Association of folate and vitamin B12 deficiency with vasovagal syncope: a case-control study

Background

Studies demonstrated an association between vitamin B12 deficiency and vasovagal syncope (VVS) in pediatric patients. Moreover, some evidence suggested a pathophysiological role of plasma catecholamines elevation in VVS, which can arise from folate or vitamin B12 deficiency in terms of biochemical pathways.

Purpose

We aimed to evaluate the association of folate and vitamin B12 deficiency with VVS in adults.

Methods

In this case-control study, adult patients (18–70 years of age) with the diagnosis of VVS based on history and physical examination (2018 ESC guidelines) who underwent a head-up tilt test (HUTT) were included as the case group. The control group comprised age- and sex-matched individuals who participated in a population-based cohort study. The most important exclusion criteria were taking vitamin B12 or folate supplements, carbamazepine and phenobarbital, and a history of bariatric surgeries. Plasma levels of vitamin B12, folate, homocysteine, and thyroid-stimulating hormone (TSH), a possible confounder, were measured by Abbott Diagnostics chemiluminescence kits. We compared categorical variables and continuous variables by Chi-square and t-test, respectively. Logistic regression models were employed for adjusting for possible confounders, including age, sex, and TSH.

Results

From February 2020 to February 2021, we screened 157 patients with VVS, of whom 44 patients were included. After matching for age and sex, 44 healthy individuals without a history of syncope were examined as the control group. The mean age was 37.9 years in both groups, with 23 women (52.3%) in each group. Baseline characteristics were comparable across the study groups. There were no significant differences between serum levels of vitamin B12, folate, homocysteine, and TSH, as well as the prevalence of deficiency of folate and vitamin B12 between case and control groups (Table 1), even after adjusting for confounding variables. Serum levels of vitamin B12 were remarkably lower in patients with a lifetime syncopal episodes of ≥3 compared to patients with <3 lifetime attacks (Table 2, P=0.042). This correlation remained statistically significant after adjusting for possible confounders, including age, sex, and TSH by the logistic regression model (P=0.032).

Conclusions

In this study, we found that there is no significant difference between the prevalence of folate and vitamin B12 deficiency and serum levels of these vitamins in adult patients with VVS and healthy individuals; however, serum vitamin B12 was significantly lower in patients with recurrent VVS compared to patients with a lower burden of syncopal episodes. Future studies with larger sample sizes are recommended in the recurrent VVS subgroup. Therapeutic implications of these findings should be investigated in randomized-controlled trials.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Iran National Science Foundation Table 1Table 2

Atomoxetine in patients with recurrent vasovagal syncope for preventing vasovagal attacks and improvement of depression and anxiety: a randomized double-blind placebo-controlled clinical trial

Background

Studies showed that sibutramine or reboxetine reduced head-up tilt (HUT)-induced syncope and pre-syncope by 78%. Furthermore, in an open-label series of highly symptomatic patients with vasovagal syncope (VVS), sibutramine reduced frequency of vasovagal spells. In a recent proof of principle study, atomoxetine reduced number of HUT-induced syncopal episodes by about 50% compared to placebo.

Purpose

In this study, we aimed to evaluate the effectiveness of atomoxetine on preventing recurrence of syncopal and pre-syncopal episodes in patients with recurrent VVS after three months of follow-up. Moreover, we determined whether it can improve patients' anxiety and depression.

Methods

In this double-blind placebo-controlled randomized clinical trial, we screened 843 patients with VVS. Patients with 10 < age < 70 years who had ≥3 syncopal episodes in the past three months were included. Eventually, 46 patients were randomized to receive atomoxetine (20 mg daily for two weeks followed by 40 mg daily for two weeks, N=23) or placebo (for four weeks, N=23). The primary endpoint was the number of syncopal and pre-syncopal episodes at one and three months and was analyzed by the repeated measures analysis of variance. Secondary endpoints were decrements of depression and anxiety measured by the Hospital Anxiety and Depression Scale after three months and were analyzed by the Mann-Whitney U test.

