1
|
Tian T, Aaron RE, Huang J, Yeung AM, Svensson J, Gentile S, Forbes A, Heinemann L, Seley JJ, Kerr D, Klonoff DC. Lipohypertrophy and Insulin: An Update From the Diabetes Technology Society. J Diabetes Sci Technol 2023; 17:1711-1721. [PMID: 37555266 PMCID: PMC10658672 DOI: 10.1177/19322968231187661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Lipohypertrophy is a common skin complication associated with insulin-treated diabetes. The impact of lipohypertrophy as a contributing factor to suboptimal glycemic control, glucose variability, and hypoglycemia is often under-recognized by health care professionals. In a recent Webinar on April 26, 2023, Diabetes Technology Society asked international experts to provide updates on the latest knowledge related to lipohypertrophy for practicing clinicians and educators, researchers, and industries involved in insulin delivery. A recording of the Webinar is freely available on the Diabetes Technology Society Web site (https://www.diabetestechnology.org/).
Collapse
Affiliation(s)
- Tiffany Tian
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | - Jannet Svensson
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sandro Gentile
- Department of Internal Medicine, Campania University “Luigi Vanvitelli,” Naples, Italy
- Diabetes Unit AID Stabia, Nefrocenter Research and Nyx Start-Up, Naples, Italy
| | - Angus Forbes
- Division of Care in Long-term Conditions, King’s College London, London, UK
| | | | - Jane Jeffrie Seley
- Division of Endocrinology, Diabetes & Metabolism, Weill Cornell Medicine, New York, NY, USA
| | - David Kerr
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| |
Collapse
|
2
|
Sindie R, Mwakilama E, Chizala P, Namangale J. A retrospective study on side effects of first-line antiretroviral drugs on HIV patients based on 1A, 2A, and 5A regimen records at Zomba Central Hospital, Malawi. Afr Health Sci 2023; 23:468-480. [PMID: 38357124 PMCID: PMC10862583 DOI: 10.4314/ahs.v23i3.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
AIDS is an incurable disease that is common in Africa. Patients with HIV/AIDS having a CD4 count of less than 240 are put on life prolonging ARV drugs. The ARVs have serious side effects on some patients which may be handled by treating them or switching patient's drug to one with no or less serious side effects. However, before doing this, more understanding of the circumstances that lead to a side effect is vital. We use statistical analyses to link side effects of 1A, 2A, and 5A treatment regimens to the patient's social and demographic characteristics based on hospital data records. A retrospective review of patients' master cards (2011-2014) was done to assess adverse effects associated with different ARV regimens. Out of the 901 patients that showed side effects, 65.37% were females aged 31-40 and 34.63% were males. Comparatively, 1A regimen showed more side effects than 2A and 5A regimens. Age, gender and occupation correlated significantly with regimen symptoms (p< 0.05). Unlike men, women had the following extra side effects; cough, peripheral neuropathy and leg pains as compared to lipodystrophy. Our results show that old people (50years+) are less likely to get skin rash and other symptoms compared to lipodystrophy (RRR=0.973). Further, the probability of either having cough (0.0021, p< 0.05), or skin rash (0.0021, p< 0.05), as a side effect, on average, decreases as age increases with the same sex and weight. The probability of having peripheral neuropathy (0.0042, p< 0.01), however, increases with age. Knowledge of HIV patient's socio-demographics and the patient's regimen side effects can be utilised to appropriately manage severe ARV side effects. A therapy consideration that takes into account chemicals in ARV regimen responsible for specific side effects can be directed to patients with compatible socio-demographic characteristics.
Collapse
Affiliation(s)
- Ruth Sindie
- SouthWest University, China
- University of Malawi, Zomba, Malawi
| | | | | | | |
Collapse
|
3
|
Elsayed S, Soliman AT, De Sanctis V, Fawzy D, Ahmed S, Alaaraj N. Insulin-induced lipodystrophy and predisposing factors in children and adolescents with type 1 diabetes mellitus (T1DM) in a tertiary care Egyptian center. Acta Biomed 2023; 94:e2023078. [PMID: 37326270 PMCID: PMC10308467 DOI: 10.23750/abm.v94i3.14117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Lipodystrophy (LH) is one of the most common complications of subcutaneous insulin injection. Many factors are incriminated in the evolution of LH in children with diabetes type 1 (T1DM). LH may affect insulin absorption in the skin areas involved, resulting in a negative impact on blood glucose levels and glycemic variability. PATIENTS AND METHODS We calculated and evaluated the prevalence of LH in relation to possible clinical factors associated with the development of LH in a cohort of children (n =115) with T1DM using insulin pens or syringes and we studied possible predisposing factors including their age, duration of T1DM, injection technique, insulin dose/kg, degree of pain perception, and HbA1c level. RESULTS In our cross-sectional study, 84% of patients were using pens for insulin injection and 52.2 % of them were rotating the site of injection on daily basis. 27 % did not experience pain during an injection while 6 % had the worst hurt. 49.5 % had clinically detectable LH. Those with LH had higher HbA1c levels and more unexplained hypoglycemic events compared to those without LH (P: 0.058). The hypertrophied site was related to the preferred site of injection which was the arms in 71.9 % of the cases. Children who had LH were older with a longer duration of T1DM, rotating sites of injection less frequently, and were more frequently reusing needles compared to children without LH (P: < 0.05). CONCLUSION Improper insulin injection technique, older age, and longer duration of T1DM were associated with LH. Proper education of patients and their parents must include correct injection techniques, rotating injection sites, and minimal reuse of needles.
Collapse
Affiliation(s)
- Shaymaa Elsayed
- Pediatric Endocrinology and Diabetology Unit, Faculty of Medicine, Alexandria University, Egypt.
| | | | - Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy.
| | - Dina Fawzy
- Pediatric Endocrinology and Diabetology Unit, Faculty of Medicine, Alexandria University, Egypt.
| | - Shaymaa Ahmed
- Department of Pediatrics, Hamad General Hospital, Doha, Qatar.
| | - Nada Alaaraj
- Department of Pediatrics, Hamad General Hospital, Doha, Qatar.
| |
Collapse
|
4
|
Korkmaz FN, Gökçay Canpolat A, Güllü S. Determination of insulin-related lipohypertrophy frequency and risk factors in patients with diabetes. ENDOCRINOL DIAB NUTR 2022; 69:354-361. [PMID: 35697467 DOI: 10.1016/j.endien.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/05/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Insulin, which is used in the treatment of diabetes mellitus (DM), may lead to the development of lipohypertrophy (LH) which can negatively affect the management of diabetes mellitus. Two common methods to detect LH are palpation and superficial subcutaneous ultrasonography (SSU). We investigated the frequency of non-palpable LH using SSU, as well as examining risk factors. METHOD We included in our study patients who had been receiving insulin injections at least twice a day for over one year without palpable LH. The epidermis and the subcutaneous tissue thickness of each region were examined using SSU. The presence of LH and associated risk factors for LH were evaluated. RESULTS We included 136 patients in our study. The mean age of all patients was 52.87±14.93 years, 59.6% were female and 73.5% had type 2 DM. The duration of DM and insulin usage were 15.76±9.20 and 11.42±8.26 years, respectively. The mean body mass index (BMI) of all patients was 30.59±7.40kg/m2. Non-palpable LH was detected in 87.5% (n=116) of the patients using SSU. In the multivariate logistic regression analyses, total cholesterol level, short-acting insulin dose and coronary artery disease (CAD) were associated with LH presence. CONCLUSION Non-palpable LH can be seen at high rates in patients who have multiple insulin injections. Palpation is likely not enough to detect LH and we believe it would be appropriate to evaluate the presence of LH using SSU, especially for those who need high-dose insulin to control hyperglycaemia.
Collapse
Affiliation(s)
- Fatma Nur Korkmaz
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey.
| | - Asena Gökçay Canpolat
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey
| | - Sevim Güllü
- Ankara University, School of Medicine, Department of Internal Medicine, Division of Endocrinology, Ankara, Turkey
| |
Collapse
|
5
|
Abstract
Immune checkpoint inhibitors are being prescribed increasingly widely for a range of malignancies. They are effective at treating certain cancers, but also have significant side effects. Evidence suggests that efficacy is greatest in patients who experience one or more immune-related adverse events (irAEs). Common irAEs include skin and hepatic reactions, and a range of immune-related endocrinopathies. These include hypophysitis, thyroid disease, and autoimmune diabetes mellitus, and rarer endocrinopathies such as primary adrenal insufficiency, diabetes insipidus, parathyroid disease, autoimmune polyglandular syndrome, lipodystrophy, and ACTH-dependent Cushing's syndrome. Herein, we review the current literature related to these rarer immunotherapy-induced endocrinopathies.
Collapse
|
6
|
Meral R, Malandrino N, Walter M, Neidert AH, Muniyappa R, Oral EA, Brown RJ. Endogenous Leptin Concentrations Poorly Predict Metreleptin Response in Patients With Partial Lipodystrophy. J Clin Endocrinol Metab 2022; 107:e1739-e1751. [PMID: 34677608 PMCID: PMC8947785 DOI: 10.1210/clinem/dgab760] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Leptin replacement with metreleptin improves glycemia and hypertriglyceridemia in severely hypoleptinemic patients with generalized lipodystrophy (GLD), but its effects are variable in partially leptin-deficient patients with partial lipodystrophy (PLD). OBJECTIVE Compare 3 leptin assays (Study I); identify diagnostic performance of leptin assays to detect responders to metreleptin for each assay (Study II). DESIGN Study I: cross-sectional analysis of average bias between leptin assays. Study II: retrospective analysis of diagnostic accuracy of potential leptin cut points to detect clinical responders to metreleptin. SETTING National Institutes of Health; University of Michigan. PARTICIPANTS AND INTERVENTIONS Study I: Metreleptin-naïve patients with lipodystrophy (GLD, n = 33, PLD, n = 67) and healthy volunteers (n = 239). Study II: GLD (n = 66) and PLD (n = 84) patients treated with metreleptin for 12 months. OUTCOME MEASURES Leptin concentrations by Millipore radioimmunoassay (RIA), Millipore enzyme-linked immunosorbent assay (MELISA), and R&D Systems enzyme-linked immunosorbent assay (RDELISA). Response to metreleptin therapy was defined as either reduction ≥1.0% in A1c or ≥30% in serum triglycerides. RESULTS RDELISA measured 3.0 ± 9.5 ng/mL higher than RIA; MELISA measured 11.0 ± 17.8 and 14.0 ±19.2 less than RIA and RDELISA, respectively. Leptin by RIA, MELISA, and RDELISA modestly predicted metreleptin response in GLD + PLD [receiver operating characteristic (ROC) area under the curve (AUC) 0.74, 0.69, and 0.71, respectively; P < 0.01 for all] with lower predictive power in PLD (ROC AUC 0.63, 0.61 and 0.65, respectively; P > 0.05 for all). The only reproducible cut point identified on sensitivity analyses was RIA leptin 7.2 ng/mL (sensitivity 56%; specificity 78%). CONCLUSIONS Three common leptin assays are not interchangeable, and a reliable cut point to select responders to metreleptin was not identified.
