The effects of a fibre-enriched bakery product on glucose, insulin values and appetite. A pilot randomised cross-over trial

Brewers spent grain (BSG) is a valuable source of arabinoxylans with potential beneficial effects on glucose values. This pilot randomised crossover double-blind trial compared the effects of panettone, a sweet baked-product, enriched with BSG-fibre (p-rich) to unenriched panettone (p-standard) on glucose and insulin blood values and appetite scores. Ten healthy volunteers consumed each food in a random order. Blood variables and appetite scores were assessed at fasting and at different intervals after each food consumption. Glucose values were significantly higher after p-standard intake at 90-min (89.9 ± 16.1 vs 74.6 ± 19.4 mg/dL) and 120-min (81.1 ± 9.85 vs 72.1 ± 14.0 mg/dL). The areas-under-the-curve (AUCs) were lower for both glucose (p = .043) and insulin values (p = .036) with p-rich. At 240-min, satiety was higher (p = .006), and desire-to-eat lower (p = .008) with p-rich; desire-to-eat AUC was lower with p-rich too (p = .029). The integration of a small amount of BSG-derived fibre into a sweet food led to improved glycaemic control and appetite regulation.

Pre-operative micronutrient deficiencies in patients with severe obesity candidates for bariatric surgery

PURPOSE

In patients with obesity, micronutrient deficiencies have been reported both before and after bariatric surgery (BS). Obesity is a chronic pro-inflammatory status, and inflammation increases the risk of micronutrient malnutrition. Our objective was to assess in pre-BS patients the prevalence of micronutrient deficiencies and their correlation with blood values of C-reactive protein (CRP).

METHODS

Anthropometric data, instrumental examinations, and blood variables were centrally measured in the first 200 patients undergoing a pre-BS evaluation at the "Città della Salute e della Scienza" Hospital of Torino, starting from January 2018.

RESULTS

At least one micronutrient deficiency was present in 85.5% of pre-BS patients. Vitamin D deficiency was the most prevalent (74.5%), followed by folate (33.5%), iron (32%), calcium (13%), vitamin B12 (10%), and albumin (5.5%) deficiency. CRP values were high (> 5 mg/L) in 65% of the patients. These individuals showed increased rate of iron, folate, vitamin B12 deficiency, and a higher number of micronutrient deficiencies. In a multiple logistic regression model, increased CRP levels were significantly associated with deficiencies of vitamin B12 (OR = 5.84; 95% CI 1.25-27.2; p = 0.024), folate (OR = 4.02; 1.87-8.66; p < 0.001), and with the presence of ≥ 2 micronutrient deficiencies (OR = 2.31; 1.21-4.42; p = 0.01).

CONCLUSIONS

Micronutrient deficiencies are common in patients with severe obesity undergoing BS, especially when inflammation is present. In the presence of increased CRP values before surgery, it might be advisable to search for possible multiple micronutrient deficiencies.

What predicts the unsuccess of bariatric surgery? An observational retrospective study

PURPOSE

Bariatric surgery (BS) has been recognized as an effective treatment for most patients with morbid obesity, but a variable range of patients failed to achieve a successful weight-loss. Controversial data are available about predictors of unsuccess. We aimed to retrospectively assess whether clinical baseline characteristics of patients submitted to sleeve gastrectomy (SL) or gastric bypass (GBP) were associated with unsuccessful weight-loss after 12 and 24-month follow-up.

METHODS

Three hundred patients who underwent BS from the 1st January 2016, with at least 24-months follow-up, were enrolled. Patients were divided according to their percentage of excess weight-loss (%EWL) either < 50% or ≥ 50% after 12 and 24-month follow-up.

RESULTS

None of the patients was lost at follow-up; 56 (18.7%) patients showed a %EWL < 50% at 24 months. Age, neck circumference, obstructive sleep apnea (OSA) were significantly higher, while total cholesterol and %EWL 6-months lower in those with %EWL < 50% at 12-months. Age, neck circumference, male and OSA rates were increased, while %EWL at 6-months lower in patients with %EWL < 50% at 24-months. In a multiple regression model, age (OR = 1.076; 95% CI 1.029-1.125; p = 0.001; OR = 1.066; 1.027-1.107; p < 0.001) and %EWL at 6-months (OR = 0.876; 0.840-0.913; p < 0.001; OR = 0.950; 0.928-0.972; p < 0.001) were associated with %EWL < 50% both at 12- and 24-months, respectively, and neck circumference (OR = 1.142; 1.011-1.289; p = 0.032) with %EWL < 50% at 24-months.

CONCLUSION

Older age, larger neck circumference, and %EWL at 6-months were significantly associated with BS unsuccess, showing almost 90% of those patients an unsuccessful weight-loss early after surgery. Further larger studies with longer follow-up are needed to confirm these results.

Ceramides and diabetes mellitus: an update on the potential molecular relationships

Recent evidence suggests that ceramides can play an important pathophysiological role in the development of diabetes. Ceramides are primarily recognized as lipid bilayer building blocks, but recent work has shown that these endogenous molecules are important intracellular signalling mediators and may exert some diabetogenic effects via molecular pathways involved in insulin resistance, β-cell apoptosis and inflammation. In the present review, we consider the available evidence on the possible roles of ceramides in diabetes mellitus and introduce eight different molecular mechanisms mediating the diabetogenic action of ceramides, categorized into those predominantly related to insulin resistance vs those mainly implicated in β-cell dysfunction. Specifically, the mechanistic evidence involves β-cell apoptosis, pancreatic inflammation, mitochondrial stress, endoplasmic reticulum stress, adipokine release, insulin receptor substrate 1 phosphorylation, oxidative stress and insulin synthesis. Collectively, the evidence suggests that therapeutic agents aimed at reducing ceramide synthesis and lowering circulating levels may be beneficial in the prevention and/or treatment of diabetes and its related complications.

Impaired taste sensation in type 2 diabetic patients without chronic complications: a case-control study

PURPOSE

Few and contradictory data suggest changes in taste perception in type 2 diabetes (T2DM), potentially altering food choices. We, therefore, analyzed taste recognition thresholds in T2DM patients with good metabolic control and free of conditions potentially impacting on taste, compared with age-, body mass index-, and sex-matched normoglycemic controls.

METHODS

An ascending-concentration method was used, employing sucrose (sweet), sodium chloride (salty), citric acid (sour), and quinine hydrochloride (bitter), diluted in increasing concentration solutions. The recognition threshold was the lowest concentration of correct taste identification.

RESULTS

The recognition thresholds for the four tastes were higher in T2DM patients. In a multiple regression model, T2DM [β = 0.95; 95% CI 0.32-1.58; p = 0.004 (salty); β = 0.61; 0.19-1.03; p = 0.006 (sweet); β = 0.78; 0.15-1.40; p = 0.016 (sour); β = 0.74; 0.22-1.25; p = 0.006 (bitter)] and waist circumference [β = 0.05; 0.01-0.08; p = 0.012 (salty); β = 0.03; 0.01-0.05; p = 0.020 (sweet); β = 0.04; 0.01-0.08; p = 0.020 (sour); β = 0.04; 0.01-0.07; p = 0.007 (bitter)] were associated with the recognition thresholds. Age was associated with salty (β = 0.06; 0.01-0.12; p = 0.027) and BMI with sweet thresholds (β = 0.06; 0.01-0.11; p = 0.019).

CONCLUSIONS

Taste recognition thresholds were higher in uncomplicated T2DM, and central obesity was significantly associated with this impairment. Hypogeusia may be an early sign of diabetic neuropathy and be implicated in the poor compliance of these patients to dietary recommendations.

