Premixed insulin regimens in type 2 diabetes: pros

Because of the increasing prevalence of type 2 diabetes, the need to intensify treatment to manage hyperglycemia is expanding. Premixed insulin regimens were designed to maximize patient convenience and reduce the number of daily injections required by providing both rapid-acting and intermediate-acting components in one formulation. Although the basal bolus insulin regimen is considered by many as "the golden standard" in reaching goals of glycemic control, proper use of intensified insulin regimens, such as basal bolus or premixed, will result in similar HbA1c reduction, hypoglycemic events, and weight gain. At the same number of daily insulin injections (2 shots/day), the premixed regimen is associated with a significant 0.2 % HbA1c decrease, as compared with the basal plus regimen (one shot of long-acting plus one shot of short-acting insulin). The choice of insulin regimen should consider the preferences, and resources of the individual and the family for adapting treatment to the patient needs. At last, the process of insulin initiation and intensification in type 2 diabetes must be carried out in the context of patient safety, minimizing the risk of hypoglycemia, weight gain, and injection burden.

Mediterranean diet cools down the inflammatory milieu in type 2 diabetes: the MÉDITA randomized controlled trial

Mediterranean-style diets provide cardiovascular benefits and increase insulin sensitivity. There is little evidence that adherence to Mediterranean diet may influence the levels of the inflammatory milieu in type 2 diabetes. The aim of this study was to assess whether Mediterranean diet influences both C-reactive protein (CRP) and adiponectin in newly diagnosed type 2 diabetes, and whether adherence to Mediterranean diet affects their circulating levels. In a two-arm, single-center trial, 215 men and women with newly diagnosed type 2 diabetes were randomized to a Mediterranean diet (n = 108, 54 males and 54 females) or a low-fat diet (n = 107, 52 males and 55 females), with a total follow-up of 8.1 years. At baseline visit and at 1 year, body weight, HOMA index, CRP, and adiponectin and its fractions were assessed. Adherence to the diets was assessed by calculating the Mediterranean-diet score. At 1 year, CPR fell by 37 % and adiponectin rose by 43 % in the Mediterranean diet group, while remaining unchanged in the low-fat diet group. The pattern of adiponectin fractions (high and non-high molecular weight) showed a response similar to that of total adiponectin. Diabetic patients with the highest scores (6-9 points) of adherence to Mediterranean diet had lower circulating CRP level and higher circulating total adiponectin levels than the diabetic patients who scored <3 points on the scale (P = 0.001). The results of this randomized controlled trial demonstrate that Mediterranean diet cools down the inflammatory milieu of type 2 diabetes.

Revisitation of autoimmune hypophysitis: knowledge and uncertainties on pathophysiological and clinical aspects

PURPOSE

This publication reviews the accepted knowledges and the findings still discussed on several features of autoimmune hypophysitis, including the most recently described forms, such as IgG4 and cancer immunotherapy- related hypophysitis.

METHODS

The most characteristic findings and the pending controversies were derived from a literature review and previous personal experiences. A single paragraph focused on some atypical examples of the disease presenting under confounding pretences.

RESULTS

Headache, visual field alterations and impaired pituitary secretion are the most frequent clinical findings of the disease. Pituitary biopsy, still considered the gold diagnostic standard, does not always receive consent from the patients. The role of magnetic resonance imaging is limited, as this disease may generate images similar to those of other diseases. The role of antipituitary and antihypothalamus antibodies is still discussed owing to methodological difficulties and also because the findings on the true pituitary antigen(s) are still debated. However, the low sensitivity and specificity of immunofluorescence, one of the more widely employed methods to detect these antibodies, may be improved, considering a predetermined cut-off titre and a particular kind of immunostaining.

CONCLUSION

Autoimmune hypophysitis is a multifaceted disease, which may certainly be diagnosed by pituitary biopsy. However, the possible different clinical, laboratory and imaging features must be considered by the physician to avoid a misdiagnosis when examining a possibly affected patient. Therapeutic choice has to be made taking into account the clinical conditions and the degree of hypothalamic-pituitary involvement, but also considering that spontaneous remissions can occur.