Collapse
Affiliation(s)
- Rasimcan Meral
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Medical Biology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Noemi Malandrino
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - Mary Walter
- Clinical Core Laboratory, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Adam H Neidert
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ranganath Muniyappa
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - Elif Arioglu Oral
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rebecca J Brown
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
- Correspondence: Rebecca J. Brown, MD, MHSc, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Building 10-CRC, Room 6-5942, 10 Center Dr, Bethesda, MD 20892, USA.
| |
Collapse
|
7
|
Xatzipsalti M, Alvertis H, Kourousi G, Patouni K, Konstantakopoulos S, Delis D, Vazeou A. Lipoatrophy, a rare complication of diabetes: a single-center experience. Hormones (Athens) 2022; 21:61-69. [PMID: 34671939 DOI: 10.1007/s42000-021-00324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Lipoatrophy (LA), a rare skin complication in patients with type 1 diabetes (T1D), has decreased dramatically over the past decades due to the use of human purified insulin preparations. METHODS We collected data from the records of T1D patients with LA. Types of insulin and insulin regimen, presence of eosinophilia, anti-insulin (IAA), anti-GAD, anti-IA2 autoantibodies, other autoimmune disorders, site of atrophy and its relationship to catheter, HbA1c at LA onset and after resolution, and different treatment modalities (i.e., change of insulin type or site, sodium cromoglycate (SCG) cream, cortisone cream or percutaneous injections, and laser treatment) were recorded. RESULTS Thirteen out of 1200 T1D subjects (1%) presented with LA. The majority were on insulin pump using rapid-acting analogs. Twelve out of 13 patients had changed the type of insulin, and most of them had switched injection sites. Ten out of 13 patients used SCG cream and 7/10 showed complete/partial improvement. One patient used dexamethasone injection with improvement. Five patients showed self-improvement. In 3/7 patients who were receiving SCG, treatment was combined with change of insulin type (glulisine); however, in 1/3, the result should be attributed to concomitant laser treatment. In 4/7 patients, there was a clear, beneficial effect of SCG. In 1/4 with partial resolution of LA, laser treatment was used after SCG, which further improved the result. CONCLUSIONS LA is a rare skin complication seen even today with the use of insulin analogs. SCG alone or combined with change of insulin type seems to be the most effective treatment. Laser treatment is a promising new therapy.
Collapse
Affiliation(s)
- Maria Xatzipsalti
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece.
| | | | - Giannoula Kourousi
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | - Konstantina Patouni
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | | | - Dimitris Delis
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | - Andriani Vazeou
- Diabetes Center, A' Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| |
Collapse
|
8
|
Abstract
Insulin is primarily considered for its glycemic effects in patients with diabetes. There are, however, non-glycemic adverse effects of insulin that may significantly impact patient health and interfere with glycemic control. Insulinogenic edema primarily occurs with rapid improvement in glycemic control either in patients with newly discovered diabetes or in patients with poorly-controlled diabetes. Insulin-induced sympathetic activation, vasodilation, changes in vascular permeability, and most importantly, sodium retention play significant etiologic roles in the development of edema. Clinically, it is usually self-limited, but significant complications can develop. Allergic reactions to all insulin preparations and various compounds used in insulin formulations with a wide range of severity have been reported. Frequently, changing the type of insulin or delivery method is sufficient, but more advanced treatments such as insulin desensitization and anti-IgE antibody treatment may be needed. Lipohypertrophy and lipoatrophy frequently develop with the overuse of injection sites. Lipohypertrophy can affect tissue insulin absorption and glycemic control.
Collapse
Affiliation(s)
- Alissa M Guarneri
- Department of Pediatrics Division of Endocrinology and Diabetes UPMC Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh, Pittsburgh, PA 15224, USA
| | - Robert P Hoffman
- Department of Pediatrics Division of Endocrinology Nationwide Children\'s Hospital The Ohio State University College of Medicine Columbus, OH 43205, USA
| |
Collapse
|
9
|
Vieira DB, Antel J, Peters T, Miehle K, Stumvoll M, Hebebrand J, Schlögl H. Suggestive Evidence for an Antidepressant Effect of Metreleptin Treatment in Patients with Lipodystrophy. Obes Facts 2022; 15:685-693. [PMID: 36037795 PMCID: PMC9669995 DOI: 10.1159/000526357] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/27/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Lipodystrophy (LD) syndromes are rare heterogeneous disorders characterized by reduction or absence of subcutaneous fat, low or nondetectable leptin concentrations in blood and impaired hunger/satiety regulation. Metreleptin treatment reverses metabolic complications and improves eating behavior in LD. Because depression in anorexia nervosa (AN), which is also characterized by hypoleptinemia, improves substantially upon treatment with metreleptin, we hypothesized that metreleptin substitution may be associated with an antidepressant effect in patients with LD, too. METHODS In this ancillary study, 10 adult patients with LD were treated with metreleptin. To assess depressive symptoms, the self-rating questionnaire Beck's Depression Inventory (BDI) was filled in at preestablished time points prior (T1) and after initiation of metreleptin (T2: 1 week; T3: 4 weeks; T4: 12 weeks) dosing. The differences between time points were tested with nonparametric Friedman's analysis of variance. Sensitivity analyses were performed upon exclusion of the BDI items addressing appetite and weight changes. RESULTS According to their BDI scores, 4 patients had mild depression and 2 had moderate depression at baseline. Friedman's test revealed significant differences in BDI scores between the four time points. Post hoc analyses revealed that the difference between T1 and T3 was significant upon Bonferroni correction (p = 0.034, effect size r = 0.88). The sensitivity analyses upon exclusion of the appetite and weight change items again revealed a significant Friedman's test and significant Bonferroni corrected differences in the revised BDI scores between T1 versus T2 (p = 0.002, r = 0.99) and T1 versus T3 (p = 0.007, r = 0.79). DISCUSSION/CONCLUSION Our study for the first time revealed suggestive evidence for an antidepressant effect of metreleptin in patients with LD. Metreleptin caused a rapid drop in depression scores within 1 week of treatment. A reduction of the depression score was also observed in 2 of the 3 LD patients whose BDI scores were in the normal range before start of the treatment. The reduction in total scores of BDI was still apparent after 3 months (T4) of dosing. This observation matches findings obtained in clinical case studies of AN patients, in whom depression scores also dropped during the first week of metreleptin treatment. It needs to be noted that by the nature of this observational study without a placebo group, nonspecific treatment expectation affecting mood cannot fully be ruled out.
Collapse
Affiliation(s)
- Diana Branco Vieira
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Child and Adolescent Psychiatry, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Jochen Antel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Triinu Peters
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Konstanze Miehle
- Division of Endocrinology, Department of Endocrinology, Nephrology, Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Michael Stumvoll
- Division of Endocrinology, Department of Endocrinology, Nephrology, Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Hebebrand
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Haiko Schlögl
- Division of Endocrinology, Department of Endocrinology, Nephrology, Rheumatology, University Hospital Leipzig, Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Zentrum München at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
- **Haiko Schlögl,
| |
Collapse
|
10
|
Di Bartolo P, Eckel RH, Strollo F, Gentile S. Hundred-year experience with insulin and lipohypertrophy: An unresolved issue. Diabetes Res Clin Pract 2021; 178:108924. [PMID: 34153354 DOI: 10.1016/j.diabres.2021.108924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
In the article recently published in Diab Res Clin Pract (1), we described one of the most exciting paths in the history of medicine from the perspective of diabetologists and people with type 1 diabetes. Such a history lasted 100 years, from the discovery of insulin to the most technologically advanced technologies aimed at making treatment as close to physiology and user-friendly as possible. Indeed, we are luckier than others because, by living in Italy and the USA, respectively, we have access to miniaturized and computerized insulin delivery systems, but this is not the case worldwide. Due to that, while receiving many favorable comments from colleagues and friends, we were encouraged to further expand on the issue and go deeper into insulin injection technique.
Collapse
Affiliation(s)
- Paolo Di Bartolo
- Diabetes Clinic of Ravenna, Ravenna Dept. of Internal Medicine, Romagna Local Health Authority, Italy
| | - Robert H Eckel
- Division of Endocrinology, Metabolism and Diabetes, Division of Cardiology, University of Colorado Anschutz Medical Campus, United States
| | - Felice Strollo
- Endocrinology and Diabetes, IRCCS San Raffaele Pisana, Rome, Italy.
| | - Sandro Gentile
- Department of Experimental and Clinical Medicine, Campania University "Luigi Vanvitelli", and Nefrocenter Research, Naples, Italy
| |
Collapse
|
11
|
Wang W, Huang R, Chen Y, Tu M. Values of ultrasound for diagnosis and management of insulin-induced lipohypertrophy: A prospective cohort study in China. Medicine (Baltimore) 2021; 100:e26743. [PMID: 34398053 PMCID: PMC8294902 DOI: 10.1097/md.0000000000026743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/28/2021] [Indexed: 01/04/2023] Open
Abstract
The aim of this study was to explore the values of ultrasound for diagnosis and management of insulin-induced lipohypertrophy and further analyzing the impact of body mass index and subcutaneous fat thickness on ultrasound manifestations of lipohypertrophy.In this 3-month, prospective cohort study, a total of 162 patients with diabetes who used insulin therapy more than 1 year with unknown lipohypertrophy status were enrolled into this study. Demographic information, assessment of glycemic control and insulin injection technique were evaluated. Physical and ultrasound examination were separately performed to detect lipohypertrophy by a team of diabetes educator nurses or ultrasonographer in a blinded fashion. Patients with lipohypertrophy received insulin injection technique education based on ultrasound examination and Chinese guideline.Ultrasound examination detected 41.1% more patients (74.1% vs 52.5%; P < .001) with lipohypertrophy and 61.2% more lesions (216 vs 134; P < .001) than physical examination. Glycosylated hemoglobin A1c and fasting blood glucose were significantly decreased in patients with lipohypertrophy or subclinical lipohypertrophy (lipohypertrophy without visual and palpation changes) after receiving insulin injection technique education based on ultrasound examination and Chinese guideline than baseline at 3 months (P < .001). The proportion of lesions with ultrasound manifestation 2 (distortion of surrounding connective tissue) in obese and STF (>15 mm) groups were no more than 50% and showed a decreased trend with increased subcutaneous fat thickness and body mass index (P < .001).Lipohypertrophy has characteristic ultrasound manifestations which can detect more accurate results than palpation alone and provide detailed information to promote effective education on lipohypertrophy management, thereby improving glycemic control.
Collapse
|
12
|
Luo D, Shi Y, Zhu M, Wang H, Yan D, Yu J, Ji J, Liu X, Fan B, Xu Y, Zhang M, He W, Xu J, Yang T. Subclinical lipohypertrophy--Easily ignored complications of insulin therapy. J Diabetes Complications 2021; 35:107806. [PMID: 33280982 DOI: 10.1016/j.jdiacomp.2020.107806] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 12/28/2022]
Abstract
AIMS Subclinical lipohypertrophy is a lesion meeting ultrasonic criteria for lipohypertrophy that was not detected by inspection and palpation. Little information is published on subclinical lipohypertrophy among insulin injection people with diabetes. We aimed to investigate the subclinical lipohypertrophy prevalence, risk factors, and the association between subclinical lipohypertrophy and glycemic control. METHODS This observational study included 316 people with diabetes who had continuously received insulin therapy for at least one year. We performed ultrasound scanning and clinical examination for evidence of subclinical lipohypertrophy. Demographic characteristics, clinical information, and glycated hemoglobin were measured. RESULTS The overall prevalence of subclinical lipohypertrophy was 19.9%. By stepwise logistic regression, higher BMI (OR = 1.44, 95%CI: 1.15-1.81, P = 0.002), incorrect rotation of sites (OR = 3.11, 95%CI: 1.02-9.47, P = 0.046), insulin needle reusage for more than four times (OR = 10.00, 95%CI: 3.23-31.02, P = 0.000) and type 1 diabetes (OR = 6.33, 95%CI: 1.32-30.47, P = 0.021) remained associated with subclinical lipohypertrophy. Subclinical lipohypertrophy demonstrated a significant independent correlation with the nonoptimal glycemic control (OR = 9.97, 95% CI: 3.46-28.75, P = 0.000) when accounting for demographic and diabetes-related parameters. CONCLUSIONS Subclinical lipohypertrophy is common among insulin-injecting patients with diabetes and is related to glycemic control deterioration. Ultrasonography may be an ideal adjunct in the evaluation of easily ignored lipohypertrophy lesions, especially where poor glycemic control, incorrect injection behaviors, overweight or obesity are documented.
