Heterotopic Ossification with Intrathyroidal Extramedullary Hematopoiesis in Multifocal Papillary Thyroid Carcinoma: Histopathological Findings and Literature Review

In recent decades, there has been an increase in the identification of thyroid nodules, both benign and malignant, due to the rise in imaging studies and complementary tests. Among thyroid gland tumors, papillary thyroid carcinoma (PTC) stands out as the most prevalent. Degenerative changes, mainly in the form of nodular goiter, have been recorded, occasionally including areas of calcification and, more rarely, ossification; although the latter seldom progresses to calcinosis. Ectopic bone formation, known as osseous metaplasia, is a rare phenomenon in the thyroid gland, even more so when associated with extramedullary hematopoiesis (EMH), characterized by the presence of hematopoietic elements outside the bone marrow. We present the first documented instance in our country of a patient diagnosed with malignant thyroid nodule, specifically PTC, exhibiting areas of heterotopic ossification with EMH on histopathological examination of the surgical specimen. A possible relationship between heterotopic ossification, EMH, and PTC is suggested. Various growth factors such as bone morphogenetic proteins (BMPs), specific BMP subtypes, and associated receptors could play a crucial role in initiating and developing ectopic bone formation in the context of PTC. However, further research is needed to fully elucidate its clinical significance and impact on the therapeutic management of these patients.

Anabolic-androgenic steroid use disorder: case for recognition as a substance use disorder with specific diagnostic criteria

Approximately one in three people who use anabolic-androgenic steroids (AASs) develop dependence, characterised by both psychiatric and somatic symptoms. Despite this, AAS use disorder (AASUD) is not distinctly recognised in the latest versions of either the ICD or DSM, impeding both clinical care and research progress. It is clear that AASUD shares many features and correlates with substance use disorders (SUDs) that have specific diagnostic criteria in these classification systems, such as stimulants or opioids. We aim to outline the overlap between AASUD and more 'typical' SUDs as well as highlight the specific concerns related to AASUD that warrant recognition and distinct diagnostic criteria.

Association between the atherogenic index of plasma and testosterone deficiency in American adults: a cross-sectional study from NHANES 2011-2016

Background

A common pathophysiological association between lipid metabolism and sex hormone levels has been revealed in recent research. The atherogenic index of plasma (AIP) is the marker currently used to evaluate metabolism. The purpose of this research was to discover the relationship between the AIP and testosterone deficiency (TD) in a nationwide representative population.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) database from 2011 to 2016 were utilized in this cross-sectional research. The formula, lg [TG (mmol/L)/HDL-C(mmol/L)], was applied to determine the AIP. Total serum testosterone levels were used to define TD. Our researcher utilized smoothed curve fitting and multivariate logistic or linear regression analysis to inspect the relationship between AIP and TD among adult males. The consistency of these results was examined in various population subgroups.

Results

In total, 1,198 individuals (28.6%) were stratified into the TD group. We observed statistically significant differences (P values < 0.05) in the TD population for all variables. After correcting for potential confounders, our researchers discovered a strong positive relationship between the AIP and the probability of developing TD. With each additional unit of the AIP, the incidence of TD increased by 2.81-fold in adult males. Subgroup analyses showed the correlations for the majority of the subgroups remained stable. However, marital status, CKD, smoking, and alcohol consumption may modify this association.

Conclusions

A higher AIP is correlated with a lower level of testosterone in adult males. This correlation may be altered by factors including marriage, chronic kidney disease, alcohol, and smoking consumption.

Prognosis value of pituitary neuroendocrine tumor volume

This study highlights the significance of considering pituitary neuroendocrine tumor volume when determining the appropriate line of therapy for patients with acromegaly. The findings suggest that, although tumor volume may assist in predicting the need for more aggressive treatment strategies, it is not a reliable indicator of disease persistence following surgical intervention. Further research is warranted to investigate additional factors influencing acromegaly treatment outcomes to enhance patient care.

Diabetes mellitus secondary to endocrine diseases: a position statement of the working group of the club of the Italian society of endocrinology (SIE)-Nutrition hormones and metabolism

PURPOSE

This position statement addressed the limited scientific literature on the management of diabetes mellitus secondary to endocrinopathies, despite its frequent occurrence in hormonal diseases such as acromegaly, Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, hyperthyroidism, and neuroendocrine tumors. The aim was to review the pathophysiological mechanisms, clinical features, and management strategies, focusing on nutritional and pharmacological approaches.

METHODS

A comprehensive review of existing literature was conducted regarding studies on diabetes secondary to endocrinopathies and the effects of treatments for these conditions, such as somatostatin analogues and pancreatic surgery. Particular emphasis was placed on understanding glucose metabolism derangements and the interplay between endocrine excess and therapeutic interventions.

RESULTS

Secondary diabetes arises not only from hormone excess but also as a consequence of treatments for endocrine disorders. For instance, somatostatin analogues, while effective in resolving hormone hypersecretion, impair glucose metabolism by inhibiting pancreatic insulin secretion. Similarly, pancreatic surgery for neuroendocrine tumors often exacerbates glycemic disturbances. The management of secondary diabetes requires a multidisciplinary approach that includes treating the underlying endocrine disorder, tailoring antidiabetic therapy, and optimizing nutritional strategies to mitigate metabolic disruptions.

CONCLUSION

Diabetes secondary to endocrinopathies presents unique challenges due to its complex etiology and the metabolic effects of treatments. This position statement underscores the importance of an integrated management approach, offering guidance for clinicians in addressing this multifaceted condition. Further research is needed to develop evidence-based guidelines for optimal care.

Dose dependent relationship of metformin use and diabetic peripheral neuropathy risk in patients with type 2 diabetes mellitus

This study investigated the correlation between metformin use and diabetic peripheral neuropathy (DPN) risk in patients with type 2 diabetes mellitus (T2DM) and its dose-dependent relationship. The study included new-onset T2DM patients from 2002 to 2013. Patients were divided into two groups based on metformin treatment, and DPN risk was assessed at 2- and 5-year follow-ups. After adjusting for various factors, two logistic models, metformin cumulative defined daily dose (cDDD) and metformin treatment intensity (defined daily dose [DDD]/month), evaluated the metformin-DPN risk association. Results showed that patients with metformin cDDD < 300, 300-500, and > 500 had higher DPN risk at both follow-ups. Odds ratios (ORs) and confidence intervals (CIs) for DPN were 1.74 (1.69-1.79), 2.05 (1.81-2.32), and 2.36 (1.34-4.16) at 2 years and 1.63 (1.60-1.65), 1.82 (1.69-1.96), and 2.17 (1.56-3.03) at 5 years. Similarly, patients with < 10, 10-25, and > 25 DDD/month had higher DPN risk at both follow-ups. Metformin use correlated with DPN risk in T2DM patients, with a dose-dependent relationship. Higher metformin cDDD or treatment intensity increased DPN risk. However, the absence of vitamin B12 data limits the understanding of the underlying mechanisms. Well-designed, large-scale studies are required to evaluate the potential risks of metformin therapy for DPN in patients with T2DM.

Anemia in diabetes mellitus: Pathogenetic aspects and the value of early erythropoietin therapy

Anemia is a frequent, yet increasingly recognized, comorbidity in diabetes mellitus (DM), with prevalence often driven by multifactorial mechanisms. Hematinic deficiencies, common in this population, may arise from associated comorbidities or medications, such as metformin, as well as other drugs commonly employed for DM-related conditions. Among contributing factors, diabetic kidney disease (DKD) plays a pivotal role, with anemia developing more frequently and being more pronounced in earlier stages, than in CKD of other causes. This enhanced susceptibility stems primarily from the combined impact of impaired renal oxygen sensing and deficient erythropoietin (EPO) production linked to tubulointerstitial fibrosis. Additional mechanisms comprise glomerular dysfunction, shortened erythrocyte lifespan, uremia-induced bone marrow suppression, and increased bleeding risk. DM is also recognized as a chronic low-grade inflammatory condition, with its inflammatory burden driving iron maldistribution, suppression of erythropoiesis, and resistance to EPO. The diagnostic approach of anemia in DM mirrors that in the general population. Addressing modifiable causes such as hematinic deficiencies, and other chronic conditions, such as DKD and bone marrow disorders, is paramount. In total, the underlying pathophysiology of anemia in DM primarily reflects a state of absolute or relative EPO deficiency and/or diminished bone marrow responsiveness, effectively corresponding to 'anemia of chronic disease. Early initiation of EPO therapy, even in DM patients without overt DKD, may mitigate disease progression and improve outcomes. Future research should focus on diabetes-specific strategies integrating optimal EPO use, potentially implementing targeted management of renal and inflammatory contributors to anemia.

