Re-emergence of a forgotten diabetes complication: Euglycemic diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is the most common emergency complication of diabetes. Euglycemic DKA (EDKA), on the other hand, has been known for many years but is a rare and under-recognized condition and constitutes a very small proportion of DKA cases. However, in recent years, an increase in the incidence of EDKA has been observed with the widespread use of sodium-glucose co-transporter 2 inhibitors, which have proven benefits in the treatment of diabetes mellitus and its cardiorenal complications, heart failure, and chronic kidney disease. Unlike classical DKA, these patients without significant hyperglycemia can easily be missed in emergency departments. EDKA should be kept in mind in patients with diabetes presenting with DKA but with a blood glucose level <250 mg/dL. The diagnostic and therapeutic approach after clinical suspicion in these patients is similar to classical DKA and is briefly summarized in this review. The most important point in treatment is that these patients are normoglycemic but have a significant insulin deficiency (relative or absolute). Therefore, insulin is the mainstay of the treatment and should be given together with dextrose solutions to avoid hypoglycemia.

Are disease-related symptoms important to predicting developing diabetes from prediabetes?

BACKGROUND: There are not many studies conducted to detect and recognize the symptoms during the prediabetes period. In our study, we aimed to determine the symptoms that can be seen in prediabetes and diabetes and their prevalence and to determine the similarities and differences between the two groups. METHODS: Individuals who were diagnosed with prediabetes or diabetes, over the age of 18, literate, and accepted to collaborate were included in our study. The "Diabetes Symptoms Checklist Scale" was used by interviewing 321 participants, 161 prediabetic and 160 diabetic, face-to-face. RESULTS: It has been found that the most common symptom in both the prediabetes and the diabetes group is "fatigue" (88.2% prediabetes, 89.4% diabetes). The symptoms seen in the dimensions of neurology and hyperglycemia are more common in individuals with diabetes than in individuals with prediabetes [neurology score: 1.85 ± 0.84 vs. 1.66 ± 0.64 (p = 0.02), respectively; hyperglycemia score: 2.39 ± 0.94 vs. 2.08 ± 0.83 (p = 0.002), respectively]. It was observed that the symptom burden increased in all subdimensions with the long duration of illness, being a female, not working, having a family history, and not doing exercise, and high fasting blood glucose and high HbA1c values. The level of education, family history, accompanying hyperlipidemia, neurology, and hyperglycemia symptoms are associated with diabetes; and it has been determined that cardiology symptoms are associated with prediabetes. DISCUSSION: Especially; during the follow-up of patients with prediabetes who have a low education level and diabetic family history and concomitant hyperlipidemia, there may be an increase in neurological and hyperglycemic symptoms at the point of development of type 2 diabetes. In this respect, we recommend that these factors, which we found to be predictive of diabetes compared to prediabetes, should be questioned more carefully during patient visits.

Serum irisin levels in newly diagnosed type-II diabetic patients: No association with the overall diet quality but strong association with fruit intake.

OBJECTIVE: This study aimed to investigate the serum irisin levels and diet quality of newly-diagnosed type 2 diabetes mellitus (T2DM) patients in comparison with healthy controls and to identify the correlations between serum irisin levels with diet quality, anthropometric measurements and biochemical parameters. SUBJECTS/METHODS: This case-control study was conducted with 38 newly-diagnosed T2DM patients and 38 healthy control individuals. Diet quality was calculated from the semi-quantitative food frequency questionnaire by using the Healthy Eating Index (HEI) 2015. The anthropometric measurements were taken and body composition was analyzed with bioelectric impedance analysis (BIA) method. Biochemical parameters and serum irisin levels were analyzed in blood samples which were obtained after overnight fasting. RESULTS: Irisin levels were higher in the T2DM group compared to the healthy control group (2.57 ± 0.44 ng/mL and 2.15 ± 0.44 ng/mL, respectively; p < 0.001). The optimal cut-off value for irisin to predict T2DM was 2.195 ng/mL (specificity = 71.1%, sensitivity = 78.9%). In both groups, irisin levels were not associated with overall HEI 2015; however, they were positively associated with total and whole fruit scores in the T2DM group (p < 0.05). After adjustment according to age, sex and BMI, in the T2DM group HDL cholesterol positively affected by irisin levels, while in the control group triglyceride positively affected irisin levels (p < 0.05). CONCLUSION: High levels of irisin in newly diagnosed T2DM patients compared to healthy individuals indicate that irisin may have a role in the monitoring and treatment of T2DM. Though irisin levels were not associated with total diet quality, they were associated with fruit consumption.

