Homocysteine as a predictor and prognostic marker of atherosclerotic cardiovascular disease: a systematic review and meta-analysis

OBJECTIVE

Hyperhomocysteinemia is a well-known marker that is associated with an increased risk of atherosclerosis due to its toxic effect on endothelial cells. This, in turn, leads to cardiovascular injury and increases morbidity. Different studies have shown alterations in the levels of homocysteine with respect to multiple disease states. Whether this non-traditional marker is associated with cardiovascular injury or not is subject to conflicting results. The purpose of this systematic review is to evaluate the role of homocysteine in the formation of atherosclerotic cardiovascular disease in young adults and children.

MATERIALS AND METHODS

This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA). A search was done using specific keywords, including "homocysteine", "coronary artery disease", and "atherosclerosis", amongst several others, from the databases of PubMed, COCHRANE, and EBSCO. The data items included the diseased sample population along with the intervention used, or investigations carried out and the findings of the studies. Finally, 35 eligible studies were included.

RESULTS

Young patients with atherosclerotic cardiovascular disease were more likely to have elevated levels of homocysteine compared to elderly patients. Elevated levels of homocysteine have been observed with several genetic, nutritional deficiencies, and autoimmune states such as rheumatoid arthritis. On the other hand, decreased levels of homocysteine have been observed after certain intervention treatments, such as oral contraceptive pills, L-thyroxine, and even the adoption of certain diets. In the majority of studies, whenever homocysteine levels were higher than normal, this was reflected by an increased carotid intima-media thickness.

CONCLUSIONS

Homocysteine has a high correlation with atherosclerotic cardiovascular disease in young and overweight patients. In addition, the relationship of homocysteine with smoking, genetic polymorphism, specific hormonal and renal disorders, nutritional deficiencies (vitamin B12 and folic acid), and the use of specific medicines are among the other recurring findings. Given that many of these studies focus only on women, the relationship between homocysteine and atherosclerotic cardiovascular diseases in males is still unclear. Whether males are more prone to hyperhomocysteinemia needs to be assessed. Still, precise processes underlying variations in homocysteine in relation to all influencing factors are unclear and need further studies.

Decreased plasma myonectin levels in female patients with type 2 diabetes mellitus and its correlation with lipid and glycemic parameters

OBJECTIVE

Myonectin is a novel myokine which has significant implications on diabetes. This study aimed to investigate plasma myonectin levels in patients with type 2 diabetes mellitus (T2DM), and their correlation with body composition, lipid and glycemic parameters.

PATIENTS AND METHODS

The study participants included 40 diabetic and 33 non-diabetic healthy adult Saudi females matched for their BMI and age. Body composition was assessed by bioelectrical impedance analysis. Fasting blood samples were used to investigate plasma myonectin levels by ELISA, along with lipid and glycemic parameters.

RESULTS

We found that plasma myonectin levels were significantly decreased in diabetic patients (40.90±4.13 ng/ml, p<0.05) compared to non-diabetic participants (59.58±4.41). Diabetic patients with poor glycemic parameters had significantly decreased myonectin levels (35.18±4.03 ng/ml p<0.05) compared to non-diabetic healthy subjects. There was no significant difference in myonectin levels between diabetic patients with good glycemic control (55.76±8.09 ng/ml p>0.05) and non-diabetic healthy participants. Pearson correlation analysis indicated a significant negative correlation with fasting blood sugar (R=-0.366, p=0.001), HbA1c (R=-0.406, p<0.0001), triglycerides (R=-0.264, p=0.024), insulin (R=-0.278, p=0.017), and HOMA-IR (R=-0.409, p<0.0001).

CONCLUSIONS

Our findings highlight an important aspect of myonectin in the pathophysiology of T2DM. They also show that myonectin has the potential to be a useful biomarker and therapeutic target in T2DM.

