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).

The treatment of distal third humeral diaphyseal fractures: Is there still a place for the external fixation?

INTRODUCTION

The treatment for humeral diaphyseal fractures is still controversial. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating humeral distal third diaphyseal fractures by using external fixation technique.

MATERIALS AND METHODS

We retrospectively review 65 cases of diaphyseal humeral fractures (31 type A, 23 type B and 11 type C of the AO/OTA classification) treated with external fixation (Orthofix FAD small) between 2008 and 2013. The mean follow-up was 48 months (24-72 months). There were 12 open fractures; however, no cases of concomitant vascular injury were described. The transolecranic traction was always applied to promote partial reduction through ligamentotaxis. In case of interposition of soft tissues impeding reduction, a small incision was performed allowing mobilization of bone ends.

RESULTS

All fractures resulted healed at a mean of 11 weeks (range 9-13 weeks); the average time of removal of the external fixator was 88 days (range 65-95 days). At the last follow-up, the mean elbow flexion was 132.6° (Min 126°-Max 137°) and the mean elbow extension was 6.4° (Max 0°-Min 13°). The Cassebaum's index rated as excellent in 47.8 % (31 patients), good in 37 % (24 patients), fair in 9.2 % (6 patients) and poor in 6 % (4 patients). The mean DASH score at the final follow-up was 14.7 (range 0-33); 15 patients had a range score between 10 and 20, 43 had less than 10, and seven had more than 20. We observed three cases of superficial infections and two cases of acute radial nerve palsy recovered within 3 months.

CONCLUSION

According to the excellent clinical results and full rate of consolidation, we state external fixation as a valid option in the treatment of distal third humeral diaphyseal fractures.

Restoring the femoral offset prevent early migration of the stem in total hip arthroplasty: an EBRA-FCA study

The use of modular stems is still debated and controversial. Some authors have highlighted a number of disadvantages of modular prostheses including high costs, the tendency to fracture, the fretting and corrosion and the increased production of debris. Other authors have emphasized several advantages to adapt the prosthesis to the morphometric differences of patients, to allow better accuracy in restoring the anatomy and biomechanics of hip joint. The advantages of the modular devices appear to be more evident in patients with developmental dysplasia of the hip (DDH). In our study we compared 96 patients, operated for arthritis of the hip with 55 modular neck prostheses (PROFEMUR®, Wright® Arlington, Tennesse, USA) and 41 standard femoral stems (SYMAX®, Striker® Kalamazoo, Michigan, USA). The precision of restoring the natural offset during surgery was correlated with the clinical outcome and the radiological early migration of each stem measured using the computer-assisted EBRA-FCA method. The average preoperative HHS (Harris Hip Score) was 44 (23-66); the postoperative 86.56 in the 55 patients operated with modular prostheses and 81.70 in the 41 patients with monoblock stem. The worst HH Scores were seen in patients in whom the offset was not restored properly. On the contrary, the best scores have been reached in patients in which that value is closer to the “target” value (offset value of the contralateral hip). Restoring the proper offset seems to determine an appropriate tension of the abductor muscles of the hip and implies a better functioning of the joint and a better primary stability of the implant, with less early migration. This has to be a primary objective of THA surgery.

OPTIMAL IMPROVEMENT IN FUNCTION AFTER TOTAL HIP AND KNEE REPLACEMENT: HOW DEEP DO YOU KNOW YOUR PATIENT’S MIND?

Osteoarthritis (OA) of the hip and knee causes pain and loss of joint mobility, leading to limitations in physical function. When conservative treatment fails total hip and knee replacement is a cost-effective surgical option. Patients have high expectations regarding functional outcome after these procedures. If such expectations are not met, they may still be dissatisfied with the outcome of a technically successful procedure. Recently, numerous studies reported that psychological factors can influence the outcome of total knee replacement (tkr) and total hip artrhoplasty with total hip replacement (thr). We conducted a prospective study on a consecutive sample of 280 patients affected by hip or knee OA who underwent total joint replacement. At patients’ admission, Harris Hip Score (HHS) and Knee Society Score (KSS) were used to assess pain and function. Furthermore, SF-36, Mini-Mental Status Examination (MMSE), Symptom Checklist-90-R (SCL-90-R), Coping Orientation to Problems Experienced (BRIEF-COPE) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS) were administered. Patients had clinical and radio graphical follow up at 1, 3 and 6 months post-operatively. The HHS and KSS values before surgery showed a linear correlation with both SCL-90-R and MMSE. None of the investigated variables influenced post-operative HHS and KSS scores; however, the improvement of functional scores resulted conditioned by SCL-90-R values, VAS score, schooling and MMSE. Psychological factors and mental status in primary total hip and knee replacement can affect outcome and patient satisfaction. Strategies focused on identification and facing of these conditions must be considered to improve outcome of total replacement.

