Effects of Incretin-Based Treatment on the Diastolic (Dys)Function in Patients with Uncontrolled Type 2 Diabetes Mellitus: A Prospective Study with 1-Year Follow-Up

Left ventricular diastolic dysfunction (DD) is a subclinical cardiac abnormality in patients with type 2 diabetes mellitus (T2DM) that can progress to heart failure (HF) and increase cardiovascular risk. This prospective study evaluated the DD in T2DM patients without atherosclerotic cardiovascular disease after one year of incretin-based drugs added to standard treatment. Of the 138 enrolled patients (49.30% male, mean age 57.86 ± 8.82, mean T2DM history 5 years), 71 were started on dipeptidyl peptidase-4 inhibitor sitagliptin/saxagliptin, 21 on glucagon-like peptide-1 receptor agonist exenatide, and 46 formed the control group (metformin and sulphonylurea/acarbose). At baseline, 71 patients had grade 1 DD, another 12 had grade 2 and 3 DD, and 15 had indeterminate DD. After one year, DD was evidenced in 50 cases. Diastolic function improved in 9 cases, and 27 patients went from grade 1 to indeterminate DD. The active group benefited more, especially patients treated with exenatide; their metabolic and inflammation profiles also improved the most. An in-depth analysis of echocardiographic parameters and paraclinical results in the context of literature data justifies the conclusion that early assessment of diastolic function in T2DM patients is necessary and the benefits of affordable incretin-based treatment may extend to subclinical cardiovascular manifestations such as DD.

Glucagon-like Peptide-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus and Nonalcoholic Fatty Liver Disease-Current Background, Hopes, and Perspectives

Nonalcoholic fatty liver disease (NAFLD) represents the most common chronic liver disease worldwide, reaching one of the highest prevalences in patients with type 2 diabetes mellitus (T2DM). For now, no specific pharmacologic therapies are approved to prevent or treat NAFLD. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are currently evaluated as potential candidates for NAFLD treatment in patients with T2DM. Some representatives of this class of antihyperglycemic agents emerged as potentially beneficial in patients with NAFLD after several research studies suggested they reduce hepatic steatosis, ameliorate lesions of nonalcoholic steatohepatitis (NASH), or delay the progression of fibrosis in this population. The aim of this review is to summarize the body of evidence supporting the effectiveness of GLP-1RA therapy in the management of T2DM complicated with NAFLD, describing the studies that evaluated the effects of these glucose-lowering agents in fatty liver disease and fibrosis, their possible mechanistic justification, current evidence-based recommendations, and the next steps to be developed in the field of pharmacological innovation.

Ultrasound-Based Hepatic Elastography in Non-Alcoholic Fatty Liver Disease: Focus on Patients with Type 2 Diabetes

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease and is the hepatic expression of metabolic syndrome. The development of non-invasive methods for the diagnosis of hepatic steatosis and advanced fibrosis in high-risk patients, especially those with type 2 diabetes mellitus, is highly needed to replace the invasive method of liver biopsy. Elastographic methods can bring significant added value to screening and diagnostic procedures for NAFLD in patients with diabetes, thus contributing to improved NAFLD management. Pharmacological development and forthcoming therapeutic measures that address NAFLD should also be based on new, non-invasive, and reliable tools that assess NAFLD in at-risk patients and be able to properly guide treatment in individuals with both diabetes and NAFLD. This is the first review aiming to outline and discuss recent studies on ultrasound-based hepatic elastography, focusing on NAFLD assessment in patients with diabetes.

