Prevalence of anemia and its associated factors among patients with type 2 diabetes mellitus in a referral diabetic clinic in the north of Iran.

BACKGROUND: PURPOSE: This study intended to investigate the prevalence of anemia and its associated factors among patients with type 2 diabetes mellitus (T2DM) in Gorgan, Iran. METHODS: This cross-sectional study was conducted on 415 (109 men) patients with T2DM referred to the referral diabetes clinic of Sayad Shirazi Hospital in Gorgan in 2021. Demographic information, anthropometric indices, past medical history,  and some laboratory data on cell counts, serum blood glucose, HbA1c, creatinine, lipid/iron profiles, and urinary albumin were collected. The univariable and multivariable logistic regression analysis was applied to compute odds ratios (ORs) and 95% confidence intervals (CI) for potential associated factors, using SPSS version 21. The multivariable Model was adjusted for obesity, Hb A1c, T2DM duration, using glucose-lowering drugs (GLDs), chronic kidney disease (CKD), albuminuria, hypertriglyceridemia, and hypercholesterolemia.  RESULTS: The prevalence of anemia was 21.5% [95%CI: 17.6-25.7] among our total participants. The corresponding values for men and women were 20.2 (13.1-29.0) and 21.9 (17.4-27.0), respectively.The adjusted model revealed that obesity (OR, 1.94 [95% CI, 1.17-3.23]), T2DM duration for more than five years (OR, 3.12 [1.78-5.47]), albuminuria (OR, 6.37 [3.13-10.91]), chronic kidney disease (OR, 4.30 [ 2.83-7.29]) and hypertriglyceridemia (OR, 1.72 [ 1.21-2.77]) were significantly associated with prevalent anemia among patients with T2DM. Moreover, using insulin separately or in combination with oral GLDs associated positively with the prevalence of anemia with ORs of 2.60 [1.42-6.42] and 1.87 [1.30-4.37] , respectively. CONCLUSION: Anemia had a high prevalence among patients with T2DM in the north of Iran (about 22%), which is associated with obesity, hypertriglyceridemia, duration of T2DM, and diabetic kidney disease.

Three-year change in glycemic state and the future risk of incident hypertension among Iranian adults: Tehran Lipid and Glucose Study.

The impact of 3-year change in glycemic state on the risk of hypertension among Tehranian adults aged ≥20 years was assessed. The study population included 1679 men and 2348 women who were non-diabetic normotensive at enrollment. The following categories were defined both at baseline visit and three years later (second visit): normoglycemia [normal fasting glucose (NFG) and normal glucose tolerance (NGT)] and prediabetes [impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)]. Changes in the categories, i.e., regression to normoglycemia, remaining in previous status, and progression to diabetes were assessed. Changes in fasting plasma glucose (FPG) and 2-hour plasma glucose (2hPG) categories were also considered separately. We used the Cox models adjusted for traditional hypertension risk factors to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). During a median follow-up of 9.4 years, 485 men and 589 women developed hypertension. Among men, considering both FPG and 2hPG, compared to individuals remaining normoglycemic, changing from prediabetes to normoglycemia had a HR of 1.30 (95% CI: 0.98-1.71; P-value: 0.064). Defining changes by 2hPG showed that compared to remaining NGT, incident IGT (progression from NGT to IGT) had a significant association with increased risk of hypertension development by a HR of 1.61 (1.13-2.30). Among women, on the other hand, change in glycemic state generally didn't show a significant association with incident hypertension. To sum up, change in glycemic state hadn't a significant association with hypertension development among women; however, compared to remaining NGT, men with incident IGT had a significant higher risk.

Three-year weight change and risk of all-cause, cardiovascular, and cancer mortality among Iranian adults: over a decade of follow-up in the Tehran Lipid and Glucose Study.

