A Contemporary Approach to the Diagnosis and Management of Adrenal Insufficiency.

Adrenal insufficiency (AI) can be classified into three distinct categories based on its underlying causes: primary adrenal disorders, secondary deficiencies in adrenocorticotropin, or hypothalamic suppression from external factors, most commonly glucocorticoid medications used for anti-inflammatory therapy. The hallmark clinical features of AI include fatigue, appetite loss, unintentional weight loss, low blood pressure, and hyponatremia. Individuals with primary AI additionally manifest skin hyperpigmentation, hyperkalemia, and salt craving. The diagnosis of AI is frequently delayed due to the non-specific symptoms and signs early in the disease course, which poses a significant challenge to its early detection prior to an adrenal crisis. Despite the widespread availability of lifesaving glucocorticoid medications for decades, notable challenges persist, particularly in the domains of timely diagnosis while simultaneously avoiding misdiagnosis, patient education for averting adrenal crises, and the determination of optimal replacement therapies. This article reviews recent advancements in the contemporary diagnostic strategy and approaches to optimal treatment for AI.

Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening.

Importance: Primary aldosteronism (PA) is a common cause of secondary hypertension and an independent risk factor for cardiovascular morbidity and mortality. Fewer than 2% to 4% of patients at risk are evaluated for PA. Objective: To develop and evaluate an electronic health record best-practice advisory (BPA) that assists with PA screening. Design, Setting, and Participants: This prospective quality improvement study was conducted at academic center outpatient clinics. Data analysis was performed between February and June 2023 and included adults with hypertension and at least 1 of the following: 4 or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). Patients previously tested for PA were excluded. Exposure: A noninterruptive BPA was developed to trigger for PA screening candidates seen in outpatient setting by clinicians who treat hypertension. The BPA included an order set for PA screening and a link to results interpretation guidance. Main Outcomes and Measures: (1) The number of PA screening candidates identified by the BPA between October 1, 2021, and December 31, 2022; (2) the rates of PA screening; and (3) the BPA use patterns, stratified by physician specialty were assessed. Results: Over 15 months, the BPA identified 14 603 unique candidates (mean [SD] age, 65.5 [16.9] years; 7300 women [49.9%]; 371 [2.5%] Asian, 2383 [16.3%] Black, and 11 225 [76.9%] White individuals) for PA screening, including 7028 (48.1%) with treatment-resistant hypertension, 6351 (43.5%) with hypokalemia, 1537 (10.5%) younger than 35 years, and 445 (3.1%) with adrenal nodule(s). In total, 2040 patients (14.0%) received orders for PA screening. Of these, 1439 patients (70.5%) completed the recommended screening within the system, and 250 (17.4%) had positive screening results. Most screening orders were placed by internists (40.0%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders via the embedded order set, while specialists placed most orders (83.0%-95.4%) outside the BPA. Patients who received screening were younger and included more women and Black patients than those not screened. The likelihood of screening was higher among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications. Conclusions and Relevance: The study results suggest that noninterruptive BPAs are potentially promising PA screening-assistance tools, particularly among primary care physicians. Combined with artificial intelligence algorithms that optimize the detection yield, refined BPAs may contribute to personalized hypertension care.

Trabecular Bone Score Improves Fracture Risk Discrimination in Postmenopausal Rheumatoid Arthritis Patients Receiving Glucocorticoids.

Background: Bone mineral density (BMD) might not be a sensitive tool for predicting osteoporotic fracture risk among patients with rheumatoid arthritis (RA), especially when receiving glucocorticoids. Trabecular bone score (TBS), which has emerged as a new assessment technique representing bone microarchitecture and strength, may be considered an alternative approach. Materials and Methods: In this cross-sectional analytical study, postmenopausal RA patients receiving glucocorticoids were identified from the postmenopause BMD database. The database included clinical data of postmenopausal outpatients who had at least one BMD measurement between January 2014 and December 2017. TBS was calculated from lumbar spine BMD with the microarchitecture assessment software. The presence of osteoporotic fractures, either vertebral or non-vertebral, was identified at the time of BMD measurement. Results: A total of 64 postmenopausal RA patients receiving glucocorticoids were included. The TBS values were inversely associated with osteoporotic fractures, with a TBS cut-off of less than 1.24, showing the best accuracy with a sensitivity of 79% and a specificity of 84% in discriminating fractures. This newly proposed TBS threshold combined with a BMD T-score of -2.5 or less demonstrated a greater area under receiver operating characteristic curve in identifying patients with osteoporotic fractures than the BMD threshold alone (p value = 0.003). Conclusion: The reduction in TBS was associated with an osteoporotic fracture in postmenopausal RA patients receiving glucocorticoids. Combining TBS and BMD in these patients incrementally improves fracture risk discrimination and may serve as a supplementary tool in identifying patients at greatest risk of osteoporotic fracture.