Self-reported adherence to diet and preferences towards type of meal plan in patient with type 2 diabetes mellitus. A cross-sectional study

BACKGROUND AND AIMS

Few studies have evaluated the attitudes of patients with type 2 diabetes mellitus (T2DM) towards the given dietary plans. In this study, we aimed to evaluate: i) the self-reported adherence of T2DM patients to the prescribed diets; ii) the use of other types of diet schemes; iii) the patients' preferences towards the type of meal plans.

METHODS AND RESULTS

A 16 multiple-choice items questionnaire was administered to 500 T2DM patients; 71.2% (356/500) of them had the perception of having received a dietary plan; only 163/356 declared to be fully adherent. The latter had lower BMI (25.8 ± 4.5 vs 29.1 ± 4.5 kg/m², p < 0.001) than patients who were partly adherent. Among patients not following the given diet, 61.8% was eating in accordance to a self-made diet and 20.9% did not follow any diet. Only a few patients (2.4%) had tried a popular diet/commercial program. Most patients preferred either a "sufficiently free" (201/500) or a "free" (218/500) scheme. The use of supplements attracted younger, obese individuals, with higher education, and most managers. In a multinomial regression model, age and diabetes duration were inversely associated with the choice of a "rigid" scheme, diabetes duration and glycated hemoglobin levels were inversely correlated with a "free" diet choice, obesity was associated with a "strategic" scheme choice, while lower education (inversely) and obesity (directly) correlated with the preference for "supplement use".

CONCLUSIONS

Socio-cultural/individual factors could affect attitudes and preferences of T2DM patients towards diet. These factors should be considered in order to draw an individually tailored dietary plan.

Effects of 6 months of resveratrol versus placebo on pentraxin 3 in patients with type 2 diabetes mellitus: a double-blind randomized controlled trial

AIMS

The anti-inflammatory effects of the polyphenol resveratrol in patients with type 2 diabetes mellitus (T2DM) are controversial. Its role on pentraxin 3 (PTX3) concentrations, a human acute phase protein, has never been evaluated. Our aim was to determine whether a two-dosage resveratrol supplementation (500 and 40 mg/day) has an impact on PTX3 values in T2DM patients from a double-blind randomized placebo-controlled trial. Variations in total antioxidant status (TAS) were evaluated too.

METHODS

A total of 192 T2DM patients were randomized to receive resveratrol 500 mg/day (Resv 500 arm), resveratrol 40 mg/day (Resv 40 arm) or placebo for 6 months. At baseline and at the trial end, PTX3 and TAS values were determined.

RESULTS

A dose-dependent increase in PTX3 concentrations of 4.7% (Resv 40 arm) and 26.3% (Resv 500 arm), and 8.0% reduction after placebo were found. Adjusted mean differences of change versus placebo were 0.16 (95% CI 0.01-0.32) and 0.25 (0.09-0.42) in the Resv 40 and Resv 500 arms, respectively. At subgroup analyses, lower diabetes duration, aspirin, alcohol use, younger age, female gender, smoking (Resv 500 arm) and female gender and aspirin use (Resv 40 arm) were associated with higher PTX3 increments. A dose-dependent increment in TAS values in the resveratrol arms (1.4 and 6.4% for Resv 40 and Resv 500, respectively), and a reduction in placebo arm (-8.9%) were observed. Adjusted mean differences of change were 28.5 (95% CI 10.1-46.8) and 44.8 (25.4-64.1) in the Resv 40 and Resv 500 arms, respectively.

CONCLUSION

Resveratrol supplementation increased PTX3 and TAS levels in a dose-dependent manner in T2DM patients. At present, potential clinical implications of these results remain unclear. CLINICALTRIALS.

GOV IDENTIFIER

NCT02244879.

The acute impact of the intake of four types of bread on satiety and blood concentrations of glucose, insulin, free fatty acids, triglyceride and acylated ghrelin. A randomized controlled cross-over trial

The purpose of the present study is to compare the effects of four different breads (one commercial par-baked wheat bread, three sourdough breads prepared with commercial wheat flour, organic wheat flour, organic einkorn flour) in 16 healthy subjects. The primary outcome of this randomized cross-over trial was evaluating intra-individual changes in glycemic areas-under-the-curve (AUCs) after 50g carbohydrate portions of each bread; secondary outcomes were changes in insulin, fatty free acids (FFA), triglyceride, acylated ghrelin and satiety AUCs. Blood samples and satiety ratings were collected every 30-min for 2-h after the consumption of each bread. The einkorn flour showed the lowest amylase activity, the commercial flour the highest; commercial bread had the highest carbohydrate content and the lowest dietary fiber content. Glucose AUCs were significantly lower after the consumption of sourdough breads made with organic (12,754±1433mg/dL×h) and einkorn flour (12,216±1210mg/dL×h), with respect to the commercial bread (13,849±2193mg/dL×h). Insulin AUCs decreased after the consumption of all sourdough breads when compared to commercial bread. FFA and triglyceride AUCs did not differ by kind of breads. Median ghrelin AUC was significantly lower and satiety higher after the einkorn bread (3710pg/mL×h; 3225±2414, respectively) than after commercial bread consumption (4140pg/mL×h; 1706±1766, respectively), but not with other sourdough breads. In conclusion, the use of sourdough may improve the nutritional features of breads; einkorn bread induced the least disturbance in carbohydrate homeostasis and the greater satiety. If confirmed by further research, these results might have implications in the approach towards chronic dysmetabolic diseases.

Utility of DSM-5 section III personality traits in differentiating borderline personality disorder from comparison groups

OBJECTIVE

Borderline Personality Disorder (BPD) is a highly prevalent diagnosis in mental health care and includes a heterogeneous constellation of symptoms. As the field of personality disorder (PD) research moves to emphasize dimensional traits in its operationalization, it is important to determine how the alternative DSM-5 Section III personality trait dimensions differentiates such features in BPD patients versus comparison groups. To date, no study has attempted such validation.

METHOD

The current study examined the utility of the DSM-5 trait dimensions in differentiating patients with the categorical DSM-IV/5 diagnosis of BPD (n=101) from systematically matched samples of other PD patients (n=101) and healthy controls (n=101). This was investigated using one-way ANOVA and multinomial logistic regression analyses.

RESULTS

Results indicated that Emotional Lability, Risk Taking, and Suspiciousness uniquely differentiated BPD patients from other PD patients, whereas Emotional Lability, Depressivity, and Suspiciousness uniquely differentiated BPD patients from healthy controls.

CONCLUSION

Emotional Lability is in particular a key BPD feature of the proposed Section III model, whereas Suspiciousness also augments essential BPD features. Provided that these findings are replicated cross-culturally in forthcoming research, a more parsimonious traits operationalization of BPD features is warranted.

Time to positivity of blood culture and its prognostic value in bloodstream infection

The purpose of this study was to investigate the relationship between the time to positivity (TTP) of blood cultures and outcome in patients with bloodstream infections (BSIs). Between January 1st, 2011 and December 31st, 2013, the blood cultures of inpatients with BSI or catheter-related BSI were collected at Peking University Third Hospital. The TTP of different isolates was analyzed, and the relationship between the TTP of isolates and outcome of patients with Enterobacter BSI was retrospectively analyzed. We analyzed the TTP of 886 isolates. Escherichia coli has the shortest (11.97 ± 10.06 h) and Candida has the longest first TTP (61.62 ± 42.77 h). 68.01 % of isolates reached positivity within 24 h and 88.33 % within 48 h. Over 90 % of E. coli isolates reached positivity within 24 h. Over 50 % of Candida isolates reached positivity within 48 h. The TTP differed significantly between cultures that were single or double positive for coagulase-negative staphylococci isolates, Enterobacteriaceae, and Pseudomonas aeruginosa, and between aerobic and anaerobic cultures of E. coli (p < 0.05). However, the TTP did not differ significantly between coagulase-negative staphylococci (double positivity) and Staphylococcus aureus. The best TTP threshold for prediction of mortality from Enterobacter species BSI was 16.3 h [area under the curve (AUC) 0.730, 95 % confidence interval (CI) 0.557, 0.864, sensitivity 100 %, specificity 44.4 %]. The TTP of clinical isolates may represent a valuable marker of the clinical significance of BSIs. Laboratories and clinics should consider using the TTP to predict the prognosis of patients with BSI by bacteria, including Enterobacter and other species.

