Effects of insulin therapy optimization with sensor augmented pumps on glycemic control and body composition in people with cystic fibrosis-related diabetes

Objective

Cystic fibrosis (CF)-related diabetes (CFRD) resulting from partial-to-complete insulin deficiency occurs in 40-50% of adults with CF. In people with CFRD, poor glycemic control leads to a catabolic state that may aggravate CF-induced nutritional impairment and loss of muscle mass. Sensor augmented pump (SAP) therapy may improve glycemic control as compared to multiple daily injection (MDI) therapy.

Research design and methods

This non-randomized clinical trial was aimed at evaluating the effects of insulin therapy optimization with SAP therapy, combined with a structured educational program, on glycemic control and body composition in individuals with insulin-requiring CFRD. Of 46 participants who were offered to switch from MDI to SAP therapy, 20 accepted and 26 continued the MDI therapy. Baseline demographic and clinical characteristics were balanced between groups using a propensity score-based overlap weighting procedure and weighted mixed-effects regression models were used to estimate changes in study outcomes.

Results

After 24 months changes in HbA1c were: -1.1% (-12.1 mmol/mol) (95% CI: -1.5; -0.8) and -0.1% (-1 mmol/mol) (95% CI: -0.5; 0.3) in the SAP and MDI therapy group, respectively, with a between-group difference of -1.0 (-10 mmol/mol) (-1.5; -0.5). SAP therapy was also associated with a decrease in mean glucose (between group difference: -32 mg/dL; 95% CI: -44; -20) and an increase in TIR (between group difference: 19.3%; 95% CI 13.9; 24.7) and in fat-free mass (between group difference: +5.5 Kg, 95% CI: 3.2; 7.8).

Conclusion

Therapy optimization with SAP led to a significant improvement in glycemic control, which was associated with an increase in fat-free mass.

Sex- and gender-differences in chronic long-term complications of type 1 and type 2 diabetes mellitus in Italy

AIMS

This review summarizes the contribution of Italian diabetologists devoted to a better understanding of the complex relationship linking sex/gender and long-term complications of type 1 (T1DM) and type 2 diabetes (T2DM) over the last fifteen years.

DATA SYNTHESIS

Microvascular and macrovascular complications of diabetes show sex- and gender-related differences, involving pathophysiological mechanisms, epidemiological features and clinical presentation, due to the interaction between biological and psychosocial factors. These differences greatly impact on the progression of diabetes and its long-term complications, especially in the cardiovascular, renal and liver districts.

CONCLUSION

A better knowledge of such sex- and gender-related characteristics is required for a more precise patient phenotypization, and for the choice of a personalized antihyperglycemic treatment. Despite such mounting evidence, current diabetes clinical guidelines do not as yet adequately consider sex/gender differences.

The use of real time continuous glucose monitoring or flash glucose monitoring in the management of diabetes: A consensus view of Italian diabetes experts using the Delphi method

Until recently, in Italy, the use of continuous glucose monitoring (CGM) systems has been limited, but is now rapidly increasing, including the so-called real-time CGM (rtCGM) and the intermittently viewed CGM (iCGM), also called Flash Glucose Monitoring (FGM). These technologies overcome many of the limitations of self-monitoring of blood glucose (SMBG) by fingerprick and allow to go beyond HbA1c to check glucose control in diabetes. However, standardized protocols for applying and interpreting rtCGM and FGM data are lacking. In this paper, we delineate a consensus amongst Italian diabetes physicians on the attributes of rtCGM and FGM technologies, and introduce a consistent approach for their use by Italian healthcare professionals. Most experts consider rtCGM and FGM as two separate categories of interstitial subcutaneous fluid (ISF) sensing technologies, and see them as superior to SMBG. Furthermore, there is strong consensus that rtCGM and FGM reduce hypoglycemia risk, increase the amount of time in the target glucose range and augment treatment satisfaction. However, there is still no agreement on the indication of the FGM for subjects who suffer asymptomatic hypoglycemia. Consensus on the role of education in initiating and optimizing use of rtCGM/FGM and about the interpretation of glucose trends was near unanimous, whereas no consensus was reached on the statement that there are no disadvantages/risks of rtCGM/FGM. Some issues remain in rtCGM/FGM management: a) risk of excessive correction of high or low glucose; b) risk of alert fatigue leading to alert silencing or rtCGM termination; c) allergic reaction to the adhesive keeping rtCGM or FGM sensors in place. The panel almost unanimously agreed that sensor accuracy depends on multiple variables, that alarm setting should be individualized, and that global glycemic profile represent an useful tool in interpreting glucose data. More clinical studies and a wider use of these devices will increase the efficacy and effectiveness of continuous glucose monitoring in Italy.

Bone involvement and mineral metabolism in Williams' syndrome

CONTEXT

The previous studies suggested a possible increased risk of hypercalcaemia and reduced bone mineral density (BMD) in Williams' syndrome (WS). However, an extensive study regarding bone metabolism has never been performed.

OBJECTIVE

To investigate bone health in young adults with WS.

DESIGN

Cross-sectional study.

SETTINGS

Endocrinology and Metabolic Diseases and Medical Genetic Units.