Collapse
Affiliation(s)
- Dan Luo
- School of Nursing, Nanjing Medical University, 101 Longmian Dadao, Jiangning District, Nanjing, China
| | - Yun Shi
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Min Zhu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Hong Wang
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Dan Yan
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Jian Yu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - JiaJia Ji
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Xiaoyun Liu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Boqiang Fan
- Department of Radiology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Yang Xu
- Department of Dermatology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Mei Zhang
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| | - Wei He
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China.
| | - Jingjing Xu
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China.
| | - Tao Yang
- Department of Endocrinology, First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Gulou District, Nanjing, China
| |
Collapse
|
13
|
Akita S, Suzuki K, Yoshimoto H, Ohtsuru A, Hirano A, Yamashita S. Cellular Mechanism Underlying Highly-Active or Antiretroviral Therapy-Induced Lipodystrophy: Atazanavir, a Protease Inhibitor, Compromises Adipogenic Conversion of Adipose-Derived Stem/Progenitor Cells through Accelerating ER Stress-Mediated Cell Death in Differentiating Adipocytes. Int J Mol Sci 2021; 22:ijms22042114. [PMID: 33672735 PMCID: PMC7924614 DOI: 10.3390/ijms22042114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Lipodystrophy is a common complication in human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy (HAART) or antiretroviral therapy (ART). Previous studies demonstrated that endoplasmic reticulum (ER) stress-mediated unfolded protein response (UPR) is involved in lipodystrophy; however, the detailed mechanism has not been fully described in human adipogenic cell lineage. We utilized adipose tissue-derived stem cells (ADSCs) obtained from human subcutaneous adipose tissue, and atazanavir (ATV), a protease inhibitor (PI), was administered to ADSCs and ADSCs undergoing adipogenic conversion. Marked repression of adipogenic differentiation was observed when ATV was administered during 10 days of ADSC culture in adipogenic differentiation medium. Although ATV had no effect on ADSCs, it significantly induced apoptosis in differentiating adipocytes. ATV treatment also caused the punctate appearance of CCAAT-enhancer-binding (C/EBP) protein homologous protein (CHOP), and altered expression of CHOP and GRP78/Bip, which are the representation of ER stress, only in differentiating adipocytes. Administration of UPR inhibitors restored adipogenic differentiation, indicating that ER stress-mediated UPR was induced in differentiating adipocytes in the presence of ATV. We also observed autophagy, which was potentiated in differentiating adipocytes by ATV treatment. Thus, adipogenic cell atrophy leads to ATV-induced lipodystrophy, which is mediated by ER stress-mediated UPR and accelerated autophagy, both of which would cause adipogenic apoptosis. As our study demonstrated for the first time that ADSCs are unsusceptible to ATV and its deleterious effects are limited to the differentiating adipocytes, responsible target(s) for ATV-induced lipodystrophy may be protease(s) processing adipogenesis-specific protein(s).
Collapse
Affiliation(s)
- Sadanori Akita
- Department of Plastic Surgery, Wound Repair and Regeneration, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan;
- Department of Plastic and Reconstructive Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; (A.H.); (H.Y.)
| | - Keiji Suzuki
- Department of Radiation Medical Sciences, Atomic Bomb Disease Institute, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan;
- Correspondence: Correspondence: ; Tel.: +81-95-819-7116
| | - Hiroshi Yoshimoto
- Department of Plastic and Reconstructive Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; (A.H.); (H.Y.)
| | - Akira Ohtsuru
- Takashi Nagai Memorial International Hibakusha Medical Center, Nagasaki University Graduate School of Biomedical Science, 1-12-4 Nagasaki, Nagasaki852-8523, Japan;
| | - Akiyoshi Hirano
- Department of Plastic and Reconstructive Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; (A.H.); (H.Y.)
| | - Shunichi Yamashita
- Department of Radiation Medical Sciences, Atomic Bomb Disease Institute, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan;
- Takashi Nagai Memorial International Hibakusha Medical Center, Nagasaki University Graduate School of Biomedical Science, 1-12-4 Nagasaki, Nagasaki852-8523, Japan;
- Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima 960-1295, Japan
- Center for Advanced Radiation Emergency Medicine at the National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| |
Collapse
|
14
|
Gentile S, Strollo F, Satta E, Della-Corte T, Romano C, Guarino G. Insulin-induced lypodistrophy in hemodialyzed patients: A new challenge for nephrologists? Diabetes Metab Syndr 2019; 13:3081-3084. [PMID: 31765982 DOI: 10.1016/j.dsx.2019.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
Diabetes Mellitus (DM) is the most common cause of renal failure and ESRD all over the world, and often requires an individualized insulin treatment regimen. Malnutrition, depression-related eating behavior changes, high on-off-dialysis day-to-day glycemic variability and frequent hypoglycemic events occurring during or immediately after dialysis make it hard to identify best insulin dosage in hemodialyzed patients. This suggests a prudent attitude including non-stringent control, despite which repeated hypoglycemia quite often occurs in such patients. When looking for possible sources of hypoglycemia, health professionals too often overlook the identification of skin lipodystrophy (LD) due to an incorrect insulin injection technique. This mini-review focuses on the high frequency (57%) of LD in a cohort of 1004 insulin-treated people with DM on dialysis consecutively referring to our joint medical centers, and on its relationship with hypoglycemia and glycemic control/variability. When taking on such patients, care team members accept to face a complex disease burdened with several risk factors requiring high professional skills, and have to keep in mind also the possible presence of any LD areas eventually interfering with expected results. A timely educational intervention on the correct injection technique can help reduce the high risk of hypoglycemia and large glycemic variability in dialysed people with DM.
Collapse
Affiliation(s)
- S Gentile
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy.
| | - F Strollo
- Nefrocenter Research Network, Naples, Italy; Elle-Di and San Raffaele Research Institute, Rome, Italy
| | - E Satta
- Nefrocenter Research Network, Naples, Italy
| | - T Della-Corte
- Campania University ''Luigi Vanvitelli", Naples, Italy; Nefrocenter Research Network, Naples, Italy
| | - C Romano
- Nefrocenter Research Network, Naples, Italy
| | - G Guarino
- Campania University ''Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
15
|
Falcao CK, Cabral MCS, Mota JM, Arbache ST, Costa-Riquetto AD, Muniz DQB, Cury-Martins J, Almeida MQ, Kaczemorska PC, Nery M, Teles MG. Acquired Lipodystrophy Associated With Nivolumab in a Patient With Advanced Renal Cell Carcinoma. J Clin Endocrinol Metab 2019; 104:3245-3248. [PMID: 30779841 DOI: 10.1210/jc.2018-02221] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/14/2019] [Indexed: 01/20/2023]
Abstract
CONTEXT Lipodystrophy syndromes are rare disorders characterized by the selective loss of adipose tissue. We aimed to report a case of acquired generalized lipodystrophy possibly associated with nivolumab. CASE DESCRIPTION A woman was referred to our Endocrinology Department for uncontrolled diabetes mellitus. At 50 years of age, she was diagnosed with type 2 diabetes after a routine laboratory test and her diabetes was well controlled with low doses of metformin. In 2010, she was diagnosed with clear cell renal carcinoma. The cancer progressed in the following years, leading to the initiation of treatment with nivolumab in 2017. Two months later she presented with facial lipoatrophy, with loss of the buccal fat pads and prominent zygomatic arch. Her neck, shoulders, arms, and buttocks were also affected. Her diabetes control worsened. She received maximal doses of metformin and pioglitazone and was administered 1.5 units/kg/d insulin. Subcutaneous biopsy of medial surface of the arm revealed chronic lobular panniculitis. Despite nivolumab's possible involvement in the onset of lipodystrophy, the maintenance of nivolumab therapy was justified by the observed reduction in the progression of the cancer, combined with the lack of an alternative chemotherapy. The therapy was withdrawn after 8 months of treatment because of grade 3 hepatitis. CONCLUSION Anti-PD1 therapy has great potential. Early recognition of the onset of unusual collateral effects is important to improve decision making regarding the treatment of patients with tumors.
Collapse
Affiliation(s)
- Camila Kruschewsky Falcao
- Department of Endocrinology and Metabolism, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Marina Campos Simoes Cabral
- Department of Endocrinology and Metabolism, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Jose Mauricio Mota
- Division of Oncology, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Samia Trigo Arbache
- Division of Dermatology, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Aline Dantas Costa-Riquetto
- Department of Endocrinology and Metabolism, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - David Queiroz Borges Muniz
- Division of Oncology, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Jade Cury-Martins
- Division of Dermatology, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Madson Q Almeida
- Department of Endocrinology and Metabolism, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Priscilla Cukier Kaczemorska
- Department of Endocrinology and Metabolism, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Marcia Nery
- Department of Endocrinology and Metabolism, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Milena Gurgel Teles
- Department of Endocrinology and Metabolism, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| |
Collapse
|
16
|
Cordoba-Chacon J, Sugasini D, Yalagala PCR, Tummala A, White ZC, Nagao T, Kineman RD, Subbaiah PV. Tissue-dependent effects of cis-9,trans-11- and trans-10,cis-12-CLA isomers on glucose and lipid metabolism in adult male mice. J Nutr Biochem 2019; 67:90-100. [PMID: 30856468 DOI: 10.1016/j.jnutbio.2019.01.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 12/22/2018] [Accepted: 01/29/2019] [Indexed: 12/22/2022]
Abstract
Mixtures of the two major conjugated linoleic acid (CLA) isomers trans-10,cis-12-CLA and cis-9,trans-11-CLA are used as over the counter supplements for weight loss. Because of the reported adverse effects of CLA on insulin sensitivity in some mouse studies, we sought to compare the impact of dietary t10c12-CLA and c9t11-CLA on liver, adipose tissue, and systemic metabolism of adult lean mice. We fed 8 week-old C57Bl/6J male mice with low fat diets (10.5% Kcal from fat) containing 0.8% t10c12-CLA or c9t11-CLA for 9 or 38 days. Diets containing c9t11-CLA had minimal impact on the endpoints studied. However, 7 days after starting the t10c12-CLA diet, we observed a dramatic reduction in fat mass measured by NMR spectroscopy, which interestingly rebounded by 38 days. This rebound was apparently due to a massive accumulation of lipids in the liver, because adipose tissue depots were visually undetectable. Hepatic steatosis and the disappearance of adipose tissue after t10c12-CLA feeding was associated with elevated plasma insulin levels and insulin resistance, compared to mice fed a control diet or c9t11-CLA diet. Unexpectedly, despite being insulin resistant, mice fed t10c12-CLA had normal levels of blood glucose, without signs of impaired glucose clearance. Hepatic gene expression and fatty acid composition suggested enhanced hepatic de novo lipogenesis without an increase in expression of gluconeogenic genes. These data indicate that dietary t10c12-CLA may alter hepatic glucose and lipid metabolism indirectly, in response to the loss of adipose tissue in mice fed a low fat diet.