Predictors of Cardiovascular Morbidities in Adults With 21-Hydroxylase Deficiency Congenital Adrenal Hyperplasia.

CONTEXT: The prevalence of cardiovascular and metabolic complications among adults with 21-hydroxylase deficiency (21OHD) is unknown. OBJECTIVE: We sought to determine the prevalence of cardiovascular and metabolic morbidities among adults with 21OHD and to identify clinical factors and biomarkers associated with cardiovascular outcomes. METHODS: A 10-year retrospective cross-sectional analysis was conducted on adult patients with confirmed 21OHD, aged 18 to 70 years, who had at least one clinical visit for assessment at the University of Michigan. The presence of cardiovascular diseases (CVDs) and other metabolic comorbidities was extracted from medical records based on International Classification of Diseases (ICD) codes. Medical treatments, glucocorticoid (GC) and mineralocorticoid doses, as well as specific biomarkers of disease control since age 18, were collected for analysis. RESULTS: A total of 254 patients with 21OHD, median age of 35 years (interquartile range, 28.25-46 y), were included in the analysis. The prevalence of CVDs in the entire cohort was 7.5%. An increase in prevalence was seen from early adulthood, reaching 25% in patients older than 60 years. Increasing age (adjusted odds ratio [OR], 1.05; 95% CI, 1.01-1.09), hypertension (OR, 4.27; 95% CI, 1.41-12.92), and higher GC doses (OR, 1.51; 95% CI, 1.11-2.06) were significantly associated with prevalent CVDs. Higher plasma renin activity was significantly associated with CVDs (OR, 1.07; 95% CI, 1.01-1.15) but not other biochemical markers of disease. CONCLUSION: Cardiometabolic morbidities are prevalent among adults with 21OHD. Hypertension, age, and GC exposure are the main predictive factors of established CVDs in our cohort.

Therapeutic management of congenital forms of endocrine hypertension.

Congenital forms of endocrine hypertension are rare and potentially life-threatening disorders, primarily caused by genetic defects affecting adrenal steroid synthesis and activation pathways. These conditions exhibit diverse clinical manifestations, which can be distinguished by their unique molecular mechanisms and steroid profiles. Timely diagnosis and customized management approach are crucial to mitigate unfavorable outcomes associated with uncontrolled hypertension and other related conditions. Treatment options for these disorders depend on the distinct underlying pathophysiology, which involves specific pharmacological therapies or surgical adrenalectomy in some instances. This review article summarizes the current state of knowledge on the therapeutic management of congenital forms of endocrine hypertension, focusing on familial hyperaldosteronism (FH), congenital adrenal hyperplasia, apparent mineralocorticoid excess, and Liddle syndrome. We provide an overview of the genetic and molecular pathogenesis underlying each disorder, describe the clinical features, and discuss the various therapeutic approaches available and their risk of adverse effects, aiming to improve outcomes in patients with these rare and complex conditions.

Primary Aldosteronism Prevalence - An Unfolding Story.

Primary aldosteronism (PA) is characterized by dysregulated, renin-independent aldosterone excess. Long perceived as rare, PA has emerged as one of the most common causes of secondary hypertension. Failure to recognize and treat PA results in cardiovascular and renal complications, through processes mediated by both direct target tissue insults and indirectly, by hypertension. PA spans a continuum of dysregulated aldosterone secretion, which is typically recognized in late stages after treatment-resistant hypertension and cardiovascular and/or renal complications develop. Determining the precise disease burden remains challenging due to heterogeneity in testing, arbitrary thresholds, and populations studied. This review summarizes the reports on PA prevalence among the general population and in specific high-risk subgroups, highlighting the impact of rigid versus permissive criteria on PA prevalence perception.

Prevalence and clinical associations with primary hypogonadism in male systemic sclerosis.