Exploring oncology treatment strategies with tyrosine kinase inhibitors through advanced 3D models (Review)

The limitations of two-dimensional (2D) models in cancer research have hindered progress in fully understanding the complexities of drug resistance and therapeutic failures. However, three-dimensional (3D) models provide a more accurate representation of in vivo environments, capturing critical cellular interactions and dynamics that are essential in evaluating the efficacy and toxicity of tyrosine kinase inhibitors (TKIs). These advanced models enable researchers to explore drug resistance mechanisms with greater precision, optimizing treatment strategies and improving the predictive accuracy of clinical outcomes. By leveraging 3D models, it will be possible to deepen the current understanding of TKIs and drive forward innovations in cancer treatment. The present review discusses the limitations of 2D models and the transformative impact of 3D models on oncology research, highlighting their roles in addressing the challenges of 2D systems and advancing TKI studies.

Association of Nerve Conduction Study Variables with Hematologic Tests in Patients with Type 2 Diabetes Mellitus

Background and Objective: Diabetic peripheral neuropathy (DPN) is a prevalent complication of type 2 diabetes mellitus (T2DM), with nerve conduction studies (NCSs) serving as the diagnostic gold standard. Early diagnosis is critical for effective management, yet many cases are detected late due to the gradual onset of symptoms. This study explores the relationship between hematological tests and NCS outcomes in T2DM patients to improve the early detection of DPN. Material and Methods: This retrospective study involved T2DM patients exhibiting neuropathic symptoms, and patients were divided based on NCS findings into groups with normal and abnormal results to assess the diagnostic value of various hematological markers, clinical, and demographic data for DPN. Results: Among 400 participants, 57% (n = 228) had abnormal NCS results indicative of DPN. Significant differences were observed in the abnormal-NCS group, including older age, longer diabetes duration, higher levels of fasting plasma glucose, HbA1c, and apolipoprotein B, along with lower eGFR, HDL-C, and Apo A-I levels. Notably, negative correlations were found between HDL-C, Apo A-I, vitamin B12, and specific NCS measurements, while positive correlations existed with sural sensory nerve amplitudes. Multivariate analysis highlighted the importance of age, diabetes duration, hyperglycemia, and specific hematologic markers in predicting DPN. Conclusions: The findings confirm that NCSs, combined with hematologic testing, can effectively identify DPN in T2DM patients. Consistent with prior research, prolonged hyperglycemia and nephropathy progression are strongly linked to DPN development. Additionally, lower levels of HDL-C, Apo A-I, and vitamin B12 are associated with the condition, suggesting their potential utility in early diagnostic protocols.

[Research advances in maturity-onset diabetes of the young]

Maturity-onset diabetes of the young (MODY) is a special type of diabetes characterized by clinical features including early onset of diabetes (before 30 years of age), autosomal dominant inheritance, impaired glucose-induced insulin secretion, and hyperglycemia. So far, 14 types of MODY have been reported, accounting for about 1%-5% of the patients with diabetes. MODY often presents with an insidious onset, and although 14 subtypes have been identified for MODY, it is frequently misdiagnosed as type 1 or type 2 diabetes due to overlapping clinical features and high costs and limitations of genetic testing. This article reviews the clinical features of MODY subtypes in order to improve the accuracy of the diagnosis and treatment of MODY.

Alterations of Krüppel-like Factor Signaling and Potential Targeted Therapy for Hepatocellular Carcinoma

Krüppel-like factors (KLFs, total 18 members) from the zinc finger protein (ZFP) super-family have a wide range of biological functions in hepatocellular carcinoma (HCC). This paper reviews the recent some progresses of aberrant KLFs with their potential values for diagnosis, prognosis, and targeted therapy in HCC. The recent advances of oncogenic KLFs in the diagnosis, prognosis, and targeted therapy of HCC were reviewed based on the related literature on PUBMED and clinical investigation. Based on the recent literature, KLFs, according to biological functions in HCC, are divided into 4 subgroups: promoting (KLF5, 7, 8, 13), inhibiting (KLF3, 4, 9~12, 14, 17), dual (KLF2, 6), and unknown functions (KLF1, 15, 16, or 18 ?). HCC-related KLFs regulate downstream gene transcription during hepatocyte malignant transformation, participating in cell proliferation, apoptosis, invasion, and metastasis. Some KLFs have diagnostic or prognostic value, and other KLFs with inhibiting promoting function or over-expressing inhibiting roles might be molecular targets for HCC therapy. These data have suggested that Abnormal expressions of KLFs were associated with HCC progression. Among them, some KLFs have revealed the clinical values of diagnosis or prognosis, and other KLFs with the biological functions of promotion or inhibition might be as effectively molecular targets for HCC therapy.

Negative correlation between cardiometabolic index and testosterone in male adults

Background

Insulin resistance (IR) is closely correlated with a deficiency or decrease of testosterone levels in males. Cardiometabolic index (CMI) is correlated with various diseases correlated with IR. The primary objective of this study is to explore the correlation between CMI and testosterone levels in male adults.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) during the period from 2013 to 2020 were analyzed through a cross-sectional design. CMI was calculated by multiplying waist-to-height ratio (WHtR) with the triglyceride-to-high-density lipoprotein cholesterol ratio (TG/HDL-C).

Results

A total of 5012 subjects were included in the final analysis. After controlling confounding variables, multiple linear regression analysis indicated an independent negative correlation between CMI and testosterone levels (β= -6.40, 95% CI: -8.95, -3.86, P<0.001) through the. In addition, a negative non-linear correlation was also found between CMI and testosterone (P<0.05), with CMI's inflection point as 0.73. Subgroup analyses indicated a more significant negative correlation among those with normal weight and the elderly (p< 0.05 for all interactions). The area under the ROC curve (AUC) of CMI (AUC =0.724, 95% CI: 0.709-0.740) was the largest compared with those of TG/HDL and WHtR.

Conclusion

Elevated CMI is significantly and negatively correlated with testosterone in male adults.

Glucagon-Producing Pancreatic Neuroendocrine Tumors (Glucagonomas) are Enriched in Aggressive Neoplasms with ARX and PDX1 Co-expression, DAXX/ATRX Mutations, and ALT (Alternative Lengthening of Telomeres)

Glucagonomas are functioning pancreatic neuroendocrine tumors (PanNETs) responsible for glucagonoma syndrome. This study aims to shed light on the clinicopathological and molecular features of these neoplasms. Six patients with glucagonomas were identified. All neoplasms were investigated with immunohistochemistry for neuroendocrine markers (Synaptophysin, Chromogranin-A), ATRX, DAXX, ARX, and PDX1 transcription factors. Fluorescent in situ hybridization (FISH) for assessing alternative lengthening of telomeres (ALT), and next-generation sequencing (NGS) for molecular profiling were performed. All cases were large single masses (mean size of 8.2 cm), with necrolytic migratory erythema as the most common symptom (6/6 cases, 100%). All neoplasms were well-differentiated G1 tumors, except one case that was G2. The tumors consistently showed classic/conventional histomorphology, with solid-trabecular and nested architecture. Lymphatic and vascular invasion (6/6, 100%), perineural infiltration (4/6, 66.6%), and nodal metastasis (4/6, 66.6%) were frequently observed. Transcription factors expression showed strong ARX expression in all tumors, and PDX1 expression in 5/6 cases (83.3%), indicating co-occurring alpha- and beta-cell differentiation. NGS showed recurrent somatic MEN1 and ATRX/DAXX biallelic inactivation. Cases with ATRX or DAXX mutations also showed matched loss of ATRX or DAXX protein expression and ALT. One case harbored somatic MUTYH inactivation and showed a high tumor mutational burden (TMB, 41.0 mut/Mb). During follow-up, one patient died of the disease, and four patients developed distant metastasis. Pancreatic glucagonomas are distinct PanNETs with specific clinicopathological and molecular features, including histological aspects of biological aggressiveness, co-occurring alpha- and beta-cell differentiation, MEN1 and DAXX/ATRX mutations enrichment, and the possible presence of high-TMB as an actionable marker.

Diabetic Neuropathy: A Guide to Pain Management

PURPOSE OF REVIEW

Diabetic neuropathy is a common complication of diabetes mellitus (DM) and can affect up to 50% of DM patients during their lifetime. Patients typically present with numbness, tingling, pain, and loss of sensation in the extremities. Since there is no treatment targeting the underlying mechanism of neuropathy, strategies focus on preventative care and pain management.