Simple lifestyle recommendations and the outcomes of gestational diabetes. A 2 × 2 factorial randomized trial

The benefits of exercise and behavioural recommendations in gestational diabetes mellitus (GDM) are controversial. In a randomized trial with a 2 × 2 factorial design, we examined the effect of exercise and behavioural recommendations on metabolic variables, and maternal/neonatal outcomes in 200 GDM patients. All women were given the same diet: group D received dietary recommendations only; group E was advised to briskly walk 20-min/day; group B received behavioural dietary recommendations; group BE was prescribed the same as B + E. Dietary habits improved in all groups. In a multivariable regression model, fasting glucose did not change. Exercise, but not behavioural recommendations, was associated with the reduction of postprandial glucose (p < 0001), glycated haemoglobin (HbA1c; p < 0.001), triglycerides (p = 0.02) and C-reactive protein (CRP; p < 0.001) and reduced any maternal/neonatal complications (OR = 0.50; 95%CI=0.28-0.89;p = 0.02). In GDM patients a simple exercise programme reduced maternal postprandial glucose, HbA1c, CRP, triglycerides and any maternal/neonatal complications, but not fasting glucose values.

High-normal blood pressure and impaired renal function. A prospective study in a population-based cohort

AIM

The association between high-normal blood pressure and the impairment of renal function is highly controversial. We analysed the contribution of high-normal blood pressure on incident impaired renal function.

METHODS

The study was performed in a population-based cohort of 1307 subjects free of diabetes, cardiovascular and renal disease at baseline, who attended both at baseline and after 6-year follow-up a metabolic screening. The outcome was incident impaired renal function, defined as a glomerular filtration rate <60 mL/min/1.73 m2.

RESULTS

Incidence of impaired renal function was 2.5%, 4.5%, 8.7% and 10.8% in optimal, normal, high-normal blood pressure and hypertension, respectively. Adjusted relative odds ratio (OR) of impaired renal function were modelled using logistic regression analyses including multiple confounders. The adjusted OR were 1.6 (95% CI 0.5-5.0) for normal blood pressure, 3.4 (1.2-10.3) for high-normal blood pressure and 3.7 (1.3-10.7) for hypertension. Results were similar after excluding overweight or obese patients.

CONCLUSION

High-normal blood pressure is an independent predictor of impaired renal function. Trials are warranted to test if therapeutic intervention on blood pressure is justified also in subjects with high-normal blood pressure to preserve renal function.

Variations of serum levels of adiponectin and resistin in chronic viral hepatitis

BACKGROUND AND AIMS

Several studies investigated the possible role of adipokines during chronic viral hepatitis, not producing defined results neither clearly establishing their behavior in course of anti-viral treatment. Our study evaluated blood concentrations of adiponectin and resistin in patients with chronic hepatitis C (CHC), B (CHB), and D (CHD) receiving anti-viral treatment, at baseline and after therapy.

METHODS

We examined 122 subjects, divided into two groups: 64 patients with chronic hepatitis C virus (HCV) infection (38 males and 26 females, mean age 47.25 yr) and 58 patients including 39 ones with chronic hepatitis B virus (HBV) infection (26 males and 13 females, mean age 48.46 yr) and 19 ones with chronic HBV-hepatitis D virus (HDV) infection (15 males and 4 females, mean age 45.79 yr). Serum levels of adiponectin and resistin were assayed by enzyme-linked immunosorbent assay.

RESULTS

In the group of CHC patients we observed a significant decrease in resistin after therapy (p=0.006), while not a significant increase in adiponectin after treatment (p=0.32). Evaluation of changes in adiponectin and resistin levels after anti-viral treatment, both in responders and non-responders, revealed no significant variations. In the group of HBV+ and HBV-HDV+ patients, we found a decrease in resistin after therapy (p=0.0016) and a not significant reduction in adiponectin after treatment (p=0.13). Furthermore, we noticed a significant reduction of resistin (p=0.006) in the sub-group of responders.

CONCLUSIONS

Our data suggested the possible marker role of adiponectin and resistin in the inflammatory process in course of chronic viral hepatitis.

Is left ventricular hypertrophy a low-level inflammatory state? A population-based cohort study

BACKGROUND AND AIMS

Cross-sectional studies have shown that chronic sub-clinical inflammation is associated with left ventricular hypertrophy (LVH), but results are conflicting. We investigated the association between baseline LVH and high-sensitivity C-reactive protein (CRP) values, both cross-sectionally and after a six-year-follow-up, in a population-based cohort (n = 1564) and a subgroup from this cohort (n = 515), without obesity, diabetes, metabolic syndrome or any drugs.

METHODS AND RESULTS

ECG tracings at baseline were interpreted according to the Cornell voltage-duration product criteria: 166/1564 subjects (10.6%) showed LVH. Patients with baseline LVH showed increased BMI, waist circumference, blood pressure, and a worse metabolic pattern. Their CRP values both at baseline and at follow-up were almost two-fold higher than in patients without LVH. Similar results were found in the healthier sub-sample. In a multiple regression model, CRP at follow-up was directly associated with baseline LVH (expressed as Cornell voltage-duration product) in the whole cohort (β = 0.0003; 95%CI 0.0002-0.0006; p < 0.001) and in the sub-sample (β = 0.0003; 0.0002-0.0004; p < 0.001), after adjusting for age, sex, BMI, waist circumference, smoking, exercise levels, blood pressure and baseline CRP values.

CONCLUSION

Baseline LVH, which is associated with systemic inflammation, predicts increased CRP values at follow-up, independently of cardiovascular and metabolic risk factors, both in a population-based cohort and a healthier sub-sample. The inflammatory consequences of LVH might be an intriguing subject for further researches.

C-peptide and the risk for incident complications and mortality in type 2 diabetic patients: a retrospective cohort study after a 14-year follow-up

OBJECTIVE

C-peptide, a cleavage product of insulin, exerts biological effects in patients with type 1 diabetes mellitus, but its role in type 2 diabetes mellitus is controversial. Our aim was to examine the associations between fasting C-peptide levels and all-cause mortality, specific-cause mortality and the incidence of chronic complications in patients with type 2 diabetes.

DESIGN

Retrospective cohort study with a median follow-up of 14 years.

METHODS

A representative cohort of 2113 patients with type 2 diabetes mellitus and a subgroup of 931 individuals from this cohort without chronic complications at baseline from a diabetic clinic were studied.

RESULTS

Patients with higher C-peptide levels had higher baseline BMI and triglyceride and lower HDL-cholesterol values. During the follow-up, 46.1% of the patients died. In a Cox proportional hazard model, after multiple adjustments, no significant association was found between the C-peptide tertiles and all-cause mortality or mortality due to cancer, diabetes or cardiovascular diseases. In the subgroup of 931 patients without chronic complications at baseline, the incidence of microvascular complications decreased from the first to the third C-peptide level tertile, while the incidence of cardiovascular disease did not differ. The risks for incident retinopathy (hazard ratio (HR)=0.33; 95% confidence interval (CI) 0.23-0.47), nephropathy (HR=0.27; 95% CI 0.18-0.38) and neuropathy (HR=0.39; 95% CI 0.25-0.61) were negatively associated with the highest C-peptide tertile, after adjusting for multiple confounders.