Results

The primary endpoint was lower after three months in the atomoxetine arm (2.3±1.3 vs 4.3±1.7), with a significant between-subjects effect by atomoxetine versus placebo (P<0.001). This observation was primarily due to the reduction of pre-syncopal episodes rather than syncopal episodes (P<0.001 vs P=0.944, respectively, Table). In contrast with placebo, atomoxetine significantly improved anxiety (P=0.048 vs P=0.352) and depression (P=0.001 vs P=0.206) after three months; nonetheless, anxiety and depression scores of the patients were not different across the groups after three months (P>0.05, Figure).

Conclusions

In patients with VVS, atomoxetine significantly reduced the recurrence of a composite of syncopal and pre-syncopal episodes, and remarkably improved anxiety and depression at three months.

Anxiety and Depression of the Patients

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Tehran University of Medical Sciences

Global, regional, and national quality of care and burden of ischemic heart disease, 1990 to 2017: results from the GBD study 2017

Background

Sustainable development goal (SDG) target 3.4 aims at reducing premature death from non-communicable diseases including ischemic heart disease (IHD) by one-third by 2030.

Purpose

We aimed to compare the quality of care (QoC) of IHD between countries, genders, and age groups by employing its fatal and non-fatal estimates from the Global Burden of Diseases study 2017 to guide future policy makings for achieving SDGs.

Methods

We employed three epidemiologically meaningful combinations of fatal and non-fatal estimates of IHD: 1) Mortality to incidence ratio. 2) Disability-adjusted life-years (DALYs) to prevalence ratio. 3) Years of life lost to years lived with disability ratio. In the setting of IHD, the greater these measures, the poorer the QoC of IHD. We summarized these indices by principal component analysis and taking its first principal component as the quality of care index (QCI) scaled from 0 to 100 with the bigger score indicating better QoC. Based on the mean of the socio-demographic index (SDI) of countries between 1990 and 2017, countries were divided into high- and low-SDI groups and their QCIs were compared in different maps (Figure). We defined gender disparity ratio (GDR) as the ratio of female QCI to male QCI for evaluating gender inequity. For evaluation of inequities between age groups, we categorized countries into five groups based on the quintiles of SDI in the year of interest and plotted QCI against age for each group. Statistical analyses were done by R software v3.6.0.

Results

IHD was the fourth contributor to global DALYs in 1990 and climbed to the second rank in 2017. Although all-ages DALYs of IHD increased by 0.6% and was relatively stable, its age-standardized DALYs steadily decreased by 27.7% from 1990 to 2017 worldwide. The global QCI increased by 7.4% from 71.2 in 1990 to 76.4 in 2017. In 2017, the Netherlands, France, Israel, Italy, and Japan had the highest QCI in the world, respectively, and the United States with the QCI of 84.7 was in the third quintile of the high-SDI countries (Figure 1). Peru, Iraq, Thailand, Jamaica, and Saint Lucia had the top five QCIs amongst the low-SDI countries in 2017. The global GDR steadily increased from 1.04 in 1990 to 1.08 in 2017. Most countries of Western Europe, North America, and Australasia have a GDR between 1 and 1.2 in 1990 and 2017. In 1990, the plot of QCI against age demonstrated that QCI of elderlies is lower than other age groups in high, high-middle, and middle SDI countries; nevertheless, this pattern was not evident in low-middle and low SDI countries. Although this difference was disappeared in high SDI countries in 2017, it persisted in high-middle and middle SDI countries.

Conclusions

QoC of IHD has been improved in the last decades; however, it was not consistent between countries, genders, and age groups. These results have implications for monitoring and modifying public health policies toward SDGs and health for all worldwide.