RECENT FINDINGS

Up to 69% of patients with diabetic neuropathy receive pharmacological treatment for neuropathic pain. The United States Food and Drug Administration (FDA) confirmed four drugs for painful diabetic neuropathy (PDN): pregabalin, duloxetine, tapentadol, and the 8% capsaicin patch. Nonpharmacological treatments such as spinal cord stimulation (SCS) and transcutaneous electrical nerve stimulation (TENS) both show promise in reducing pain in DM patients. Despite the high burden associated with PDN, effective management remains challenging. This update covers the background and management of diabetic neuropathy, including its epidemiology, pathogenesis, preventative care, and current therapeutic strategies.

Association between cardiometabolic index and testosterone levels in adult men: NHANES 2011-2016

OBJECTIVE

Exploring the relationship between the cardiometabolic index (CMI) and serum testosterone levels as well as testosterone deficiency in American adult males. Additionally, comparing the diagnostic value of the CMI with several common obesity and metabolism indices for identifying testosterone deficiency.

METHODS

This cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2016. Serum testosterone levels and testosterone deficiency were used as dependent variables, with the cardiometabolic index as the independent variable. Multivariable regression was used to assess the relationship between the independent and dependent variables, while subgroup analyses were performed to ensure the stability of the results. Smooth curve fitting was utilized to evaluate the nonlinear relationship between the CMI and testosterone levels. Receiver operating characteristic curves (ROC) were plotted for several obesity and metabolism prediction indices and the area under the curve was calculated to compare the specificity and sensitivity of each diagnostic index in the diagnosis of testosterone deficiency.

RESULTS

Among 3541 adult male participants, CMI is negatively associated with serum testosterone levels and positively associated with testosterone deficiency. In the fully adjusted model, for every unit increase in CMI, serum testosterone decreased by 14.89 ng/dl. Comparing the highest quartile to the lowest quartile of CMI, each unit increase in CMI, serum testosterone decreased by 98.58 ng/dl. Furthermore, each unit increase in CMI was associated with a 16% increase in incidence of testosterone deficiency. By plotting the ROC curves, we found that the AUCs for Lipid Accumulation Product (LAP), Body Mass Index (BMI), Weight Adjusted Waist Index (WWI), CMI, Visceral Adiposity Index (VAI) and Triglyceride glucose index (TyG) were 0.73, 0.72, 0.71, 0.69, 0.66, and 0.66 respectively.

CONCLUSION

Elevated levels of CMI are associated with lower testosterone levels and an increased risk of testosterone deficiency. The predictive value of the LAP was superior to that of CMI, while the predictive value of CMI was higher than VAI and TyG.

Case report: Surgical treatment and literature review of a recurrent case of glucagonoma

A 40-year-old male patient was admitted due to abdominal distension and discomfort in the upper abdomen persisting for three days. Enhanced CT of the upper abdomen revealed an irregularly dense soft tissue area in the body and tail of the pancreas, approximately 7.6 × 3.1 cm in size, with blurred boundaries, and indistinct separation from the splenic artery and vein. Multiple liver lesions of varying sizes and slightly lower densities were also observed. Liver tumor biopsy considering a neuroendocrine tumor G2, combined with the medical history, led to a diagnosis of pancreatic neuroendocrine tumor G2 with liver metastasis. Physical examination showed mild tenderness in the upper abdomen but no other significant positive signs. During treatment, the patient developed multiple red papular rashes around the mouth, on both lower limbs, and the perineum, accompanied by itching. The glucagon level was 1138.3 pg/L. The patient underwent resection of the pancreatic body and tail, splenectomy, partial liver tumor resection, and cholecystectomy. Within five days post-surgery, the skin lesions began to crust and flake off. On the 14th day post-surgery, the serum glucagon level was rechecked at 136.4 pg/L. As of April 2024, progression of liver lesions was noted, with no significant skin symptoms during the period.

Vitamin B12 deficiency in diabetic patients treated with metformin: A narrative review

Metformin is the most prescribed oral hypoglycemic drug and is considered by many health practitioners as the first-line treatment for non-insulin-dependent diabetes mellitus (T2DM). It is used either as a monotherapy or adjuvant to other anti-hyperglycemic agents. Most of its side effects are usually mild and self-limiting. However, several studies have shown an association between the use of metformin and low vitamin B12 levels in diabetic patients. The current review aimed to provide a literature review of the current published reports on the association, the possible mechanisms, and the related individualized risk factors that might lead to this incidence. The most accepted mechanism of the effect of metformin on vitamin B12 level is related to the absorption process where metformin antagonism of the calcium cation and interference with the calcium-dependent IF-vitamin B12 complex binding to the ileal cubilin receptor. In addition, many risk factors have been associated with the impact of metformin on vitamin B12 levels in diabetic patients such as dose and duration where longer durations showed a greater prevalence of developing vitamin B12 deficiency. Male patients showed lower levels of vitamin B12 compared to females. Black race showed a lower prevalence of vitamin B12 deficiency in metformin-treated patients. Moreover, chronic diseases including T2DM, hyperlipidemia, coronary artery disease, polycystic ovary disease (PCOD), obesity, and metformin therapy were significantly associated with increased risk of vitamin B12 deficiency.

Sex Hormones and Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study and Mendelian Randomization Analysis

Background

Sex steroid hormones, including testosterone and estradiol, play significant roles in various aspects of pulmonary health and diseases. However, although there were a few studies trying to link sex hormones with COPD, their effect remained limited due to small sample size and insufficient causal results. This study aims to investigate the association between sex hormones and chronic obstructive pulmonary disease (COPD) based on the National Health and Nutrition Examination Survey (NHANES) database and evaluate causality via a two-sample Mendelian randomization (MR).

Methods

Data from NHANES 2013-2016 were enrolled for the cross-sectional study. The association between sex hormones and COPD was evaluated via multivariable logistic regression. Sex-stratified analysis, subgroup analyses and interaction tests were performed to further evaluate the correlation. For MR analysis, data were collected from genome-wide association studies and FinnGen datasets. The inverse-variance-weighted (IVW) approach, along with four other approaches, was applied in the analysis. Further sensitivity analysis was conducted to assess the existence of pleiotropy and heterogeneity.

Results

7,617 eligible participants were enrolled in the cross-sectional analysis. Negative associations were observed in both testosterone-COPD (OR 0.770, 95% CI 0.626, 0.948, p = 0.018) and estradiol-COPD (OR 0.794, 95% CI 0.688, 0.915, p = 0.005) relationships after covariate adjustments. However, the results from IVW-MR analysis showed that no causal relationship was observed in either the testosterone-COPD (OR 0.83, 95% CI 0.53, 1.29, p = 0.407) or estradiol-COPD (OR 0.74, 95% CI 0.23, 2.38, p = 0.616) relationship, which was also supported by the other four approaches (all p values > 0.05).

Conclusion

Although a significant negative association was observed between sex hormones and COPD, the results of MR analysis did not support the causality of this relationship. Our study suggested that sex hormones may indirectly rather than directly affect the development of COPD via potential covariates, which warranted further investigations.

A pilot study of diabetes effects on radiation attenuation characteristics of tibia and femur of rats

This study aimed to investigate the effect of diabetes on radiation attenuation parameters of the femur and tibia of rats using Monte Carlo Simulations. First, control and diabetic rats were identified and tibias and femurs were removed. Then, the elemental ratios of the bones obtained were calculated using EDS (Energy Dissipative X-ray Spectroscopy). Therefore, radiation permeability properties of control and diabetic bones were simulated by using the content ratios in the bones in MCNP6 (Monte Carlo N-Particle) and PHITS (Particle and Heavy Ion Transport code System) 3.22 and Stopping and Range of Ions in Matter (SRIM) simulation codes. Attenuation coefficient results were compared with the NIST database via XCOM. Although differences in absorption coefficients are observed at low energies, these differences disappear as the energy increases.

