Targeting educational therapy for type 2 diabetes: identification of predictors of therapeutic success

Patient education is a key component of diabetes care. Limits in resources often prevent the participation of many patients with type 2 diabetes to structured education programs. The identification of predictors of response to group education could help in selecting those patients in whom the intervention is more cost-effective. A structured interactive group program was proposed to a consecutive series of 150 type 2 diabetes patients, who were then followed prospectively in 24 months, with measurements of HbA1c, BMI, quality of life, eating habits. For comparison, another consecutive series of 113 patients who had received no intervention was also observed for 12 months. A significant reduction in HbA1c was observed in the intervention group at 12 and 24 months (from 7.5 ± 1.4 to 6.9 ± 1.2 and 6.6 ± 1.1% at 12 and 24 months, respectively, both P < 0.01), with no variation in BMI and quality of life. A sustained reduction in total energy, protein, and fat intake was observed after education. The proportion of success (HbA1c < 7% and/or HbA1c reduction from baseline > 1%) in the intervention group was 60.7% (vs. 38.1% in controls) and 63.3% at 12 and 24 months, respectively. In the intervention group, patients with success at 12 months showed lower baseline HbA1c, BMI, duration of diabetes, protein, and cholesterol intake. Patients with a lower duration of diabetes appear to have a greater response to structured group education, whereas age is not a predictor of response. Therefore, educational intervention should be planned in the earlier phases of the disease.

Fat boosts, while androgen receptor activation counteracts, BPH-associated prostate inflammation

BACKGROUND

Metabolic syndrome (MetS) and benign prostate hyperplasia (BPH) are often comorbid. Chronic inflammation, a determinant pathogenic factor for BPH, is a putative link between the two conditions.

METHODS

In a multi-center cohort of BPH patients (n = 244) who underwent prostatectomy, we evaluated whether MetS is associated with prostatic inflammation in BPH specimens. In addition, we investigated the in vitro inflammatory effects of metabolic insults on human prostatic myofibroblastic cells (hBPH).

RESULTS

Inflammatory infiltrates score (IS) in prostatectomy specimens showed a step-wise association with the number of MetS factors present (P = 0.001). After adjusting for age, reduced HDL cholesterol, and elevated triglycerides were the only factors significantly associated with IS. Increased IS was also significantly associated with hypogonadism. In an age- and testosterone (T)-adjusted model, dyslipidemia was still associated with IS. To investigate whether metabolic factors could directly trigger prostate inflammation, we performed preliminary studies in myofibroblastic hBPH. Among the different factors, oxidized low-density lipoprotein (oxLDL) showed the highest secretion of IL-8 (>10-fold)-a surrogate marker of prostate inflammation--as well as IL-6, and bFGF. Co-treatment with DHT significantly inhibited oxLDL-induced secretion of IL-8, whilst an AR-antagonist, bicalutamide, reversed DHT effects. DHT suppresses oxLDL receptor (LOX-1) expression.

CONCLUSIONS

Our data suggest that fats and insulin could have a detrimental effect on prostate health, boosting inflammation, a key pathogenic factor in BPH. Conversely, beneficial effects of DHT in counteracting lipid- and insulin-induced prostatic alterations, suggest that T-via its conversion into DHT-may have unexpected beneficial effects on prostate health.

Personality features of obese women in relation to binge eating and night eating

Personality traits can affect eating behaviors, the development of obesity, and obesity treatment failure. We investigated the personality characteristics and their relation with disordered eating in 586 obese women consecutively seeking treatment at eight Italian medical centers (age, 47.7±9.8 years) and 185 age-matched, normal weight women without symptoms of eating disorders (Eating Attitude Test<20). The assessment included anthropometry, the Temperament and Character Inventory (TCI), the Binge Eating Scale (BES) and the Night Eating Questionnaire (NEQ). Logistic regression analyses were carried out in different models with BES score≥27 and NEQ≥30 as dependent variables and TCI scores as independent factors. Personality traits of obese individuals included significantly lower self-directedness and cooperativeness on TCI. BES and NEQ scores were higher in obese women, and values above the defined cut-offs were present in 77 and 18 cases (14 with high BES), respectively. After controlling for age and BMI, high BES values were associated with high novelty seeking and harm avoidance and low self-directedness, the last two scales being also associated with high NEQ. We conclude that personality traits differ between obese patients seeking treatment and controls, and the presence of disordered eating is associated with specific personality characteristics.

