1
|
Scherer D, Leite BF, Morimoto MA, Oliveira TL, Klemz BNC, Freitas RAMS, Pappiani C, Damasceno NRT, Pinheiro MDM. Nutritional effect on lipoproteins and their subfractions in patients with Psoriatic Arthritis: a 12-week randomized trial-the DIETA trial. Adv Rheumatol 2024; 64:47. [PMID: 38872193 DOI: 10.1186/s42358-024-00389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/30/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Patients with psoriatic arthritis have some lipid metabolism changes and higher risk of metabolic syndrome (MetS) and cardiovascular diseases, regardless of traditional risk factors, suggesting that chronic inflammation itself plays a central role concerning the atherosclerosis. However, there is a lack of information regarding atherogenic pattern and lipoprotein subfractions burden in these individuals. AIM To evaluate the HDL and LDL-cholesterol plasmatic levels and their subfractions after a nutritional intervention in patients with psoriatic arthritis (PsA). METHODS This was a randomized, placebo-controlled clinical trial of a 12-week nutritional intervention. PsA patients were randomly assigned to 1-Placebo: 1 g of soybean oil daily, no dietetic intervention; 2-Diet + Supplementation: an individualized diet, supplemented with 604 mg of omega-3 fatty acids, three times a day; and 3-Diet + Placebo: individualized diet + 1 g of soybean oil. The LDL subfractions were classified as non-atherogenic (NAth), atherogenic (Ath) or highly atherogenic (HAth), whereas the HDL subfractions were classified as small, medium, or large particles, according to the current recommendation based on lipoproteins electrophoresis. RESULTS A total of 91 patients were included in the study. About 62% of patients (n = 56) had an Ath or HAth profile and the main risk factors associated were male gender, longer skin disease duration and higher BMI. Thirty-two patients (35%) had a high-risk lipoprotein profile despite having LDL plasmatic levels below 100 mg/dL. The 12-week nutritional intervention did not alter the LDL subfractions. However, there were significant improvement of HDL subfractions. CONCLUSION Recognizing the pro-atherogenic subfractions LDL pattern could be a relevant strategy for identifying PsA patients with higher cardiovascular risk, regardless total LDL plasmatic levels and disease activity. In addition, a short-term nutritional intervention based on supervised and individualized diet added to omega-3 fatty acids changed positively the HDLLARGE subfractions, while LDLLARGE subfraction was improved in hypercholesterolemic individuals. CLINICALTRIALS gov identifier: NCT03142503 ( http://www. CLINICALTRIALS gov/ ).
Collapse
Affiliation(s)
- Daniele Scherer
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, UNIFESP/EPM), Borges Lagoa Street, 913, room 53, Vila Clementino, São Paulo/SP, 04038-034, Brazil
| | - Beatriz Figueiredo Leite
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, UNIFESP/EPM), Borges Lagoa Street, 913, room 53, Vila Clementino, São Paulo/SP, 04038-034, Brazil
| | - Melissa Aparecida Morimoto
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, UNIFESP/EPM), Borges Lagoa Street, 913, room 53, Vila Clementino, São Paulo/SP, 04038-034, Brazil
| | - Thauana Luiza Oliveira
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, UNIFESP/EPM), Borges Lagoa Street, 913, room 53, Vila Clementino, São Paulo/SP, 04038-034, Brazil
| | - Barbara N Carvalho Klemz
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, UNIFESP/EPM), Borges Lagoa Street, 913, room 53, Vila Clementino, São Paulo/SP, 04038-034, Brazil
| | | | - Caroline Pappiani
- Nutrition Department, School of Public Health, University of São Paulo, São Paulo, Brazil
| | | | - Marcelo de Medeiros Pinheiro
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, UNIFESP/EPM), Borges Lagoa Street, 913, room 53, Vila Clementino, São Paulo/SP, 04038-034, Brazil.