Is oxidative stress a factor in the pathogenesis of subacute thyroiditis?

INTRODUCTION: In a performed study, selenium levels were detected to be lower in subacute thyroiditis (SAT). This outcome suggests that the oxidant-antioxidant system may play a role in the aetiopathogenesis of SAT, as is the case for many other diseases. The aim of the present study was to detect whether any association exists between SAT and oxidative stress, and to determine the factors of a possible association. MATERIAL AND METHODS: Twenty-five patients who were newly diagnosed with SAT and 30 healthy volunteers were enrolled in the study. Total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), paraoxonase 1 (PON1), and dynamic thiol/disulphide [native thiol (NT), total thiol (TT), disulphide (DS), DS/TT, DS/NT, and NT/TT] levels of the participants were evaluated. RESULTS: Total thiol and NT levels were found to be lower in the SAT group (p < 0.001). DS/NT and DS/TT levels were significantly higher in the patients with SAT, whereas NT/TT levels were lower (p < 0.05). A negative correlation was detected between C-reactive protein (CRP) and TAS, whereas a positive correlation was detected between CRP and OSI. There was a negative association between TSH and TAS only in the partial correlation analysis by adjusting for age, white blood cell count, neutrophil (Neu) level, CRP, and erythrocyte sedimentation rate (ESR) (r = -0.481, p = 0.043). CONCLUSIONS: Thiol levels are significantly decreased and thiol/disulphide homoeostasis is disrupted in patients with SAT. The present study has presented for the first time that there may be an association between SAT and oxidative stress.

Dynamic thiol/disulfide homeostasis and oxidant status in patients with hypoparathyroidism.

BACKGROUND: In this study, we aimed at determining the dynamic thiol/disulfide homeostasis and oxidant balance, and investigating the relation of these parameters to the severity of the disease and the serum calcium levels. METHODS: 55 patients with iatrogenic hypoparathyroidism follow-ups and 40 healthy volunteers were included in the study. The blood dynamic thiol/sulfide balance, Total Antioxidant Status (TAS), Total Oxidant Status (TOS), Paraoxonase Enzyme Activity (PON) levels were measured in serum samples. RESULTS: In our study, it was found that the disulfide, disulfide/native thiol, disulfide/total thiol levels were higher in the hypoparathyroidism group. A negative correlation was found between 25-hydroxy vitamin D (25-OH vitamin D) and disulfide, disulfide/native thiol and disulfide/total thiol, and a positive correlation was found between native thiol and total thiol ratio; and the corrected calcium levels and PON levels were negatively correlated. CONCLUSIONS: Consequently, a change in favour of disulfide was found in the dynamic thiol-disulfide homeostasis in the hypoparathyroidism group in our study.

Can neutrophil/lymphocyte ratio be used as an indicator of inflammation in patients with hyperthyroidism?

BACKGROUND: In our study, we aimed to evaluate changes in the neutrophil and lymphocyte series and investigate whether the neutrophil/lymphocyte ratio (NLR) is indicative of inflammations in patients with hyperthyroidism. METHODS: A total of 161 patients were enrolled, 121 of which had hyperthyroidism (71 Graves' Disease (GD) and 50 non-Graves hyperthyroidism (NGH) patients) and 40 of which were control group members. Retrospectively, patients' neutrophil and lymphocyte counts were taken, and the NLR was calculated. RESULTS: While the number of neutrophils was significantly lower in the GD group (p = 0.003), there was no significant difference between the NGH and the control group. In the GD group, NLR values were significantly lower than the other two groups (median 1.39 for GD, median 1.84 for NGH and median 1.83 for the control group, p < 0.001). Only three patients in the GD group had neutropenia. There was also a significant negative correlation between free T3 and neutrophil count and NLR in hyperthyroid patients (r = -0.28, p = 0.001 and r = -0.34, p < 0.001, respectively). CONCLUSIONS: In our study, we found that NLR did not in crease in hyperthyroid patients and that this ratio decreased due to the decrease in neutrophil levels in GD. We thus concluded that NLR is not a suitable indicator of hyperthyroidism.