Efficacy and safety of degludec insulin: a meta-analysis of randomised trials

OBJECTIVES

Degludec is a novel long-acting insulin analogue, providing an adequate supply of basal insulin over 24 hours with one daily injection, with a supposed greater reproducibility and flexibility than other basal insulins.

METHODS

An extensive search of Medline and the Cochrane Library for 'degludec' was performed, up to July 1st, 2012, collecting all randomised trials with a duration of at least 16 weeks and enrolling patients with diabetes. The principal outcome was the effect of degludec, compared with other basal insulins, on endpoint HbA1c and hypoglycaemia. Secondary outcomes included BMI, FPG at endpoint, and the incidence of cardiovascular events and cancer.

RESULTS

In the four trials comparing degludec with glargine, endpoint HbA1c was similar in the two groups, whereas FPG was significantly lower in degludec-treated patients. Degludec was associated with a lower rate of overall and nocturnal hypoglycaemia in type 2 and type 1 diabetes, respectively. No differences were observed for cardiovascular events and cancer.

STUDY LIMITATIONS

The number of available trials and the duration of exposure were limited, so the results obtained should be considered preliminary.

CONCLUSIONS

Degludec appears to be associated with a lower incidence of hypoglycaemia in comparison with glargine, for similar levels of glycaemic control. The use of this agent could represent one step further in insulin therapy.

Further data on beta-blockers and cancer risk: observational study and meta-analysis of randomized clinical trials

BACKGROUND

The aim of the present paper is to provide some further data on the relationship between β-blocker treatment and the incidence of cancer, using two different approaches (epidemiological study and meta-analysis of clinical trials).

METHODS

In a consecutive series of 1340 diabetic patients starting insulin therapy, 112 cases of cancer during a mean follow-up of 75.9 months were identified as first hospital admission or death. For each case, the controls were chosen randomly from those members of the cohort matched for age, sex and BMI. The main predefined analysis was the comparison of cases and controls for length of exposure to β-blockers and proportion of patients exposed using a conditional logistic regression which takes into account the matching structure. For the meta-analytic sub-study, an extensive search of Medline and the Cochrane Library (any date up to December 31st, 2011) was performed for all trials in which a β-blocker was used. Mantel-Haenszel Odds Ratios (MH-OR) with 95% confidence intervals for incident malignancies were calculated using a random effect model.

RESULTS

After adjusting for mean daily dose of glargine and metformin, and ischemic heart disease, exposure to β-blockers was associated with a reduced overall risk of cancer (HR 0.33 [0.13; 0.83], p = 0.019; HR for each month of exposure 0.87 [0.77; 0.98], p = 0.025). In the meta-analysis sub-study, performed on nine trials, β-blockers were associated with a non-significant trend toward lower risk of cancer (MH-OR 0.93 [0.86; 1.01], p = 0.070).

STUDY LIMITATION

Limitations of the observational study are the small sample size that limits the statistical power of analyses, that it was performed on diabetic patients only, and that diagnoses of malignancies were derived from administrative data.

CONCLUSIONS

In conclusion, this research seem to confirm a possible beneficial effect of β-blockers against the risk of cancer development.

HbA1c levels and all-cause mortality in type 2 diabetic patients: epidemiological evidence of the need for personalised therapeutic targets

BACKGROUND AND AIM

The aim of the present case-control study is to explore the effect of case mix on the relationship between glycated haemoglobin (HbA1c) and mortality in type 2 diabetic patients.

