Low-carb and ketogenic diets are popular among clinicians and patients, but the appropriateness of reducing carbohydrates intake in obese patients and in patients with diabetes is still debated. ...Studies in the literature are indeed controversial, possibly because these diets are generally poorly defined; this, together with the intrinsic complexity of dietary interventions, makes it difficult to compare results from different studies. Despite the evidence that reducing carbohydrates intake lowers body weight and, in patients with type 2 diabetes, improves glucose control, few data are available about sustainability, safety and efficacy in the long-term. In this review we explored the possible role of low-carb and ketogenic diets in the pathogenesis and management of type 2 diabetes and obesity. Furthermore, we also reviewed evidence of carbohydrates restriction in both pathogenesis of type 1 diabetes, through gut microbiota modification, and treatment of type 1 diabetes, addressing the legitimate concerns about the use of such diets in patients who are ketosis-prone and often have not completed their growth.
Aims/hypothesis
The aim of the study was to characterise the humoral response against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients with diabetes. Demonstrating the ability ...to mount an appropriate antibody response in the presence of hyperglycaemia is relevant for the comprehension of mechanisms related to the observed worse clinical outcome of coronavirus disease 2019 (COVID-19) pneumonia in patients with diabetes and for the development of any future vaccination campaign to prevent SARS-CoV-2 infection.
Methods
Using a highly specific and sensitive measurement of antibodies by fluid-phase luciferase immunoprecipitation assays, we characterised the IgG, IgM and IgA response against multiple antigens of SARS-CoV-2 in a cohort of 509 patients with documented diagnosis of COVID-19, prospectively followed at our institution. We analysed clinical outcomes and antibody titres according to the presence of hyperglycaemia, i.e., either diagnosed or undiagnosed diabetes, at the time of, or during, hospitalisation.
Results
Among patients with confirmed COVID-19, 139 (27.3%) had diabetes: 90 (17.7%) had diabetes diagnosed prior to the hospital admission (comorbid diabetes) while 49 (9.6%) had diabetes diagnosed at the time of admission (newly diagnosed). Diabetes was associated with increased levels of inflammatory biomarkers and hypercoagulopathy, as well as leucocytosis and neutrophilia. Diabetes was independently associated with risk of death (HR 2.32 95% CI 1.44, 3.75,
p
= 0.001), even after adjustment for age, sex and other relevant comorbidities. Moreover, a strong association between higher glucose levels and risk of death was documented irrespective of diabetes diagnosis (HR 1.14 × 1.1 mmol/l 95% CI 1.08, 1.21,
p
< 0.001). The humoral response against SARS-CoV-2 in patients with diabetes was present and superimposable, as for timing and antibody titres, to that of non-diabetic patients, with marginal differences, and was not influenced by glucose levels. Of the measured antibody responses, positivity for IgG against the SARS-CoV-2 spike receptor-binding domain (RBD) was predictive of survival rate, both in the presence or absence of diabetes.
Conclusions/interpretation
The observed increased severity and mortality risk of COVID-19 pneumonia in patients with hyperglycaemia was not the result of an impaired humoral response against SARS-CoV-2. RBD IgG positivity was associated with a remarkable protective effect, allowing for a cautious optimism about the efficacy of future vaccines against SARs-COV-2 in people with diabetes.
Graphical abstract
Purpose
Gonadotroph adenomas are pituitary adenomas with inefficient and variable secretory characteristics, that is why they are usually considered as a subgroup of nonfunctioning pituitary adenomas ...(NFPA) and are recognized only at immunohistochemistry. When gonadotroph adenomas secrete active hormones, they may cause spontaneous ovarian hyperstimulation syndrome (OHSS) in premenopausal women. Aim of our study is to describe three women with OHSS diagnosed before the removal of the adenoma and to calculate the prevalence of OHSS in premenopausal women with a clinical diagnosis of NFPA.
Methods
We reviewed clinical records of premenopausal women that underwent neurosurgery for NFPA at our centre between 1993 and 2014. OHSS was diagnosed in patients with high levels of FSH, suppressed LH, hyperestrogenism, abdominal symptoms, polymenorrhea, enlarged ovaries with cysts or previous surgery for ovarian cysts.
Results
171 women were included into the study; 62 (36.6%) had a gonadotroph adenoma diagnosed at immunohistochemistry. Two patients were retrospectively diagnosed as having OHSS due to gonadotroph adenoma and three had OHSS diagnosed before neurosurgery. The prevalence of OHSS was 2.9% in the overall group of patients with NFPA and 8.1% among patients with a gonadotroph adenoma detected at immunohistochemistry.
Conclusions
Frequency of OHSS due to a gonadotroph adenoma is not negligible. Increased awareness of the characteristic clinical and hormonal picture should permit an early detection of this condition in premenopausal women with a pituitary adenoma.
Aim
The aim of this study was to understand whether the dysglycemia associated with SARS-CoV-2 infection persists or reverts when the viral infection resolves.
Methods
We analyzed fasting blood ...glucose (FBG) after hospital discharge in a cohort of 621 adult cases with suspected COVID-19 pneumonia.