Sexual dysfunction in women with cancer: a systematic review with meta-analysis of studies using the Female Sexual Function Index

Cancer may impair sexual function in women. We provide an overview of studies that address Female Sexual Dysfunction (FSD) in women with cancer with a meta-analysis of observational studies that used a validated diagnostic tool. Searches included MEDLINE, Scopus, and Google Scholar for studies published from January 2000 to 31 December 2014. Every included study had to involve at least 30 cancer patients, to investigate FSD based on the Female Sexual Function Index (FSFI), and to have been published in peer-review journals. Duplicate independent data extraction and quality assessment were performed. Data were pooled using a random effects model if statistical heterogeneity was present. The main outcomes were FSFI total score and FSD prevalence. FSFI is a 19-item self-report instrument for assessing key dimensions of female sexual function. A value less than 26.55 is consistent with FSD. Thirty-five studies met the inclusion criteria. Among these, 27 reported FSFI scores, and 16 FSD prevalence. Most studies (56 %) had low to moderate quality. The mean value of FSFI was lower than 20 at all cancer sites: 16.25 (pooled random effect, 95 % CI 14.91-17.58, I ² = 14.5 %) for colorectal cancer, 18.11 (95 % CI 14.45-21.77, I ² = 97.8 %) for gynecological cancer, and 19.58 (95 % CI 17.64-21.53, I ² = 90.9 %) for breast cancer. FSD prevalence was higher than 60 % at all cancer sites, with the highest value for gynecological cancer (78.44 %, 95 % CI 68.36-88.52 %, I ² = 94.1 %). Women with cancer showed low FSFI scores with a high prevalence of FSD.

Effects of Mediterranean diet on sexual function in people with newly diagnosed type 2 diabetes: The MÈDITA trial

AIMS

To assess the long-term effect of Mediterranean diet, as compared with low-fat diet, on sexual function in patients with newly diagnosed type 2 diabetes.

METHODS

In a randomized clinical trial, with a total follow-up of 8.1years, 215 men and women with newly diagnosed type 2 diabetes were assigned to Mediterranean diet (n=108) or a low-fat diet (n=107). The primary outcome measures were changes of erectile function (IIEF) in diabetic men and of female sexual function (FSFI) in diabetic women.

RESULTS

There was no difference in baseline sexual function in men (n=54 vs 52) or women (n=54 vs 55) randomized to Mediterranean diet or low-fat diet, respectively (P=0.287, P=0.815). Over the entire follow-up, the changes of the primary outcomes were significantly lower in the Mediterranean diet group compared with the low-fat group: IIEF and FSFI showed a significantly lesser decrease (1.22 and 1.18, respectively, P=0.024 and 0.019) with the Mediterranean diet. Baseline C-reactive protein levels predicted erectile dysfunction in men but not female sexual dysfunction in women.

CONCLUSIONS

Among persons with newly diagnosed type 2 diabetes, a Mediterranean diet reduced the deterioration of sexual function over time in both sexes.

Effect of a Mediterranean diet on endothelial progenitor cells and carotid intima-media thickness in type 2 diabetes: Follow-up of a randomized trial