METHODS AND RESULTS

A nested case-control study data set was generated from the cohort-study data set (n = 4140 type 2 diabetic outpatients) by sampling controls from the risk sets. Cases (n = 427) were compared with an equal number of controls chosen from those members of the cohort who were at risk for the same follow-up time of the case, matched for age (±3 years), sex, body mass index (BMI) (±2 kg m(-2)), duration of diabetes (±5 years), and Charlson's Comorbidity Score (CCS) (±1). The main predefined analysis was the comparison of cases and controls for proportion of patients with each HbA1c class (<6.5%, 6.5-7.4%, 7.5-8.4% and ≥8.5%). During a mean follow-up of 5.7 ± 3.5 years, 427 deaths were recorded. The lowest risk of death was observed in the HbA1c 6.5-7.4% category; a lower HbA1c was associated with a non-significant trend towards a higher risk. The risk associated with a low (<6.5%) HbA1c was significantly greater in patients who were insulin-treated than in the rest of the sample.

CONCLUSIONS

The present study suggests that glycaemic targets should be individualised on the basis of the characteristics of each patient, considering age, co-morbidity and duration of diabetes. Caution should be used in prescribing insulin to reach near-normoglycaemia, particularly in older, frail patients.

The Eating Disorders Well Being Questionnaire (EDwell): a new measure of quality of life in eating disorders

PURPOSE

Eating disorders (EDs) are an important cause of physical morbidity and psychosocial impairment, and eating disordered patients have a worse quality of life than peers. The aim of this study was to develop and validate a new self-report instrument, the Eating Disorders Well Being Questionnaire (EDwell), a measure of eating disorders-related quality of life, which takes into consideration not only the intensity, but also the subjective relevance of physical and psychosocial distress.

METHODS

The questionnaire was administered to 120 eating disordered patients and 60 healthy controls. Patients underwent a psychopathological and clinical evaluation. Test-retest reliability, internal consistency, and psychopathological correlates were evaluated. All patients were also administered the Eating Disorder Examination (EDE12.0D) and the Short Form 36 Health Survey (SF36). A factor analysis was performed to verify the distribution of items into subscales.

RESULTS

EDwell showed good test-retest reliability and internal consistency. EDwell scores significantly correlated with EDE12.0D total and subscale scores. A significant correlation was also found between several EDwell and SF36 scores. Factor analysis identified three factors: Perfectionism/Control, Loneliness/Avoidance, Social Functioning.

CONCLUSIONS

The EDwell questionnaire is a feasible and reliable measure of the specific impact of Eating Disorders psychopathology on quality of life.

Effect of pioglitazone versus metformin on cardiovascular risk markers in type 2 diabetes

INTRODUCTION

Besides its critical role in metabolic homeostasis, peroxisome proliferator-activated receptor (PPAR)-γ modulates several cellular responses involved in atherothrombosis. This multicenter, double-blind, randomized study investigated the effects of two oral hypoglycemic agents on markers of inflammation, platelet activation, thrombogenesis, and oxidative stress in patients with type 2 diabetes.

METHODS AND RESULTS

The primary objective of this study was to evaluate the effect on C-reactive protein (CRP) after a 16-week treatment period with either pioglitazone or metformin. Additionally, markers of vascular inflammatory response, platelet activation, thrombogenesis, oxidative stress, glucose, and lipid metabolism, as well as liver function, were measured. In total, 50 patients completed the study. Pioglitazone-treated patients were found to have statistically significantly larger decreases in mean CRP levels (-0.4 mg/dL) compared to those treated with metformin (-0.2 mg/dL) (P=0.04), as well as greater reductions in levels of mean fasting plasma glucose (-27 vs. -9 mg/dL; P=0.01), serum insulin (-2 vs. -1.9 mU/L; P=0.014), homeostatic model assessment (HOMA) (-1.2 vs. -0.9; P=0.015), and E-selectin (-12.4 vs. +3.4 μg/mL; P=0.01). Mean glycated hemoglobin (HbA1c) levels decreased in both treatment groups from baseline to week 16 (-0.4% in the pioglitazone group, -0.2% in the metformin group; P=0.36). Pioglitazone treatment was also found to be associated with a statistically significant increase in total cholesterol levels (+10 mg/dL in the pioglitazone arm, -3 mg/dL in the metformin arm; P=0.05) and a decrease in liver enzyme levels.

CONCLUSIONS

The favorable changes in markers of systemic and vascular inflammatory response with pioglitazone suggest that it may positively influence the atherothrombotic process in type 2 diabetes.

