Comparative Effectiveness of Team-Based Care With and Without a Clinical Decision Support System for Diabetes Management : A Cluster Randomized Trial.

BACKGROUND: Uncontrolled hyperglycemia, hypercholesterolemia, and hypertension are common in persons with diabetes. OBJECTIVE: To compare the effectiveness of team-based care with and without a clinical decision support system (CDSS) in controlling glycemia, lipids, and blood pressure (BP) among patients with type 2 diabetes. DESIGN: Cluster randomized trial. (ClinicalTrials.gov: NCT02835287). SETTING: 38 community health centers in Xiamen, China. PATIENTS: 11 132 persons aged 50 years or older with uncontrolled diabetes and comorbid conditions, 5475 receiving team-based care with a CDSS and 5657 receiving team-based care alone. INTERVENTION: Team-based care was delivered by primary care physicians, health coaches, and diabetes specialists in all centers. In addition, a computerized CDSS, which generated individualized treatment recommendations based on clinical guidelines, was implemented in 19 centers delivering team-based care with a CDSS. MEASUREMENTS: Coprimary outcomes were mean reductions in hemoglobin A1c (HbA1c) level, low-density lipoprotein cholesterol (LDL-C) level, and systolic BP over 18 months and the proportion of participants with all 3 risk factors controlled at 18 months. RESULTS: During the 18-month intervention, HbA1c levels, LDL-C levels, and systolic BP significantly decreased by -0.9 percentage point (95% CI, -0.9 to -0.8 percentage point), -0.49 mmol/L (CI, -0.53 to -0.45 mmol/L) (-19.0 mg/dL [CI, -20.4 to -17.5 mg/dL]), and -9.1 mm Hg (CI, -9.9 to -8.3 mm Hg), respectively, in team-based care with a CDSS and by -0.6 percentage point (CI, -0.7 to -0.5 percentage point), -0.32 mmol/L (CI, -0.35 to -0.29 mmol/L) (-12.5 mg/dL [CI, -13.6 to -11.3 mg/dL]), and -7.5 mm Hg (CI, -8.4 to -6.6 mm Hg), respectively, in team-based care alone. Net differences were -0.2 percentage point (CI, -0.3 to -0.1 percentage point) for HbA1c level, -0.17 mmol/L (CI, -0.21 to -0.12 mmol/L) (-6.5 mg/dL [CI, -8.3 to -4.6 mg/dL]) for LDL-C level, and -1.5 mm Hg (CI, -2.8 to -0.3 mm Hg) for systolic BP. The proportion of patients with controlled HbA1c, LDL-C, and systolic BP was 16.9% (CI, 15.7% to 18.2%) in team-based care with a CDSS and 13.0% (CI, 11.7% to 14.3%) in team-based care alone. LIMITATION: There was no usual care control, and clinical outcome assessors were unblinded; the analysis did not account for multiple comparisons. CONCLUSION: Compared with team-based care alone, team-based care with a CDSS significantly reduced cardiovascular risk factors in patients with diabetes, but the effect was modest. PRIMARY FUNDING SOURCE: Xiamen Municipal Health Commission.

Diagnostic performance of six ultrasound-based risk stratification systems in thyroid follicular neoplasm: A retrospective multi-center study.

