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

BACKGROUND AND AIM

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

METHODS AND RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

The "Sapienza University Mortality and Morbidity Event Rate (SUMMER) study in diabetes": Study protocol

BACKGROUND AND AIMS

The rate of mortality in diabetic patients, especially of cardiovascular origin, is about twice as much that of nondiabetic individuals. Thus, the pathogenic factors shaping the risk of mortality in such patients must be unraveled in order to target intensive prevention and treatment strategies. The "Sapienza University Mortality and Morbidity Event Rate (SUMMER) study in diabetes" is aimed at identifying new molecular promoters of mortality and major vascular events in patients with type 2 diabetes mellitus (T2DM).

METHODS/DESIGN

The "SUMMER study in diabetes" is an observational, prospective, and collaborative study conducted on at least 5000 consecutive patients with T2DM, recruited from several diabetes clinics of Central-Southern Italy and followed up for a minimum of 5 years. The primary outcome is all-cause mortality; the secondary outcomes are cardiovascular mortality, acute myocardial infarction, stroke, and dialysis. A biobank will be created for genomic, transcriptomic, and metabolomic analysis, in order to unravel new molecular predictors of mortality and vascular morbidity.

DISCUSSION

The "SUMMER study in diabetes" is aimed at identifying new molecular promoters of mortality and major vascular events in patients with T2DM. These novel pathogenic factors will most likely be instrumental in unraveling new pathways underlying such dramatic events. In addition, they will also be used as additional markers to increase the performance of the already existing risk-scoring models for predicting the above-mentioned outcomes in T2DM, as well as for setting up new preventive and treatment strategies, possibly tailored to specific pathogenic backgrounds.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02311244; URL https://clinicaltrials.gov/ct2/show/NCT02311244?term=SUMMER&rank=5.

Influence of dietary fat and carbohydrates proportions on plasma lipids, glucose control and low-grade inflammation in patients with type 2 diabetes-The TOSCA.IT Study

PURPOSE

The optimal macronutrient composition of the diet for the management of type 2 diabetes is debated, particularly with regard to the ideal proportion of fat and carbohydrates. The aim of the study was to explore the association of different proportions of fat and carbohydrates of the diet-within the ranges recommended by different guidelines-with metabolic risk factors.

METHODS

We studied 1785 people with type 2 diabetes, aged 50-75, enrolled in the TOSCA.IT Study. Dietary habits were assessed using a validated food-frequency questionnaire (EPIC). Anthropometry, fasting lipids, HbA1c and C-reactive protein (CRP) were measured.

RESULTS

Increasing fat intake from <25 to ≥35 % is associated with a significant increase in LDL-cholesterol, triglycerides, HbA1c and CRP (p < 0.05). Increasing carbohydrates intake from <45 to ≥60 % is associated with significantly lower triglycerides, HbA1c and CRP (p < 0.05). A fiber intake ≥15 g/1000 kcal is associated with a better plasma lipids profile and lower HbA1c and CRP than lower fiber consumption. A consumption of added sugars of ≥10 % of the energy intake is associated with a more adverse plasma lipids profile and higher CRP than lower intake.

CONCLUSIONS

In people with type 2 diabetes, variations in the proportion of fat and carbohydrates of the diet, within the relatively narrow ranges recommended by different nutritional guidelines, significantly impact on the metabolic profile and markers of low-grade inflammation. The data support the potential for reducing the intake of fat and added sugars, preferring complex, slowly absorbable, carbohydrates.

Efficacy, safety and acceptability of the new pen needle 33G × 4 mm. AGO 01 study

OBJECTIVES

Adherence to insulin therapy can be threatened by pain and needle fear. This cross-over randomized non-inferiority trial evaluated a new Pic Insupen 33G × 4 mm needle vs. a 32G × 4 mm needle in terms of metabolic control, safety and acceptability in patients with diabetes treated with insulin.

RESEARCH DESIGN AND METHODS

We used a centralized, permuted block randomization, stratified by center and maximum insulin dose per single injection. Subjects used the two needles in two 3 week treatment periods. The primary endpoint was the absolute percentage variation of the blood fructosamine between the two treatments (% |ΔFru|). Additional endpoints were: glycemic variability, total insulin doses, body weight, severe hypoglycemic episodes, leakage at injection sites and pain measured by visual analogue scale. Equivalent glycemic control was defined a priori as % |ΔFru| (including 95% CI) within 20%.