Results
At admission, 18.8% of the patients in our cohort had pre-existing diabetes, 9.3% fasting glucose in the diabetes range without a prior diagnosis (DFG), 26% impaired fasting glucose (IFG), 44.9% normal fasting glucose (NFG), while 2% had no FBG available. FBG categories were similarly distributed in the 71 patients without confirmed COVID-19 pneumonia. During follow-up (median time 6 month) FBG was available for 321 out of the 453 (70.9%) surviving patients and showed a trend to a marginal increase from 97 (87–116) to 100 (92–114) mg/dL;
p
= 0.071. Transitions between FBG categories were analyzed in subjects without pre-existing diabetes (265 out of 321). We identified three groups: (i) patients who maintained or improved FBG during follow-up Group A,
n
= 185; from 100 (86–109) to 94 (88–99) mg/dL;
p
< 0.001; (ii) patients who moved from the NFG to IFG category Group B,
n
= 66: from 89 (85–96) to 106 (102–113) mg/dl;
p
< 0.001; (iii) patients who maintained or reached DFG during follow-up Group C,
n
= 14: from 114 (94–138) to 134 (126–143) mg/dl;
p
= 0.035. Male sex and ICU admission during the hospitalization were more prevalent in Group C compared to Group A or B.
Conclusions
Six months after the SARS-CoV-2 infection DFG was evident in only few patients who experienced severe COVID-19 pneumonia.
Aims
A higher
SGLT1
and
GLUT2
gene expression was shown in the intestine of subjects with type 2 diabetes, while no data have been reported in type 1 diabetes (T1D). The purpose of our study was to ...evaluate the expression of glucose transporters in duodenal mucosa of subjects with T1D, compared to healthy controls (CTRL) and to patients with celiac disease (CD), as gut inflammatory disease control group.
Materials and methods
Gene expression of
GLUT1
,
GLUT2
,
SGLT1
and
SGLT2
was quantified on duodenal mucosa biopsies of subjects with T1D (
n
= 19), CD (
n
= 16), T1D and CD (
n
= 6) and CTRL (
n
= 12), recruited at San Raffaele Hospital (Milan, Italy), between 2009 and 2018.
SGLT2
expression was further evaluated by immunohistochemical and immunofluorescence staining.
Results
The expression of all four glucose transporters was detected in duodenal mucosa of all groups. A reduced
GLUT2
,
SGLT1
and
SGLT2
expression was observed in CD in comparison with T1D and CTRL, as expected;
GLUT1
was significantly more expressed in T1D compared to CTRL.
SGLT2
expression was quantified at much lower levels than other transporters, with no differences between groups.
SGLT2
expression was confirmed by immunohistochemistry in a restricted number of enterocytes lining in the mucosa of intestinal villi, also shown on immunofluorescence.
Conclusions
Our results show that glucose transporters expression in duodenal mucosa of subjects with T1D, except an increased
GLUT1
, is not different from that observed in healthy controls. The expression of
SGLT2
in human duodenal mucosa, although at low intensity, represents a novel finding.
To describe trends in modifiable and non-modifiable unfavorable factors affecting pregnancy outcomes, over time (years 2004-2017), in women with diabetes of childbearing age from an English primary ...care perspective.
We identified women with diabetes aged 16-45 years from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network, an English primary care sentinel database. Repeated annual cross-sectional analyses (2004-2017) assessed the prevalence of unfavorable factors for pregnancy, such as obesity, poor glycaemic control, microalbuminuria, hypertension, use of medications for treating diabetes, and associated comorbidities not recommended for pregnancy.
We identified 3,218 women (61.5% with Type 2 diabetes) in 2004 and 6,657 (65.0% with Type 2 diabetes) in 2017. The proportion of women with ideal glycaemic control for conception (HbA1c<6.5%) increased over time, in patients with Type 1 diabetes from 9.0% (7.1%-11.0%) to 19.1% (17.2%-21.1%), and in those with Type 2 diabetes from 27.2% (24.6%-29.9%) to 35.4% (33.6%-37.1%). The proportion of women with Type 2 diabetes prescribed medications different from insulin and metformin rose from 22.3% (20.5%-24.2%) to 27.3% (26.0%-28.6%).In 2017, 14.0% (12.6%-15.4%) of women with Type 1 and 30.7% (29.3%-32.0%) with Type 2 diabetes were prescribed angiotensin-modulating antihypertensives or statins. We captured at least one unfavorable factor for pregnancy in 50.9% (48.8%-52.9%) of women with Type 1 diabetes and 70.7% (69.3%-72.0%) of women with Type 2 diabetes. Only one third of women with Type 1 diabetes (32.2%, 30.3%-34.0%) and a quarter of those with Type 2 diabetes (23.1%, 21.9%-24.4%) were prescribed hormonal contraception. Contraception was prescribed more frequently to women with unfavorable factors for pregnancy compared to those without, however, the difference was significant only for women with Type 1 diabetes.