CONCLUSIONS

Higher baseline C-peptide levels were associated with a reduced risk of incident microvascular complications but imparted no survival benefit to patients with type 2 diabetes mellitus.

The rs553668 polymorphism of the ADRA2A gene predicts the worsening of fasting glucose values in a cohort of subjects without diabetes. A population-based study

AIMS

Single-nucleotide polymorphisms in the human ADRA2A gene have been associated with increased risk of Type 2 diabetes. The associations between the rs553668 polymorphism and fasting glucose concentrations both cross-sectionally and longitudinally after 6-year follow-up were evaluated in an adult Caucasian population-based cohort.

METHODS

From a cohort of 1658 individuals, after excluding patients with diabetes, those who died and those whose blood samples were not available for genotyping, data of 1345 individuals were analysed.

RESULTS

Subjects homozygous for the A allele showed significantly increased baseline fasting glucose values and a significant worsening of fasting glucose (β = 0.48; 95% CI 0.10-0.86) and insulin secretion (β =-20.75; -32.67 to -8.82 for homeostasis model assessment for β-cell function) at follow-up by using generalized estimating equations. Incidence of impaired fasting glucose and diabetes was almost twofold higher in subjects homozygous for the A allele (respectively: incident impaired fasting glucose 7.6-8.2, 16.1%, incident diabetes 1.7-2.3, 3.2% in GG, AG, AA carriers).

CONCLUSIONS

Our results suggested that the rs553668 polymorphism is associated with glucose worsening in subjects without diabetes at baseline.

Does use of metformin protect against cancer in Type 2 diabetes mellitus?

BACKGROUND

Type 2 diabetes mellitus has been associated with an increased cancer risk, which can be modified by specific hypoglycemic drugs. In particular, metformin, the most frequently prescribed biguanide, is now considered a protective agent against cancer incidence and mortality in Type 2 diabetic patients.

AIMS

To review the potential associations between metformin use and cancer incidence and mortality and the possible biological links implicated in these associations.

MATERIALS AND METHODS

We searched English-language original investigations published through September 2011.

RESULTS

Metformin could block the mitogenic effects of insulin, but this effect does not entirely explain the reduction in cancer incidence. Metformin also plays a direct inhibition of cancer cell growth via the inhibitory effects of AMP-activated protein kinase on the mTOR pathway, which regulates cell growth and proliferation. Accordingly, many epidemiological studies have shown that metformin use is associated with a lower cancer incidence and mortality through a dose-response relationship, with greater exposure being associated with stronger risk reduction. Randomized clinical trials testing the effects of metformin on both recurrence and survival in early-stage breast cancer are on-going; these trials are based on pilot studies demonstrating an adjuvant effect of this drug in breast cancer.

CONCLUSIONS

Metformin is an inexpensive and safe drug, that may modify the increased cancer risk of Type 2 diabetic patients. On-going clinical trials will show whether this drug can enhance the effect of chemotherapy in the treatment of cancer.

Cancer mortality reduction and metformin: a retrospective cohort study in type 2 diabetic patients

AIMS

Few studies suggest that metformin decreases cancer mortality in type-2 diabetic patients (T2DP). We explored the association between the type and duration of antidiabetic therapies and cancer and other-than-cancer mortality in a T2DP cohort, taking into account the competing risks between different causes of death and multiple potential confounding effects. The mortality rates were compared with the general population from the same area.

METHODS

In 1995, all T2DP (n = 3685) at our diabetes clinic in Turin (∼12% of all T2DP in the city), without cancer at baseline, were identified. Vital status was assessed after a mean 4.5-year follow-up.

RESULTS

Metformin users had greater adiposity, while insulin users had more co-morbidities. All-cause- and cancer-related deaths occurred in: 9.2 and 1.6% of metformin users, 13.1 and 3.0% of sulfonylureas users and 26.8 and 4.8% of insulin users, respectively. In a Cox regression model for competing risks, adjusted for propensity score, metformin users showed a lower cancer mortality risk [hazard ratio (HR) = 0.56; 95% confidence interval (CI) 0.34-0.94], while insulin was positively associated with other-than-cancer mortality (HR = 1.56; 95%CI 1.22-1.99). Each 5-year metformin exposure was associated with a reduction in cancer death by 0.73, whereas every 5-year insulin exposure was associated with 1.25-fold increase in other-than-cancer death. Standardized mortality ratios for cancer and other-than-cancer mortality in metformin users were 43.6 (95%CI 25.8-69.0) and 99.1 (95%CI 79.3-122.5), respectively, in comparison with the general population.

CONCLUSIONS

Metformin users showed a lower risk of cancer-related mortality than not users or patients on diet only; this may represent another reason to choose metformin as a first-line therapy in T2DP.

Issues of internal medicine in psychiatric patients

In opposition to opinions of a sectorialization of psychiatric illness, phenomena of comorbidity due to susceptibility of psychiatric patients to contract other diseases--whose co-presence is difficult to translate and treat--are more and more evident. In this review we have marked main issues of internal medicine in psychiatric patients. This review will discuss particularly main cardiovascular diseases (CAD, VTE), lung diseases (COPD,asthma, restrictive lung disease) gastroenterologic disease (IBS, coeliac disease, ulcerous rectocolitis), diabetes and metabolic syndrome, more likely infections verified in these patients (HIV, viral hepatitis), cancers considerably underlined (breast cancer, colon-rectal cancer and lung cancer), internistic issues in alcohol abuse which is a frequent state in these subjects. A special chapter is dedicated to antipsychotics. These drugs are characterized by a complex action modality and by frequent interactions with a large number of other drugs.

Male sexual disturbances in liver diseases: what do we know?

The alterations of sexual function known as the erectile dysfunction are quite frequent among patients affected by liver diseases and they tend to increase in advanced liver failure. This process is directly linked to cirrhosis or its treatments, such as liver transplantation, or to certain drugs (e.g. beta-blockers). Independent of cirrhosis, other factors may cause sexual problems in these patients. Alcohol itself seems to worsen sexual function in the absence of cirrhosis. Viral hepatitis has an uncertain influence on male gonadic function and even antiviral therapy itself can worsen some seminal and hormonal parameters, although it is reversible. Quality of life may be greatly decreased in cases of cirrhosis where these alterations are present, so it is important to value and care for them, if possible. This review investigates the major male sexual disturbances in liver diseases of various origins.

Plasma visfatin concentrations after a lifestyle intervention were directly associated with inflammatory markers

BACKGROUND AND AIMS

The biological activity and regulation of the novel adipokine visfatin are still largely unknown. Our aim was to evaluate if visfatin plasma concentrations may be influenced by a lifestyle intervention.

METHODS AND RESULTS

Out of 335 dysmetabolic patients from a population-based cohort, randomized to receive a lifestyle intervention program (intervention group) or family physician usual care (controls), 20 patients per group were randomly selected for plasma visfatin determination. The before-after variation (Delta) in visfatin concentration at 1-year from randomization, and the correlations between (Delta)visfatin and intervention-induced changes in waist circumference, fasting glucose, markers of inflammation, and oxidative stress were evaluated. The intervention group showed a significant improvement in waist circumference, and many metabolic/inflammatory variables, while the controls worsened. Visfatin concentrations slightly decreased in the former and significantly increased in the controls ((Delta)visfatin=-2.4 vs 66.0 ng/ml, p<0.001). In robust regression models, the following variables resulted associated with (Delta)visfatin: (Delta)waist circumference, (Delta)fasting glucose, (Delta)hs-CRP (high-sensitivity C-reactive protein) and (Delta)TNFalpha (tumor necrosis factor-alpha). Significant effects on (Delta)visfatin of (Delta)TNFalpha (beta=16.8; 6.1-25.6; p=0.003) and, modified by group, of (Delta)hs-CRP (beta=29.8; 95% CI 15.4-44.2; p<0.001 and beta=4.2; 2.9-5.5; p<0.001 in the control and intervention group, respectively) were detected. By controlling for (Delta)waist, the effects of (Delta)TNFalpha and of (Delta)hs-CRP on (Delta)visfatin by group did not change, while (Delta)waist was no longer associated. The association between (Delta)visfatin and (Delta)glucose was no longer significant, after adjusting for (Delta)hs-CRP.