Background: Systemic sclerosis may affect male and female fertility. Premature ovarian failure has been reported in female systemic sclerosis patients, but the effects on male fertility in systemic sclerosis have not been studied. Objectives: We aimed to determine the prevalence and clinical associations with primary hypogonadism among male systemic sclerosis patients. Methods: This was a cross-sectional pilot study, including 30 adult male systemic sclerosis patients attending the Scleroderma Clinic, Khon Kaen University. Testosterone deficiency symptoms were assessed using the Aging Males' Symptoms Rating Scale, urological examination, and blood testing (for total testosterone, free testosterone, follicle-stimulating hormone, and luteinizing hormone). We excluded patients with congenital hypogonadism and any acquired disorders of the testes and genitalia. The definition of primary hypogonadism was based on the International Society for the Study of the Aging Male 2015 diagnostic criteria for hypogonadism. Results: Seven patients met the definition of primary hypogonadism-a prevalence of 23.3% (95% confidence interval: 9.9-42.3). The respective mean age and mean systemic sclerosis duration was 59.4 ± 11.9 and 5.5 ± 4.7 years. Older age at onset, high triglyceride level, and older age starting corticosteroid treatment were significantly associated with primary hypogonadism (p = 0.02, 0.02, and 0.03, respectively). Systemic sclerosis subset, disease severity, and immunosuppressant use were not associated with primary hypogonadism among Thai male systemic sclerosis patients. Conclusion: Around one-quarter of male systemic sclerosis patients had primary hypogonadism. Elderly onset of systemic sclerosis, hypertriglyceridemia, and late corticosteroid treatment were risk factors for developing primary hypogonadism.

An optimal intervention threshold of FRAX in postmenopausal Thai women.

This study was designed to determine a FRAX intervention threshold in postmenopausal Thais, based on a history of hip fracture. The optimal FRAX thresholds for hip fracture were 4.9% (without BMD) and 4% (with BMD), while the thresholds for major osteoporotic fracture were 9.8% (without BMD) and 8.9% (with BMD). INTRODUCTION: Fracture Risk Assessment Tool (FRAX) has been widely used as an intervention threshold for initiating osteoporosis treatment. However, there is a lack of data to validate the threshold in Thai population. METHODS: A cross-sectional study was conducted from January 2014 to February 2019. Postmenopausal women in the Northeast of Thailand whom has bone mineral density (BMD) measured using dual-energy X-ray absorptiometry (DXA) in the study period were recruited. Participants who had previously received anti-osteoporotic treatment were not eligible. FRAX score, both with and without BMD, was calculated using a Thai reference. Prevalent hip fracture was identified by reviewing the ICD-10 diagnosis from the hospital database during the study period. The receiver operating characteristic (ROC) curve and Youden index were used to determine the FRAX threshold in predicting hip fracture, based on the rationale that women with a prevalent hip fracture would be eligible for treatment. RESULTS: A total of 2872 postmenopausal Thai women were recruited, with 45 sustained a recent hip fracture. In association with hip fracture, the optimal FRAX thresholds for hip fracture without and with BMD were 4.9% and 4%, respectively, with 71.1% sensitivity and 83.3% specificity, and 82.2% sensitivity and 78.6% specificity, while the optimal FRAX thresholds for major osteoporotic fracture (MOF) without and with BMD were 9.8% and 8.9%, respectively, with 75.6% sensitivity and 77.0% specificity, and 86.7% sensitivity and 70.9% specificity. CONCLUSION: An optimal intervention threshold based on FRAX of hip fracture and MOF in postmenopausal Thai women is slightly different from the standard recommendation, which confirmed the marked variations of thresholds across ethnicities. The proposed threshold should be considered as new cutoff for initiating osteoporosis treatment in postmenopausal Thais.

The Impact of New-Onset Diabetes Mellitus and Hypertension on All-Cause Mortality in an Apparently Healthy Population: A Ten-Year Follow-Up Study.