Central and peripheral blood pressures and arterial stiffness increase in hypoparathyroidism.

Objective The aim of the present study was to evaluate whether arterial stiffness is affected in the patients with hypoparathyroidism through pulse wave analysis (PWA). Subjects and methods Sixty-three patients diagnosed with hypoparathyroidism and sixty volunteers were evaluated for the study. When 21 patients were excluded in the hypoparathyroidism group due to exclusion criteria, the research continued with 42 patients and 60 volunteers who are similar to the patients in terms of age, gender and body mass index (BMI). Fasting plasma glucose after 10 hours of fasting, creatinine, thyroid stimulating hormone (TSH), free thyroxine (fT4), albumin, calcium, phosphorus, magnesium, 25-OH vitamin D, parathormone (PTH) and urine calcium results in 24-hour urine for the patients in the hypoparathyroidism group were recorded. Evaluation of arterial stiffness was performed by Mobil-O-Graph 24h PWA device. Results Systolic blood pressure (SBP) (p = 0.01), diastolic blood pressure (DBP) (p = 0.005), mean blood pressure (p = 0.009), central SBP (p = 0.004), central DBP (p = 0.01) and pulse wave velocity (PWV) (p = 0.02) were found higher in the hypoparathyroidism group. A positive correlation was detected between phosphorus level and SBP [(p = 0.03. r = 0.327)], central SBP [(p = 0.04, r = 0.324)] and PWV [(p = 0.003, r = 0.449)]. We detected that age and serum phosphorus levels were independent predictor variables for PWV (B = 0.014, p < 0.001 and B = 0.035, p < 0.001, respectively). Conclusion We detected that hypoparathyroidism causes an increase in blood pressure and arterial stiffness. The most significant determinant factors were detected as advanced age and hyperphosphatemia. The patients diagnosed with hypoparathyroidism should be closely monitored and treatment planning should include to prevent the patients from hyperphosphatemia.

Should the dose of levothyroxine be changed in hypothyroidism patients fasting during Ramadan?

Background/aim: Muslims worship by fasting from predawn (suhoor) until sunset (iftar) for 30 days in the religious month of Ramadan. In addition to prolonged hunger, patients fasting with a diagnosis of hypothyroidism take their doses of levothyroxine (LT4) outside of daytime fasting hours. The purpose of our study is to compare the values of hypothyroid patients which have been obtained through thyroid function tests before and after Ramadan. Materials and methods: Ninety-seven patients; ranging from 18 to 65 years old, who were followed with a diagnosis of hypothyroidism, who fasted during Ramadan, and who had no change of their LT4 dose for at least 6 months were included in the study. Results: The median serum thyroid-stimulating hormone (TSH) level of patients prior to fasting was 2.19 mIU/L, while median serum TSH after fasting was 2.73 mIU/L. Serum TSH values after Ramadan increased significantly compared to those prior to Ramadan (P = 0.004). Conclusion: Our study demonstrates a significant increase in serum TSH levels after Ramadan but no significant change in serum free thyroxine (fT4) levels in hypothyroidism patients who are fasting. It may be appropriate to take precautions by making a small increase in LT4 dose before Ramadan in some hypothyroid patients wishing to fast.

Changes in Conjunctiva Morphology Using Impression Cytology in Patients with Hashimoto's Thyroiditis without Thyroid-Associated Ophthalmopathy

OBJECTIVE: To compare the conjunctival morphological changes in patients with Hashimoto's thyroiditis (HT) without thyroid-associated ophthalmopathy (TAO) and controls using impression cytology technique. MATERIAL AND METHOD: We included 25 HT patients and 33 healthy controls who did not have TAO findings or dry eye. For both groups, thyroid stimulating hormone (TSH), free T4(FT4), and anti-thyroid peroxidase (anti-TPO) were measured. Thyroid ultrasonography was performed, together with all routine eye check-ups and the Schirmer's test. Also, conjunctival impression cytology (CIC) test was performed to analyze the conjunctival morphology. RESULTS: When the CIC of HT patients was observed; 12% had grade 0, 40% had grade 1, 28% had grade 2 and 20% had grade 3. While patients with squamous metaplasia made up 48% of the HT group, this was observed at 6.1% in the control group (p < 0,001). In the regression model formulated, it was observed that obesity (OR=7.500; p=0.017) and anti TPO levels (OR=1.370, p=0,007) were independent stipulations for the squamous metaplasia. CONCLUSION: Conjunctival squamous metaplasia was more frequently seen in HT than controls and serum Anti-TPO level and obesity were detected as independent predictors of the worsening at the conjunctival impression cytology.