Collapse
Affiliation(s)
- Jose Cordoba-Chacon
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL.
| | - Dhavamani Sugasini
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL
| | - Poorna C R Yalagala
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL
| | - Apoorva Tummala
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL
| | - Zachary C White
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL
| | - Toshihiro Nagao
- Osaka Research Institute of Industrial Science and Technology, Osaka, Japan
| | - Rhonda D Kineman
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL; Research and Development Division, Jesse Brown Veterans Affairs Medical Center, Chicago, IL
| | - Papasani V Subbaiah
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, IL; Research and Development Division, Jesse Brown Veterans Affairs Medical Center, Chicago, IL.
| |
Collapse
|
17
|
Abstract
AIMS To define standard criteria for the detection of lipohypertrophy using ultrasonography and to determine the accuracy of this method. METHOD Individuals using insulin therapy for ≥2 years with unknown lipohypertrophy status were enrolled at a diabetes education centre. A team of diabetes educator nurses performed a clinical examination for evidence of lipohypertrophy and a separate team of ultrasonographers examined participants in a blinded fashion. RESULTS The echo signature for lipohypertrophy consisted of location in the subcutaneous layer and lesions that were 1) well circumscribed either by hyperechoic foci with defined borders or a nodular shape with a hypoechoic halo, 2) heterogeneous in echotexture compared with surrounding tissue, 3) associated with distortion of surrounding connective tissue with 4) absence of vascularity and 5) absence of capsule. Ultrasonography identified individuals with lipohypertrophy significantly more frequently than inspection or palpation (P<0.0001). Inter-observer agreement was moderate (κ=0.50) and limited by the presence of subclinical lesions in 73% of the participants. CONCLUSIONS The ultrasound detection of lipohypertrophy is consistent with clinical examination and is reproducible using a defined echo signature. (ClinicalTrials.gov registration no: NCT02348099).
Collapse
Affiliation(s)
- J E Kapeluto
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - B W Paty
- Division of Endocrinology, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - S D Chang
- Department of Radiology, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| | - G S Meneilly
- Division of Geriatric Medicine, Department of Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, Canada
| |
Collapse
|
18
|
Tsadik AG, Atey TM, Nedi T, Fantahun B, Feyissa M. Effect of Insulin-Induced Lipodystrophy on Glycemic Control among Children and Adolescents with Diabetes in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. J Diabetes Res 2018; 2018:4910962. [PMID: 30116742 PMCID: PMC6079411 DOI: 10.1155/2018/4910962] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Lipodystrophy is one of the clinical complications of insulin injection that affects insulin absorption and leads to poor glycemic control. OBJECTIVE To assess insulin-induced lipodystrophy and glycemic control. METHODS A cross sectional study was done on 176 diabetic children and adolescents who inject insulin for a minimum of one year. First, anthropometric and clinical characteristics of the patients were recorded in questionnaire, and then observation and palpation techniques were used in assessing lipodystrophy. RESULT Out of the total 176 participants, 103 (58.5%) had insulin-induced lipodystrophy, of them 100 (97.1%) had lipohypertrophy and 3 (2.9%) had lipoatrophy. Being younger, failure to rotate the injection site every week and multiple reuse of insulin syringe had significant influence in development of insulin-induced lipohypertrophy. Lipohypertrophy in turn was associated with the use of higher dose of insulin and nonoptimal glycemic control. CONCLUSION Findings of this study revealed that in spite of using recombinant human insulin, the magnitude of the lipohypertrophy still remained high. Therefore, a routine workup of insulin-injecting patients for such complication is necessary, especially in the individuals who have a nonoptimal glycemic control.
Collapse
Affiliation(s)
- Afewerki Gebremeskel Tsadik
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Tesfay Mehari Atey
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Teshome Nedi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bereket Fantahun
- Department of Pediatrics, School of Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mamo Feyissa
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
19
|
Bredella MA, Schorr M, Dichtel LE, Gerweck AV, Young BJ, Woodmansee WW, Swearingen B, Miller KK. Body Composition and Ectopic Lipid Changes With Biochemical Control of Acromegaly. J Clin Endocrinol Metab 2017; 102:4218-4225. [PMID: 28945897 PMCID: PMC6283448 DOI: 10.1210/jc.2017-01210] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/11/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Acromegaly is characterized by growth hormone (GH) and insulinlike growth factor-1 (IGF-1) hypersecretion, and GH and IGF-1 play important roles in regulating body composition and glucose homeostasis. OBJECTIVE The purpose of our study was to investigate body composition including ectopic lipids, measures of glucose homeostasis, and gonadal steroids in patients with active acromegaly compared with age-, body mass index (BMI)-, and sex-matched controls and to determine changes in these parameters after biochemical control of acromegaly. DESIGN Cross-sectional study of 20 patients with active acromegaly and 20 healthy matched controls. Prospective study of 16 patients before and after biochemical control of acromegaly. MAIN OUTCOME MEASURES Body composition including ectopic lipids by magnetic resonance imaging/proton magnetic resonance spectroscopy; measures of glucose homeostasis by an oral glucose tolerance test; gonadal steroids. RESULTS Patients with active acromegaly had lower mean intrahepatic lipid (IHL) and higher mean fasting insulin and insulin area under the curve (AUC) values than controls. Men with acromegaly had lower mean total testosterone, sex hormone-binding globulin, and estradiol values than male controls. After therapy, homeostasis model assessment of insulin resistance, fasting insulin level, and insulin AUC decreased despite an increase in IHL and abdominal and thigh adipose tissues and a decrease in muscle mass. CONCLUSIONS Patients with acromegaly were characterized by insulin resistance and hyperinsulinemia but lower IHL compared with age-, BMI-, and sex-matched healthy controls. Biochemical control of acromegaly improved insulin resistance but led to a less favorable anthropometric phenotype with increased IHL and abdominal adiposity and decreased muscle mass.
Collapse
Affiliation(s)
- Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
- Correspondence and Reprint Requests: Miriam A. Bredella, MD, Massachusetts General Hospital, Yawkey 6E, 55 Fruit Street, Boston, Massachusetts 02114. E-mail:
| | - Melanie Schorr
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| | - Laura E Dichtel
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| | - Anu V Gerweck
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| | - Brian J Young
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| | - Whitney W Woodmansee
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts 02115
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| | - Karen K Miller
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| |
Collapse
|
20
|
Bertuzzi F, Meneghini E, Bruschi E, Luzi L, Nichelatti M, Epis O. Ultrasound characterization of insulin induced lipohypertrophy in type 1 diabetes mellitus. J Endocrinol Invest 2017; 40:1107-1113. [PMID: 28452000 DOI: 10.1007/s40618-017-0675-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 04/09/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Subcutaneous insulin absorption is one of the key factors affecting glycemic control in patients with diabetes mellitus under insulin therapy. Insulin-induced subcutaneous lipohypertrophy has been reported to impair insulin regular absorption and hence glycemic control. So far, lipohypertrophy diagnosis has only been clinical. This study aims at evaluating the possible role of ultrasound scan in the assessment of subcutaneous lipohypertrophy in patients affected by type 1 diabetes mellitus. METHODS A pilot observational retrospective study was performed in 20 patients affected by type 1 diabetes mellitus. In these patients the areas with clinical evidence of lipohypertrophy dependent on the insulin injections were characterized by the presence of tissues that at the ultrasound scan resulted similar to fibrotic tissues (hyperechogenic) or to an interstitial edema or to fat tissues (hypoechogenic). It was utilized a multi frequency linear probe (6-18 MHz). The patients were advised to avoid insulin injections on the areas with lipohypertrophy scanned by the ultrasound and the HbA1c changes were evaluated 3 months later. RESULTS The lipohypertrophic areas presented at least three different aspects upon ultrasound assessment: the iso-hyperechogenic one, with a predominant fibrotic component; the isoechogenic one, with "large tangles" fibrotic elements and the iso-hypoechogenic aspect with no fibrotic elements. When patients were advised to avoid insulin injections on areas with lipohypertrophy defined by ultrasound scan, 3 months after the first evaluation HbA1c had significantly improved (basal HbA1c 7.87 ± 0.56 versus 7.67 ± 0.52 3 months later, p = 0.029). No significant improvements of the HbA1c were found in the control matched group in which lipohypertrophy was only clinically valued through inspection and palpation. CONCLUSIONS Ultrasound scan can help identify and characterize the lipohypertrophic areas and this might be useful to improve glycemic control.
Collapse
Affiliation(s)
- F Bertuzzi
- Diabetes Unit, SSD Diabetologia, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - E Meneghini
- SS Diabetologia, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - E Bruschi
- SC Reumatologia, Niguarda Ca' Granda Hospital, Milan, Italy
| | - L Luzi
- Metabolism Research Center and Endocrinology and Metabolism, IRCCS Policlinico San Donato Milanese, Milan, Italy
- Department of Biomedical and Health Sciences, University of Milan, Milan, Italy
| | - M Nichelatti
- Service of Biostatistics Niguarda Cancer Center, Niguarda Ca' Granda Hospital, Milan, Italy
| | - O Epis
- SC Reumatologia, Niguarda Ca' Granda Hospital, Milan, Italy
| |
Collapse
|
21
|
Ji L, Sun Z, Li Q, Qin G, Wei Z, Liu J, Chandran AB, Hirsch LJ. Lipohypertrophy in China: Prevalence, Risk Factors, Insulin Consumption, and Clinical Impact. Diabetes Technol Ther 2017; 19:61-67. [PMID: 28099050 DOI: 10.1089/dia.2016.0334] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lipohypertrophy (LH) is a complication of insulin therapy. We assessed LH prevalence, risk factors, insulin usage, and clinical and health economic effects in China. METHODS In four cities, 401 adult patients injecting insulin ≥1 year were surveyed for diabetes/insulin injection history and practices, pen needle reimbursement (PNR), and health resource utilization, followed by structured examination and HbA1c testing. Differences between those with and without LH were evaluated by Student's t-test or the Wilcoxon rank sum test. Insulin costs were calculated. RESULTS Patients were 59.6 ± 11.5 years old; 50% male; 93.5% type 2 diabetes. LH prevalence was 53.1%. Compared to those without LH, patients with LH had higher body mass index (BMI; 26 vs. 24.8 kg/m2) and HbA1c (8.2% vs. 7.7% [66 vs. 61 mmol/mol]), took 11 IU (0.13 IU/kg or 31.7%) more insulin costing $1.4 versus $1.0 (RMB 9.5 vs. 6.8) daily, reused PNs more times, and had less PNR (all P ≤ 0.003). LH patients correctly rotated injection sites less often (67.6% vs. 92.3%, P < 0.0001). By stepwise logistic regression, BMI, needle reuse frequency, and PNR remained modestly associated with LH prevalence (odds ratios [OR] <1.9; P ≤ 0.03); weight-adjusted insulin dose and incorrect site rotation showed ORs of nearly 7 and 8.4, respectively (P ≤ 0.001). Extrapolated to 9 million insulin-injecting patients in China and adjusted for therapy adherence, LH-related excess annual insulin consumption cost is estimated at nearly $297 million (RMB 2 billion). CONCLUSIONS LH is common in China and associated with worse glycemic control, despite nearly one-third greater insulin consumption, with large cost implications. Proper injection technique education may reduce LH prevalence.
Collapse
Affiliation(s)
- Linong Ji
- 1 Department of Endocrinology, Peking University People's Hospital , Beijing, China
| | - Zilin Sun
- 2 Department of Endocrinology, Southeast University Zhongda Hospital , Nanjing, China
| | - Qifu Li
- 3 Department of Endocrinology, Chongqing Medical University First Affiliated Hospital , Chongqing, China
| | - Guijun Qin
- 4 Department of Endocrinology, Zhengzhou University First Affiliated Hospital , Zhengzhou, China
| | - Zheng Wei
- 5 BD (Becton Dickinson, Inc.) Medical Affairs , Beijing, China
| | - Junhao Liu
- 5 BD (Becton Dickinson, Inc.) Medical Affairs , Beijing, China
| | | | | |
Collapse
|
22
|
Lund PS, Sjøstrand H, Matzen SH. [Lipoatrophy after insulin injections can be treated with lipofilling]. Ugeskr Laeger 2016; 178:V07160480. [PMID: 27959262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Lipoatrophy is a known, albeit rare, side effect of insulin injections. We describe a case concerning a 17-year-old woman with insulin-dependent diabetes, who was treated with an insulin pump. In the areas surrounding the injection point subcutaneous lipoatrophy occurred. Such lipoatrophy is of cosmetic importance, and it may incur glycaemic imbalance due to altered and unpredictable absorption of insulin in the atrophied areas. With no spontaneous regeneration of the atrophied areas observed the patient was successfully treated with lipofilling in the atrophied areas.
