From the Sun to the Cell: Examining Obesity through the Lens of Vitamin D and Inflammation

Obesity affects more than one billion people worldwide and often leads to cardiometabolic chronic comorbidities. It induces senescence-related alterations in adipose tissue, and senescence is closely linked to obesity. Fully elucidating the pathways through which vitamin D exerts anti-inflammatory effects may improve our understanding of local adipose tissue inflammation and the pathogenesis of metabolic disorders. In this narrative review, we compiled and analyzed the literature from diverse academic sources, focusing on recent developments to provide a comprehensive overview of the effect of vitamin D on inflammation associated with obesity and senescence. The article reveals that the activation of the NF-κB (nuclear factor kappa B subunit 1) and NLRP3 inflammasome (nucleotide-binding domain, leucine-rich-containing, pyrin domain-containing-3) pathways through the toll-like receptors, which increases oxidative stress and cytokine release, is a common mechanism underlying inflammation associated with obesity and senescence, and it discusses the potential beneficial effect of vitamin D in alleviating the development of subclinical inflammation. Investigating the main target cells and pathways of vitamin D action in adipose tissue could help uncover complex mechanisms of obesity and cellular senescence. This review summarizes significant findings related to opportunities for improving metabolic health.

Survival Prediction in Diabetic Foot Ulcers: A Machine Learning Approach

Our paper proposes the first machine learning model to predict long-term mortality in patients with diabetic foot ulcers (DFUs). The study includes 635 patients with DFUs admitted from January 2007 to December 2017, with a follow-up period extending until December 2020. Two multilayer perceptron (MLP) classifiers were developed. The first MLP model was developed to predict whether the patient will die in the next 5 years after the current hospitalization. The second MLP classifier was built to estimate whether the patient will die in the following 10 years. The 5-year and 10-year mortality models were based on the following predictors: age; the University of Texas Staging System for Diabetic Foot Ulcers score; the Wagner-Meggitt classification; the Saint Elian Wound Score System; glomerular filtration rate; topographic aspects and the depth of the lesion; and the presence of foot ischemia, cardiovascular disease, diabetic nephropathy, and hypertension. The accuracy for the 5-year and 10-year models was 0.7717 and 0.7598, respectively (for the training set) and 0.7244 and 0.7087, respectively (for the test set). Our findings indicate that it is possible to predict with good accuracy the risk of death in patients with DFUs using non-invasive and low-cost predictors.

Evaluating Classification Systems of Diabetic Foot Ulcer Severity: A 12-Year Retrospective Study on Factors Impacting Survival

(1) Background: This study examines the survival of patients after their first presentation with diabetic foot ulcers (DFUs) to the regional Diabetes, Nutrition, and Metabolic Diseases Clinic within the Emergency Clinical Hospital "Sf. Spiridon", Iaşi, and analyzes the factors associated with this outcome. (2) Methods: In this retrospective study, patients with DFUs consecutively referred between 1 January 2007 and 31 December 2017 were followed up until 31 December 2020 (for 13 years). The study group included 659 subjects. (3) Results: During the study period, there were 278 deaths (42.2%) and the average survival time was 9 years. The length of hospitalization, diabetic nephropathy, chronic kidney disease, glomerular filtration rate, cardiovascular disease, hypertension, anemia, and DFU severity were the most significant contributors to the increase in mortality. Patients with severe ulcers, meaning DFUs involving the tendon, joint, or bone, had a higher mortality risk than those with superficial or pre-ulcerative lesions on initial presentation (Texas classification HR = 1.963, 95% CI: 1.063-3.617; Wagner-Meggitt classification HR = 1.889, 95% CI: 1.024-3.417, SINBAD Classification System and Score HR = 2.333, 95% CI: 1.258-4.326) after adjusting for confounding factors. (4) Conclusions: The findings of this study suggested that patients presenting with severe ulcers involving the tendon, joint, or bone exhibited a significantly higher risk of mortality, even when potential confounders were taken into consideration.

Diet in Scleroderma: Is There a Need for Intervention?

Systemic sclerosis (SSc) patients exhibit a plethora of risk factors for nutritional decline, including the presence of chronic inflammation and the progressive nature of disease-related multisystem involvement. The prevalence and consequences of nutritional decline in scleroderma are frequently underestimated, its management currently remaining a subject of debate. The main objective of the present study was to perform a detailed assessment of scleroderma patients' diet as well as their eating habits and to describe the relationships with weight loss and malnutrition risk in the absence of professional nutritional counseling.

METHODS

We used a translated and validated version of the EPIC-Norfolk FFQ (European Prospective Investigation into Cancer and Nutrition Norfolk Food Frequency Questionnaire) to evaluate the patients' diet and MUST (Malnutrition Universal Screening Tool) to investigate the risk of malnutrition. Disease activity was estimated using the EUSTAR-AI (European Scleroderma Trials and Research group Activity Index).

RESULTS

We included 69 patients with SSc, of which 42 underwent a detailed dietary assessment. Dietary factors were connected to body composition and digestive symptoms. We found high sodium intake and frequent suboptimal energy consumption in our study group, including patients with cardiopulmonary involvement. Liver transaminases were inversely correlated with the consumption of nuts and seeds. Malnutrition and weight loss were significantly associated with pulmonary hypertension, heart failure, albumin levels, and the extent of skin fibrosis, but not advanced age. Although the patients with EUSTAR-AI ≥ 2.5 were more frequently included in the moderate and high malnutrition risk categories, these results did not reach statistical significance.

CONCLUSIONS

Currently, there is an unmet need for longitudinal and interventional research focusing on the long-term significance, ramifications, and management of nutritional impairment in SSc patients with various clinical manifestations. Our results indicate that scleroderma patients could benefit from personalized nutritional counseling in an interdisciplinary setting.

The role of RANKL and FGF23 in Assessing Bone Turnover in Type 2 Diabetic Patients

CONTEXT

Type 2 diabetes is a chronic metabolic disease which affects bone. There is evidence in the literature about some serum markers that reflect the bone turnover metabolism, such as RANKL (Receptor Activator of Nuclear factor Kappa-b Ligand) and Fibroblast Growth Factor (FGF) 23.

OBJECTIVE

We aimed to investigate the correlations between RANKL and FGF23 and other diabetes-related factors possibly influencing early bone turnover changes.

SUBJECTS AND METHOD

We conducted a cross-sectional analytical study on a group of 171 patients with type 2 diabetes, without Charcot's arthropathy or a history of amputations, in which a complete history and anthropometric, clinical, biochemical and dietary evaluation were performed. We evaluated the serum level of RANKL and FGF 23.

RESULTS

RANKL was significantly lower in patients with macroangiopathy (0.42±0.15 pmol/L vs. 0.47±0.2 pmol/L, p=0.001). The level of FGF23 was lower in patients with neuropathy (0.37±0.36 pmol/L vs. 0.41±0.17 pmol/L, p=0.001). We found that FGF23 increased with age, but decreased with the duration of diabetes. We also found an inverse relationship between FGF23 levels and HbA1c, triglycerides, diastolic blood pressure, total proteins, albuminemia.

CONCLUSIONS

RANKL was significantly lower in patients with macroangiopathy, and FGF 23 in patients with neuropathy. Therefore, more studies are needed to elucidate their role in early bone turnover changes.