BACKGROUND: We investigated the impact of weight change on mortality in a population-based cohort setting. METHODS: We conducted two weight measurements for 5436 participants aged ≥ 30 years with an approximate 3-year interval. Based on their weight change, we categorized participants to: > 5% weight loss, 3-5% weight loss, stable weight (± < 3%), 3-5% weight gain, > 5% weight gain. We followed participants for mortality annually up to March 20th 2018. We applied the multivariable Cox proportional hazard models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of weight change categories for all-cause, cardiovascular (CV), and cancer mortality, considering stable weight as reference. The Cox models was adjusted for age, sex, educational level, body mass index, smoking status, hypertension, hypercholesterolemia, diabetes, and cardiovascular disease (CVD) at baseline. RESULTS: During a median follow-up of 14.4 years, 629 deaths (247 CV and 126 cancer deaths) have occurred. Over 5% weight loss and gain were associated with increased risk of all-cause mortality in multivariable analysis with HRs of 1.47 [95% CI: 1.17-1.85] and 1.27 [1.02-1.57], respectively; however, a 3-5% loss or gain did not alter the risk of all-cause mortality significantly. These significant risks for wight change > 5% were not modified by the presence of diabetes, obesity, and smoking status; however, the unfavorable impact of weight change on mortality events was more prominent in those older than > 65 years (P-value for interaction: 0.042). After excluding those with history of CVD, diabetes, and cancer during the weight measurements period, these associations significantly attenuated (HR: 1.29 [0.89-1.87] for > 5% weight loss and 1.12 [0.84-1.50] for > 5% weight gain). Additionally, a > 5% weight loss was also associated with about 60% higher risk for CV mortality (HR: 1.62 [1.15-2.28]), and a 3-5% weight loss was associated with about 95% higher risk of cancer mortality (HR: 1.95 [1.13-3.38]). CONCLUSIONS: Our findings showed a U-shaped association across weight change categories for all-cause mortality risk with over 5% weight gain and loss causing higher risk. Moreover, weight loss can have adverse impact on CV and cancer mortality events.

Incidence and risk factors of severe non-proliferative/proliferative diabetic retinopathy: More than a decade follow up in the Tehran Lipids and Glucose Study.

AIMS/INTRODUCTION: To examine the incidence rate of severe non-proliferative and proliferative diabetic retinopathy (severe-NPDR/PDR) and determine its potential risk factors. MATERIALS AND METHODS: The study consisted of 1,169 participants (675 women) with type 2 diabetes mellitus, aged ≥20 years. A trained interviewer collected information about the history of pan-retinal photocoagulation as a result of diabetic retinopathy. Multivariable Cox proportional hazards regression models were applied. RESULTS: We found 187 cases (126 women) of severe-NPDR/PDR during a median follow-up period of 12.7 years; the corresponding incidence rate was 13.6 per 1,000 person-years. Being overweight (hazard ratio [HR], 95% confidence interval [CI] 0.60, 0.39-0.92) and obese (HR 0.48, 95% CI 0.27-0.83) were associated with lower risk, whereas being smoker (HR 1.75, 95% CI 1.12-2.74), having fasting plasma glucose levels 7.22-10.0 mmol/L (HR 2.81, 95% CI 1.70-4.62), fasting plasma glucose ≥10 mmol/L (HR 5.87, 95% CI 3.67-9.41), taking glucose-lowering medications (HR 2.58, 95% CI 1.87-3.56), prehypertension status (HR 1.65, 95% CI 1.05-2.58) and newly diagnosed hypertension (HR 1.96, 95% CI 1.06-3.65) increased the risk of severe-NPDR/PDR. Among newly diagnosed diabetes patients, being male was associated with a 59% lower risk of severe-NPDR/PDR (HR 0.41, 95% CI 0.21-0.79). Furthermore, patients who had an intermediate level of education (6-12 years) had a higher risk of developing PDR (HR 1.86, 95% CI 1.05-3.30) compared with those who had <6 years of education. CONCLUSIONS: Among Iranians with type 2 diabetes mellitus, 1.36% developed severe-NPDR/PDR annually. Normal bodyweight, being a smoker, out of target fasting plasma glucose level, prehypertension and newly diagnosed hypertension status were independent risk factors of severe-NPDR/PDR. Regarding the sight-threatening entity of advanced diabetic retinopathy, the multicomponent strategy to control diabetes, abstinence of smoking and tight control of blood pressure should be considered.

Acute Kidney Injury After Liver Transplant: Incidence, Risk Factors, and Impact on Patient Outcomes.