PATIENTS

29 WS young adults and 29 age- and sex-matched controls.

MAIN OUTCOME MEASURES

In all subjects, calcium, phosphorus, bone alkaline phosphatase (bALP), parathyroid hormone (PTH), 25-hydroxyvitamin D (25OHVitD), osteocalcin (OC), carboxyterminal cross-linking telopeptide of type I collagen (CTX), 24-h urinary calcium and phosphorus, femoral-neck (FN) and lumbar-spine (LS) BMD and vertebral fractures (VFx) were assessed. In 19 patients, serum fibroblast growth factor-23 (FGF23) levels were measured.

RESULTS

WS patients showed lower phosphorus (3.1 ± 0.7 vs 3.8 ± 0.5 mg/dL, p = 0.0001) and TmP/GFR (0.81 ± 0.32 vs 1.06 ± 0.25 mmol/L, p = 0.001), and an increased prevalence (p = 0.005) of hypophosphoremia (34.5 vs 3.4%) and reduced TmP/GFR (37.9 vs 3.4%). Moreover, bALP (26.3 ± 8.5 vs 35.0 ± 8.0 U/L), PTH (24.5 ± 12.6 vs 33.7 ± 10.8 pg/mL), OC (19.4 ± 5.3 vs 24.5 ± 8.7 ng/mL), and FN-BMD (- 0.51 ± 0.32 vs 0.36 ± 0.32) were significantly lower (p < 0.05), while CTX significantly higher (401.2 ± 169.3 vs 322.3 ± 122.4 pg/mL, p < 0.05). Serum and urinary calcium and 25OHVitD levels, LS-BMD and VFx prevalence were comparable. No cases of hypercalcemia and suppressed FGF23 were documented. Patients with low vs normal phosphorus and low vs normal TmP/GFR showed comparable FGF23 levels. FGF23 did not correlate with phosphorus and TmP/GFR values.

CONCLUSIONS

Adult WS patients have reduced TmP/GFR, inappropriately normal FGF23 levels and an uncoupled bone turnover with low femoral BMD.

Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

Clinical significance of epithelial-to-mesenchymal transition in laryngeal carcinoma: Its role in the different subsites

BACKGROUND

During epithelial-to-mesenchymal transition, cancer cells lose adhesion capacity gaining migratory properties. The role of the process on prognosis has been evaluated in 50 cases of laryngeal carcinoma.

METHODS

E-cadherin, N-cadherin, β-catenin, α-catenin, γ-catenin, caveolin-1, and vimentin immunohistochemical expression were evaluated using a double score based on staining intensity and cellular localization.

RESULTS

Cytoplasmic E-cadherin and α/γ catenin staining were associated with a decrease in survival, cytoplasmic β-catenin was associated with advanced stage, and N-cadherin and vimentin expression were associated with poor differentiation and tumor relapse. On the basis of cancer cells, epithelial or mesenchymal morphological and immunophenotypic similarity we identified 4 main subgroups correlated with a transition to a more undifferentiated phenotype, which have a different pattern of relapse and survival.

CONCLUSION

The negative prognostic role of epithelial-to-mesenchymal transition has been confirmed and a predictive role in glottic tumors has been suggested, leading us to propose epithelial-to-mesenchymal transition as an additional adverse feature in laryngeal carcinoma.

The utility of lumbar spine trabecular bone score and femoral neck bone mineral density for identifying asymptomatic vertebral fractures in well-compensated type 2 diabetic patients

The objective of the study was to evaluate the usefulness of trabecular bone score (TBS) and bone mineral density (BMD) for identifying vertebral fractures (VFx) in well-compensated type 2 diabetic (T2D) patients. TBS and femoral neck BMD below certain cutoffs may be useful for identifying VFx in well-compensated T2D patients.

INTRODUCTION

In T2D, the prevalence of VFx is increased, especially in poorly compensated and complicated diabetic patients. The possibility of predicting the fracture risk in T2D patients by measuring BMD and TBS, an indirect parameter of bone quality, is under debate. Therefore, the objective was to evaluate the usefulness of TBS and BMD for identifying VFx in well-compensated T2D patients.

METHODS

Ninety-nine T2D postmenopausal women in good metabolic control (glycosylated haemoglobin 6.8 ± 0.7 %) and 107 control subjects without T2D were evaluated. In all subjects, we evaluated the following: the BMD at the lumbar spine (LS) and the femoral neck (FN); the TBS by dual X-ray absorptiometry; and VFx by radiography. In T2D subjects, the presence of diabetic retinopathy, neuropathy, and nephropathy was evaluated.

RESULTS

T2D subjects had increased VFx prevalence (34.3 %) as compared to controls (18.7 %) (p = 0.01). T2D subjects presented higher BMD (LS -0.8 ± 1.44, FN -1.06 ± 1.08), as compared to controls (LS -1.39 ± 1.28, p = 0.002; FN -1.45 ± 0.91, p = 0.006, respectively). TBS was not different between diabetics and controls. In fractured T2D patients, LS-BMD, FN-BMD, and TBS were reduced (-1.2 ± 1.44; -1.44 ± 1.04; 1.072 ± 0.15) and the prevalence of retinopathy (15.4 %) was increased than in nonfractured T2D subjects (-0.59 ± 1.4, p = 0.035; -0.87 ± 1.05, p = 0.005; 1.159 ± 0.15, p = 0.006; 1.8 %, p = 0.04, respectively). The combination of TBS ≤1.130 and FN-BMD less than -1.0 had the best diagnostic accuracy for detecting T2D fractured patients (SP 73.8 %, SN 63.6 %, NPV 78.9 %, PPV 56.8 %).