Background We assessed the long-term effects of a Mediterranean diet on circulating levels of endothelial progenitor cells (EPCs) and the carotid intima-media thickness (CIMT) in patients with type 2 diabetes. Design This was a parallel, two-arm, single-centre trial. Methods Two hundred and fifteen men and women with newly diagnosed type 2 diabetes were randomized to a Mediterranean diet ( n = 108) or a low-fat diet ( n = 107). The primary outcome measures were changes in the EPC count and the CIMT of the common carotid artery after the treatment period defined as the end of trial (EOT). Results At the EOT, both the CD34⁺KDR⁺ and CD34⁺KDR⁺CD133⁺ counts had increased with the Mediterranean diet compared with the low-fat diet ( p < 0.05 for both). At the EOT evaluation, there was a significant ( p = 0.024) difference of -0.025 mm in the CIMT favouring the Mediterranean diet. Compared with the low-fat diet, the rate of regression in the CIMT was higher in the Mediterranean diet group (51 vs. 26%), whereas the rate of progression was lower (25 vs. 50%) ( p = 0.032 for both). Changes in the CIMT were inversely correlated with the changes in EPC levels (CD34⁺KDR⁺, r = -0.24, p = 0.020; CD34⁺KDR⁺CD133⁺, r = -0.28, p = 0.014). At the EOT, changes in levels of HbA1c, HOMA, total cholesterol, high-density lipoprotein cholesterol and systolic blood pressure were significantly greater with the Mediterranean diet than with the low-fat diet. Conclusion Compared with a low-fat diet, a long-term trial with Mediterranean diet was associated with an increase in circulating EPCs levels and prevention of the progression of subclinical atherosclerosis in patients with newly diagnosed type 2 diabetes.

Glucose, cholesterol, and blood pressure: is lower always better for type 2 diabetes?

Diabetes mellitus is a major risk factor for cardiovascular disease. However, the excess risk of death may vary substantially in subgroups of patients with type 2 diabetes, being highest in those younger than 55 years of age. A HbA1c value of 7.0 % or less is recommended for most patients with type 2 diabetes to reduce the incidence of microvascular disease, although individualized approaches that balance the benefits of glycemic control against the harms of hypoglycemia are encouraged. The selection of antidiabetic medications is of paramount importance, as the drug should not aggravate, and ideally even improve cardiovascular risk factors, with the hope to reduce cardiovascular morbidity and mortality. Patients with diabetes mellitus between 40 and 75 years of age with LDL-C between 70 and 189 mg/dL should be treated with a moderate-intensity statin. Implicit in this recommendation is the aim to reduce further LDL-C level in diabetes, in order to improve the cardiovascular outlook. The new PCSK9 inhibitors (evolocumab and arilocumab) are very promising, but, at present, their cost-effectiveness ratios exceed commonly accepted thresholds. For many people with diabetes mellitus and hypertension blood pressure should be <140/90 mmHg, although lower systolic targets (e.g., <130 mmHg) may be appropriate for certain individuals. With the likely exception of LDL-C, it is difficult to define a universal HbA1c and blood pressure target for all patients with type 2 diabetes mellitus. Ultimately, in the face of uncertainty in medicine, the final decision regarding a specific patient is best left to the clinician.

Serum but not salivary cortisol levels are influenced by daily glycemic oscillations in type 2 diabetes

Diurnal salivary and plasma cortisol variations are considered valid expression of circadian cortisol rhythmicity. The aim of this study was to assess the reliability of salivary and plasma cortisol and if glycemia and glycemic oscillations may interfere with their concentration. Forty-seven type 2 diabetic patients and 31 controls were studied for glycemic profile and diurnal salivary and plasma cortisol variations on two contemporary samples taken at 08:00 a.m.-11:00 p.m (Late Night, LN). Glucose variability was evaluated in diabetic patients by considering the standard deviation of blood glucose (BGSD) readings, by calculating the mean amplitude of glycemic excursions (MAGEs) and continuous overlapping net glycemic action (CONGA). A significant correlation between LN serum cortisol and morning fasting glycemia (r = 0.78; p = 0.004) was observed in T2DM group but not in the control group (r = 0.09; p = 0.74). While LN serum cortisol significantly correlated with CONGA in diabetic patients (r = 0.50; p < 0.001), LN salivary cortisol did not correlate with any indices of glucose variability. Moreover, a highly significant correlation between LN salivary and LN serum cortisol concentrations was found in control group (r = 0.80; p < 0.001) but not in diabetic patients (r = 0.07; p = 0.62). This study shows for the first time that LN salivary rather than plasma cortisol may give information on the dynamics of adrenal function of type 2 diabetic patients, as it is not significantly influenced by glycemic variations. However, our preliminary results need to be confirmed by further studies with more complete evaluations including many more patients.