The relationship between lifestyle components and dietary patterns

We conducted a narrative review on the interaction between dietary patterns with demographic and lifestyle variables in relation to health status assessment. The food pattern has the advantage of taking into account the correlations that may exist between foods or groups of foods, but also between nutrients. It is an alternative and complementary approach in analysing the relationship between nutrition and the risk of chronic diseases. For the determination of dietary patterns one can use indices/scores that evaluate the conformity of the diet with the nutrition guidelines or the established patterns (a priori approach). The methods more commonly used are based on exploratory data (a posteriori): cluster analysis and factor analysis. Dietary patterns may vary according to sex, socio-economic status, ethnicity, culture and other factors, but more, they may vary depending on different associations between these factors. The dietary pattern exerts its effects on health in a synergistic way or even in conjunction with other lifestyle factors, and we can therefore refer to a 'pattern of lifestyle'.

Sleep duration and body mass index: moderating effect of self-perceived stress and age. Results of a cross-sectional population-based study

PURPOSE

The objective of this analysis was to assess whether the association between sleep duration and BMI and between sleep duration and waist circumference is moderated by age and self-perceived stress.

METHODS

We analyzed data from 2034 participants enrolled in 2014 in the cross-sectional study Obesity in Romania Study-study of the prevalence of obesity and related risk factors in Romanian general population (ORO study).

RESULTS

Interaction between sleep duration, self-perceived stress and age, with BMI as dependent variable, was statistically significant after adjustment for demographic and lifestyle factors (p value for interaction 0.003). In participants without self-perceived stress, a linear negative association between sleep duration and BMI was observed only in those 18-39 years old (p = 0.049), with BMI decreasing in parallel with increased sleep duration. In participants with self-perceived stress, a U-shaped relationship was observed between BMI and sleep duration in those 40-64 years old, with higher BMI in those sleeping ≤ 6 h and ≥ 9 h/night compared to those sleeping > 6 and < 9 h/night (p = 0.002 and 0.005). Those ≥ 65 years old with self-perceived stress sleeping ≥ 9 h/night had a significantly higher BMI compared to those in other sleep duration categories (p = 0.041 vs. those sleeping ≤ 6 h/night and p = 0.013 vs. to those sleeping > 6 and < 9 h/night). No interaction between age, self-perceived stress and sleep duration, with waist circumference as dependent variable was observed.

CONCLUSIONS

In our sample, the association between sleep duration and BMI was moderated by self-perceived stress and age.

Prevalence of dyslipidemia and its association with cardiometabolic factors and kidney function in the adult Romanian population: The PREDATORR study

The aims were to assess the prevalence and characteristics of dyslipidemia phenotypes in a Romanian population-based sample from the PREDATORR study.

METHODS

PREDATORR was an epidemiological study with a cross-sectional, cluster random sampling design. Participants were classified into four dyslipidemia phenotypes based on the NCEP ATP III criteria: isolated hypertrigliceridemia, isolated hypoHDL-C, isolated hyperLDL-C and mixed dyslipidemia (≥2 standard lipid abnormalities). Overall, 2656 were included in the analysis by dyslipidemia phenotypes.

RESULTS

An estimated 67.1% of Romanian adults have at least one lipid abnormality: 27.5% (95%CI26.0-28.9%) have elevated TG, 29.4% (95%CI27.9-30.8%) have low HDL-C and 47.8% (95%CI46.3-49.2%) have elevated LDL-C (26.2% had LDL-C levels ≥2.58 mmol/l associated with CHD or CHD risk equivalent). Also, 30% Romanian adults have mixed dyslipidemia with 7.6% (95%CI6.1-9.0%) having all three lipid abnormalities. THE AGE: and sex-adjusted prevalence of isolated dyslipidemia phenotypes in Romanian adult population was 23.7% (95%CI22.2-25.1%) for hyperLDL-Cholesterolemia, 9.3% (95%CI7.8-10.7%) for hypoHDL-Cholesterolemia and 4.1% (95%CI2.6-5.5%) for hypertriglyceridemia. Among participants with triglycerides ≥2.25 mmol/l, 15.2% (95%CI13.7-16.6%) of Romanian adults have non-HDL-C levels ≥3.36 mmol/l.

CONCLUSIONS

The PREDATORR survey indicated a high prevalence of dyslipidemia phenotypes in the Romanian population aged 20-79 years, providing data on its association with several cardiometabolic risk factors.

DIETARY PATTERNS AND THEIR ASSOCIATION WITH OBESITY: A CROSS-SECTIONAL STUDY

Context

Scarce data on dietary habits in Eastern European countries is available and reports investigated individual food items and not dietary patterns in these populations.

Objective

To identify dietary patterns and to explore their association with obesity in a sample from Romanian population.

Design

Cross-sectional.

Subjects and Methods

This was an analysis of data collected from 1398 adult participants in ORO study. Data on lifestyle, eating habits and food frequency consumption were collected.

Results

By principal component analysis we identified 3 dietary patterns explaining 31.4% of the diet variation: High meat/High fat pattern, Western pattern and Prudent pattern. High meat/High fat pattern was associated with male gender, lower educational level, living in a rural, smoking and a higher probability for the presence of obesity (OR 1.2 [95%CI: 1.1-1.4]). Western pattern was associated with younger age, a higher level of physical activity and smoking. Prudent pattern was associated with older age, female gender, a higher level of physical activity, not smoking status and a lower probability for the presence of obesity (OR 0.8 [95%CI: 0.7-0.9]).

Conclusions

This study provides for the first-time information on the association between dietary patterns in adults from an Eastern European country and the presence of obesity.

Evaluation of Serum Vitamin B12 Levels in Type 2 Diabetes Patients Metformin Treated

Vitamin B12 deficiency is a condition characterized by neurological or haematological abnormalities, and may occur after treatment with metformin in patients with type 2 diabetes. We evaluated 119 patients with type 2 diabetes mellitus, treated with oral antidiabetic agents. The parameters evaluated were: vitamin B12 intake, anthropometric data, disease history, neuropathic complications evaluation (using MNSI), serum vitamin B12, glycated hemoglobin, erythrocyte indices. Vitamin B12 deficiency was defined at values below 194 pg/mL. We have found a prevalence of vitamin B12 deficiency of 13.9% in the patients treated with metformin (10.9% in all participants). B12 levels were not correlated with age, metformin dose or duration of treatment. Patients using B12 supplements had higher B12 serum levels (472.50 vs. 329.22, p � 0.05).

Nutritional Decline in Scleroderma Patients Data from a single Romanian center

Malnutrition has been known to provide poor survival outcomes in systemic sclerosis (SSc). We recruited a series of 40 consecutive SSc patients, 22 (55%) with limited cutaneous involvement and 18 (45%) with the diffuse form of disease. The study group was evaluated using the modified Rodnan skin score (mRSS), anthropometric measurements, the EPIC-Norfolk Food Frequency Questionnaire, the Malnutrition Universal Screening Tool (MUST) as well as circulating albumin and vitamin D. MUST scores were correlated with mRSS and serum albumin (R=0.40, p=0.010, and R=-0.46, p=0.003, respectively). Serum vitamin D values were inversely related to mRSS (R=-0.35, p=0.026). We recorded a greater number of daily gastrointestinal symptoms associated with diets rich in sodium, fat, sugars and snacks, carotene, and �-tocopherol equivalents (vitamin E) in our study population. Scleroderma patients might benefit from nutritional counseling in order to follow a diet tailored to their specific needs.