CONCLUSIONS

TBS and FN-BMD below certain cutoffs may be useful for identifying VFx in well-compensated T2D patients.

Lipid abnormalities in patients with adrenal incidentalomas: role of subclinical hypercortisolism and impaired glucose metabolism

BACKGROUND

Subclinical hypercortisolism (SH) has been associated with metabolic complications such as type 2 diabetes mellitus, obesity and dyslipidemia. Scarce data are available regarding the lipid pattern abnormalities in SH, in relation to insulin resistance and impaired glucose metabolism (IGM). We aimed to evaluate the possible influence of SH on lipid pattern in relation to the presence/absence of impaired glucose metabolism.

METHODS

In 338 patients with adrenal incidentaloma, the presence of SH, hypertension, dyslipidemia and IGM was evaluated. According to the presence of SH and IGM the patients were divided into 4 groups (IGM+SH+, IGM+SH-, IGM-SH+, IGM-SH-). We recruited 98 subjects without IGM (IGM-) and 100 with IGM (IGM+) as control groups.

RESULTS

The prevalence of dyslipidemia was comparable among Group IGM+SH+, Group IGM+SH- and IGM+ controls (57.9, 58.4, 56%, P = NS). No difference in dyslipidemia prevalence among IGM- patients and IGM- controls was observed. The IGM+SH+ patients had a higher prevalence of dyslipidemia (57.9%) than IGM-SH+ ones (29.1%, P < 0.01). The IGM+SH- patients showed an increased prevalence of hypertension (76.6 vs 54.8%, P < 0.01) and dyslipidemia (58.4 vs 23.8%, P < 0.0001) as compared with IGM-SH- patients. Logistic regression analysis showed that only IGM was associated to dyslipidemia (OR 4.31, 95% CI 2.61-7.12, P = 0.0001) regardless of age, SH and gender.

CONCLUSIONS

In the absence of alterations of glucose metabolism the presence of a subtle cortisol excess has no effect on lipid pattern. IGM seems to influence the lipid metabolism regardless of the presence of SH.

Standard of care and promising new agents for triple negative metastatic breast cancer

Triple negative breast cancer (TNBC) is a cluster of heterogeneous diseases, all of them sharing the lack of expression of estrogen and progesterone receptors and HER2 protein. They are characterized by different biological, molecular and clinical features, including a poor prognosis despite the increased sensitivity to the current cytotoxic therapies. Several studies have identified important molecular features which enable further subdivision of this type of tumor. We are drawing from genomics, transcription and translation analysis at different levels, to improve our knowledge of the molecular alterations along the pathways which are activated during carcinogenesis and tumor progression. How this information should be used for the rational selection of therapy is an ongoing challenge and the subject of numerous research studies in progress. Currently, the vascular endothelial growth factor (VEGF), poly (ADP-ribose) polymerase (PARP), HSP90 and Aurora inhibitors are most used as targeting agents in metastatic setting clinical trials. In this paper we will review the current knowledge about the genetic subtypes of TNBC and their different responses to conventional therapeutic strategies, as well as to some new promising molecular target agents, aimed to achieve more tailored therapies.

Chronic kidney disease in type 2 diabetes: lessons from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study

The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study is an ongoing observational survey that examines the role of estimated glomerular filtration rate (eGFR) as an independent predictor of cardiovascular and renal outcomes in 15,773 Italian subjects with type 2 diabetes. The analysis of data collected at the enrollment visit provided a picture of chronic kidney disease (CKD) and its association with other complications, risk factors for cardiovascular disease (CVD) and treatments in a large contemporary cohort. Main results of this analysis were that (a) non-albuminuric renal impairment is the predominant clinical phenotype in patients, particularly women, with reduced eGFR; (b) concordance between CKD and diabetic retinopathy is low, with only a minority of patients with renal dysfunction presenting with any or advanced retinal lesions; (c) the non-albuminuric form is associated with a significant prevalence of CVD, especially at the level of the coronary vascular bed; (d) CKD is associated with hemoglobin (Hb) A1c variability more than with average HbA1c, whereas retinopathy and CVD are not; (e) in elderly individuals with moderate-to-severe eGFR reduction, use of agents which are not recommended, such as sulphonylureas and metformin, is still frequent; and (f) though complications are generally more prevalent in men (except non-albuminuric renal impairment) women show a less favorable CVD risk profile and achieve therapeutic targets to a lesser extent than men, despite the fact that treatment intensity is not lower. These data update existing information on the natural history of CKD in patients with type 2 diabetes.

Gender differences in cardiovascular disease risk factors, treatments and complications in patients with type 2 diabetes: the RIACE Italian multicentre study

OBJECTIVES

Poorer control of risk factors for cardiovascular disease (CVD) has been reported in diabetic women, as compared with diabetic men. It has been proposed that this finding is due to gender disparities in treatment intensity. We investigated this hypothesis in a large contemporary cohort of subjects with type 2 diabetes.

DESIGN

Observational, cross-sectional study.

SUBJECTS AND SETTING

Consecutive patients with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian multicentre study (n = 15 773), attending 19 hospital-based diabetes clinics in 2007-2008.

MAIN OUTCOME MEASURES

Traditional CVD risk factors, macro- and microvascular complications and current glucose-, lipid- and blood pressure (BP)-lowering treatments were assessed.

