X-Linked Familial Hypophosphatemia: A Case Report of 27-Year Old Male and Review of Literature.

X-linked hypophosphatemia (XLH) associated with short stature during childhood are mostly referred to the hospital and diagnosed as vitamin D deficiency rickets and received vitamin D before adulthood. A case is presented with clinical features of hypophosphatemia from childhood who did not seek medical care for diagnosis and treatment, nor did his mother or two brothers, who have short statures, bone pain, and fractures. The patient was assessed for sociodemographic, hematological, and biochemical parameters together with a genetic assessment. A DEXA scan and X-ray were done to determine the abnormalities and deformities of joints and bones despite clinical examination by an expert physician. All imaging, laboratory parameters, and the genetic study confirmed the diagnosis of XLH. A detailed follow-up of his condition was performed after the use of phosphate tablets and other treatments. X-linked hypophosphatemia needs a good assessment, care, and follow up through a complementary medical team including several specialties. Phosphate tablets in adulthood significantly affects clinical and physical improvement and prevention of further skeletal abnormality and burden on daily activity. The patients should be maintained with an adequate dose of phosphate for better patient compliance. More awareness is needed in society and for health professionals when conducting medical checkups during the presence of stress fractures, frequent dental and gum problems, rickets, short stature, or abnormality in the skeleton or walking to think of secondary causes such as hypophosphatemia. Further investigations including a visit to a specialist is imperative to check for the primary cause of these disturbances.

Hypogonadism among patients with transfusion-dependent thalassemia: a cross-sectional study.

Patients with thalassemia major are liable to have complications from blood transfusion and iron excess despite using iron-chelating agents. It is common to have endocrine complications in these patients. Hypogonadism is one of the most common complications in thalassemic patients. Early detection and treatment are essential to restore puberty and prevent complications from hypogonadism. Patients and methods: The authors conducted this cross-sectional study in the Kurdistan Region of Iraq, from 1 July 2022, to 1 December 2022. Eighty patients with ß-thalassemia major who were referred to the endocrinology clinic were enrolled. The patients were evaluated sequentially, starting with a history, followed by a clinical examination and laboratory tests related to endocrine disease. Those who met the inclusion criteria were enrolled in the study, while the others were excluded. Results: Out of 80 patients with major thalassemia who were referred to the endocrinology clinic, 53 (66.3%) were female, and 27 (33.7%) were male, with a mean (SD) age of 24.86±7.66 (14-59) years. Fifty-five (68.75%) of them had hypogonadism, three patients (3.8%) had hypothyroidism, while two (2.5%) had hypoparathyroidism. Five patients (6.3%) had diabetes. None of the patients had adrenal insufficiency. The mean ferritin level in thalassemic patients with hypogonadism and thalassemic patients without hypogonadism was 2326±2625 ng/ml vs. 1220±2625 ng/ml. Conclusion: To minimize the risk of endocrinopathy in patients with thalassemia major, they should receive blood transfusions regularly and initiate chelating agents early, because the leading cause of endocrinopathy in thalassemic patients is related to the severity of anemia and iron overload.

Gingko biloba extract improves the lipid profile, inflammatory markers, leptin level and the antioxidant status of T2DM patients poorly responding to metformin: A double- blind, randomized, placebo-controlled trial

Abstract The present study aims to evaluate the effects of Ginkgo biloba (GKB) extract as "add- on" therapy with metformin on the lipid profile, inflammatory markers, leptin and the total antioxidant capacity (TAOC) of patients with type 2 diabetes mellitus (T2DM). It is a multi- center, randomized, placebo-controlled double-blinded clinical study. Sixty patients were allocated into two groups: control and treatment groups; they received orally either 120 mg starch/capsule or 120mg GKB/capsule, respectively as an adjuvant with metformin for 90 days. Blood samples were obtained at zero time and after 90 days. The blood was utilized for analysis of the lipid profile, inflammatory markers, leptin, and TAOC. The GKB extract produced a significant decrease in the levels of TG, LDL-c, and CRP, with a significant increase in HDL-c compared to baseline values. There were no significant changes reported in the placebo-treated group. It also produced a significant decrease in the concentrations of IL-6, TNF-α, and leptin compared to baseline values and placebo-treated groups with a significant increase in TAOC compared to baseline values. In conclusion, GKB extract, as an adjuvant with metformin, decreases inflammatory mediators, leptin level and improves the antioxidant status and lipid profile of T2DM patients improperly managed with metformin

Below-the-Knee Intervention for Ischemic Diabetic Foot in Kurdistan, Iraq: A Case-Control Study.