HNF1A gene mutations and premature ovarian failure (POF): evidence from a clinical paradigm combining MODY 3 and POF

Premature ovarian failure (POF) defines the occurrence of ovarian failure prior to the age of 40. It occurs in one out of 100 women but is very rare before age 20 (1:10,000). Maturity-onset diabetes of the young (MODY), caused by mutations in the HNF1A gene, is also a rare disorder; all types of MODY account for 1-2% of adult diabetic cases. These two rare nosologic entities coexisted in an adolescent girl evaluated for delayed puberty. Although this combination could represent a chance association, an interrelation might exist. We examined HNF1A expression in human fetal and adult ovaries by immunohistochemistry using a polyclonal HNF1A antibody. HNF1A protein was expressed in both the fetal and adult human ovaries. Based on these findings, we hypothesize that HNF1A participates in ovarian organogenesis and/or function and that mutations in the HNF1A gene might represent another molecular defect causing POF, possibly in combination with other genetic factors. The study underlines the importance of rare clinical paradigms in leading the way to elucidation of the pathogenetic mechanisms of rare diseases.

Serum vitamin B12, distal symmetrical polyneuropathy and anaemia in type 2 diabetes: the Fremantle Diabetes Study Phase 2

BACKGROUND

There are limited data relating to the effects of metformin-associated vitamin B12 deficiency on the risk of distal symmetrical polyneuropathy (DSPN) and megaloblastic anaemia in well-characterised community-based cohorts.

AIMS

To assess inter-relationships between metformin therapy, vitamin B12 deficiency assessed using serum active B12 concentrations, and DSPN and anaemia in 1492 Fremantle Diabetes Study Phase 2 (FDS2) participants with type 2 diabetes.

METHODS

Prevalence rates of vitamin B12 deficiency (total <80 pmol/L, active <23 pmol/L) and borderline deficiency (total ≥80 and ≤200 pmol/L, active ≥23 and ≤35 pmol/L) were determined using baseline sera. The relationship between vitamin B12 status and both DSPN and anaemia was assessed using multivariable analyses.

RESULTS

Most FDS2 participants (94.4%) were vitamin B12 replete (total serum concentration >200 pmol/L, active >35 pmol/L), 2.0% were deficient (total <80 pmol/L, active <23 pmol/L) and the remainder (3.6%) borderline. Although metformin treatment increased the odds of deficiency (4.2%, 3.1% borderline) in a dose-dependent fashion (odds ratio (95% confidence interval) 39.4 (4.90-316) for >2000 mg daily compared with no treatment; P < 0.001), there was no significant association between vitamin B12 status and DSPN, anaemia (haemoglobin ≤130 g/L males, ≤120 g/L females), haemoglobin concentration or mean corpuscular volume (P ≥ 0.147). Metformin increased the likelihood of anaemia, especially at high doses, independent of vitamin B12 deficiency.

CONCLUSIONS

Since nutritional sources likely attenuate metformin-associated vitamin B12 malabsorption and its clinical sequelae in developed countries such as Australia, there is no need for routine/opportunistic serum vitamin B12 screening in metformin-treated patients.

Krüpple-like factors in cardiomyopathy: emerging player and therapeutic opportunities

Cardiomyopathy, a heterogeneous pathological condition characterized by changes in cardiac structure or function, represents a significant risk factor for the prevalence and mortality of cardiovascular disease (CVD). Research conducted over the years has led to the modification of definition and classification of cardiomyopathy. Herein, we reviewed seven of the most common types of cardiomyopathies, including Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), diabetic cardiomyopathy, Dilated Cardiomyopathy (DCM), desmin-associated cardiomyopathy, Hypertrophic Cardiomyopathy (HCM), Ischemic Cardiomyopathy (ICM), and obesity cardiomyopathy, focusing on their definitions, epidemiology, and influencing factors. Cardiomyopathies manifest in various ways ranging from microscopic alterations in cardiomyocytes, to tissue hypoperfusion, cardiac failure, and arrhythmias caused by electrical conduction abnormalities. As pleiotropic Transcription Factors (TFs), the Krüppel-Like Factors (KLFs), a family of zinc finger proteins, are involved in regulating the setting and development of cardiomyopathies, and play critical roles in associated biological processes, including Oxidative Stress (OS), inflammatory reactions, myocardial hypertrophy and fibrosis, and cellular autophagy and apoptosis, particularly in diabetic cardiomyopathy. However, research into KLFs in cardiomyopathy is still in its early stages, and the pathophysiologic mechanisms of some KLF members in various types of cardiomyopathies remain unclear. This article reviews the roles and recent research advances in KLFs, specifically those targeting and regulating several cardiomyopathy-associated processes.

Severity of Neuropathy-Related Disability and Associated Factors of Diabetic Peripheral Neuropathy in a Tertiary Healthcare Center: A Comparative Cross-Sectional Study

BACKGROUND AND OBJECTIVES

The widespread presence of diabetic peripheral neuropathy (DN) and its related variables among diagnosed diabetes mellitus (DM) patients in Kerala lacks sufficient evidence. The objective of this study was to evaluate the frequency of DN and its related risk variables among those with DM who were receiving care at a tertiary health institution in Kerala.

MATERIALS AND METHODS

This study was conducted in a tertiary health center in Kerala using a cross-sectional design. The diagnosis of diabetes was established by assessing the glycated hemoglobin A1c (HbA1c) level and the fasting blood glucose (FBG) level. A validated survey questionnaire was employed to gather demographic data as well as the medical history of DM and associated ailments. A thorough physical examination, BMI, and blood pressure were recorded. Dermatological, musculoskeletal, neurological, and vascular assessments were conducted. The subjects were assessed for neuropathy using a neuropathy disability score (NDS). Consequently, those who met the criteria for DM were classified into two groups: those with neuropathy and those without neuropathy. All research participants underwent laboratory examinations such as blood lipid profiles, HbA1c, and vitamin B12 complex concentrations.

RESULTS

The study included 200 DM patients; 120 men and 80 women. Study participants were 40-70 years old, with a median age of 53. The prevalence of DN significantly increased with age (p<0.001). The longer a patient had DM, the higher the prevalence of DN, and this variance in percentage was statistically significant (p<0.009) with an OR (odds ratio) of 9.246. A statistically significant 81 (40.5%) of participants graduated, compared to 119 (59.5%) with only higher secondary education or less (OR = 2.042; p = 0.014). Approximately 107 (53.5%) of individuals earned an income under two lakhs, and this disparity was deemed statistically significant (p = 0.003) with an OR of 2.357. In the group of individuals being studied, 53 (26.5%) of them experienced a decrease in pressure sensation, 47 (23.5%) had a decrease or absence of vibration perception, 48 (24%) had an absence or decreased pinprick response, and 46 (23%) had an absent ankle reflex. The study found that the most commonly reported symptoms were tingling (n = 44; 22%), numbness (n = 42; 21%), burning (n = 37; 18.5%), pricking (n = 29; 14.5%), and pain (n = 27; 13.5%). A strong association was found between DN and glycemic status, namely, FBG levels exceeding 140 mg/dL (OR = 4.511, p < 0.001) and HbA1c levels exceeding 6.5% (OR = 3.87, p < 0.001). The prevalence of abnormal vitamin B12 levels in individuals with DN was 63% (p = 0.19), indicating that the finding was not statistically significant. Within the group of individuals with DN being studied, 22% exhibited mild neuropathy, 34% displayed moderate neuropathy, and 44% had severe neuropathy. The DN individuals had significantly reduced ankle dorsiflexion in cases of severe NDS scores compared to those with mild to moderate NDS scores (p = 0.009). During the binary logistic regression analysis, it was shown that the duration of DM (OR = 1.73; p = 0.038) and FBG levels (OR = 2.87; p = 0.018) were determined as predictors for DN.

CONCLUSION

The findings of this study reveal that the duration of diabetes, age, literacy level, income, HbA1c, and FBG were substantially related to a higher likelihood of DN among diabetic patients.

