The number of risk factors not at target is associated with cardiovascular risk in a type 2 diabetic population with albuminuria in primary cardiovascular prevention. Post-hoc analysis of the NID-2 trial

Background

Nephropathy in Diabetes type 2 (NID-2) study is an open-label cluster randomized clinical trial that demonstrated that multifactorial intensive treatment reduces Major Adverse Cardiac Events (MACEs) and overall mortality versus standard of care in type 2 diabetic subjects with albuminuria and no history of cardiovascular disease. Aim of the present post-hoc analysis of NID- 2 study is to evaluate whether the number of risk factors on target associates with patient outcomes.

Methods

Intervention phase lasted four years and subsequent follow up for survival lasted 10 years. To the aim of this post-hoc analysis, the whole population has been divided into 3 risk groups: 0–1 risk factor (absent/low); 2–3 risk factors (intermediate); 4 risk factors (high). Primary endpoint was a composite of fatal and non-fatal MACEs, the secondary endpoint was all-cause death at the end of the follow-up phase.

Results

Absent/low risk group included 166 patients (52.4%), intermediate risk group 128 (40.4%) and high-risk group 23 (7.3%). Cox model showed a significant higher risk of MACE and death in the high-risk group after adjustment for confounding variables, including treatment arm (HR 1.91, 95% CI 1.04–3.52, P = 0.038 and 1.96, 95%CI 1.02–3.8, P = 0,045, respectively, vs absent/low risk group).

Conclusions

This post-hoc analysis of the NID-2 trial indicates that the increase in the number of risk factors at target correlates with better cardiovascular-free survival in patients with type 2 diabetes at high CV risk.

Clinical Trial Registration

ClinicalTrials.gov number, NCT00535925. https://clinicaltrials.gov/ct2/show/NCT00535925

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01674-7.

Lipohypertrophy in Elderly Insulin-Treated Patients With Type 2 Diabetes

BACKGROUND

The number of older adults with insulin-treated diabetes mellitus (DM) is steadily increasing worldwide. Errors in the insulin injection technique can lead to skin lipohypertrophy (LH), which is the accumulation of fat cells and fibrin in the subcutaneous tissue. While lipohypertrophic lesions/nodules (LHs) due to incorrect insulin injection techniques are very common, they are often flat and hardly visible and thus require thorough deep palpation examination and ultrasonography (US) for detection. Detection is crucial because such lesions may eventually result in poor diabetes control due to their association with unpredictable insulin release patterns. Skin undergoes fundamental structural changes with aging, possibly increasing the risk for LH. We have therefore investigated the effect of age on the prevalence of LHs and on factors potentially associated with such lesions.

METHODS

A total of 1227 insulin-treated outpatients with type 2 DM (T2DM) referred to our diabetes centers were consecutively enrolled in the study. These patients underwent a thorough clinical and US evaluation of the skin at injection sites, as previously described, with up to 95% concordance betweenthe clinical and US screening techniques. Of these 1227 patients, 718 (59%) had LH (LH+) and 509 (41%) were LH-free (LH-). These patients were then assigned to two age class groups (≤ 65 years and > 65 years), and several clinical features, diabetes complication rates, and injection habits were investigated.

RESULTS

Comparison of the two age subgroups revealed that 396 (48%) and 322 (79%) patients in the younger and older groups, respectively, had LHs (p < 0.001). Compared to the younger subgroup, the older subgroup displayed a higher LH rate in the abdomen (52.9 vs. 38.3%; p < 0.01) and a lower rate in the arms (25.4 vs. 35.8%; p < 0.05), thighs (26.7 vs. 33.4%; p < 0.05), and buttocks (4.9 vs. 26.2%; p < 0.01). In older subjects, the most relevant parameters were: habit of injecting insulin into LH nodules (56 vs. 47% [younger subjects]; p < 0.01), rate of post-injection leakage of insulin from injection site (drop-leaking rate; 47 vs. 39% [younger subjects]; p < 0.05), and rate of painful injections (5 vs. 16% [younger subjects]; p < 0.001). Multivariate analysis showed a stronger association between LH and poor habits, as well as between several clinical parameters, among which the most relevant were hypoglycemic events and glycemic variability.

DISCUSSION

The higher rate of post-injection drop-leaking and pain-free injections might find an explanation in skin changes typically observed in older adults, including lower thickness, vascularity and elasticity, and a more prominent fibrous texture, all of which negatively affect tissue distensibility. Consequently, in addition to the well-known association between aging skin impaired drug absorption rate, aging skin displays a progressively decreasing ability to accommodate large volumes of insulin-containing fluid.

CONCLUSIONS

The strong association between LH rate and hypoglycemic events plus glycemic variability suggests the need (1) to take specific actions to prevent and control the high risk of acute cardiovascular events expected to occur in older subjects in the case of hypoglycemic events, and (2) to identify suitable strategies to fulfill the difficult task of performing effective educational programs specifically targeted to the elderly.

