Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Rhinorrhea triggered by obturator prosthesis after surgical intervention of partial maxillary resection: a clinical report

This clinical report describes a case of rhinorrhea that arose after surgical intervention of partial maxillary resection and obturator prosthesis positioning. Ultimately, the diagnosis was that rhinorrhea was induced by mechanical irritation of the nasal mucosa determined by the nasal part of the obturator prosthesis. The differential diagnosis of nasal irritation, vasomotor rhinitis, gustatory rhinorrhea are presented and discussed, as well as the technical notes and measures taken to reach the final diagnosis and a satisfactory functional and aesthetic result for the patient.

Parental experience of end-of life care in the pediatric intensive care unit

BACKGROUND

There is a considerable variability among European countries regarding the management of end-of-life (EOL) care in the pediatric critical care setting. In Italy, recommendations on these issues are available but no study has investigated the parents' experience. The aim of this study was to explore parents' experience of EOL care in a Pediatric Intensive Care Unit (PICU) in Italy.

METHODS

The study was conducted in a 6-bed PICU of a university affiliated hospital in Milan. Parents of children who died between 2007-2010 after a stay of at least 24 hours were eligible to participate. Through semi-structured interviews, parents were asked to describe the story of their child's stay in the PICU, including his/her final moments. The interviews were audio-recorded, transcribed verbatim and analyzed according to the hermeneutic-phenomenology approach.

RESULTS

Twelve parents of 8 children were interviewed. Four themes emerged that described the parents' experience: 1) loss of parental role; 2) lack of physical intimacy with their child; 3) ambivalence about end-of-life decisions; and 4) reclaiming the dying process.

CONCLUSION

Our findings suggest that in order to improve pediatric EOL care we need to better integrate medical and parental priorities, in a shared process that allows parents to preserve their role and relationship with their child. The most critical aspect for parents was not related to the involvement (or not) in EOL decisions, but rather to the possibility of staying connected with their child during the hospitalization and at the time of death.

Common polymorphisms of the growth hormone (GH) receptor do not correlate with the growth response to exogenous recombinant human GH in GH-deficient children

CONTEXT

GH acts through the GH receptor (GHR), whose polymorphisms might affect the growth response to recombinant human GH (rhGH).

OBJECTIVE

The objective of this study was to investigate possible influences of GHR polymorphisms on the growth response to rhGH in GH-deficient (GHD) children.

DESIGN

This was a 2-yr study (first year, spontaneous growth; second year, growth during rhGH treatment).

SETTING

This study was performed at a referral center.

PATIENTS

Fifty-four prepubertal GHD children (11 females; mean age, 7.8 yr; sd, 3.96) were studied.

INTERVENTION

Patients were treated with rhGH (0.2 mg/kg.wk) for at least 1 yr after diagnosis. Growth velocity (GV) was measured 1 yr before treatment and during the first treatment year. GHR exons were amplified by PCR using pairs of intronic primers. The presence of single or multiple mismatches in the PCR products was revealed by denaturing high-pressure liquid chromatography. For exons in which mismatches were found by denaturing high-pressure liquid chromatography, direct sequencing was performed by automatic sequencer.

MAIN OUTCOME MEASURES

Before the start of treatment, the mean height (Ht) sd score was -1.93 (sd, 0.70), and the mean GV sd score was -1.49 (sd, 1.26).

RESULTS

The posttreatment (first 12 months) mean GV sd score was 3.55 (sd, 3.27). Molecular analysis revealed a high frequency of GHR polymorphisms; in particular: exon 3 deletion (Del 3) in 26 subjects (48%), polymorphism 504 A>G at codon 168 of exon 6 in 44 (82%), and polymorphism 1576 A>C at codon 526 of exon 10 in 35 (65%). In most patients, these different polymorphisms recurred in association. We found no significant differences in GV between the groups of subjects defined by the polymorphic genotypes.

CONCLUSION

The most common GHR polymorphisms, alone or in association, do not appear to affect the growth response to rhGH in GHD children.

[Training and information for competent physicians]

The rule in force and the Guide-Lines concerning the topic point out specific duties for the Occupational Physician; the most important is certainly health survey, which is organized in several formal medical actions; another Occupational Physician's relevant activity is the "collaboration to the risk assessment". Because of the complexity of the construction building industry and because of the central role of the Occupational Physician in health care, the problems which he has to face are two: firstly he has to improve the knowledge about specific risks of the construction building industry; secondly he must adapt his specialistic knowledge, including the methodology acquired during the school training, to the specific organization conditions and risk of the field.

