Rodhan Khthir

Metabolic disease and shift work: Is there an association? An analysis of NHANES data for 2007–2008

Previous epidemiological studies have shown that shift work is associated with higher levels of obesity and diabetes, possibly related to physiological maladaptation as a direct result of sleeping and eating at abnormal circadian times.1 In a previously performed cross-sectional study, shift work was associated with higher levels of triglycerides, lower levels of high-density lipoprotein cholesterol, and higher odds of metabolic syndrome in a multiple logistic regression analysis (OR 2.4; 95% CI 1.1 to 5.0).2 We performed an analysis of the cross-sectional NHANES data3 for 2007–2008 and compared the different metabolic parameters between regular daytime workers and shift workers. Shift workers included …

The Metabolic Syndrome in Rural UAE: The Effect of Gender, Ethnicity and theEnvironment in its Prevalence

Objective: The purpose of this study was to examine the prevalence of the metabolic syndrome and its individual components among multiethnic population in a rural area in the Western region of Abu Dhabi in The United Arab Emirates (UAE). Methods: The analytic sample consisted of 575 adults (males: 309, females: 266), between the age of 22 and 65 years. The National Cholesterol Education Program’s Adult Treatment Panel III (NCEP/ATP III) guidelines (with race specific abdominal circumference cutoff level) were used to identify adults who met their criteria for metabolic syndrome with. Prevalence estimates were calculated for each component of the metabolic syndrome in addition to the overall prevalence of metabolic syndrome. Prevalence estimates were analyzed by sex, ethnicity and working hours. Results: Approximately 22% of adults met the criteria for metabolic syndrome. The prevalence was 26% in Males and 14% in females, P. Value <0.01. The prevalence was 16% among South East Asians (SEA), 20% among Arabs (ARB) and 26% among South Asians (SA), with P value of 0. 523, 0.075 and <0.05 for ARB versus SEA, ARB versus SA, and SA vs SEA respectively. The prevalence of the metabolic syndrome among night shift workers was 25% in comparison to 19% among daytime workers (P value 0.1). The prevalence of the different components of the metabolic syndrome varied by race and ethnicity Conclusions: These results demonstrate that metabolic syndrome is less prevalent in rural area than inner city population in UAE which was reported to be around 40% in previous studies possibly because of lifestyle differences. The prevalence varied significantly by race and ethnicity and gender. Night shift work was associated with higher prevalence of the metabolic syndrome in our study but this was not statistically significant.

Femoral Neck Bone Mineral Density in Persons Over 50 Years Performing Shiftwork: An Epidemiological Study.

Objective: Shiftwork has been associated with bone loss due to hormonal fluctuations. Our aim was to assess the femoral neck bone mineral density and content in persons over 50 years performing shiftwork. Methods: We performed analysis on the femoral neck bone mineral parameters in persons over age 50 years from the National Health and Nutrition Examination Survey cross-sectional data for 2010 to 2011 in regular and shiftworkers. We also assessed the degree of moderate physical activity and smoking in both groups. Results: Middle-aged men performing shiftwork had significantly higher total femur bone mineral content (37.33 ± 11.00 vs 34.09 ± 10.45, P = 0.01) and femoral neck bone mineral content (4.57 ± 1.07 vs 4.29 ± 1.0, P = 0.03). This difference was not seen in middle aged women. Conclusions: Shiftwork does not seem to affect bone mineral density in those performing moderate physical activity.

Association Between Serum Total Bilirubin and Serum Creatinine and the Effect of Hypertension

