficial effect of moderate sun exposure on cutaneous vitamin D synthesis (and psychological well-being) must not be overlooked.

[Vitamin D status in aged subjects. Study of a Lebanese population]. / Statut vitaminique D des sujets âgés. Etude de la population libanaise.

OBJECTIVES: To evaluate vitamin D status in two subgroups of the Lebanese aged population. To compare results with reference values observed in healthy young volunteers. METHODS: Fifty aged institutionalized patients (25 men and 25 women) and 51 aged ambulatory subjects (25 men and 26 women) underwent the following explorations during winter: serum 25-OH vitamin D, parathyroid hormone, corrected serum calcium, phosphorus, creatinine, and alkaline phosphatases and urinary calcium/creatinine. Serum 25-OH vitamin D and urinary calcium/creatinine were also measured in 34 healthy young volunteers. RESULTS: Serum 25-OH vitamin D levels in 25 ambulatory subjects (49%) and 30 institutionalized patients (60%) were below 10 ng/ml. There was non significant difference in 25-OH vitamin D levels between the ambulatory and institutionalized aged populations, nor between aged women and aged men. Parathyroid hormone, alkaline phosphatases and urinary calcium/creatinine levels were higher in the institutionalized population than in the ambulatory population (p = 0.07; p = 0.0001; p = 0.0001 respectively). Aged women had higher parathyroid hormone and calcium/creatine levels than aged men (p = 0.005; p = 0.005 respectively). Finally, in the young population, 25-OH vitamin D was higher than in the aged institutionalized and ambulatory populations (p = 0.0001 and p = 0.0009 respectively). An inverse non-significant correlation (r = -0.16) was found between parathyroid hormone and 25-OH vitamin D. CONCLUSION: Our results show that even in a sunny country like Lebanon, vitamin D deficiency is often observed. The degree of deficiency probably lies between that observed in Europe and the United States. It could be related to low vitamin D diet.

[Parathyroidectomy under local anesthesia. First two cases in Lebanon and review of the literature]. / Parathyroïdectomie sous anesthésie locale. Deux premiers cas au Liban et revue de la littérature.

The routine use of automated techniques to measure serum calcium levels have made disease states of the parathyroid gland a common endocrinologic problem. Because of the low sensitivity and specificity of early radiologic techniques to identify enlarged parathyroid glands, and because skilled endocrine surgeons report success rates of > 95% in identifying abnormal parathyroid glands, historically most parathyroid glands surgery consisted in a large cervicotomy under general anesthesia without preoperative localization. However, the development of sophisticated imaging techniques has now made it possible to identify the abnormal gland in a significant number of patients, leading some surgeons to choose unilateral neck exploration under local anesthesia for primary hyperparathyroidism. The success of the procedure is ascertained by measuring PTH peroperatively. We report the first two Lebanese patients, presenting with a solitary parathyroid adenoma, who underwent this easy, safe and cost-effective surgical technique.

The spinal curvature irregularity index independently identifies vertebral fractures.

INTRODUCTION AND HYPOTHESIS: The spinal curvature irregularity index (SCII) is a quantitative measure of the irregularity of the spinal curvature. We evaluated the predictive ability of SCII to identify subjects with vertebral fractures (VF). METHODS: Vertebral heights were measured by quantitative vertebral morphometry in 461 Lebanese women 20-89 years of age and VFs were ascertained by the grade 1 Eastell method. SCII scores were log-transformed and expressed as Z-SCII, the number of standard deviations above or below the mean ln(SCII) of young patients without VF. Univariate and multivariate binary logistic regression models were used to identify clinical predictors of VF. RESULTS: Women with a higher SCII were more likely to have prevalent VF. A higher SCII was associated with a greater prevalence of VF within each category of femoral neck BMD (normal, osteopenia, osteoporosis). In univariate analysis, predictors of VF included Z-SCII (odds ratio, OR: 2.21, 95% CI: 1.80-2.71) and femoral neck T-score (OR: 1.35, 95% CI: 1.12-1.63). In multivariate analysis, predictors of VF were: Z-SCII (OR: 1.54, 95% CI: 1.02-2.32), femoral neck T-score (OR: 1.41, 95% CI: 1.11-1.78) and age(3) (OR: 1.40, 95% CI 1.10-1.82). At a cutoff SCII of 9.5%, the sensitivity and specificity of SCII for VF were 71 and 64% respectively, and higher SCII cutoffs identified VFs with greater specificity. CONCLUSION: The SCII is a robust, simple and independent indicator of the presence of VFs.

Primary hypergonadotropic hypogonadism, partial alopecia, and Müllerian hypoplasia: report of a second family with additional findings.

Two sisters with primary hypergonadotropic hypogonadism associated with microcephaly, flat occiput, partial alopecia, absent or streak ovaries, and Müllerian hypoplasia are reported. Their parents are first cousins. Despite some clinical differences, their features were very close to a family described with such an association by Al-Awadi et al. [1985: Am J Med Genet 22:619-622] in Kuwait.

Effects of a short-term calcium and vitamin D treatment on serum cytokines, bone markers, insulin and lipid concentrations in healthy post-menopausal women.

In vitro studies have shown that 1,25 dihydroxyvitamin D3 [1,25(OH)2D3] decreases cytokine production by monocytes and lymphocytes. In addition, intravenous or oral pulse calcitriol treatment suppresses interleukin 6 (IL6) and interleukin1beta (IL1beta) in hemodialysis patients. We studied the effect of a daily 12-week course of 1000 mg calcium and 800 U cholecalciferol on circulating 25 hydroxyvitamin D [25(OH)D], PTH, cytokines, osteoprotegerin (OPG), C-reactive protein (CRP), bone markers, lipid parameters and insulin levels in 47 healthy post-menopausal women. Thirty-nine women completed the study. A significant increase in 25(OH)D and a significant decrease in PTH were observed (p=0.0043 and p<0.0001, respectively). In addition, alkaline phosphatase, osteocalcin and, to a lesser extent, urinary free deoxypiridinoline (DPD) decreased significantly (p<0.0001, p=0.0002 and p=0.026, respectively). No change in circulating IL6, tumor necrosis factor alpha (TNFalpha), CRP, OPG, triglycerides, LDL- and HDL-cholesterol, and insulin levels was observed. Correlation studies in the 47 women enrolled in the study revealed inverse significant correlations between OPG on one side and body mass index, LDL-cholesterol, IL6, CRP and insulin levels on the other (p=0.002, p=0.002, p=0.004, p=0.023 and p=0.0001). Also, IL6 was significantly correlated with insulin levels (p=0.0005). In a multivariate model, both insulin and LDL-cholesterol were independently associated with OPG, while only insulin was independently associated with IL6. Our results showed no effect of a short-term calcium-vitamin D treatment on circulating cytokines, CRP, insulin levels and lipid parameters. This could be related to the low circulating cytokine concentrations in healthy subjects or to the short duration of treatment. The interesting association we found between OPG and some cardiovascular risk markers deserves further investigation.