| |
Collapse
|
2
|
Lőrincz H, Csiha S, Ratku B, Somodi S, Sztanek F, Seres I, Paragh G, Harangi M. Gender-Dependent Associations between Serum Betatrophin Levels and Lipoprotein Subfractions in Diabetic and Nondiabetic Obese Patients. Int J Mol Sci 2023; 24:16504. [PMID: 38003693 PMCID: PMC10671489 DOI: 10.3390/ijms242216504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
Betatrophin, also known as angiopoietin-like protein 8 (ANGPTL8), mainly plays a role in lipid metabolism. To date, associations between betatrophin and lipoprotein subfractions are poorly investigated. For this study, 50 obese patients with type 2 diabetes (T2D) and 70 nondiabetic obese (NDO) subjects matched in gender, age, and body mass index (BMI) as well as 49 gender- and age-matched healthy, normal-weight controls were enrolled. Serum betatrophin levels were measured with ELISA, and lipoprotein subfractions were analyzed using Lipoprint gel electrophoresis. Betatrophin concentrations were found to be significantly higher in the T2D and NDO groups compared to the controls in all subjects and in females, but not in males. We found significant positive correlations between triglyceride, very low density lipoprotein (VLDL), large LDL (low density lipoprotein), small LDL, high density lipoprotein (HDL) -6-10 subfractions, and betatrophin, while negative correlations were detected between betatrophin and IDL, mean LDL size, and HDL-1-5. Proportion of small HDL was the best predictor of betatrophin in all subjects. Small LDL and large HDL subfractions were found to be the best predictors in females, while in males, VLDL was found to be the best predictor of betatrophin. Our results underline the significance of serum betatrophin measurement in the cardiovascular risk assessment of obese patients with and without T2D, but gender differences might be taken into consideration.
Collapse
Affiliation(s)
- Hajnalka Lőrincz
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Sára Csiha
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Doctoral School of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary
| | - Balázs Ratku
- Doctoral School of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary
| | - Sándor Somodi
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Ferenc Sztanek
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Ildikó Seres
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - György Paragh
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Mariann Harangi
- Division of Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, 4032 Debrecen, Hungary
| |
Collapse
|
3
|
Lőrincz H, Somodi S, Ratku B, Harangi M, Paragh G. Crucial Regulatory Role of Organokines in Relation to Metabolic Changes in Non-Diabetic Obesity. Metabolites 2023; 13:270. [PMID: 36837889 PMCID: PMC9967669 DOI: 10.3390/metabo13020270] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023] Open
Abstract
Obesity is characterized by an excessive accumulation of fat leading to a plethora of medical complications, including coronary artery disease, hypertension, type 2 diabetes mellitus or impaired glucose tolerance and dyslipidemia. Formerly, several physiological roles of organokines, including adipokines, hepatokines, myokines and gut hormones have been described in obesity, especially in the regulation of glucose and lipid metabolism, insulin sensitivity, oxidative stress, and low-grade inflammation. The canonical effect of these biologically active peptides and proteins may serve as an intermediate regulatory level that connects the central nervous system and the endocrine, autocrine, and paracrine actions of organs responsible for metabolic and inflammatory processes. Better understanding of the function of this delicately tuned network may provide an explanation for the wide range of obesity phenotypes with remarkable inter-individual differences regarding comorbidities and therapeutic responses. The aim of this review is to demonstrate the role of organokines in the lipid and glucose metabolism focusing on the obese non-diabetic subgroup. We also discuss the latest findings about sarcopenic obesity, which has recently become one of the most relevant metabolic disturbances in the aging population.
Collapse
Affiliation(s)
- Hajnalka Lőrincz
- Division of Metabolic Diseases, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
| | - Sándor Somodi
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, H-4032 Debrecen, Hungary
| | - Balázs Ratku
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, H-4032 Debrecen, Hungary
- Doctoral School of Health Sciences, University of Debrecen, H-4032 Debrecen, Hungary
| | - Mariann Harangi
- Division of Metabolic Diseases, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
- Institute of Health Studies, Faculty of Health Sciences, University of Debrecen, H-4032 Debrecen, Hungary
| | - György Paragh
- Division of Metabolic Diseases, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary
| |
Collapse
|
4
|
Zeinalian R, Mosharkesh E, Tahmassian AH, Kalhori A, Alizadeh M, Kheirouri S, Jabbari M. The association of a body shape index and visceral adiposity index with neurotrophic, hormonal and metabolic factors among apparently healthy women: a cross-sectional analysis. J Diabetes Metab Disord 2022; 21:209-218. [PMID: 35673422 PMCID: PMC9167328 DOI: 10.1007/s40200-021-00959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Purpose A body shape index (ABSI) and visceral; adiposity index (VAI) can reflect some cardio-metabolic risk factors in the population. To the best of our knowledge, there are no previous studies conducted on the assessment of the association between neurotrophic factors, Ghrelin and Obestatin with ABSI and VAI. We aimed to investigate this association among apparently healthy women. Methods Ninety apparently healthy women were recruited in the present study. All participants were in need of dietary intervention for weight loss and participated in the study before receiving any intervention. Dietary, anthropometric, physical activity, stress level and biochemical assessments, as well as blood pressure measurements were done for all participants. Results Women in the highest tertile of ABSI had significantly lower SBP compared to the lowest ABSI tertile. Women who were in the highest tertile of VAI had significantly lower serum Obestatin levels compared to the first and second tertiles in both crude and adjusted comparisons. Serum NGF, Obestatin and Ghrelin levels were significantly lower in the highest tertile of VAI compared to the lowest tertile in both crude and adjusted comparisons. HOMA-IR, serum insulin, LDL-C, TG and TC were significantly higher in the highest tertile of VAI compared to the lowest tertile. QUICKI in the highest tertiles were significantly lower than the first tertile in adjusted model. Conclusion This evidence can be useful for researchers in applying appropriate anthropometric indices regarding different populations with multifactorial metabolic complications. The current findings need approving by prospective population study and also clinical trial researches.