This study aimed to compare the diagnostic performances of six commonly used ultrasound-based risk stratification systems for distinguishing follicular thyroid adenoma (FTA) from follicular thyroid carcinoma (FTC), including the American Thyroid Association Sonographic Pattern System (ATASPS), ultrasound classification systems proposed by American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinology (AACE/ACE/AME), Korean thyroid imaging reporting and data system (K-TIRADS), European Thyroid Association for the imaging reporting and data system (EU-TIRADS), American College of Radiology for the imaging reporting and data system (ACR-TIRADS), and 2020 Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules (C-TIRADS). A total of 225 FTA or FTC patients were retrospectively analyzed, involving 251 thyroid nodules diagnosed by postoperative pathological examinations in three centers from January 2013 to October 2021. The diagnostic performances of six ultrasound-based risk stratification systems for distinguishing FTA from FTC were assessed by plotting the receiver operating characteristic (ROC) curves and compared at different cut-off values. A total of 205 (81.67%) cases of FTA and 46 (18.33%) cases of FTC were involved in the present study. Compared with those of FTA, FTC presented more typical ultrasound features of solid component, hypoechoic, irregular margin and sonographic halo (all P<0.001). There were no significant differences in ultrasound features of calcification, shape and comet-tail artifacts between cases of FTA and FTC. There was a significant difference in the category of thyroid nodules assessed by the six ultrasound-based risk stratification systems (P<0.001). The areas under the curve (AUCs) of ATASPS, AACE/ACE/AME, K-TIRADS, EU-TIRADS, ACR-TIRADS and C-TIRADS in distinguishing FTA from FTC were 0.645, 0.729, 0.766, 0.635, 0.783 and 0.798, respectively. Our study demonstrated that all the six ultrasound-based risk stratification systems present potential in the differential diagnosis of FTA and FTC. Specifically, C-TIRADS exerts the best diagnostic performance among the Chinese patients. ATASPS possesses a high sensitivity, while K-TIRADS possesses a high specificity in distinguishing FTA from FTC.

Sex-Specific Associations Between Low Muscle Mass and Glucose Fluctuations in Patients With Type 2 Diabetes Mellitus.

Objective: Studies have shown that sex differences in lean mass, concentrations of sex hormones, and lifestyles influence cle health and glucose metabolism. We evaluated the sex-specific association between low muscle mass and glucose fluctuations in hospitalized patients with type 2 diabetes mellitus (T2DM) receiving continuous subcutaneous insulin infusion (CSII) therapy. Methods: A total of 1084 participants were included. Body composition was determined by dual-energy X-ray absorptiometry. Intraday blood glucose fluctuation was estimated by the Largest amplitude of glycemic excursions (LAGE) and standard deviation of blood glucose (SDBG). Results: The prevalence of low muscle mass was higher in males than in females (p<0.001). There was a significant sex-specific interaction between the status of low muscle mass and glucose fluctuations (LAGE and SDBG) (p for interaction=0.025 and 0.036 for SDBG and LAGE, respectively). Among males, low muscle mass was significantly associated with a higher LAGE and SDBG (difference in LAGE: 2.26 [95% CI: 1.01 to 3.51], p < 0.001; difference in SDBG: 0.45 [95% CI: 0.25 to 0.65], p < 0.001) after adjustment for HbA1c, diabetes duration, hyperlipidemia, diabetic peripheral neuropathy, diabetic nephropathy, and cardiovascular disease. These associations remained significant after further adjustment for age and C-peptide. Among females, low muscle mass was not associated with LAGE or SDBG after adjustment for all covariates. Conclusion: The prevalence of low muscle mass was higher in males than in females. Low muscle mass was significantly associated with higher LAGE and SDBG among males, but not females.

Relationship between Obstetric Mode of Delivery and Risk of Overweight/Obesity in 1- to 4-Year-Old Children.

INTRODUCTION: Childhood obesity is an important public health problem, which may lead to increased risk of obesity in adulthood. The relationship between the incidence of obesity and the mode of delivery is not clear. Cesarean section (CS) may be one of the risk factors of obesity in children. We investigated the relationship between the mode of delivery of pregnant women and the risk of overweight/obesity in children of all ages from 1 to 4 years. METHODS: Registered in the maternal and child registration system of Xiamen city, newborns born between January 2011 and December 2012 were followed up to 4 years old. RESULTS: 9,964 cases were included in the study, of which 3,462 cases (34.7%) were cesarean deliveries. From 1 to 4 years of age, BMI Z-scores and the risk for overweight/obesity of children delivered by CS were higher than by the vagina. Longitudinal analysis of anthropometric outcomes assessed during study visits in 1- to 4-year-old offspring exposed to CS showed that after adjustment for kinds of effect factors, the changes in BMI Z-scores were 0.04 (95% CI: 0.01-0.09, p = 0.003), significantly higher than vaginal delivery, and the risk incidence of overweight/obesity by increased 8% in CS offspring; OR = 1.08 (1.01-1.21, p< 0.05). CONCLUSION: The mode of cesarean delivery is related to the risk of overweight and obesity in children aged 1-4 years. When pregnant women choose cesarean delivery without medical indications, they should be concerned that their offspring may have a higher risk of obesity.