Subclinical cardiovascular disease assessment and its relationship with cardiovascular risk SCORE in a healthy adult population: A cross-sectional community-based study

INTRODUCTION

The aim of this study is to evaluate the relationship and the accuracy of SCORE (Systematic Coronary Risk Evaluation Project) risk correlated to multiple methods for determining subclinical cardiovascular disease (CVD) in a healthy population.

MATERIAL AND METHODS

This cross-sectional study included 120 completely asymptomatic subjects, with an age range 35-75 years, and randomly selected from the general population. The individuals were evaluated clinically and biochemical, and the SCORE risk was computed. Subclinical atherosclerosis was assessed by various methods: carotid ultrasound for intima-media thickness (cIMT) and plaque detection; aortic pulse wave velocity (aPWV); echocardiography - left ventricular mass index (LVMI) and aortic atheromatosis (AA); ankle-brachial index (ABI).

RESULTS

SCORE mean value was 2.95±2.71, with 76% of subjects having SCORE <5. Sixty-four percent of all subjects have had increased subclinical CVD changes, and SCORE risk score was correlated positively with all markers, except for ABI. In the multivariate analysis, increased cIMT and aPWV were significantly associated with high value of SCORE risk (OR 4.14, 95% CI: 1.42-12.15, p=0.009; respectively OR 1.41, 95% CI: 1.01-1.96, p=0.039). A positive linear relationship was observed between 3 territories of subclinical CVD (cIMT, LVMI, aPWV) and SCORE risk (p<0.0001). There was evidence of subclinical CVD in 60% of subjects with a SCORE value <5.

CONCLUSIONS

As most subjects with a SCORE value <5 have subclinical CVD abnormalities, a more tailored subclinical CVD primary prevention program should be encouraged.

Patterns of diabetes care in Slovenia, Croatia, Serbia, Bulgaria and Romania : An observational, non-interventional, cross-sectional study

BACKGROUND

National guidelines for treating type 2 diabetes in the Balkans generally follow European guidelines. The current study was undertaken to estimate the rate of glycated hemoglobin (HbA1c) measurements and level of HbA1c control in diabetic patients treated in regular clinical practice settings in the Balkans and to evaluate if providing HbA1c measurements improves adherence to treatment guidelines.

METHODS

This cross-sectional study enrolled type 2 diabetic patients treated by 79 primary care physicians and 102 specialists. The participants were provided with HbA1c measuring devices to measure HbA1c during regular office visits and a physician survey evaluated HbA1c the results feedback. Relevant clinical, demographic, drug treatment and specialist referral data were extracted from patient charts. Descriptive statistics and stepwise multivariate regression analysis were used.

RESULTS

Among 1853 patients included (average age 63.5 ± 10.7 years, 51% male) the average diabetes duration was 8.9 ± 7.1 years, 40% of patients had HbA1c measured every 6 months and 34% every 12 months (or less frequently). The rate of 6‑month measurement was higher among specialists (43%) vs. primary care physicians (32%, p < 0.01). The average HbA1c was 7.3 ± 1.5 and 35% of patients achieved the target HbA1c level of < 6.5%. Metformin monotherapy was prescribed to 28% of patients and metformin + sulphonylurea to 23%, 55% of patients on metformin monotherapy and 32% of patients on dual therapy metformin + sulphonylurea achieved the target HbA1c < 6.5%. Treatment remained unchanged in 91% and was stepped up in only 7.2% of patients. Physicians were not surprised (in 79% of patients) or were pleasantly surprised (in 11%) by the HbA1c results at the time of visit. Average diabetes duration and patient use of home glucometers were associated with the level of disease control.

CONCLUSIONS

The rates of HbA1c measurements remain low in the Balkans, although higher among specialists. Over 60% of patients, mostly treated with traditional oral antidiabetics did not achieve disease control. Providing convenient HbA1c measurement devices was not associated with a marked change in diabetes management. Future research is needed to evaluate the impact of these treatment patterns on long-term outcomes and costs to society.

Dietary Vitamin D, Calcium, and Magnesium Intake in Type 2 Diabetes Patients

AIM

To estimate specific nutrient intake in patients with type 2 diabetes.

MATERIALS AND METHODS

The study was conducted on a group of subjects with type 2 diabetes. The collected data included: anthropometry, lifestyle, blood measurements, and the mean daily nutrient intake assessed by the EPIC food frequency questionnaire.

RESULTS

The study group included 101 subjects with type 2 diabetes mellitus (DM) with a mean age of 60.6±10 years, of which 45 men (59±10.6 years) and 56 women (62±9.6 years). The average energy intake was 1714.4±713.9 Kcal/day, with a statistically significant gender difference (1877.7±850.9 kcal/day for men, 1583.1±554.9 kcal/day for women, p = 0.039, and the average daily micronutrient intake was 2.44±1.44 μg/day for vitamin D, 724.5μ263.2 mg/day for Calcium (Ca), 266.7±98 mg/day for magnesium (Mg), which was low compared to dietary recommendations. Calcium intake was correlated with intake of carbohydrates, saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), fiber and energy. Vitamin D intake was correlated only with protein intake (R=0.695), while magnesium intake correlated with intake of fibers, energy, carbohydrates and SFA.

CONCLUSIONS

Our study in patients with type 2 diabetes showed a reduced average intake of calcium, magnesium and vitamin D compared to standard recommendations, requiring an individualized approach.

Is Liver Biopsy Necessary in Patients With Nonalcoholic Fatty Liver Disease?

Nonalcoholic fatty liver disease is the most common cause of liver disease in the Western world. Liver biopsy is considered the gold standard in the diagnosis and progression of the disease and its usefulness cannot be neglected in terms of research. But in current clinical practice, liver biopsy tends to be replaced by less expensive and noninvasive methods allowing the identification of cardiovascular and metabolic risks. Given the fact that a small percentage of individuals with nonalcoholic fatty liver disease will progress to cirrhosis, attention will be focused more on cardiovascular risk as nonalcoholic fatty liver is now regarded as a distinct component of the metabolic syndrome. The aim of the clinician is to identify the early stages of fatty liver, using in this purpose simple and easily accessible methods. Many techniques have been proposed for the diagnosis of nonalcoholic fatty liver, from simple clinical factors (anthropometric indices measuring,blood pressure) laboratory biomarkers, imaging methods and scores, which should allow early treatment. This review describes different methods for identifying nonalcoholic fatty liver and various stages of this disease.

A RARE CASE OF SEVERE TYPE 4 POLYGLANDULAR AUTOIMMUNE SYNDROME IN A YOUNG ADULT

Objective

The association of type 1 diabetes mellitus with autoimmune thyroiditis or with celiac disease is frequently mentioned in literature, but the concomitant presence of these three autoimmune diseases, especially in adults, represents a rarity.

