Until recently, in Italy, the use of continuous glucose monitoring (CGM) systems has been limited, but is now rapidly increasing, including the so-called real-time CGM (rtCGM) and the intermittently ...viewed CGM (iCGM), also called Flash Glucose Monitoring (FGM). These technologies overcome many of the limitations of self-monitoring of blood glucose (SMBG) by fingerprick and allow to go beyond HbA1c to check glucose control in diabetes. However, standardized protocols for applying and interpreting rtCGM and FGM data are lacking. In this paper, we delineate a consensus amongst Italian diabetes physicians on the attributes of rtCGM and FGM technologies, and introduce a consistent approach for their use by Italian healthcare professionals. Most experts consider rtCGM and FGM as two separate categories of interstitial subcutaneous fluid (ISF) sensing technologies, and see them as superior to SMBG. Furthermore, there is strong consensus that rtCGM and FGM reduce hypoglycemia risk, increase the amount of time in the target glucose range and augment treatment satisfaction. However, there is still no agreement on the indication of the FGM for subjects who suffer asymptomatic hypoglycemia. Consensus on the role of education in initiating and optimizing use of rtCGM/FGM and about the interpretation of glucose trends was near unanimous, whereas no consensus was reached on the statement that there are no disadvantages/risks of rtCGM/FGM. Some issues remain in rtCGM/FGM management: a) risk of excessive correction of high or low glucose; b) risk of alert fatigue leading to alert silencing or rtCGM termination; c) allergic reaction to the adhesive keeping rtCGM or FGM sensors in place. The panel almost unanimously agreed that sensor accuracy depends on multiple variables, that alarm setting should be individualized, and that global glycemic profile represent an useful tool in interpreting glucose data. More clinical studies and a wider use of these devices will increase the efficacy and effectiveness of continuous glucose monitoring in Italy.
That cardiovascular disease occurs more frequently in patients with Type II (non-insulin-dependent) diabetes mellitus has been recognized for a long time. However, the extent to which hyperglycaemia ...contributes to atherosclerosis and cardiovascular disease is still not clear. Epidemiological studies published in recent years suggest that postprandial blood glucose might be an independent risk factor of cardiovascular disease. The main results of these studies, which are reviewed in this article, are that subjects from the general population with mild to moderate hyperglycaemia, following oral glucose load, but not in the fasting state, showed an increased cardiovascular risk. Furthermore, the post-challenge as well as postprandial glucose concentrations of subjects with Type II diabetes were found to be directly associated to incident cardiovascular disease independently of fasting glucose. Also, the correction of fasting hyperglycaemia or HbA1 c or both, disregarding the specific correction of postprandial hyperglycaemia was not found to significantly reduce the incidence of cardiovascular disease in patients with Type II diabetes. Finally, the strict control of both preprandial and postprandial hyperglycaemia yielded a substantial reduction of cardiovascular disease in Type II diabetes. Trials specifically designed to address this issue are needed to determine whether postprandial hyperglycaemia plays an independent and causative role in cardiovascular disease in patients with Type II diabetes.
Mortality from infectious diseases in diabetes Zoppini, G.; Fedeli, U.; Schievano, E. ...
Nutrition, metabolism, and cardiovascular diseases,
20/May , Letnik:
28, Številka:
5
Journal Article
Recenzirano
To investigate the risk of mortality from infections by comparing the underlying causes of death versus the multiple causes of death in known diabetic subjects living in the Veneto region of Northern ...Italy.
A total of 185,341 subjects with diabetes aged 30–89 years were identified in the year 2010, and causes of death were assessed from 2010 to 2015. Standardized Mortality Ratios (SMRs) with 95% confidence intervals (CIs) were computed with regional mortality rates as reference. The underlying causes of death and all the diseases reported in the death certificates were scrutinized. At the end of the follow-up, 36,382 subjects had deceased. We observed an increased risk of death from infection-related causes in subjects with diabetes with a SMR of 1.83 (95% CI, 1.71–1.94). The SMR for death from septicemia was 1.91 (95% CI, 1.76–2.06) and from pneumonia was 1.47 (95% CI, 1.36–1.59). The use of the multiple causes of death approach emphasized the association of infectious diseases with mortality.
The results of the present study demonstrate an excess mortality due to infection-related diseases in patients with diabetes; more interestingly, by routine mortality analyses, the results show a possible underestimation of the effect of these diseases on mortality.
•Infections are growing as a major problem in diabetes.•The risk of death from infections in diabetes is quite high.•Septicemia and pneumonia are major threateners.•The multiple causes of death approach may give a more realistic estimate of mortality.