Individuals Diagnosed With Type 2 Diabetes Mellitus and the Status of Vitamin B12 Deficiency: A Review

Type 2 diabetes mellitus (T2DM) is a complex metabolic disorder with a multifactorial etiology and a significant global burden. In recent years, emerging evidence has suggested a potential link between T2DM and vitamin B12 deficiency, raising concerns about its impact on disease progression, management, and associated complications. This comprehensive review critically examines the current understanding of the prevalence, risk factors, clinical implications, and management strategies related to vitamin B12 deficiency in individuals diagnosed with T2DM. The review begins by providing an overview of the epidemiology of T2DM and its associated complications, underscoring the need for comprehensive management approaches. Subsequently, it delves into the physiology of vitamin B12, including its sources, absorption mechanisms, and biological functions, laying the groundwork for understanding the potential implications of deficiency in T2DM. A thorough analysis of the literature is conducted to elucidate the prevalence and risk factors of vitamin B12 deficiency in individuals with T2DM, considering factors such as age, duration of diabetes, medication use (e.g., metformin), dietary patterns, and comorbidities. Special attention is given to the role of metformin, the first-line therapy for T2DM, in precipitating or exacerbating vitamin B12 deficiency through mechanisms involving alterations in the gut microbiota and intestinal absorption. The review further explores the clinical manifestations and diagnostic challenges associated with vitamin B12 deficiency in the context of T2DM, emphasizing the importance of recognizing subtle symptoms and implementing appropriate screening protocols. It discusses the potential implications of vitamin B12 deficiency on glycemic control, diabetic neuropathy, cognitive function, cardiovascular health, and overall quality of life in individuals with T2DM. In addressing the management of vitamin B12 deficiency in T2DM, the review examines various therapeutic strategies, including oral and parenteral supplementation, dietary modifications, and lifestyle interventions. It critically evaluates the evidence supporting routine screening for vitamin B12 deficiency in individuals with T2DM and discusses controversies surrounding optimal supplementation protocols, dosing regimens, and monitoring strategies. Furthermore, the review highlights gaps in current knowledge and identifies areas for future research, such as the long-term effects of vitamin B12 supplementation on clinical outcomes in T2DM, the impact of genetic factors on vitamin B12 metabolism, and the potential role of personalized interventions. Overall, this review consolidates existing evidence and provides insights into the complex relationship between T2DM and vitamin B12 deficiency, aiming to inform clinical practice, enhance patient care, and guide future research endeavors in this important area of metabolic medicine.

Maturity-onset Diabetes of the Young Type 7 (MODY7) and the Krüppellike Factor 11 Mutation (KLF11). A Review

INTRODUCTION

Maturity-onset diabetes of the young (MODY) is a rare disease due to a single gene mutation that affects several family members in most cases. The Krüppel-like factor 11 (KLF11) gene mutation is associated with decreased insulin sensitivity to high glucose levels. KLF 11 has been implicated in the pathogenesis of MODY type 7 but given its low prevalence, prolonged subclinical period, and the emergence of new information, doubts are raised about its association.

METHODS

A literature search of the PubMed, Scopus, and EBSCO databases was performed. The terms "Diabetes Mellitus, Type 2/genetics", "Mason-Type Diabetes" , "Maturity-Onset diabetes of the young", "KLF11 protein, human", and "Maturity-Onset Diabetes of the Young, Type 7" were used"., "Diagnosis" The search selection was not standardized.

RESULTS

The KLF1 mutation is rare and represents <1% of the mutations associated with monogenic diabetes. Its isolation in European family lines in the first studies and the emergence of new variants pose new diagnostic challenges. This article reviews the definition, epidemiology, pathophysiology, diagnosis, and treatment of MODY type 7.

CONCLUSION

MODY type 7 diabetes represents a rare form of monogenic diabetes with incomplete penetrance. Given its rarity, its association with impaired glucose metabolism has been questioned. Strict evaluation of glycemic control and the appearance of microvascular complications are key areas in the follow-up of patients diagnosed with MODY 7. More studies will be required to characterize the population with KLF11 mutation and clarify its correlation with MODY.

Neuropathic Pain in Aged People: An Unresolved Issue Open to Novel Drug Approaches, Focusing on Painful Diabetic Neuropathy

A majority of older patients suffer from neuropathic pain (NP) that significantly alters their daily activities and imposes a significant burden on health care. Multiple comorbidities and the risk of polypharmacy in the elderly make it challenging to determine the appropriate drug, dosage, and maintenance of therapy. Age-dependent processes play a contributing role in neuropathy given that diabetic neuropathy (DN) is the most common form of neuropathy. This narrative review is mainly focused on the drug treatment approach for neuropathy-associated pain in aged people including both drugs and dietary supplements, considering the latter as add-on mechanism-based treatments to increase the effectiveness of usual treatments by implementing their activity or activating other analgesic pathways. On one hand, the limited clinical studies assessing the effectiveness and the adverse effects of existing pain management options in this age segment of the population (> 65), on the other hand, the expanding global demographics of the elderly contribute to building up an unresolved pain management problem that needs the attention of healthcare providers, researchers, and health authorities as well as the expansion of the current therapeutic options.

Bidirectional association between diabetic peripheral neuropathy and vitamin B12 deficiency: Two longitudinal 9-year follow-up studies using a national sample cohort

AIM

This study aims to investigate the association among metformin use, vit B12 deficiency, and DPN occurrence in diabetes.

METHODS

This retrospective, propensity-matched cohort study was performed using National Health Insurance Service database - National Sample Cohort in South Korea. Study 1 analyzed DPN incidence according to vit B12 deficiency and study 2 analyzed vit B12 deficiency incidence according to the presence/absence of DPN. Moreover, we compared the results with respect to metformin use.

RESULTS

In study 1, DPN incidence per 10000 person-year (PY) was 179.7 and 76.6 in the vit B12 and non-vit B12 deficiency groups, respectively. The adjusted HR was 1.32 (95% CI; 1.21-1.44, P < 0.05) and metformin use elicited a more significant effect of DPN occurrence in patient with vit B12 deficiency (HR: 5.76 (95% CI; 5.28-6.29). In study 2, vit B12 deficiency incidence per 10000 PY was 250.6 and 129.4 in the DPN and non-DPN groups, respectively. The adjusted HR was 2.44 (95% CI; 2.24-2.66, P < 0.05), however, metformin prescription was associated with the reduced incidence of vit B12 deficiency in DPN patients (HR 0.68 (95% CI; 0.62-0.74, P < 0.05).

CONCLUSION

DPN occurrence increased in diabetes with vit B12 deficiency and the incidence of vit B12 deficiency was also high in DPN patients. However, metformin showed opposite effects in both cohorts. Further studies clarifying the causal relationship among DPN occurrence, vit B12 deficiency, and metformin use are warranted.

Painful Diabetic Peripheral Neuropathy: Practical Guidance and Challenges for Clinical Management

Painful diabetic peripheral neuropathy (PDPN) is present in nearly a quarter of people with diabetes. It is estimated to affect over 100 million people worldwide. PDPN is associated with impaired daily functioning, depression, sleep disturbance, financial instability, and a decreased quality of life. Despite its high prevalence and significant health burden, it remains an underdiagnosed and undertreated condition. PDPN is a complex pain phenomenon with the experience of pain associated with and exacerbated by poor sleep and low mood. A holistic approach to patient-centred care alongside the pharmacological therapy is required to maximise benefit. A key treatment challenge is managing patient expectation, as a good outcome from treatment is defined as a reduction in pain of 30-50%, with a complete pain-free outcome being rare. The future for the treatment of PDPN holds promise, despite a 20-year void in the licensing of new analgesic agents for neuropathic pain. There are over 50 new molecular entities reaching clinical development and several demonstrating benefit in early-stage clinical trials. We review the current approaches to its diagnosis, the tools, and questionnaires available to clinicians, international guidance on PDPN management, and existing pharmacological and non-pharmacological treatment options. We synthesise evidence and the guidance from the American Association of Clinical Endocrinology, American Academy of Neurology, American Diabetes Association, Diabetes Canada, German Diabetes Association, and the International Diabetes Federation into a practical guide to the treatment of PDPN and highlight the need for future research into mechanistic-based treatments in order to prioritise the development of personalised medicine.

A Case of Recurrent Thyrotoxicosis in a Thyroglossal Duct Cyst 18 Years Following Thyroid Surgery

Graves' disease (GD) is an immune-mediated condition related to high thyroid-stimulating immunoglobulin levels. Here, we present a rare case of recurrent thyrotoxicosis that developed in a thyroglossal duct cyst (TGDC) and the residual thyroid tissue in a 46-year-old female following subtotal thyroidectomy. In 2005, she was diagnosed with GD causing thyrotoxicosis and treated with subtotal thyroidectomy. In 2022, she was seen at our clinic with a neck swelling gradually growing in size over the last 10 years. On examination, the mass was found to be moving with tongue protrusion. She was on thyroxin 100 mcg daily, and the dose was reduced gradually until she was maintained on no therapy for hypothyroidism and was still thyrotoxic. The combined clinical, laboratory thyroid scintigraphy and ultrasonographic features favored early developing recurrent Graves' disease in the thyroid residual and TGDC. She was started on carbimazole and was referred for surgery. Our case represents a rare occurrence of recurrent GD in the thyroid residual and TGDC.

