Mucocutaneous manifestations and nail changes in patients with end-stage renal disease on hemodialysis.

Mucocutaneous manifestations are common among patients on hemodialysis (HD). This study was undertaken to determine the prevalence of mucocutaneous manifestations in patients with end-stage renal disease (ESRD) who are on HD. In this cross-sectional, descriptive and analytic study conducted in 2009, 100 patients on HD at the Five Azar Hospital in Gorgan city were randomly selected. All the patients underwent detailed examination by a dermatologist to look for lesions in the skin, hair, nail and mucous membranes; if felt necessary, biopsy was obtained from the lesions. The findings were statistically analyzed using SPSS-13 software. For evaluation of normality of distribution, Kolmogorov-Smirnov was used, for quantitative variables Mann-Whitney and T-test (abnormal distribution) were used and for qualitative variables, Chi-2 and Fisher were used. In this study, P-value less than 0.05 was considered significant. Fifty-one males and 49 females were enrolled. The mean age was 49 ± 12 years. Diabetes was the most common cause of ESRD. In 95% of the patients, at least one mucocutaneous manifestation was present. Xerosis (78.3%) was the most common lesion, followed by pruritus (39.1%), lentigo (34.8%), skin discoloration (32.6%), leukonychia (32%) and thinning of the nail bed (24%). Xerosis, scaling, lentigo, folliculitis, idiopathic guttate hypopigmentation, leukonychia and half and half nail were associated with age. A significant relationship was seen between duration on dialysis and skin discoloration and leukonychia. Clubbing had a significant association with calcium-phosphorus product (Ca � P). There was a significant association between serum ferritin level and pruritus and tinea versicolor lesions. Our study shows that mucocutaneous manifestations are common among patients with ESRD. Identification of these manifestations and their association with causative factors are useful for preventing the lesions

Sex specific impact of different obesity phenotypes on the risk of incident hypertension: Tehran lipid and glucose study

Background: To investigate the association between different obesity phenotypes and the risk of incident hypertension among both genders. Methods: The study population included 3659 Iranians (men = 1540), aged �20 years free of hypertension at baseline. Participants were classified into six categories of body mass index (BMI)-metabolic health status, in which unhealthy metabolic status was defined based on the presence of > 1 component of metabolic syndrome (MetS) using the joint interim statement (JIS) criteria or the presence of insulin resistance (IR). The association between different obesity phenotypes and incident hypertension was assessed using multivariate Cox's proportional hazard models adjusted for age, current smoking, low physical activity, diabetes mellitus, family history of premature cardiovascular disease, estimated glomerular filtration rate, phase of recruitment, BMI and systolic blood pressure, considering metabolically healthy normal weight group as the reference. Results: After a median follow-up of 11.6 years 1122 participants (men = 493) experienced hypertension. Using JIS criteria, a significant higher risk of hypertension was observed among metabolically healthy obese and well as metabolically unhealthy groups among men in the age adjusted model; however, a significant higher risk in the fully adjusted model was seen among women in the metabolically healthy obese hazard ratio (HR) 95% confidence interval (CI) 1.96(1.16-3.32) as well as metabolically unhealthy normal weight 1.98(1.37-2.86), overweight 2.08(1.49-2.90) and obese 2.06(1.27-3.30) groups. Using insulin sensitive normal weight group as the reference, among men, being overweight or obese with and without IR was significant predictors of incident hypertension in the age adjusted model; however, among women, insulin resistant overweight 1.46(1.06-2.02) and obese groups, 1.63(1.01-2.62) showed significant risk in the fully adjusted model. Conclusion: We concluded that first, there was significant difference between genders in the associations between obesity phenotypes and incident hypertension. Second, in general, metabolic status defined by MetS components as compared to IR could do better in identifying high risk women for hypertension. Third, women populations who are metabolically healthy obese using MetS definition or those with either > 1 component of metabolic syndrome or overweight/obese ones with IR should be prioritized for implementing urgent preventive strategies against hypertension focusing on lifestyle changes. © 2019 The Author(s)