TRIAL REGISTRATION

Trial registration number 172-11:12.2019, Scientific and Ethical Committee of Campania University "Luigi Vanvitelli", Naples, Italy).

Insulin-Induced Skin Lipohypertrophy in Type 2 Diabetes: a Multicenter Regional Survey in Southern Italy

INTRODUCTION

Lipohypertrophies (LHs) due to incorrect insulin injection techniques have been described in the literature for decades. Their rate averages 38%, but this is still controversial because of the vast range reported by different publications, most of which fail to describe the selected detection protocol and therefore are not entirely reliable. We still need to identify the real LH rate, and only consistently using a standardized method in a large cohort of insulin-treated (IT) patients make this possible.

METHODS

Our group performed thorough clinical skin examinations on patients suffering from type 2 diabetes mellitus (T2DM): 1247 IT T2DM outpatients were examined according to a standardized protocol, previously published elsewhere, as well as an ultrasound scan of the same skin areas to assess the degree of concordance between the two methods and to evaluate the demographic, clinical, and behavioral risk factors (RF) as well as metabolic consequences of identified LHs.

RESULTS

The concordance between the two methods was 99%. Identified risk factors for LHs were needle reuse, failure to rotate injection sites, and ice-cold insulin injections. High HbA1c values, wide glycemic variability, and longstanding proneness to hypoglycemia with a high rate of ongoing hypoglycemic events proved to be significantly associated with LHs, too; the same applied to cardiovascular and renal complications as well as to living alone and being retired.

CONCLUSIONS

Based on a strict well-structured methodology, our data confirmed what has already been reported in the literature on factors leading to, or associated with, LHs and, for the first time in adults, indicated cryotrauma from ice-cold insulin injections and specific social conditions as factors facilitating LH occurrence. HCPs should therefore plan a yearly clinical examination of all injection sites to improve patient quality of life through better glucose control and a reduced rate of hypoglycemic events.

TRIAL REGISTRATION

Trial registration no. 127-11.01.2019, approved by the Scientific and Ethics Committee of Campania University "Luigi Vanvitelli," Naples, Italy.

Is pizza sutable to type 1 diabetes? A real life identification of best compromise between taste and low glycemic index in patients on insulin pump

Opposed to whole wheat (WWP), traditional pizza (TP) is loved by patients with type 1 diabetes mellitus (T1DM) despite causing hyperglycemia. 50 well-trained T1DM patients had higher glucose levels after TP than after WWP or mixed flour pizza, which however was tasty, digestible and metabolically appropriate to break diet monotony.

A randomized, open-label, comparative, crossover trial on preference, efficacy, and safety profiles of lispro insulin u-100 versus concentrated lispro insulin u-200 in patients with type 2 diabetes mellitus: a possible contribution to greater treatment adherence

BACKGROUND

Several outstanding pharmacological advances making innovative drugs sophisticateddevices available during the last few years. Nevertheless too many patients still disappointingly fail to meetthe metabolic targets suggested by current guidelines. Incorrect insulin administration techniques may greatly affect metabolic control in T2DM people. The aim of our study was to compare glycemic control associated with a concentrated insulin analog preparation (U-200 lispro) in people with T2DM to the one observed with standard U-100 lispro. The secondary endpoint of our study was patients' preference and performance ratings of U-200 lispro.

METHODS

126 patients with T2DM were enrolled. They were also assessed for limited joint mobility syndrome (LJMS),defined as limitation in at least two anatomical areas of the dominant upper extremity. After a 4-weekstructured insulin injection education period. Half of them were randomized to U-100 lispro, half to U-200 and after 12 weeks they were switched to the other preparation for 12 weeks. At the end a questionnaire was also administered to investigate patient preference.

RESULTS

No significant variation in fasting blood glucose, HbA1c, severe or mild hypoglycemic rate and daily fast-acting insulin analog dose was observed with U-100 lispro while U-200 lispro treatment was associated with a significant improvement of all the above mentioned parameters and with around 20% decrease in insulin requirement. Moreover patients' answers to the questionnaire pointed out a higher preference for U-200 lispro for continuing treatment due to fewer difficulties completing injection.

DISCUSSION

The explanation of better metabolic results with the U-200 device might be the lower inner piston inertia and volume and shorter duration of a complete injection.

CONCLUSIONS

Checking for LJIMS before insulin prescription could be adopted as a standard practiceaimed at choosing the most suitable device for patient's specific characteristics and abilities. The use of U-200 lispro might improve treatment adherence and metabolic control. This would also result intocost reduction by saving about half the amount of pens per year and of time spent to both fill prescriptionand dump the pharmacy.