BACKGROUND: Management of the ischemic diabetic foot (DF) due to infrapopliteal arterial disease is challenging and controversial. Observation, bypass surgery, and endovascular intervention are the 3 available options. Outcome of percutaneous transluminal angioplasty (PTA) versus conservative therapy is evaluated in this prospective study from Sulaymaniyah, Iraq. METHODS: Over 2 years starting at January 2018, 40 patients with ischemic DF underwent PTA and compared with a control group (n = 78) of ischemic DF managed conservatively. Besides clinical assessment, all patients underwent Doppler ultrasonography and computed tomography angiography while conventional angiography was reserved for PTA group. Patients who fulfilled the standard angiographic findings underwent standard PTA, and their outcome was compared with the control group. RESULTS: Mean age was 64 years; 70% (n = 28) were men with a male: female ratio of 2.3: 1. Renal function was impaired in (n = 11, 27.5%), and 7 (17.5%) patients were smokers. The commonest clinical presentation was nonhealing ulcers (n = 39, 97.5%), and most patients (n = 39, 97.5%) had Fontaine IV and Rutherford V-VI grades. Most lesions were anatomically complex; Trans-Atlantic Inter-Society Consensus C and D types, Graziani class ≥4 (75%), long segment (n = 28, 70%), and chronic total occlusion (n = 26, 65%). Success rate was (n = 38, 95%), and no patient died. Ulcer healing was higher (67.5% vs. 34.6%), and ulcer recurrence was lower (20% vs. 47.4%) in PTA group but amputation rate was not significantly different (12.5% vs. 12.8%) (P < 0.05). CONCLUSIONS: Although amputation and death rates were not significantly different, endovascular intervention achieved better ulcer healing in ischemic DF compared with the conservative approach.

Iraqi Experts Consensus on the Management of Type 2 Diabetes/Prediabetes in Adults.

Type 2 diabetes mellitus (T2DM) management differs dramatically between Iraqi public and private sectors; this variability is due to treatment access discrepancy. The aim of this consensus is to put for the first-time uniform recommendation on how to manage patients with T2DM taking in consideration the local obstacles in Iraq. These consensuses were approved by a group of Iraqi Internist and diabetologist from all over the country. Up-to-date and latest level of evidence was used throughout the recommendation.

Utility of Tetrahydrobiopterin Pathway in the Assessment of Diabetic Foot Ulcer: Significant and Complex Interrelations.

OBJECTIVES: Tetrahydrobiopterin (BH4) pathway that included generation of neopterin (Neop), biopterin (Biop), and nitric oxide (NO) is altered in type 2 diabetes (T2D). The aim of this study was to assess the biomarkers of BH4 pathway in noninfected DFUs and to relate these levels to the variables of diabetes as well as to the hematological indices. METHODS: We performed a cross-sectional investigating study in a Kurdish people including 30 healthy subjects (group I), 66 T2D patients (group II), and 57 DFUs patients (group III). Hematological indices including red cell distribution width (RDW), mean platelet volume (MPV), and platelet distribution width (PDW) were determined by Coulter hematological analysis. Serum BH4 markers including NO, Neop, and Biop were determined by using an enzyme-linked immunosorbent assay (ELISA) technology. The relationship between BH4 markers with glycemic and hematological indices was assessed by Spearman's correlation and multivariable regression analysis. RESULTS: Neop was significantly increased while PDW was significantly decreased in group III compared with group II patients. Nitric oxide was found to be inversely correlated with age (r = -0.382), duration of diabetes (r = -0.264), mean arterial blood pressure (r = -0.532), body mass index (r = -0.321), RDW (r = -0.322), and PDW (r = -0.284) in group III patients. Circulating Neop and Biop significantly correlated with RDW and erythrocyte sedimentation rate. Multivariable regression analysis revealed that serum Neop predicted the DFUs in 92.5% of group III patients. CONCLUSION: Tetrahydrobiopterin biomarkers are predictors of DFUs and the significant correlation of neopterin with red distribution width and erythrocyte sedimentation rate indicating the role of neopterin in the vascular and inflammation concerns of noninfected DFUs.