RESULTS

Although CVD was more prevalent in men, women showed a less favourable CVD risk profile and worse performance in achieving treatment targets for haemoglobin A1c , LDL, HDL and non-HDL cholesterol, systolic blood pressure (BP) and in particular obesity [body mass index (BMI) and waist circumference], but not for triglycerides and diastolic BP. However, women were more frequently receiving pharmacological treatment for hypertension and to a lesser extent hyperglycaemia and dyslipidaemia than men, and female gender remained an independent predictor of unmet therapeutic targets after adjustment for confounders such as treatments, BMI, duration of diabetes and, except for the systolic BP goal, age.

CONCLUSIONS

In women with type 2 diabetes from the RIACE cohort, a more adverse CVD risk profile and a higher likelihood of failing treatment targets, compared with men, were not associated with treatment differences. This suggests that factors other than gender disparities in treatment intensity are responsible.

Involvement of the Src-cortactin pathway in migration induced by IGF-1 and EGF in human breast cancer cells

Cancer cells need to become motile in order to escape the primary tumor and move to distant areas to form metastasis. They move as single cells or as a group, following different stimuli, including growth factors. Among them, insulin-like growth factor‑1 (IGF-1) and epidermal growth factor (EGF) and their receptors have been implicated in the development and progression of human breast carcinoma. In this report, we provide evidence that the tyrosine kinase Src is responsible for migration promoted by both IGF-1 and EGF in MDA-MB-231 and MCF7 cells, although with a different effect. Moreover, both IGF-1 and EGF induce reorganization of actin cytoskeleton in lamellipodia and membrane ruffles in a time- and Src-dependent manner. Furthermore, we analyzed the tyrosine phosphorylation status of the actin-binding protein cortactin upon growth factor stimulation, showing that even the activation of cortactin is time- and Src-dependent. In addition, immunofluorescence analysis with anti-paxillin antibody reveals that, after treatment with growth factors, tyrosine phosphorylated cortactin is localized on the plasma membrane in correspondence of focal adhesions. Collectively, our findings suggest a crucial role for Src-mediated activation of cortactin in cell migration, reorganization of actin cytoskeleton and phosphotyrosine cortactin localization to the focal adhesions in human breast cancer cell lines upon both IGF-1 and EGF stimulation.

Neuroendocrine tumors of the gallbladder: a case report and review of the literature

INTRODUCTION

Primary gallbladder neuroendocrine tumors are extremely rare, representing 0.2% of all neuroendocrine tumors. The diagnosis is incidental in most cases.

CASE PRESENTATION

We describe the case of a 57-year-old Caucasian man who underwent laparoscopic cholecystectomy for the evaluation of a gallbladder polyp that had been incidentally detected by ultasonography. Histologically, his lesion was composed of monomorphic cells that contained small round nuclei and that were organized in small nodular, trabecular, and acinar structures. His cells were positive for chromogranin A and synaptophysin, and a diagnosis of "typical" carcinoid of the gallbladder was made. His post-operative computerized axial tomography, 111In-pentetreotide scintigraphy, and hormone-specific marker results were negative. He is disease-free 45 months after surgical treatment.

CONCLUSIONS

Characteristic pathological findings of the gallbladder neuroendocrine tumors predict the prognosis. Whereas classical carcinoids of the gallbladder only rarely have a metastatic or invasive phenotype, the "atypical" variants are more aggressive and are associated with a poorer prognosis. Given the difficulty in distinguishing between benign and malignant lesions in the pre-surgical setting, we tend to consider each polypoid-like lesion of the gallbladder to be a high-risk lesion if it is larger than 1 cm and, as a result, to emphasize the need for cholecystectomy in all cases, relying on the pathological and immunohistochemistry analyses for the final diagnosis.

Relationship of thyroid function with body mass index and insulin-resistance in euthyroid obese subjects

BACKGROUND AND AIMS

It is recognized that overt thyroid dysfunction is associated with weight changes, but the influence of a minor alteration of thyroid function remains unclear. This study aimed to further investigate the relationship between obesity and thyroid function and to examine the possible role of insulin resistance on the hypothalamic-pituitary- thyroid axis.

METHODS AND RESULTS

Serum TSH and free T4 (FT4) levels, anthropometric and metabolic parameters were evaluated in 581 obese patients. In all patients TSH values progressively increased according to the severity of obesity and were positively correlated with body mass index (p=0.001, r=0.13) and waist circumference (p=0.02, r=0.11). Patients with insulin resistance showed higher TSH (1.8±1.0 vs 1.6±0.9 μUI/l; p=0.03) and lower FT4 levels (13.8±2.3 vs 15.0±2.2 pmol/l; p<0.001), as compared with patients with normal insulin sensitivity. Moreover, TSH was positively correlated with fasting insulin (p<0.001, r=0.152) and homeostasis model assessment of insulin resistance (HOMA-IR; p<0.001, r=0.148), and negatively correlated with Quantitative Insulin Sensitivity Check Index (QUICKI; p<0.001, r=-0.148); FT4 was negatively associated with fasting insulin (p<0.001, r=-0.287) and HOMA-IR (p<0.001, r=-0.295), and positively associated with QUICKI (p<0.001, r=0.295).