Association of Inflammatory and Metabolic Biomarkers with Mitral Annular Calcification in Type 2 Diabetes Patients

(1) Background: Type 2 diabetes mellitus (T2DM) contributes to cardiovascular disease and related mortality through the insidious effects of insulin resistance and chronic inflammation. Mitral annular calcification (MAC) is one such degenerative process promoted by T2DM. (2) Methods: This is a post hoc analysis of insulin resistance, inflammation, and hepatic steatosis markers in T2DM patients without atherosclerotic manifestations, but with incidental echocardiographic detection of mild MAC. (3) Results: 138 consenting patients were 49.3% men, 57.86 years old, with a history of T2DM of 6.16 years and HbA_1c 8.06%, of whom sixty had mild MAC (43.47%). The statistically significant differences between patients with/without MAC were higher HOMA C-peptide and C-peptide index for insulin resistance, higher TNF-α for inflammation, and lower estimated glomerular filtration rate. High-sensitive C-reactive protein (hsCRP) was significantly associated with insulin resistance and the strength of the relationship was higher in the MAC group. Predictive of MAC were TNF-α, HOMA C-peptide, and especially hepatic steatosis and hypertension. (4) Conclusions: MAC was more prevalent than reported in the literature. Insulin resistance and inflammation were predictive of MAC, but significant markers differ across studies. Widely available routine tests and echocardiographic assessments are useful in the early identification of mitral annular calcifications in diabetes patients.

New Insights into Non-Alcoholic Fatty Liver Disease and Coronary Artery Disease: The Liver-Heart Axis

Non-alcoholic fatty liver disease (NAFLD) represents the hepatic expression of the metabolic syndrome and is the most prevalent liver disease. NAFLD is associated with liver-related and extrahepatic morbi-mortality. Among extrahepatic complications, cardiovascular disease (CVD) is the primary cause of mortality in patients with NAFLD. The most frequent clinical expression of CVD is the coronary artery disease (CAD). Epidemiological data support a link between CAD and NAFLD, underlain by pathogenic factors, such as the exacerbation of insulin resistance, genetic phenotype, oxidative stress, atherogenic dyslipidemia, pro-inflammatory mediators, and gut microbiota. A thorough assessment of cardiovascular risk and identification of all forms of CVD, especially CAD, are needed in all patients with NAFLD regardless of their metabolic status. Therefore, this narrative review aims to examine the available data on CAD seen in patients with NAFLD, to outline the main directions undertaken by the CVD risk assessment and the multiple putative underlying mechanisms implicated in the relationship between CAD and NAFLD, and to raise awareness about this underestimated association between two major, frequent and severe diseases.

Association of Antihyperglycemic Therapy with Risk of Atrial Fibrillation and Stroke in Diabetic Patients

Type 2 diabetes mellitus (DM) is associated with an increased risk of cardiovascular disease (CVD). Atrial fibrillation (AF) and stroke are both forms of CVD that have major consequences in terms of disabilities and death among patients with diabetes; however, they are less present in the preoccupations of scientific researchers as a primary endpoint of clinical trials. Several publications have found DM to be associated with a higher risk for both AF and stroke; some of the main drugs used for glycemic control have been found to carry either increased, or decreased risks for AF or for stroke in DM patients. Given the risk for thromboembolic cerebrovascular events seen in AF patients, the question arises as to whether stroke and AF occurring with modified incidences in diabetic individuals under therapy with various classes of antihyperglycemic medications are interrelated and should be considered as a whole. At present, the medical literature lacks studies specifically designed to investigate a cause-effect relationship between the incidences of AF and stroke driven by different antidiabetic agents. In default of such proof, we reviewed the existing evidence correlating the major classes of glucose-controlling drugs with their associated risks for AF and stroke; however, supplementary proof is needed to explore a hypothetically causal relationship between these two, both of which display peculiar features in the setting of specific drug therapies for glycemic control.

The Inflammatory Marker HSCRP as a Predictor of Increased Insulin Resistance in Type 2 Diabetics without Atherosclerotic Manifestations

Low-grade inflammation is not only a specific feature in type 2 diabetes mellitus, but also a contributor to cardiovascular risk. Together with insulin resistance as the main characteristic of type 2 diabetes mellitus, subclinical imflammation maintains a vicious cycle of health-damaging processes. Our study assessed the inflammatory marker hsCRP in relation to the metabolic profiles of type 2 diabetic patients without clinical atherosclerotic manifestations. The results confirmed the hypothesized connection, which should be taken into consideration when designing and recommending diabetes care plans.