Collapse
|
23
|
Bolze F, Bast A, Mocek S, Morath V, Yuan D, Rink N, Schlapschy M, Zimmermann A, Heikenwalder M, Skerra A, Klingenspor M. Treatment of diet-induced lipodystrophic C57BL/6J mice with long-acting PASylated leptin normalises insulin sensitivity and hepatic steatosis by promoting lipid utilisation. Diabetologia 2016; 59:2005-12. [PMID: 27272237 DOI: 10.1007/s00125-016-4004-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Abstract
AIMS/HYPOTHESIS Recombinant leptin offers a viable treatment for lipodystrophy (LD) syndromes. However, due to its short plasma half-life, leptin replacement therapy requires at least daily subcutaneous (s.c.) injections. Here, we optimised this treatment strategy in LD mice by using a novel leptin version with extended plasma half-life using PASylation technology. METHODS A long-acting leptin version was prepared by genetic fusion with a 600 residue polypeptide made of Pro, Ala and Ser (PASylation), which enlarges the hydrodynamic volume and, thus, retards renal filtration, allowing less frequent injection. LD was induced in C57BL/6J mice by feeding a diet supplemented with conjugated linoleic acid (CLA). Chronic and acute effects of leptin treatment were assessed by evaluating plasma insulin levels, insulin tolerance, histological liver sections, energy expenditure, energy intake and body composition. RESULTS In a cohort of female mice, 4 nmol PAS-leptin (applied via four s.c. injections every 3 days) successfully alleviated the CLA-induced LD phenotype, which was characterised by hyperinsulinaemia, insulin intolerance and hepatosteatosis. The same injection regimen had no measurable effect when unmodified recombinant leptin was administered at an equivalent dose. In a cohort of LD males, a single s.c. injection of PAS-leptin did not affect energy expenditure but inhibited food intake and promoted a shift in fuel selection towards preferential fat oxidation, which mechanistically substantiates the metabolic improvements. CONCLUSIONS/INTERPRETATION The excellent pharmacological properties render PASylated leptin an agent of choice for refining both animal studies and therapeutic strategies in the context of LD syndromes and beyond.
Collapse
Affiliation(s)
- Florian Bolze
- Lehrstuhl für Molekulare Ernährungsmedizin and Else Kröner-Fresenius Center, Technische Universität München, Gregor-Mendel-Str. 2, 85354, Freising (Weihenstephan), Germany
- Research Center for Nutrition and Food Science (ZIEL), Technische Universität München, Freising (Weihenstephan), Germany
| | - Andrea Bast
- Lehrstuhl für Molekulare Ernährungsmedizin and Else Kröner-Fresenius Center, Technische Universität München, Gregor-Mendel-Str. 2, 85354, Freising (Weihenstephan), Germany
- Research Center for Nutrition and Food Science (ZIEL), Technische Universität München, Freising (Weihenstephan), Germany
| | - Sabine Mocek
- Lehrstuhl für Molekulare Ernährungsmedizin and Else Kröner-Fresenius Center, Technische Universität München, Gregor-Mendel-Str. 2, 85354, Freising (Weihenstephan), Germany
- Research Center for Nutrition and Food Science (ZIEL), Technische Universität München, Freising (Weihenstephan), Germany
| | - Volker Morath
- Munich Center for Integrated Protein Science (CIPS-M) and Lehrstuhl für Biologische Chemie, Technische Universität München, Emil-Erlenmeyer-Forum 5, 85354, Freising (Weihenstephan), Germany
| | - Detian Yuan
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nadine Rink
- Lehrstuhl für Molekulare Ernährungsmedizin and Else Kröner-Fresenius Center, Technische Universität München, Gregor-Mendel-Str. 2, 85354, Freising (Weihenstephan), Germany
- Research Center for Nutrition and Food Science (ZIEL), Technische Universität München, Freising (Weihenstephan), Germany
| | - Martin Schlapschy
- Munich Center for Integrated Protein Science (CIPS-M) and Lehrstuhl für Biologische Chemie, Technische Universität München, Emil-Erlenmeyer-Forum 5, 85354, Freising (Weihenstephan), Germany
| | - Anika Zimmermann
- Lehrstuhl für Molekulare Ernährungsmedizin and Else Kröner-Fresenius Center, Technische Universität München, Gregor-Mendel-Str. 2, 85354, Freising (Weihenstephan), Germany
- Research Center for Nutrition and Food Science (ZIEL), Technische Universität München, Freising (Weihenstephan), Germany
| | - Mathias Heikenwalder
- Division of Chronic Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Arne Skerra
- Munich Center for Integrated Protein Science (CIPS-M) and Lehrstuhl für Biologische Chemie, Technische Universität München, Emil-Erlenmeyer-Forum 5, 85354, Freising (Weihenstephan), Germany.
- XL-protein GmbH, Freising, Germany.
| | - Martin Klingenspor
- Lehrstuhl für Molekulare Ernährungsmedizin and Else Kröner-Fresenius Center, Technische Universität München, Gregor-Mendel-Str. 2, 85354, Freising (Weihenstephan), Germany.
- Research Center for Nutrition and Food Science (ZIEL), Technische Universität München, Freising (Weihenstephan), Germany.
| |
Collapse
|
24
|
Wu AW, Wansom T, Huang IC, CoFrancesco J, Conant MA, Sarwer DB. The Facial Appearance Inventory: Development and Preliminary Evidence for Reliability and Validity in People with HIV and Lipoatrophy. Aesthet Surg J 2016; 36:842-51. [PMID: 26931304 DOI: 10.1093/asj/sjw010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Facial lipoatrophy is common in people on antiretroviral (ARV) regimens for HIV/AIDS and can impair health-related quality of life. OBJECTIVES We developed the Facial Appearance Inventory (FAI) to measure the impact of ARV-associated facial lipoatrophy. METHODS Qualitative methods were used to identify key concerns of people with facial lipoatrophy. The major concerns were used to identify 24 items for the FAI. The FAI was administered to a cross-sectional sample of 96 people with HIV and facial lipoatrophy and compared to the established Assessment of Body Change Distress (ABCD) and MOS-HIV questionnaires. RESULTS Mean age was 48.8 years, 87.5% were men, 69.8% were Caucasian, and 60% had some college education. Mean CD4 count was 435 cells/mm(3). There were few missing data, and the summary score showed no floor or ceiling effects, with a mean (SD) of 25.6 (17.9). Cronbach's alpha for the scale was 0.98. FAI items satisfied criteria for convergent and discriminant construct validity. FAI items were more strongly correlated with mental health domains (R = 0.33) than with physical health domains (R = 0.26) on the MOS-HIV. Patients with greater severity of lipoatrophy had significantly worse scores than those with less severity (James 3-4, vs. James 0-2). There were no significant differences for FAI scores by age group, income group, CD4 cell count, or HIV viral load group. Those with less education and those with darker skin types reported less impairment (P < .05). CONCLUSIONS The 24-item FAI shows evidence for reliability, validity, and usefulness as a measure of the impact of facial lipoatrophy.
Collapse
Affiliation(s)
- Albert W Wu
- Dr Wu is a Professor of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Dr Wansom is Clinical Research Physician, Henry M. Jackson Foundation, Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand. Dr Huang is an Associate Professor, Department of Epidemiology and Cancer Control Outcomes and Policy, St. Jude Children's Research Hospital, Memphis, TN. Dr CoFrancesco is a Professor of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Dr Conant is a Clinical Professor of Dermatology, Emeritus, University of California, San Francisco School of Medicine, San Francisco, CA. Dr Sarwer is the Associate Dean for Research and Director, Center for Obesity Research and Education College of Public Health, Temple University, Philadelphia, PA
| | - Tanyaporn Wansom
- Dr Wu is a Professor of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Dr Wansom is Clinical Research Physician, Henry M. Jackson Foundation, Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand. Dr Huang is an Associate Professor, Department of Epidemiology and Cancer Control Outcomes and Policy, St. Jude Children's Research Hospital, Memphis, TN. Dr CoFrancesco is a Professor of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Dr Conant is a Clinical Professor of Dermatology, Emeritus, University of California, San Francisco School of Medicine, San Francisco, CA. Dr Sarwer is the Associate Dean for Research and Director, Center for Obesity Research and Education College of Public Health, Temple University, Philadelphia, PA
| | - I-Chan Huang
- Dr Wu is a Professor of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Dr Wansom is Clinical Research Physician, Henry M. Jackson Foundation, Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand. Dr Huang is an Associate Professor, Department of Epidemiology and Cancer Control Outcomes and Policy, St. Jude Children's Research Hospital, Memphis, TN. Dr CoFrancesco is a Professor of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Dr Conant is a Clinical Professor of Dermatology, Emeritus, University of California, San Francisco School of Medicine, San Francisco, CA. Dr Sarwer is the Associate Dean for Research and Director, Center for Obesity Research and Education College of Public Health, Temple University, Philadelphia, PA
| | - Joseph CoFrancesco
- Dr Wu is a Professor of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Dr Wansom is Clinical Research Physician, Henry M. Jackson Foundation, Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand. Dr Huang is an Associate Professor, Department of Epidemiology and Cancer Control Outcomes and Policy, St. Jude Children's Research Hospital, Memphis, TN. Dr CoFrancesco is a Professor of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Dr Conant is a Clinical Professor of Dermatology, Emeritus, University of California, San Francisco School of Medicine, San Francisco, CA. Dr Sarwer is the Associate Dean for Research and Director, Center for Obesity Research and Education College of Public Health, Temple University, Philadelphia, PA
| | - Marcus A Conant
- Dr Wu is a Professor of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Dr Wansom is Clinical Research Physician, Henry M. Jackson Foundation, Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand. Dr Huang is an Associate Professor, Department of Epidemiology and Cancer Control Outcomes and Policy, St. Jude Children's Research Hospital, Memphis, TN. Dr CoFrancesco is a Professor of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Dr Conant is a Clinical Professor of Dermatology, Emeritus, University of California, San Francisco School of Medicine, San Francisco, CA. Dr Sarwer is the Associate Dean for Research and Director, Center for Obesity Research and Education College of Public Health, Temple University, Philadelphia, PA
| | - David B Sarwer
- Dr Wu is a Professor of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Dr Wansom is Clinical Research Physician, Henry M. Jackson Foundation, Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand. Dr Huang is an Associate Professor, Department of Epidemiology and Cancer Control Outcomes and Policy, St. Jude Children's Research Hospital, Memphis, TN. Dr CoFrancesco is a Professor of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Dr Conant is a Clinical Professor of Dermatology, Emeritus, University of California, San Francisco School of Medicine, San Francisco, CA. Dr Sarwer is the Associate Dean for Research and Director, Center for Obesity Research and Education College of Public Health, Temple University, Philadelphia, PA
| |
Collapse
|
25
|
Sheng WH, Hsieh SM, Lee SC, Chen MY, Wang JT, Hung CC, Chang SC. Fatal lactic acidosis associated with highly active antiretroviral therapy in patients with advanced human immunodeficiency virus infection in Taiwan. Int J STD AIDS 2016; 15:249-53. [PMID: 15075019 DOI: 10.1258/095646204773557785] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lactic acidosis (LA), a rare but life-threatening adverse effect associated with antiretroviral therapy, has been reported with an increasing frequency since the mid1990s. From June 1994 to June 2002, a total of six patients, four males and two females with a median age of 43 years (range, 30 to 74 years), had been diagnosed with LA. The estimated incidence of LA was 5.1 per 1000 patient-years (PYs) on highly active antiretroviral therapy (HAART) (95% confidence interval [95% CI], 4.5-5.5 per 1000 PYs) and 4.4 per 1000 PY on nucleoside analogues (NAs) (95% CI, 3.9-4.7 per 1000 PYs). Their median body mass index at diagnosis of LA was 17.6 kg/m2 (range 16.3 to 22.6 kg/m2). The median CD4+ lymphocyte count at the initial diagnosis of HIV infection and at the onset of LA was 38 cells/µL (range, 4 to 103 cells/µL) and 108 cells/µL (range, 79 to 224 cells/µL), respectively. The most common symptoms were nausea, vomiting, and dyspnoea. All of the patients had findings suggestive of NA-related mitochondrial toxicity, such as myositis, pancreatitis, fatty hepatitis, peripheral neuropathy or lipodystrophy. The prescribed NA related to LA were stavudine in six patients, lamivudine, five, and didanosine, one. Despite treatment, all patients died of persistent circulatory collapse following LA. The median duration from diagnosis to death was eight days (range, 4-17 days). Our report highlights that clinicians caring for patients with AIDS should be alerted to the potentially fatal LA associated with antiretroviral therapy when patients present with low body mass index, lipodystrophy, unexplained abdominal symptoms, dyspnoea, or elevated aminotransferases.