Diabetes mellitus as a risk factor for depression. A meta-analysis of longitudinal studies

AIM

The present meta-analysis is aimed at the assessment of the risk of incident clinical depression and/or depressive symptoms in patients with diabetes.

METHODS

A Medline search was performed on December 30th, 2011, using the search string: "diabetes AND (depression OR antidepressant)", selecting longitudinal studies that assessed the risk of incident depression in subjects with or without diabetes. Study design and characteristics were verified for each study. A meta-analysis was performed for unadjusted and adjusted risk ratios of incident depression in subjects with diabetes using a random effect model. Additional analyses were performed to assess heterogeneity, publication bias and specific hazard ratios for several possible confounders.

RESULTS

Of the 1898 retrieved studies, 16 were included in the meta-analysis, enrolling 497,223 subjects, with a mean follow-up of 5.8 years and 42,633 cases of incident depression. A higher incidence of depression was found in diabetic subjects (1.6% vs 1.4% yearly), with unadjusted and adjusted risk [95% confidence interval] of 1.29 [1.18-1.40] (p<0.001) and 1.25 [1.10-1.44] (p=0.001), respectively.

CONCLUSIONS

Diabetes is associated with a significantly increased risk for depressive symptoms. Pathogenetic mechanisms connecting diabetes with depression deserve further exploration.

Dipeptidyl peptidase-4 inhibitors and cardiovascular risk: a meta-analysis of randomized clinical trials

AIMS

Preliminary data from randomized trials with metabolic outcomes have shown that treatment with dipeptidyl peptidase-4 inhibitors (DPP4i) could be associated with a reduced incidence of major cardiovascular events (MACE). The present meta-analysis is aimed at verifying this protective effect, collecting all available data from randomized trials.

METHODS

A comprehensive search for published and unpublished trials with a duration ≥24 weeks comparing DPP4i with placebo or other drugs was performed, retrieving all MACE reported as serious adverse events together with death from any cause. Mantel-Haenzel odds ratio (MH-OR) was calculated with random effect models for MACE, myocardial infarction, stroke and mortality. When available, effects on glycated haemoglobin, lipid profile and blood pressure were also assessed and used for the estimation of the modification of risk for myocardial infarction using the UKPDS risk engine.

RESULTS

A total of 70 trials, enrolling 41 959 patients with a mean follow-up of 44.1 weeks, was collected and included in the analysis. The MH-OR (95% Confidence Interval) was 0.71[0.59;0.86], 0.64[0.44;0.94], 0.77[0.48;1.24] and 0.60[0.41;0.88] for MACE, myocardial infarction, stroke and mortality, respectively.

CONCLUSIONS

Treatment with DPP4i reduces the risk of cardiovascular events (particularly myocardial infarction) and all-cause mortality in patients with type 2 diabetes. The reduction in the incidence of myocardial infarction is greater than what predicted on the basis of conventional risk factors, suggesting a role for other mechanisms.

Impaired masturbation-induced erections: a new cardiovascular risk factor for male subjects with sexual dysfunction

INTRODUCTION

Erectile dysfunction (ED) is considered an early surrogate marker of silent, or even overt, cardiovascular diseases (CVD). However, epidemiological studies take into account only sexual intercourse-related erections. Although autoeroticism is a very common practice, data on masturbation-induced erections as a possible predictor of major adverse cardiovascular events (MACE) are lacking.

AIM

To evaluate the clinical correlates of impaired masturbation-induced erections and to verify the importance of this sexual aspect in predicting MACE.

METHODS

A consecutive series of 4,031 male patients attending the Outpatient Clinic for sexual dysfunction for the first time was retrospectively studied. Among these subjects, 64% reported autoeroticism during the last 3 months, and only this subset was considered in the following analyses. In the longitudinal study, 862 subjects reporting autoeroticism were enrolled.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and instrumental (Prostaglandin E1 [PGE1 ] test and penile color Doppler ultrasound) parameters were studied.