Association between metformin and vitamin B12 deficiency in patients with type 2 diabetes

Diabetes mellitus (DM) is still one of the most common diseases worldwide, and its prevalence is still increasing globally. According to the American and European recommendations, metformin is considered a first-line oral hypo-glycemic drug for controlling type 2 DM (T2DM) patients. Metformin is the ninth most often prescribed drug in the world, and at least 120 million diabetic people are estimated to receive the drug. In the last 20 years, there has been increasing evidence of vitamin B12 deficiency among metformin-treated diabetic patients. Many studies have reported that vitamin B12 deficiency is related to the ma-labsorption of vitamin B12 among metformin-treated T2DM patients. Vitamin B12 deficiency may have a very bad complication for the T2DM patient. In this review, we will focus on the effect of metformin on the absorption of vitamin B12 and on its proposed mechanisms in hindering vitamin B12 absorption. In addition, the review will describe the clinical outcomes of vitamin B12 deficiency in metformin-treated T2DM.

A Double-Blind, Randomized, Placebo-Controlled Study to Assess the Efficacy of a Nerve Support Formula on Neuropathic Pain in Individuals Suffering from Type II Diabetes Mellitus

Background

The primary objective of the present study was to evaluate the effects of a Nerve Support Formula NeuropAWAY® on diabetic neuropathic pain.

Methods

This double-blind, placebo-controlled, randomized trial was conducted between August 2020 and February 2021. Patients aged ≥40 and ≤65 years with a history of type 2 diabetes (T2D) with a confirmed diagnosis of diabetic neuropathic pain were included in the study. The primary efficacy endpoint was to assess the effect of the 42 days administration of the Nerve Support Formula on the neuropathic pain as assessed by the 11 point Pain Intensity Numeric Rating Scale (PI-NRS). The secondary objectives were to assess the effect on plasma vitamin B12 levels, nerve conduction velocity, blood flow velocity, Brief Pain Inventory, Neuropathy Total Symptom Score, and Insomnia Severity Index.

Results

The enrolled study population (n=59) was randomized in two study groups; the Investigational Product (IP) group - Nerve Support Formula (n=27) and placebo group (n=32). The mean age of these participants was 52.63 and 53.72 for IP and placebo group, respectively. The mean (SD) HbA1c levels for IP and placebo group were 8.37 (0.85) and 8.16 (0.86), respectively. By the end of the study (Day 42) the decrease in PI-NRS scores for the IP group was maximal (↓61.32%) and highly significant (p<0.001) in comparison to the placebo group (↑2.47%). Significant improvements (p<0.05) were also noted in the secondary efficacy variables after 42 days of IP intake.

Conclusion

The formula was found to be significantly effective as compared to placebo in reducing pain and other sensory symptoms related to the diabetic peripheral neuropathy.

A Glucagonoma Presenting as Cerebral Vein Thrombosis and Diabetes

Glucagonomas are rare pancreatic neuroendocrine tumors (pNETs), malignant in 80% of cases, thus highlighting the importance of early diagnosis and treatment. Primary manifestations are diabetes, dermatosis, depression, weight loss, and deep vein thrombosis. Unlike other pNETs, glucagonomas are associated with a higher incidence of thromboembolic events, often resulting in death. We present the case of a glucagonoma patient whose primary manifestation was cerebral sinus venous thrombosis (CS-VT). Early diagnosis enabled curative resection. The purpose of this paper is to review the underlying mechanisms associated with increased coagulopathy in glucagonomas.

Third reported case of rare necrolytic migratory erythema associated with bacteraemia due to severe zinc deficiency after revisional Roux-En-Y gastric bypass: case report and literature review

INTRODUCTION

Obesity is a risk factor for zinc deficiency. After bariatric surgery, non-compliance to diet/vitamin supplements, surgical complications leading to vomiting/diarrhea, poor follow-up and malabsorption can precipitate or exacerbate pre-existing zinc deficiency.

CASE REPORT

We report a patient with rare necrolytic migratory erythema associated with bacteraemia due to severe zinc deficiency after revisional Roux-en-Y gastric bypass (following primary laparoscopic sleeve gastrectomy).

CONCLUSION

Bariatric teams should screen patients before bariatric surgery for nutritional deficiencies and continue surveillance of their nutritional status after surgery. They should maintain a high index of suspicion for zinc deficiency in patients with skin rash after bariatric surgery.

LEVEL OF EVIDENCE

Level V, case report.

Metformin: Sex/Gender Differences in Its Uses and Effects—Narrative Review

Metformin (MTF) occupies a major and fundamental position in the therapeutic management of type 2 diabetes mellitus (T2DM). Gender differences in some effects and actions of MTF have been reported. Women are usually prescribed lower MTF doses compared to men and report more gastrointestinal side effects. The incidence of cardiovascular events in women on MTF has been found to be lower to that of men on MTF. Despite some promising results with MTF regarding pregnancy rates in women with PCOS, the management of gestational diabetes, cancer prevention or adjunctive cancer treatment and COVID-19, most robust meta-analyses have yet to confirm such beneficial effects.

Vitamin B12 Supplementation and Vitamin B12 Blood Serum Levels: Evaluation of Effect Modification by Gender and Smoking Status

Research suggests that high intake of supplemental vitamin B₁₂ may be associated with increased risk of cancer, with some evidence that this association may vary by gender and smoking status. This investigation evaluates if similar patterns in association are observed for data for 11,757 adults from the National Health and Nutrition Examination Survey (1999-2006). Survey-weighted multivariable-adjusted linear regression was used to evaluate the association between regular B₁₂ supplement use and log-transformed serum B₁₂ levels. Persons taking vitamin B₁₂ through a multivitamin/multimineral (MVMM) had a median supplemental intake of 12 mcg/day (Q1: 6, Q3: 25), compared to 100 mcg/day (Q1: 22, Q3: 500) for persons reporting supplemental B₁₂ intake through a MVMM-exclusive source. MVMM users had a geometric mean serum B12 26% (95% CI: 23%-30%) higher than nonusers, whereas MVMM-exclusive users' geometric mean was 61% (95% CI: 53%-70%) higher than nonusers (p-trend < 0.001). Although a positive trend (p-trend < 0.001) was observed for both men and women, the association was stronger among women (p-interaction < 0.001). No interaction was observed for smoking status (p-interaction = 0.45). B₁₂ supplementation is associated with higher levels of serum B₁₂, with significant interaction by gender but not smoking. Further work is needed to better understand the interplay of B₁₂ and gender.

Physicians' Perception About Use of Vitamin B12 in the Treatment or Prevention of Diabetic Neuropathy: A Cross-sectional Survey in Saudi Arabia

BACKGROUND

Diabetic neuropathy is a condition that is prevalent among type 2 diabetic patients. Some physicians prescribe vitamin B12 or vitamin B complex supplements to improve symptoms, but studies have shown that there is little to no evidence of vitamin B12 being an effective treatment for diabetic neuropathy. Thus, this study aims to investigate local physicians' knowledge and tendency to prescribe vitamin B12 or vitamin B complex for the treatment or prevention of diabetic peripheral neuropathy.

METHODS

It was a cross-sectional study, conducted between May and November of 2019, in several primary healthcare centers in different cities of Saudi Arabia. A total of 412 physicians with a minimum of three years of experience answered a three-part questionnaire on their demographic information, prescribing behavior, and knowledge of the relationship between vitamin B12 or vitamin B complex and diabetic neuropathy.

RESULTS

The study found that only 42% of the physicians believed that vitamin B12 supplementation did not prevent diabetic neuropathy, while only 52.7% found it to be an ineffective treatment for this condition. Moreover, 58.7% stated that they had certainly prescribed vitamin B12 or multivitamins as a form of treatment or prevention of diabetic neuropathy. 47.8% of the patients requested a vitamin B12 prescription 1-6 times from their physicians, while 31.6% of them requested it ≥ 7 times, with 42.5% of physicians agreeing that their prescriptions of vitamin B12 had been a result of patient demand more than clinical justification. Likewise, 43% of respondents were aware that vitamin B12 levels should be tested annually. Furthermore, a higher proportion of consultants chose not to prescribe vitamin B12 to prevent or treat diabetic neuropathy than any other rank.

CONCLUSION

The findings of this study indicate a tendency of unnecessarily prescribing vitamin B12 supplementation for the prevention or treatment of diabetic neuropathy as well as a lack of knowledge on the matter among doctors in primary care hospitals in Saudi Arabia. The study has also shown that there are patients who often request this prescription, adding pressure on their physicians to comply. Future studies should investigate most of the hospitals in Saudi cities and include less experienced residents and medical students.