Case report

We present the case of a young man with severe generalized oedema admitted to the emergency department and diagnosed with severe hypothyroidism (TSH=100 μUI/mL, fT4 = 0.835 pmol/L) in the context of a long-lasting autoimmune thyroiditis (anti-TPO antibodies 64 UI/mL, anti-TG antibodies 17 UI/mL, the thyroid ultrasonography). At the same time, he was diagnosed with type 1 diabetes mellitus. He was also submitted to further tests which confirmed the diagnosis of celiac disease (endoscopy with intestinal mucosa biopsy, confirmed by immunological tests). The association of these three diseases slows down the process of reaching a final diagnosis and delays the adoption of a therapeutic strategy.

Conclusion

This case underlines the difficulty of differential diagnosis of severe oedema syndrome with polyserositis in a patient with polyglandular autoimmune syndrome. Whenever there is a suspicion of the association of these autoimmune diseases, the evolution of the patient is unpredictable and most medical results are highly dependent upon the decision of applying a concomitant treatment.

Assessing Intake of Water and Sugar-Sweetened Beverages in Adolescents: its Relationship with Weight Status

Background and aims. The aim of the study is to evaluate fluid intake during adolescence and correlate it with weight status. Material and methods. We assessed fluid intake using a validated questionnaire in a group of 106 adolescent students (22 boys - 20.8%), aged 15-19 years. Weight status was evaluated with the BMI-for-age values,using growth normograms. Results. There were no statistically significant differences in the frequency of water intake between sexes (p>0.05). Water intake at least 3 times a day was declared by 72.16% of normal weight students and in 66% of overweight and obese, the difference being statistically significant (p=0.003). Boys consumed larger amounts of water (p=0.042) than girls. Intake of 100% natural fruit juice was significantly higher in boys compared to girls (p=0.002). A significantly higher percentage of normal weight adolescents consumed≤500 mL/day non-carbonated (p=0.004) and carbonated (p<0.001) sugar-sweetened beverages compared to the overweight or obese, who consumed ≥500 mL/day. Conclusions. The quantitative and qualitative assessment of fluid intake among adolescents is a mandatory step in the assessment of calorie and nutritional intake. Promoting low-calorie fluid intake in this age group, along with the principles of healthy eating, could contribute to achieving an optimal weight status.

Assessment of preoperative and postoperative prealbumin in thoracic surgery – a two months experience in a Romanian university hospital / Evaluarea preoperatorie şi postoperatorie a prealbuminei în chirurgia toracică - experiența de 2 luni a unui spital universitar din România

Malnutrition is a frequent and serious finding in surgical departments. Although its consequences include postoperative complications and higher costs, nutritional assessment is not part of the routine preoperative protocols. Nutritional assessment involves clinical and biological parameters and is vital in order to start treatment and improve outcome. Prealbumin is currently recognized as a faithful marker of malnutrition being introduced in practice guidelines. One of the most important aspects about prealbumin is the fact that its variations in time are more valuable than the absolute values. The aim of this study was to assess and compare the perioperative nutritional evolution of patients requiring thoracic surgery, with and without cancer, using prealbumin - preoperative and postoperative - as main marker. Thirty six patients from the Thoracic Surgery Department were assessed prior to surgery by body mass index, Subjective Global Assessment nutrition risk score and routine biochemical parameters. Prealbumin was assessed prior to surgery and 3 days after surgery. The age, length of postoperative stay and the presence was complications was noted. Patients with cancer (n=19) were significantly older than patients without cancer (p=0.007) and were more frequently, but not significantly, evaluated as malnourished through SGA (42.1% compared to 11.6%). Preoperative prealbumin and other parameters did not differ significantly between groups. However, there was a significant postoperative decrease in prealbumin only in patients with cancer. Therefore, prealbumin has been found to be valuable in assessing acute malnutrition in cancer patients, especially if variations are monitored in time, which could be useful in planning nutritional treatment

ST segment depression in asymptomatic male patient with normal coronary arteries

ST segment depression and T waves inversion are electrocardiographic (ECG) repolarization abnormalities often encountered in clinical medical practice that have been proved to predict future cardiovascular events. We present the case of a 62-year-old male patient, asymptomatic, with ST segment depression and inverted T waves discovered incidentally on resting ECG. Echocardiographic and laboratory examinations ruled out multiple causes of ECG abnormalities. Suspecting a silent myocardial ischemia, an ECG exercise stress test was performed; it revealed pseudo normalization of T waves during exercise and early recovery phase. Being inconclusive, a coronary CT was the final election test; it showed normal coronary arteries with no stenosis, the patient being scheduled for regular follow-up. The possible causes of ST segment depression are reviewed since it is important that early cardiovascular signs especially in asymptomatic patients to be prevented and detected.

Pathological aspects underlying pancreatogenous hyperinsulinemic hypoglycemia--report of three cases

Pancreatogenous hyperinsulinemic hypoglycemia (PHH) is a rare disorder determined by an abnormally high secretion of insulin in the pancreas, in the absence of other medical or pharmacological factors. Either β-cell tumors (insulinomas) or β-cell hyperplasia (nesidioblastosis) can determine this pathology. Most publications on insulinomas or nesidioblastosis approached these subjects from a clinical point of view. This paper aims to analyze pathological aspects underlying pancreatogenous hyperinsulinemic hypoglycemia. We present two cases of insulinomas with unusual pancreatic localization and size, one of them showing amyloid deposits in the stroma. In both cases, immunohistochemistry confirmed the clinical and imagistic supposition. The third reported case refers to a 57-year-old patient with nesidioblastosis with isolated disposition of endocrine cells and areas of focal organization, both morphological aspects being extremely rare in adults. Although clinical and laboratory data are usually identical in the two forms of PHH, histopathological and immunohistochemical diagnosis is essential in differentiating insulinomas from nesidioblastosis, as the surgical management is different: enucleation for insulinomas and total or subtotal pancreatectomy for nesidioblastosis.

The evaluation of preoperative nutritional status in patients undergoing thoracic surgery

AIM

The aim of this study was to assess the preoperative nutritional status of patients undergoing thoracic surgery using different nutritional tools.

MATERIAL AND METHOD

. We conducted a prospective study on a sample of 43 thoracic patients, including 23 with neoplasms and 20 with non-neoplastic pathology who underwent thoracic surgery procedures between July-September 2011, in the Thoracic Surgery Clinic in Iaşi. Weight and height were measured and body mass index (BMI) was calculated. WHO classification for BMI categories was used. Preoperative serum level of transthyretin (TTR) and demographic data (gender, age) were also assessed. All patients were examined by the Subjective Global Assessment (SGA) and the Nutritional Risk Screening 2002 (NRS 2002).

RESULTS

After performing SGA, 67.9% of the patients were well-nourished, 21.4% were moderately or suspected of being malnourished and 10.7% were severely malnourished. The level of TTR was significantly lower in the moderately or severely malnourished group, compared to those considered well-nourished. According to NRS-2002, 42.9% of the patients were considered at nutritional risk. The level of TTR of these patients was lower than the level of TTR of the patients without nutritional risk, but without statistical significance.

CONCLUSIONS

Subjective Global Assessment (SGA) and the Nutritional Risk Screening 2002 (NRS 2002) are useful in identifying patients with nutritional risk, so that appropriate nutritional management could be initialised even before surgery.

Determinants of inadequate weight gain in pregnancy

AIM

The aim of the study was to explore the anthropometric maternal characteristics and prenatal care as determinants of pregnancy weight gain.