[Management of the new first aid service at enterprises and construction sites]

First aid at work organization and management represents a complex and critical aspect of the manifold problems of hygiene and security at work; nevertheless, even in relatively well organized productions, these themes are often neglected, if not completely ignored. In this work the authors analize the laws which regulate the correct first aid at work organization and management and an approach to the problem based on the preliminary risk assessment is suggested.

[Assessment of exposure to organic aromatic compounds and PAH in asphalt industry: the PPTP-POPA Study results]

Asphalt is a mixture of mineral matter and bitumen, its fumes contain about 1% of Polycyclic Aromatic Hydrocarbons (PAH), some of which are carcinogens. In the PPTP-POPA Study of Lombardy Region, a group of 100 asphalt workers (exposed to bitumen fumes and diesel exhausts) and a group of 47 ground construction operators (exposed only to diesel exhausts) were investigated to assess PAH exposure in Italy, by means of environmental-air monitoring (the 16 most relevant, according to the American Environmental Protection Agency, EPA) and biological monitoring (urinary 1-hydroxypyrene excretion). Our results show that PAH exposure in these workers is not higher than that observed in traffic policemen working in urban areas. Since dermal exposure has been suggested as a major determinant of the total PAH dose absorbed by road pavers from bitumen fumes, we assessed skin contamination by organic aromatic compounds and by sixteen PAH: in both groups, six pads were applied to each subject in different parts of the body, during the workshift. The results show that the dermal contamination in road pavers is higher than in ground construction operators and that cutaneous dose rate is higher than respiratory dose rate, whereas the amount of absorption the ratio is inverted.

[Assessment of exposure to polycyclic aromatic hydrocarbons during road paving]

Asphalt is a mixture of bitumen, (its fumes contain about 1% of polycyclic aromatic hydrocarbons, PAH), and mineral matter. 18 Workers were investigated during road paving to assess PAH exposure by environmental air-monitoring (the 16 most relevant, according to the American Environmental Protection Agency, EPA) and biological monitoring (urinary 1-hydroxypyrene excretion). Our results show that PAH exposure in these workers is not higher than that observed in traffic policemen working in urban areas.

[Occupational disease in construction work]

BACKGROUND

There are very few studies in the Italian and international literature concerning occupational diseases and their prevention in the building industry.

OBJECTIVES

The aim of this study was risk assessment in the building industry.

METHODS

We analyzed the international literature and the results of our cross-sectional study, which involved more than 1000 workers.

RESULTS

The analysis of several studies and of our experience suggests a high occupational risk in this field and shows as main risk factors: noise, dusts, fibers, manual lifting, prolonged static positions, repetitive motions, hand-shoulder and whole-body vibrations, chemicals and weather conditions. In addition, non-occupational risk factors can influence health: e.g., habits and lifestyle, like hypercaloric diet, cigarette smoking and alcohol consumption.

CONCLUSIONS

Preventive measures and training initiatives are urgently needed to improve the safety and the health among building workers.

[Significance of bronchoalveolar lavage in demonstrating previous exposure to asbestos]

A study was made via a clinical approach in the absence of environmental data with the aim of demonstrating a possible past exposure to asbestos in a working population that had never been examined before nor had ever undergone any specific health checks. It was deemed useful to compare this working population with a control population not exposed to asbestos. The population under study consisted of 126 employees of a single (thermonuclear) department of a metal engineering industry who reported having used asbestos as insulation material in all heat processes up to the beginning of the 1980's. Pleural plaques were observed in 13 workers that were also confirmed by high resolution TC (HRTC) except in one case. The control group consisted of subjects seen at the Clinica del Lavoro of Milan for non-asbestos related diseases in whom a fibrobronchoscopy with broncho-alveolar lavage (BAL) was performed for diagnostic purposes. In each group asbestos bodies were counted in the BAL liquid using a method with a detection limit of 0.1 bodies/ml. The asbestos bodies detected in the alveolar liquid of subjects in the control group were between a maximum of 0.25 and a minimum of 0 bodies/ml of liquid (mean = 0.03; SD = 0.64) whereas in the sample of subjects from the population under study who underwent BAL the results gave a concentration of asbestos bodies in the BAL liquid between a maximum of 9.0 and a minimum of 0.15 bodies/ml of liquid (mean = 2.38; SD = 2.72). In order to obtain a statistically significant difference between the control population, which was certainly not exposed, and the sample of subjects undergoing BAL from the population for which an occupational exposure was assumed, we applied the non-parametric Wilcoxon-Mann-Whitney test for independent samples in view of the asymmetric distribution of the values of asbestos body concentration in the alveolar liquid: the result was a statistically significant difference (p < 0.001) between the two populations. We also calculated the total asbestos bodies recovered in the BAL liquid of subjects from both populations. In the control group total asbestos bodies were between a maximum of 15 and a minimum of 0 (mean = 1.8; SD = 3.9) while in the group under study the concentration of total asbestos bodies recovered in BAL liquid was between a maximum of 990 and a minimum of 12.7 (mean = 206.5; SD = 270). The Wilcoxon-Mann-Whitney test was also applied to these data, the result of which was that the difference in exposure between the two populations was statistically significant (p < 0.001). Concluding, the study demonstrates the importance of asbestos body count in BAL liquid as an objective indicator of past occupational exposure to asbestos, thus providing documented proof that overcomes any doubts arising from case history and any lack of environmental data that could prove exposure.