CONCLUSION

Visfatin values increased with waist circumference and were associated with variations of inflammatory markers, suggesting participation in inflammatory mechanisms.

Molecular characterisation of outbreak-related strains of vancomycin-resistant Enterococcus faecium from an intensive care unit in Beijing, China

We investigated an outbreak of vancomycin-resistant Enterococcus faecium affecting 14 patients in a 20-bed intensive care unit (ICU) between September 2006 and August 2007 (incidence: 3.56 cases per 1000 ICU patient days). Eighteen isolates of vanA type E. faecium were analysed by pulsed field gel electrophoresis, which showed 14 types overall. Multilocus sequence typing (MLST) identified eight different sequence types (STs) (ST78, ST117, ST203, ST316, ST362, ST363, ST364 and ST365), including four new types (ST362, ST363, ST364 and ST365) and 17 strains belonged to clonal complexes CC17. Sixteen of these carried the esp gene. Eighteen Tn1546-like elements encoding vanA-type VRE were classified into three types (types I to III) and all of them contained both IS1216V and IS1542 insertions. Vancomycin resistance of 14 vanA type E. faecium isolates was transferred at a frequency of 1.3 x 10(-6) to 6.4 x 10(-5) between E. faecium strains during filter mating. Our findings indicate that conjugative dissemination of Tn1546-like elements among CC17 E. faecium occurred during the outbreak in this ICU.

Characteristics of liver diseases in the elderly: a review

Chronic liver diseases are becoming more commonly diagnosed in the elderly, although they are not age-related. Most liver functions in advanced age appear to be well preserved, but some changes in liver morphology and physiology with aging may lead to several differences in clinical course and management of liver diseases in older patients compared to younger. A cautious individual evaluation is therefore required in aged patients, especially concerning reduced hepatic drug clearance and comorbidity. Many chronic liver diseases are characterized by a slow and indolent course with non-specific clinical presentation and this may lead a later diagnosis in the elderly. The presence of an advanced liver disease or cirrhosis is more frequent in old patients as the first clinical presentation. No significant differences in diagnostic investigations or treatment options occur between the elderly and the young. Hepatocellular carcinoma is an affliction of the old patients (mean age 65 age) and follow up with ultrasonography and alpha-fetoprotein is mandatory. Advanced age is not considered a contraindication to liver transplantation, but recipients older than 60 years with poor hepatic synthetic function and comorbidity show a worse prognosis with lower survival rates. This review focuses on new emerging conditions, clinical features and updated therapeutic approaches of the most common chronic liver diseases among the elderly.

What predicts the occurrence of the metabolic syndrome in a population-based cohort of adult healthy subjects?

BACKGROUND

Metabolic syndrome (MS), the concurrence of hyperglycaemia, dyslipidaemia, hypertension and visceral obesity, increases cardiovascular risk and mortality. Predictors of MS were previously evaluated in patients without the full syndrome, but with some of its traits. This might confound the resulting associations.

METHODS

The relationship between baseline variables and MS development was evaluated in healthy middle-aged subjects without any MS component at baseline, over a 4.5-year follow-up.

RESULTS

From a population-based cohort of 1658 subjects, 241 individuals showed no MS components and 201 (83.4%) of them participated in a follow-up screening. At baseline, patients who developed the MS (n = 28/201; 13.9%) showed significantly higher Homeostasis Model Assessment-Insulin Resistance score (HOMA-IR) and C-reactive protein (CRP) values, and lower exercise level than subjects who did not. In a multiple logistic regression analysis, after multiple adjustments, the only baseline variable significantly (p < 0.01) associated with the MS was CRP (OR = 4.05; 95% CI 2.23-7.38; p < 0.001). Results did not change after adjusting for weight gain. The area under the receiver-operating curve was 0.83 for CRP after multiple adjustments. The optimal cut-off point of baseline CRP values was 2.1 mg/L, with 86% (95% CI 81-90) sensitivity and 75% (69-81) specificity in predicting the MS. Baseline CRP resulted associated with after-study glucose values in a multiple regression model (beta = 0.14; 0.08-0.20; p < 0.001).

CONCLUSIONS

Higher baseline CRP values confer a significant increased risk of developing the MS in healthy subjects, independently of weight gain.

Plasma adiponectin levels in primary biliary cirrhosis: a novel perspective for link between hypercholesterolemia and protection against atherosclerosis

INTRODUCTION

Hypercholesterolemia is a common finding in primary biliary cirrhosis (PBC), but the risk of cardiovascular events in PBC patients is not increased in respect to the general population. High serum adiponectin levels appear to play a protective role in the development of either metabolic syndrome or cardiovascular disease.

AIM

To investigate factors potentially preventing atherosclerosis in PBC patients.

METHODS

Circulating levels of adiponectin, resistin, leptin, and tumor necrosis factor-alpha (TNF-alpha) were measured in 137 consecutive PBC patients (125 women, 12 men; mean age 61.6 +/- 12.3 yr), 137 sex- and age-matched healthy controls, and 30 female patients with nonalcoholic steatohepatitis (NASH) and associated metabolic syndrome.

RESULTS

The body mass index (BMI) was comparable in the three groups, whereas total cholesterol was significantly higher in both PBC and NASH cases than in controls (221.6 +/- 50.5 mg/dL in PBC vs 221.7 +/- 39.7 mg/dL in NASH vs 209.8 +/- 39.2 mg/dL in controls, P < 0.05). Serum concentrations of adiponectin, resistin, and leptin were significantly higher in PBC patients than in either NASH cases or controls (P < 0.05). Among the PBC patients, only adiponectin correlated positively with histological progression of the disease (P= 0.001) and negatively with BMI (P= 0.01). Logistic regression analysis revealed that adiponectin correlated independently with age, BMI, Mayo score, and gamma-glutamyl transpeptidase.

CONCLUSIONS

The high adiponectin concentrations observed in PBC patients should be regarded as a possible protective factor against atherogenesis. The search for further protective factors should be encouraged.

Associations between serum uric acid and adipokines, markers of inflammation, and endothelial dysfunction

AIM

Serum uric acid is associated with the metabolic syndrome and its components, while its relationship with cardiovascular disease is controversial. The aim of the study was to evaluate the association between uric acid and adipokines, markers of inflammation, oxidative stress, and endothelial dysfunction, which are all linked to cardiovascular disease.

METHODS

The associations between uric acid and adiponectin, resistin, leptin, high-sensitivity-C-reactive protein (hs-CRP), interleukin-6, tumor necrosis factor-alpha, nitrotyrosine, Total Antioxidant Status (TAS), E-selectin, vascular adhesion molecule-1 (VCAM-1), and intercellular adhesion molecule-1 (ICAM-1) were cross-sectionally evaluated in a randomly collected sample of 100 men from a population-based cohort.

RESULTS

Subjects within the highest uric acid quartile showed a worse metabolic pattern and a higher prevalence of the metabolic syndrome [odds ratio (OR)=3.6; 95% confidence interval (CI) 1.6-8.2; p<0.001 for each 50 micromol/l uric acid increment in a logistic regression model after multiple adjustments]. Nitrotyrosine and adiponectin were significantly lower, while TAS, hs-CRP, E-selectin, ICAM-1, and VCAM-1 were higher in the groups with increased uric acid levels. In a multiple regression model, after adjustments for multiple confounders, uric acid levels were inversely associated with nitrotyrosine (p<0.001) and adiponectin (p=0.02), and directly with TAS (p<0.001), and E-selectin (p=0.006).