Collapse
Affiliation(s)
- W H Sheng
- Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan 100
| | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
Switch studies have been carried out to explore changes in side effects in adherence. Discontinuing the protease inhibitor (PI) component of highly active antiretroviral therapy (HAART) regimen is often associated with improved adherence and improved quality of life. Following switching from a PI to a non-nucleoside reverse transcriptase inhibitor or abacavir, there is however a clear trend toward an improved metabolic profile particularly in insulin resistance and triglyceride levels when patients discontinue their PI. Peripheral wasting is likely to be associated with nucleoside analogues and for individuals with isolated fat accumulation, modification of HAART is not recommended. Virological suppression can be maintained following switch if adequate suppression of the virus has been achieved for at least six months prior to switch and the patient has not been previously exposed to suboptimal HAART. Discontinuing the PI preserves this class of agents for future use. Switching however may be associated with other side effects; hypersensitivity, skin rashes, hepatic or neuropsychiatric events.
Collapse
Affiliation(s)
- C L S Leen
- Regional Infectious Diseases Unit, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
| |
Collapse
|
27
|
Eftekhari K, Mifflin MD, Anderson RL. Prostaglandin-Associated Periorbital Lipodystrophy in Cosmetic Eyelid Surgery: A Novel Cause of Facial Asymmetry. Aesthet Surg J 2016; 36:NP119-21. [PMID: 26374814 DOI: 10.1093/asj/sjv184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/13/2022] Open
Abstract
A 70-year-old woman presented to our practice with profound ptosis of the left upper eyelid and notable asymmetry of the periocular area. On examination, she was noted to have significant atrophy of the periocular tissues on the left side, with lower eyelid retraction. These features were present but less severe on the right side. Upon further questioning, she stated that she had cataract surgery on the left side that was complicated by a high intraocular pressure and required subsequent secondary surgery. She had taken a prostaglandin eyedrop for many months after her cataract surgery to keep the eye pressure low. Recently, a newly recognized adverse effect of prostaglandin eyedrops has been described in the ophthalmic literature in which patients develop periorbital lipodystrophy. This case emphasizes that this may occur unilaterally in patients taking the eyedrop in only one eye, and should be recognized prior to considering functional and aesthetic surgery of the periocular area.
Collapse
Affiliation(s)
- Kian Eftekhari
- Dr Eftekhari is a fellow and Dr Anderson is an oculoplastic surgeon in private practice in Salt Lake City, UT, USA. Dr. Mifflin is a Clinical Professor of Ophthalmology and Fellowship Director in Corneal Surgery, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Mark D Mifflin
- Dr Eftekhari is a fellow and Dr Anderson is an oculoplastic surgeon in private practice in Salt Lake City, UT, USA. Dr. Mifflin is a Clinical Professor of Ophthalmology and Fellowship Director in Corneal Surgery, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Richard L Anderson
- Dr Eftekhari is a fellow and Dr Anderson is an oculoplastic surgeon in private practice in Salt Lake City, UT, USA. Dr. Mifflin is a Clinical Professor of Ophthalmology and Fellowship Director in Corneal Surgery, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
28
|
Abstract
When prescribed appropriately and taken adherently, antiretroviral therapy can consistently and durably suppress HIV replication, potentially translating into years of near normal health for HIV-infected persons. However, presently available antiretrovirals are associated with a cluster of physical and metabolic symptoms termed HIV lipodystrophy. This article reviews the state of knowledge about the pathogenesis and treatment of the various manifestations of these adverse effects.
Collapse
Affiliation(s)
- Stephen Kravcik
- Department of Medicine, Ottawa Hospital/University of Ottawa, 501 Smyth Road, Ottawa, Ontario, Canada K4M 1K3.
| |
Collapse
|
29
|
Sesmilo G, Resmini E, Bernabeu I, Aller J, Soto A, Mora M, Picó A, Fajardo C, Torres E, Alvarez-Escolá C, García R, Blanco C, Cámara R, Gaztambide S, Salinas I, Pozo CD, Castells I, Villabona C, Biagetti B, Webb SM. Escape and lipodystrophy in acromegaly during pegvisomant therapy, a retrospective multicentre Spanish study. Clin Endocrinol (Oxf) 2014; 81:883-90. [PMID: 24612232 DOI: 10.1111/cen.12440] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/02/2013] [Accepted: 02/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pegvisomant is an effective treatment for acromegaly. OBJECTIVE To investigate escape (loss of biochemical control in patients previously controlled) and lipodystrophy in acromegalic patients treated with pegvisomant and to evaluate possible associations with clinical features. PATIENTS AND METHODS Multicentre retrospective study involving 19 Spanish centres. RESULTS Ninety-seven patients were included (59% women, mean age at diagnosis 42 ± 13 years, 80% macroadenomas); mean follow-up on pegvisomant was 5 ± 2·5 years, and 89 (92%) achieved normal IGF-1. Escape was reported in 30/89 (34%) of responders, after a mean treatment duration of 25 ± 21 months. The mean initial dose of pegvisomant was 11 ± 5 mg/day, and mean dose at escape was 14 ± 7 mg/day. Most patients (26/30, 87%) achieved control with dose increase (57%), additional medical treatment (3%) or both (27%). Mean new dose that controlled IGF-1 after escape was 20 ± 7 mg/day. Treatments associated were somatostatin analogues (SSA in 47%), cabergoline (CAB in 47%) and both (6%). Lipodystrophy was observed in 15 patients (13 females), mild in six, moderate in six, severe in three and persistent in four. Among patients with lipodystrophy, three escaped and three were nonresponders to pegvisomant. Four patients discontinued the drug, and four had dose reductions because of lipodystrophy. It tended to be more frequent in females (P = 0·06) and in patients treated with triple association SSA+CAB+PEG (P = 0·018). No relationship between escape and clinical variables was found, except prior CAB (P = 0·04) and metformin treatment (0·02) and grade of lipodystrophy (P = 0·02). CONCLUSIONS A significant proportion of patients treated with pegvisomant escaped (34%); however, the majority (87%) was easily controlled with either dose increase, further medical treatment or both. Lipodystrophy developed in 15%, mostly females, and influenced the response to treatment.
Collapse
Affiliation(s)
- Gemma Sesmilo
- Servicio Endocrinología, Hospital Quirón- Dexeus, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Bechara FG, Rotterdam S, Stücker M, Hoffmann K, Altmeyer P. A Case of Localized Bilateral Lipodystrophy Associated with Self-Injection of Xenogenous Material. J Dermatol 2014; 30:924-6. [PMID: 14739522 DOI: 10.1111/j.1346-8138.2003.tb00350.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
31
|
Egaña-Gorroño L, Martínez E, Pérez I, Escribà T, Domingo P, Gatell JM, Arnedo M. Contribution of genetic background and antiretroviral therapy to body fat changes in antiretroviral-naive HIV-infected adults. J Antimicrob Chemother 2014; 69:3076-84. [PMID: 25185137 DOI: 10.1093/jac/dku266] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To evaluate the association of host genetics with changes in limb or trunk fat in a group of antiretroviral therapy (ART)-naive HIV-infected patients prospectively followed up according to the initiation and the type of ART. METHODS Fifty single nucleotide polymorphisms (SNPs) in 26 genes, associated with obesity, insulin resistance, lipid metabolism or lipodystrophy in previously published genetic studies, were assessed in ART-naive HIV-infected Caucasian patients divided into three groups: 24 (27%) did not start ART, 29 (32.6%) received zidovudine or stavudine and 36 (40.4%) received neither zidovudine nor stavudine in their initial regimen. Patients underwent body fat measurements (using dual-energy X-ray absorptiometry) at baseline and Month 12. A multivariate model using backward stepwise elimination was used to assess the influence of SNPs and baseline levels of non-genetic covariates on changes in limb or trunk fat. RESULTS The baseline characteristics were: 73% men, 17% coinfected with hepatitis C virus and/or hepatitis B virus, median age 37 years, median CD4+ T cell count 228/mm(3), median HIV-RNA 5.2 log copies/mL, median plasma glucose 85 mg/dL, median plasma insulin 9.1 IU/mL, median limb fat 5.6 kg and median trunk fat 7.0 kg. There were no baseline differences among the three groups except for the CD4+ T cell count. The decrease in limb fat was greater in the no-ART group relative to the other two groups (P < 0.05). The multivariate model showed associations of rs1801278 in IRS1 (P = 0.029, OR = 0.13), baseline viral load (P = 0.006; OR = 4.453) and baseline glucose levels (P = 0.008, OR = 0.926) with loss of limb fat, and rs2228671 in LDLR (P = 0.012, OR = 0.108), rs405509 in APOE (P = 0.048, OR = 0.205), baseline viral load (P = 0.005, OR = 0.186) and baseline CD4+ T cell count (P = 0.01, OR = 1.008) with gain of trunk fat. CONCLUSIONS Specific polymorphisms in IRS1 (limb fat loss) and LDLR and APOE (trunk fat gain) were identified as independent markers of fat changes irrespective of the initiation of ART and the type of ART and deserve further validation.