Abstract Aim To investigate the association of glycemic control with depression, anxiety, self-efficacy and other diabetes-specific psychological measures in a cohort of adult patients with type 2 ...diabetes (T2D) free of severe chronic diabetes-related complications. Methods and Results In 172 T2D outpatients consecutively recruited at the Diabetes Center of Verona City Hospital, we performed a standard medical assessment and completed the Beck Depression Inventory-II (BDI-II), the Beck Anxiety Inventory (BAI) and the Multidimensional Diabetes Questionnaire (MDQ) Age, body mass index (BMI) and glycosylated hemoglobin (HbA1c) were (median IQR): 64.0 58.0–69.0 years, 31.0 28.0–34.4 kg/m2 , and 7.3 6.7–8.0 %, respectively. The overall prevalence of anxiety and depression was 14.5% and 18.6%, respectively. Higher levels of HbA1c were significantly (p < 0.001) associated with a number of MDQ dimensions, such as higher perceived interference with daily activities (Spearman's rho coefficient = 0.33), higher perceived diabetes severity (rho = 0.28) and lower self-efficacy (rho = −0.27), but not with depression or anxiety. These three variables were also independent predictors of higher HbA1c levels, when entered in a multivariable stepwise-forward regression model that also included age, BMI, diabetes duration and diabetes-specific social support as covariates. Conclusion Lower self-efficacy and higher diabetes distress were closely associated with poorer glycemic control. No direct association between HbA1c and clinical psychological symptoms was detected. These results highlight that a number of diabetes-specific psychological variables may play a role amidst psychological distress and glycemic control. Further studies are needed to elucidate the relevance of diabetes distress and self-efficacy to the achievement of individual glycemic targets.
Purpose
Diabetes is a growing health problem. The aim of this study was to capture time trends in mortality associated with diabetes.
Methods
The mortality database of the Veneto region (Italy) ...includes both the underlying causes of death, and all the diseases mentioned in the death certificate. The annual percent change (APC) in age-standardized rates from 2008 to 2017 was computed by the Joinpoint Regression Program.
Results
Overall 453,972 deaths (56,074 with mention of diabetes) were observed among subjects aged ≥ 40 years. Mortality rates declined for diabetes as the underlying cause of death and from diabetes-related circulatory diseases. The latter declined especially in females − 4.4 (CI 95% − 5.3/− 3.4), while in males the APC was − 2.8 (CI 95% − 4.0/− 1.6).
Conclusion
We observed a significant reduction in mortality during the period 2008–2017 in diabetes either as underlying cause of death or when all mentions of diabetes in the death certificate were considered.
Recent observational studies assessed the association between non-alcoholic fatty liver disease (NAFLD) and lung function in adults, but the magnitude of this association remains uncertain. We ...estimated the magnitude of the association between NAFLD and lung function on spirometry (predicted forced expiratory volume in 1 s FEV1 and forced vital capacity FVC).
We searched publication databases using predefined keywords to identify studies (published up to October 4, 2018), in which NAFLD was diagnosed by imaging or biochemistry (no studies with biopsy-proven NAFLD were available). Data from selected studies were extracted, and meta-analysis was performed using random-effects modelling.
Six observational studies (5 cross-sectional and 1 longitudinal) with aggregate data on 133,707 individuals (27.8% with NAFLD) of predominantly Asian ethnicity (74.6%) were included in the final analysis. There were significant differences in predicted FEV1 (n = 5 studies; pooled weighted mean difference WMD: −2.43%, 95% CI: −3.28 to −1.58; I2 = 69.7%) and predicted FVC (pooled WMD: −2.96%, 95% CI: −4.75 to −1.17; I2 = 91.7%) between individuals with and without NAFLD. Decreased FEV1 and FVC at baseline were also independently associated with a ∼ 15% increased risk of incident NAFLD (n = 1 study in Korean individuals). Subgroup analyses did not materially modify these findings.
NAFLD is associated with significant reductions of both FEV1 and FVC in Asian and United States adults, and such small, but significant, reductions of lung volumes at baseline may be also associated with increased NAFLD incidence in Asian individuals. Further research is needed to better elucidate the link between NAFLD and impaired lung volumes.
Information is lacking on the association between non-alcoholic fatty liver disease (NAFLD) and bone mineral density (BMD) or circulating bone turnover biomarkers in post-menopausal women with type 2 ...diabetes (T2DM).
We recruited 77 white post-menopausal women with T2DM, who consecutively attended our diabetes outpatient service during a 3-month period. Liver ultrasonography and transient elastography (Fibroscan®) were used for diagnosing and staging NAFLD. A dual energy X-ray absorptiometry, and serum levels of 25-hydroxyvitamin D3 25(OH)D, parathyroid hormone and multiple bone turnover biomarkers (periostin, sclerostin, dickkopf-related protein-1 DKK-1, C-terminal telopeptide of type 1 collagen sCTX, procollagen type 1 N-terminal propeptide P1NP, receptor activator of nuclear factor-kB ligand RANKL) were also measured.