Lifestyle modifications and erectile dysfunction: what can be expected?

Erectile dysfunction (ED) is a common medical disorder whose prevalence is increasing worldwide. Modifiable risk factors for ED include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption. Quite interestingly, all these metabolic conditions are strongly associated with a pro-inflammatory state that results in endothelial dysfunction by decreasing the availability of nitric oxide (NO), which is the driving force of the blood genital flow. Lifestyle and nutrition have been recognized as central factors influencing both vascular NO production, testosterone levels, and erectile function. Moreover, it has also been suggested that lifestyle habits that decrease low-grade clinical inflammation may have a role in the improvement of erectile function. In clinical trials, lifestyle modifications were effective in ameliorating ED or restoring absent ED in people with obesity or metabolic syndrome. Therefore, promotion of healthful lifestyles would yield great benefits in reducing the burden of sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, should be addressed.

Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: analysis of risk factors and review of modern trends

In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90% of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach.

Reducing glucose variability with continuous subcutaneous insulin infusion increases endothelial progenitor cells in type 1 diabetes: an observational study

Circulating endothelial progenitor cells (EPCs) are involved in the repairing mechanisms of vascular damage. Glucose variability may contribute to the development of chronic vascular complications of diabetes. We evaluated whether reducing glucose variability with continuous subcutaneous insulin infusion (CSII) would increase circulating levels of EPCs in type 1 diabetes. The study population consisted of 106 type 1 diabetic patients: 41 subjects considered eligible for CSII completed a 6-month follow-up. Sixty-five patients on intensified insulin therapy with multiple daily injections served as control group. Seven EPCs phenotypes were assessed by flow cytometry, and glucose variability by mean amplitude of glycemic excursions (MAGE). Both CD34+KDR+ [difference between groups 32.0, 95 % CI (19.6-44.4) number/10(6) cells, P < 0.001] and CD34+KDR+CD133+ [12.5 (5.5-19.5), P < 0.001)] cell count increased at endpoint in the CSII group, associated with a reduction of MAGE [-1.1 (-2.1 to -0.1), P = 0.026]. No changes occurred in the control group. In multivariate analyses, changes in MAGE were independently associated with changes in both CD34+KDR+ (P = 0.019) and CD34+KDR+CD133+ (P = 0.022) cell count. Reducing glucose variability with CSII in type 1 diabetes increases circulating EPCs levels, suggesting a novel mechanism of vascular damage by oscillating glucose.

Intensification of insulin therapy with basal-bolus or premixed insulin regimens in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

The purpose of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the effect of intensified insulin regimens (basal-bolus versus premixed) on glycemic control in patients with type 2 diabetes. We conducted an electronic search until March 2015 on many electronic databases including online registries of ongoing trials. All RCTs comparing basal-bolus with premixed insulin regimens, with a duration of >12 weeks and with >30 patients per arm, were included. Investigators extracted data on study characteristics, outcome measures, and methodological quality. We found thirteen RCTs lasting 16-60 weeks and involving 5255 patients assessed for the primary endpoint (reduction of HbA1c from baseline). Meta-analysis of change in HbA1c level between basal-bolus and premixed insulin regimens resulted in a small and non-significant difference of 0.09% (95% CI -0.03 to 0.21), with substantial heterogeneity between studies (I(2) = 74.4%). There was no statistically significant difference in the event rate for overall hypoglycemia (0.16 episode/patient/year, 95%CI -2.07 to 2.3), weight change (-0.21 kg, -0.164 to 0.185), and daily insulin dose (-0.54 U/day, -2.7 to 1.6). The likelihood for reaching the HbA1c <7% was 8% higher (3-13%, I(2) = 68.8%) with the basal-bolus as compared with the premixed regimen. There is no clinically relevant difference in the efficacy of basal-bolus versus premixed insulin regimens for HbA1c decrease in type 2 diabetic patients. These findings may be helpful to adapt treatment to individual patient needs.