RESULTS

Of 87 subjects randomized, 77 completed the study (median age 53.1 [IR 42.3-61.2], median BMI 24.3 Kg/m(2) [IR 21.3-28.5], median duration of insulin therapy [in months] 141.4 (IR 56.3-256.9), median baseline HbA1c 7.9% [IR 7.2-8.8]). The % |ΔFru| was 7.93% (95% CI 6.23-9.63), meeting the non-inferiority criterion. The fasting blood glucose standard deviation was 46.2 (mean 154.6) with the 33G needle and 42.8 (mean 157.3) with the 32G needle (p=0.42). Insulin daily dose and patients' weight did not show any statistically significant variation. We observed 95 episodes of symptomatic hypoglycemia with the 33G needle and 96 with the 32G needle. One episode of severe hypoglycemia was documented in the latter group. As for insulin leakage we observed 37.55 episodes per 100 patient-days with the 33G needle and 32.21 episodes per 100 patient-days with the 32G needle (p=0.31). Patients reported less pain with the 33G × 4 mm needle (p=0.05).

STUDY LIMITATIONS

Study sample was mainly composed of adults with type 1 diabetes and study was not blinded.

CONCLUSIONS

The 33G needle is not inferior to the 32G needle in terms of efficacy and safety, with reduced pain and no difference in insulin leakage.

CLINICAL TRIAL REGISTRATION

NCT01745549.

Palifermin reduces infection rate and hyperfibrinogenemia in patients treated with high-dose chemotherapy based on beam or BU-thiothepa

We performed a retrospective study in patients who underwent high-dose chemotherapy and auto-SCT because of haematological malignancies. Forty patients were treated with palifermin while 80 were controls selected after being matched for diagnosis and length of neutropenia. Patients treated with BEAM or BU-CY or THIO-CY (BEAM/BUS) displayed, after palifermin, a lower rate of severe oral mucositis (P=0.03). This beneficial effect of palifermin was not evident in the stratum of patients treated with high-dose melphalan (HD-PAM). After palifermin, we observed in the whole treated population a reduced rate of 'fever of unknown origin' (FUO, P=0.02) and of severe infections not related to Gram-positive bacteria (FUO, Gram-negative bacteremia or pneumonia) (P=0.003). This effect of palifermin on infections not related to Gram-positive bacteria was evident only in patients receiving BEAM/BUS (P=0.01) and not in patients treated with HD-PAM (P=0.11). Fibrinogen peak in plasma was found to be reduced after palifermin in the whole population (P=0.01) and in the stratum who received BEAM/BUS (P=0.02) but not in the stratum of HD-PAM. In conclusion, anti-infectious beneficial effects of palifermin are more evident in BEAM/BUS-treated patients and toward some types of infections. Reduction of fibrinogen level after palifermin suggests that this agent reduces not only the rate of infections but also their severity.

eHealth: individualisation of infliximab treatment and disease course via a self-managed web-based solution in Crohn’s disease

BACKGROUND

Infliximab (IFX) maintenance therapy for Crohn's disease (CD) is administered every 8 weeks, but inter-patient variation in optimal treatment intervals may exist.

AIM

To assess, in a prospective pilot study, the efficacy, safety and quality of life (QoL) of IFX maintenance treatment scheduled through web-based self-monitoring of disease activity.

METHODS

Twenty-seven CD patients in IFX maintenance therapy were enrolled and received a standardised disease education and web-training. Using the http://www.cd.constant-care.dk concept, patients recorded their disease activity and faecal calprotectin weekly. From this, the inflammatory burden (IB) score was calculated, placing patients in the green, yellow or red zones of a ‘traffic light’ system. If placed in the yellow or red zones, the computer directed these patients to consult their physician for IFX infusion.

RESULTS

Seventeen patients (63%) completed 52 weeks of follow-up, 6 (22%) completed 26 weeks and 4 (15%) were excluded due to loss of response, patient decision or non-adherence. In total, 121 IFX infusions were given with a median interval of 9 (range: 4–18) weeks. Only 10% of infusions were given at 8-week intervals, whereas 39% were administered with shorter and 50% with longer intervals respectively. The mean IB and the QoL remained stable during the web-treatment. One mild infusion reaction and one case of folliculitis were observed, while three patients underwent surgery.

CONCLUSIONS

The program http://www.cd.constant-care.dk appears to be a practical and safe concept for the individualised scheduling of maintenance treatment with IFX in patients with Crohn's disease. Larger studies are awaited to confirm this preliminary outcome.

Clinical and socio-economic correlates of quality of life and treatment satisfaction in patients with type 2 diabetes

BACKGROUND AND AIM

The aim of the present study was to assess health-related quality of life (HRQOL) and treatment satisfaction in a large, ambulatory based sample of patients with type 2 diabetes. In particular, we evaluated a large array of socio-economic, clinical, and management-related factors, to investigate the extent to which they correlate with physical and psychological well-being, and with treatment satisfaction.