Collapse
Affiliation(s)
- Reihaneh Zeinalian
- Department of Nutrition in Community, Faculty of Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Erfan Mosharkesh
- Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran
| | - Amir Hossein Tahmassian
- Department of Clinical Nutrition, Faculty of Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Kalhori
- Nutrition department, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Mohammad Alizadeh
- Nutrition Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sorayya Kheirouri
- Department of Nutrition, Faculty of Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoumeh Jabbari
- Faculty of Nutrition Sciences and Food Industry, Department of Community Nutrition, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
5
|
Olaniyi KS, Atuma CL, Sabinari IW, Mahmud H, Saidi AO, Fafure AA, Olatunji LA. Acetate-mediated-obestatin modulation attenuates adipose-hepatic dysmetabolism in high fat diet-induced obese rat model. Endocrine 2022; 76:558-569. [PMID: 35229234 DOI: 10.1007/s12020-022-03023-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Approximately 650 million of world adult population is affected by obesity, which is characterized by adipose and hepatic metabolic dysfunction. Short chain fatty acids (SCFAs) have been linked to improved metabolic profile. However, the effect of SCFAs, particularly acetate on adipose-hepatic dysfunction is unclear. Therefore, the present study investigated the role of acetate on adipose-hepatic metabolic dysfunction and the possible involvement of obestatin in high fat diet-induced obese Wistar rats. METHODS Adult male Wistar rats (160-190 g) were allotted into groups (n = 6/group): Control, acetate-treated, obese and obese + acetate-treated groups received vehicle (distilled water), sodium acetate (200 mg/kg), 40% HFD and 40% HFD plus sodium acetate respectively. The administration lasted for 12 weeks. RESULTS HFD caused increased body weight gain and visceral adiposity, insulin resistance, hyperinsulinemia and increased pancreatic-β cell function and plasma/hepatic triglyceride and total cholesterol as well as decreased adipose triglyceride and total cholesterol, increased plasma, adipose, and hepatic malondialdehyde, TNF-α, uric acid, lactate production and plasma/adipose but not gamma-glutamyl transferase and decreased plasma, adipose, and hepatic nitric oxide, glucose-6-phosphate dehydrogenase (G6PD), glutathione (GSH) and obestatin concentration compared to the control group. Notwithstanding, treatment with acetate attenuated the alterations. CONCLUSIONS The results demonstrate that high fat diet-induced obesity is characterized with adipose and hepatic lipid dysmetabolism, which is associated with obestatin suppression. Findings also suggest that acetate provide protection against adipose and hepatic metabolic perturbations by restoring obestatin as well as G6PD/GSH-dependent antioxidant system.
Collapse
Affiliation(s)
- Kehinde S Olaniyi
- Cardio/Repro-metabolic and Microbiome Research Unit, Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria.
- HOPE Cardiometabolic Research Team & Department of Physiology, College of Health Sciences, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria.
| | - Chukwubueze L Atuma
- Cardio/Repro-metabolic and Microbiome Research Unit, Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria
| | - Isaiah W Sabinari
- HOPE Cardiometabolic Research Team & Department of Physiology, College of Health Sciences, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
| | - Hadiza Mahmud
- Cardio/Repro-metabolic and Microbiome Research Unit, Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria
| | - Azeezat O Saidi
- Cardio/Repro-metabolic and Microbiome Research Unit, Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria
| | - Adedamola A Fafure
- Neuroscience Unit, Department of Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria
| | - Lawrence A Olatunji
- HOPE Cardiometabolic Research Team & Department of Physiology, College of Health Sciences, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
| |
Collapse
|
6
|
García-González CL, Romero-Velarde E, Gurrola-Díaz CM, Sánchez-Muñoz MP, Soto-Luna GIC. [Metabolic profile and concentration of ghrelin and obestatin in children and adolescents with obesity]. REVISTA MEDICA DEL INSTITUTO MEXICANO DEL SEGURO SOCIAL 2022; 60:268-274. [PMID: 35759751 PMCID: PMC10399755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/14/2021] [Indexed: 06/15/2023]
Abstract
Background It has been pointed out that ghrelin and obestatin could have an impact on the genesis of obesity, since they estimulate and inhibit apetite and, therefore, food consumption. Objective To compare the metabolic profile, lipid profile and the concentrations of ghrelin and obestatin in children with normal weight or obesity. Material and methods Cross-sectional design with 97 normal weight or obese children, 6 to 18 years of age, who did not present systemic diseases. The serum concentrations of glucose, insulin, total cholesterol, triglycerides, high (HDL), low (LDL) and very low density (VLDL) lipoproteins, aspartate aminotransferase (AST), alanine aminotransferase (ALT), ghrelin and obestatin were determined. Descriptive statistics were performed. Student's t test was used to compare groups, and correlation coefficients of ghrelin and obestatin values with biochemical and anthropometric variables. A p value of ≤ 0.05 was significant. Results 55 children with normal weight and 42 with obesity were included; mean age was 10.7 years. Triglycerides, LDL, VLDL, ALT and insulin were higher, and HDL lower in obese children (p < 0.05). Ghrelin values were higher in normal weight children (p < 0.05), and there was no difference in obestatin values. Conclusions The lower concentration of ghrelin in obese children may indicate a negative feedback to regulate energy consumption. Children and adolescents with obesity show metabolic and lipid profile alterations that place them at risk of early development of cardiovascular risk factors.
