Massimo Perotto

Fasting plasma C-peptide and micro- and macrovascular complications in a large clinic-based cohort of type 1 diabetic patients.

OBJECTIVE—A protective effect of residual β-cell function on microvascular complications of type 1 diabetes has been suggested. Our aim was to retrospectively evaluate the association of fasting plasma C-peptide values with micro- and macrovascular complications. RESEARCH DESIGN AND METHODS—We recruited a clinic-based cohort of 471 type 1 diabetic patients born after 1945 and cared for in the period 1994–2004. Centralized measurements and standardized procedures of ascertainment of micro- and macrovascular complications were employed. Individual cumulative averages of A1C up to 2007 were calculated. RESULTS—Residual β-cell secretion was detected even many years after diabetes diagnosis. In multivariate linear regression analysis, fasting plasma C-peptide values were positively associated with age at diagnosis (β = 0.02; P < 0.0001) and triglycerides (β = 0.20; P = 0.05) and inversely associated with diabetes duration (β = −0.03; P < 0.0001) and HDL cholesterol (β = −0.006; P = 0.03). The final model explained 21% of fasting C-peptide variability. With respect to fasting C-peptide values in the lowest tertile (<0.06 nmol/l), higher values were associated with lower prevalence of microvascular complications (odds ratio [OR] 0.59 [95% CI 0.37–0.94]) independently of age, sex, diabetes duration, individual cumulative A1C average during the study period, hypertension, and cardiovascular diseases. No association was evident with macrovascular complications (0.77 [0.38–1.58]). CONCLUSIONS—Our study shows an independent protective effect of residual β-cell function on the development of microvascular complications in type 1 diabetes, suggesting the potential beneficial effect of treatment that allows the preservation of even modest β-cell function over time.

Uric acid is not an independent predictor of cardiovascular mortality in type 2 diabetes: a population-based study.

OBJECTIVE Although some studies have suggested that uric acid is a risk factor for mortality, this relationship is still uncertain in people with type 2 diabetes. METHODS The study base was the population-based cohort of 1540 diabetic subjects (median age 68.9 years) of the Casale Monferrato Study. The role of serum uric acid on 15-years all-cause, cardiovascular and non-cardiovascular mortality was assessed by multivariate Cox proportional hazards modeling. RESULTS Baseline levels of serum uric acid were negatively correlated with HbA1c, were higher in men and in the elderly and were independently associated with components of the metabolic syndrome. Out of 14,179 person-years, 1000 deaths (514 due to cardiovascular diseases) were observed. Compared to the lower quartile of uric acid, HRs (95% CI) in the upper quartile were 1.47 (1.22-1.76) for all-cause mortality; 1.40 (1.09-1.80) for cardiovascular mortality and 1.50 (1.15-1.96) for non-cardiovascular mortality. In multiple adjusted models, however, HRs were 1.30 (1.06-1.60) for all-cause mortality, 1.13 (0.85-1.50) for cardiovascular mortality and 1.50 (1.11-2.02) for non-cardiovascular mortality (men 1.87, 1.19-2.95; women 1.20, 0.80-1.80); the latter appeared to be due to neoplastic diseases (HR in all combined quartiles vs. lower quartile: both sexes 1.59, 1.05-2.40; men 1.54, 0.83-2.84, women 1.68, 0.95-2.92). CONCLUSIONS In diabetic people, uric acid is associated with components of the metabolic syndrome but it may not be accounted as an independent risk factor for cardiovascular mortality. The increased all-cause mortality risk with higher levels of uric acid might be due to increased neoplastic mortality and deserves future studies.

C-Reactive Protein and 5-Year Survival in Type 2 Diabetes: The Casale Monferrato Study

OBJECTIVE To determine to what extent plasma C-reactive protein (CRP) values influence 5-year all-cause and cardiovascular mortality in type 2 diabetic individuals, independently of albumin excretion rate (AER) and other cardiovascular risk factors, and its incremental usefulness for predicting individual risk of mortality. RESEARCH DESIGN AND METHODS Measurements of CRP were performed in 2,381 of 3,249 (73.3%) subjects as part of the population-based Casale Monferrato Study. Its association with 5-year all-cause and cardiovascular mortality was assessed with multivariate Cox proportional hazards modeling. The C statistic and measures of calibration and global fit were also assessed. RESULTS Results are based on 496 deaths in 11.717 person-years of observations (median follow-up 5.4 years). With respect to subjects with CRP ≤3 mg/l, those with higher values had an adjusted hazard ratio (HR) of 1.51 (95% CI 1.18–1.92) for all-cause mortality and 1.44 (0.99–2.08) for cardiovascular mortality. In normoalbuminuric subjects, respective HRs of CRP were 1.56 (1.13–2.15) and 1.65 (1.00–2.74), AER being neither a modifier nor a confounder of CRP association. In analysis limited to diabetic subjects without cardiovascular disease (CVD), adjusted HRs were 1.67 (1.24–2.24) for all-cause mortality and 1.36 (0.83–2.24) for cardiovascular mortality. The improvement in individual risk assessment was marginal when measured with various statistical measures of model discrimination, calibration, and global fit. CONCLUSIONS CRP measurement is independently associated with short-term mortality risk in type 2 diabetic individuals, even in normoalbuminuric subjects and in those without a previous diagnosis of CVD. Its clinical usefulness in individual assessment of 5-year risk of mortality, however, is limited.