INTRODUCTION: The comparative effect of new-onset diabetes mellitus (DM) and hypertension (HT) on long-term mortality is a matter of debate. MATERIALS AND METHODS: From 2007 to 2017, a 10-year longitudinal retrospective cohort study was conducted in Thailand's tertiary care setting. As baseline data, health check-up data from apparently healthy participants without underlying disease from 2007 were extracted. The vital status of all participants was determined in 2017, ten years after an initial examination. The impact of new-onset DM and HT at baseline on 10-year all-cause mortality was investigated using multivariable logistic regression analysis. RESULTS: The prevalence of new-onset DM and HT was 6.4% and 28.8%, respectively, at baseline. Newly diagnosed diabetes increased the risk of all-cause mortality over 10 years (adjusted OR 4.77 and 95% CI 2.23-9.99). HT, on the other hand, did not increase the risk of death (adjusted OR 1.24 and 95% CI 0.65-2.35). Different HT and DM status combinations were compared to a nondiabetic, nonhypertensive reference. Individuals who were diabetic and hypertensive had a greater risk of death (adjusted OR 6.22 and 95% CI 2.22-17.00). Having DM without HT also increased the risk of death (adjusted OR 4.36 and 95% CI 1.35-12.87). However, having HT without DM did not result in a significant increase in 10-year mortality risk (adjusted OR 1.21 and 95% CI 0.57-2.56). CONCLUSION: In an apparently healthy population, new-onset DM is more strongly associated with 10-year all-cause mortality than new-onset HT. Having both DM and HT was associated with a greater risk of death when compared to having DM or HT alone.

Hypertriglyceridemia as an Independent Predictor for Ten-Year Incidence of Diabetes in Thais.

BACKGROUND: Fasting hypertriglyceridemia commonly associates with insulin resistance and is frequently prevalent in type 2 diabetes mellitus (DM). However, hypertriglyceridemia has not been investigated as an independent predictor of incidence of DM, especially in Thais. METHODS: A 10-year hospital-based retrospective cohort study was conducted in a tertiary care setting in Thailand. Health check-up data in 2007 from healthy participants without underlying disease were extracted as baseline data. In 2017, 10 years following an initial examination, the diagnosis of DM and other laboratory data were identified. Hypertriglyceridemia was defined as fasting triglyceride level ≥ 150 mg/dL. A generalized additive model (GAM) was applied to demonstrate a relationship between fasting TG level and probability of incident DM in 10 years. An association between hypertriglyceridemia and 10-year incidence of DM was evaluated using univariable and multivariable logistic regression analysis. RESULTS: A total of 1342 non-diabetic adults with complete both baseline and 10-year follow-up data were included in the analysis. The incidence of DM in the study period was 10.3%. Baseline fasting triglyceride level is significantly higher in participants with incidence of DM, with a median difference of 45 mg/dL (P < 0.01). Univariable logistic regression showed that hypertriglyceridemia was associated with 10-year incidence of DM (odds ratio (OR) 3.03, 95% CI 2.12-4.35). After adjusting for potential confounders, hypertriglyceridemia remained significantly associated with incidence of DM (OR 2.33, 95% CI 1.61-3.39). CONCLUSION: Fasting triglyceride level is an independent risk factor for the development of new-onset DM. Testing for hypertriglyceridemia in people without diabetes may be an alternative screening tool to identify populations at risk of developing future DM, as well as providing triglyceride as a new target for DM risk reduction.

The prevalence and clinical features associated of hypothyroidism among Thai systemic sclerosis patients.

Thyroid disease, particularly hypothyroidism, has been reported in systemic sclerosis (SSc). Some clinical features of SSc can also present in hypothyroidism. Our aims were to determine the prevalence of, and describe clinical features associated with, hypothyroidism in SSc patients. We conducted a historical cohort study of adult SSc patients who underwent screening thyroid function tests at the Scleroderma Clinic, Khon Kaen University, Thailand, between 2009 and 2018. The patients who had any thyroid disorders before the onset of SSc and were diagnosed as an overlap syndrome were excluded. A total of 200 SSc were included according to sample size calculation, among whom the female to male ratio was 2:1. The majority of cases (137; 69.5%) were diffuse cutaneous SSc subset. The mean age was 55.8 ± 10.7 years and the median duration of disease 4.9 (IQR 1.6-9.9) years. Of the total, 9 had primary hypothyroidism (prevalence 4.5%; 95%CI 2.1-8.4) and 22 had subclinical hypothyroidism (prevalence 11%; 95%CI 7.0-16.2). Of the latter 22, 71% had dcSSc. Logistic regression analysis indicated that unexplained anemia was significantly associated with either subclinical hypothyroid or hypothyroidism (OR 2.74; 95% CI 1.17-6.47), whereas Raynaud's phenomenon had a negative association (OR 0.28; 95% CI 0.11-0.66). Neither severity of skin tightness nor internal organ involvement were associated with hypothyroidism among SSc patients. Clinical-subclinical hypothyroidism is uncommon among SSc patients, it is frequently associated with anemia, and less so Raynaud's phenomenon. Clinical-subclinical hypothyroidism should thus be considered in cases of unexplained anemia in SSc patients.