Collapse
Affiliation(s)
- L Egaña-Gorroño
- Group of Genomics and Pharmacogenomics, Retrovirology and Viral Immunopathology Laboratory, IDIBAPS, Barcelona, Spain
| | - E Martínez
- Department of Infectious Diseases, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - I Pérez
- Department of Infectious Diseases, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - T Escribà
- Group of Genomics and Pharmacogenomics, Retrovirology and Viral Immunopathology Laboratory, IDIBAPS, Barcelona, Spain
| | - P Domingo
- Department of Infectious Diseases, Hospital de Sant Pau, Barcelona, Spain
| | - J M Gatell
- Group of Genomics and Pharmacogenomics, Retrovirology and Viral Immunopathology Laboratory, IDIBAPS, Barcelona, Spain Department of Infectious Diseases, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - M Arnedo
- Group of Genomics and Pharmacogenomics, Retrovirology and Viral Immunopathology Laboratory, IDIBAPS, Barcelona, Spain
| |
Collapse
|
32
|
Stéphan F, Korkomaz J, Abadjian G, Okais J, Tomb R. A case of lipoatrophy following quadrivalent human papillomavirus vaccine administration. J Am Acad Dermatol 2014; 70:e132-4. [PMID: 24831333 DOI: 10.1016/j.jaad.2013.09.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 09/24/2013] [Accepted: 09/25/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Farid Stéphan
- Department of Dermatology, Hotel Dieu de France University Hospital, Beirut, Lebanon - Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Joelle Korkomaz
- Department of Dermatology, Hotel Dieu de France University Hospital, Beirut, Lebanon - Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.
| | - Gerard Abadjian
- Department of Pathology, Hotel Dieu de France University Hospital, Beirut, Lebanon - Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Jad Okais
- Department of Rhumatology, Hotel Dieu de France University Hospital, Beirut, Lebanon - Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Roland Tomb
- Department of Dermatology, Hotel Dieu de France University Hospital, Beirut, Lebanon - Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| |
Collapse
|
33
|
Domingo P, Gutierrez MDM, Gallego-Escuredo JM, Torres F, Mateo GM, Villarroya J, de los Santos I, Domingo JC, Villarroya F, Rio LD, Estrada V, Giralt M. Effects of switching from stavudine to raltegravir on subcutaneous adipose tissue in HIV-infected patients with HIV/HAART-associated lipodystrophy syndrome (HALS). A clinical and molecular study. PLoS One 2014; 9:e89088. [PMID: 24586518 PMCID: PMC3935839 DOI: 10.1371/journal.pone.0089088] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 01/16/2014] [Indexed: 11/18/2022] Open
Abstract
HIV-1/HAART-associated lipodystrophy syndrome (HALS) has been associated with exposure to stavudine (d4T) through mitochondrial dysfunction. We performed a 48-week study to assess the effects of switching from d4T to raltegravir (RAL) on metabolic and fat molecular parameters of patients with HALS. Forty-two patients with HALS and a median exposure to d4T > 7 years were switched to RAL and followed for 48 weeks. Fasting metabolic tests, HIV RNA, CD4 cell count, and fat measured by DEXA were obtained at baseline and week 48. mtDNA and gene transcripts for PPAR gamma, adiponectin, cytochrome b, Cox IV, TNF alpha, MCP-1 and CD68 were assessed in paired subcutaneous fat tissue biopsies. Lipid parameters, fasting glucose, insulin, and HOMA-IR did not change significantly. Whole body fat (P = 0.0027) and limb fat mass (P<0.0001) increased from baseline. Trunk/limb fat ratio (P = 0.0022), fat mass ratio (P = 0.0020), fat mass index (P = 0.0011) and percent leg fat normalized to BMI (P<0.0001) improved after 48 weeks. Relative abundance of mtDNA, expression of PPAR gamma, adiponectin, Cyt b, and MCP-1 genes increased, whereas Cox IV, TNF alpha, and CD68 did not change significantly from baseline. Switching from d4T to RAL in patients with HALS is associated with an increase in limb fat mass and an improvement in markers of adipocyte differentiation and mitochondrial function in SAT.
Collapse
Affiliation(s)
- Pere Domingo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- * E-mail:
| | - María del Mar Gutierrez
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Miguel Gallego-Escuredo
- Department of Biochemistry and Molecular Biology and Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Fisiopatología de la Obesidad y Nutrición, Centros de Investigación Biomédica en Red (CIBER), Santiago de Compostela, Spain
| | - Ferran Torres
- Biostatistics and Data Management Platform, Institut d′Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Biostatistics Unit, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gracia María Mateo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Villarroya
- Department of Biochemistry and Molecular Biology and Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Institut de Recerca del Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Fisiopatología de la Obesidad y Nutrición, Centros de Investigación Biomédica en Red (CIBER), Santiago de Compostela, Spain
| | | | - Joan Carles Domingo
- Department of Biochemistry and Molecular Biology and Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Fisiopatología de la Obesidad y Nutrición, Centros de Investigación Biomédica en Red (CIBER), Santiago de Compostela, Spain
| | - Francesc Villarroya
- Department of Biochemistry and Molecular Biology and Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Fisiopatología de la Obesidad y Nutrición, Centros de Investigación Biomédica en Red (CIBER), Santiago de Compostela, Spain
| | | | - Vicente Estrada
- Infectious Diseases Unit, Hospital Clínico de San Carlos, Madrid, Spain
| | - Marta Giralt
- Department of Biochemistry and Molecular Biology and Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Institute of Biomedicine, University of Barcelona, Barcelona, Spain
- Fisiopatología de la Obesidad y Nutrición, Centros de Investigación Biomédica en Red (CIBER), Santiago de Compostela, Spain
| |
Collapse
|
34
|
Breznik V, Kokol R, Luzar B, Miljković J. Insulin-induced localized lipoatrophy. Acta Dermatovenerol Alp Pannonica Adriat 2013; 22:83-85. [PMID: 24336944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Insulin lipoatrophy is a rare immunologic cutaneous complication in diabetes mellitus that presents with localized subcutaneous fat atrophy at the insulin injection site. We report the case of a 62-year-old woman with type 2 diabetes mellitus that developed localized lipoatrophy on the abdomen after 6 years of therapy with the insulin analogues detemir and aspart.
Collapse
Affiliation(s)
- Vesna Breznik
- Department of Dermatology, University Medical Centre Maribor, Slovenia. Department of Dermatology, Medical Faculty, University of Maribor, Slovenia. Department of Pathology, Medical Faculty, University of Ljubljana, Slovenia. Corresponding author:
| | | | | | | |
Collapse
|
35
|
Affiliation(s)
- Sachin M Shridharani
- Department of Plastic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
| | | |
Collapse
|
36
|
Affiliation(s)
- Hiroshi Numao
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Japan.
| | | |
Collapse
|
37
|
Fardet L, Antuna-Puente B, Vatier C, Cervera P, Touati A, Simon T, Capeau J, Fève B, Bastard JP. Adipokine profile in glucocorticoid-treated patients: baseline plasma leptin level predicts occurrence of lipodystrophy. Clin Endocrinol (Oxf) 2013; 78:43-51. [PMID: 22268638 DOI: 10.1111/j.1365-2265.2012.04348.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/12/2011] [Accepted: 01/18/2012] [Indexed: 02/06/2023]
Abstract
CONTEXT Glucocorticoid therapy may result in adipose tissue redistribution of unknown pathophysiology. OBJECTIVES To evaluate the effects of glucocorticoids on adipokine levels and adipose tissue inflammation. To compare the results in patients with or without glucocorticoid-induced lipodystrophy (GIL) after 3 months of therapy. DESIGN AND SETTING Prospective monocentric study. PATIENTS Adult patients initiating systemic, high-dose prednisone therapy for at least 3 months. Blood samples and subcutaneous abdominal adipose tissue biopsies were collected at baseline and month 3. The presence of GIL after 3 months of therapy was assessed using standardized photography. RESULTS Thirty-two patients were enrolled. Blood samples and subcutaneous abdominal adipose tissue were available at baseline and month 3 for 30 patients [median age: 61 (38-79) years, 77% women]. Among those 30 patients, 15 were classified as GIL+ and 15 were GIL- at month 3. Between baseline and month 3, adiponectin and leptin levels increased in the overall population while the level of resistin remained unchanged. At baseline, leptin level was higher [19.3 (8.3-31.1) vs 4.5 (2.4-11.3) μg/l, P = 0.006] and resistin level lower [7.1 (6.3-12.4) vs 10.4 (8.0-21.7) μg/l, P = 0.05] in GIL+ than in GIL- patients. Baseline leptin level was predictive of GIL occurrence. Receiver operating characteristic curve analysis demonstrated that the best diagnostic accuracy was obtained with a baseline leptin cut-off of 5.9 μg/l (sensitivity: 93%, specificity: 60%). At month 3, leptin and adiponectin levels increased more in the GIL+ than in the GIL- group, as did the number of anti-inflammatory M2 macrophages in subcutaneous abdominal fat. CONCLUSION Glucocorticoid-induced lipodystrophy is associated with a different adipokine profile both before and after glucocorticoid therapy. Serum leptin level prior to glucocorticoid therapy is highly predictive of GIL occurrence.
Collapse
Affiliation(s)
- Laurence Fardet
- Service de Médecine Interne, AP-HP, Hôpital Saint-Antoine, Paris, France
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Abstract
The prostaglandin F2a (PGF2a) analogue bimatoprost 0.03% (Allergan, Inc, Irvine, California) has been employed for the treatment of hypotrichosis since it gained Food and Drug Administration approval as Latisse in 2008. In this report, the authors retrospectively review the cases of 7 patients who presented to their outpatient ophthalmology clinic with glaucoma. These patients had periorbital hollowing due to fat atrophy as a side effect of topical ophthalmic bimatoprost therapy. The series of patients described in this report emphasizes the small but significant risk of periocular fat changes associated with bimatoprost 0.03%, which is the exact formulation marketed as Lumigan for glaucoma treatment. Patients using Latisse for its cosmetic enhancement of eyelash length should be warned of this potentially disfiguring side effect, since the cosmetic and ophthalmic preparations are identical. Such changes can be irreversible, and the implications of the decision to prescribe this drug either in the form of an eyelash application or for topical ophthalmic use should be clearly understood by both clinicians and patients alike.
Collapse
Affiliation(s)
- Mano Sira
- Corneoplastic Unit, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, West Sussex, UK.
| | | | | |
Collapse
|
39
|
Uchigata Y. [Insulin preparation]. Nihon Rinsho 2012; 70 Suppl 6:190-195. [PMID: 23156507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Yasuko Uchigata
- Diabetes Center, Tokyo Women's Medical University School of Medicine
| |
Collapse
|
40
|
Gupta S, Knight AG, Losso BY, Ingram DK, Keller JN, Bruce-Keller AJ. Brain injury caused by HIV protease inhibitors: role of lipodystrophy and insulin resistance. Antiviral Res 2012; 95:19-29. [PMID: 22580130 PMCID: PMC3400265 DOI: 10.1016/j.antiviral.2012.04.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 04/26/2012] [Accepted: 04/27/2012] [Indexed: 11/30/2022]
Abstract
HIV-associated neurocognitive disorders (HAND) remain prevalent even with widespread use of combination antiretroviral therapy (ART), suggesting a potential role for co-morbidities in neurologic decline. Indeed, it is well established that ART drugs, particularly HIV protease inhibitors, can induce hyperlipidemia, lipodystrophy, and insulin resistance; all of which are associated with neurologic impairment. This study was designed to determine how metabolic dysfunction might contribute to cognitive impairment and to reveal specific metabolic co-morbidities that could be targeted to preserve brain function. Adult male C57BL/6 mice were thus treated with clinically relevant doses of lopinavir/ritonavir for 4 weeks, and subjected to thorough metabolic, neurobehavioral, and biochemical analyses. Data show that lopinavir/ritonavir resulted in manifestations of lipodystrophy, insulin resistance, and hyperlipidemia. Evaluation of neurologic function revealed cognitive impairment and increased learned helplessness, but not motor impairment following treatment with lopinavir/ritonavir. Further analyses revealed a significant linear relationship between cognitive performance and specific markers of lipodystrophy and insulin resistance. Finally, analysis of brain injury indicated that lopinavir/ritonavir treatment resulted in cerebrovascular injury associated with decreased synaptic markers and increased inflammation, and that the cerebral cortex was more vulnerable than the cerebellum or hippocampus. Collectively, these data reveal an intimate link between metabolic co-morbidities and cognitive impairment, and suggest that remediation of selective aspects of metabolic syndrome could potentially reduce the prevalence or severity HIV-associated neurocognitive disorders.