CONCLUSION

Serum uric acid showed opposite relationships, being associated with both beneficial (inverse association with nitrotyrosine, direct association with TAS) and detrimental (inverse association with adiponectin, direct association with E-selectin) markers, thus providing a possible explanation for the previously reported controversial and not linear association between uric acid and cardiovascular disease.

Should we consider gestational diabetes a vascular risk factor?

Few and contrasting data have reported vascular endothelial dysfunction and increased serum levels of endothelial dysfunction and inflammatory markers in women with previous gestational diabetes mellitus (pGDM). We aimed at evaluating 6.5 years after delivery: intimal medial thickness (IMT), and C-reactive protein (CRP), interleukin-6 (IL-6), E-selectin, intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1) levels in 82 non-pregnant pGDM and 113 control women without pGDM. A subgroup of 21 women, taken from the pGDM group, showing current normal BMI, and no metabolic abnormalities, was separately analysed. All the subjects were free of medication and non-smokers. Women with pGDM, independently by their current BMI and presence of metabolic abnormalities, showed significantly higher E-selectin, ICAM-1 and IMT values than controls. IMT proved to be significantly associated with pGDM in a regression model, after adjustments for BMI, waist circumference, blood pressure, and glucose values (beta=0.046; 95% CI 0.028-0.064). In all pGDM women, E-selectin, ICAM-1, IL-6 and hs-CRP values were significantly associated with IMT in the same model. Post-GDM women, despite being currently free from metabolic abnormalities, showed higher values of markers of endothelial dysfunction and IMT than controls, consistent with an increased future cardiovascular risk.

Gastrointestinal problems in the elderly

Gastrointestinal (GI) disorders represent the third cause of consultations by general practitioners among subjects older than 65 years in Western countries. Although GI diseases in the elderly do not show peculiar characteristics, they often may present a more severe course, due to comorbidities and intake of many drugs. Moreover, several illnesses, such as neoplasias, are more frequent in the elderly. This review focuses on the epidemiological, physiopathological, and clinical aspects of GI diseases in advanced age. Some relevant issues are considered. It is advisable to avoid empirical approaches in the elderly and to choose endoscopic examinations because of the possibility to detect conditions such as already complicated gastroesophageal reflux disease or peptic ulcers as well as to diagnose precociously neoplastic formations in esophagus, stomach or colon. The monitoring of chronic liver disease is very important, mainly to prevent or detect hepatocellular carcinoma early. Idiopathic (or autoimmune) chronic pancreatitis in the elderly is more frequent than other forms of pancreatic diseases, like alcoholic pancreatitis.

Evaluating cardiovascular mortality in type 2 diabetes patients: an analysis based on competing risks Markov chains and additive regression models

RATIONALE, AIMS AND OBJECTIVES

Type 2 diabetes represents a condition significantly associated with increased cardiovascular mortality. The aims of the study are: (i) to estimate the cumulative incidence function for cause-specific mortality using Cox and Aalen model; (ii) to describe how the prediction of cardiovascular or other causes mortality changes for patients with different pattern of covariates; (iii) to show if different statistical methods may give different results.

METHODS

Cox and Aalen additive regression model through the Markov chain approach, are used to estimate the cause-specific hazard for cardiovascular or other causes mortality in a cohort of 2865 type 2 diabetic patients without insulin treatment. The models are compared in the estimation of the risk of death for patients of different severity.

RESULTS

For younger patients with a better covariates profile, the Cumulative Incidence Function estimated by Cox and Aalen model was almost the same; for patients with the worst covariates profile, models gave different results: at the end of follow-up cardiovascular mortality rate estimated by Cox and Aalen model was 0.26 [95% confidence interval (CI) = 0.21-0.31] and 0.14 (95% CI = 0.09-0.18).

CONCLUSIONS

Standard Cox and Aalen model capture the risk process for patients equally well with average profiles of co-morbidities. The Aalen model, in addition, is shown to be better at identifying cause-specific risk of death for patients with more severe clinical profiles. This result is relevant in the development of analytic tools for research and resource management within diabetes care.

Diagnostic and therapeutic questions in overlap syndromes of autoimmune hepatitis

The term ''overlap syndromes of liver diseases'' includes coexistence of autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), primary biliary cirrhosis (PBC). Due to their unknown etiology, as well as their variable presentation with mixed clinical and biochemical features, these overlap syndromes are often a diagnostic and therapeutic challenge for hepatologists. The most frequent association reported occurs between AIH and PBC. More rare is the overlap between AIH and PSC, typical in young age and often concomitant with an inflammatory bowel disease as ulcerative colitis. The treatment of choice is based on ursodeoxycholic acid and immunosoppressive drugs, used at the same time or consecutively, according to the course of disease. Histological examination seems an important tool, but often does not help for a correct diagnosis due to lack of specificity. Two particular forms of variant syndrome are the so called outlier syndromes, without clear characteristics of overlap: the autoimmune cholangitis, probably a form of PBC anti-mitochondrial antibodies negative, and the hepatitis C virus related with stigmata of autoimmunity, such as nonspecific autoantibodies at low titer. The diagnostic score system elaborated in 1999 by the International AIH Group can help for diagnosis, even if its definite validity is lacking.

Evaluating hospital costs in type 2 diabetes care: does the choice of the model matter?

BACKGROUND

Awareness of the economic burden of diabetes has led to a number of studies on economic issues. However, comparison among cost-of-illness studies is problematic because different methods are used to arrive at a final cost estimate.

OBJECTIVE

The aim of the study is to show how estimates of hospitalisation costs for diabetic patients can vary significantly in relation to the statistical method adopted in the analysis.

RESEARCH DESIGN AND METHODS

The study analyses diabetic patients' costs as a function of demographic and clinical covariates, by applying the following statistical survival models: the parametric survival model assuming Weibull distribution, the Cox proportional hazard (PH) model and the Aalen additive regression for modelling costs. The Aalen approach is robust both for the non proportionality in hazard and for departures from normality. In addition it is able to easily model the effect of covariates on the extreme costs. This cost analysis is based on data collected for a retrospective observational study analysing repeated hospitalisations (N = 4816) in a cohort of 3892 diabetic patients.

RESULTS

There is agreement in all models with the effects of the considered covariates (age, sex, duration of disease and presence of other pathologies). An effect of over- or under-estimation, according to the chosen model due to arguably inappropriate model fitting, was observed, being more evident for some specific profiles of the patients, and overall accounting for as much as 20% of the estimated effect. The Aalen model was able to cope with all the other models in furnishing unbiased estimates with the advantage of a greater flexibility in representing the covariates' effect on the cost process.

CONCLUSIONS

An appropriate choice of the model is crucial in avoiding misinterpretation of cost determinants of type 2 diabetes care. For our data set the Aalen model proved itself to be a realistic and informative way to characterise the effect of covariates on costs.

Insulin resistance in pre-school very-low-birth weight pre-term children

AIMS

To evaluate the metabolic pattern of a group of pre-school small- (SGA) and appropriate-for-gestational age (AGA) pre-term very-low-birthweight (VLBW) (<1500 gr) Italian children and retrospectively verify if the growth rate in the first years of life is associated to the laboratory and anthropometric characteristics of these children.

METHODS

58 (16 SGA, 42 AGA) VLBW children, without major congenital malformations/conditions were enrolled; their anthropometric, clinical and (in 34 of them) laboratory characteristics were evaluated at pre-school age (> 2<6 years of corrected age).