METHODS AND RESULTS

Patients were requested to fill in a questionnaire including the SF-36 Health Survey (SF-36), the WHO-Well Being Questionnaire (WBQ), and the WHO-Diabetes Treatment Satisfaction Questionnaire (DTSQ). The analyses were based on multivariate analyses, adjusted for patient clinical and socio-demographic characteristics. The study involved 2499 patients, enrolled in 203 diabetes outpatient clinics. Female gender and diabetes complications were associated with worse physical and psychological well-being, while socioeconomic variables were mainly related to general well-being. The perceived frequency of hyperglycemic episodes was negatively associated with all the dimensions explored. Treatment satisfaction was inversely related to female gender, insulin treatment, perceived frequency of hyperglycemic episodes and diabetes complications. Blood glucose self-monitoring, and among patients treated with insulin, self-management of insulin doses and the use of pen for insulin injections, were associated with higher levels of satisfaction. Finally, higher levels of satisfaction were associated with a better perception of physical and psychological well-being.

CONCLUSIONS

Health related quality of life and treatment satisfaction are associated with each other and are both affected by a complex interplay between clinical and socio-economic variables. Some negative aspects, mainly associated with insulin treatment and poor perceived metabolic control, can be attenuated by a deeper involvement of the patients in the management of the disease.

Adverse events after infusions of cryopreserved hematopoietic stem cells depend on non-mononuclear cells in the infused suspension and patient age

BACKGROUND

Adverse events (AE) represent a significant clinical problem after infusion of cryopreserved HPC. However, the factors playing a role in the pathogenesis have not yet been fully established.

METHODS

We prospectively collected data on AE that occurred with 179 HPC infusions performed on patients affected with hematologic neoplasm after high-dose chemotherapy. The stem cell source was hemopoietic progenitor cells aphaeresis (HPC-A) in 157 cases and hemopoietic progenitor cell BM (HPC-BM) in 22 cases. In all cases, an endotoxin-free DMSO was used.

RESULTS

One or more AE were registered in 51/179 infusions (28.6%). The frequency of AE was higher after HPC-A than after HPC-BM (31.3% vs. 4.5%; chi(2) test, P =0.008). With univariate logistic regression, other factors found important for AE were age (P =0.028), number of total nucleated cells infused per kilogram (P =0.002), volume per kilogram infused (P =0.057), volume of packed RBC (P =0.019), a content of non-mononuclear cells >0.5 x 10(8)/kg (<P =0.0001) and actual time of infusion (P =0.058). When all aforementioned factors were evaluated with a multivariate logistic regression, only age of patient (P =0.024) and a content of non-mononuclear cells >0.5 x 10(8)/kg (P =0.0003) remained significant. A significant correlation existed between reduction of cardiac frequency both with volume per kilogram infused (r =0.221, P =0.02) and actual time of infusion (r =0.269, P =0.005).

DISCUSSION

Cardiovascular changes are influenced by volume per kilogram infused and by actual time of infusion, while non-cardiovascular AE are dependent on patient age and contamination by non-mononuclear cells in apheretic harvests.

G-CSF alone vs cyclophosphamide plus G-CSF in PBPC mobilization of patients with lymphoma: results depend on degree of previous pretreatment

We performed a randomized study to compare 'G-CSF alone' (administered at dose of 10 mcg/kg/day) and 'cyclophosphamide plus G-CSF' (cyclophosphamide at dose of 4 g/m(2) and G-CSF at dose of 10 microg/kg/day), as PBPC mobilization schedules in 52 patients with NHL or HD. Randomization was stratified according to the amount of previous chemotherapy (< or =2 and >2 lines of previous chemotherapy). Mean CD34+ cell peak in P.B., mean 'Total CD34+ cells' harvested and percentage of patients successfully mobilized, in the group mobilized with 'G-CSF alone' vs the group mobilized with 'cyclophosphamide plus G-CSF', were: 35.3 x 10(6) vs 45.8 x 10(6)/l (P=0.3), 5.4 x 10(6) vs 6.8 x 10(6)/kg (P>0.9) and 50 vs 61% (P=0.4). No differences were observed in the stratum of less pretreated patients. However, in the stratum of patients who had previously received more than two lines of chemotherapy, CD34+cell peak (P=0.05) and percentage of successful mobilization (P=0.01) were higher when 'cyclophosphamide plus G-CSF' was used. Using logistic regression, both age and mobilization with 'G-CSF alone' were significantly associated with a low CD34+ cell peak in P.B. However, in the stratum of less pretreated patients, only age was significantly associated with this risk.

[Voluntary dilating pneumosinus (secondary hernia)]

In the present work authors describe an unusual case of pneumosinus dilatans caused willingly by a patient himself operated on a frontal-ethmoidal mucocele. They take the opportunity to summarize what it is known about the etiopathogenesis and the form of display of this uncommon disease.

[A case of a particularly destructive carcinoma of the lip]

We present a case of squamous-cells carcinoma of the inferior lip in a man at the age of 59 years, of particular interest either of the extension and infiltration of the neoplasia, of considerable longevity, since the patient had his first operation for the removal of the tumour. Fifteen years ago he had radiotherapy and it was found he had no visceral metastases. The outcome of the patient stage, had increased the neoplasia, which depended on the overall isolated condition in which he lived.