Overall, 10 patients had NAFLD with clinically significant fibrosis (i.e., liver stiffness measurement > 7 kPa), 52 had NAFLD without fibrosis and 15 patients were free from steatosis. Although the three patient groups had comparable values of BMD, after adjustment for age, waist circumference, HOMA-insulin resistance and serum 25(OH)D levels, patients with NAFLD and significant fibrosis had significantly higher sclerostin levels (54.1 ± 16.4 vs. 36.1 ± 11.9 vs. 42.3 ± 14.7 pmol/L) and lower levels of serum DKK-1 (26.6 ± 17.8 vs. 49.0 ± 22.4 vs. 42.9 ± 19.4 pmol/L), RANKL (0.04 ± 0.03 vs. 0.08 ± 0.06 vs. 0.11 ± 0.06 pmol/L) and sCTX (0.16 ± 0.09 vs. 0.29 ± 0.17 vs. 0.40 ± 0.28 ng/mL) compared to other groups. Serum periostin and P1NP levels did not significantly differ between the groups.
In post-menopausal women with T2DM, the presence of NAFLD and clinically significant fibrosis was strongly associated with a low bone turnover, which may reflect the presence of qualitative bone abnormalities.
Despite the high prevalence and serious clinical implications of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM), NAFLD is usually overlooked during routine ...diabetes care. This study explored the proportion of NAFLD cases and increased liver fibrosis (LF), and the association between LF and either chronic kidney disease (CKD) or cardiovascular complications in T2DM patients.
The study included 137 patients with non-insulin-treated T2DM and no known liver disease consecutively attending our diabetes outpatients’ service who underwent liver ultrasonography and liver stiffness measurement (LSM) using vibration-controlled transient elastography (FibroScan®).
The proportion of patients with hepatic steatosis on ultrasonography was 73.7%, and the proportion with significant LF was 17.5% with an LSM cut-off ≥7kPa or 10.2% with an LSM cut-off ≥8.7kPa. The presence of CKD (estimated GFR <60mL/min/1.73m2 and/or abnormal albuminuria) increased significantly across LSM tertiles (from around 15% in tertile 1 to 45% in tertile 3). Cardiovascular complications (previous ischaemic heart disease, ischaemic stroke, permanent atrial fibrillation) also tended to increase across LSM tertiles (from around 15% to 30%). After adjusting for established risk factors and potential confounders, LSM tertile 3 remained significantly associated with an approximately threefold higher risk of prevalent CKD (adjusted OR: 3.28, 95% CI: 1.22–8.90; P=0.019), but not for cardiovascular complications.
These results suggest that NAFLD and significant LF (as assessed by FibroScan®) are very commonly seen in T2DM outpatients with no known liver disease attending a secondary-care diabetes service, and that increased LF is associated with a greater proportion of chronic vascular complications, especially CKD.
Estimated pulse wave velocity (ePWV), a surrogate measure of arterial stiffness, was shown to independently predict morbidity and mortality from cardiovascular disease and other causes in both the ...general population and high-risk individuals. However, in people with type 2 diabetes, it is unknown whether ePWV adds prognostic information beyond the parameters used for calculating it.
To assess the independent association of ePWV with all-cause mortality in individuals with type 2 diabetes.
Prospective cohort study that enrolled 15,773 patients in 19 Italian centres in 2006-2008.
ePWV was calculated from a regression equation using age and mean blood pressure (BP). All-cause mortality was retrieved for 15,656 patients in 2015.
Percentage and rate of deaths, Kaplan-Meier estimates, and unadjusted hazard ratios increased from quartile I to quartile IV of ePWV. After adjustment for age, sex, BP levels and anti-hypertensive treatment, the strength of association decreased but mortality risk remained significantly higher for quartiles II (+34%), III (+82%), and IV (+181%) versus quartile I and was virtually unchanged when further adjusting for other cardiovascular risk factors and complications/comorbidities. Each m·s - 1 increase in ePWV was associated with an increased adjusted risk of death in the whole cohort (+53%) and in participants with (+52%) and without (+65%) cardiorenal complications. Moreover, ePWV significantly improved prediction of mortality risk over cardiovascular risk factors and complications/comorbidities, though the net increase was modest.
These findings suggest that ePWV may represent a simple and inexpensive tool for providing prognostic information beyond traditional cardiovascular risk factors.
ClinicalTrials.gov, NCT00715481, https://clinicaltrials.gov/ct2/show/NCT00715481.
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