Metabolomic profile associated with obstructive sleep apnoea severity in obese pregnant women with gestational diabetes mellitus: A pilot study.

Obstructive sleep apnoea (OSA) is prevalent in obese women with gestational diabetes mellitus (GDM). The present pilot study explored associations between OSA severity and metabolites in women with GDM. A total of 81 obese women with diet-controlled GDM had OSA assessment (median gestational age [GA] 29 weeks). The metabolic profile was assayed from fasting serum samples via liquid chromatography-mass spectrometry (LC-MS) using an untargeted approach. Metabolites were extracted and subjected to an Agilent 1,290 UPLC coupled to an Agilent 6,545 quadrupole time-of-flight (Q-TOF) MS. Data were acquired using electrospray ionisation in positive and negative ion modes. The raw LC-MS data were processed using the OpenMS toolkit to detect and quantify features, and these features were annotated using the Human Metabolite Database. The feature data were compared with OSA status, apnea-hypopnea index (AHI), body mass index (BMI) and GA using "limma" in R. Correlation analyses of the continuous covariates were performed using Kendall's Tau test. The p values were adjusted for multiple testing using the Benjamini-Hochberg false discovery rate correction. A total of 42 women (51.8%) had OSA, with a median AHI of 9.1 events/hr. There were no significant differences in metabolomics profiles between those with and without OSA. However, differential analyses modelling in GA and BMI found 12 features that significantly associated with the AHI. These features could be annotated to oestradiols, lysophospholipids, and fatty acids, with higher levels related to higher AHI. Metabolites including oestradiols and phospholipids may be involved in pathogenesis of OSA in pregnant women with GDM. A targeted approach may help elucidate our understanding of their role in OSA in this population.

FRAX score with and without bone mineral density: a comparison and factors affecting the discordance in osteoporosis treatment in Thais.

We investigate the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD. We found that predictions were concordant in 83.8% of patients. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD. INTRODUCTION: The Fracture Risk Assessment Tool (FRAX) is used to calculate the 10-year probability of fracture using important clinical factors, with bone mineral density (BMD) as an optional input variable. We aimed to determine the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD and to identify relevant clinical risk factors associated with discordance. METHODS: This was a cross-sectional study conducted in patients between 40 and 90 years of age who were screened for osteoporosis by BMD measurement using dual energy X-ray absorptiometry (DXA) from 2010 to 2018 at a university hospital in Thailand. A FRAX questionnaire was administered to determine demographic data and osteoporotic risk factors. FRAX scores with and without BMD were calculated for each participant using the Thai reference, and patients were categorized into either the treatment or non-treatment group based on a cut-off of 3% 10-year probability of hip fracture. When FRAX scores with and without BMD results were consistent, they were considered concordant. Otherwise, they were deemed discordant. Clinical risk factors were compared between the concordant and discordant groups. RESULTS: A total of 3545 participants were included in the study. The majority (83.8%) were in the concordant group. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were significantly associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD. CONCLUSION: FRAX scores with and without BMD yielded concordant predictions regarding the 10-year probability of hip fracture suggesting pharmacological treatment. However, this concordance declined in elderly and osteoporotic participants and in those with FRAX without BMD around intervention threshold. BMD data may be required in these populations in order to facilitate accurate risk assessment.

Ketogenic Diet-Induced Diabetic Ketoacidosis in a Young Adult with Unrecognized Type 1 Diabetes.

Ketogenic diet, a very low-carbohydrate diet and high-fat diet, has emerged as a popular approach for weight reduction, particularly in young adults. However, a serious but rare complication of the ketogenic diet is ketoacidosis associated with low carbohydrate intake, which should be cautiously monitored in people with a predisposition to the condition. We report a 22-year-old Thai woman with an unremarkable past medical history who presented with an acute onset of dyspnea of 2 days' duration. Diabetic ketoacidosis was diagnosed by elevated capillary blood glucose, significant metabolic acidosis, and a high serum beta-hydroxybutyrate level. Low C-peptide level and positive islet autoantibodies confirmed the new diagnosis of type 1 diabetes in this patient. After her conditions were stabilized, the patient revealed that she began a ketogenic diet for weight reduction 4 days before her illness. Other precipitating factors were not identified. This highlights that ketogenic diet may increase diabetic ketoacidosis risk at the presentation of previously unrecognized type 1 diabetes.