Investigation of blood groups in benign thyroid diseases in Turkey.

It is known that there is a relationship between some diseases and blood groups. The objective of our study is to investigate how often ABO and Rh blood groups are seen in benign thyroid diseases, especially in autoimmune-mediated thyroid diseases, and hence whether there is an association between blood groups and thyroid diseases. A total of 958 patients who were followed due to any benign thyroid disease were included in the study. The study population comprised 958 patients, 550 with Hashimoto's hypothyroidism, 160 with non-Hashimoto's hypothyroidism, 103 with iatrogenic hypothyroidism, 93 with central hypothyroidism, and 28 with Graves' and 24 with non-Graves' hyperthyroidism. Of the patients, 47.1% belonged to the O blood group, 30% to the A blood group, 15.2% to the B blood group, and 7.7% to the AB blood group while 90% were Rh-positive. The ratio of those with the O blood group was determined to be significantly higher in the Hashimoto's hypothyroidism group compared to the other disease groups. In the non-Hashimoto's hypothyroidism group, however, the ratio of the AB blood group was statistically significantly higher. While autoimmune diseases were more common in those with the O blood group, they were significantly lower in the AB blood group (p < 0.001). In our study, we determined that the ratio of the O blood group was significantly higher among patients with hypothyroidism due to Hashimoto's thyroiditis. These findings imply that there might be a relation between O blood group and Hashimoto's thyroiditis.

The Relationship Between Obesity, Insulin Resistance, and Conjunctival Impression Cytology.

OBJECTIVE: This study was designed to determine whether obesity causes the development of metaplasia in conjunctival epithelial cells. MATERIAL AND METHOD: A total of 61 volunteer participants who had no previous history of illness or drug use were involved in this study. Of those, 20 were obese, and 41 were of normal weight. We measured the glucose and insulin values of all volunteers. We also measured the Body Mass Index (BMI) and Homeostasis Model Assessment for Insulin Resistance (HOMA IR). The impression cytology method was used to analyze the conjunctival epithelium cells, and to classify them between Grades 0 to 3 according to the Nelson criteria. RESULTS: There was a certain level of loss of goblet cells on the 90% level as well as squamous metaplasia (Grade 2-3) in 80% of the obese participants and impression cytology was found to be normal in only two patients. The expected results were observed in 56.1% of the control group where the squamous metaplasia rate was nearly 17% (p < 0.001). 90.9% of the grade 3 patients were obese. The variables as independent predictors were found to indicate the existence of abnormal cytology in the conjunctiva at various levels; BMI (OR: 1.24; p=0.002) and HOMA IR (OR= 28.6; p= 0.001) in a Model I multivariable regression model, and the existence of obesity (OR: 11.91; p=0.002) and HOMA IR (OR= 15.08; p < 0.001) in a Model II multivariable regression model. CONCLUSION: Obesity was found to be a disorder that causes metaplasia in the conjunctival epithelium cells for the first time.

Evaluation of Cardiovascular Risk With Arterial Stiffness in Patients with Nonfunctioning Pituitary Adenoma.