RESULTS

Clinical, anthropometric and laboratory characteristics at pre-school age were similar in SGA and AGA. Sixty-nine percent of SGA and 51% of AGA children showed a significant weight centile crossing (CC) at 24 months. Fasting serum glucose, insulin and insulin resistance (evaluated by the Homeostasis Model Assessment -HOMA-IR-) were higher in AGA and SGA with CC. The increment in weight standard deviation scores from birth-to-24 months was significantly associated with pre-school BMI SDS, waist, fasting insulin, and HOMA-IR values, both in unadjusted and adjusted models. In a multiple regression model, after multiple adjustments, this increment is the only significant predictor of pre-school insulin (B = 0.19; 95%CI 0.07-0.31; P = 0.006) and HOMA-IR levels (B = 0.20; 95%CI 0.08-0.32; P = 0.004) both in SGA and AGA children.

CONCLUSIONS

The adverse metabolic pattern of pre-school VLBW children seems related to post-natal events (rapid weight growth) independently by their being small- or appropriate-for gestational age.

Comparison of two enzyme immunometric assays to measure tumor necrosis factor-alpha in human serum

BACKGROUND

Tumor necrosis factor-alpha is a 17.5 kDa, 157 amino acid protein that is a potent lymphoid factor, which exerts cytotoxic effects on a wide range of tumor cells and other target cells. TNF-alpha has been suggested to play a pro-inflammatory role by influencing transendothelial migration of monocytes and elicits the expression of proteolytic enzymes by macrophages and smooth muscle cells within the atherosclerotic plaque.

METHODS

We compared two methods for the quantitative determination of human tumor necrosis factor-alpha in serum samples. Either kit follows the same assay procedure. Serum samples do not need to be diluted before sampling. Standard is provided lyophilized and serial dilutions after reconstitution generate the standard point curves. The tests are enzyme immunometric assays based on a standard 96-well microtiter plate. The wells are coated with anti-human TNF-alpha antibody.

RESULTS

The range of the standard curve is similar in both kits. It spans from 1000 through 15.6 pg/mL. The median TNF-alpha concentration in samples measured by Pierce assay (n=368) was 4.23 pg/mL, (range, 1.34-77.2 pg/mL). A very different median was obtained for the same specimen measured with the Titerzyme EIA (median, 176.96 pg/mL; range, 54.7-283.9 pg/mL; n=364). Substantial significant differences were observed between the two methods.

CONCLUSION

Our results show that the two kits are unmatchable for results they can give when TNF-alpha concentrations are measured in serum samples. One reason of this disagreement could be the matrix effect or a cross-reactivity of one of the two methods. This study shows that the determination of human serum TNF-alpha needs to be standardized, especially when a comparison of results is required.

Mortality within the first 10 years of the disease in type 2 diabetic patients

BACKGROUND AND AIMS

An excess of long-term mortality in type 2 diabetes is mainly due to cardiac diseases, predicted by diabetes-related conditions; less is known about early death from clinical diagnosis. The aim of this study was to evaluate pattern and predictors of mortality after a 4.5 year follow-up in a cohort of type 2 diabetic patients, according to diabetes duration.

METHODS AND RESULTS

A mortality follow-up was carried out in 1200 patients with < or = 5 years diabetes duration and 2692 patients with >5 (median 2 and 15) years diabetes duration in 1995. Four-year survival was 92.0% and 83.7%, respectively; most deaths are due to cardiovascular diseases (36% and 41%, respectively). The duration of diabetes is no longer a significant predictor of death after adjustments for age, HbA1c and chronic complications (which are all significantly higher in patients who have had diabetes for longer time). In a Cox proportional hazard model, best predictors of death are nephropathy, insulin therapy and pre-existent co-morbidity in both groups. Nephropathy is significantly associated with cardiovascular deaths in the younger cohort.

CONCLUSION

Clinical nephropathy is a significant predictor of early and late mortality from clinical diagnosis, above all cardiovascular deaths, indicating that an aggressive approach should be adopted for prevention or treatment of renal impairment right from the clinical onset of diabetes.

C-reactive protein and tumor necrosis factor-alpha in gestational hyperglycemia

OBJECTIVES AND STUDY DESIGN

Increasing evidences support an inflammatory origin for gestational hyperglycemia. This paper aims at investigating, cross-sectionally and prospectively, the relationships between tumor necrosis factor-alpha (TNF-alpha) and C-reactive protein (CRP) levels in normoglycemic and hyperglycemic pregnancies of women with and without conventional risk factors for gestational diabetes (GDM).

RESULTS

Both at simple and multiple correlations TNF-alpha levels are associated to fasting insulin, homeostasis model assessment-insulin resistance (HOMA-IR) values and gestational hyperglycemia, while high sensitivity CRP (hsCRP) levels to body mass index (BMI). Furthermore, the TNF-alpha levels of the second trimester and their increments in the third trimester are significant predictors of insulin levels measured at 32-36 weeks in the subgroup of hyperglycemic women with < or = 35 yr, BMI <25 kg/m2 and the absence of a first-degree relative with Type 2 diabetes (respectively, beta=1.1; 95%CI 0.66-1.48; p=0.002 and beta=1.0; 95%CI 0.36-1.66; p=0.02), in a multiple regression model, after multiple adjustments. In a second cohort of women at low risk for GDM (<25 yr, BMI <25 kg/m2 and absence of a first-degree relative with Type 2 diabetes), 24-28 weeks TNF-alpha levels are highly associated with corresponding insulin and HOMA values in the same model (respectively, beta=0.27; 95%CI 0.11-0.43; p=0.001 and beta=0.30; 95%CI 0.14-0.46; p<0.001).

CONCLUSIONS

The data support the developing hypothesis that low-grade systemic inflammation is associated to GDM, in particular for pregnant women without conventional risk factors for gestational hyperglycemia, whose insulin resistance seems less explainable.

Plasma nitrotyrosine levels, antioxidant vitamins and hyperglycaemia

AIMS

Studies on plasma nitrotyrosine (NT) levels, a measure of oxidative injury, in diabetes are limited and discordant; the amount of antioxidants might represent a possible explanation for the discordant results. The aim of this paper is to evaluate the association between plasma NT levels and glucose tolerance status, according to antioxidant vitamin intakes.

METHODS

In three hundred men randomly selected from a population-based cohort, NT levels were measured and dietary intake assessed by a food-frequency questionnaire. Results NT values were similar in patients with diabetes (n = 34), impaired fasting glucose (n = 77) and normoglycaemic subjects (n = 189). However, in subjects with lower than recommended daily intakes of antioxidant vitamins C and A, NT levels were significantly higher in the diabetic patients. In a multiple regression model, after adjustments for age, body mass index (BMI) and smoking habits, NT levels were significantly associated with fasting glucose in patients with lower intakes of vitamin C (beta = 11.4; 95% CI 1.3-21.5) and vitamin A (beta = 14.9; 95% CI 3.9-25.9), but not in subjects with lower intake of vitamin E.

CONCLUSION

A significant positive correlation between NT levels and fasting glucose is evident only in the presence of a reduced intake of some antioxidant vitamins. These findings might explain, at least in part, the discrepant results of previous studies and, if confirmed by further studies, suggest a simple measure (a balanced diet) to alleviate the increased oxidative stress of diabetes.

Relationships between human serum resistin, inflammatory markers and insulin resistance

OBJECTIVE

Data on the association of resistin levels with markers of insulin resistance are highly contrasting in humans and very few studies about its role in inflammation are available. This study investigates associations between serum resistin levels and markers of insulin resistance, inflammation (C-reactive protein (CRP)) and of oxidative stress (nytrotirosine (NT)).

SUBJECTS

A randomly collected sample of 300 men from a population-based cohort was analysed, separated into two groups according to body mass index (BMI) and waist values.