Relationship of serum inducible and endothelial nitric oxide synthase with exercise in healthy adult males and patients with type 2 diabetes mellitus

OBJECTIVE

The importance of physical activities in the control of diabetes mellitus disorder is well known but its correlation with endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in diabetic patients needs to be assessed. The aim of the study is to examine inducible and endothelial nitric oxide synthase in healthy adult male patients with type 2 diabetes mellitus (T2DM) in relation to exercise.

PATIENTS AND METHODS

This is a cross-sectional study that has been performed in the Department of Physiology, King Saud University, Riyadh, Saudi Arabia. Subjects were divided into Group 1: control (n=79), and Group 2: T2DM (n=85). Each group was subdivided into three subcategories: sedentary, moderate activity, and active subjects. Serum nitric oxide (NO), iNOS, eNOS, high sensitivity C-reactive protein (hs-CRP), nitrates, and nitrites, were compared between different groups.

RESULTS

We observed significant differences in iNOS in diabetic patients compared to the control [29.1 (2.8) vs. 22.4 (1.4), p=0.050] with a significant decrease in eNOS when compared to the control group [79.5 (4.8) vs. 101.8 (5.7), p=0.003]. In the control group, eNOS showed significant differences (increase) between subgroups; sedentary, moderate, and active control subjects [77.4 (9.2), 114.7 (9.3), and 105.6 (9.5), p=0.026]. It also showed insignificant differences between subgroups in iNOS [23.4 (2.5), 24.2 (2.2), and 20.4 (2.4), p=0.520]. In addition, hsCRP showed a decrease with exercise but with no statistically significant difference between the groups [4.0 (0.5), 3.3 (0.3), and 2.9 (0.4), p=0.271]. In the diabetic patients' group, a significant difference (decrease) between subgroups in iNOS [43.5 (4.8), 20.8 (3.9), and 19.8 (4.6), p<0.001] and hsCRP [5.7 (0.5), 3.8 (0.4), and 3.6 (0.5), p=0.006] was detected. In addition, eNOS showed a decrease with exercise but with no statistically significant difference between groups [82.9 (7.8), 74.6 (7.9), and 81.7 (10.2), p=0.741].

CONCLUSIONS

Patients with T2DM have shown significantly low eNOS and high iNOS levels. Furthermore, regular exercise can significantly decrease iNOS in patients with T2DM. Therefore, the importance of exercise for diabetic patients has to be emphasized to prevent long-term complications related to diabetes mellitus.

Predictive value of arm circumference (AC) and arm muscle circumference (AMC) with cardiovascular risk in healthy and diabetic males

OBJECTIVE

The predictive value of body simplified indices needs to be evaluated properly for cardiovascular risk. This study aimed to assess and compare the relative relationship of arm circumference (AC), arm muscle circumference (AMC), body mass index (BMI), and waist-hip ratio (WHR) with Ultra-Sensitive C-Reactive Protein (US-CRP) in healthy male subjects and with type 2 diabetes mellitus (T2DM).

PATIENTS AND METHODS

We performed the study at the department of Physiology, College of Medicine & King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. It was a cross-sectional study with 93 healthy male subjects and 112 type 2 diabetic male patients who underwent body composition analysis by BIA and fasting venous blood samples were collected. US-CRP and body composition were determined for all subjects.

RESULTS

US-CRP is correlated positively with AC (0.378) and BMI (0.394) more than AMC (0.282) and WHR (0.253) which have lower correlation both in control and DM group. BCM has the lowest correlation with US-CRP (0.105). The association between US-CRP and AC, AMC, Body Fat Percent (BFP), and body fat mass (BFM) are statistically significant except for BFP in DM group. In control group, AC is noticed to be a better predictor for US-CRP, with area under curve (AUC) 64.2% (p=0.019), WHR with AUC 72.6% (p<0.001), and BMI with AUC 65.4% (p=0.011) but AMC is not a good predictor in control group with AUC 57.5% (p=0.213). In DM group, AC is noticed to be a better predictor for US-CRP, with AUC 71.5% (p<0.001), WHR with AUC 67.4% (p=0.004), BMI with AUC 70.9% (p=0.001), and AMC with AUC 65.2% (p=0.011).