Investigating obesity among professional drivers: The high risk professional driver study

OBJECTIVE The aim of this study is to detect the main individual and transportation factors associated with obesity and its prevalence among Italian professional drivers (PDs). METHODS We performed a cross-sectional questionnaire survey. Data from PDs (n = 497) were used for analyses. RESULTS Sixty-one percent of participants were either overweight or obese according to their body mass index. Predictive factors for obesity were traveling more than 40,000 miles per year (odds ratio [OR] 4.20, confidence interval [CI] 1.41-12.56) and hours spent behind the wheel per day (OR 1.27, CI 1.02-1.58). Bus drivers had half the risk of being obese compared to truck drivers (OR 0.45, CI 0.23-0.87). An inverse association was detected between educational attainment and obesity (OR 0.32, CI 0.11-0.90). CONCLUSIONS PDs with high number of driving hours per day, miles driven per year, and low educational level should be subject to special educational programs to reduce and prevent obesity.

What is the clinical usefulness of the metabolic syndrome? The Casale Monferrato study.

Objective Data on the clinical usefulness of the metabolic syndrome with respect to cardiovascular risk are not conclusive. We have assessed this issue in a large population-based cohort of diabetic and nondiabetic people in Southern Europe. Methods An Italian population-based cohort of 3729 individuals (2211 without diabetes and 1518 with diabetes) was examined, with centralized measurements, including the Homeostasis Model Assessment (HOMA) index in nondiabetic people. The usefulness of the metabolic syndrome (ATP III criteria) as an indicator of cardiovascular disease (CVD), independently of classical and novel risk factor [C-reactive protein (CRP) and albumin excretion rate (AER)] was assessed by using unconditional logistic regression. Results One thousand, seven hundred and fifty-three individuals (47.0%) had neither diabetes nor the metabolic syndrome, 458 (12.3%) had the metabolic syndrome only, 442 (11.8%) had type 2 diabetes only and 1076 (28.9%) had both diabetes and the metabolic syndrome. The highest likelihood of having CVD was conferred by both diabetes and the metabolic syndrome [odds ratio (OR) = 4.37, 95% confidence interval (CI) 3.25–5.87], independently of age, sex, low-density lipoprotein-cholesterol, smoke, AER, and CRP values. After further adjustment for its individual components, the association between CVD and the metabolic syndrome was no more evident. Among people with CRP 3 mg/l or less, ORs were similar in nondiabetic people with the metabolic syndrome and in diabetic people without it, whereas among those with CRP greater than 3 mg/l OR was two-fold higher in the latter. Values in upper quartiles of the HOMA-IR conferred a significant two-fold increased OR of CVD, even after adjustment for individual components of the metabolic syndrome, CRP and AER. Conclusions The additional information provided by the metabolic syndrome is limited, in both diabetic and nondiabetic people, whereas the HOMA index is a useful indicator of CVD, independently of individual components of the metabolic syndrome, classical and novel risk factors.

Diabetes-specific variables associated with quality of life changes in young diabetic people: the type 1 diabetes Registry of Turin (Italy).

BACKGROUND AND AIMS Type 1 diabetes (T1DM) affects young people during the most active years of their life. Our aim was to assess quality of life (QoL) and associated variables in a large cohort of adults with childhood-onset and adult-onset T1DM. METHODS A cohort of adult patients (18 years and older) from the T1DM Registry of Turin, Italy, was recruited. Clinical characteristics and Diabetes QoL (DQOL) questionnaire were assessed by standardized procedures. RESULTS 310 adults completed the questionnaire. Age and diabetes duration at assessment (mean ± SD) were 32.8 ± 7.3 years and 17.3 ± 6.3 years, respectively. DQOL and its subscores were in the lower quartiles of their distributions, indicating a good level of QoL. However, scores were significantly higher in females than in males, particularly for the subscale of diabetes-related worries. In multivariate analysis, lower QoL was independently associated with female sex (β = 1.07, 95% CI 1.03-1.11, p = 0.003), higher age at onset (β = 1.03, 1.00-1.05, p = 0.009), lower schooling (β = 1.05, 1.00-1.09, p = 0.02), higher fasting plasma glucose (β = 1.03, 1.01-1.05, p = 0.008), daily SMBG >4 (β = 1.06, 1.01-1.10, p = 0.01), severe hypoglycemia over the last year (β = 1.06, 1.01-1.11, p = 0.02), lower numbers of diabetologic visits (β = 1.07, 1.01-1.13, p = 0.02) and hypertension (β = 1.06, 1.02-1.10, p = 0.005). Autonomic neuropathy was associated with diabetes impact. Female sex (β = 4.36, 2.43-7.83) and daily SMBG >4 (β = 3.77, 1.72-8.30) were independently associated with worst level and CSII with better level (β = 0.22, 0.07-0.68) of diabetes-related worries. CONCLUSIONS The impact of T1DM on QoL may depend on demographic, metabolic control-related variables, presence of complications and insulin delivery modality.