Distribution of Biochemical and Ultrasound Markers Values in the First Trimester Screening Program in Timisoara

The aim of our study was to analyze the distribution of biochemical markers (free-� hCG and PAPP-A) and nuchal translucency (NT) values and their deviation from expected median in our screening program. NT, free-� hCG and PAPP-A values were measured in first trimester sera of 1313 singleton pregnant women. The age (mean �standard deviation) of pregnant women at the time of screening was 28.94�4.95 years and the gestational age was 87.66�4.74 days. The value of NT (median�standard error of mean) was 0.87�0.01 multiple of median corrected (MoMc), of free-b hCG was 1.07�0.02 MoMc and of PAPP-A was 1.06�0.01 MoMc. Since the huge majority of pregnant women carried a healthy fetus it was assumed that the median value of measurements was equal to 1 MoMc and the deviation from median was equal to null. Our results showed that the greatest deviation from the expected median (-0.13 MoMc) was recorded for the NT measurement while the deviation for the free-� hCG and PAPP-A values was 0.07 respectively 0.06. In conclusion the main disturbing factor in calculating the aneuploidy risk was the measurement of NT. A systematic audit of laboratory and ultrasound measurement is necessary.

Is there a Need for Own Median Calculation in the Second Trimester Biochemical Markers Screening?

Screening of fetal aneuploidies in early pregnancy is a well-established method in the materno-fetal medicine. The aim of our study was to analyze if the medians recommended by the manufacturers are adequate to perform an accurate screening or if there is a need for own laboratory medians calculation in second trimester biochemical marker screening.Sera were collected between 14 wp and 22 wp from 3374 singleton pregnancies. We analyzed three second trimester biochemical markers (AFP, hCG and free Estriol) concentration in all pregnant women and in a subgroup of pregnant women in which gestational age was determined based on crown-rump length. Our results showed that for all biochemical markers the difference between the manufacturer and the own calculated median was lower than 10% excepting the hCG value in the group of pregnant women in which the gestational age was determined on basis of crown-rump-length. Our results show it is recommended to replace the values of the median for hCG measurement with the own laboratory calculated medians. This does not seem to be necessary in the case of AFP and free Estriol measurement.

Correlation of Glycemic Control Parameters in Non-Diabetic Persons with Cardiovascular Risk Scores - Results from a Cross- Sectional Study

To assess the correlation between main parameters of glycemic control and cardiovascular risk scores in non-diabetic persons. Risk scores were calculated by using the University of Edinburgh Risk Calculator. Risk scores are used to estimate the probability of cardiovascular disease in individuals who have not already developed major atherosclerotic disease. We correlated the results of these scores with the parameters that describes the glycaemic profile: preprandial glicaemia, HbA1c and 1 hour and 2 h post-prandial glycaemia, determined during Oral Glucose Tolerance Test (OGTT).Both fasting glycaemia and HbA1c significantly correlated with cardiovascular risk scores calculated for a period of 10 years. The recorded post-prandial glycaemic values at 1h and 2h after glucose loading didn�t significantly correlate with calculated scores, in the study group. The observed correlations underline the importance of glycaemia in the pathogenesis of cardiovascular diseases.

Communication as a Key Issue in the Care of Diabetes Mellitus

The physician-patient communication has an essential role in establishing and supporting the relationship between these two partners. Moreover, modern medicine highlights the patient-centered approach. Publications assessing the impact of an efficient physicianpatient communication on medical care results in diseases such as diabetes and hypertension have revealed a positive correlation between patient’s satisfaction about the communication with the physician and values of blood pressure, glycated hemoglobin and pain intensity. Interventions needed in both doctors and patients for developing communication abilities were paid special attention in order to achieve an appropriate improvement in their communicative interaction during periodical appointments. In the field of diabetes mellitus, the medical challenge is to improve patients’ knowledge about medical care; this aim is achieved only by therapeutic education, using high-quality communication techniques.