Independent associations of thyroid-related hormones with hepatic steatosis and insulin resistance in euthyroid overweight/obese Chinese adults.

PURPOSE: The aim of the study is to explore the independent association of free triiodothyronine (FT3), free thyroxine (FT4) and thyroid stimulating hormone (TSH) with hepatic steatosis and insulin resistance. METHODS: A cross-sectional study of 88 overweight/obese adults who underwent anthropometric measurements [BMI, waist circumference (WC) and waist-to-height ratio (WHtR)], hepatic steatosis assessment (FibroScan) and thyroid-related hormones tests was conducted from 2018 to 2020 in Xiamen, China. RESULTS: Subjects with increasing tertiles of FT3 showed significantly higher levels of controlled attenuation parameter (CAP) ((295.4 ± 44.1, 290.1 ± 68.2 and 331.7 ± 43.6 (dB/m) for tertile 1-3, respectively, p = 0.007) and fatty liver index (FLI) score (47.7 (33.9-60.8), 61.5 (45.1-88.9) and 90.5 (84.5-94.8), respectively, p < 0.001). FT3 significantly and positively correlated with obesity index (BMI, WC, and WHtR), homeostatic model assessment of insulin resistance (HOMA-IR) and hepatic steatosis (CAP and FLI). Multivariable linear regression analyses with adjustment for potential confounding factors showed FT3 was independently associated with BMI (regression coefficient (ß (95%CI): 0.024 (0.004-0.043), p = 0.020), HOMA-IR (ß (95%CI): 0.091 (0.007-0.174), p = 0.034), CAP (ß (95%CI): 25.45 (2.59-48.31), p = 0.030) and FLI (ß (95%CI): 0.121 (0.049-0.194), p = 0.001). Neither FT4 nor TSH was significantly associated with any indicators of obesity, insulin resistance or hepatic steatosis. CONCLUSIONS: Increased FT3, but not FT4 or TSH, was independently associated with higher risks of hepatic steatosis and insulin resistance in euthyroid overweight/obese Chinese adults. Trial registration Registration is not applicable for our study.

Benefits and harms of hemithyroidectomy, total or near-total thyroidectomy in 1-4 cm differentiated thyroid cancer.

OBJECTIVE: For 1-4 cm differentiated thyroid cancer (DTC), current ATA guideline recommended hemithyroidectomy (HT) as an acceptable alternative initial procedure to total or near-total thyroidectomy (TT). The aim of this study was to evaluate benefits and harms of HT, TT in 1-4 cm DTC. DESIGN: Retrospective cohort study. PATIENTS: DTC patients aged 18 years or older who underwent initial thyroidectomy in a tertiary medical centre were included from January 2008 to July 2018. MEASUREMENTS: The structural persistent/recurrent disease, reoperation rates and surgical complications were compared using Cox proportional regression and logistic regression. Propensity score matching was performed to adjust for related clinicopathological variables. RESULTS: Among 1824 DTC patients, 795 patients sized 1-4 cm were included. A total of 286 patients underwent HT and 509 patients underwent TT. In the matched analysis, no significant difference in disease-free survival (DFS) between HT and TT was observed during the median follow-up period of 56.5 months (hazard ratio [HR] 0.86; 95% CI, 0.37-2.00; p = .733). The difference in DFS between two groups was consistent regardless of age, sex, tumour size, follow-up duration. Meanwhile, HT was associated with a decreased risk of surgical complications (odds ratio [OR] 0.47, 95% CI 0.31-0.71, p < .001), as well as lower proportion of levothyroxine replacement (p = .007). Two cases in HT group received reoperation. Further multivariate analysis showed surgical procedure was not associated with structural persistence/recurrence (HR 0.68; 95%CI, 0.29-1.58, p = .367). CONCLUSIONS: For patients with 1-4 cm DTC without clinical evidence of lymph node metastasis or extrathyroidal extension, HT was associated with lower risk of surgical complications than TT while provided similar benefits as TT.