CONCLUSIONS

Simplified muscle mass body indices like AC and AMC have significant predictive value for assessing cardiovascular risk in both healthy population and patients with T2DM. Therefore, AC could be used as a future predictor for cardiovascular disease in healthy and DM patients. Further investigations are needed to confirm its applicability.

Knowledge, attitude and practices of schoolteachers toward epilepsy and students with epilepsy

OBJECTIVE

This study aimed to estimate and evaluate teachers' knowledge, attitudes, and practices toward students with epilepsy and to determine the association between selected demographic factors.

SUBJECTS AND METHODS

This cross-sectional study was approved by the ethical committee of King Saud University, Riyadh, Saudi Arabia. The study was conducted at the department of physiology, King Saud University, from October 2020 until October 2021. The data was collected through anonymous online self-administered 44-item questionnaires. The sampling technique used was Snowball sampling from ten randomly selected schools in Riyadh.

RESULTS

The total sample size was 456 participants. The mean age of the respondents was 41.5 ± 8.52, and a male to female ratio of 1.4:1. The mean years of experience of the respondents is 16.14 ± 8.85. Almost all teachers knew that epilepsy is a neurological disorder (97.8%). However, females were more likely to know the cause of epilepsy (p=0.003). The majority of public-school teachers (80.2%) thought that epileptic students have normal intelligence (p=0.004). A considerable proportion of public-school teachers (82.8%) do not mind having a student with epilepsy in their classes (p=0.012). The vast majority of schoolteachers (95.4%) have not had any training on how to deal with an epileptic student during a seizure.

CONCLUSIONS

This study shows that schoolteachers have very good knowledge about epilepsy but poor practice towards it. Well-directed training programs are needed to qualify teachers in providing first aid to epileptic students during seizures.

Serum inducible and endothelial nitric oxide synthase in coronary artery disease patients with Type 2 Diabetes mellitus

OBJECTIVE

Coronary artery disease (CAD) is a well-known cause of morbidity and mortality in type 2 diabetes mellitus (T2DM). The role of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in T2DM patients in relation to CAD is not well understood. We examined serum inducible and endothelial nitric oxide synthase activities in patients with T2DM in relation to the presence of coronary artery disease.

PATIENTS AND METHODS

The present study was conducted in the Department of Physiology, King Saud University, Riyadh, Saudi Arabia. Subjects were grouped into control (Group A, n=87), T2DM without CAD (Group B, n=70), and T2DM patients with CAD (Group C, n=49). The selection of T2DM subjects was according to the American Diabetes Association (ADA). Serum iNOS, eNOS, hsCRP, nitrates and nitrites along with lipid profile were compared between different groups. Spearman's correlation and ROC analysis were also performed.

RESULTS

Serum eNOS levels were significantly high in the control group (112.38±47.16 U/ml) than in DM without CAD (81.43±49.91 U/ml) and DM with CAD (84.80±43.32 U/ml, p<.001). Serum iNOS levels were significantly higher in DM with CAD (42.87±28.83 U/ml) compared to both control (22.08±11.77 U/ml) and DM without CAD (16.24±12.30 U/ml, p<.001). Additionally, the differences in nitrite and NO were not significant between the three groups (34.06±24.75, 33.02±21.50, 38.83±24.34 uM, p = .384), and (56.51±36.78, 49.89±28.83 vs. 55.77±30.34 uM, p=.416) respectively. ROC curve analysis revealed a sensitivity and specificity of 73.5% and 68.6% of iNOS level at a cutoff point of 21.1 U/ml to predict CAD in T2DM patients. The ROC analysis for iNOS, eNOS, and hs-CRP were .782 (p<.001), .574 (p=.170), and .726 (p<.001), respectively.

CONCLUSIONS

Patients with T2DM have significantly higher levels of serum iNOS and lower levels of eNOS. However, iNOS levels were significantly higher in T2DM patients with concomitant CAD. Moreover, iNOS activity positively correlated with glycemic control and hsCRP. Therefore, iNOS could be an emerging future marker for CAD in T2DM patients and its antagonists could be useful in the management of these patients.