CONCLUSIONS

A relationship between thyroid function and overweight/ obesity condition seems to exist, mainly influenced by insulin resistance. Whether variations in TSH and/or thyroid hormones, within a normal range, can influence body weight or whether obesity per se can alter thyroid function cannot be stated so far. Further studies are needed to assess the link between thyroid function and body weight, by considering not only changes in thyroid hormones, but also body fat distribution, obesity duration and low-grade inflammation.

Transgingival lag-screw osteosynthesis of alveolar process fracture

Fracture of the alveolar process is a common injury. In some cases, traditional fixation may not be possible. The teeth needed for splinting or mandibulo-maxillary fixation may be missing. The fracture line and soft tissue injury may jeopardize the blood supply of the broken bone. In these extreme and rare situations, the best rehabilitation is needed to avoid the loss of hard and soft tissues, and a secondary reconstruction is required. Between January 2003 and December 2006, of 468 cranio-facial trauma patients studied, alveolar process fracture was reported in 28 (6%) cases. In six (1%) cases, the anatomy of the fracture lines, and the position and number of the remaining teeth made splinting and mandibulo-maxillary fixation impossible. Patients were treated with a transgingival lag-screw (TLS) osteosynthesis. All patients healed well with no complications. There was no bone or tooth loss in the surgical area, and broken fragments were not absorbed. The TLS technique is recommended for alveolar fractures when the blood supply is jeopardized and dental splinting or mandibulo-maxillary fixation is not possible. There is no need for flap reflection.

Metabolic parameters after BioEnterics Intragastric Balloon placement in obese patients

BACKGROUND

BioEnterics Intragastric Balloon (BIB) is a non-invasive, temporary and relatively safe procedure shown to be effective in the short-term treatment of obesity. Nowadays, BIB does not show convincing evidence of significant long-term weight loss, as compared with conventional management, and data regarding changes in metabolic and nutritional parameters are lacking.

METHODS

Forty obese patients [11 males, 29 females, age 36.65+/-10.6 yr, body mass index (BMI) 44.9+/-8.9 kg/m2] were evaluated before and 3 and 6 months after BIB placement by assessment of anthropometric and biochemical parameters as well as nutritional habits.

RESULTS

Patients showed a significant reduction in weight (-13.2+/-6.5%), BMI (-13.2%), waist circumference (-6.5 cm), and percentage of fat mass (-19.5%), but not fat-free mass. A significant improvement in insulin sensitivity but not in lipid pattern was seen. After BIB insertion, a significant reduction in caloric intake was paralleled by a redistribution of nutrients; in particular, increased lipid (12.8%) and decreased carbohydrate (-11.7%) percentage, but not absolute intake was observed.

CONCLUSION

These data show that BIB improves anthropometric parameters, with reduction of fat mass and preservation of fat-free mass, as well as insulin resistance, but not other metabolic features. The observed change in dietary habits, with a relative increase in lipid intake, once BIB is removed, might favor body weight regain and impact negatively on body weight composition and the other traits of the metabolic syndrome.

Reduced levels of adiponectin in sleep apnea syndrome

BACKGROUND

To investigate adiponectin levels in an obese population with and without obstructive sleep apnea syndrome (OSAS) and the acute modifications in adiponectin after a whole-night control by auto continuous positive air pressure (CPAP).

METHODS

46 obese subjects [22 males, 24 females, age 55.1+/-11.4 yr, body mass index (BMI) 38.9+/-6.5 kg/m2]: 11 OSAS with apnea/hypopnea index (AHI) from 10/h to 30/h, 14 OSAS with AHI >30/h and 21 without OSAS. Thirty-seven normal weight healthy subjects (20 males, 17 females, age 31.3+/-9.5 yr, BMI 21.5+/-1.8 kg/m2). Serum adiponectin levels, biochemical parameters, anthropometric measurements, pulmonary function, pulse-oxymetry and polisomnography.

RESULTS

The 3 groups of obese patients were comparable for gender, BMI, age, fat mass, fat free mass, hip and waist circumference, waist-to-hip ratio (WHR), systolic and diastolic blood pressure and glycometabolic parameters. Adiponectin levels were significantly reduced in obese patients compared to healthy normal weight subjects (8.1+/-3.5 vs 11.3+/-4.8 microg/ml p<0.001) In particular, adiponectin showed a trend to decrease according to the severity of OSAS. No differences in adiponectin levels were found after a whole-night control by Auto CPAP.

CONCLUSIONS

OSAS is associated with reduced levels of adiponectin independently of insulin-resistance and BMI. These low adiponectin levels may contribute to the increased mortality seen in such patients.

[Mininvasive treatment of strangulated paraesophageal hiatal hernia in emergency. Case report]

The Authors report a case of strangulated paraesophageal hiatal hernia occurred in a elderly woman and treated with laparoscopic approach. After review of the literature regard on this uncommon pathology that present about 5% of the hiatal hernias, they emphasize that the laparoscopic approach is appropriated even in emergency and comprises complete reduction of the stomach in abdomen, control of suitable position of the distal esophagus and cardias and making of effective hiatus-plasty.