OBJECTIVES: Acute kidney injury is a frequent complication of liver transplant. Here, we assessed the rate and contributing factors of acute kidney injury and need for renal replacement therapy in patients undergoing liver transplant at a transplant center in Tehran, Iran. MATERIAL AND METHODS: We identified all patients who underwent liver transplant at the Imam Khomeini Hospital Complex from March 2018 to March 2019 and who were followed for 3 months after transplant. Acute kidney injury was defined based on the Acute Kidney Injury Network criteria. We collected demographic and pretransplant, intraoperative, and posttransplant data. Univariable and multivariable models were applied to explore independent risk factors for acute kidney injury incidence and need for renal replacement therapy. RESULTS: Our study included 173 deceased donor liver transplant recipients. Rates of incidence of acute kidney injury and need for renal replacement therapy were 68.2% and 14.5%, respectively. The 3-month mortality rate among those with severe and mild or moderate acute kidney injury was 44.0% (14/25) and 9.7% (9/ 93), respectively (P < .001). Multivariable analyses indicated that serum albumin (relative risk of 0.55; 95% confidence interval, 0.34-0.87; P = .021), baseline serum creatinine (relative risk of 2.11; 95% confidence interval, 1.56-2.90; P = .037), and intraoperative mean arterial pressure (relative risk of 0.76; 95% confidence interval, 0.63-0.82; P = .008) were independent factors for predicting posttransplant acute kidney injury. Independent risk factors for requiring renal replacement therapy were pretransplant serum creatinine (relative risk of 1.99; 95% confidence interval, 1.89-4.47; P = .044) and intraoperative vasopressor infusion (relative risk of 1.41; 95% confidence interval, 1.38-2.00; P = .021). CONCLUSIONS: We found a high incidence of acute kidney injury among liver transplant recipients in our center. There was a significant association between severity of acute kidney injury and 3-month and in-hospital mortality.

Persistent hypercalcemia with similar familial Hypocalciuric hypercalcemia features: a case report and literature review.

BACKGROUND: Primary hyperparathyroidism (PHPT) and familial hypocalciuric hypercalcemia (FHH) are the most important differential diagnosis of parathyroid hormone (PTH)-dependent hypercalcemia. The clinical features of FHH and PHPT can overlap in some cases. Therefore, these two diseases must be differentiated to prevent unnecessary parathyroidectomy. Here, we present a case that was not entirely matched with any of the known differential diagnoses of hypercalcemia. CASE PRESENTATION: A 19-year-old girl with no history of any disease presented with persistent hypercalcemia without any specific musculoskeletal complaint. We found persistent hypercalcemia in her routine laboratory data from 3 years ago; while no data was available during the childhood period. Her dietary calcium intake was normal. She did not mention any history of renal stone, bone fracture as well as family history of hypercalcemia. Biochemical features showed normal values of serum creatinine, high normal serum calcium (range, 10.3-11.3 mg/dL; (normal range: 8.8-10.4)), and non-suppressed PTH levels (range, 37.2-58.1 pg/mL; (normal range: 10-65)). Serum 25 OH vitamin D level at the first visit was 16.1 ng/mL that treated by vitamin D supplementation. Since then, all 25 OH vitamin D levels were in the acceptable range. After correction of vitamin D deficiency during the follow-up period the calcium creatinine clearance ratio(s) (CCCR) were calculated in the range of 0.009 to 0.014 (means below 1%). The clinical and laboratory data indicate more FHH rather than PHPT. Genetic studies were negative for the common genes associated with FHH (CASR, GNA11, and AP2S1 genes) and multiple endocrine neoplasia type1 (MEN1). On the other hand, no evidence of autoimmunity was found in her to support an autoimmune FHH-like syndrome. Hence, the case did not match completely to any diagnosis of FHH and PHPT, so we decided to follow her. CONCLUSION: We presented a patient with FHH phenotype whose common genetic tests were negative. Further research is needed to ascertain other causes leading to similar manifestations.

The association of parity/live birth number with incident type 2 diabetes among women: over 15 years of follow-up in The Tehran Lipid and Glucose Study.