MATERIAL AND METHODS

We conducted a cross-sectional study on a total of 400 pregnant women admitted to Cuza-Vodă Obstetrics and Gynecology Clinical Hospital, Iaşi. Information on demographic characteristics, number of prenatal visits, and education on nutrition and food changes occurring during pregnancy were recorded in a structured questionnaire. Anthropometric parameters analyzed were pregestational BMI (body mass index) and weight gain during pregnancy.

RESULTS

Weight gain was associated with pregestational BMI category. An increase in weight more than recommended occured more frequently in overweight (53.1%) and obese women (66.7%) (p < 0.001). Weight gain during pregnancy was related to area of residence, age, APCU (adequate prenatal care utilization) index. The multivariate analysis identified the following variables as significant determinants of pregnancy weight gain: inadequate prenatal care, BMI and changes in diet.

CONCLUSIONS

Pregestational BMI and changes in diet during pregnancy identified as determinants of weight gain suggests that overweight and underweight women must carefully be counseled regarding recommendations for weight gain in pregnancy. Tracking diet changes is important to ensure that a weight gain lies within the guidelines recommendations.

Nutritional knowledge as a determinant of vitamin and mineral supplementation during pregnancy

BACKGROUND

Pregnancy is a critical period for both woman and baby from a nutritional perspective. Nutritional education is considered an important tool for promoting a healthy lifestyle, but has not been studied as a determinant for maternal use of supplements during pregnancy, especially in Romania, where evidence about pregnancy and nutrition is scarce. This study aimed to evaluate the relationship between nutritional knowledge and the use of folic acid, iron and multivitamin supplements during pregnancy and to assess the influence of socio-demographic factors and prenatal care.

METHODS

We conducted a cross-sectional study on a sample of 400 pregnant women admitted to the Cuza-Vodă Obstetrics and Gynaecology Clinical Hospital in Iaşi, Romania, during August-September 2010. We collected self-reported data regarding socio-demographic characteristics, number of prenatal check-ups and the use of folic acid, iron and multivitamin supplements during pregnancy. We assessed nutritional knowledge using a standardized questionnaire divided into three sections: general nutritional recommendations for pregnant women; the roles of nutrients; and sources of nutrients. We used logistic regression to analyse the associations between these factors.

RESULTS

The prevalence of the use of supplements during pregnancy was 48% for folic acid, 45.3% for iron and 68% for multivitamins. Above-average nutritional knowledge was independently associated with the use of folic acid (aOR, 4.7; 95% CI, 1.6-13.8), iron (aOR, 2.6; 95% CI, 1.2-5.7) and multivitamins (aOR, 2.8; 95% CI, 1.2-6.8). The use of folic acid was independently associated with a higher level of formal education (aOR, 5.2; 95% CI, 2.1-12.8) and an early start in prenatal care (aOR, 3.4; 95% CI, 1.0-11.1). Women with a higher education (aOR, 2.3; 95% CI, 1.1-4.9), more than 10 prenatal visits (aOR, 7.2; 95% CI, 3.4-15.0) and those who received advice on breastfeeding (aOR, 2.0; 95% CI, 1.1-3.5) were more likely to use iron during pregnancy. Similar results were found when analysing the contributing factors for the use of multivitamins: more than 12 years of schooling (aOR, 3.4; 95% CI, 1.4-7.9) and appropriate prenatal care (aOR, 9.4; 95% CI, 4.5-19.5).

CONCLUSIONS

Level of nutritional knowledge has a strong independent association with the use of supplements during pregnancy.

The role and interactions of ghrelin concerning the nutritional and inflammatory status

Ghrelin is an important neuroendocrine peptide having as main purpose the stimulation of growth hormone (GH) secretion. It is also an important regulator of the long-term energy balance and short-term nutritional intake. Ghrelin has several other biological actions, among which the capacity to regulate gastrointestinal motility, to modulate the reproductive and stress axes as well as the glucose metabolism, and other well-defined actions within the cardiovascular and renal physiology. Due to its numerous effects, ghrelin is considered on one hand a potential target in the treatment of obesity and on the other, a therapeutic option in other dysfunctions and illnesses.

Non-alcoholic fatty liver disease is associated with cardiovascular risk factors of metabolic syndrome

AIM

To evaluate the prevalence of steatosis and to assess its correlations with the classical cardiovascular (CV) risk factors, components of metabolic syndrome (MS) in a rural population.

MATERIAL AND METHODS

A sample of 254 subjects was enrolled in the study. Collected data included: age, gender, complete medical history, anthropometric and blood pressure (BP) measurements. The biological evaluation included metabolic and hepatic parameters. Ultrasound evaluation of steatosis relied on the criteria of the National Health and Nutrition Examination Survey (NHANES) III.

RESULTS

Two thirds of the study population were obese or overweight (64.96%); 32.66% had systolic BP and 27.16% diastolic BP levels higher than normal. 38% of the subjects had abnormal fasting blood glucose levels, 14.56% having glycated hemoglobin (HbA1c) values corresponding to pre-diabetes, and 9.84% to overt diabetes; 8% had low HDL-cholesterol and 14.96% high triglycerides (Tg) levels. MS was present in 50.8% of individuals. Only 10.8% of all subjects did not have an ultrasound appearance of steatosis; 28.8% had moderate and 32% severe steatosis. There were statistically significant differences in subjects with steatosis vs. subjects without steatosis with regard to body mass index (BMI), WC, presence of MS, and BP and Tg levels, but not to ALAT, ASAT and GGT values.

CONCLUSIONS

The important prevalence of obesity, fasting hyperglycamia, steatosis and MS shows a particularly metabolic fragile population; early diagnosis and interventional strategies are mandatory.

Socio-demographic and lifestyle characteristics associated with the risk for obstructive sleep apnea syndrome in a rural population

AIM

To evaluate socio-demographic and lifestyle characteristics in relationship to the risk for obstructive sleep apnea syndrome (OSAS).

MATERIAL AND METHODS

The study was carried out on 254 subjects. Socio-demographic data (age, gender, occupation, education level, and economic status), smoking status, alcohol consumption, and hours/day spent watching TV were recorded. For physical activity assessment the international physical activity questionnaire and for identifying the risk for OSAS Berlin Questionnaire were used.

RESULTS

Of the 254 subjects, 29.4% of men and 36.8% of women were at high risk for OSAS (p=0.22). Age was higher in the group at high risk for OSAS (p=0.002) and in women (p<0.001). The highest percentage (47.5%) of participants at high risk for OSAS was found among retired people, whereas farmers generated the lowest percentage (18.6 %) (p<0.001). 57.1% of retired women were at high risk for OSAS as compared to 5.6% of the farmers (p<0.001). Education level and monthly income did not influence the risk of OSAS (p=0.172, p=0.113, respectively). No differences in the risk of OSAS were found in relation with smoking (p=0.887), alcohol consumption (p=0.688), and sedentary lifestyle. We found that individuals at low risk for OSAS performed more physical activity at work (p=0.053) and significantly more vigorous physical activity (p=0.036).

CONCLUSIONS

In the study rural population, age, occupation and physical activity are related to the risk for OSAS.

Anthropometric parameters--predictive factors for cardio-metabolic diseases

The aim of this study was to evaluate comparatively the predictive power of body mass index (BMI) and waist circumference (WC), two anthropometric parameters used in daily practice, for detecting cardio-metabolic diseases, in a rural community in north-east Romania.