Somatostatin receptor scintigraphy in metastatic breast cancer patients

The purpose of this study was to evaluate the efficacy of somatostatin receptor scintigraphy (SRS) in imaging metastases in patients with advanced breast cancer (BC), and assess the relationship between exposure to chemotherapy and hormonotherapy with overexpression of somatostatin receptor (SS-R) on the breast cancer cell surface. Twelve patients with metastatic breast cancer were intravenously (i.v.) injected with In-111 pentatreotide (120 MBq). Early and later images were obtained with a double-head gamma camera equipped with medium-energy collimators. SPECT was performed when needed. Imaging results were compared with computed tomography and bone scan. Uptake levels were evaluated by site-specific visual analysis. Metastatic breast cancer can be visualized with SRS. Global sensitivity of imaging was 80% and specificity for correct prediction of tumor absence was 100%. Sensitivity was significantly higher for bone and lung metastases. SRS results related to the expression of SS-R on metastatic cell surfaces did not evidence a relationship with the biologic characteristics of the primary BC and drug exposure. In our series, SRS quantitative analysis demonstrated that tumor metastases differ greatly in uptake levels. Fifteen percent of metastatic sites in our series showed strong uptake. Our data support the important specificity of SRS in identifying BC metastases, mostly in cases of bone and lung disease, as well as the role of SRS in predicting responsiveness of metastatic BC cells to treatment with somatostatin analogues (SS), when SS-Rs are overexpressed on cell surfaces. If our results are confirmed in large scale studies, SRS shows the potential to treat selected patients with overexpressed SS-R on their tumoral cells with designed target therapies with SS analogue.

[A fecal fistula in patient who underwent an abdomino-perineal resection with a continent magnetic prosthesis: observations on an obsolete technique]

The Authors consider a case of a patient who underwent an abdominal-perineal resection and presented a fecal fistula as a late complication of a magnetic prosthesis implant. After a revision of the literature, the Authors evaluate the reasons for abandoning this surgical technique of continence many years ago, underlying not only the complications observed during the experimentation but also the lack of those benefits for which this technique was proposed.

Growth hormone therapy in GH-deficient adults: continuous vs alternate-days treatment

In the present report, we have compared 12 months of rhGH therapy given daily (D) at the beginning and then on alternate days (A) to 20 subjects with severe adult-onset GH deficiency (GHD). Aim of the study was to establish whether the lower frequency injection regimen is as effective as the daily dose. Measurements included: IGF-I levels, body composition (BF%), lipid profile, insulin sensitivity by homeostasis model assessment (HOMA-IR) and quantitative insulin check index (QUICKI), as well as thyroid function. Evaluation on A therapy was performed both 12 and 36 hours after the last rhGH injection. The final rhGH dose was 0.3 +/- 0.1mg/day. During A, the dose used in D was doubled and given on alternate days. Recombinant hGH given during the A period induced changes in IGF-I levels, BF% and lipid profile comparable to daily treatment. HOMA-IR increased similarly after both regimens, though QUICKI did not significantly change. A significant reduction in serum FT4 levels occurred after both D and A therapy, so that an adjustment of L-T4 replacement dose in 5 of 20 patients was necessary. No differences were found in the various parameters after 12 and 36 hours post rhGH injection. In conclusion, rhGH therapy given on alternate days is clinically effective and may result in improved patient compliance. Monitoring glucose tolerance and thyroid function while on rhGH is essential.

Evaluation of insulin resistance in acromegalic patients before and after treatment with somatostatin analogues

Many studies have recently shown that simple computer-solved indices, based on fasting glucose and insulin levels, closely mirror the euglycemic clamp technique in studying insulin resistance or pancreatic insulin secretion. Few data are at present available on the evaluation of these novel indices in acromegalic patients, known to be GH-dependent insulin-resistant subjects, in particular during medical treatment with somatostatin analogues. Indeed, these drugs are able to inhibit not only GH and IGF-I levels, but also insulin and glucagon pancreatic secretion, with contrasting effects on glucose metabolism. In this study, insulin resistance was evaluated by the homeostasis model assessment (HOMA-IR) and insulin sensitivity by quantitative insulin check index (QUICKI) in 27 normoglycemic acromegalic patients, before and after 6-month therapy with somatostatin analogues (lanreotide-SR 30-60 mg every 7-28 days in 15 and octreotide-LAR 20-30 mg every 28 days in 12). Thirty-five age- and sex-matched healthy subjects and 17 surgically treated acromegalic patients (5 cured and 12 not cured) were studied as control groups. Before medical treatment, HOMA-IR was higher in acromegalic patients than in healthy controls (4 +/- 3 vs 1.7 +/- 0.7, p < 0.05), while QUICKI was lower (0.33 +/- 0.04 vs 0.36 +/- 0.03, p < 0.05). During medical therapy, HOMA-IR decreased to 2.4 +/- 1.6 (p < 0.05) and became similar to that recorded in both healthy subjects and surgically treated patients. However, fasting glucose was increased and fasting insulin was decreased. QUICKI did not significantly change from basal values. No differences were observed between patients who normalized or not hormonal levels. The effects of the 2 drugs, though higher glucose levels were seen in patients treated with octreotide-LAR. In conclusion, this study demonstrates that medical treatment is able to improve insulin resistance, even if only successful surgery is able to completely normalize both HOMA-IR and QUICKI.

[Gastric leiomyoma. Diagnostic and surgical problems]

The Authors report their three year experience with five patients suffering from gastric leiomyoma, each with different anatomical and clinical characteristics. The Authors have performed a research of the different diagnostics, clinical and therapeutic problems of these rare tumors that sometimes are asymptomatic in spite of the large size they reach, but more frequently they present with haemorrhagic symptoms which tend to point to other more frequent pathological conditions. Diagnosis can only be suspected, but cannot be reached without a histological examination, also if the classifications of these tumors have been argument of many changes, particularly by the light of the recent diagnostics possibilities offered by ultrastructural and immunohistochemical examination.