BACKGROUND: Childbearing may increase the future risk of developing type 2 diabetes mellitus (T2DM) in mothers. However, the issue is not clear completely and not investigated in the Middle East, a region with a high burden of T2DM. In the current study, we examined the association of parity/live birth number with incident T2DM among Iranian women. METHODS: The study population included 2552 women aged 30-65 years recruited in 1999-2001 and were followed for incident T2DM by 3-year intervals. Multivariable Cox proportional hazard models were applied to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of the parity/live birth number for incident T2DM. Parity number was defined as the number of live childbirth (number of live birth) plus the number of stillbirth (defined as birth of an infant that died after the 20th week of pregnancy in the uterus). RESULTS: During a median follow-up of 15.4 years, 557 incident T2DM cases have occurred. After adjustment for potential T2DM risk factors and reproductive factors, each additional parity caused a 9% higher risk for incident T2DM. Moreover, compared to women with one parity, those with 3 and ≥ 4 parity had HRs of 1.73 [95% CI: 1.06-2.83] and 2.23 [1.36-3.65], respectively. After further adjustment for body mass index (BMI) and waist circumference, although the HRs were attenuated prominently, parity ≥ 4 was associated with significantly higher risk (HR: 1.72 [1.05-2.83]); even after further adjustment for triglycerides (TG)/ high-density lipoprotein cholesterol (HDL-C), the risk remained marginally significant (HR: 1.64 [1.00-2.70; P value: 0.051]). For the number of live birth, the results were also similar. Moreover, in a sensitivity analysis, when we considered BMI change during follow-up as another covariate, generally, the effect sizes did not change; the trend of HRs across categories of parity number remained marginally significant (P value: 0.064). CONCLUSIONS: During a long-term follow-up, after adjustment for potential T2DM risk factors, reproductive factors, obesity indices, and TG/HDL-C (insulin resistance surrogate), we demonstrated that higher parity/live birth numbers could be associated with increased risk of T2DM development among Iranian women. Moreover, even after further adjustment for BMI change, the suggestive higher risk was still found.

Comparison of empathy with patients between first-year and last-year medical students of Tehran University of Medical Sciences.

PURPOSE: This study was conducted to assess the developmental factors of empathy among medical students of Tehran University of Medical Sciences (TUMS). METHODS: To assess the empathy levels, 42 first-year and an equal number of last-year medical students were randomly selected. They answered a questionnaire including the medical student version of the Jefferson Scale, demographic, and some related variables. Statistical analyses were performed using the Chi-square test, T-test, univariate, and multivariate regressions. RESULT: The study population consisted of 51 (60.7 %) men and 33 (39.3 %) women with a mean (SD) age of 22.24 (4.10) years. The Jefferson score was 110.19 ± 13.61 and 103.52 ± 20.00 in first- and last-year medical students, respectively. Moreover, medical students who completely passed at least one of the considered empathy courses of the TUMS curriculum had higher empathy scores compared to their counterparts (109.83 ± 15.54 vs. 103.68 ± 19.02). There was no significant association between empathy and gender, self-experience of illness, marital status, family history of chronic disease, and parents' education (all P-values > 0.05). After adjusting for the effects of confounders, the empathy scores were significantly associated with the academic year level (p = 0.04), level of interest in medicine (p = 0.001), and passing the empathy courses (p = 0.04). CONCLUSIONS: The data provided from a top Iranian medical school indicated that the academic year level, level of interest in medicine, and passing the empathy courses were significantly associated with the empathy level. Further studies are recommended.

Weight change and risk of cardiovascular disease among adults with type 2 diabetes: more than 14 years of follow-up in the Tehran Lipid and Glucose Study.