Elevated Serum Uric Acid is Associated with Rapid Decline in Kidney Function: A 10-Year Follow-Up Study.

PURPOSE: The long-term impact of changes in serum uric acid (SUA) concentration on the estimated glomerular filtration rate (eGFR) among the general population remains unclear. We investigated the longitudinal associations between changes in SUA and eGFR over 10 years in 1222 participants with baseline eGFR ≥60 mL/min/1.73 m2. METHODS: This was a 10-year retrospective cohort study conducted from 2007 to 2017. Rapid eGFR decline (defined as the highest quartile of change in eGFR between 2007 and 2017) and new-onset kidney disease (defined as an eGFR <60 mL/min/1.73 m2 at a 10-year follow-up) were examined using multiple logistic regression analysis, adjusted for sex, age, body mass index, systolic blood pressure, SUA, fasting plasma glucose, serum total cholesterol, and triglyceride at baseline. RESULTS: SUA was inversely correlated with eGFR, and the slopes of the SUA-eGFR regression lines were consistently steeper in females than males. A significant inverse correlation was also observed between 10-year changes in SUA and eGFR in both sexes. Multivariate analysis showed that every 1 mg/dL increase in SUA from baseline was associated with higher risk of rapid eGFR decline and new-onset kidney disease (OR 1.25; 95% CI 1.14-1.33 and OR 1.40; 95% CI 1.26-1.49, respectively). Furthermore, the subjects in the highest SUA quartile (>6.0 mg/dL) had a 2.45 times higher risk of rapid eGFR decline (95% CI 1.51-3.42) compared to those in the lowest SUA quartile (<3.9 mg/dL). CONCLUSION: Elevated baseline SUA is an independent risk factor for rapid eGFR decline and new-onset kidney disease in the general population.

The Trabecular Bone Score as a Predictor for Thalassemia-Induced Vertebral Fractures in Northeastern Thailand.

INTRODUCTION: Thalassemia bone disease is one of the disease-related complications in patients with thalassemia. Prevalence of fractures and the role of a trabecular bone score (TBS) as a predictive factor for fractures were evaluated in patients with thalassemia. METHODS: A cross-sectional study was conducted in patients with thalassemia aged ≥18 years at Srinagarind Hospital, Khon Kaen University, Thailand. A lateral thoracolumbar radiograph and bone mineral density (BMD) at the lumbar spine and hip, as well as the TBS measured by dual-energy X-ray absorptiometry (DXA), were evaluated in all patients. RESULTS: Among 86 patients, 14 patients were found to have radiographic vertebral fracture yielding a prevalence of 16.3%. All patients who had fractures were ß-thalassemia/Hb E. Combined low BMD and TBS at lumbar spines and a presence of endocrinopathies were significantly associated with vertebral fractures. CONCLUSIONS: The prevalence of vertebral fractures in patients with thalassemia was not uncommon. A combined low BMD and TBS and a presence of endocrinopathies were associated with vertebral fractures. These findings suggested that BMD testing and TBS measurement have a clinical implication as a screening tool for evaluating the risk of vertebral fractures in thalassemic patients, particularly in ß-thalassemia/Hb E who have endocrinopathies.

Prevalence of asymptomatic radiographic vertebral fracture in postmenopausal Thai women.

We aim to investigate the nationwide prevalence of asymptomatic radiographic vertebral fracture in Thailand. We found 29% of postmenopausal women had at least one radiographic vertebral fracture. The prevalence was significantly higher among women with osteoporosis at the total hip (TH) region which implies that TH bone mineral density is a determinant of vertebral fracture risk. INTRODUCTION: Radiographic vertebral fracture is associated with an increased risk of osteoporotic fracture and mortality in postmenopausal women. We designed a study to determine the prevalence of asymptomatic vertebral fractures in postmenopausal Thai women. METHODS: The study was designed as a cross-sectional investigation at five university hospitals so as to achieve representation of the four main regions of Thailand. Radiographs were taken from 1062 postmenopausal women averaging 60 years of age. The presence of vertebral fracture was assessed by the Genant's semiquantitative method with three independent radiologists. Respective bone mineral density was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar spine (LS), femoral neck (FN), and total hip (TH). RESULTS: Among the 1062 women, 311 were found to have at least one radiographic vertebral fracture-yielding a prevalence of 29% (95% CI 23.6-32.0%)-and 90 (8.5%, 95% CI 6.8-10.2%) had at least two fractures. The prevalence of vertebral fracture increased with advancing age. Most fractures occurred at one vertebra (71%) and only 29% at multiple vertebrae. The prevalence of vertebral fracture was significantly higher among women with osteoporosis compared with non-osteoporosis at the TH region. There was no significant difference in the prevalence among women with or without osteoporosis at the LS or FN. CONCLUSIONS: Radiographic vertebral fractures were common among Thai postmenopausal women (~ 29%). These findings suggest that approximately one in three postmenopausal women has undiagnosed vertebral fracture. Radiographic diagnosis should therefore be an essential investigation for identifying and confirming the presence of vertebral fractures.