Change in glucose intolerance status and risk of incident cardiovascular disease: Tehran Lipid and Glucose Study

Background: To assess the impact of changes in different glucose tolerance states on risk of incident cardiovascular disease (CVD)/coronary heart disease (CHD). Methods: A total of 4094 Iranians (43.9 men) aged � 30 years, without diabetes and CVD at enrolment were included. The following categories were defined both at baseline visit and 3 years later (second visit): normal fasting glucose (NFG), normal glucose tolerance (NGT), NFG and NGT (NFG/NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and IFG and/or IGT (IFG/IGT). Changes in the categories, i.e. regression to normoglycemia, remaining in previous status and progression to diabetes were assessed. We used Cox's proportional hazard models adjusted for traditional risk factors and their changes, to estimate the hazard ratio (HR) with 95 confidence interval (CI) of different changing categories for incident CVD/CHD. Results: During a median follow-up of 12.42 years, 428 subjects (men = 265) experienced CVD. Considering persistent NFG/NGT as reference, participants who shifted from NFG/NGT to IFG/IGT showed a lower hazard of CVD in the fully adjusted model, HR 0.72 95% CI 0.52-0.996, P = 0.048. Moreover, subjects who shifted from IFG, IGT and IFG/IGT to diabetes had an increased risk of CVD/CHD. The risk however, was only statistically significant for those with IFG/IGT, 1.61 (1.03-2.51), P = 0.04 for CVD and 1.75 (1.10-2.78), P = 0.02 for CHD; considering IFG/IGT at both visits as reference. Furthermore, those who regressed from IFG/IGT to normoglycemia were at the same risk as those remained in IFG/IGT state, 1.12 (0.79-1.60), P = 0.52 for CVD and 1.04 (0.70-1.53), P = 0.85 for CHD. Among a subgroup of population with insulin data (n = 803) those with insulin resistance (IR) that converted to diabetes showed a higher risk for CVD, 3.68 (1.49-9.06), P = 0.01 and CHD, 2.76 (1.00-7.60), P = 0.05 events in the fully adjusted model. Conclusions: Among participants with IFG, IGT or IFG/IGT at baseline, only those who developed diabetes had a higher risk of developing CVD/CHD. Persistent IFG/IGT was not associated with higher risk, compared with those reverted to normoglycemia. Moreover, subjects who converted from NFG/NGT to incident IFG/IGT showed a signal for lower risk of CVD/CHD. © 2020 The Author(s)

Radiation-Free myeloablative allogeneic hematopoietic stem cell transplantation for adult acute lymphoblastic leukemia: A comparison of outcomes between patients with and without central nervous system involvement

For patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), total body irradiation (TBI) has been particularly advocated as a part of the conditioning regimen in case of extramedullary involvement in sanctuary sites such as the central nervous system (CNS), to ensure greater tissue penetration. In resource-limited countries lacking TBI facilities; however, ALL patients undergo radiation-free myeloablative conditioning, though its impacts on post-HSCT outcomes of the patients with pre-HSCT CNS involvement have not been analyzed. In this 14-year series of 278 adult (> 18 y) ALL patients undergoing TBI-free busulfan/cyclophosphamide conditioning allo-HSCT, we found that the long-term probabilities of overall survival, disease free survival, relapse and non-relapse mortality were not significantly different between CNS-involved and CNS-spared patients. Moreover, there was no statistically significant difference in the incidence of post-HSCT CNS relapse between CNS-involved and CNS-spared patients. Pre-HSCT cranial radiation therapy (CRT) showed no significant preventive effect on the likelihood of post-HSCT CNS relapse. Through multivariable regression analysis, grade III-IV acute graft-versus-host disease (GvHD), extensive chronic GvHD and post-HSCT relapse were ascertained as independent determinants of mortality (Adj.R2 = 53.9 , F(12,265) = 28.1, P < 0.001), while other parameters including Philadelphia translocation, pre-HSCT CNS involvement and CRT were found to have no independent effect. Although this study was not an attempt to compare TBI-based vs. non-TBI conditioning, the TBI-free myeloablative allo-HSCT was shown to be feasible and an option for adult ALL patients with CNS involvement, considering the comparable outcomes between patients with and without CNS involvement. © 2021 Elsevier Lt