Figure 1. Comparison of QCI of Countries

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Bill and Melinda Gates Foundation

Thyroid autoantibodies in women with and without thyroid disorders in an iodine-replete area

To compare the prevalence of positive autoantibodies in patients with thyroid disorders and healthy subjects in an iodine-replete area of the Islamic Republic of Iran, we studied 930 women in a clinic-based study: 698 patients (286 hypothyroid, 140 hyperthyroid, 272 with simple goitre) and 232 healthy women. Serum thyroxine (T4), triiodothyronine (T3), thyroid stimulating hormone, and anti-thyroid antibodies were measured. Positive autoantibodies were detected in 75.5% of patients with hypothyroidism, 73.6% of those with hyperthyroidism, 48.9% of those with simple goitre and 35.8% of the control group (P < 0.001). Autoimmunity may have a role in the genesis of common thyroid disorders.

Lovastatin effects on bone mineral density in postmenopausal women with type 2 diabetes mellitus

The objective of this study was to examine the effects of lovastatin on bone mineral density (BMD) of postmenopausal women with type 2 diabetes mellitus (DM). The study was an open-label clinical trial conducted from March 2002 to November 2003. Fifty-five postmenopausal women age 54-67 years with type 2 DM were allocated to lovastatin-treated and control (without lovastatin) groups based on low-density lipoprotein cholesterol (LDL-C) >130 or < or =130 mg/dl. The first group received lovastatin (20 mg daily titrated every 3 months to keep LDL-C less than 130 mg/dl) for a total of 18 months. The second group received their own diabetic regimen without statin. The BMD of the lumbar spine (L1 - L4), femoral neck, Wards triangle, trochanter and total hip was measured by dual-energy X-ray absorptiometry at baseline and after 18 months. In the 28 women treated with lovastatin, the BMD increased in lumbar spine (from 0.946 (0.122) to 0.978 (0.135) g/cm2, p<0.01) and Ward's triangle (from 0.685 (0.123) to 0.780 (0.186) g/cm2, p<0.01). In the 27 women not treated with statin, the changes in BMD at all bone sites were not statistically significant. BMD was higher in femoral neck (1.2% vs. -2.7%, p<0.05), Ward's triangle (13.9% vs. 3.3%, p<0.05), trochanter (-0.1% vs. -2.9%, p<0.05), total hip (1.2% vs. -1.4%, p<0.05) and lumbar spine (3.4% vs. 1.2%, p>0.05) at the end of the study. Treatment with lovastatin may prevent bone loss in postmenopausal women with type 2 DM.

Severe Cognitive Dysfunction in a Patient with Polyendocrinopathy

BACKGROUND

Polyglandular Autoimmune syndromes (PGAs) or polyendocrinopathies are immune mediated multiple endocrine gland failure sometimes accompanied by nonendocrine autoimmune disorders with varieties of presentations.

CASE REPORT

We describe a case of a middle aged man with severe cognitive dysfunction, brain atrophy, adrenal insufficiency, hypothyroidism, renal failure, thrombocytopenia, and positive antiphospholipid antibodies, with significant renal and cognitive improvement after hormone replacement.

CONCLUSIONS

PGAs may present with a broad spectrum of manifestations related to different organs like nervous,renal,cardiac and hematopoietic systems, sometimes challenging both to physician and the patient.

An open-label pilot study of the combination therapy of metformin and fluoxetine for weight reduction

BACKGROUND

Obesity is a very important risk factor for cardiovascular disease, type 2 diabetes mellitus, hypertension, osteoarthritis, fatty liver, metabolic syndrome and respiratory problems. Many weight-reducing drugs cannot be used in obese patients because of numerous complications. Fluoxetine, an antidepressant, and metformin, an antidiabetic drug, reduce weight as their side effect, but the potency of each drug is not always enough. Here, we studied the effects of combination therapy of them for weight reduction in obese women.

MATERIALS AND METHODS

This study was designed as an open, prospective, controlled clinical trial. Obese and overweight patients referred to obesity clinics were first put under a diet and behavior therapy education program before being invited to this study. The patients who accepted drug therapy were put in the case group. Those who did not accept drug therapy were put in the control group. Fluoxetine, 20 mg daily, and metformin, 500 mg three times daily, were prescribed to the participants. Weight and body mass index (BMI) changes within case and control groups were analyzed by paired t-tests and between groups by t-testing. Side effects were evaluated by interview and questionnaire.