Peribulbar anesthesia with either 0.75% ropivacaine or a 2% lidocaine and 0.5% bupivacaine mixture for vitreoretinal surgery: a double-blinded study

No study has evaluated the efficacy of ropivacaine in peribulbar block for ophthalmic surgery. The purpose of this prospective, randomized, double-blinded study was to compare ropivacaine and a lidocaine-bupivacaine mixture in peribulbar anesthesia. Sixty ASA physical status I or II patients scheduled for elective vitreoretinal surgery were randomized to receive a peribulbar block with 8 mL of either 0.75% ropivacaine (ropivacaine group, n = 30) or a 1:1 mixture of 2% plain lidocaine and 0.5% plain bupivacaine (lido-bupivacaine group, n = 30). Time required for onset of surgical anesthesia, quality of postoperative analgesia, incidence of side effects, and analgesic consumption were recorded. Surgical block was achieved after 8 +/- 5 min in the lido-bupivacaine group and after 10 +/- 5 min in the ropivacaine group (P = 0.23). A 3-mL supplemental injection 15 min after block placement was required in 6 patients in the lido-bupivacaine group (20%) and in 10 patients in the ropivacaine group (33%) due to inadequate motor block (P = 0.38). On Postoperative Day 1, 26 patients in the ropivacaine group (87%) reported no pain at the verbal rating score, compared with 18 patients in the lido-bupivacaine group (60%) (P = 0.005). We conclude that 0.75% ropivacaine may be a suitable choice when performing peribulbar anesthesia for vitreoretinal surgery.

IMPLICATIONS

Quick onset of block with prolonged postoperative analgesia is an important goal in regional anesthesia for ophthalmic surgery. Evaluating clinical properties of 0.75% ropivacaine and a 1:1 mixture of 2% lidocaine and 0.5% bupivacaine for peribulbar anesthesia, we demonstrated that ropivacaine has an onset similar to that of the lidocaine-bupivacaine mixture and provides a better quality of postoperative analgesia.

In normal subjects bracing impairs the function of the inspiratory muscles

Normal subjects can increase their capacity to sustain hyperpnoea by bracing their arms on fixed objects, a procedure which is also known to reduce dyspnoea in patients with chronic obstructive pulmonary disease (COPD). In the present study, it was tested whether bracing per se could improve the function of the diaphragm. The effect of bracing on diaphragm function was studied in six normal subjects by recording changes in oesophageal (delta Poes) and transdiaphragmatic (delta Pdi) pressure during inspiratory capacity (IC) manoeuvres in the seated and upright postures, and in the seated posture, also during bilateral phrenic nerve stimulation (BPNS) at functional residual capacity (FRC). The pattern of ribcage motion and deformation associated with bracing and with diaphragm contraction was also evaluated using inductance plethysmography and magnetometers. Bracing increased FRC by >300 mL and reduced IC by approximately 200 mL, in both postures. Delta Pdi during BPNS decreased on average by 15% indicating an impaired diaphragmatic function. The ribcage was deformed with bracing and was more distortable during BPNS. In conclusion, in normal subjects, bracing impairs the function of the inspiratory muscles and reduces ribcage stability. These negative effects cannot explain the improved capacity to sustain hyperpnoea when the arms are braced.