Comparative effectiveness of team-based care with a clinical decision support system versus team-based care alone on cardiovascular risk reduction among patients with diabetes: Rationale and design of the D4C trial.

BACKGROUND: Diabetes has become a major public health challenge worldwide, especially in low- and middle-income countries (LMICs). Uncontrolled hyperglycemia, hypertension, and dyslipidemia major risk factors for all-cause mortality and cardiovascular disease (CVD) are common in patients with diabetes in China. We propose to compare the effectiveness of team-based care plus a clinical decision support system (CDSS) with team-based care alone on glycemic, blood pressure (BP), and lipid control, and clinical CVD reduction among patients with type-2 diabetes and at high risk for CVD. METHODS: The Diabetes Complication Control in Community Clinics (D4C) study is a cluster-randomized trial conducted among 38 community health centers in Xiamen City, China. Nineteen clinics have been randomly assigned to team-based care plus CDSS and 19 to team-based care alone. Team-based care includes primary care providers, health coaches, and diabetes specialists working collaboratively with patients to achieve shared treatment goals for CVD risk factor reduction. The CDSS integrates guideline-based treatment algorithms for glycemic, BP, and lipid control, along with a patient's medical history and insurance policy, to recommend treatment and follow-up plans. In phase 1, the co-primary outcomes are mean reduction in glycated hemoglobin (HbA1c), systolic BP (SBP), and low-density lipoprotein (LDL)-cholesterol over 18 months, and the proportion of patients with controlled HbA1c, SBP, and LDL-cholesterol at 18 months' between the 2 comparison groups. In phase 2, the primary outcome is the difference in major CVD incidence (non-fatal stroke, non-fatal myocardial infarction, hospitalized heart failure, and CVD mortality) between the 2 comparison groups. Mean reduction in HbA1c, SBP, and LDL-cholesterol levels will be simultaneously modeled for a single overall treatment effect. CONCLUSION: The D4C trial will generate evidence on whether a CDSS will further reduce the CVD burden among patients with diabetes beyond team-based care at community clinics. If proven effective, this implementation strategy could be scaled up within primary care settings in China and other LMICs to reduce CVD incidence and mortality among patients with diabetes.

Resistance to thyroid hormone caused by heterozygous mutation of thyroid hormone receptor B gene c.G1378A: Report of one Chinese pedigree and literature review.

The same thyroid hormone receptor B gene (THRB) mutation led to thyroid hormone resistance with different clinical manifestations in the kindreds.

Neck circumference is a good predictor for insulin resistance in women with polycystic ovary syndrome.

OBJECTIVE: To assess the role of neck circumference (NC) in assessing insulin resistance (IR) in polycystic ovary syndrome (PCOS). DESIGN: A cross-sectional study. SETTING: University-affiliated hospital. PATIENT(S): One hundred forty-three women with PCOS were recruited from November 2018 to February 2020. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The associations of NC with IR and the cutoff points of NC for IR. RESULT(S): The prevalence rates of IR were 64.3%. The patients with PCOS with IR had significantly greater values of systolic blood pressure, NC, body mass index, waist-to-hip ratio, waist circumference, fasting blood glucose, fasting insulin, and homeostasis model assessment of insulin resistance (HOMA-IR). Pearson correlation analysis showed body mass index (log-transformed), waist circumference, waist-to-hip ratio, and HOMA-IR (log-transformed) were positively correlated with NC. Multivariable linear regression showed that NC was significantly associated with HOMA-IR (log-transformed), with the standardized regression coefficient of 0.330 with adjustment for potential confounding factors. Furthermore, multivariate logistic regression analyses showed NC was associated significantly with increased risk of IR, with the adjusted odds ratio of 1.423. Additionally, NC was able to identify IR in women with PCOS; the optimal cut-off points was 34.3 cm (Youden index = 0.586). CONCLUSION(S): Neck circumference is positively associated with IR in women with PCOS. We suggest NC as a novel, simple, practical, and reliable anthropometric measure to be used to predict the risk of IR in patients with PCOS.