Collapse
Affiliation(s)
- Sunita Gupta
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA 70808
| | - Alecia G. Knight
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA 70808
| | - Boriss Y. Losso
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA 70808
| | - Donald K. Ingram
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA 70808
| | - Jeffrey N. Keller
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, LA 70808
| | | |
Collapse
|
41
|
Alam N, Cortina-Borja M, Goetghebuer T, Marczynska M, Vigano A, Thorne C. Body fat abnormality in HIV-infected children and adolescents living in Europe: prevalence and risk factors. J Acquir Immune Defic Syndr 2012; 59:314-24. [PMID: 22205436 PMCID: PMC3433033 DOI: 10.1097/qai.0b013e31824330cb] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate the prevalence of and identify risk factors for lipodystrophy syndrome (LS) and body fat abnormality in a population of HIV-infected children and adolescents. DESIGN Cross-sectional observational study. METHODS HIV-infected subjects aged 2-18 years were recruited from 15 HIV centers in Belgium, Italy, and Poland between January 2007 and December 2008. Standardized assessments by the patient's long-term clinician were performed to establish the presence of abnormality. Risk factors were explored in logistic regression models for fat abnormality outcomes and LS (abnormality plus dyslipidemia). RESULTS Among 426 subjects (70% white), median age was 12.2 years (interquartile range: 9.0-15.0 years) and median duration of antiretroviral therapy was 5.2 years (interquartile range: 2.2-8.8 years). Prevalence was 57% (n = 235) for LS and 42% (n = 176) for fat abnormality; 90 subjects with abnormality were affected in ≥3 locations. Lipoatrophy occurred in 28% (n = 117) of subjects and lipohypertrophy in 27% (n = 115), most commonly in the face and trunk, respectively. In multivariable analysis, white ethnicity, body mass index, ritonavir/lopinavir, and nonnucleoside reverse transcriptase inhibitors were each associated with an increased risk of LS (P < 0.05). White ethnicity, history of Centers for Disease Control and Prevention-defined disease, and stavudine were associated with risk of lipoatrophy (P < 0.05). Increased risk of lipohypertrophy was associated with body mass index and prior HIV disease. CONCLUSIONS Fat abnormality was prevalent in close to half of children and adolescents, who had accumulated long treatment durations. Risk of fat abnormality was associated with specific drugs, including stavudine and ritonavir, and other variables. Our results underline the importance of continued surveillance of children treated with antiretroviral therapy.
Collapse
Affiliation(s)
- Naufil Alam
- MRC Centre of Epidemiology for Child Health, University College London Institute of Child Health, London, UK.
| | | | | | | | | | | |
Collapse
|
42
|
Affiliation(s)
- Stanley Landau
- Centre for Diabetes and Endocrinology, Johannesburg, South Africa.
| |
Collapse
|
43
|
Signorini DJHP, Monteiro MCM, Andrade MDFCD, Signorini DH, Eyer-Silva WDA. What should we know about metabolic syndrome and lipodystrophy in AIDS? Rev Assoc Med Bras (1992) 2012; 58:70-75. [PMID: 22392319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 10/16/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Prevalence of chronic complications of HIV infection is increasing and early recognition and treatment of the components of metabolic syndrome (MS) are essential to prevent cardiovascular and metabolic complications. Considering this, we performed a cross-sectional study on the prevalence and risk-factors for MS among HIV-infected subjects. METHODS A total of 819 patients followed at a large outpatient HIV unit were assessed by an interviewer-administered questionnaire that recorded several demographic, epidemiologic, clinical, laboratory, and social variables. Lipodystrophy diagnosis relied on agreement between patient's self-report and physician's observation of altered body-fat deposits. The presence of three or more of the following characteristics identified MS: increased waist circumference, hypertriglyceridemia, low HDL cholesterol level, hypertension, and hyperglycemia. We used logistic regression analyses to study variables independently associated with MS. RESULTS The prevalence of MS was 20.6% and that of lipodystrophy was 38.5%. 61 (36.1%) out of 169 patients with MS had also lipodystrophy. Patients with metabolic syndrome were significantly more likely to be older (OR = 1.08), had higher CD4 counts (OR = 1.001), had an increased body mass index (OR = 1.27) and had longer exposure to antiretroviral therapy (OR = 1.01) than those without metabolic syndrome. CONCLUSION Both traditional risk factors for cardiovascular disease and factors associated with HIV infection itself, such as an increased CD4 cell count and a longer exposure to antiretroviral therapy, seem to be associated with metabolic syndrome in the present study population.
Collapse
|
44
|
Tapsfield J, Mathews T, Lungu M, van Oosterhout JJ. Underreporting of side effects of standard first-line ART in the routine setting in Blantyre, Malawi. Malawi Med J 2011; 23:115-117. [PMID: 23451563 PMCID: PMC3588579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION In the Malawi ART programme, 92% of 250,000 patients are using the standard first-line regime of stavudine-lamivudine-nevaripine. National ART reports indicate <4% experience ART side effects, much less than expected from literature. METHODS We interviewed adult patients on standard first-line ART for at least one year, after routine visits to an urban clinic in Blantyre, Malawi. We determined the prevalence of symptoms that are common side-effects, described discrepancies between symptoms that patients reported to us and those that had been recorded by attending staff as side-effects in the point-of-care electronic monitoring system, and studied factors associated with such discrepancies. RESULTS Of 170 participants, 75 (44%) reported at least one symptom, most common were symptoms suggesting peripheral neuropathy (n=57) and lipodystrophy (n=16). Forty-six (66%) symptomatic patients said they reported symptoms to attending ART staff. Side-effects were recorded in the clinic database for just 4 patients. Toxicity recording was too low for meaningful analysis of factors associated with discrepancies between reporting and recording of side-effects. The prevalence of symptoms indicating characteristic side-effects of the standard first-line regimen was 39% based on interviews, and 2% in the electronic monitoring system. CONCLUSION There was gross under-recording of side-effects in this setting, mainly due to not recording by ART staff. Pressure of work and insufficient perceived benefit of side-effect recording are suspected causes. Local and national ART reports do not reflect the true toxicity of the standard first line regimen.
Collapse
Affiliation(s)
| | - Teena Mathews
- Department of Medicine College of Medicine Blantyre, Malawi
| | - Molly Lungu
- ART clinic, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | |
Collapse
|
45
|
|
46
|
Winter M. [Soft tumors in the mid abdomen and thighs. Diabetes, lipohypertrophy]. MMW Fortschr Med 2011; 153:5. [PMID: 22097618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
|
47
|
Hajheydari Z, Kashi Z, Akha O, Akbarzadeh S. Frequency of lipodystrophy induced by recombinant human insulin. Eur Rev Med Pharmacol Sci 2011; 15:1196-1201. [PMID: 22165682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVE Lipodystrophy is a potential clinical complication induced by insulin therapy, and it is believed that its frequency has been reduced by using recombinant human insulin. Aim of this study was to determine the frequency of recombinant human insulin induced lipodystrophy in diabetic patients. MATERIALS AND METHODS This cross sectional study was done on 220 diabetics referring to Imam Educational Hospital of Sari Township in 2007-2008 who had been under treatment with recombinant human insulin at least three months before. First, the anthropologic and clinical features of the patients were recorded in questionnaire, then all of the patients were examined clinically for lipodystrophy. In all patients, glycosylated hemoglobin (HbA1C) was measured for control of the blood glucose. The obtained data were analyzed by the descriptive statistical methods, t-test and 2 test. RESULTS From the total 220 diabetics under study, 35 (15.9%) had insulin induced lipodystrophy, of them 32 (14.5%) had lipohypertrophy and 3 (1.4%) with lipoatrophy. Factors such as age, sex, level of education, body mass index (BMI), type of diabetes, period of using insulin and injection site had significant influence in development of insulin induced lipodystrophy (p<0.05). CONCLUSIONS Findings of this study revealed that despite using a recombinant human insulin, the frequency of the lipodystrophy particularly of lipohypertrophy still remained high level. Therefore, a regular examination of the diabetic patients for this complication is necessary, specially in the individuals who have a defective control on their blood glucose level.
Collapse
Affiliation(s)
- Z Hajheydari
- Department of Dermatolog, Mazandaran University of Medical Sciences, Sari, Iran
| | | | | | | |
Collapse
|
48
|
Yazdanyar S, Dolmer B, Strauss G. [Picture of the month: insulin-related lipoatrophy]. Ugeskr Laeger 2011; 173:1968. [PMID: 21849139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
|
49
|
Dimock D, Thomas V, Cushing A, Purdy JB, Worrell C, Kopp JB, Hazra R, Hadigan C. Longitudinal assessment of metabolic abnormalities in adolescents and young adults with HIV-infection acquired perinatally or in early childhood. Metabolism 2011; 60:874-80. [PMID: 20947103 PMCID: PMC3021796 DOI: 10.1016/j.metabol.2010.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 08/19/2010] [Accepted: 08/19/2010] [Indexed: 12/14/2022]
Abstract
Metabolic complications of HIV pose challenges for health maintenance among young adults who acquired HIV in early childhood. Between July 2004 and July 2009, we evaluated 47 HIV-infected subjects who acquired HIV in early life. Participants completed glucose tolerance testing; insulin, lipid, urine albumin, and creatinine determinations; and dual-energy x-ray absorptiometry scans. Longitudinal data were available for 39 subjects; duration of follow-up was 26.4 ± 16.8 months. At baseline, participants were 17.1 ± 3.9 years old; and duration of antiretroviral therapy was 12.7 ± 3.4 years. CD4 count was 658 ± 374 cells per cubic millimeter, and 55% had undetectable viral load. Impaired glucose tolerance was present in 15%; 33% had insulin resistance (homeostasis model assessment of insulin resistance >4.0). Furthermore, 52% had triglycerides of at least 150 mg/dL, 36% had high-density lipoprotein cholesterol less than 40 mg/dL, 18% had low-density lipoprotein cholesterol of at least 130 mg/dL, and 25% had total cholesterol of at least 200 mg/dL. Microalbuminuria was present in 15% of participants and was inversely correlated with CD4% (P = .001). During follow-up, more than one third remained insulin resistant; lipid parameters tended to improve. There were significant increases in body mass index (P = .0002), percentage leg fat (P = .008), and percentage trunk fat (P = .002). Impaired glucose tolerance, insulin resistance, dyslipidemia, and microalbuminuria are common among young adults with HIV. Long-term exposure to therapy may translate into substantial persistent metabolic risk.
Collapse
Affiliation(s)
- David Dimock
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Vijaya Thomas
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Anna Cushing
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Julia B. Purdy
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
- HIV and AIDS Malignancy Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Carol Worrell
- Pediatric, Adolescent, and Maternal AIDS Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Jeffrey B. Kopp
- Kidney Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Rohan Hazra
- HIV and AIDS Malignancy Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Pediatric, Adolescent, and Maternal AIDS Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Colleen Hadigan
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| |
Collapse
|
50
|
Abstract
BACKGROUND Insulin allergy is a rare complication of insulin use. Localized lipoatrophy is also known to occur following subcutaneous injections of insulin. CASE REPORT A 53-year-old non-obese female patient with Type 2 diabetes displayed local allergic-type symptoms to all available insulin preparations. This was complicated by the development of severe lipoatrophy on her abdominal and thigh injection sites and subsequently resulted in suboptimal glycaemic control. CONCLUSIONS Whilst uncommon, insulin allergy and lipoatrophy can cause major problems in diabetic management. Potential pathophysiological mechanisms and a stepwise approach to management are discussed.
Collapse
Affiliation(s)
- A N Tavare
- Department of Diabetes and Endocrinology, The Hillingdon Hospital, Uxbridge, UK.
| | | | | |
Collapse
|