Serum alkaline phosphatase and the risk of coronary heart disease, stroke and all-cause mortality: Tehran Lipid and Glucose Study

OBJECTIVES: To investigate the association of alkaline phosphatase (ALP) levels with the risk of the composite end point of cardiovascular disease (CVD), and all-cause mortality as well as each of them separately. DESIGN: Prospective cohort study. SETTING: Within the framework of the Tehran Lipid and Glucose Study (TLGS) cohort, participants were followed from baseline examination (1999-2001) until March 2014. PARTICIPANTS: A total of 2578 participants, aged ≥30 years free of prevalent CVD at baseline examination. PRIMARY OUTCOME: The main outcome measures were composite end point of coronary heart disease (CHD), stroke, all-cause mortality and each per se. RESULTS: During a median follow-up of 11.3 years, 369, 68, 420, 170 and 495 participants experienced CHD, stroke, CVD, all-cause mortality and the composite outcome, respectively. In the multivariable Cox regression models, the adjusted HRs (95 CI) for mentioned events per one SD increase in ALP level after full adjustment were 1.11 (1.01 to 1.22), 1.20 (0.97 to 1.49, p=0.058), 1.10 (1.01 to 1.21), 1.16 (1.01 to 1.33) and 1.11 (1.02 to 1.21), respectively. Furthermore, participants with ALP levels in the highest tertile had significant adjusted HRs (95 CI) for stroke (1.88 (1.00 to 3.61)), CVD (1.30 (1.01 to 1.68)) and composite outcome (1.27 (1.00 to 1.61)). The cut-off value of ALP ≥199 IU/L for predicting composite outcome was derived using Youden's index, based on which this cut-off point was associated with significant risk of 80, 26, 43 and 26 for incident stroke, CVD, all-cause mortality and composite outcome. Additionally, no improvement was seen in the predictive ability of traditional risk factors models after adding ALP values, considering the levels of Akaike information criterion, C-index and Net Reclassification Index. CONCLUSION: Independent associations between ALP levels and the risks of CVD and mortality events were shown, despite the fact that adding the data of ALP to known risk factors did not improve the prediction of these events. © Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ

Gestational diabetes mellitus in mothers and long term cardiovascular disease in both parents: Results of over a decade follow-up of the Iranian population

Background and aims: We aimed at evaluating whether the presence of gestational diabetes mellitus (GDM) in mothers is associated with increased risk of incident cardiovascular disease (CVD) in both mothers and fathers. Methods: In this population-based study, 4308 Iranian women, aged 18�64 years, with at least 1 live-birth delivery, and free of CVD at baseline, were followed. Corresponding spouses were identified in 2547 cases. The association between history of GDM and incident CVD was assessed using multivariate Cox's proportional hazard in 3 models: model 1, unadjusted; model 2, adjusted for age, body mass index, smoking (for men), maternal parity, miscarriage, physical activity, hypertension and hypercholesterolemia, and model 3, further adjusted for diabetes mellitus. Results: After a median follow-up of 14.1 years, 314 mothers and 424 fathers experienced CVD. Women with history of GDM had an adjusted hazard ratio (HR), 95 CI of 1.85 (1.38�2.48) and 1.29 (0.96�1.75) for CVD in models 1 and 2, respectively. Furthermore, an independent association with CVD was observed in fathers with an adjusted HR of 1.35 (1.02�1.79) in the confounder adjusted model and even after further controlling for diabetes 1.36 (1.03�1.80). Moreover, all traditional risk factors, excluding BMI, showed an independent risk for CVD in both genders. Conclusions: Women with prior GDM showed an increased risk of CVD that was not independent of important CVD risk factors. However, among men, spousal history of GDM was an independent risk factor for incident CVD, even after considering important traditional risk factors, including diabetes. © 2019 Elsevier B.V