Assessment of respiratory system viscoelasticity in spontaneously breathing rabbits

Airflow, volume (V), inspiratory time (TI), tracheal pressure (Ptr), abdomen (Dab) and rib cage diameters (Drc), peak diaphragm (Adi) and parasternal muscle activity (Aic) were measured in thirteen anaesthetized and vagotomized rabbits and in six vagotomized rabbits with cordotomy at T1 during unimpeded inspirations followed by rapid end-inspiratory airway occlusion, relaxation against closed airways, and inspiratory effort. To modify the inspiratory flow pattern, such sequences were performed at different volume, levels of chemical drive, and body temperatures (BT). Under all conditions, Adi, Aic, TI, Drc and Dab at iso-volume were the same for unimpeded and occluded inspirations; end-inspiratory Ptr was lower for occluded than for unimpeded inspirations, the difference (Pdiff) being larger the lower the volume at which occlusions were performed and the higher the chemical drive and BT. After paralysis, the viscoelastic constants of the respiratory system, modelled as a Kelvin body, were assessed according to the rapid airway occlusion method and used together with the inspiratory flow waveform to predict the end-inspiratory viscoelastic pressure (Pvisc) of unimpeded inspirations. Since the slope of the Pdiff vs. Pvisc relationship never differed from unity, Pdiff under the specified conditions should represent the effective Pvisc of unimpeded inspirations.

Insertional action of the abdominal muscles in rabbits and dogs

The insertional action of the abdominal muscles was studied in supine anesthetized, apneic rabbits and dogs by comparing the changes in esophageal pressure (Pes), upper and lower rib cage circumference (Cru,u and Crc,I) and lung volume (VL) in response to electrical stimulation of all abdominal muscles before and after evisceration. In eviscerated animals, abdominal muscle contraction increased Pes and decreased both VL and Cre,I, but had no effect on Crc,u. Maximal responses were obtained at submaximal intensities of stimulation, and became larger with increasing lung volume. Relative to the vital capacity in intact animals, maximal delta VL for stimulation performed at FRC and TLC were 7.2 +/- 2.9(SD) and 39.5 +/- 7% in rabbits, and 6.3 +/- 0.8 and 18.3 +/- 5.9% in dogs, respectively. Relative to the changes in lung volume occurring with maximal contraction of the abdominal muscles in intact animals, the values of delta VL observed in the eviscerated animals amounted to approximately 35 and approximately 45% for stimulation performed at FRC and TLC, respectively. Hence, abdominal muscles exert substantial insertional action on the lower rib cage that can result in appreciable lung deflationary effects, particularly at elevated lung volumes.

Dependence of maximal flow-volume curves on time course of preceding inspiration in patients with chronic obstruction pulmonary disease

Thirteen patients with chronic obstructive pulmonary disease (COPD) performed forced vital capacity (FVC) maneuvers either immediately after a rapid inspiration (maneuver 1) or after a slow inspiration with a 4- to 6-s end-inspiratory pause (maneuver 2). Seated in a body plethysmograph, they breathed through a pneumotachograph. Inspirations were initiated from resting end-expiratory lung volume. Abdominal muscle activity was recorded by means of surface electrodes. With maneuver 1: (1) expiratory flows were 20 to 40% larger in the volume range 10 to 95% FVC; (2) peak expiratory flow was on average 30% higher; and (3) FEV1, expressed as percent of FVC, increased by about 8%. No substantial differences in the pattern of abdominal muscle activity occurred between maneuvers. The dependence of maximal flow-volume curves on the time course of the preceding inspiration is probably related in part to the viscoelastic elements present within the respiratory system, which, stretched during rapid inspirations, increase the effective elastic recoil during the FVC maneuver 1. This cannot occur with maneuver 2, because of stress relaxation of the viscoelastic elements during the 4- to 6-s breathhold preceding the FVC maneuver. Other factors (e.g., time constant inequality) might also be involved. In any case, the results imply that the inspiratory maneuver prior to FVC must be standardized.

Chest wall interrupter resistance in anesthetized paralyzed humans

Tracheal (Ptr) and esophageal (Pes) pressure and flow were measured in 12 supine anesthetized paralyzed normal subjects aged 16-22 yr. The subjects were ventilated with a fixed inflation volume (range 0.57-0.62 liter) and with different constant flows ranging between 0.24 and 1.12 l/s. A rapid airway shutter (closing time 10-15 ms) was used to briefly occlude (0.4-0.9) the airways at end inspiration for 33-44 consecutive breaths. At each flow level, Ptr and Pes records obtained during end-inspiratory occlusions were ensemble averaged to allow for the cardiac artifacts. The interrupter resistances of the chest wall and respiratory system were assessed as the rapid fall in Pes and Ptr with occlusion divided by the flow preceding the occlusion. Interrupter resistances of both the chest wall and lung were independent of flow and averaged 0.4 +/- 0.1 and 1.5 +/- 0.4 (SD) cmH2O.s.l-1, respectively. The contribution of the chest wall to the total interrupter resistance was approximately 27% at flows < or = 1 l/s.