Impacts of statin and metformin on neuropathy in patients with type 2 diabetes mellitus: Korean Health Insurance data

BACKGROUND

Neuropathy is a common chronic complication in type 2 diabetes mellitus (T2DM). Statin and metformin are commonly used medications in T2DM patients, and some studies showed statin- or metformin-induced neuropathy.

AIM

To evaluate the incidence of neuropathy among patients with T2DM associated with statin and metformin therapies.

METHODS

Korean Health Insurance Review and Assessment national patient sample data from 2016 and 2017 were used. Patients with T2DM and no complications were divided into statin/metformin/statin + metformin users and non-users. Neuropathy incidence was defined by International Statistical Classification of Diseases and Related Health Problems, 10^th revision codes and concomitant prescriptions for anticonvulsants or antidepressants. Logistic regression analyses were conducted to examine the associations between statin/metformin/statin + metformin therapies and the incidence of neuropathy. Propensity score (PS) matching was performed on the basis of age, sex and comorbidities.

RESULTS

Overall, 34964 and 35887 patients with T2DM and no complications were included in the Korean Health Insurance Review and Assessment national patient sample datasets from 2016 and 2017, respectively. Statin therapy was associated with increased risks of neuropathy in 2016 and 2017 [PS-matched odds ratio (OR) = 1.22, 95% confidence interval (CI): 1.08-1.38; PS-matched OR = 1.17, 95%CI: 1.03-1.33, respectively]. Metformin therapy was associated with reduced risks of neuropathy in 2016 and 2017 (PS-matched OR = 0.30, 95%CI: 0.21-0.42; PS-matched OR = 0.44, 95%CI: 0.32-0.60, respectively). Combined statin + metformin therapy was not significantly associated with neuropathy in 2016 or 2017 (PS-matched OR = 0.85, 95%CI: 0.61-1.19; PS-matched OR = 0.95, 95%CI: 0.66-1.38, respectively).

CONCLUSION

Statin therapy was associated with enhanced risk of new-onset neuropathy in patients with T2DM, but metformin therapy showed the opposite association.

Metformin for diabetes prevention: update of the evidence base

We have conducted a narrative review based on a structured search strategy, focusing on the effects of metformin on the progression of non-diabetic hyperglycemia to clinical type 2 diabetes mellitus. The principal trials that demonstrated a significantly lower incidence of diabetes in at-risk populations randomized to metformin (mostly with impaired glucose tolerance [IGT]) were published mainly from 1999 to 2012. Metformin reduced the 3-year risk of diabetes by -31% in the randomized phase of the Diabetes Prevention Program (DPP), vs. -58% for intensive lifestyle intervention (ILI). Metformin was most effective in younger, heavier subjects. Diminishing but still significant reductions in diabetes risk for subjects originally randomized to these groups were present in the trial's epidemiological follow-up, the DPP Outcomes Study (DPPOS) at 10 years (-18 and -34%, respectively), 15 years (-18 and -27%), and 22 years (-18 and -25%). Long-term weight loss was also seen in both groups, with better maintenance under metformin. Subgroup analyses from the DPP/DPPOS have shed important light on the actions of metformin, including a greater effect in women with prior gestational diabetes, and a reduction in coronary artery calcium in men that might suggest a cardioprotective effect. Improvements in long-term clinical outcomes with metformin in people with non-diabetic hyperglycemia ("prediabetes") have yet to be demonstrated, but cardiovascular and microvascular benefits were seen for those in the DPPOS who did not vs. did develop diabetes. Multiple health economic analyses suggest that either metformin or ILI is cost-effective in a community setting. Long-term diabetes prevention with metformin is feasible and is supported in influential guidelines for selected groups of subjects. Future research will demonstrate whether intervention with metformin in people with non-diabetic hyperglycemia will improve long-term clinical outcomes.

Molecular Aspects in the Potential of Vitamins and Supplements for Treating Diabetic Neuropathy

PURPOSE OF REVIEW

To discuss and provide evidence-based data on dietary supplements as part of treating diabetic neuropathy RECENT FINDINGS: Few randomized controlled trials are available, but some have shown beneficial efficacy of various dietary supplements on objective primary endpoints including nerve conduction velocities and axon potentials as well as subjective patient-reported outcomes. No medical cure for diabetic neuropathy exists, and prevention is therefore crucial. Tight glucose control slows the progression of nerve damage in diabetes, but an unmet clinical need for effective interventions is warranted. Consequently, a growing number of patients turn to dietary supplements proposed to possess neuroprotective properties. However, the postulated effects are often not evidence-based as they have not been tested scientifically. Taken together, this review will focus on dietary supplements investigated in clinical trials for their potential capabilities in targeting the molecular mechanisms involved in the underlying pathogenesis of diabetic neuropathy.

Serum vitamin B12 status of patients with type 2 diabetes mellitus on metformin: A single-center cross-sectional study from Bangladesh

BACKGROUND

Metformin use is a known cause of B12 deficiency in patients with type 2 DM (T2DM). Diabetic peripheral neuropathy (DPN) often has clinically indistinguishable clinical features of B12 deficiency-induced peripheral neuropathy (PN).

OBJECTIVE

The present study aims to assess serum vitamin B12 levels in patients with T2DM on metformin.

SUBJECTS AND METHODS

This cross-sectional study was conducted at a specialized endocrine outpatient clinic in Cumilla, Bangladesh, over six months from January 2020 to June 2020. Non-pregnant adults (≥18 years age) receiving metformin for T2DM for at least six months were evaluated for PN and assessed for serum B12 levels.

RESULTS

Among 90 subjects evaluated, 28 (31.1%) had B12 deficiency and 6 (6.7%) had borderline B12 deficiency; 56 (62.2%) had normal B12 levels. Study subjects with subnormal B12 used metformin for a longer duration [8.5 (7.0-14.0) vs. 5.0 (2.25-10.0) years, median (IQR), P = 0.006], gram-years of metformin use was higher in them [12.0 (7.9-14.0) vs. 5.75 (2.0-13.6) years, median (IQR), P = 0.005] and they had a higher mean corpuscular volume [85.9±7.2 vs. 82.4±6.4 fL, mean±SD, P = 0.020] compared to those having normal B12 levels. Serum B12 levels had a strong negative correlation with duration of metformin use and gram-years of metformin use. B12 status did not influence the presence and severity of PN.

CONCLUSIONS

A considerable number of patients with T2DM have subnormal B12 levels. Periodic screening for serum vitamin B12 level may be of clinical benefit in such patients.

Profiling immuno-metabolic mediators of vitamin B12 deficiency among metformin-treated type 2 diabetic patients in Ghana

BACKGROUND

The association between prolong metformin usage and B12 deficiency has been documented. However, the prevalence estimates of metformin-induced vitamin B12 deficiency showed substantial disparity among studies due to varied study definitions of vitamin B12 deficiency. Metformin blocks the calcium dependent absorption of the vitamin B12-Intrinsic Factor complex at the terminal ileum. Lack of intrinsic factor due to the presence of auto-antibodies to parietal cells (IFA) could lead to vitamin B12 deficiency and subsequently cause peripheral neuropathy. We investigated the prevalence of vitamin B12 deficiency using more sensitive, combined markers of vitamin B12 status (4cB12) and the immuno-biochemical mediators of vitamin B12 deficiency.

METHODS

In this observational study, 200 consecutive consenting metformin-treated T2DM patients, aged 35 and above, attending the diabetic clinic at KATH were recruited. Vitamin B12 deficiency was classified based on the Fedosov age-normalized wellness quotient. Anthropometric measurement was taken as well as blood samples for immunological and biochemical mediators. Peripheral neuropathy was assessed using the Michigan Neuropathy Screening Instrument (MNSI). Statistical analysis was performed using the R Language for Statistical Computing.

RESULTS

Using the combined indicator (4cB12), the prevalence of metformin induced vitamin B12 deficiency was 40.5% whilst the prevalence of MNSI-Q and MNSI-PE diabetic neuropathy was 32.5% and 6.5% respectively. Participants with vitamin B12 deficiency had significantly higher levels of IFA, GPA, TNF-α, TC, LDL and albumin compared to those with normal vitamin B12 levels (p < 0.05). Correlation analysis revealed a statistically significant negative association between 4cB12 and the immunological markers [IFA (rs = -0.301, p<0.0001), GPA (rs = -0.244, p = 0.001), TNF-α (rs = -0.242, p = 0.001) and IL-6 (rs = -0.145, p = 0.041)]. Likewise, 4cB12 was negatively associated with TC (rs = -0.203, p = 0.004) and LDL (rs = -0.222, p = 0.002) but positively correlated with HDL (rs = 0.196, p = 0.005).