Pregnancy and recurrence rates in infertile patients operated for ovarian endometriosis

AIM

The study deals with the preoperative ultrasound diagnosis of ovarian endometriosis, postoperative ultrasound reassessment, laparoscopic surgical resolution of ovarian endometriosis, estimation of recurrence risk 12 months after surgery by ultrasound, reappearance of clinical symptoms (such as pain) or second-look laparoscopy, and pregnancy rate 2 years after surgery.

MATERIAL AND METHODS

140 patients with en- dometriosis and infertility admitted to the Iasi "Cuza-Vodă" Clinical Hospital of Obstetrics and Gynecology between the years 2009-2011 were included in the study. The patients were divided into 2 groups: group 1-59 cases that refused in vitro fertilization procedures, did not afford in vitro fertilization (IVF) or had minimal endometriosis and young ages and thus a possibility of delaying treatment, and group 2--62 cases which underwent IVF procedures immediately after surgery.

RESULTS

No significant differences in the chance of becoming pregnant were found between the two groups (χ2 = 2.06, p = 0.0891, 95% CI); in group 1, 11.86% pregnancies were obtained while in group 2 the pregnancy rate was 11.29%. Based on the nonparametric method of analysis of contingency tables we could estimate the odds of becoming pregnant in the study groups, obtaining an odds ratio (OR = 1.16, CI: 1.04-2.23, 95% CI). This result indicated that in group 1 the odds of becoming pregnant was not significantly higher, and the estimation was made for a confidence interval of 95%. The study had in view the assessment of pregnancies obtained in the study groups and the time interval (number of weeks) from the time of intervention until the occurrence of pregnancy. The Kaplan-Meier analysis enabled the assessment of the mean value and the median value of the number of weeks until becoming pregnant, and these values did not show significant differences (χ2 = 1.55, p = 0.212, 95% CI).

CONCLUSIONS

For endometriosis associated with infertility, hormonal suppression does not improve fertility, and therefore surgery followed by controlled ovarian hyperstimulation and intrauterine insemi- nation (IUI), provided the anatomy of the pelvis is preserved in early cases or in vitro fertilization in severe cases is preferred.

GnRH Antagonist IVF Protocol in PCOS

The aim of the present study was to compare the GnRH agonist long protocol with the flexible GnRH antagonist protocol in infertile PCOS women undergoing COS in terms of clinical pregnancy rate (CPR), with special reference to the incidence of OHSS. Materials and Methods. The study was conducted at the Hospital Obstetrics and Gynecology Cuza Vodă Iaşi and Fertility Reproductive Medical Center Omini Clinic Iaşi from June 1, 2010, to September 31, 2012. PCOS as defined by the Rotterdam 2003 consensus, i.e. presence of two of the following three features: presence of oligo- and/ or anovulation, clinical and/or biochemical signs of hyperandrogenism, polycystic ovaries and exclusion of other endocrinopathies. Results. No differences were observed in clinical pregnancy rate (CPR) in the agonist and antagonist protocols, respectively. Incidence of OHSS was lower in the antagonist compared with agonist group (4% versus 28%). Duration of stimulation (13,80 + 1,4 vs 11,85 + 2,4 p < 0,001) and total gonadotrophin required (2435,5 + 884,5 versus 2005, 5 + 545,5 IU p < 0.003) were also lower in the antagonist compared with agonist protocol. Conclusions. The current study suggests that the flexible GnRH antagonist protocol is associated with a similar ongoing pregnancy rate, lower incidence of OHSS grade II, lower gonadotrophin requirement and shorter duration of stimulation, compared with GnRH agonist. The GnRH antagonist might be the treatment choice for patients with PCOS undergoing IVF.