MATERIAL AND METHODS

We evaluated 3248 persons, aged 19 or over, for whom we collected the following data: medical history, anthropometric parameters, blood pressure value and biochemical parameters.

RESULTS AND CONCLUSIONS

Both WC and BMI help correctly determine the presence of arterial hypertension, diabetes and dislipidemia. However, the cut-off value of each of these parameters differs for each pathology. The predictive value of WC for different cardio-metabolic diseases is maintained even at normal or borderline overweight values of BMI.

The central role of the non alcoholic fatty liver disease in metabolic syndrome

Non-alcoholic fatty liver disease (NAFLD) covers a spectrum of liver disease from steatosis to non-alcoholic steatohepatitis (NASH) and cirrhosis. Most NAFLD patients are hyperinsulinaemic and more insulin resistant compared with nonsteatotic healthy subjects, and there is a near universal association between NAFLD and insulinresistance (IR) irrespective of obesity. The metabolic syndrome (MS) is highly prevalent in the general adult population (approximatively 22%) and it carries an increased cardiovascular morbidity and mortality. Pathophysiologic considerations, clinical associations, and laboratory investigations support that IR and hyperinsulinaemia have a central role in pathogenesis of both MS and NAFLD. The fatty liver is resistant to the action of insulin to suppress hepatic glucose production, which results in hyperglycaemia and, further, in hyperinsulinemia. The MS is associated with maldistribution of body fat, increased free fatty acids (FFAs) and IR, leading to type 2 diabetes, hypertension, dyslipidemia. Visceral fat is an important clinical marker of metabolic cardiovascular risk and a marker of IR in multiple tissues, independent of body mass index (BMI). NAFLD and atherosclerosis share common molecular mediators and NAFLD itself might play an early role in the development and progression of atherosclerosis. These data suggest that NAFLD should be considered part of a multi-organ system derangement in insulin sensitivity, and help explain why NAFLD is so closely linked with diabetes, MS and is an important risk factor for coronary heart disease. NAFLD may be the hepatic manifestation of the MS and raises the possibility that it may play an early role in the etiology of MS.

[Neuropad test in evaluation of diabetic foot]

AIM

Diabetic neuropathy (DN) is the main cause of foot ulceration. One of the earliest modifications is the loss of normal sudomotor function, a sign of autonomic neuropathy. The aim of this study is to evaluate sudomotor dysfunction using a new tool (Neuropad) in diabetic patients with foot ulceration.

MATERIAL AND METHODS

We included 58 diabetic patients with foot ulceration admitted in 2010 in the Clinical Center for Diabetes, Nutrition and Metabolic Diseases. We collected data regarding age, gender, type and duration of diabetes, glycated hemoglobin (HbAlc), history of amputations and duration of hospital admission. Peripheral neuropathy was evaluated through the Neuropathy Disability Score (NDS) and autonomic neuropathy was tested through Neuropad.

RESULTS

95% of patients had NDS > or = 6, among which 76% had also positive Neuropad test. Patients with both peripheral and autonomic neuropathy had longer duration of diabetes (p = 0.027) but similar HbA1c as patients with only peripheral neuropathy (p = 0.09). The former also had longer duration of current admission (p = 0.022) and a higher percentage of these patients had history of amputations (p = 0.041).

CONCLUSIONS

Neuropad is a reliable, easy to use test for the diagnosis of autonomic neuropathy, which puts patients at greater risk for foot ulceration and amputation.

[Surgical treatment of tarsal tunnel syndrome in diabetic neuropathy]

Posterior tibial nerve decompression surgery in tarsal tunnel syndrome in patients with diabetic neuropathy reduces pain, improves sensitivity and prevents foot ulcers and lower leg amputations.

AIM

To observe and assess the recovery of plantar sensitivity recovery and the healing of ulcerative lessions of the foot, by clinical examination, exploration and analysis of quantitative neurosensory by surgical decompression of the tarsal tunnel.

MATERIAL AND METHODS

We evaluated a total of 10 patients and 12 symptomatic diabetic neuropathy feet in a prospective clinical study, surgically treated in the Clinic of Plastic Surgery and Reconstructive Microsurgery Iaşi, during January 2008 - June 2011, where we practiced tibial nerve decompression and neurolysis in tarsal tunnel syndrome.

RESULTS

Gender distribution of patients in the study group was predominantly male (60%), the ratio M/F = 1.5/1. Posterior tibial nerve decompression surgery resulted in recovery of plantar foot sensitivity in 90% patients in the study group. Testing Semmes-Weinstein 10 g monofilament was positive in 83.3% of the feet preoperatively whereas postoperatively only 25%, distribution of statistically significant (chi2 = 6.04, GL = 1, p = 0.014). Postoperative score to test a range of Riedel-Seiffer returned to normal in all patients: score 7 to 58.3% and score 8 to 41.7% of total standing tested.

CONCLUSIONS

Tarsal tunnel decompression in diabetic patients with peripheric neuropathy improves plantar sensitivity, leads to healing of ulcerative plantar lesions and improves quality of life and should be performed in all patients with diabetic peripheral neuropathy in which conservative and/or medical treatment failed.

[Prevalence of obstructive sleep apnea symptoms in a rural population]

AIM

Obstructive Sleep Apnea Syndrome (OSAS) is an under diagnosed condition with significant consequences on health. The aim of this study is to estimate the prevalence of symptoms and key features of OSAS in a rural population.

MATERIAL AND METHODS

254 subjects were enrolled. We measured height (H) and weight (W), calculated body mass index (BMI) and determined glycated hemoglobin (HbA1c). Information about age, gender, medical history (diabetes, hypertension) was collected. All the participants filled in the Berlin questionnaire, which has separate questions regarding the symptoms of OSAS.

RESULTS

Snoring was reported by 44.1% of the subjects, observed apneas by 6.7% and excessive daytime sleepiness by 36.6%. All symptoms were more frequently reported by women. A higher percentage of obese, hypertensive and diabetics reported snoring (p < 0.001). When analyzing gender differences, the significance was maintained, except for diabetic men. Witnessed apneas were more prevalent in hypertensive subjects (p = 0.034), but were significantly associated with hypertension only in (p = 0.003). No correlation was found regarding excessive daytime sleepiness and the risk factors studied.

CONCLUSIONS

Prevalence of OSAS symptoms and risk factors in this rural population was noticeable and efforts for early diagnosis and treatment are recommended.

[Chronic hepatitis C, steatosis and insulin resistance--clinical implications]

Chronic infection with hepatitis C virus is nowadays responsible for many cases of liver disease. According to recent research, it seems to be characterized by a great deal of metabolic abnormalities, most of them due to insulin resistance, which is present in the virus C-induced disease more often than in chronic hepatitis B or in the general population. As insulin resistance significantly impairs the natural course of the viral disease by reducing the efficacy of antiviral treatment and aggravating the development of fibrosis, it becomes more and more plausible that therapeutic intervention aiming to reduce it might contribute to a better course in many patients. Hepatic steatosis is also a frequent feature of chronic hepatitis C, being either induced by the infection with genotype 3 or by a predisposing metabolic background. The relation between steatosis and viral disease prognosis is controversial, probably due to the various factors inducing lipid accumulation. A better understanding of the metabolic substrate of chronic hepatitis C would help developing new approaches in its diagnosis and therapy, hopefully providing a better future to many patients.