BACKGROUND: To examine the impact of weight change on incident cardiovascular disease and coronary heart disease (CVD/CHD) among an Iranian population with type 2 diabetes mellitus (T2DM). METHODS: The study population included 763 participants with T2DM aged ≥ 30 years without a history of CVD and cancer at baseline. Two weight measurements done at baseline and about 3 years later. Based on their weight change, they categorized into: > 5% loss, 3-5% loss, stable (± < 3%), 3-5% gain, > 5% gain. Participants were then followed for incident CVD/CHD annually up to 20 March 2018. Multivariable Cox proportional hazard models, adjusted for age, sex, body mass index, educational level, current smoking, glucose-lowering drug use, family history of CVD, hypertension, hypercholesterolemia, chronic kidney disease, and fasting plasma glucose (FPG) were applied to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of weight change categories for incident CVD/CHD, considering stable weight as reference. RESULTS: After the weight change measurement, during a median follow-up of 14.4 years, 258 CVD and 214 CHD occurred. Over 5% weight gain was associated with reduced risks of CVD and CHD development by the HRs of 0.70 [95% CI 0.48-1.01; P-value: 0.058] and 0.61 [0.40-0.93], respectively, in multivariable analysis. After further adjustment for FPG change, the HRs of weight gain > 5% were attenuated to 0.75 [0.51-1.10; P-value: 0.138] and 0.66 [043-1.01; P-value: 0.053] for incident CVD and CHD, respectively. The effect of weight loss > 5% was in opposite direction among those older versus younger than 60 years; with suggestive increased risk (not statistically significant) of incident CHD/CVD for the older group. Moreover, weight gain > 5% significantly reduced the risk of CHD only among those older than 60 years (P-value for interaction < 0.2). Furthermore, weight gain > 5% had an association with lower risk of CVD and CHD among sulfonylurea users (0.56 [0.32-0.98] for CVD and 0.54 [0.29-0.99] for CHD). CONCLUSIONS: Our results with a long-term follow-up showed that weight gain > 5% was associated with better CVD/CHD outcomes among Iranian participants with T2DM, especially older ones. Moreover, we did not find an unfavorable impact on incident CVD/CHD for sulfonylurea-induced weight gain.

Nasopharyngeal B-cell lymphoma with pan-hypopituitarism and oculomotor nerve palsy: a case report and review of the literature.

BACKGROUND: Primary nasopharyngeal lymphoma (NPL) is a very rare tumor of Waldeyer ring (WR) lymphoid tissue. It is challenging to differentiate lymphoma infiltration of pituitary from a pituitary adenoma, meningioma infiltration, and other sellar lesions to plan a suitable treatment strategy. We presented for the first time a unique case of NPL with an unusual presentation of oculomotor nerve palsy associated with pan-pituitary involvement in a diabetic patient. CASE PRESENTATION: A 64-year old diabetic woman with no previous history of malignancy presented with intermittent diplopia for about the last nine months. Severe headache, left eye ptosis and hypoglycemic episodes were added to her symptoms after a while. Further complaints include generalized weakness, loss of appetite, generalized musculoskeletal pain, and 6-7 kg weight loss within six months. Her family history was unremarkable. Physical examinations of eyes indicated left eye 3rd, 4th, and 6th nerve palsy. But, she was not anisocoric, and the pupillary reflexes were normal on both eyes. No lymphadenopathy, organomegaly and other abnormalities were found. Magnetic resonance imaging (MRI) showed a heterogeneous enhancement in the seller and suprasellar regions, enlargement of the stalk, parasellar dural enhancement and thickening of the sphenoid sinus without bone erosion. Also, both cavernous sinuses were infiltrated and both internal carotid arteries were encased by the neoplastic lesion. It suggested an infiltrative neoplastic lesion which compressed the cranial nerves. Pituitary hormone levels assessment indicated a pan-hypopituitarism. Following nasopharyngeal mucosal biopsy, the immunohistochemistry (IHC) findings revealed a low-grade non-Hodgkin's B-cell lymphoma. Systemic workup, including cerebrospinal fluid (CSF) studies, bone marrow aspiration, chest and abdominopelvic high-resolution computed tomography (HRCT) indicated no other involvement by the lymphoma. After chemotherapy courses, central adrenal insufficiency, partial central diabetes incipidious (CDI) and central hypothyroidism have been resolved. To our best knowledge, we found 17 cases of NPL with cranial nerve palsy, 1 case of NPL with pan-hypopituitarism and no NPL case with both cranial nerve palsy and pituitary dysfunction. CONCLUSIONS: The incidence of cranial neuropathy in patients with diabetes should not merely be attributed to diabetic neuropathy without further evaluation.