Pentoxifylline improves the quality of life in type-2 diabetes foot syndrome.

OBJECTIVES: To evaluate the effect of pentoxifylline on the quality of life (QoL) in diabetic foot syndrome (DFS) by using Short Form-36 questionnaire, and in reference to the revised neuropathy disability score (RNDS) and grading of diabetic foot. METHODS: This randomized placebo-controlled study was carried in the Department of Pharmacology at University of the Sulaimani through 2018. A total number of 80 T2D patients were recruited from outpatients Department attended the Center of Diabetes and the Shar Teaching Hospital in the University of Sulaimani, Sulaimani-Iraq. Group I (non-DFS, n=40) were subgrouped into Group-IA treated with placebo (n=20), and Group-IB treated with 400 mg pentoxifylline thrice daily for 8 weeks. Group II (DFS, n=40) sub grouped into Group-IIA treated with placebo (n=20), and Group-IIB treated with pentoxifylline. The primary outcome measures including the data of SF-36, RNDS, and grading of diabetic foot. RESULTS: Pentoxifylline therapy significantly reduced the RNDS, improved the clinical evidence of diabetic foot, improved the QoL particularly the domains that related to emotional problems and physical health. Pentoxifylline offered a better effect in DFS compared with non-DFS patients. CONCLUSION: Pentoxifylline treatment improves the quality of life in diabetic foot syndrome and its effect is related to the scoring of revised neuropathy disability and grading of diabetic foot.

Relation of Different Components of Climate with Human Pituitary-Thyroid Axis and FT3/FT4 Ratio: A Study on Euthyroid and SCH Subjects in Two Different Seasons.

BACKGROUND: Various changes in thyroid hormones (TH) and thyroid-stimulating hormone (TSH) level were observed in different seasons among euthyroid and hypothyroid subjects living in areas with an extreme temperature difference between summer and winter. OBJECTIVES: This study aims at finding the effect of temperate climate on the seasonal variations of TSH and TH in euthyroid and subclinical hypothyroidism (SCH) subjects and at evaluating if the test season has an effect on the number of subjects diagnosed as SCH. It basically focuses on the relation of different components of climate with TH and TSH. METHOD: In a prospective study on 152 healthy (euthyroid) volunteers and 25 SCH subjects, the serum hormone levels (TSH, FT4, and FT3) were measured in both the summer and winter seasons and correlated with all the climate components using Pearson's correlation coefficient. The effect of duration of outdoor exposure on hormone levels was compared using a paired sample t-test (P < 0.05). RESULTS: Small but statistically significant increased FT3 level and decreased FT4 level were observed during the winter season in euthyroid and SCH subjects, respectively. There was a significant negative correlation between FT3 and FT3/FT4 ratio with temperature and sunshine duration and a positive correlation with humidity and atmospheric pressure. A positive correlation was found between FT4 and sunshine duration. CONCLUSION: The climate components contributed to the slight variance in hormone levels in different seasons, and the effect was mostly on peripheral conversion of FT4 to FT3 rather than the pituitary-thyroid axis leading to slightly higher FT3 in winter. Seasonal variation does not affect the diagnosis of SCH cases.

Assessment of hair cortisol in euthyroid, hypothyroid, and subclinical hypothyroid subjects.

PURPOSE: Hypothyroidism is associated with an increase in serum cortisol level while the long-term activity of hypothalamic-pituitary-adrenal (HPA) axis in hypothyroid, and subclinical hypothyroid (SCH) subjects has not been studied. This study aimed to assess the hair cortisol levels as a long-term activity of HPA axis in hypothyroid, SCH and a group of healthy adult subjects. Also, it aimed to examine the correlation of hair cortisol levels with hypothalamic-pituitary-thyroid (HPT) axis and anthropometric measures. METHODS: We prospectively evaluated a group of normal, SCH and hypothyroid subjects. Serum TSH, FT4, and FT3 were measured as a component of the HPT axis. Hair samples were collected, prepared, followed by extraction of hair cortisol and measurement in pg/mg of hair. Hair cortisol levels were compared in normal, SCH and hypothyroid groups and correlated with HPT axis and anthropometric data. RESULTS: A total of 65 healthy volunteers were analyzed, and the mean hair cortisol level was reported to be 17.38 pg/mg of hair. Hair cortisol level was slightly higher in the SCH subjects, 18.19 pg/mg of hair; however the difference was not significant. Compared to the euthyroid subject, a significantly higher hair cortisol level was recorded in the hypothyroid subjects, 24.17 pg/mg hair, p < .05. Hair cortisol was significantly and positively associated with each of the serum TSH, age, weight and BMI (p < .05). CONCLUSIONS: Overt hypothyroidism but not SCH is significantly associated with higher hair cortisol levels compared to normal subjects, and a significant relation between hair cortisol with HPT axis was found. Also, weight and BMI were positively correlated with hair cortisol level.