Mechanics of the abdominal muscles in rabbits and dogs

In anesthetized, apneic rabbits and dogs, direct tetanic stimulations of the abdominal muscles (AMS) were performed at different tracheal pressures (Ptr) in the supine and upright posture. Lung volume (V), esophageal (Pes) and abdominal pressure (Pab), circumference of the upper and lower lung apposed rib cage (Crc, u and Crc, l) and of the abdomen (Cab), and transverse diameter of the rib cage facing the abdominal contents (Drc,ab) were measured. At Ptr = 0, Pab and Pes increased, and V decreased with increasing the strength of AMS; delta Pes and delta V eventually levelled off, while delta Pab was still increasing. Both delta Pes and delta V were larger in the upright posture, whereas delta Pab were similar. Relative to the expiratory reserve volume (ERV), maximal delta V in the supine and upright posture were 75.6 +/- 2.1 (mean +/- SE) and 86.1 +/- 2.2% in rabbits, and 56.5 +/- 3.4 and 75.2 +/- 3.7% in dogs. Maximal AMS decreased V and increased delta Pab the more so the larger the lung volume. In the volume range 10-70% VC, delta V were 3-4% VC larger in the upright posture, while delta Pab were similar in both postures. With AMS, Cab decreased, and Crc,u and Crc,l increased, while Drc,ab increased in dogs and decreased in rabbits. Hence, (a) the abdominal muscles can account for most of the ERV, particularly in the upright posture; (b) their maximal deflationary effects on the lung are already reached with submaximal activation; (c) their expiratory capacity is hindered by the expansion of the lung apposed rib cage and limited by diaphragmatic passive tension, and (d) their efficiency is reduced by paradoxical motion and distortion both between and within the lung apposed rib cage and abdominal compartments. Possible mechanisms for the dependency of delta V on species, volume and posture are discussed.

Dependence of maximal flow-volume curves on time course of preceding inspiration

Thirteen normal subjects, sitting in a body plethysmograph and breathing through a pneumotachograph, performed forced vital capacity maneuvers after a rapid inspiration without or with an end-inspiratory pause (maneuvers 1 and 2) and after a slow inspiration without or with an end-inspiratory pause (maneuvers 3 and 4), the pause lasting 4-6 s. Inspirations were initiated close to functional residual capacity. At all lung volumes, expiratory flow was larger with maneuver 1 than with any other maneuver and, over the upper volume range, larger with maneuver 3 than with maneuver 4, whereas it was similar for maneuvers 2 and 4. Relative to corresponding values with maneuver 4, peak expiratory flow was approximately 16 and approximately 4% larger with maneuvers 1 and 3, respectively, whereas forced expiratory volume in 1 s increased by approximately 5% only with maneuver 1. The time dependence of maximal flow-volume curves is consistent with the presence of viscoelastic elements within the respiratory system (D'Angelo et al. J. Appl. Physiol. 70: 2602-2610, 1991).

Activities of human alveolar macrophages (HAMs). Note 1: Observations on phagocytosis and bacterial killing in the presence of miocamycin

We studied the activity of human alveolar macrophages (HAMs) obtained by bronchoalveolar lavage (BAL) from human lungs. In particular, we studied in vitro phagocytosis and bacterial killing in basal conditions and in the presence of miocamycin (MOM), a macrolide antibiotic. At a dose of 600 mg every 12 hours, MOM concentrations in the serum were 2.60 micrograms/ml 1 hour after administration and 0.75 microgram/ml 8 h after. The antibiotic cannot be assayed by the microbiological method in the acellular liquid of alveolar lavage. After penetrating the HAMs, it can be detected at a concentration of about 0.4 mcirograms/1.10(6) HAMs. MOM was able to penetrate HAM cytoplasm without altering their vitality. As a matter of fact, the Trypan blue exclusion dye test was not modified after long incubation in the presence of MOM. The HAMs, resuspended in a RPMI 1640 enriched medium, were able to phagocytize either live Staphylococci or inert Latex beads of 1 micron. MOM stimulated the HAM phagocytosis on both Staphylococci and Latex beads. The increase in Latex phagocytosis, a relatively inert substance on which MOM should not be active, is a confirmation of the antibiotic's directed stimulation of the HAMs. Finally, we have seen that the HAMs, which were noteworthy in killing the phagocytized bacteria, were stimulated by MOM after only 30 minutes of contact with the antibiotic.