The role of high resolution pulsed and color Doppler ultrasound in the differential diagnosis of benign and malignant lymphadenopathy: results of multivariate analysis

BACKGROUND

The role of high resolution pulsed and color Doppler ultrasound in the differential diagnosis of benign and malignant lymphadenopathy is still unclear.

METHODS

High resolution pulsed and color Doppler ultrasound was used prospectively to investigate superficial lymph node enlargement in 71 patients undergoing surgical biopsy at the onset of lymphadenopathy. The aim of this study was to define, in multivariate analysis, the ultrasonographic parameters useful in the differential diagnosis of benign and malignant lymphadenopathy.

RESULTS

Volume, vascularization score, pulsatility index, and resistive index were significantly higher in the 53 malignant lymph nodes studied than in the 18 benign lymph nodes studied. The long-to-short axis ratio was significantly lower in neoplastic lymph nodes than in reactive lymph nodes. Stepwise logistic regression selected only the long-to-short axis ratio and the vascularization score as parameters that independently and significantly contributed to the differentiation of neoplastic from reactive lymph nodes. The diagnostic efficiency of the combined criteria evaluated by the area under the receiver operating characteristic curve was 0.8339.

CONCLUSIONS

High resolution pulsed and color Doppler ultrasound may provide information that is useful in making correct differential diagnoses of malignant or benign lymphadenopathy.

[Cervical neurinomas. (Considerations in five cases operated in Day-Surgery)]

We report the experiment of five cases of neurinoma observed in the division of Day Surgery of the Third Surgery Clinic, operating in the Hematology Institute of University of Studies "La Sapienza" in Rome. The problems of the diagnosis of this neoplasia has been faced, though it is commonly unknown or confused with other cervical especially lymphonodules tumefactions, from which it is almost impossible to distinguish before the operation. In the period of six years on 775 cases of cervical neoformations have been operated only 5 patients bearers of neuromi; two originated from vago cervicale (right and left), one from simpatico cervicale on the left, another from the left spinal accessory and the last from the secondary medial trunk of the left brachial plexus. All the patients have been operated in Day-Surgery anaesthesia, locoregional and with calming of spontaneous breath. One case, that originated from the secondary medial trunk of the left brachial plexus, has been operated with microsurgical technique. On all the cases has been done a subcapsular exeresis to preserve nervous continuity. No post operating complications have been recorded; all the patients discharged in the evening. The diagnosis about the nature is left to the final histological test on the operating piece. The surgical removal remains even today the elective treatment able to exclude probable relapses and potential malignant transformation of these tumours.

[Surgery in hemopathies: experience in ambulatory care and day surgery]

The one day surgery experience of our team developed in many years of a Special Surgical Service in Haematologic Diseases (within the III Surgical Department directed by Prof. G. Di Matteo of the University of Rome "La Sapienza") is herein reported. From 1989 to December 1995, 2,126 haematologic patients (1127 M, 999 F) were operated in day-surgery regimen. Five-hundred-fifty-six patients were over 65 years old. In most cases surgery was required for diagnostic purposes to ascertain the type, the stadiation or re-stadiation of the haematologic disease. Five-hundred-eighty-three operations were carried on the axillary region, 825 on the cervical region, 202 on the supraclavicular region and 163 on the groin region. In 729 patients a diagnosis of non-Hodgkin lymphoma was obtained, while 308 patients resulted affected by Hodgkin lymphoma. In 124 patients metastases from solid tumors (pulmonary, mammary, thyroidal adenocarcinoma, etc.) were found at histologic examination of the specimen. Furthermore, other types of pathologies such as lateral neck cysts, salivary gland adenomas, schwannomas, groin and crural hernias were identified. Outpatient surgery and one day surgery represent a valid procedure for the early diagnosis of haemotologic diseases also taking into account the low cost and the minimal invasiveness.

[Dysplasia epiphysealis hemimelica]

The Authors present 9 patients affected by Dysplasia Epiphysealis Hemimelica with a mean follow-up of 11 years (range 5 years-21 years). The Authors confirm the benignity of the disease and report the variability of the clinical evolution of this rare type of osteochondrodysplasia. Besides cases with spontaneous evolution characterized by no clinical evidence of the disease, there are cases that require surgical removal of the osteochondromas and, sometimes, corrective interventions because of axial deviations and/or limb discrepancy.

[Ultrasonography in the diagnosis and follow-up of hip pain in children]

Fifty-seven subjects aged 1.5-14 years (mean: 6.5; standard deviation: 3.3) complaining of hip pain and/or limp underwent clinical, US and radiologic examinations on admission and after variable time intervals. Twenty-eight of them were found to be affected with transient synovitis, 2 with rheumatic fever, 2 with slipped capital femoral epiphysis and 5 with Legg-Calvè-Perthes disease. The extant 20 subjects with normal US and X-ray findings were diagnosed as having irritable hip without effusion. No false-negative results were obtained from US (100% sensitivity), whereas X-ray provided false-negative results in 28 of 37 patients with hip disorders other than irritable hip without effusion (24.3% sensitivity). No significant difference in the extent of hip joint effusion was found at US between the various groups. In the transient synovitis group, joint effusion was apparent on X-ray image in 3 of 28 patients, in whom the effusion was significantly more severe than in the extant 25 patients. Capsular joint effusion resolved more rapidly in transient synovitis than in Legg-Calvè-Perthes disease. The patients with both rheumatic fever and transient synovitis exhibited the most rapid onset of symptoms. On the basis of our results, we suggest that each patient complaining of hip pain and/or limp should undergo US first and that X-rays be performed second, in selected cases only.

