Patrizio Tatti

Sleep Apnea, Sleep Disturbance, and Fasting Glucose Variability: A Pilot Study

Background: Disturbed sleep and nocturnal altered breathing are related to disturbances of glucose metabolism. The present uncontrolled observational study explores the role of these factors on the variability of fasting glycemia. Methods: The number and duration of nocturnal awakenings and the fasting glycemia of 97 patients with type 2 diabetes treated with diet, metformin, or gliptins were recorded over seven consecutive days. During the same time period, the main respiratory indexes—oxygen disturbance index, apnea/hypopnea index, and respiratory disturbance index—were recorded for one night. Results: The three respiratory indexes and the number of nocturnal awakenings are highly correlated with the coefficient of variation of the fasting blood glucose recorded over the 7-day period at p < .005 level. A multiple regression analysis showed that the variables in the model explained 86% of the variability. Discussion: Respiratory/sleep disturbances appear to be modulators superimposed on blood glucose levels determined by other factors.

Application of Technology in Endocrine Disease

We live in a period of rapid change, in which many new technologies appear and are diffused through medical meetings, the Internet, specialized journals, the lay press, and media. While these innovations may bring a substantial improvement to the quality of care, sometimes, due to commercial pressures, technology can enter the market without adequate evidence of true benefit and without an analysis of the cost/benefit ratio. The converse is also true. Other potentially useful technologies can be underestimated due to insufficient commercial interest preventing further investment and development.

The undisclosed role of disturbed sleep and hypoxia on metabolism: the importance of upper airways pathology

Dear Editor, The patency of the upper respiratory airways and metabolic functions are both critical to survival, but in the last few decades, the connection between respiratory disturbances and metabolic disorders has been elucidated [1]. Nasopharyngeal obstruction can occur at different anatomical levels and may be caused by multiple pathologies (rhinitis, rhinosinusitis, turbinate hypertrophy, severe septal deviation, nasal polyposis, valvular dysfunction, and adenoid/tonsillar hypertrophy). The most obvious and dramatic consequences are snoring and more dangerously obstructive sleep apnea syndrome (OSAS) [2]. While the relationship of sleep with blood pressure, the central nervous system, and hormonal secretion is widely recognized, there are a limited number of studies, some with controversial results, on disturbed respiration/sleep apnea and glucose control [3]. The presence of OSAS causes an increase in the inflammatory cytokines, especially TNF alpha, which in turn can cause a further increase in insulin resistance and atherosclerotic cardiovascular damage. Interestingly, the inflammatory cytokines appear to have a role in causing pancreatic B cell damage, and this is a further link to diabetes [4]. Furthermore, OSAS subjects appear particularly prone to gain weight and obesity, which may in turn be a factor in causing or worsening diabetes. Sleep can modulate appetite through the hormone leptin: short sleep duration is associated with decreased leptin levels, increased ghrelin levels, and increased appetite. The mechanism involved may be a direct suppressive effect of OSAS on gene expressing leptin. Another correlation is that using CPAP to control apnea episodes seems able to modulate the secretion of leptin. Conversely, OSAS increases daytime somnolence and inactivity and alters the hormonal balance interfering with appetite [5]. With this background knowledge in mind, we studied sleep disturbances and glucose variability evaluating the relationship between sleep fragmentation and the level and variability of the fasting blood glucose values (FBG). We used the Armband, an instrument that records the number and the duration of the awakenings during sleep (AW), for six consecutive days in 60 obese, diabetic type 2 subjects on a diet or oral hypoglycemic agents with a history of sleep disturbance. Blood glucose levels were recorded in duplicate upon awakening with the same brand of glucometer using an interference-free electrochemical method throughout the observation period. The standard deviation (SD) was calculated as an index of variability. All the data were log transformed. The correlation coefficients versus the number of awakenings were for the FBG .76 (p<0.001) and the SD .81 (p< 0.001), and the ANOVAwas <0.001 for both. After removing the effect of BMI, age, and HbA1c, the correlation of AW with the FBG was p00.001 and with the SD, p00.049. D. Passàli : L. Bellussi ENT Unit, Siena University, Siena, Italy

Diabetic Gastrointestinal Neuropathy: Elusive Diagnosis and Difficult Treatment

Diabetic Gastrointestinal Neuropathy is an elusive diagnosis and often overlooked. The affected patients do not connect the symptoms with diabetes and undergo a painstaking and expensive search for other disorders of the digestive tract. Diabetic Gastrointestinal Neuropathy additionally causes a baffling glucose instability that further aggravates the condition. The treatment is difficult. The less severe cases respond to prokinetic treatment, but when the disease is advanced the only available therapy is the insertion of a pacemaker.

Nutritional Treatment of Diabetic Foot Ulcers - A Key to Success

Diabetic Foot Ulcers (DFUs) represent a frequent occurrence in the diabetic population and up to 15% of these subjects may be expected to develop a foot ulcer at least one time in his/her life1,2. DFUs cause personal, social and economic problems and are a serious risk factor for death3,4. These ulcers can be broadly classified as neuropathic, vascular5 or mixed, although the pathogenesis is much more complex. Biochemical6, hygienic7, structural deformity8,9, dynamic, pressure, skeletal, nutritional, socioeconomic factors, reduced antibacterial activity10,11,12, workplace influences, all concur to cause and maintain the lesion. A multicenter study attributed 63 percent of diabetic foot ulcers to the critical triad of peripheral sensory neuropathy, trauma, and deformity13. Most often healing requires the cooperation of many specialists, including surgeons, podiatrists, wound nurses and endocrinologists. In many cases, the definitive treatment demands minor or major surgery.

Therapeutic Use of Glutamine for Diabetic Foot Ulcers and Related Conditions

The incidence of diabetes is increasing throughout the world. Ulcers affecting the lower limbs of diabetics are among the most frequent and costly clinical complications of the disease. Approximately

The Use of a Specialized Nutritional Supplement for Diabetic Foot Ulcers Reduces the Use of Antibiotics

6–15 billion annually is spent on caring for all chronic wounds in the United States [1]. Among the diabetic population, approximately 1–4 % will develop a foot ulcer per year, with up to 25 % developing an ulcer during their lifetime. Many of these ulcers result in significant morbidity, leading to amputations, disfigurement, sepsis, and sometimes, even death.