Usefulness of prolactin measurement in inferior petrosal sinus sampling with desmopressin for Cushing�s syndrome

Background: Bilateral inferior petrosal sinus sampling (IPSS) is used to distinguish pituitary from ectopic adrenocorticotropin (ACTH) excess in patients with ACTH-dependent Cushing�s syndrome. Our objective was to examine the utility of prolactin measurement during IPSS with desmopressin (DDAVP) stimulation in localization of the source of ACTH excess. Method: Retrospective review of 20 patients with ACTH-dependent Cushing�s syndrome who underwent IPSS with DDAVP stimulation. Baseline, DDAVP-stimulated, and prolactin-normalized ACTH IPS:P (inferior petrosal sinus to peripheral) ratios were calculated. Cut-off values for each test were obtained from receiver-operating characteristic (ROC) curve analysis. Results: Fifteen patients had Cushing disease (CD), and five were diagnosed with ectopic ACTH syndrome (EAS). For the baseline ACTH IPS:P ratio of �2, the diagnostic sensitivity (80), specificity (100), positive predictive value (PPV) (100) and negative predictive value (NPV) (62.5) were calculated. These values for DDAVP-stimulated IPS:P ACTH ratio � 3, were 86.7, 100, 100 and 71.4, respectively. The corresponding value for the prolactin-normalized ACTH IPS:P ratio � 0.8 were 86.6, 80, 92.8 and 66.7. The cut-off value for the baseline, DDAVP-stimulated and prolactin-normalized ACTH IPS:P ratios were 1.76, 3.9, and 0.33, respectively. Conclusion: Prolactin-normalized ACTH IPS:P ratio measurement showed comparable sensitivity and less specificity than baseline/DDAVP-stimulated IPS/P ACTH ratios. Moreover, when baseline and stimulated IPS/P ACTH tests were discordant, prolactin-normalized ACTH IPS: P ratio correctly localized the source of ACTH excess. The sensitivity of the test increased, applying a prolactin-normalized ACTH IPS: P ratio �0.33. © 2020, © 2020 The Neurosurgical Foundation

Long term prognostic implication of newly detected abnormal glucose tolerance among patients with stable cardiovascular disease: a population-based cohort study

Background: Fasting plasma glucose (FPG) and 2-h post challenge plasma glucose (2 h-PCPG), whether as continuous or categorical variables, are associated with incident cardiovascular disease (CVD) and diabetes; however, their role among patients with existing CVD is a matter of debate. We aimed to evaluate associations of different glucose intolerance states with recurrent CVD and incident diabetes among subjects with previous CVD. Methods: From a prospective population-based cohort, 408 Iranians aged � 30 years, with history of CVD and without known diabetes were included. Associations of impaired fasting glucose (IFG) according to the American Diabetes Association (ADA) and World Health Organization (WHO) criteria, impaired glucose tolerance (IGT), newly diagnosed diabetes (NDM) with outcomes of interest were determined by multivariable Cox proportional hazard models after adjustment for traditional risk factors. Furthermore, FPG and 2 h-PCPG were entered as continuous variables. Results: Over a decade of follow-up, 220 CVD events including 89 hard events (death, myocardial infarction and stroke) occurred. Regarding prediabetes, only IFG-ADA was associated with increased risk of hard CVD hazard ratio(HR), 95%CI: 1.62,1.03�2.57 in the age-sex adjusted model. In patients with NDM, those with FPG � 7 mmol/L were at higher risk of incident CVD/coronary heart disease(CHD) and their related hard outcomes (HR ranged from 1.89 to 2.84, all P 2, P < 0.05). Conclusions: Among subjects with stable CVD, NDM whether as high FPG or 2 h-PCPG, but not pre-diabetes status was significantly associated with CVD/CHD and related hard outcomes. © 2021, The Author(s)

Usefulness of prolactin measurement in inferior petrosal sinus sampling with desmopressin for Cushing�s syndrome