SUBJECTS

Two hundred and three patients were referred to obesity clinics. Of these, 177 were female with 91 being volunteers for this study. Of this 91, 66 were in the case group and 25 in the control group.

RESULTS

In a 6.68-month period, a 7.89 kg decrease in weight (9.32%) and a 3.43 U decrease in BMI (10.14%) were observed in participants of the case group that was statistically significant (P<0.0001). The participants of the control group were followed for a mean period of 8.12 months. In this period, the participants of the control group showed a 0.48 kg decrease in weight (0.52%) and a 0.11 U decrease in BMI (0.42%). This was not significant. No serious side effects of the drugs were observed in the case group.

CONCLUSION

This open-label pilot study of combination therapy of metformin and fluoxetine gave encouraging weight reduction, and these results suggest the need for a randomized double-blind clinical trial comparing the two components and the combination to placebo.

Effects of iodized salt consumption on goiter prevalence in Isfahan: the possible role of goitrogens

OBJECTIVE

To evaluate the success of the Iranian Iodine Deficiency Disorders Committee in achieving World Health Organization (WHO) goals for reducing the prevalence of goiter in children by adding iodine to table salt beginning in 1989.

METHODS

In 1997, 8,000 male and female 6- to 18-year-old students were selected by cluster sampling in schools of Isfahan. Their thyroids were examined by four endocrinologists, and goiter was staged on the basis of the WHO classification. As an index of iodine consumption, urinary iodine concentrations were measured in 3,000 students.

RESULTS

Goiter was observed in 62% of the students. Of the overall study group, 94% had sufficient iodine consumption (urinary iodine concentration of 10.0 microg/dL or more). Of those students who had sufficient iodine intake, 63.2% had goiter. Of the 6% of students with iodine deficiency, 5% had mild, 0.9% had moderate, and only 0.1% had severe iodine deficiency. Goiter was absent in half of the students with severe iodine deficiency. The prevalence of goiter in 6- to 10-year-old children was 65%.

CONCLUSION

Despite sufficient iodine intake, the prevalence of goiter is still high in Isfahan City. Apparently, either this high prevalence has no relationship to iodine deficiency and possibly other unknown goitrogens are involved in the pathogenesis of goiter in Isfahan or the period of iodine intake has been too brief to affect thyroid sizes. Inasmuch as goiter prevalence is also high in the 6- to 10-year-old children, who have had iodized salt available for most of their lives, the second option is less probable. Another possibility is an increased rate of autoimmune thyroid diseases (because of iodine repletion) that resemble goiter during their early stages.

Prevalence and risk factors of diabetes mellitus in the Isfahan city population (aged 40 or over) in 1993

The objective of this study was to estimate the prevalence of diabetes among people aged 40 or more and to compare selected factors such as systolic and diastolic blood pressure, body mass index and lipid profile in diabetic and non-diabetic subjects. This is a cross-sectional study of subjects aged over 40 in Isfahan. Selection of diabetic subjects were based on multi-stage random sampling. Diabetes status was defined by the World Health Organization criteria and was based on fasting plasma glucose and oral glucose tolerance test results. Data on age, body mass index, blood pressure and lipid profile were obtained. Results show that a total of 3910 eligible subjects were examined and classified into different diabetes status. The overall age-standardized prevalence of diabetes was 7.54% (95% CI: 6.24-8.84%) in males and 7.97% (95% CI: 6.75-9.19%) in females with no difference. Similarly, the overall age standardized prevalence was 7.76% (95% CI: 6.87-8.65%). The prevalence of diabetes was shown to increased in the older age groups. Multiple logistic regression analysis showed that age, systolic blood pressure, hypertriglyceridemia, being overweight and also obesity were independently associated with diabetes. A large number of newly-diagnosed diabetic subjects were identified, which necessitates powerful screening programs. High levels of blood pressure, body mass index and lipid profile should draw attention to probable presence of diabetes.