Reduced pulmonary functions and respiratory muscle strength in Type 2 diabetes mellitus and its association with glycemic control

OBJECTIVE

Diabetes mellitus is one of the main devastating causes of mortality and morbidity due to its detrimental complications. We aimed to evaluate the pulmonary functions and respiratory muscle strength in relationship with glycemic control and gender in type 2 Diabetes Mellitus (T2DM).

MATERIALS AND METHODS

This cross-sectional study was performed at King Saud University and King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from June 2107 to June 2019. We evaluated pulmonary functions, respiratory muscle strength, body composition and glycemic control in T2DM (n=110) and control group (n=119). Gender differences were also evaluated in T2DM.

RESULTS

Subjects with T2DM have significantly decreased forced vital capacity (FVC) (3.6±0.7 vs 3.3±0.9, p = 0.012), forced expiratory volume in first second (FEV1) (3.3±2.2 vs 2.7±0.6, p = 0.019), peak expiratory flow (PEF) (127.4±210.9 vs. 49.2±133.6, p = 0.003), FEF25-75 (3.6±1.3 vs. 3.1±1.1, p-value = 0.025), and maximum inspiratory pressure (MIP) (99.3±26.9 vs. 87.4±19.3, p=0.001). However, no significant difference between control and diabetes was found in maximum expiratory pressure (MEP) (132.5±34.9 vs 126.2±30.0, p = 0.202). Significant reduction in FVC (male=3.7±0.8 vs female = 3.0±0.7 p = 0.000), FEV1 (3.3±1.9 vs 2.6±0.5 p = 0.000), FEF25-75 (3.6 ± 1.3 vs 2.9 ± 1.0 with p-value = 0.000), MIP (96.9±23.1 vs 87.5±27.1 with p = 0.017), and MEP (134.0±32.2 vs. 120.1±33.5 with p = .011) were observed in females compared to males in T2DM subjects.

CONCLUSIONS

Decline in the pulmonary function and inspiratory muscle strength are associated with poor glycemic control in T2DM. Moreover, there are significant differences between male and female in lung parameters and inspiratory as well as expiratory muscles strength. The exact pathophysiological mechanism to explain this association requires further investigations.

Knowledge attitude and practices of university students to Vitamin D and Vitamin D supplements during times of low sun exposure and post lockdown

OBJECTIVE

Vitamin D deficiency is prevalent in Saudi Arabia. Inability to get sun exposure greatly influences Vitamin D levels. Getting enough Vitamin D during childhood and young adulthood can prevent possible future diseases. We aim to estimate the level of knowledge of Saudi University students about Vitamin D and Vitamin D supplements, to correlate it with their attitudes and practices to sun exposure and Vitamin D supplements and to compare between males and females.

MATERIALS AND METHODS

This is an epidemiological cross-sectional KAP study conducted at King Saud University in Riyadh. A stratified random sampling technique was used where students were randomly selected from 3 colleges and stratified to males and females. N= 767 students completed the online survey used to assess the knowledge, attitudes, and practices of the students.

RESULTS

We found that the level of knowledge of university students was moderate to low (mean equivalent to 40%) whereas females had better knowledge. Also, their practices are not sufficient to maintain healthy Vitamin D levels as only 8.2% stay in the sun for more than an hour during weekdays. Only 10.2% of students take regular Vitamin D supplements, where females are the more likely users. 99.1% of students stay indoors during work.

CONCLUSIONS

The knowledge about Vitamin D is low among university students but slightly higher in females and medical students. Almost all participants work indoors and most of them wear a mask whenever going out. Few students take regular Vitamin D supplements. Females agreed more they have Vitamin D deficiency and take supplements more than males.

Healthcare workers' knowledge and attitudes towards COVID-19 in Saudi Arabia

OBJECTIVE

The world is facing a devastating challenge in the COVID-19 (coronavirus disease 19) outbreak.  Healthcare workers (HCWs) provide the first line of defense against any disease outbreak. Thus, the present study is designed to assess HCWs' attitudes towards, knowledge of, and awareness of COVID-19.

MATERIALS AND METHODS

A cross-sectional observational study was conducted using an online survey on social media; the participants were 597 adults. The study was conducted from March to April 2020. The questionnaire was randomly administered on Arabic-language social media applications; the 26-item survey assessed knowledge levels, attitudes, and practices.

RESULTS

The analysis includes 597 complete responses from HCWs; participants included physicians, nurses, medical students, and pharmacists. Most participants were females aged 18 to 25 years. Most participants agreed that the virus can spread via direct and indirect contact. Most participants indicated that they wash their hands; avoid touching their eyes, nose, or mouth; and avoid crowded places to protect themselves against infection. Most indicated that a bat was the original source of the virus. Most participating HCWs indicated that the symptoms of COVID-19 include fever, cough, and shortness of breath. Most of the participants also indicated that there is no specific treatment for patients infected with COVID-19.

CONCLUSIONS

The findings of this work can support the design of effective measures to prevent and control COVID-19 infections during the pandemic. The results also highlight where improvement is needed to HCWs' knowledge of and attitudes towards COVID-19; the findings also highlight the best healthcare practices regarding this illness.

Relationship of asthma control test scores with pulmonary function tests, quality of life and adiposity in asthmatic children

OBJECTIVE

This study aimed at assessing asthma control test (ACT score), quality of life (QOL), and pulmonary functions in asthmatic children, and to see the correlations between ACT score, QOL, and pulmonary functions.

PATIENTS AND METHODS

This cross-sectional study was conducted at the departments of pediatrics and physiology, College of Medicine, King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia. A total of 109 (53 asthmatics and 56 controls) children (aged 6 to 13 years) of both genders were studied. All subjects underwent clinical evaluation, 36-Item Short Form Survey (SF-36) for QOL, Spirometry, and cognitive assessment through mini mental state examination (MMSE).

RESULTS

QOL showed significantly lower scores in asthmatic compared to non-asthmatic children. The higher social functioning [SF] (p=0.0012) and less role limitation due to physical health [RLPH] (non-asthmatic patients had had higher physical functioning [PF] (p=0.0001), less energy/fatigue [EF] (p=0.0008=0.0068). On the opposite side, no significant difference was found regarding role limitations due to emotional problems [RLEP] (p=0.0644) and Emotional well-being [EW] (p=0.0758) between the two groups. A significant positive correlation was seen between QOL items and ACT score in PF (r=.535, p<0.01), less RLPH (r=.593, p<0.01), less FE (r=.379, p<0.01), higher EW (r=.310, p<0.05), and higher SF (r=.495, p<0.01). No significant correlation was found between body mass index (BMI) and lung functions in children with asthma. Interestingly, a positive correlation was found in asthmatic children between BMI and MMSE scores (r=.298, p=0.030).

CONCLUSIONS

Our study concluded that QOL in asthmatic patients was significantly lower than healthy subjects in terms of patient's physical functioning and social life. However, the emotional aspects of QOL were not significantly affected in asthmatic children.

Relationship of serum novel adipokine chemerin levels with body composition, insulin resistance, dyslipidemia and diabesity in Saudi women

OBJECTIVE

Chemerin is believed to be a mediator for the adipose tissue inflammation that occurs in obesity. The present study compared chemerin levels between healthy and type 2 diabetic women matched for age and body composition. We also aimed to assess the relationship of serum chemerin levels with body composition, insulin resistance, dyslipidemia, and diabesity.

PATIENTS AND METHODS

This observational case-control study was conducted at the Departments of Physiology and Medicine, Saud University Riyadh, Saudi Arabia, from September 2013 to April 2014. A total of 100 subjects were recruited, including 51 adult diabetic females, and a control group consisting of 49 healthy females. Finally, 80 subjects were selected as per inclusion criteria. In the finally selected group, 45 of were type 2 diabetics and 35 were healthy subjects matched for age, body mass index (BMI) and body composition with age ranging between 30-65 years. Body composition analysis was estimated using bioelectrical impendence analyzer. Fasting venous blood samples were analyzed for glycemic markers, lipids, and chemerin. Insulin resistance and sensitivity indices were calculated by HOMA-IR and QUICKI using standard formulas.

RESULTS

The two groups were matched for age, BMI, body fat percentage (BF%), basal metabolic rate (BMR), truncal fat and waist hip ratio (WHR). Serum chemerin levels were higher in diabetics than controls (p=0.001). Systolic blood pressure, weight, fat mass and visceral fat were found to be significantly higher in diabetics when compared to controls. Fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), low-density lipoprotein (LDL), triglycerides (TG), insulin and HOMA-IR were significantly higher in diabetics compared to controls. While QUICKI and HDL were significantly lower in diabetics compared to controls. Chemerin levels correlated positively with age (r=0.300, p=0.007), waist hip ratio (r=0.250, p=0.026), weight (r=0.270, p=0.016), BMI (r=0.334, p=0.003), BF% (r=0.325, p=0.003), fat mass (r=0.250, p=0.026), visceral fat (r=0.356, p=0.001), truncal fat mass (r=0.245, p=0.030), truncal fat % (r=0.249, p=0.027), serum basal insulin levels (r=0.354, p=0.001) and HOMA IR (0.275, p=0.015), while it correlated inversely with QUICKI (r=-0.283*, p=0.012). In multiple linear regression analysis age (r=0.236, p=0.023), BF% (r=0.265, p=0.014) and basal insulin levels (r=0.265, p=0.014) were independent predictors of chemerin.

CONCLUSIONS

Serum chemerin levels are elevated in patients with type 2 DM compared to healthy control subjects and are positively correlated with adiposity and Insulin resistance in patients with type 2 DM.

Lipids and lipoprotein(a) concentrations in Pakistani patients with type 2 diabetes mellitus

AIM

The aim of the present study was to analyze serum lipoprotein(a) [Lp(a)] levels in Pakistani patients with type 2 diabetes mellitus (DM) and to find correlations between clinical characteristics and dyslipidaemias in these patients.

METHODS

Fasting blood samples were analyzed for Lp(a), total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), glucose and glycosylated haemoglobin (HbA1c) in 68 Pakistani patients with type 2 DM and 40 non-diabetic healthy control subjects.

RESULTS

Lp(a) levels were significantly raised in diabetics as compared to the control group. No correlation of Lp(a) was seen with age, body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP) and fasting glucose. There was a positive correlation of BMI to SBP and DBP. There was a significant positive correlation between Lp(a) and total cholesterol and LDL-c. No correlation of Lp(a) was observed with HDL-c, triglycerides and glycosylated haemoglobin (HbA1c).

CONCLUSION

The present study led us to conclude that serum Lp(a) levels are significantly raised in type 2 DM and have a positive correlation with serum total and LDL-c levels.

Lipoprotein (a) and glycaemic control in Pakistani subjects with diabetes mellitus

AIMS

To measure lipoprotein (Lp)(a) levels in people with diabetes mellitus (DM) and to see if there is any difference in Lp(a) levels between diabetics with good glycaemic control and those with poor glycaemic control.

METHODS

Sixty subjects with DM and thirty healthy individuals were studied. Fasting blood samples were analyzed for glucose, glycosylated hemoglobin, Serum total cholesterol, triglycerides, low density lipoproteins, high density lipoproteins and Lp(a).

RESULTS

A non significant difference was found between the lipid profile of normal individuals and subjects with DM with a good glycemic control. Lp(a) levels were significantly raised in diabetics. The difference in Lp(a) levels between well controlled and poorly controlled diabetics was non significant. In the control group 23.4% of individuals had high risk levels of Lp(a) while it was 46.7 % for people with DM.

CONCLUSION

Glycaemic control improves lipid profile positively in diabetics and may even lead to near normalization of lipoprotein concentrations. Diabetics have elevated levels of Lp(a) and the difference in Lp(a) levels between well controlled and poorly controlled diabeticsts is non-significant.