RESULTS

Subjects with an impaired erection during masturbation (46% of those reporting autoeroticism) had more often a positive personal or family history of CVD, a higher risk of reduced intercourse- and sleep-related erections, hypoactive sexual desire and perceived reduced ejaculate volume, and impaired PGE1 test response. Prolactin levels were lower in those having impaired erection during masturbation. In the longitudinal study, unadjusted incidence of MACE was significantly associated with impaired masturbation-induced erections. When dividing the population according to the median age and diagnosis of diabetes, the association between impaired masturbation-induced erections and incidence of MACE was maintained only in the youngest (<55 years old) and in nondiabetic subjects, even after adjusting for confounders (hazard ratio [HR] = 3.348 [1.085-10.335], P = 0.032 and HR = 2.108 [1.002-4.433], P = 0.049; respectively).

CONCLUSION

This study indicates that, in subjects with male sexual dysfunction, evaluating an often neglected sexual parameter, such as masturbation-induced erections, can provide further insights on forthcoming MACE in particular in "low risk" subjects.

The identification of prediabetes condition with ARIC algorithm predicts long-term CV events in patients with erectile dysfunction

INTRODUCTION

The Atherosclerosis Risk in Communities (ARIC) algorithm is one of the most efficient instruments for the prediction of incident type 2 diabetes. Recently, it has been shown to predict another relevant cardiovascular (CV) risk factor, such as chronic kidney disease.

AIM

To verify whether, in patients with erectile dysfunction (ED), the use of ARIC diabetes risk score might improve the efficacy in predicting major CV events of other CV risk algorithms specifically developed for the assessment of CV risk.

METHODS

A consecutive series of 2,437 men (mean age 52.5 ± 12.9 years) attending our outpatient clinic for sexual dysfunction was retrospectively studied. A subset of this sample (N = 1,687) was enrolled in a longitudinal study (mean follow-up of 4.3 ± 2.6 years).

MAIN OUTCOME MEASURES

The assessment of metabolic risk was evaluated with the ARIC algorithm. The assessment of CV risk was evaluated using the Progetto Cuore risk engine.

RESULTS

In the cross-sectional study, ARIC score was inversely related with testosterone levels, sexual functioning, and penile blood flow. When longitudinal sample was analyzed, higher baseline ARIC score significantly predicted major adverse cardiovascular event (MACE) even when subjects with diabetes mellitus at baseline were excluded from the analysis (hazard ratio = 1.522 [1.086-2.135]; P = 0.015 for trend). In addition, among subjects classified as "low risk" (CV risk <20% at 10 years corresponding to <9% at 4.3 years) by Progetto Cuore, a receiving operating curve (ROC) analysis for ARIC (vs. MACE) allowed the identification of a threshold of 0.22, which had a positive predictive value for 4.3-year MACE of 9%. Applying the ARIC score (with a threshold of 0.22) to Progetto Cuore "low-risk" subjects, we could classify as "at high risk" 89.8% of subjects with incident MACE vs. 79.6% with Progetto Cuore only.

CONCLUSIONS

In patients with ED, identifying prediabetes, even with algorithms, predicts long-term CV events.

Depression as a risk factor for diabetes: a meta-analysis of longitudinal studies

OBJECTIVE

The present meta-analysis aimed to assess the risk of incident diabetes associated with clinical depression, depressive symptoms, or both in nondiabetic subjects.

DATA SOURCES

We performed a MEDLINE search for studies published in the English language using the search string diabetes AND (depression OR antidepressant). The search included studies from any date to December 30, 2011.

STUDY SELECTION

1,898 studies were independently assessed for eligibility, and longitudinal studies that assessed the risk of incident diabetes in subjects with or without clinical depression were selected.

DATA EXTRACTION

Study design and characteristics were verified for each study. A meta-analysis was performed for unadjusted and adjusted risk ratios of incident diabetes in subjects with depression by using a random-effects model. Additional analyses were performed to assess heterogeneity, publication bias, and specific hazard ratios for diabetes associated with antidepressant drug use.