Longitudinal behavior of autoimmune GH deficiency: from childhood to transition age

BACKGROUND

Some cases of apparently idiopathic GH deficiency (GHD) may be caused by pituitary autoimmunity.

OBJECTIVE

To study the variations in pituitary function and antipituitary antibodies (APA) from childhood to transition age in patients with apparently idiopathic GHD.

DESIGN

We conducted a longitudinal study.

PATIENTS AND METHODS

Pituitary function and APA detection by immunofluorescence were investigated in 24 childhood patients with isolated GHD before starting recombinant GH therapy and after the stopping of this therapy in transition age. Sera of patients positive for APA were processed by double immunofluorescence to identify their pituitary target.

RESULTS

At diagnosis, 16 out of 24 patients were APA positive targeting only somatotrophs (group 1), while the remaining eight were APA negative (group 2). When retested off therapy, 12 out of 16 patients in group 1 persisted being APA positive, while the remaining four became negative with recovery of pituitary function. All patients in group 2 persisted being APA negative but still showing GHD. Of the 12 patients persistently APA positive, eight with confirmed GHD showed APA still targeting somatotrophs, whereas four showed APA targeting only gonadotrophs associated with isolated hypogonadotropic hypogonadism (HH).

CONCLUSION

Patients with APA at middle but not at high titer in childhood may show a remission of autoimmune GHD in childhood after GH replacement therapy. As APA may shift their target in transition period, an early characterization of APA by double immunofluorescence is advisable in APA positive GHD patients showing delayed puberty, to allow an early diagnosis and an appropriate therapy, thus preventing the progression toward HH.

Particulate matter pollutants and risk of type 2 diabetes: a time for concern?

The World Health Organization estimates that worldwide in 2012 around 7 million deaths occurred prematurely due to air pollution, which is now the world's largest single environmental health risk. The higher premature mortality associated with air pollution is due to exposure to small particulate matter of 10 microns (PM10) or less in diameter. Exposure to air pollution has also been suggested as a contributing to diabetes incidence and progression. There are a number of possible biological pathways linking air pollutants to diabetes, including endothelial dysfunction, dysregulation of the visceral adipose tissue through inflammation, hepatic insulin resistance, elevated hemoglobin A1c level, elevated blood pressure, and alterations in autonomic tone, which may increase insulin resistance. The risk of future diabetes associated with exposure to 10 μg/m(3) increase of PM2.5 has been quantified in the range of 10 to 27%; the risk of diabetes mortality associated with PM2.5 appears to be quite lower, around 1% for each increment exposure of 10 μg/m(3) of both PM2.5 and PM10. Limitations of the current epidemiological evidence include the complex mixture of pollutants, the different design of the studies, the limited data available for non Western populations, and the lack of demonstration that improvement of air quality is associated with a decrease incidence of type 2 diabetes. Although the most sources of outdoor air pollution are well beyond the control of individuals, people should be informed that there are means to reduce the burden of air pollutants on diabetes risk, including avoidance of passive smoking, adoption of an healthy diet, and increasing leisure-time physical activity.

The Bitter Taste Receptor Agonist Quinine Reduces Calorie Intake and Increases the Postprandial Release of Cholecystokinin in Healthy Subjects

Background/Aims

Bitter taste receptors are expressed throughout the digestive tract. Data on animals have suggested these receptors are involved in the gut hormone release, but no data are available in humans. Our aim is to assess whether bitter agonists influence food intake and gut hormone release in healthy subjects.

Methods

Twenty healthy volunteers were enrolled in a double-blind cross-over study. On 2 different days, each subject randomly received an acid-resistant capsule containing either placebo or 18 mg of hydrochloride (HCl) quinine. After 60 minutes, all subjects were allowed to eat an ad libitum meal until satiated. Plasma samples were obtained during the experiment in order to evaluate cholecystokinin (CCK) and ghrelin levels. Each subject was screened to determine phenylthiocarbamide (PTC) tasting status.