[Prevalence of overweight and obesity in a rural population]

The main objective of this study is to estimate the prevalence of overweight and obesity in a rural population, from the north-east part of Romania.

MATERIAL AND METHOD

The study population included 3248 adult subjects (1341 men, 1907 women), aged 18 or over, registered with their general practitioner. Anthropometric parameters were assessed by medical staff and obesity and overweight were defined according to World Health Organization's (WHO) criteria. Abdominal obesity was described according to International Diabetes Federation's (IDF) criteria.

RESULTS

The prevalence of overweight and obesity is 33.9% and 12.2% in men and respectively 35% and 21.3% in women. The majority of overweight and obese subjects had an increased waist circumference. There can be observed the predominance of the women in the overweight and obese group, as well as the increase of the obesity prevalence with age.

CONCLUSION

Our results show that the weight excess could become a public health problem in Romania, therefore national screening programs are needed along with public information campaigns regarding effectual prevention and treatment possibilities.

[Pharmacologic therapy in peripheral diabetic polyneuropathy]

Neuropathy is one of the many complications of diabetes mellitus, along with micro- and macroangiopathy. Chronic sensorimotor distal symmetric polyneuropathy is the most common form between neuropathies; more than 30% of the diabetic patients are affected by this complication. Treatment is based on three cornerstones: (1) multifactorial intervention aimed at normoglycemia; (2) drugs that target pathogenic mechanisms and (3) symptomatic treatment. Among pathogenic treatments, alpha-lipoic acid and benfotiamine are available in several countries. Neuropathic pain, which affects 8-26% of diabetic patients, exerts a substantial impact on the quality of life. Among the centrally acting analgesic drugs, tricyclic antidepressants, carbamazepine, gabapentin and opioids have been mainly used to treat neuropathic pain. More recently, significant pain relief has been reported using agents such as duloxetine, a dual selective serotonin noradrenaline reuptake inhibitor, and pregabalin, an anticonvulsant, a specific modulator of the alpha2delta subunit of the voltage-dependent calcium channels. Until now, at least 50 new molecular entities have reached clinical stage of development. Strategies that may show promise over existing treatments include topical therapies, analgesic combinations and, in future, gene-related therapies.

Vascular and nerve lesions of the diabetic foot--a morphological study

The microcirculation in neuropathic diabetic feet is the subject of the same changes found in other end organs of the diabetic patients. In diabetic neuropathy, abnormal neurogenic regulation of the hemodynamics in the small vessels may contribute to the development of microangiopathy, which is manifested as increased basement thickening.

MATERIAL AND METHODS

The study has been made on a group of 25 patients: nine with diabetes mellitus type 1 and 16 patients with diabetes mellitus type 2. All patients were affected by peripheral diabetic neuropathy and showed various degrees of lesions on the foot level. All cases required amputations done at the lower extremity of the limbs. Tissue fragments were processed for the standard histopathological exam, using Hemalaun-Eosin, trichromic Szekely and van Gieson staining.

RESULTS

The histopathological examination revealed on the skin level--ulcerations covering large areas, while entire sections showed hyperacanthosis. At the dermis level, the microscopic panel was dominated by the presence of the inflammatory infiltrate. The absence or the degeneration of the sweat glands, the presence of venous stasis and perivascular bleedings completed the morphological panel of the dermis. On the microcirculation level, the endothelial cells have a flat smooth inflated aspect. In the case of the large arterioles and arteries of muscular type, we observed the presence of the fibrous tissue on the level of media, calcium deposits on intima, mediocalcinosis.

CONCLUSIONS

The identification of vascular and nervous morphological structures in the complicated diabetic foot allows the extension of the knowledge related to the pathological background of this condition. The vascular lesions, which appeared on the microcirculation level, are consequently involving arterioles and arteries of muscular type and are being accompanied by nervous lesions shown through morphological changes of the peripheral nerves. The overall morphological contest of the complicated diabetic foot involves lesions of the epidermis, dermis, and muscles.

[Prevalence of Helicobacter pylori infection in patients with diabetes mellitus]

Helicobacter pylori (H. pylori) and diabetes mellitus are the most important causes of dyspepsia. The aim of this study was to evaluate the prevalence of H. pylori infection in patients with diabetes mellitus, and to assess whether the infection was associated with severity of dyspeptic syndrome and metabolic glycemic control.

MATERIAL AND METHOD

100 patients with diabetes mellitus type 1 and 2 (41 men and 59 women, mean age 58.59 ani) were included in our study. Each patient completed a self-report questionnaire to obtain information concerning the presence and severity of upper gastrointestinal tract symptoms. H. pylori status was confirmed by serological test and histophatology study of gastric biopsy or 13C-urea breath test.

RESULTS

Prevalence of H. pylori infection was found not to be significantly higher in diabetics than in controls (70% vs 73% ). 49% H. pylori positive diabetics had type 2 insulinonecesitant diabetes mellitus, 27% had type 1 diabetes mellitus and 24% had type 2 diabetes mellitus, with no statistically significant difference (p > 0.05). We found no statistically significant difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. The main value of HbA1 levels in H. pylori--infected diabetics was 7.31% and 7.47% in H. pylori non-infected diabetics, without significant difference.

CONCLUSION

There was no statistically significant difference in the prevalence of H. pylori infection between diabetics and non-diabetics patients and no difference in the symptoms score between H. pylori positive and H. pylori negative diabetic patients. H. pylori in diabetics appears no influence glycemic status.

[Adipocytokines and nonalcoholic steatohepatitis]

Nonalcoholic steatohepatitis is one of the most common liver diseases. It is part of the nonalcoholic fatty liver disease, which ranges from simple hepatic steatosis to necroinflammation and fibrosis of various degrees, so that many patients can evolve towards advanced liver disfunction and even cirrhosis. Insulin resistance is the main factor involved in the development of fatty liver. As the adipose tissue is the source of many metabolically active peptides (the adipocitokines), their involvement in the pathogenesis of the hepatic steatosis and steatohepatitis began to be intensively studied during the last years. The most substantial information collected until now concerns the tumor necrosis factor alpha (a proinflammatory cytokine that induces insulin resistance, fat accumulation in the liver and even fibrosis and necrosis), adiponectin (an anti-inflammatory adipokine that acts as an insulin sensitizer and a hepatic protector) and leptin (a signal from the adipose tissue mass with effects on the appetite and food intake, but also acting upon insulin secretion and action and perhaps upon the liver fat accumulation).

[Adipocitokines and nonalcoholic steatohepatitis]

Nonalcoholic steatohepatitis is one of the most common liver diseases. It is part of the nonalcoholic fatty liver disease, which ranges from simple hepatic steatosis to necroinflammation and fibrosis of various degrees, so that many patients can evolve towards advanced liver disfunction and even cirrhosis. Insulin resistance is the main factor involved in the development of fatty liver. As the adipose tissue is the source of many metabolically active peptides (the adipocitokines), their involvement in the pathogenesis of the hepatic steatosis and steatohepatitis has begun to be intensively studied during the last years. The most substantial information collected until now concerns the tumor necrosis factor alpha (a proinflammatory cytokine that induces insulin resistance, fat accumulation in the liver and even fibrosis and necrosis), adiponectin (an anti-inflammatory adipokine that acts as an insulin sensitizer and a hepatic protector) and leptin (a signal of the adipose tissue mass with effects on the appetite and food intake, but also acting upon insulin secretion and action and perhaps upon the liver fat accumulation).