To the Editor: A recent post hoc analysis of two large clinical trials has demonstrated that serum bilirubin level(s) are inversely correlated with the progression of diabetic nephropathy (DN). The findings suggest that measurement of bilirubin levels may identify patients at risk for progression of DN. We performed an analysis of the cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2011–2012 to examine the association between serum total bilirubin level (in mg/dL) and serum creatinine (in mg/dL). We categorized serum creatinine into low (0.5–0.99), intermediate (1.0–1.49), and high (>1.5) groups. We excluded patients with creatinine <0.5 mg/dL. We performed one-way analysis of variance (ANOVA) comparing multiple variables between the groups. For subgroup analysis, blood pressure (BP) was categorized as normotensive (systolic BP <140 mm Hg) and hypertensive (systolic BP ≥140 mm Hg). We compared total bilirubin level(s) between the low and intermediate creatinine groups and intermediate and high creatinine groups using t test or the Mann-Whitney test where the sample lacked homogeneity. We performed nonparametric (Spearman) correlation between total bilirubin and serum creatinine. SPSS version 18 (IBM, Armonk, NY) was used for statistical analysis. The results from ANOVA are shown in the Table. There were 4905 persons in the study population. Our study found a significant positive correlation between serum total bilirubin and creatinine (Spearman’s correlation coefficient, 0.20; P<.01, with exclusion of persons with creatinine <0.5). The positive correlation was maintained in the hypertensive population (n=454, Spearman’s correlation coefficient, 0.26; P<.01). No relationship between creatinine and bilirubin was shown in patients with renal insufficiency (n=105, P .20). The results are illustrated in the Figure. Mean total bilirubin was higher in the intermediate creatininegroup (n=1043) comparedwith thehigh creatinine (n=114) and low creatinine (n=3751) groups (0.77 0.29 vs 0.69 0.28 vs 0.69 0.29, respectively; P<.01). In persons with hypertension, there was a trend toward higher mean total bilirubin level in the intermediate creatinine group compared with the high creatinine group (P=.051). There was persistence of significance in the difference in the total bilirubin level (s) between the low and intermediate creatinine groups in the hypertensive population (n=439, 0.70 0.25 vs 0.76 0.26, P=.03). There was no difference in the urinary albumin or urinary creatinine levels in the oneway ANOVA in the study population (P=.79 and P=.82, respectively). Our study is limited in its ability to draw major conclusions as it is cross-sectional and does not take into account ethnic and racial differences. In addition, creatinine may not be a true measure of glomerular filtration rate in some situations. Moderate unconjugated hyperbilirubinemia (ranging from 1.2 mg/dL to 6.0 mg/dL) that is seen in patients with Gilbert syndrome confers protection from cardiovascular disease. The possible explanation for the protective effect of bilirubin include its effects in improving endothelial function and its antioxidant role. In an animal model (using Gunn rats, which have a genetic deficiency in UDP-GT), blood vessels isolated from hyperbilirubinemic rats exhibited reduced levels of superoxide production and a blunted tonic response to angiotensin II infusion.

Severe Cushing Syndrome Due to an ACTH-Producing Pheochromocytoma: A Case Presentation and Review of the Literature

Abstract Adrenocorticotropic hormone (ACTH)-dependent Cushing syndrome is rarely caused by a pheochromocytoma. We present a case of a 46-year-old woman who developed severe hypertension, hypokalemia, and typical Cushingoid features. Investigations revealed extremely high metanephrine, cortisol, and ACTH levels. Imaging showed a 3.8-cm left adrenal mass. Preoperative control of hypertension and hypokalemia was very challenging. The patient was cured after surgical removal of the adrenal mass. We followed this by a review of the literature using the databases Google Scholar and PubMed. A total of 58 cases have been reported to date. In summary, ACTH-producing pheochromocytoma is a rare condition that poses a clinical challenge in the perioperative period. It is important that physicians be aware of such a condition because early recognition and treatment are crucial to decrease morbidity and mortality.

The relationship of BRAFV600E mutation status to FDG PET/CT avidity in thyroid cancer: A review and meta-analysis

OBJECTIVE Papillary thyroid cancer (PTC) harboring a BRAFV600E gene mutation has been shown to exhibit aggressive tumor behavior and carries higher risks of recurrence and disease-specific death. In this systematic review and meta-analysis, we examined published evidence related to the accuracy of fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in detection of residual disease in patients with BRAFV600E mutated thyroid cancer. METHODS We extracted data from PUBMED/MEDLINE and EMBASE published between January 1995 and March 2017. We included studies that compared FDG PET standardized uptake values (SUVs) between BRAFV600E-positive and BRAFV600E-negative subjects, as well as those that evaluated the odds of having FDG avidity between BRAFV600E-positive and -negative patients with thyroid cancer. RESULTS There were a total of 12 studies in the systematic review. Seven studies qualified for the analysis for calculating the pooled odds ratio (OR). The pooled cohort with binary data had 1,144 patients out of which 843 were BRAFV600E positive and 301 were BRAFV600E negative. Those with a BRAFV600E mutation had a significantly greater likelihood of having FDG-avid lesions. The pooled OR was 2.12 (confidence interval [CI] 1.53-3.00, P<.01). The pooled mean SUV (cohort of 315 patients) was significantly higher in BRAFV600E-positive compared to BRAFV600E negative patients, with a pooled mean difference of 5.1 (CI 4.3-5.8). CONCLUSION Our meta-analysis shows that presence of BRAFV600E mutation in PTC confers a higher likelihood of FDG PET avidity and is associated with higher SUV uptake values compared to BRAFV600E-mutation negative status. ABBREVIATIONS BRAF = B-Raf proto-oncogene, serine/threonine kinase; CI = confidence interval; CT = computed tomography; DTC = differentiated thyroid cancer; FDG = fluorodeoxyglucose; PET = positron emission tomography; PTC = papillary thyroid cancer; SUV = standardized uptake value.