MATERNAL GESTATIONAL DIABETES MELLITUS AND OFFSPRING BODY MASS INDEX FROM 1 TO 4 YEARS.

Objective: Using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria to diagnose gestational diabetes mellitus (GDM), the association between GDM and offspring body mass index (BMI) gains in early childhood in China remains unclear. We aimed to assess the association between GDM diagnosed by the IADPSG criteria and BMI gain and the risk for overweight/obesity in offspring from 1 to 4 years. Methods: This prospective cohort study was based on the healthcare records data from the Medical Birth Registry in Xiamen, China. We included 10,412 mother-child pairs tested for GDM using IADPSG criteria. Results: A total of 1,786 (17.2%) offspring were exposed to GDM. The offspring exposed to GDM had higher mean BMI Z-score (difference, 0.07; 95% confidence interval [CI], 0.02 to 0.12) and risk for overweight/obesity (odds ratio [OR], 1.22; 95% CI, 1.06 to 1.40) compared to those unexposed to GDM from 1 to 4 years of age. However, after adjustment for maternal pre-pregnancy BMI (Model 2), these associations attenuated towards the null (difference in BMI Z-score, 0.02; 95% CI, -0.03 to 0.07; OR for overweight/obesity, 1.09; 95% CI, 0.95 to 1.25). Conclusion: The associations between GDM diagnosed using IADPSG criteria and BMI Z-score and the risk for overweight/obesity in offspring at the age of 1 to 4 years were largely explained by maternal pre-pregnancy BMI. Reducing the prevalence of childhood overweight and obesity in China should focus on maternal weight status before pregnancy, in addition to glycemia during pregnancy. Abbreviations: BMI = body mass index; CI = confidence interval; GDM = gestational diabetes mellitus; IADPSG = International Association of Diabetes and Pregnancy Study Groups; LGA = large for gestational age; MBRX = Medical Birth Registry in Xiamen; OGTT = oral glucose tolerance test; OR = odds ratio.

Maternal postload 1-hour glucose level during pregnancy and offspring's overweight/obesity status in preschool age.

BACKGROUND: Childhood obesity is associated with adverse outcomes such as metabolic syndrome, diabetes, and cardiovascular diseases in adulthood. Identifying risk factors related to excessive adiposity in early childhood is of great importance for obesity intervention. The results of studies for associations between maternal with gestational diabetes and offspring obesity are conflicting. Nonetheless, the association of maternal glucose across a spectrum of glucose values with childhood adiposity outcomes is less clear. AIM: To assess the association of maternal glucose across a spectrum of glucose values with childhood adiposity at age 5 years. METHODS: A population-based cohort study was conducted between 2011 and 2018. Using the healthcare records data were from the Medical Birth Registry in Xiamen, China. The primary outcome was offspring obese/obesity. Primary predictors were maternal oral glucose tolerance test values during pregnancy. RESULTS: 6090 mother-child pairs were analyzed. The mean age of the children at follow-up was 5.2 years. At multiple logistic regression, after adjustment for variables, including maternal pre-pregnancy body mass index (BMI), birth weight of offspring, and insulin therapy, ORs for offspring overweight/obesity were 1.13 (95% CI 0.90 to 1.42) for maternal fasting glucose levels, 1.12 (95% CI 1.04 to 1.22) for 1-hour glucose, and 1.04 (95% CI 0.95 to 1.14) for 2-hour glucose. The adjusted association of offspring BMI Z-score with maternal 1-hour glucose level remained significant. There were no significant associations between BMI Z-score and maternal fasting glucose and 2-hour glucose level. Exploratory sex-specific analyses indicated generally consistent associations for boys and girls. CONCLUSION: Maternal postload 1-hour glucose across a spectrum of glucose values during pregnancy was an independent risk for offspring weight gain at age 5 years, indicating the importance of screen and management of maternal 1-hour glucose level, except for fasting glucose and 2-hour glucose level during pregnancy in order to prevent offspring weight gain in early childhood.