Concurrence of Myasthenia Gravis and Thyroid Disorders: A Retrospective Database Study.

INTRODUCTION: Both myasthenia gravis (MG) and autoimmune thyroid diseases (AITDs) are autoimmune diseases. Graves'disease (GD) is the most common AITD reported to be associated with MG. Currently, there is limited data on prevalence and clinical features/outcomes of MG in various thyroid diseases in a large database report. METHODOLOGY: A total of 872 patients with MG and 97,251 patients with thyroid disorders had been recorded by the tertiary hospital database. The study period was between 1997 and 2017. Patients with a thyroid disorder and MG were identified by the ICD-10-CM code. Clinical courses of MG accompanied by thyroid disorders were studied. RESULTS: During the 20-year study period, there were 872 patients with MG and 97,251 patients with thyroid disorders. In the group with thyroid disorders, 28,886 patients (29.70%) had GD, 1,612 patients (1.66%) had Hashimoto's thyroiditis (HT), 13,172 patients (13.54%) had toxic goiter and 53,581 patients (55.10%) had nontoxic goiter. Ninety-seven patients had been diagnosed with both MG and thyroid disorders. Among the four types of thyroid disorders, the rate of MG was highest in HT group (9.92/1,000 HT patients). There were four significant factors among four groups of thyroid disorders including age of onset of thyroid disease (p 0.004), MG classification (p<0.001), MG treatment (p<0.001), and thymic pathology (p 0.034). Among the four groups of thyroid disorders, patients with MG and HT were diagnosed with thyroid disease at the youngest age (27 years) compared with other thyroid diseases. Additionally, the MG patients with HT also had the highest proportion of MG class 4-5 a/b (7 patients, 43.75%), received prednisolone treatment (15 patients, 93.75%), received immunosuppressants (9 patients, 56.25%), received IVIG or PLEX (5 patients, 31.30%), and had thymoma (6 patients, 46.15%). CONCLUSION: MG is most prevalent in patients with HT. Patients with both MG and HT had more severe MG status and had higher rate of thymoma.

Trimethylamine N-Oxide and Risk of Cardiovascular Disease and Mortality.

PURPOSE OF REVIEW: Trimethylamine N-oxide (TMAO) is a gut microbiota-dependent metabolite produced from choline and phosphatidylcholine. Trimethylamine N-oxide was found associated with enhanced atherosclerosis and thrombosis in vitro and in vivo. We summarized available clinical studies which investigated TMAO's role in predicting prognostic outcomes, including mortality, in patients with cardiovascular diseases. RECENT FINDINGS: In chronic kidney disease cohorts, higher TMAO levels were significantly associated with higher mortality from 1.18 to 4.32 folds. Higher TMAO levels were not significantly associated with mortality in patient undergoing dialysis. In patients with peripheral artery disease, higher TMAO levels were associated with higher overall mortality from 1.38 to 2.06 folds. In patients with type 2 diabetes, higher TMAO levels were significantly associated with higher overall mortality 2.07 to 2.7 folds. In patients with heart failure, higher TMAO levels were associated with higher mortality or cardiac transplantation 1.18 to 1.79 folds. TMAO levels could potentially be integrated to existed risk stratification tools and could lead to novel prevention and treatment approaches to cardiovascular disease. Nonetheless, more studies would be needed to clarify predictive value of TMAO to specific groups of patients. Mechanisms how TMAO affect atherosclerosis and confounding effects of TMAO with traditional cardiovascular parameters should also be further investigated.