OBJECTIVE: Nonfunctioning pituitary adenoma (NFPA) accounts for 30% of all pituitary adenomas, and its incidence has been increasing compared to previous years. Increased risk of cardiovascular effects shown in recent studies is noteworthy in patients with NFPA diagnosis, but the number of studies on the subject is limited. In this study, we aimed to assess possible cardiovascular effects and risk via arterial stiffness measurements in patients diagnosed with NFPA. METHODS: We performed arterial stiffness measurements for 30 patients diagnosed with NFPA and 30 healthy volunteers and compared the results to explore the relationship between arterial stiffness parameters, hormone levels, and adenoma size. RESULTS: Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), central SBP, central DBP, augmentation index corrected for a heart rate of 75 beats per minute (AIx@75), and pulse wave velocity (PWV) values of the patients with NFPA diagnosis were significantly higher than the control group. PWV was found to have a significant and negative correlation with growth hormone and insulin-like growth factor 1 (IGF-1). A significant and positive correlation was found between adenoma median short-axis length and PWV. IGF-1 was found to have a significant and negative correlation with adenoma median long- and short-axis length. In multivariate linear regression analysis, we found that IGF-1 was an independent predictor of PWV. CONCLUSION: Both arterial stiffness parameters such as AIx@75 and PWV and peripheral SBP, DBP, and MBP values were found to be high in NFPA patients with no cardiovascular risk factors. Our findings suggest increased cardiovascular effect and risk in patients with NFPA diagnosis, and therefore, we recommend that patients are monitored closely in this respect. ABBREVIATIONS: ACTH = adrenocorticotropic hormone; AIx@75 = augmentation index corrected for a heart rate of 75 beats per minute; BMI = body mass index; CVD = cardiovascular disease; DBP = diastolic blood pressure; FSH = follicle-stimulating hormone; GH = growth hormone; HT = hypertension; IGF-1 = insulin-like growth factor 1; LH = luteinizing hormone; MBP = mean blood pressure; MRI = magnetic resonance imaging; NFPA = nonfunctioning pituitary adenoma; PP = pulse pressure; PWA = pulse wave analysis; PWV = pulse wave velocity; SBP = systolic blood pressure; TSH = thyroid-stimulating hormone.

Nonfunctioning adrenal incidentaloma affecting central blood pressure and arterial stiffness parameters.

PURPOSE: Recently, cardiovascular risk is thought to be increased in patients with nonfunctioning adrenal incidentaloma (NFAI). There are no sufficient studies in the literature to evaluate this situation in NFAI patients without cardiovascular risk. The objective of this study is to compare peripheral and central blood pressure and arterial stiffness between patients with NFAI and healthy volunteers (of a similar age, gender and body mass index as the NFAI group) who have no traditional cardiovascular risk factors and autonomous cortisol secretion, with pulse wave analysis (PWA). METHODS: In this cross-sectional study, we evaluated 35 NFAI patients who have no traditional cardiovascular risk factors and 35 healthy volunteers. PWA was performed in the participants of similar gender, age and body mass index, with a Mobil-O-Graph PWA/ABPM (I.E.M. GmBH, Stolberg, Germany) device. Radiological and biochemical data were obtained retrospectively in the NFAI group. RESULTS: In our study, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), central SBP, central DBP, peripheral vascular resistance, augmentation pressure (AP), heart rate-corrected augmentation index (Aix@75) and pulse wave velocity (PWV) values were significantly higher in the NFAI group compared to the control group. In addition, peripheral and central blood pressure and arterial stiffness parameters were correlated with age and duration of NFAI diagnosis of more than 1 year. CONCLUSIONS: NFAIs are known as cardiometabolically innocent, but in our study, both peripheral and central blood pressure values and arterial stiffness parameters were negatively affected in patients diagnosed with NFAI who have no traditional cardiovascular risk factors. These patients are at risk of cardiovascular diseases.

The effect of glycemic control on CEA, CA 19-9, amylase and lipase levels.

BACKGROUND: Diabetes mellitus is closely related to pancreas cancer. In this study we aimed to investigate the effect of hyperglycemia on tumor and inflammation markers, as well as pancreatic exocrine functions. METHODS: A total of 98 consecutive diabetic patients with poor glycemic control, and 50 healthy controls were included in the study. We measured hsCRP, erythrocyte sedimentation rate (ESR), CA19-9, CEA, amylase and lipase in addition to routine biochemistry tests, before and after euglycemia was achieved. RESULTS: Fasting blood glucose, HbA1c, CA19-9, CEA, hsCRP, ESR, triglycerides, AST, ALT, GGT, ALP, total cholesterol and LDL-C levels decreased significantly with the regulation of glycemic control. Amylase and lipase levels increased with the regulation of glycemic control. After glycemic control, CA19-9 and CEA levels were still higher, whereas amylase and lipase levels were still lower in the diabetic group compared with the control group. Basal HbA1c showed significant correlation with CA19-9, CEA, amylase and lipase. CONCLUSIONS: We propose to repeat observations of tumor markers after hyperglycemia is resolved, in order to avoid unnecessary invasive tests. Our data also suggest that pancreatic exocrine function was improved with lowering blood glucose in a short period of time.