Independent Association of Serum Fibroblast Growth Factor 21 Levels With Impaired Liver Enzymes in Hyperthyroid Patients.

Fibroblast growth factor 21 (FGF21) is identified as a potential biomarker for liver diseases. However, information is limited regarding serum FGF21 and impaired liver function in hyperthyroidism. We aim to determine the potential association of serum FGF21 levels with impaired liver enzymes in hyperthyroid patients. In this case-control study, 105 normal subjects and 122 overt hyperthyroid patients were included. Among them, 41 hyperthyroid patients who obtained euthyroid status after thionamide treatment received second visit. Serum FGF21 levels were determined using the ELISA method. Compared to the normal subjects, patients with hyperthyroidism had significantly elevated serum liver enzymes, including alanine transaminase (ALT) (p < 0.001), aspartate aminotransferase (AST) (p < 0.001) levels, as well as FGF21 levels (p < 0.001). Further analysis showed serum FGF21 (p < 0.05), as well as thyroid hormone (TH) free T3 (p < 0.05), free T4 (p < 0.05) levels were higher in hyperthyroid patients with impaired liver enzymes than in those with normal liver enzymes. After reversal of hyperthyroid state, elevated serum FGF21 levels in hyperthyroid patients declined significantly (p < 0.001), with a concomitant decrease in serum ALT (p < 0.001), AST (p < 0.001) levels. Correlation analysis showed close correlation between FGF21 and ALT (p < 0.002), AST (p < 0.012), free T3 (p < 0.001), free T4 (p < 0.001). Further logistic regression analysis revealed FGF21 is significantly associated with elevated ALT [Odds Ratio, OR 1.79, (95% confidence interval, CI), (1.30-2.47), P < 0.001], AST [1.59 (1.07-2.34), p < 0.020]. After adjustment of potential confounders, the association between FGF21 and elevated ALT remained significant [1.42 (1.01-1.99), p < 0.043]. In conclusion, serum FGF21 is independently associated with impaired liver enzymes in hyperthyroid patients.

Effect of exenatide after short-time intensive insulin therapy on glycaemic remission maintenance in type 2 diabetes patients: a randomized controlled trial.

Early short-term intensive insulin (STII) therapy can induce drug-free glycemic remission for up to 1 year in half of newly diagnosed type 2 diabetic mellitus (T2DM) patients. Whether exenatide following STII therapy will induce higher long-term glycaemic remission is currently unknown. To assess the effect of STII+ exenatide therapy, compared with STII only, on maintenance of glycaemic remission in newly diagnosed T2DM patients. In this randomized, parallel-group, open-label, controlled trial, 129 patients (66 in STII+ exenatide group and 63 in STII only group) firstly completed 3-week STII therapy, then STII+ exenatide group was treated with exenatide for 12 weeks further. The cumulative probabilities of 1-year and 2-year glycaemic remission in STII+ exenatide group were 68.2 ± 5.7% and 53.0 ± 6.1%, which were significantly higher than STII only group (36.5 ± 6.1% and 31.8 ± 5.9%) (p-values < 0.001). Patients in STII+ exenatide group, compared with STII only group, showed significantly decreased levels of waist (82.2 (81.0, 83.5) cm v.s. 84.2 (82.7, 85.7) cm, p = 0.048) and HbA1c (5.83 (5.60, 6.06)% v.s. 6.49 (6.20, 6.77)%, p < 0.001) after 12-week exenatide treatment, but these differences disappeared after 1-year and 2-year follow-up. As conclusions, Improved effect of sequential exenatide after STII therapy on maintenance of glycaemic remission only occurred during exenatide treatment and lost upon treatment cessation.