Efficacy and safety of Ginkgo biloba extract as an "add-on" treatment to metformin for patients with metabolic syndrome: a pilot clinical study.

BACKGROUND AND AIM: Ginkgo biloba (GKB) extract has shown to be beneficial in experimental models of metabolic and inflammatory disorders such as diabetes and metabolic syndrome (MTS). The objective of this pilot clinical study was to evaluate the effects of GKB extract as an "add-on" treatment with metformin (Met) in MTS patients. PATIENTS AND METHODS: We performed a randomized, placebo-controlled, double-blinded clinical study in subjects with MTS. Forty patients completed the 90-day clinical trial and were randomly allocated to administer either GKB extract (120 mg capsule/day) or placebo (120 mg starch/day) as an add-on treatment with their currently used doses of Met for 90 days. During the study, body mass index (BMI), waist circumference (WC), serum leptin, glycated hemoglobin (HbA1c), fasting serum glucose (FSG), insulin, insulin resistance (IR), visceral adiposity index (VAI), lipid profile, and the inflammatory markers high sensitive C-reactive protein (hsCRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were evaluated. RESULTS: GKB extract significantly decreases HbA1c, FSG and insulin levels, IR, BMI, WC, VAI, serum leptin, and the inflammatory markers compared to baseline values. Simultaneously, GKB did not negatively affect the functions of the liver, kidney, and hematopoietic system. CONCLUSION: The use of GKB extract as an adjuvant with Met was effective in improving the outcome of patients with MTS.

The efficacy and safety of Ginkgo biloba extract as an adjuvant in type 2 diabetes mellitus patients ineffectively managed with metformin: a double-blind, randomized, placebo-controlled trial.

BACKGROUND AND AIM: Type 2 diabetes mellitus (T2DM) is one of the major diseases confronting the health care systems. In diabetes mellitus (DM), combined use of oral hypoglycemic medications has been shown to be more effective than metformin (Met) alone in glycemic control. This study determined the effects of Ginkgo biloba (GKB) extract as an adjuvant to Met in patients with uncontrolled T2DM. SUBJECTS AND METHODS: Sixty T2DM patients were recruited in a randomized, placebo-controlled, double-blinded, and multicenter trial. The patients, currently using Met, were randomly grouped into those treated with either GKB extract (120 mg/day) or placebo (starch, 120 mg/day) for 90 days. Blood glycated hemoglobin (HbA1c), fasting serum glucose, serum insulin, body mass index (BMI), waist circumference (WC), insulin resistance, and visceral adiposity index (VAI) were determined before (baseline) and after 90 days of GKB extract treatment. RESULTS: GKB extract significantly decreased blood HbA1c (7.7%±1.2% vs baseline 8.6%±1.6%, P<0.001), fasting serum glucose (154.7±36.1 mg/dL vs baseline 194.4±66.1 mg/dL, P<0.001) and insulin (13.4±7.8 µU/mL vs baseline 18.5±8.9 µU/mL, P=0.006) levels, BMI (31.6±5.1 kg/m2 vs baseline 34.0±6.0 kg/m2, P<0.001), waist WC (102.6±10.5 cm vs baseline 106.0±10.9 cm, P<0.001), and VAI (158.9±67.2 vs baseline 192.0±86.2, P=0.007). GKB extract did not negatively impact the liver, kidney, or hematopoietic functions. CONCLUSION: GKB extract as an adjuvant was effective in improving Met treatment outcomes in T2DM patients. Thus, it is suggested that GKB extract is an effective dietary supplement for the control of DM in humans.