Perirenal Fluid Collection: An Uncommon Cause of Septic Shock

An 83-year-old woman was brought by ambulance to the Emergency Department (ED) with worsening dyspnea, hypotension, fever, and diffuse abdominal pain for 2–3 days. Her past medical history was significant for vascular dementia. She was a resident in a nursing home institution. She was taking no medications. Upon arrival at the ED, the patient was unresponsive, hemodynamically unstable, and febrile. Vital signs were: heart rate 130 beats/min, right arm blood pressure 80/55 mm Hg, temperature 39 C (102.2 F), and respiratory rate 30 breaths/min. Oxygen saturation was 92% on room air. The physical examination revealed abdominal tenderness in the upper-right quadrant with no rebound and normoactive bowel sounds. There were no palpable mass lesions or renal bruits. The lung sounds were clear and symmetrical with no wheezes or crackles. The heart sounds were regular but tachycardic and without murmurs. Femoral pulses were thready and equal. The

Falling asleep at the wheel and distracted driving. The High-Risk Professional Drivers study

BACKGROUND Sleepiness at the wheel and driving while engaged in other activities are well known risk factors for traffic accidents. This article estimates the prevalence of these factors among Italian Professional Drivers (PDs) and their impact on reported driving mistakes. METHODS A cross-sectional study was conducted using anonymous questionnaires. PDs (n=497) were divided into two groups: high-risk PDs (HiRis_PDs) (those who self-reported more than one incident during the last 3 years and/or more than one mistake during the past year) and non-HiRis_PDs (subjects who did not meet the above-mentioned inclusion criteria). Logistic regression analyses were performed to assess the association of self-reported sleepiness and/or risky driving behaviour with the condition of being a high-risk driver. RESULTS 161 (32.4%) subjects were defined as HiRis_PDs. Forty-one percent of the interviewees experienced at least one episode per month of sudden-onset sleep at the wheel. Twenty-eight point two percent reported a regular use of a hand-held cell phone. Predictive factors for being HiRis_PDs were: at least one self-reported episode per month of falling asleep at the wheel [odds ratio (OR) 5, 95% confidence interval (CI) 3.21-7.80, P<0.001], driving while regularly engaged in other activities (mainly hand-held cell phone use) (OR 6.11, 95% CI 2.90-12.84, P<0.001), and young age (OR 0.96, OR 1 year of age increase, 95% CI 0.94-0.98, P=0.001). CONCLUSIONS Focusing prevention efforts on recognizing sleepiness at the wheel and on avoiding other distracting activities while driving can reduce the possibility of driving errors on the road by about 5-6 times.

Discharge communication is an important underestimated problem in emergency department

We read with interest the recent article by Margaret Jane Linet et al. examining comprehension of emergency department (ED) discharge instructions of patients who receive discharge instructions for ‘‘abdominal pain’’, ‘‘chest pain’’ and ‘‘nausea and vomiting’’ [1]. They showed that patients’ perception of their understanding of discharge instructions does not necessarily correlate with actual understanding of discharge instructions. In general, patients rate a higher understanding of instructions compared with physician evaluation of their understanding. This lack of correlation is pronounced in patients with higher education levels and of the male gender. We are extremely convinced that communication at discharge is an important part of high-quality emergency department (ED) care and discharge from the hospital is a period of significant potential vulnerability for patients. Patients leaving the hospital after inpatient admission often fail to understand important elements of their discharge and home care plan, leaving them at potential risk of a medical error, adverse drug event or re-admission in ED for the same problem [2, 3]. An ongoing pilot study in our Emergency Department (S. Croce and Carle Hospital, Cuneo, Italy) regarding comprehension of discharge instructions for non-traumatic and chronic low back pain demonstrates that patients commonly remain confused about aftercare information following treatment in the ED. In this pilot study, we enrolled 50 consecutive adult patients who complained about chronic low back pain in a fixed period of 3 months. During the month following the discharge, a telephone interview was conducted by a nurse using a standardized questionnaire. We use five questions with simple possible answers: (1) What is your education level? (2) Did you understand the discharge instructions? (3) Which part of the discharge instructions was not completely clear? (4) Did you need any help to understand it (ED re-admission, General Practitioner, Pharmacist)? (5) Have you resolved your health problem? We observe that patients who do not understand the discharge instructions have a language problem (foreigners) or of low education level, and they are between the ages of 35 and 51 years. However, the most interesting results are that 46 % of the enrolled patients do not understand discharge instructions, and 37 % of them need a second ED visit to fully understand the prescriptions. We also observe that 75 % of patients during the telephone interview are dissatisfied because they have not resolved the health problem. We believe that if we are able to provide clear and understandable instructions at discharge we might partially reduce inappropriate usage of the ED due to chronic disease, reduce costs and satisfy the patients’ needs.