Pycnodysostosis with novel gene mutation and sporadic medullary thyroid carcinoma: A case report.

RATIONALE: Pycnodysostosis is a rare autosomal recessive skeletal dysplasia caused by a mutation in the cathepsin K encoded by cathepsin K gene (CTSK). Medullary thyroid carcinoma (MTC) is also a relatively rare type of primary thyroid carcinoma. PATIENT CONCERNS: A 31-year-old woman presenting a short stature and a palpable nodule in the front of her neck that had gradually increased in size during the last 2 years was referred to our department. She has experienced multiple fractures at lower limbs in the last 2 decades. DIAGNOSES: The patient's clinical examination revealed short stature, underweight, a prominent forehead, stubby fingers, and a fixed nodule in the right thyroid lobe. Intraoral examination revealed multiple clinically malposed and missing teeth, as well as chronic periodontitis with a narrow and grooved palate. Radiographic examination revealed typical widely separated cranial sutures and an open anterior/posterior fontanel with an obtuse gonial angle, acroosteolysis, and osteosclerosis with narrowed medullary cavities. Ultrasonography of the thyroid gland showed a marked hypoechoic solid nodule in the right lobe in which tumor cell clusters were confirmed by ultrasound-guided fine needle aspiration biopsy and was suspected to be MTC. Laboratory tests revealed dramatically elevated serum calcitonin >2000 pg/L (reference range: 0-5 pg/L) and carcinoembryonic antigen (CEA) 134.37 ng/mL (reference range: 0-5 ng/mL). Genotypic screening revealed compound heterozygous mutations in the CTSK gene (c.158delA, P.Asn53Thr/c.C830T, P.Ala277Val) but no mutation associated with the familial forms of MTC. INTERVENTIONS: The patient underwent a total thyroidectomy with right-sided functional neck dissection. OUTCOMES: CEA and serum calcitonin decreased significantly postthyroidectomy, and no further fracture has been reported by the patient so far. LESSONS: The present study is the first to report a rare case of the coexistence of pycnodysostosis with a compound CTSK gene mutation and sporadic MTC. Radiological techniques and gene analysis play key roles in the definitive diagnosis.

Elevated circulating irisin is associated with lower risk of insulin resistance: association and path analyses of obese Chinese adults.

BACKGROUND: Evidence on the role of irisin in insulin resistance is limited and controversial, and pathways between them remain unknown. We aimed to examine the independent effects of circulating irisin and different adiposity measurements, as well as their potential interactions, on insulin resistance. We also aimed to explore possible pathways among circulating irisin, adiposity, glucose and insulin levels and insulin resistance. METHODS: A cross-sectional study of 1,115 community- living obese Chinese adults, with data collection on clinical characteristics, glucose and lipid metabolic parameters and circulating irisin levels. RESULTS: Among the 1,115 subjects, 667 (59.8 %) were identified as insulin-resistance, and showed significantly decreased serum irisin than their controls (log-transformed irisin: 1.19 ± 2.34 v.s. 1.46 ± 2.05 ng/ml, p = 0.042). With adjustment for potential confounders, elevated circulating irisin was significantly associated with reduced risk of insulin resistance, with adjusted odds ratio per standard deviation increase of irisin of 0.871 (0.765-0.991, p = 0.036). As for different adiposity measurements, body fat percentage, but neither BMI nor waist, was significantly associated with increased risk of insulin resistance (OR: 1.152 (1.041-1.275), p = 0.006). No significant interaction effect between serum irisin and adiposity on insulin resistance was found. A one pathway model about the relationship between serum irisin and insulin resistance fits well (χ (2) = 44.09, p < 0.001; CFI-0.994; TLI =0.986; and RMSEA = 0.067), and shows that elevated circulating irisin might improve insulin resistance indirectly through lowering fasting insulin levels (standardized path coefficient = -0.046, p = 0.032). CONCLUSIONS: Elevated circulating irisin is associated with lower risk of insulin resistance indirectly through lowering fasting insulin.