Blood glucose changes in diabetic children and adolescents engaged in most common sports activities

Circulating insulin levels decrease and substrate glycogenolysis-mediated conversion into glucose increases just a few minutes after normal subjects start exercising, but during sustained physical activity muscles massively utilize blood glucose, thus causing glycogenolysis to increase further until the end of the session. After that, in order to get liver and muscle glycogen stores up to pre-exercise levels again, blood glucose is mostly utilized, thus causing late-onset hypoglycaemia in the absence of any extra carbohydrate supply and rebound hyperglycaemia after a while. This and other patho-physiological mechanisms are dealt with in the present paper, and practical hints are provided to the clinician to cope with children-specific adaptation phenomena to exercise in t1DM.

Large mediastinal mass of heterotopic thyroid tissue: a case report and review of literature

Salvatore. Incidental detection of a mediastinal mass in a asymptomatic patient poses a not easy diagnostic problem. For solid masses or cysts, histology or cytology is often necessary. Although substernal extension of a cervical goiter is common, totally intrathoracic primary thyroidal mass is unusual. We describe a rare case of heterotopic accessory mediastinal thyroid in a patient completely asymptomatic both for signs of thyroid dysfunction and mechanical compression. Radiological and hormonal 6 and 12 months follow-up is reported.

Immediate postextraction implants: a histologic and histometric analysis in monkeys

The aim of this study was to evaluate the reaction of peri-implant tissues to immediately placed titanium plasma-sprayed implants into extraction sockets. Six macaca fascicularis monkeys were used in the study. A total of 36 titanium plasma-sprayed implants (PHI, Legnano, Italy) were inserted in both arches (18 in the posterior maxilla and 18 in the posterior mandible). The two premolars and the first molars of the maxilla and the mandible of all animals were extracted, and immediate postextraction implants were placed. After a releasing periosteal incision, the flap was coronally repositioned and sutured. No barrier membranes were used, and the only graft material used was autogenous bone chips. The implants were loaded after 2 months. Six months after implant loading, a block section was carried out, the remaining defects were filled with nonresorbable hydroxyapatite, and all 36 implants were retrieved. The implants were treated with the Precise System (Assing, Rome, Italy), to obtain thin ground sections. A total of three slides were cut for each implant and were examined under normal and polarized light. A histomorphometrical analysis was done. All implants were covered by compact, mature bone under examination in light microscopy. A very high bone-implant contact percentage (65-70%) was observed. No bone loss was present after the loading period. These results indicate that implants placed into fresh extraction sites grafted with autogenous bone chips will heal in a predictable way.

Immediate loading of titanium plasma-sprayed implants: an histologic analysis in monkeys

Aim of this study was to evaluate peri-implant tissue reactions to immediately loaded titanium plasma-sprayed implants in Macaca fascicularis monkeys. A total of 48 titanium plasma-sprayed implants were inserted (24 in the posterior maxilla and 24 in the posterior mandible). A metal superstructure was cemented 3 days after implant insertion on 24 implants (12 in the maxilla and 12 in the mandible) (test implants). The remaining 24 implants (12 in the maxilla and 12 in the mandible) were left unloaded (control implants). Nine months after implant placement a block section was carried out, the defect filled with non-resorbable hydroxyapatite, and all 48 implants retrieved. The implants were treated to obtain thin ground sections. Three slides were cut for each implant and examined under normal and polarized light and a morphometrical analysis done. All implants were covered by bone under light microscopy. The histomorphometrical analysis demonstrated that in test implants, the bone-implant contact percentage was 67.3% (+/-7.6%) in the maxilla, and 73.2% (+/-5.9%) in the mandible; in control implants the percentages were, respectively, 54.5% (+/-3.3%) and 55.8% (+/-6.5%). In the test implants the bone around the implants tended to have a more compact appearance. In conclusion, our study demonstrated that in test implants the bone-implant contact percentage was significantly greater than in the controls (P < 0.01) and no fibrous connective tissue was present at the interface.

Immediate loading of titanium plasma-sprayed screw-shaped implants in man: a clinical and histological report of two cases

THIS STUDY REPORTS ON THE histological findings of two immediately loaded titanium plasma-sprayed (TPS) implants, retrieved for a fracture of the abutment and for psychological reasons, after 8 and 9 months of loading, respectively. The microscopical analysis showed that mature, compact, cortical bone was present around both implants, with the bone implant contact percentage about 60 to 70%. No fibrous tissue or gaps were present at the interface. No resorption was present in the peri-implant bone. On both implants a few osteoblasts were found positive at the interface for alkaline phosphatase (ALP); while no cells positive for acid phosphatase (ACP) were present. Immediate loading can, perhaps, be used in very selected cases of good bone quality, with implants that have certain macro- (screw shape) and micro-interlocks (titanium plasma-sprayed surface) characteristics. