51
|
Bone Metabolism and Fracture Risk in Diabetes Mellitus. J ASEAN Fed Endocr Soc 2017; 32:90-99. [PMID: 33442091 PMCID: PMC7784240 DOI: 10.15605/jafes.032.02.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/30/2017] [Indexed: 01/14/2023] Open
Abstract
Individuals with Type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) are at increased risk for fragility fractures. Bone mineral density (BMD) is decreased in T1DM but often normal or even elevated in T2DM when compared with age-matched non-DM populations. However, bone turnover is decreased in both T1DM and T2DM. The pathophysiologic mechanisms leading to bone fragility is multifactorial, and potentially leads to reduced bone formation, altered bone microstructure and decreased bone strength. Interestingly, different antidiabetic treatments may influence fracture risk due to effects on glycemic control, triggering of hypoglycemic events or osteoblastogenesis.
Collapse
|
52
|
Colleluori G, Aguirre L, Dorin R, Robbins D, Blevins D, Barnouin Y, Chen R, Qualls C, Villareal DT, Armamento-Villareal R. Hypogonadal men with type 2 diabetes mellitus have smaller bone size and lower bone turnover. Bone 2017; 99:14-19. [PMID: 28323146 PMCID: PMC8312374 DOI: 10.1016/j.bone.2017.03.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 02/08/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Both hypogonadism and type 2 diabetes mellitus (T2D) are associated with increased fracture risk. Emerging data support the negative effect of low testosterone on glucose metabolism, however, there is little information on the bone health of hypogonadal men with diabetes. We evaluated the bone mineral density (BMD), bone geometry and bone turnover of hypogonadal men with T2D compared to hypogonadal men without diabetes. MATERIALS AND METHODS Cross-sectional study, men 40-74years old, with average morning testosterone (done twice) of<300ng/dl. Areal BMD (aBMD) was measured by DXA; volumetric BMD (vBMD) and bone geometry by peripheral-quantitative-computed-tomography; serum C-telopeptide (CTX), osteocalcin, sclerostin and sex hormone-binding globulin (SHBG) by ELISA, testosterone and 25-hydroxyvitamin D (25OHD) by automated immunoassay and estradiol by liquid-chromatography/mass-spectrometry. Groups were compared by ANOVA adjusted for covariates. RESULTS One-hundred five men, 49 with and 56 without diabetes were enrolled. Adjusted vBMD at 38% tibia was higher in diabetic than non-diabetic men (857.3±69.0mg/cm3 vs. 828.7±96.7mg/cm3, p=0.02). Endosteal (43.9±5.8mm vs. 47.1±7.8mm, p=0.04) and periosteal (78.4±5.0mm vs. 81.3±6.5mm, p=0.02) circumferences and total area (491.0±61.0mm2 vs. 527.7±87.2mm2, p=0.02) at 38% tibia, were lower in diabetic men even after adjustments for covariates. CTX (0.25±0.14ng/ml vs. 0.40±0.19ng/ml, p<0.001) and osteocalcin (4.8±2.8ng/ml vs. 6.8±3.5ng/ml, p=0.006) were lower in diabetic men; there were no differences in sclerostin and 25OHD. Circulating gonadal hormones were comparable between the groups. CONCLUSION Among hypogonadal men, those with T2D have higher BMD, poorer bone geometry and relatively suppressed bone turnover. Studies with larger sample size are needed to verify our findings and possible even greater risk for fractures among hypogonadal diabetic men.
Collapse
Affiliation(s)
- Georgia Colleluori
- Baylor College of Medicine, One Baylor Plaza, 77030 Houston, TX, USA; Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, 77030 Houston, TX, USA; University Campus Biomedico of Rome, Via Alvaro del Portillo, 21 04000100, Rome, Italy
| | - Lina Aguirre
- New Mexico VA Health Care System, 1501 San Pedro SE, 87108 Albuquerque, NM, USA
| | - Richard Dorin
- New Mexico VA Health Care System, 1501 San Pedro SE, 87108 Albuquerque, NM, USA; University of New Mexico School of Medicine, 87131 Albuquerque, NM, USA
| | - David Robbins
- New Mexico VA Health Care System, 1501 San Pedro SE, 87108 Albuquerque, NM, USA; University of New Mexico School of Medicine, 87131 Albuquerque, NM, USA
| | - Dean Blevins
- Baylor College of Medicine, One Baylor Plaza, 77030 Houston, TX, USA; Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, 77030 Houston, TX, USA
| | - Yoann Barnouin
- Baylor College of Medicine, One Baylor Plaza, 77030 Houston, TX, USA; Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, 77030 Houston, TX, USA
| | - Rui Chen
- Baylor College of Medicine, One Baylor Plaza, 77030 Houston, TX, USA; Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, 77030 Houston, TX, USA
| | - Clifford Qualls
- University of New Mexico School of Medicine, 87131 Albuquerque, NM, USA; Biomedical Research Institute of New Mexico, 1501 San Pedro SE, 87108 Albuquerque, NM, USA
| | - Dennis T Villareal
- Baylor College of Medicine, One Baylor Plaza, 77030 Houston, TX, USA; Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, 77030 Houston, TX, USA
| | - Reina Armamento-Villareal
- Baylor College of Medicine, One Baylor Plaza, 77030 Houston, TX, USA; Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, 77030 Houston, TX, USA.
| |
Collapse
|
53
|
Palermo A, D'Onofrio L, Buzzetti R, Manfrini S, Napoli N. Pathophysiology of Bone Fragility in Patients with Diabetes. Calcif Tissue Int 2017; 100:122-132. [PMID: 28180919 DOI: 10.1007/s00223-016-0226-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 12/20/2016] [Indexed: 02/07/2023]
Abstract
It has been well established that bone fragility is one of the chronic complications of diabetes mellitus, and both type 1 and type 2 diabetes are risk factors for fragility fractures. Diabetes may negatively affect bone health by unbalancing several pathways: bone formation, bone resorption, collagen formation, inflammatory cytokine, muscular and incretin system, bone marrow adiposity and calcium metabolism. The purpose of this narrative review is to explore the current understanding of pathophysiological pathways underlying bone fragility in diabetics. In particular, the review will focus on the peculiar cellular and molecular system impairment that may lead to increased risk of fracture in type 1 and type 2 diabetes.
Collapse
Affiliation(s)
- Andrea Palermo
- Diabetes and Bone network, Department Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 21 - 00128, Rome, Italy
| | - Luca D'Onofrio
- Department of Experimental Medicine, Polo Pontino, Sapienza University of Rome, Rome, Italy
| | - Raffaella Buzzetti
- Department of Experimental Medicine, Polo Pontino, Sapienza University of Rome, Rome, Italy
| | - Silvia Manfrini
- Diabetes and Bone network, Department Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 21 - 00128, Rome, Italy
| | - Nicola Napoli
- Diabetes and Bone network, Department Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 21 - 00128, Rome, Italy.
- Division of Bone and Mineral Diseases, Washington University in St Louis, St Louis, USA.
| |
Collapse
|
54
|
Napoli N, Strollo R, Paladini A, Briganti SI, Pozzilli P, Epstein S. Corrigendum to "The Alliance of Mesenchymal Stem Cells, Bone, and Diabetes". Int J Endocrinol 2017; 2017:5924671. [PMID: 28751910 PMCID: PMC5511635 DOI: 10.1155/2017/5924671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/07/2017] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1155/2014/690783.].
Collapse
Affiliation(s)
- Nicola Napoli
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
- Division of Bone and Mineral Diseases, Washington University in St Louis, St Louis, MO, USA
- *Nicola Napoli:
| | - Rocky Strollo
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Angela Paladini
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Silvia I. Briganti
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Paolo Pozzilli
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
- Centre for Diabetes, The Blizard Building, Barts and The London School of Medicine, Queen Mary, University of London, London, UK
| | - Sol Epstein
- Division of Endocrinology, Mount Sinai School of Medicine, New York, USA
| |
Collapse
|
55
|
Sanches CP, Vianna AGD, Barreto FDC. The impact of type 2 diabetes on bone metabolism. Diabetol Metab Syndr 2017; 9:85. [PMID: 29075333 PMCID: PMC5649056 DOI: 10.1186/s13098-017-0278-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 10/03/2017] [Indexed: 02/07/2023] Open
Abstract
Diabetes complications and osteoporotic fractures are two of the most important causes of morbidity and mortality in older patients and share many features including genetic susceptibility, molecular mechanisms, and environmental factors. Type 2 diabetes mellitus (T2DM) compromises bone microarchitecture by inducing abnormal bone cell function and matrix structure, with increased osteoblast apoptosis, diminished osteoblast differentiation, and enhanced osteoclast-mediated bone resorption. The linkage between these two chronic diseases creates a possibility that certain antidiabetic therapies may affect bone quality. Both glycemic and bone homeostasis are under control of common regulatory factors. These factors include insulin, accumulation of advanced glycation end products, peroxisome proliferator-activated receptor gamma, gastrointestinal hormones (such as the glucose-dependent insulinotropic peptide and the glucagon-like peptides 1 and 2), and bone-derived hormone osteocalcin. This background allows individual pharmacological targets for antidiabetic therapies to affect the bone quality due to their indirect effects on bone cell differentiation and bone remodeling process. Moreover, it's important to consider the fragility fractures as another diabetes complication and discuss more deeply about the requirement for adequate screening and preventive measures. This review aims to briefly explore the impact of T2DM on bone metabolic and mechanical proprieties and fracture risk.
Collapse
Affiliation(s)
- Claudia Pinheiro Sanches
- Curitiba Diabetes Center, Division of Endocrinology, Hospital Nossa Senhora das Graças, Rua Alcides Munhoz, 433, 4° andar, Mercês, Curitiba, Paraná ZIP Code: 80810-040 Brazil
| | - Andre Gustavo Daher Vianna
- Curitiba Diabetes Center, Division of Endocrinology, Hospital Nossa Senhora das Graças, Rua Alcides Munhoz, 433, 4° andar, Mercês, Curitiba, Paraná ZIP Code: 80810-040 Brazil
- Pontifical Catholic University of Parana, Rua Imaculada Conceição, 1155 , Bloco Medicina, Prado Velho, Curitiba, Paraná ZIP Code: 80215-901 Brazil
| | - Fellype de Carvalho Barreto
- Division of Nephrology, Department of Internal Medicine, Federal University of Paraná, Rua General Carneiro 181, Alto da Gloria, Curitiba, Paraná ZIP Code: 80060-900 Brazil
| |
Collapse
|
56
|
Carnovali M, Luzi L, Banfi G, Mariotti M. Chronic hyperglycemia affects bone metabolism in adult zebrafish scale model. Endocrine 2016; 54:808-817. [PMID: 27696252 DOI: 10.1007/s12020-016-1106-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/25/2016] [Indexed: 12/25/2022]
Abstract
Type II diabetes mellitus is a metabolic disease characterized by chronic hyperglycemia that induce other pathologies including diabetic retinopathy and bone disease. The mechanisms implicated in bone alterations induced by type II diabetes mellitus have been debated for years and are not yet clear because there are other factors involved that hide bone mineral density alterations. Despite this, it is well known that chronic hyperglycemia affects bone health causing fragility, mechanical strength reduction and increased propensity of fractures because of impaired bone matrix microstructure and aberrant bone cells function. Adult Danio rerio (zebrafish) represents a powerful model to study glucose and bone metabolism. Then, the aim of this study was to evaluate bone effects of chronic hyperglycemia in a new type II diabetes mellitus zebrafish model created by glucose administration in the water. Fish blood glucose levels have been monitored in time course experiments and basal glycemia was found increased. After 1 month treatment, the morphology of the retinal blood vessels showed abnormalities resembling to the human diabetic retinopathy. The adult bone metabolism has been evaluated in fish using the scales as read-out system. The scales of glucose-treated fish didn't depose new mineralized matrix and shown bone resorption lacunae associated with an intense osteoclast activity. In addition, hyperglycemic fish scales have shown a significant decrease of alkaline phosphatase activity and increase of tartrate-resistant acid phosphatase activity, in association with alterations in other bone-specific markers. These data indicates an imbalance in bone metabolism, which leads to the osteoporotic-like phenotype visualized through scale mineral matrix staining. The zebrafish model of hyperglycemic damage can contribute to elucidate in vivo the molecular mechanisms of metabolic changes, which influence the bone tissues regulation in human diabetic patients.
Collapse
Affiliation(s)
| | - Livio Luzi
- Policlinico San Donato IRCCS, Milan, Italy
- Dep. Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | - Massimo Mariotti
- IRCCS Galeazzi Orthopedic Institute, Milan, Italy.
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
| |
Collapse
|
57
|
Epstein S, Defeudis G, Manfrini S, Napoli N, Pozzilli P. Diabetes and disordered bone metabolism (diabetic osteodystrophy): time for recognition. Osteoporos Int 2016; 27:1931-51. [PMID: 26980458 DOI: 10.1007/s00198-015-3454-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/07/2015] [Indexed: 02/06/2023]
Abstract
Diabetes and osteoporosis are rapidly growing diseases. The link between the high fracture incidence in diabetes as compared with the non-diabetic state has recently been recognized. While this review cannot cover every aspect of diabetic osteodystrophy, it attempts to incorporate current information from the First International Symposium on Diabetes and Bone presentations in Rome in 2014. Diabetes and osteoporosis are fast-growing diseases in the western world and are becoming a major problem in the emerging economic nations. Aging of populations worldwide will be responsible for an increased risk in the incidence of osteoporosis and diabetes. Furthermore, the economic burden due to complications of these diseases is enormous and will continue to increase unless public awareness of these diseases, the curbing of obesity, and cost-effective measures are instituted. The link between diabetes and fractures being more common in diabetics than non-diabetics has been widely recognized. At the same time, many questions remain regarding the underlying mechanisms for greater bone fragility in diabetic patients and the best approach to risk assessment and treatment to prevent fractures. Although it cannot cover every aspect of diabetic osteodystrophy, this review will attempt to incorporate current information particularly from the First International Symposium on Diabetes and Bone presentations in Rome in November 2014.
Collapse
Affiliation(s)
- S Epstein
- Division of Endocrinology, Mount Sinai School of Medicine, New York, NY, USA
| | - G Defeudis
- Unit of Endocrinology and Diabetes, Department of Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21-00128, Rome, Italy.
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - S Manfrini
- Unit of Endocrinology and Diabetes, Department of Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21-00128, Rome, Italy
| | - N Napoli
- Unit of Endocrinology and Diabetes, Department of Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21-00128, Rome, Italy
| | - P Pozzilli
- Unit of Endocrinology and Diabetes, Department of Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21-00128, Rome, Italy
| | | |
Collapse
|
58
|
Defeudis G, Gianfrilli D, Di Emidio C, Pofi R, Tuccinardi D, Palermo A, Lenzi A, Pozzilli P. Erectile dysfunction and its management in patients with diabetes mellitus. Rev Endocr Metab Disord 2015; 16:10.1007/s11154-015-9321-4. [PMID: 26497842 DOI: 10.1007/s11154-015-9321-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetes can be described as a syndrome of multiple closely related conditions induced by a chronic state of hyperglycaemia resulting from defective insulin secretion, insulin action or both. Chronic complications associated with diabetes (including neuropathy, vascular disease, nephropathy and retinopathy) are common, and of these, erectile dysfunction (ED) deserves special attention. ED and its correlation with cardiovascular disease require careful evaluation and appropriate treatment. PDE5 inhibitors (PDE5is) are an important tool for the treatment of ED, with new drugs coming onto the market since the late 90s. This review offers an overview of PDE5is and their use in treating ED in diabetes. We underline the differences between different types of PDE5i, focusing on available doses, duration of action, T ½, side effects and selectivity profiles in relation to patients with diabetes. We also discuss the link between diabetes and ED in presence of various associated cofactors (obesity, hypertension and its pharmacological treatments, atherosclerosis, hyperhomocysteinaemia, neuropathy, nephropathy, hypogonadism and depression). Finally a number of past and ongoing clinical trials on the use of PDE5is in patients with diabetes are presented to offer an overview of the appropriate treatment of ED in this condition.
Collapse
Affiliation(s)
- Giuseppe Defeudis
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 21, Rome, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, Rome, Italy
| | - Chiara Di Emidio
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 21, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, Rome, Italy
| | - Dario Tuccinardi
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 21, Rome, Italy
| | - Andrea Palermo
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 21, Rome, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico 155, Rome, Italy
| | - Paolo Pozzilli
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 21, Rome, Italy.
| |
Collapse
|
59
|
Napoli N, Strollo R, Sprini D, Maddaloni E, Rini GB, Carmina E. Serum 25-OH Vitamin D in relation to Bone Mineral Density and Bone Turnover. Int J Endocrinol 2014; 2014:487463. [PMID: 25110474 PMCID: PMC4119679 DOI: 10.1155/2014/487463] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 06/22/2014] [Indexed: 12/16/2022] Open
Abstract
It is unclear which vitamin D status is optimal for bone health. In this study, we aimed to assess cutoffs of 25-hydroxyvitamin D (25OHD) derived by the literature (20, 25, or 30 ng/mL) in relation to bone turnover and bone mineral density (BMD). Serum 25OHD, PTH, osteocalcin, bone alkaline phosphatase, and C-telopeptide were measured in 274 consecutive postmenopausal women. BMD of the lumbar spine (L1-L4) and of femoral neck were also evaluated. 50 patients had normal BMD, while 124 had osteopenia and 100 had osteoporosis. 37.6%, 56.2%, and 70.8% subjects had serum 25OHD lower than 20, 25, or 30 ng/mL, respectively. No differences in bone turnover markers were found when comparing patients with low 25OHD defined according to the different cutoffs. However, a cutoff of 25 ng/mL appeared to differentiate better than a cutoff of 30 ng/mL in those subjects with reduced femoral neck BMD. The PTH plateau occurred at 25OHD levels of 26-30 ng/mL. In conclusion, vitamin D deficiency is common in Sicilian postmenopausal women and it may be associated with low BMD and increased bone turnover markers. Further studies are needed to better define the right cutoff for normal vitamin D levels in postmenopausal women.
Collapse
Affiliation(s)
- Nicola Napoli
- Endocrinology and Diabetes, Universitá Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Rocky Strollo
- Endocrinology and Diabetes, Universitá Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Delia Sprini
- Dipartimento di Medicina Interna e Specialistica (DIMIS), Università di Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Ernesto Maddaloni
- Endocrinology and Diabetes, Universitá Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Giovam Battista Rini
- Dipartimento di Medicina Interna e Specialistica (DIMIS), Università di Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Enrico Carmina
- Endocrine Unit, Department of Medical and Biological Sciences, Universitá di Palermo, Via delle Croci 47, 90139 Palermo, Italy
- *Enrico Carmina:
| |
Collapse
|