Despite significant improvements in general diabetes care, the majority of women with Type 1 or Type 2 diabetes have unfavorable, although mostly modifiable, factors for the start of pregnancy. Good diabetes care for women of childbearing age should include taking into consideration a possible pregnancy.
The differential diagnoses and nuances of the surgical management of occipital migraine and occipital neuralgia have not been clearly discussed in the available literature. This study aims to ...highlight additional diagnostic features and offers an algorithm for the surgical treatment of occipital migraine and occipital neuralgia based on the vast experience of the senior author spanning over 23 years. A retrospective cohort study was conducted to review the number and distribution of patients who underwent surgical treatment for occipital migraine headaches and neuralgia and the signs and symptoms observed.
Among the 660 patients who underwent surgical treatment for headaches within the territory of the greater occipital nerves, 86 patients underwent isolated deactivation of the greater occipital site (site IV) or combined greater and lesser occipital sites (site IV and site VI surgical). Within the isolated occipital headache group, 43 patients met the criteria for migraine headaches and 43 for occipital neuralgia. Our additional observation on the differences between the occipital neuralgia and migraine groups included that occipital neuralgia is more commonly unilateral, less commonly familial, and more commonly associated with a whiplash-type injury. In addition, the patient with occipital neuralgia can consistently identify the distinct point of pain using the index finger. An ultrasound Doppler signal can also be detected at the pain site and a pulse is often palpable in the site identified by the patient. Occipital neuralgia is also commonly continuous and unrelenting, with occasional spikes of shooting pain, and is less likely to respond to botulinum toxin-A injection. Patients with occipital neuralgia often have a single-site headache while patients with migraine headaches often suffer from headaches in multiple sites. Additional clinical criteria are offered for the differential diagnosis of occipital migraine headaches and occipital neuralgia based on the vast experience of the senior author and the developed surgical management algorithm.
Aim. The aim of the current study was to compare clinical characteristics, laboratory findings, and major outcomes of patients hospitalized for COVID-19 pneumonia with COVID-associated hyperglycaemia ...or pre-existing diabetes. Methods. A cohort of 176 adult patients with a diagnosis of pre-existing diabetes (n = 112) or COVID-associated hyperglycaemia (n = 55) was studied. Results. Patients with COVID-associated hyperglycaemia had lower BMI, significantly less comorbidities, and higher levels of inflammatory markers and indicators of multi-organ injury than those with pre-existing diabetes. No differences between pre-existing diabetes and COVID-associated hyperglycaemia were evident for symptoms at admission, the humoral response against SARS-CoV-2, or autoantibodies to glutamic acid decarboxylase or interferon alpha-4. COVID-associated hyperglycaemia was independently associated with the risk of adverse clinical outcome, which was defined as ICU admission or death (HR 2.11, 95% CI 1.34–3.31; p = 0.001), even after adjustment for age, sex, and other selected variables associated with COVID-19 severity. Furthermore, at the same time, we documented a negative association (HR 0.661, 95% CI 0.43–1.02; p = 0.063) between COVID-associated hyperglycaemia to swab negativization. Conclusions. Recognizing hyperglycaemia as a specific clinical entity associated with COVID-19 pneumonia is relevant for early and appropriate patient management and close monitoring for the progression of disease severity.
Surgical treatment is the gold standard of care for vulvar cancer and is burdened by a high risk of wound complications due to the poor healing typical of the female genital area. Moreover, this ...malignancy has a high risk of local relapse even after wide excision. For these reasons, secondary reconstruction of the vulvoperineal area is a relevant and challenging scenario for gynecologists and plastic surgeons. The presence of tissue already operated on and undermined, scars, incisions, the possibility of previous radiation therapy, contamination of urinary and fecal pathogens in the dehiscent wound or ulcerated tumor, and the unavailability of some flaps employed during the primary procedure are typical complexities of this surgery. Due to the rarity of this tumor, a rational approach to secondary reconstruction has never been proposed in the literature.
In this observational retrospective study, we reviewed the clinical data of patients affected by vulvar cancer who underwent secondary reconstruction of the vulvoperineal area in our hospital between 2013 and 2023. Oncological, reconstructive, demographic, and complication data were recorded. The primary outcome measure was the incidence of wound complications. The secondary outcome measure was the indication of the different flaps, according to the defect, to establish an algorithm for decision-making.
Sixty-six patients were included; mean age was 71.3 ± 9.4 years, and the mean BMI was 25.1 ± 4.9. The mean size of the defect repaired by secondary vulvar reconstruction was 178 cm
± 163 cm
. Vertical rectus abdominis myocutaneous (VRAM), anterolateral thigh (ALT), fasciocutaneous V-Y (VY), and deep inferior epigastric perforator (DIEP) were the flaps more frequently employed. We observed five cases of wound breakdown, one case of marginal necrosis of an ALT flap, and three cases of wound infection. The algorithm we developed considered the geometry and size of the defect and the flaps still available after previous surgery.
A systematic approach to secondary vulvar reconstruction can provide good surgical results with a low rate of complications. The geometry of the defect and the use of both traditional and perforator flaps should guide the choice of the reconstructive technique.
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