A six month mitotane course induced sustained correction of hypercortisolism in a young woman with PPNAD and Carney complex

A low-dose mitotane (MT) regimen was evaluated as a pharmacological approach for correcting the severe hypercortisolism in a young woman affected by Carney complex (CNC) and primary pigmented nodular adrenocortical disease (PPNAD). In the first 12 week period, the MT daily dose was progressively increased from 0.5 to 4.0 g/day. This dosage was maintained for an additional 16 weeks (cumulative dose 602 g, plasma MT maximum level 12 microg/ml), and then stopped because of sustained signs of hypoadrenalism requiring prednisone replacement. Complete regression of seborrhea, acne, and plethora was observed after 8 weeks of treatment (cumulative dose 95 g). Regular menses returned after 13 weeks (cumulative dose 197 g, plasma MT 8 microg/ml). Profound decrease of both serum cortisol (from 615 to 220 nmol/l) and urinary free cortisol (UFC) values (from 1498 to 477 nmol/day) was noted after 16 weeks of treatment (cumulative dose 314 g, plasma MT 8 microg/ml). MT treatment was associated with mild gastric discomfort and reversible increase of cholesterol plasma levels. Low serum cortisol and UFC were still observed 41 weeks after MT was discontinued (plasma MT 0.2 microg/ml). Our report demonstrates that low dose MT treatment may be a safe and effective modality for a sustained correction of hypercortisolism by PPNAD in subjects with CNC waiting for surgery.

Diagnostic utility of thyroglobulin detection in fine-needle aspiration of cervical cystic metastatic lymph nodes from papillary thyroid cancer with negative cytology

Cystic changes in metastatic cervical lymph nodes (CLN) from papillary thyroid cancer (PTC) may be a diagnostic pitfall in fine-needle aspiration biopsy (FNAB) cytology. We investigated in a series of CLN metastases from thyroid cancers (TC), including cystic PTC, and from a wide spectrum of extrathyroidal malignancies, the diagnostic role for metastatic TC of the rapid detection of thyroglobulin in eluates from FNAB (FNAB-Tg) of CLN. The study was carried out in a group of 79 subjects (22/57 M/F; median age, 56 years; range, 20-86 years) with enlarged CLN and thyroid nodules (TN), examined for potential metastatic TC, and harboring a large spectrum of incidentally diagnosed extrathyroidal malignancies (n = 24, mostly represented by lymphomas, lung, and breast cancers), CLN metastases from thyroid cancers (n = 28, including 6 cystic metastatic PTC), 6 specific lymphadenitis and 21 reactive lymphadenitis mostly detected (n = 16) during follow-up of patients with previously ablated TC. Markedly high FNAB thyroglobulin (Tg) values were found in all metastatic CLN TC. Two of the six cases with cystic metastatic CLN PTC were diagnosed by FNAB-Tg but not by cytology. In conclusion, FNAB-Tg has been confirmed as an easy modality and fast procedure to diagnose CLN metastasis from TC and high FNAB-Tg values with nondiagnostic cystic cytology strongly suggest cystic metastatic PTC.

Relationship of obesity and body fat distribution with ceruloplasmin serum levels

OBJECTIVE

To investigate the influence of obesity and body fat distribution on serum levels of ceruloplasmin, a risk factor for myocardial infarction.

DESIGN

Fasting concentrations of ceruloplasmin, insulin, glucose, lipid pattern (cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides), blood pressure levels, and body fat distribution were determined in a population of non-diabetic subjects.

SETTING

University Hospital Outpatient Clinic.

SUBJECTS

87 consecutive individuals (35 men and 52 women), represented by 27 normal weight (BMI: < 25.0), 20 overweight (BMI: > 25.0-30.0) and 40 obese (BMI: > 30.0) subjects.

MEASUREMENTS

Serum insulin levels were quantified by radioimmunoassay, plasma glucose and lipid concentrations by enzymatic assays, and serum ceruloplasmin by nephelometry. Intra-abdominal thickness was measured by ultrasound technique.

RESULTS

Ceruloplasmin levels were significantly (P < 0.001) higher in obese (36.5 +/- 8.60 mg/dl) than in overweight (30.4 +/- 6.17 mg/dl) and normal weight (29.3 +/- 8.06 mg/dl) subjects. Of several variables associated with ceruloplasmin (BMI, waist circumference, WHR, intra-abdominal thickness, triglycerides, cholesterol, LDL-cholesterol, insulin), only triglycerides (in both men and women) and ultrasound intra-abdominal thickness (in women) maintained a significantly independent relationship with this protein in multiple stepwise analysis. Moreover, both triglycerides and total cholesterol maintained an independent correlation with ceruloplasmin when the data from both men and women were pooled together.

CONCLUSION

This study indicates that patients with central obesity have characteristically higher ceruloplasmin serum levels, and that ceruloplasmin concentrations are strongly correlated with serum triglyceride and cholesterol levels (in both sexes) and visceral fat accumulation (in women), independently of the other associated cardiovascular risk factors (insulin and blood pressure levels). Since ceruloplasmin has been shown to increase in response to the atherosclerotic inflammatory process, and to promote coronarosclerosis, the determination of serum ceruloplasmin in subjects with central obesity might be a useful tool to identify patients with the highest risk for myocardial infarction.