CONCLUSION

Vitamin B12 deficiency and diabetic neuropathy are very high among metformin-treated T2DM patients and it is associated with increased GPA, IFA, TNF-α and cardiometabolic risk factors (higher LDL and TC and lower HDL). Upon verification of these findings in a prospective case-control study, it may be beneficial to include periodic measurement of Vitamin B12 using the more sensitive combined indicators (4cB 12) in the management of patients with T2DM treated with metformin in Ghana.

Impact of antihypertensive treatment on resiliency to clinical pain

OBJECTIVES

Although progress has been made in the regulation of hypertension over the past decades, the USA and some other countries have faced a significant rise in incidence of chronic pain management cases during the same period. Studies of the relationship between pain and blood pressure (BP) regulations propose that these two processes may be interconnected. Studies of effects of antihypertensive treatment on pain in general and its chronification have never been reviewed.

METHODS

A narrative review of respective studies with analysis of credibility of the findings was conducted.

RESULTS

Some studies have suggested that aggressive reduction of high BP may contribute to a return in pain symptoms and may require more aggressive, long-term pain management. Other studies propose that long-term antihypertensive medication could also increase the risk for new cases of chronic pain. Pain initiates a central neuroplastic resetting of the baroreceptor activation accounting for sustained increase of BP with an adaptive 'pain-killing' or maladaptive 'pain-complication' effect associated with pain chronification, and these mechanisms may be moderated by antihypertensive medications. However, different antihypertensive drugs and nondrug treatments may diversely affect pain mechanisms at different stages of treatments.

CONCLUSION

Uncontrollable reduction of high BP in some patients with hypertension could increase the risk for chronic pain incidence and its severity. Practical recommendations in BP control should be reconsidered to take into account patients' chronic pain. Further research is needed of moderation effects of different antihypertensive manipulations on pain to improve pain management in these patients.

Association between neuropathy and B-vitamins: A systematic review and meta-analysis

BACKGROUND

Peripheral neuropathy (PN) is common in patients with diseases that are in turn associated with deficiency of the B-vitamins, and vitamin treatment has shown mixed results.

METHODS

This systematic review and meta-analysis studied the association between PN/pain and B-vitamin biomarkers and investigated whether vitamin treatment can ameliorate the symptoms. PubMed and Web of Science were searched according to the study protocol.

RESULTS

A total of 46 observational and seven interventional studies were identified and included in the data synthesis. The presence of PN was associated with lowered B12 levels (pooled estimate [95% CIs] = 1.51 [1.23-1.84], n = 34, Cochran Q Test I²  = 43.3%, p = 0.003) and elevated methylmalonic acid (2.53 [1.39-4.60], n = 9, I²  = 63.8%, p = 0.005) and homocysteine (3.48 [2.01-6.04], n = 15, I²  = 70.6%, p < 0.001). B12 treatment (vs. the comparators) showed a non-significant association with symptom improvement (1.36 (0.66-2.79), n = 4, I²  = 28.9%). Treatment with B1 was associated with a significant improvement in symptoms (5.34 [1.87-15.19], n = 3, I²  = 64.6%, p = 0.059). Analysis of seven trials combined showed a non-significant higher odds ratio for improvement under treatment with the B-vitamins (2.58 [0.98-6.79], I²  = 80.0%, p < 0.001).

CONCLUSIONS

PN is associated with lowered plasma vitamin B12 and elevated methylmalonic acid and homocysteine. Overall, interventional studies have suggested that B-vitamins could improve symptoms of PN. Available trials have limitations and generally did not investigate vitamin status prior to treatment. Well-designed studies, especially in non-diabetes PN, are needed. This meta-analysis is registered at PROSPERO (ID: CRD42020144917).

Diabetic Neuropathy: a Critical, Narrative Review of Published Data from 2019

PURPOSE OF REVIEW

This manuscript is a systematic, narrative review that compiles and describes all data available from 2019 related to epidemiologic, diagnostic, and therapeutic advances in diabetic neuropathy (DN).

RECENT FINDINGS

Epidemiology of DN is discussed. Diagnostic modalities include predictive models, electrodiagnostics, imaging, and biomarkers. A majority of studies on the treatment of diabetic peripheral neuropathy (DPN) involve pharmacotherapy, but complementary and alternative medicine, exercise, modalities, psychological, interventional, and surgical options are also explored. DN is a highly prevalent and debilitating consequence of diabetes that can present challenges to the clinician as the assessment is largely subjective with different phenotypic presentations among patients. Treatment of DN is largely symptomatic as the pathogenesis of DN is not fully understood and is likely multifactorial. It is evident from the broad range of treatments that too often provide unsatisfactory relief that there is no consensus about a single most effective treatment for DN, and monotherapy rarely proves to be successful.

Vitamin B12 Supplementation in Diabetic Neuropathy: A 1-Year, Randomized, Double-Blind, Placebo-Controlled Trial

AIM

To investigate the effect of normalizing vitamin B12 (B12) levels with oral B12 (methylcobalamin) 1000 μg/day for one year in patients with diabetic neuropathy (DN).

PATIENTS AND METHODS

In this prospective, double-blind, placebo-controlled trial, 90 patients with type 2 diabetes on metformin for at least four years and both peripheral and autonomic DN were randomized to an active treatment group (n = 44) receiving B12 and a control group (n = 46) receiving a placebo. All patients had B12 levels less than 400 pmol/L. Subjects underwent measurements of sural nerve conduction velocity (SNCV), sural nerve action potential (amplitude) (SNAP), and vibration perception threshold (VPT), and they performed cardiovascular autonomic reflex tests (CARTs: mean circular resultant (MCR), Valsalva test, postural index, and orthostatic hypotension). Sudomotor function was assessed with the SUDOSCAN that measures electrochemical skin conductance in hands and feet (ESCH and ESCF, respectively). We also used the Michigan Neuropathy Screening Instrument Questionnaire and Examination (MNSIQ and MNSIE, respectively) and questionnaires to evaluate quality of life (QoL) and level of pain (pain score).

RESULTS

B12 levels increased from 232.0 ± 71.8 at baseline to 776.7 ± 242.3 pmol/L at follow-up, p < 0.0001, in the active group but not in the control group. VPT, MNSIQ, QoL, pain score, SNCV, SNAP, and ESCF significantly improved in the active group (p < 0.001, p = 0.002, p < 0.0001, p < 0.000, p < 0.0001, p < 0.0001, and p = 0.014, respectively), whereas CARTS and MNSIE improved but not significantly. MCR, MNSIQ, SNCV, SNAP, and pain score significantly deteriorated in the control group (p = 0.025, p = 0.017, p = 0.045, p < 0.0001, and p < 0.0001, respectively).

CONCLUSIONS

The treatment of patients with DN with 1 mg of oral methylcobalamin for twelve months increased plasma B12 levels and improved all neurophysiological parameters, sudomotor function, pain score, and QoL, but it did not improve CARTS and MNSIE.

Metformin as a potential therapeutic for neurological disease: mobilizing AMPK to repair the nervous system

Introduction:

Metformin is currently first line therapy for type 2 diabetes (T2D). The mechanism of action of metformin involves activation of AMP-activated protein kinase (AMPK) to enhance mitochondrial function (for example, biogenesis, refurbishment and dynamics) and autophagy. Many neurodegenerative diseases of the central and peripheral nervous systems arise from metabolic failure and toxic protein aggregation where activated AMPK could prove protective.

Areas covered:

The authors review literature on metformin treatment in Parkinson’s disease, Huntington’s disease and other neurological diseases of the CNS along with neuroprotective effects of AMPK activation and suppression of the mammalian target of rapamycin (mTOR) pathway on peripheral neuropathy and neuropathic pain. The authors compare the efficacy of metformin with the actions of resveratrol.

Expert opinion:

Metformin, through activation of AMPK and autophagy, can enhance neuronal bioenergetics, promote nerve repair and reduce toxic protein aggregates in neurological diseases. A long history of safe use in humans should encourage development of metformin and other AMPK activators in preclinical and clinical research. Future studies in animal models of neurological disease should strive to further dissect in a mechanistic manner the pathways downstream from metformin-dependent AMPK activation, and to further investigate mTOR dependent and independent signaling pathways driving neuroprotection.