Influence of meal ingestion on insulin profiles following intraperitoneal delivery

This study evaluated the effect of meal ingestion on intraperitoneal insulin absorption in type I diabetic patients with an implanted pump for long-term intraperitoneal insulin delivery. On four separate occasions, patients (n = 7) were administered 15 IU insulin as a 20-minute square-wave infusion using their implanted device; hypoglycemia was prevented by intravenous infusion of 10% dextrose at a variable rate. Two studies were performed during fasting conditions (n = 2 fasting tests) and two studies after the administration of an 800-kcal standard meal (n = 2 postprandial tests). An insulin peak of 630 +/- 545.4 pmol/L (mean +/- SD) in fasting tests and 696 +/- 420.5 pmol/L in postprandial tests was reached in the peripheral circulation after 45 +/- 11.7 and 45 +/- 14.7 minutes, respectively, with no significant difference between the two experimental conditions. Areas under the insulin curves were not significantly different in fasting and postprandial tests (51,500 +/- 34,278 v 50,916 +/- 20,558 pmol/L.min-1, respectively; NS). In type I diabetic patients receiving long-term intraperitoneal insulin therapy, the increase in splanchnic blood flow following ingestion of a standard meal does not accelerate the appearance of insulin in the peripheral circulation.

Slipped capital femoral epiphysis: ultrasonographic findings

Slipped capital femoral epiphysis (SCFE) is an uncommon skeletal disorder of adolescence often overlooked because of its nonspecific clinical presentation. Anteroposterior radiography may fail to demonstrate a minimal slip even when clinical examination raises suspicion of the disease. On the other hand, prompt diagnosis is essential to obtain better therapeutic results. In our patient population joint effusion, which often accompanies SCFE, was readily recognized and quantified by ultrasonography (US). US also permitted recognition of the initial SCFE and assessment of the degree of slip by measuring the height of the physeal step. As to metaphyseal remodeling, plain radiography seems to be more informative than US; however, US has a role in the follow-up of SCFE because of the risk of slippage in the contralateral hip. This work suggests that US is useful as a primary imaging tool in the evaluation of subjects with limp or hip or knee pain to rule out SCFE.

Normal tissue plasminogen activator and plasminogen activator inhibitor activity in plasma from patients with type 1 diabetes mellitus

The fibrinolytic system was investigated in 38 patients (21 males and 17 females) affected by type 1 diabetes mellitus (18 free from complications, 10 with retinopathy, and 10 with autonomic neuropathy) and in 8 healthy controls. Two separate fibrinolysis-stimulating tests were done: standardized venous occlusion and 1-desamino-8-D-arginine vasopressin infusion. Plasma tissue plasminogen activator antigen and activity and plasma plasminogen activator inhibitor activity were measured. All the patients were in good metabolic control (mean HbA1c 7.4%, range 6.1-8.0%). No significant differences were observed either between the diabetic patients and the control subjects, nor among the subgroups of diabetic patients. The fibrinolytic system is probably not involved in type 1 diabetes mellitus.

Effect of soya and cellulose fibers on postprandial glycemic response in type II diabetic patients

OBJECTIVE

We studied the effect on serum glucose and insulin of a preprandial ingestion of 7 g of soya fibers or of an equal amount of purified cellulose on eight non-insulin-dependent (type II) diabetic patients.

RESEARCH DESIGN AND METHODS

Four tests were conducted in each patient in random order. In the first study, soya or cellulose was ingested before a standard breakfast, and postprandial glucose and insulin curves were determined. In the second study, intestinal absorption was investigated by means of a standard D-xylose absorption excretion test after the ingestion of soya or cellulose.

RESULTS

Insulin profiles did not differ between the two treatments. The glycemic profiles after soya ingestion were lower than those after cellulose ingestion. The area under the glucose curve and glucose peaks were significantly higher after cellulose ingestion (area under the curve 20.2 +/- 3.88 vs. 15.57 +/- 4.42 mM x min, P = .05; glucose peaks 4.97 +/- 0.76 vs. 3.77 +/- 0.77 mM, P less than 0.02). The xylose tests were in the normal range, indicating that there was no interference with exose absorption, and no statistical difference was found between cellulose and soya treatment.

CONCLUSIONS

It is concluded that soya fiber compared with purified cellulose has a favorable effect on the rise of postprandial glycemia in type II diabetic patients; moreover, the use of soya fibers did not carry any untoward side effect.

[Pseudoachondrodysplasia (pseudoachondroplastic spondyloepiphyseal dysplasia). Description of 2 non-familial cases]

Two non familial cases of pseudoachondroplasia are reported. The patients, observed at 4 years and 6 months and 5 years respectively, show short-limb dwarfism with disproportionated long trunk and with normal head and face. Flattening of vertebral bodies with biconvex deformity and short tubular bones with irregular epiphyses and metaphyses are the major radiographic features. In these patients to state the type of genetic transmission is very arduous, as the genetic heterogeneity of the pseudoachondroplasia.