RESULTS

The 23 studies included in the meta-analysis enrolled 424,557 subjects, with a mean follow-up of 8.3 years and 19,977 cases of incident diabetes. A higher incidence of diabetes was found in depressed versus nondepressed subjects (0.72% vs 0.47% yearly), with unadjusted and adjusted risk (95% CI) of 1.56 (1.37-1.77) and 1.38 (1.23-1.55), respectively (both P values < .001). The use of antidepressant drugs and untreated depression were associated with an adjusted risk of diabetes of 1.68 (1.17-2.40) (P = .005) and 1.56 (0.92-2.65) (P = .09).

CONCLUSIONS

Depressive symptoms are associated with a significantly increased risk for incident diabetes. This association cannot be entirely explained by the use of antidepressant drugs or being overweight. Pathogenetic mechanisms connecting depression with diabetes deserve further exploration. Depression should be included among risk factors that indicate intensified screening for diabetes.

Adiponectin, diabetes and ischemic heart failure: a challenging relationship

BACKGROUND

Several peptides, named adipokines, are produced by the adipose tissue. Among those, adiponectin (AD) is the most abundant. AD promotes peripheral insulin sensitivity, inhibits liver gluconeogenesis and displays anti-atherogenic and anti-inflammatory properties. Lower levels of AD are related to a higher risk of myocardial infarction and a worse prognosis in patients with coronary artery disease. However, despite a favorable clinical profile, AD increases in relation to worsening heart failure (HF); in this context, higher adiponectinemia is reliably related to poor prognosis. There is still little knowledge about how certain metabolic conditions, such as diabetes mellitus, modulate the relationship between AD and HF.We evaluated the level of adiponectin in patients with ischemic HF, with and without type 2 diabetes, to elucidate whether the metabolic syndrome was able to influence the relationship between AD and HF.

RESULTS

We demonstrated that AD rises in patients with advanced HF, but to a lesser extent in diabetics than in non-diabetics. Diabetic patients with reduced systolic performance orchestrated a slower rise of AD which began only in face of overt HF. The different behavior of AD in the presence of diabetes was not entirely explained by differences in body mass index. In addition, NT-proBNP, the second strongest predictor of AD, did not differ significantly between diabetic and non-diabetic patients. These data indicate that some other mechanisms are involved in the regulation of AD in patients with type 2 diabetes and coronary artery disease.

CONCLUSIONS

AD rises across chronic heart failure stages but this phenomenon is less evident in type 2 diabetic patients. In the presence of diabetes, the progressive increase of AD in relation to the severity of LV dysfunction is hampered and becomes evident only in overt HF.

Safety and efficacy of insulin aspart and soluble human insulin in Type 2 diabetes mellitus

AIM

The UpGrade study evaluated the safety profile and effectiveness of insulin aspart (IAsp, NovoRapid®) and soluble human insulin (SHI) in patients with Type 2 diabetes mellitus, under current clinical practice conditions.

METHODS

This 26-week, open-label, non-randomized, observational safety study recruited patients using insulin ± metformin and having received ≥ 2 injections of IAsp or SHI over a period of 3 months to 3 years. Data were collected via patient recall and treatment diaries, at baseline, 13- and 26-week visits. The number of major hypoglycemic episodes was the primary endpoint. Secondary endpoints were minor hypoglycemic episodes, HbA1c, fasting and post-prandial blood glucose.

RESULTS

Overall, 4099 patients were included. At study end the incidence of major hypoglycemia was low (mean rate 0.117 ev/pt-y) and rates were lower in subjects using IAsp compared with those using SHI, for both major (0.115 vs. 0.121) and minor (6.648 vs. 9.530) episodes. IAsp correlated with a significantly lower risk of minor hypoglycemic episodes (IRR=0.64, P<0.0001). Overall, HbA1c levels decreased across 26 weeks (7.97% to 7.63%, P<0.0001); IAsp had greater HbA1c reduction than SHI (-0.39% and -0.22%, respectively) and was associated with a marginally significant likelihood (vs. SHI) of achieving HbA1c reduction of ≥ 0.5% (OR=1.22, P=0.059).

CONCLUSION

Under current clinical practice conditions, treatment of patients with Type 2 diabetes mellitus using either IAsp or SHI resulted in low rates of major hypoglycemia after 26 weeks. Patients using IAsp had a better clinical safety profile and a greater reduction in HbA1c compared with patients using SHI.