Apolipoprotein B and Insulin Resistance in Hypertensive Compared With Normotensive Patients: An Epidemiological Study

To the Editor: Cross-sectional studies performed recently have suggested that the prevalence of type 2 diabetes in persons with familial hypercholesterolemia might be lower than unaffected individuals (1.75% vs 2.93%, respectively; P<.01). Moreover, statin therapy might increase the risk of type 2 diabetes by 46% with substantial decreases in insulin secretion and resistance as reported by the researchers in the Metabolic Syndrome in Men (METSIM) cohort. The exact relationship between cholesterol and insulin resistance remains unclear in persons with hypertension. We have attempted to evaluate the relationship between Apolipoprotein B (Apo B) and insulin resistance in hypertensive patients. We performed an analysis of the cross-sectional data from the National Health and Nutrition Examination Survey1 for the period 2008–2012 to evaluate the relationship between Apo B and insulin resistance in both a normotensive and hypertensive population. We stratified the serum Apo B levels into low (<100 mg/dL) and high (≥100 mg/dL) groups. Data on variables including age at screening, body mass index (kg/m), waist circumference (cm), mean systolic blood pressure (mm Hg), and cholesterol (mg/dL) were tabulated. We excluded persons 18 years or younger from our analysis. Blood pressure (BP) was categorized as normotensive (systolic BP <140 mm Hg) and hypertensive (systolic BP ≥140 mm Hg). The homeostasis model assessment of insulin resistance (HOMA-IR) was calculated using the formula (–fasting insulin (lU/mL)9fasting blood glucose (mg/dL)/405). We performed the independent sample t test comparing variables between the two groups. Additionally, we performed nonparametric (spearman) correlation between Apo B and HOMA-IR, Apo B and fasting serum insulin level(s) (lU/mL), and Apo B and fasting blood glucose (mg/dL) in both normotensive and hypertensive patients. SPSS version 21 (IBM, Armonk, NY) was used for statistical analysis. There were 3557 persons with normal BP and 497 with hypertension in the study population. Persons with low Apo B and high Apo B levels were equally distributed between normotensive and hypertensive patients (chi-square, 0.89). There was no difference in the mean Apo B level between normotensives and hypertensive patients (87.8 [ 25.1] vs 87.5 [ 25.3], P=.80). The results of the comparison (Student t test) between the low Apo B group and the high Apo B group in persons with hypertension is summarized in the Table. The high Apo B group had significantly higher fasting insulin, insulin resistance (HOMA-IR), and fasting blood glucose levels (P=.04, P<.01, and P<.01, respectively). There was a significant positive correlation between Apo B, fasting insulin, and fasting blood glucose levels, as well as HOMA-IR in both the normotensive and hypertensive groups. However, the relationship between Apo B and fasting insulin levels was stronger in hypertensive patients (Spearman correlation coefficient (q)=0.198, P<.01) as compared with persons without hypertension (Spearman correlation coefficient (q)=0.148, P<.01). This greater correlation was also seen in the relationship between Apo and HOMA-IR (q=0.214, P<.01 vs q=0.180, P<.01). Recently, higher insulin resistance was associated with lower lipoprotein (a) levels in persons with hypertension. The results of our cross-sectional study show that higher Apo B levels are associated with increased insulin resistance. A meta-analysis published last year showed that statin-induced cardiovascular risk reduction is more closely associated with Apo B levels than lowdensity lipoprotein cholesterol. Prospective studies may be needed to better describe the underlying relationship.

The Impact of Introducing Inpatient Diabetes Management Protocol on Glycemic Control in a Rural Secondary Care Hospital in the UAE

Background : Diabetes is one of the most common diagnoses encountered in hospitalized patients. In-hospital hyperglycemia is considered an independent marker of in-hospital poor outcome even in those without prior diagnosis of Diabetes. The purpose of this study is to evaluate the impact of introducing inpatient diabetes management protocol at Madinat Zayed hospital, a rural secondary care hospital in the Western region of Abu Dhabi, UAE. Methods : Adult, non-pregnant Patients admitted to the hospital with diabetes or a blood glucose >7.8 mmol/l (140 mg/dl) were included. The protocol guided physicians to start weight based insulin regimen for all patients with type 1diabetes, insulin dependent type 2 diabetes and all hyperglycemic patients regardless of history of diabetes. All patients who required insulin therapy were treated with basal and bolus insulin. A historical control was randomly selected for comparison. Results : 101 patients were identified in the intervention group and 69 patients in the historical control group. The mean glucose level in the treatment group was 9.2 ±3.1 mmol/l (165.6 ±55.8 mg/dl) and 12.4± 2.7 mmol/l (223±48.6 mg/dl) in the historical control group with a reduction of 26% in the mean glucose level (P 16.6 mmol/l or 300 mg/dl) was significantly lower in the interventional group (23% versus 66%) with p value <0.001). There was no significant difference in the rate of hypoglycemia, length of hospital stay or healthcare associated infection between the groups. Conclusions : Inpatient diabetes management protocol can significantly decrease episodes of severe hyperglycemia and decrease mean glucose level without increasing the incidence of hypoglycemia. Our study shows that evidence-based clinical pathways can impact the quality of care in rural secondary care hospitals.