RESULTS

Correlations between resistin and BMI, waist, triglyceride, uric acid, fasting glucose, insulin and Homeostasis Model Assessment (HOMA) values were significant in subjects with normal BMI, but not in overweight/obese subjects. In a multiple regression model, after multiple adjustments and exclusion of diabetic patients, only fasting glucose remained significantly associated with resistin levels. Otherwise, resistin is associated to CRP levels in all individuals, after multiple adjustments and exclusion of diabetic patients (in normal BMI beta=0.82; 95% CI 0.21, 1.42; in overweight/obese beta=0.43; 95% CI 0.10, 0.76). In the same model, resistin values are negatively related to NT levels in normal weight individuals (beta=-1.61; 95% CI -0.77-2.45).

CONCLUSIONS

Serum resistin is weakly associated with metabolic abnormalities in subjects with normal BMI, while in overweight/obese patients this correlation is not significant, perhaps due to the higher fat content in these subjects. Serum resistin is directly correlated with CRP and inversely to NT. An intriguing hypothesis, which needs to be tested, is that resistin is secreted in response to a chronic low-grade inflammation, and has antioxidant properties.

Does C-reactive protein identify a subclinical metabolic disease in healthy subjects?

BACKGROUND

Highly sensitive C-reactive protein (hs-CRP) levels are significant predictors of subsequent diabetes and metabolic syndrome (MS). Owing the strong correlations between components of the MS and obesity with hs-CRP levels, previous studies about the associations of hs-CRP with insulin resistance might have been confounded by the inclusion of overweight or dysmetabolic subjects.

DESIGN

Our aim was to evaluate the associations between hs-CRP levels and fasting insulin and insulin resistance (evaluated by the Homeostasis Model Assessment: HOMA IR) in a subgroup of subjects with normal body mass index (BMI) and without any metabolic abnormalities. Out of a cohort of 1658 middle-aged subjects, representative of the local sanitary districts of the province of Asti (north-western Italy) enrolled for metabolic screening: 241 (14.5%) showed normal BMI, glucose tolerance, blood pressure and waist values and no dyslipidaemia.

RESULTS

In this subgroup of subjects, those with hs-CRP levels > or = 3 mg L(-1) showed significantly higher median insulin and HOMA-IR values (respectively: 20.4 vs. 6.0 pmol L(-1), and 0.8 vs. 0.2 microU mL(-1)x mmol L(-1)). In a multiple regression model, insulin and insulin resistance remained significantly and independently related to hs-CRP levels, after adjustments for age, sex, BMI, waist, alcohol consumption, level of physical activity and smoking habits. Very few individuals within lower fasting insulin quartiles showed hs-CRP values > or = 3 mg L(-1) when compared with approximately 60% of those within the highest quartile.

CONCLUSIONS

The novel finding is that a state of low-grade systemic inflammation is present in normal BMI subjects who show subclinical insulin resistance but no other metabolic abnormalities.

Renal damage in patients with Type 2 diabetes: a strong predictor of mortality

AIMS

(i) To compare mortality rates in a cohort of Type 2 diabetic patients with those of the general population; (ii) to assess the prognostic role of pre-existing chronic conditions; (iii) to evaluate the impact of different severity of renal damage on mortality.

METHODS

All 3892 patients with Type 2 diabetes attending our Diabetic Clinic during 1995 and alive on 1 January 1996 were identified and followed for 4.5 years. Information on vital status (100% complete) and causes of death (98.5% complete) for 599 deceased subjects was derived from death certificates.

RESULTS

In comparison with the general population, standardized mortality ratios (x 100) were: 125 (95% confidence interval 104-148) in patients aged < 75 and 85 (75-95) in patients > or = 75 years. Cardiovascular diseases and diabetes were responsible for most of the excess deaths. In a Cox-proportional hazard model, renal damage was a powerful predictor of death (hazard ratio = 2.39; 95% confidence intervals = 2.00-2.85). The severity of renal damage was associated with increasing hazard ratios for death from all-cause mortality and from specific causes (especially coronary artery disease, other cardiovascular causes and diabetes) after multiple adjustments. Other significant predictors of death were: greater age, glycated haemoglobin, smoking, lower body mass index, pre-existing coronary and peripheral artery disease and known co-morbidity (cirrhosis and cancer).

CONCLUSIONS

Renal damage of any severity is significantly associated with subsequent mortality from all causes and from cardiovascular diseases. These associations are not confounded by pre-existing co-morbidity or coronary diseases.

Prior gestational hyperglycemia: a long-term predictor of the metabolic syndrome

Little is known about the association between prior gestational hyperglycemia of different severity and the subsequent risk for the metabolic syndrome. Eighty-one women with prior gestational diabetes mellitus (GDM), 25 with one abnormal value at the oral glucose tolerance test (OGTT), and 65 with normal OGTT were studied after a mean of 8.5 yr from the index pregnancy. Patients with prior gestational hyperglycemia (both one abnormal value at the OGTT and GDM) showed a worse metabolic pattern than subjects with gestational normoglycemia [respectively higher values of body mass index (BMI), waist, blood pressure, serum glucose, insulin, C-peptide, homeostatic model assessment (HOMA), fibrinogen and lower levels of HDL-cholesterol]. Prevalence of the metabolic syndrome and its components was 2-4-fold higher in women with prior gestational hyperglycemia (and 10-fold higher if pre-pregnancy obesity coexisted) when compared to normoglycemic controls; in a Cox proportional hazard model, after adjustments for age and pre-pregnancy BMI, gestational hyperglycemia and pre-pregnancy BMI predicted subsequent metabolic syndrome [respectively: hazard ratio (HR)=4.26 and HR=1.21] and most of its components. In the same model, the highest quartile of fasting serum glucose at the OGTT of the index pregnancy was significantly associated to the metabolic syndrome and its components. Gestational hyperglycemia and fasting glucose values were also associated to subsequent fibrinogen values, but not to albumin excretion rates. In young adult women, prior gestational hyperglycemia (particularly abnormal fasting glucose values), above all in combination with pre-pregnancy obesity, anticipates a subsequent syndrome at high cardiovascular risk and, possibly, a mild chronic inflammatory response.

Isolated systolic hypertension in a cohort of type 2 diabetic patients

BACKGROUND AND AIMS

Previous studies of the adverse effects of isolated and borderline isolated systolic hypertension excluded or under-represented type 2 diabetic patients. The aim of this study was to evaluate the prevalence and role of isolated and borderline isolated systolic hypertension in a cohort of 3892 type 2 diabetic patients.

METHODS AND RESULTS

The hypertensive patients were classified as treated (n= 1806; 46.4%), untreated diastolic hypertension (n=407; 10.4%), untreated isolated systolic hypertension (n=166; 4.3%) and untreated borderline isolated systolic hypertension (n=625; 16%). A Cox proportional hazard model including several confounders showed that the patients with untreated isolated systolic hypertension were at significantly higher risk of hospital admissions due to cerebrovascular diseases than the normotensive and untreated diastolic hypertensive patients (HR=2.05; 95% CI: 1.2-3.4 and HR=1.97; 95%CI: 1.1-3.5, respectively). In the same model, borderline isolated systolic hypertension significantly correlated with admissions for cerebrovascular diseases in comparison with normotensive patients (HR=1.73; 95% CI: 1.2-2.6).

CONCLUSIONS

This is the first report concerning the prevalence of isolated and borderline isolated systolic hypertension in a large cohort of type 2 diabetic patients. The results are in line with population-based estimates. Our data show that isolated systolic hypertension is an independent predictor of hospital admissions due to cerebrovascular diseases.

Two cases of cutaneous nodular dirofilariasis in the cat

Cutaneous nodular dirofilariasis is occasionally reported in dogs but is rare in cats. This report describes two cases of cutaneous nodular lesions due to Dirofilaria immitis adult parasites in domestic shorthaired cats living in an endemic area in northern Italy.