Results

Calorie intake was significantly lower when subjects received HCl quinine than placebo (514 ± 248 vs 596 ± 286 kcal; P = 0.007). Significantly higher CCK ΔT₉₀ vs T₀ and ΔT₉₀ vs T₆₀ were found when subjects received HCl quinine than placebo (0.70 ± 0.69 vs 0.10 ± 0.86 ng/mL, P = 0.026; 0.92 ± 0.75 vs 0.50 ± 0.55 ng/mL, P = 0.033, respectively). PTC tasters ingested a significantly lower amount of calories when they received HCl quinine compared to placebo (526 ± 275 vs 659 ± 320 kcal; P = 0.005), whereas no significant differences were found for PTC non-tasters (499 ± 227 vs 519 ± 231 kcal; P = 0.525).

Conclusions

This study showed that intra-duodenal release of a bitter compound is able to significantly affect calorie intake and CCK release after a standardized meal. Our results suggest that bitter taste receptor signaling may have a crucial role in the control of food intake.

Setting the hemoglobin A1c target in type 2 diabetes: a priori, a posteriori, or neither?

Current guidelines specify hemoglobin A1c (HbA1c) targets around or less than 7.0 %, with more (<6.5 %) or less (<8 %) stringent goals being appropriate for selected patients. The difficulty in setting a precise HbA1c target depends, at least in part, on the physician perception of the relative importance of the parameters to be considered when determining the target. Using the "a priori" approach, physicians set the HbA1c target first, then prescribe the appropriate antidiabetic drug in order to cover the distance from the target, i.e., the difference between the current HbA1c value of the patient and the individualized HbA1c target: calculating the distance from the target may also be useful as a predictor of therapeutic success. In the "a posteriori" approach, physicians first prescribe, then decide if the achieved HbA1c is an appropriate level for that patient. Attainment of the HbA1c target ultimately depends on which target the physician set: both approaches ("a priori" and "a posteriori") may be useful for both physicians to make appropriate therapeutic decisions and patients to adhere to the best possible treatment. All this presumably will avoid unnecessary therapeutic inertia.

A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta-analyses

OBJECTIVES

To summarise the evidence about the efficacy of a Mediterranean diet on the management of type 2 diabetes and prediabetic states.

DESIGN

A systematic review of all meta-analyses and randomised controlled trials (RCTs) that compared the Mediterranean diet with a control diet on the treatment of type 2 diabetes and prediabetic states was conducted. Electronic searches were carried out up to January 2015. Trials were included for meta-analyses if they had a control group treated with another diet, if they were of sufficient duration (at least 6 months), and if they had at least 30 participants in each arm. A random-effect model was used to pool data.

PARTICIPANTS

Adults with or at risk for type 2 diabetes.

INTERVENTIONS

Dietary patterns that described themselves as using a 'Mediterranean' dietary pattern.

OUTCOME MEASURES

The outcomes were glycaemic control, cardiovascular risk factors and remission from the metabolic syndrome.

RESULTS

From 2824 studies, 8 meta-analyses and 5 RCTs were eligible. A 'de novo' meta-analysis of 3 long-term (>6 months) RCTs of the Mediterranean diet and glycaemic control of diabetes favoured the Mediterranean diet as compared with lower fat diets. Another 'de novo' meta-analysis of two long-term RCTs showed a 49% increased probability of remission from the metabolic syndrome. 5 meta-analyses showed a favourable effect of the Mediterranean diet, as compared with other diets, on body weight, total cholesterol and high-density lipoprotein cholesterol. 2 meta-analyses demonstrated that higher adherence to the Mediterranean diet reduced the risk of future diabetes by 19-23%.

CONCLUSIONS

The Mediterranean diet was associated with better glycaemic control and cardiovascular risk factors than control diets, including a lower fat diet, suggesting that it is suitable for the overall management of type 2 diabetes.