Collapse
Affiliation(s)
- Claudia Lizett García-González
- Hospital Civil de Guadalajara “Dr. Juan I. Menchaca”, Unidad de Cirugía Bariátrica. Guadalajara, Jalisco, MéxicoHospital Civil de Guadalajara “Dr. Juan I. Menchaca”México
| | - Enrique Romero-Velarde
- Hospital Civil de Guadalajara “Dr. Juan I. Menchaca”, División de Pediatría. Guadalajara, Jalisco, MéxicoHospital Civil de Guadalajara “Dr. Juan I. Menchaca”México
| | - Carmen Magdalena Gurrola-Díaz
- Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Instituto de Investigación en Enfermedades Crónico Degenerativas. Guadalajara, Jalisco, MéxicoUniversidad de GuadalajaraMéxico
| | - Martha Patricia Sánchez-Muñoz
- Hospital Civil de Guadalajara “Dr. Juan I. Menchaca”, Unidad de Cirugía Bariátrica. Guadalajara, Jalisco, MéxicoHospital Civil de Guadalajara “Dr. Juan I. Menchaca”México
| | - Guadalupe Irma Catalina Soto-Luna
- Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Instituto de Investigación en Enfermedades Crónico Degenerativas. Guadalajara, Jalisco, MéxicoUniversidad de GuadalajaraMéxico
| |
Collapse
|
7
|
Somodi S, Seres I, Lőrincz H, Harangi M, Fülöp P, Paragh G. Plasminogen Activator Inhibitor-1 Level Correlates with Lipoprotein Subfractions in Obese Nondiabetic Subjects. Int J Endocrinol 2018; 2018:9596054. [PMID: 30002679 PMCID: PMC5998167 DOI: 10.1155/2018/9596054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 03/16/2018] [Accepted: 05/06/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The elevated level of plasminogen activator inhibitor-1 (PAI-1) in obese subjects with metabolic syndrome and in patients with type 2 diabetes is well established. The association of plasma PAI-1 and lipid metabolism is still unclear. The aim of the present study was to determine the relationship between plasma PAI-1 levels and the distribution of lipoprotein subfractions in obese and lean nondiabetic individuals. SUBJECTS AND METHODS We enrolled fifty nondiabetic obese patients and thirty-two healthy volunteers. Lipoprotein subfractions were detected with Lipoprint System. Plasma PAI-1, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and myeloperoxidase (MPO) concentrations were determined with enzyme-linked immunosorbent assay (ELISA), while serum paraoxonase-1 (PON1) activities were measured by spectrophotometry. RESULTS The TNF-α, IL-6, oxidized low-density lipoprotein (oxLDL), and MPO levels were found to be significantly higher, while PON1 paraoxonase and arylesterase activities were nonsignificantly lower in the obese patients. Strong significant negative correlations were found between plasma PAI-1 concentration and mean LDL size, as well as between PAI-1 concentrations and the levels of the large and intermediate high-density lipoprotein (HDL) subfractions. In multiple regression analysis, PAI-1 was predicted by waist circumference and intermediate HDL subfraction. CONCLUSION The significant correlations between PAI-1 levels and lipoprotein subfractions indicate the link between PAI-1 and lipid metabolism in obesity.
Collapse
Affiliation(s)
- Sándor Somodi
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Department of Clinical Pharmacology, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Ildikó Seres
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Hajnalka Lőrincz
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Mariann Harangi
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Fülöp
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - György Paragh
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| |
Collapse
|