[Incretin-based therapies and cardiovascular outcome: analyses, pooled analyses and meta-analyses]

The assessment of the effects on cardiovascular risk is necessary for all new drugs for diabetes, including glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors. While waiting for the results of ongoing clinical trials specifically designed for cardiovascular outcomes, some analyses were performed on major cardiovascular events reported as severe adverse events in short- and medium-term trials with metabolic endpoints. Several pooled analyses of trials with individual molecules, based on patient-level data, showed a trend toward a reduction in the incidence of major cardiovascular events, which reached statistical significance in some cases. Meta-analyses of the same trials, combining all molecules of each class, showed that DPP-4 inhibitors are associated with a significant reduction of major cardiovascular events and mortality; in trials with GLP-1 receptor agonists, which are fewer because of the smaller number of available molecules, a similar trend is observed, reaching statistical significance only for major cardiovascular events in placebo-controlled trials. In conclusion, currently available data suggest that incretin-based therapies are probably associated with a relevant reduction of cardiovascular risk. These promising results need to be confirmed by ongoing large-scale trials.

Different modulation of dipeptidyl peptidase-4 activity between microvascular and macrovascular human endothelial cells

Dipeptidyl peptidase 4 (DPP-4) is an enzyme that is produced by endothelial cells in different districts and circulates in plasma. Patients with type 2 diabetes show a reduction in active Glucagon-Like Peptide-1 (GLP-1) that could be due to impairment of secretion or its degradation or both. GLP-1 is rapidly inactivated in vivo, mainly by the DPP-4. Some authors suggest that Metformin has no direct inhibitory effect on DPP-4 activity and that Metformin and the other biguanides enhance GLP-1 secretion; others suggest a possible role of Metformin in the inhibition of the DPP-4 activity. In order to better elucidate the role of insulin sensitizers on the modulation of GLP-1 circulating levels, DPP-4 activity and mRNA expression were measured in cultured human aortic endothelial cells (HAEC) and human microvascular dermal endothelial cells (HMVEC) exposed to high glucose, Metformin and Rosiglitazone. Present data show that hyperglycemia is capable of increasing in a significant manner the DPP-4 activity only in microvascular endothelial cells. Rosiglitazone is able to modulate in a negative manner the expression of DPP-4 but not its activity in macrovascular endothelial cells, while at 24 h of exposure it is able to increase significantly DPP-4 activity but not its expression in microvascular endothelial cells. Metformin at 48 h only in microvascular endothelial cells is able to reduce in a significant manner (p = 0.01) the activity of DPP-4 but not its expression. The modulation of DPP-4 is site specific.

Are psychopathological features relevant predictors of glucose control in patients with type 2 diabetes? A prospective study

Type 2 diabetes has been associated with an increased prevalence of psychopathology, in comparison with matched non-diabetic controls. However, the cross-sectional design of most studies does not allow causal inferences. The aim of the present study is the exploration of this possible association in patients with type 2 diabetes, in a longitudinal fashion. This prospective observational study was conducted on a consecutive series of 250 type 2 diabetic outpatients and a 1-year follow-up period was performed. At enrollment, a complete medical history was collected and hemoglobin A1c was measured. General psychopathology was assessed using the Symptom Checklist 90-revised and the Eating Disorder Examination Questionnaire. Among the 187 patients available at follow-up, factors associated with unsatisfactory glycemic control at follow-up were baseline hemoglobin A1c, insulin therapy, a longer duration of diabetes, higher scores on the Eating behavior, and Somatization scales. At multivariate analysis, the attainment of hemoglobin A1c ≤ 7 % was associated with baseline hemoglobin A1c (p = 0.01), insulin therapy (p = 0.016), and Eating behavior (p = 0.02), whereas duration of diabetes and Somatization were no longer significant after adjusting for confounders. The results of the present study suggest that clinical features have a much greater impact on attainment of therapeutic goals than psychopathology. However, there are several aspects, such as temperament, motivation, self-efficacy, and well-being, not assessed in the present study, which could be crucial. These areas should be adequately explored for obtaining an overall picture of the psychological determinants of appropriate metabolic control in diabetes.