Elevated Serum Fibroblast Growth Factor 21 Levels in Patients With Hyperthyroidism.

CONTEXT: Recent evidence from animal studies indicates that fibroblast growth factor 21 (FGF21), an endocrine hormone that regulates glucose, lipid metabolism, and energy homeostasis, is regulated by T3. However, the role of FGF21 in hyperthyroid patients is unknown. OBJECTIVE: The objective was to study serum FGF21 levels in hyperthyroid patients and the association of serum FGF21 levels with hyperthyroidism. DESIGN AND SETTING: This was a case-control study. PATIENTS AND INTERVENTIONS: A total of 119 hyperthyroid patients and 108 healthy subjects were recruited. Of them, 41 hyperthyroid patients received thionamide treatment for 3 months until euthyroidism was obtained. MAIN OUTCOME MEASURES: Serum FGF21 levels were determined using the ELISA method. RESULTS: Serum FGF21 levels were significantly elevated in hyperthyroid patients as compared with normal subjects [median 290.67 (interquartile range, 156.60-502.33) vs 228.10 (169.85.25-320.10) pg/mL; P < .001]. After thionamide treatment, serum FGF21 levels in hyperthyroid patients declined markedly from 249.10 (139.10-444.00) to 106.90 (38.70-196.15) pg/mL (P < .001). Logistic regression revealed that FGF21, basal metabolic rate, low-density lipoprotein cholesterol, and alanine transaminase were significantly associated with hyperthyroidism. With adjustment for potential confounders, serum FGF21 remained independently associated with hyperthyroidism, with an adjusted odds ratio of 3.123 (95% confidence interval, 1.306-7.468) (P = .010). CONCLUSION: Serum FGF21 levels were elevated in patients with hyperthyroidism and declined after thionamide treatment. And serum FGF21 level was independently associated with hyperthyroidism.

Association of serum irisin and body composition with chronic kidney disease in obese Chinese adults: a cross-sectional study.

BACKGROUND: Irisin, an exercise induced myokine, has broad implications for metabolism and energy homeostasis. Available evidence about the association of serum irisin with chronic kidney disease (CKD) is limited. METHODS: Cross-sectional data on socio-demographic, lifestyle, clinical characteristics and serum irisin were collected for 1,115 community-living obese Chinese adults (waist circumference ≥ 90 cm for men and ≥ 80 cm for women). CKD was defined as estimated glomerular filtration rate less than 60 ml/min per 1.73 m(2) and/or the presence of albuminuria. Associations of serum irisin and body composition measurements with CKD were analyzed using multivariable logistic regression. RESULTS: The overall prevalence of CKD were 23.1% (26.6% in females and 15.5% in males, p < 0.001). Subjects within quartile 4 group of serum irisin had significantly the lowest prevalence of CKD (22.9%, 22.2%, 28.7% and 18.7% for quartile 1-4 groups, respectively, p = 0.046). With adjustment for potential confounders, compared with those within quartile 1 group of serum irisin, subjects within quartile 4 group showed significantly decreased risk of CKD and marginally decreased risk of albuminuria, with the adjusted odds ratios (ORs, 95% CI) of 0.572 (0.353-0.927, p = 0.023) and 0.611 (0.373-1.000, p = 0.050), respectively. As for body composition measurements, only body fat percentage was significantly associated with both albuminuira and CKD, with ORs (95% CI) of 1.046 (1.002-1.092, p = 0.039) and 1.049 (1.006-1.093, p = 0.025), respectively. No statistically significant interaction effect between serum irisin and body composition measurements on CKD was found. CONCLUSIONS: Our results imply that high serum irisin level was associated with reduced risk of CKD, and should be confirmed in future studies. Furthermore, adiposity per se, rather than body weight or body shape, is independently associated with increased risk of CKD. Future studies should examine whether decreasing body fat percentage may prevent or slow CKD.