[Alcoholic ketoacidosis]

Alcoholic ketoacidosis is an acute metabolic acidosis that typically occurs in people who chronically abuse alcohol and have a recent history of binge drinking, little or no food intake and persistent vomiting. Alcoholic ketoacidosis is a result of starvation with glycogen depletion and counter-regulatory hormone production, a raised nicotinamide adenine dinucleotide (NADH) to nicotinamide adenine dinucleotide (NAD+) ratio related to the metabolism of ethanol, and volume depletion resulting in ketogenesis. Alcoholic ketoacidosis is characterized by elevated serum ketone levels and a high anion gap. Once the diagnosis of alcoholic ketoacidosis is made, the mainstay of treatment is hydration with 5% dextrose in normal saline. With timely and aggressive intervention, the prognosis for a patient with alcoholic ketoacidosis is good.

[Specific elements of diagnosis in diabetic nephropathy]

Diabetic nephropathy became nowadays the main cause of end-stage renal disease in the Western world. Common diagnosis tools can detect only late stages of the renal disease, without means of reversibility. The scientific research identified some specific methods of evaluation, detecting early modifications in the renal structure and function. These methods are the subject of the present paper.

[Method for the molecular diagnosis of lipoprotein lipase genetic deficiency]

Modifications of plasma lipid profile is one of the major causes of a high cardiovascular risk. They can be the consequences of mutations in the gene encoding lipoprotein lipase (LPL), an enzyme that has an important role in the metabolism of plasma lipoproteins. The aim of the present study was to put into practice a method for detecting the Gly188Glu mutation in the LPL gene. The search was performed on a group of 107 patients with cardiovascular diseases and/or dyslipidemias. DNA investigation consisted, in a first stage, in the enzymatic digestion of exon 5 of the LPL gene, previously amplified by the PCR reaction, with the AvaII restriction endonuclease. Three of the subjects were further investigated by the sequencing of exon 5, in order to search for the presence of other mutations. We didn't detect the Gly188Glu mutation in none of the cases, and no other mutation in exon 5 was found in the three patients tested by DNA sequencing. We conclude that the amplification-restriction method can be used for the detection of known mutations in the LPL gene, allowing an early identification of the subjects with a high cardiovascular risk and the onset of the appropriate therapy. In order to detect mutations which don't affect the recognition sequence of a restriction enzyme and eventually new mutations, the sequencing of that gene is recommended.

[Medical treatment in diabetic retinopathy]

Diabetic retinopathy is a major cause of blindness worldwide with an expected increasing incidence. Tight blood sugar and blood pressure control have proven essential in preventing both appearance and evolution of retinopathy. Surgical treatments as laser therapy and vitrectomy have also been proved highly effective in preventing major visual loss in advanced stages of retinopathy. Continuous scientific research is leading to a better understanding of pathogenesis of the disease and thus an effective medical treatment is expected in both preventing and treating different stages of diabetic retinopathy. In this update we review ongoing clinical trials and also the knowledge from finalized clinical trials that were testing the clinical impact of experimental treatments or known therapies.

[The study of two immunological markers in patients with type-1 diabetes and in their first degree relatives]

The prediction of diabetes mellitus is mostly based on the existence of plasma markers. The aim of this preliminary study was to determine islet cell antibodies (ICA) and glutamic acid decarboxylase antibodies (GADA) in 28 diabetic children (12 of them having an evolutive disease of 1 year and 16 at the beginning of the diabetes) and to 47 of their first-degree relatives. There have been determined the levels of these two autoantibodies using the ELISA technique.

RESULTS

To 17 of the patients with type I diabetes have been found high levels of GADA (60.7%) while 8 cases have positive ICA (28.5%). For the patients whose disease was diagnosed 1 year ago there have been found differences between the patients with and without antibodies regarding the level of the average values of Hb A1c, the daily insulin needs and the remission period. From the tested parents (a total of 25), 7 was GADA positive (28%), 6 had both antibodies present (24%) and one mother was ICA positive (4%). 9 of the brothers and sisters of the diabetic patients had high levels of GADA and 2 had both antibodies present. To the first-degree relatives with autoantibodies must be determined other plasma markers too (IAA, IA-2A) as well as genetic markers (HLA typing).

CONCLUSION

The use of plasma markers is recommended as a first step in discovering the relatives with potential risk of developing the disease.

[The cardiovascular reflex tests in autonomic cardiac neuropathy diagnosis]

Ewing's five standard cardiovascular reflex tests were used for the assessment of autonomic function. Changes in heart rate during deep inspiration and expiration, Valsalva manoeuvre or standing up evaluate parasympathetic innervation, whereas blood pressure fluctuations during standing up and handgrip evaluate sympathetic innervation. According to physiological principles we must remind that each test is useful predominantly but not exclusively to reveal the impairment of parasympathetic or sympathetic innervation. A total of 271 patients (247 with diabetes mellitus) were estimated for the diagnosis of autonomic neuropathy. Computed time domain analysis of the heart rate variability reveals 21% of the patients with autonomic neuropathy, but this method doesn't rich the performance of spectral analysis witch is x3 times greater. The deep inspiration and expiration remains the preferable test according to its sensibility, specificity and predictive value. I found that handgrip test has, beside the known limitations (arterial hypertension, heart failure, valvular disease, emphysema, advanced diabetic retinopathy, drugs like digitalis, beta-receptor blockers, antihypertensives, sedatives, etc.) one more linked by the hand muscular force. Orthostatic hypertension has too many false results so the interpretation must be done with much precaution.

[The pathological mechanisms of glycoregulation disturbances in chronic hepatitis B and C]

Despite the abundance of reports concerning the increased frequency of diabetes and impaired glucose tolerance in chronic liver diseases, the mechanisms underlying this phenomenon have not been resolved. 30 patients with hepatitis C virus (HCV) infection and 17 with hepatitis B virus (HBV) infection who showed an altered responds to a standard oral glucose tolerance test were investigated in order to evaluate their pancreatic-endocrine features. We have also evaluated 40 patients (20 with HCV infection and 20 with HCB infection) who developed diabetes after diagnosis of liver disease. Patients with HBV infection showed signs of enhanced insulin resistance but overt diabetes develops in those who, in addition to insulin insensitivity, have a relative defect of insulin secretion. In patients with HCV infection the significantly lower plasma insulin and C-peptide levels suggest that impairment of insulin secretion is the main mechanism leading to both glucose intolerance and overt diabetes.

The relationship between the lipid structure of the hair and acute myocardial infarction

In a group of patients with acute myocardial infarction (AMI) an evaluation of the derangements in lipid metabolism was carried out by analysing the fat structure of the hair (closely reflecting serum lipid variations). The data obtained reflects the real incidence of dyslipidemia associated with myocardial infarction. Through hair analysis, the evaluation in time (over weeks, months) of lipids metabolism under hypolipidemic therapy can be carried out without taking repeated samples.