Background: Bilateral inferior petrosal sinus sampling (IPSS) is used to distinguish pituitary from ectopic adrenocorticotropin (ACTH) excess in patients with ACTH-dependent Cushing�s syndrome. Our objective was to examine the utility of prolactin measurement during IPSS with desmopressin (DDAVP) stimulation in localization of the source of ACTH excess. Method: Retrospective review of 20 patients with ACTH-dependent Cushing�s syndrome who underwent IPSS with DDAVP stimulation. Baseline, DDAVP-stimulated, and prolactin-normalized ACTH IPS:P (inferior petrosal sinus to peripheral) ratios were calculated. Cut-off values for each test were obtained from receiver-operating characteristic (ROC) curve analysis. Results: Fifteen patients had Cushing disease (CD), and five were diagnosed with ectopic ACTH syndrome (EAS). For the baseline ACTH IPS:P ratio of �2, the diagnostic sensitivity (80), specificity (100), positive predictive value (PPV) (100) and negative predictive value (NPV) (62.5) were calculated. These values for DDAVP-stimulated IPS:P ACTH ratio � 3, were 86.7, 100, 100 and 71.4, respectively. The corresponding value for the prolactin-normalized ACTH IPS:P ratio � 0.8 were 86.6, 80, 92.8 and 66.7. The cut-off value for the baseline, DDAVP-stimulated and prolactin-normalized ACTH IPS:P ratios were 1.76, 3.9, and 0.33, respectively. Conclusion: Prolactin-normalized ACTH IPS:P ratio measurement showed comparable sensitivity and less specificity than baseline/DDAVP-stimulated IPS/P ACTH ratios. Moreover, when baseline and stimulated IPS/P ACTH tests were discordant, prolactin-normalized ACTH IPS: P ratio correctly localized the source of ACTH excess. The sensitivity of the test increased, applying a prolactin-normalized ACTH IPS: P ratio �0.33. © 2020, © 2020 The Neurosurgical Foundation

Clinical features, risk factors and a prediction model for in-hospital mortality among diabetic patients infected with COVID-19: data from a referral centre in Iran

Objectives: The aim of this study was to identify risk factors of in-hospital mortality among diabetic patients infected with COVID-19. Study design: This is a retrospective cohort study. Methods: Using logistic regression analysis, the independent association of potential prognostic factors and COVID-19 in-hospital mortality was investigated in three models. Model 1 included demographic data and patient history; model 2 consisted of model 1, plus vital signs and pulse oximetry measurements at hospital admission; and model 3 included model 2, plus laboratory test results at hospital admission. The odds ratios (ORs) and 95 confidence intervals (95 CIs) were reported for each predictor in the different models. Moreover, to examine the discriminatory powers of the models, a corrected area under the receiver-operating characteristic curve (AUC) was calculated. Results: Among 560 patients with diabetes (men = 291) who were hospitalised for COVID-19, the mean age of the study population was 61.8 (standard deviation SD 13.4) years. During a median length of hospitalisation of 6 days, 165 deaths (men = 93) were recorded. In model 1, age and a history of cognitive impairment were associated with higher mortality; however, taking statins, oral antidiabetic drugs and beta-blockers was associated with a lower risk of mortality (AUC = 0.76). In model 2, adding the data for respiratory rate (OR 1.07 95% CI 1.00�1.14) and oxygen saturation (OR 0.95 95% CI 0.92�0.98) slightly increased the AUC to 0.80. In model 3, the data for platelet count (OR 0.99 95% CI 0.99�1.00), lactate dehydrogenase (OR 1.002 95% CI 1.001�1.003), potassium (OR 2.02 95% CI 1.33�3.08) and fasting plasma glucose (OR 1.04 95% CI 1.02�1.07) significantly improved the discriminatory power of the model to AUC 0.86 (95% CI 0.83�0.90). Conclusions: Among patients with type 2 diabetes, a combination of past medical and drug history and pulse oximetry data, with four non-expensive laboratory measures, was significantly associated with in-hospital COVID-19 mortality. © 2021 The Royal Society for Public Healt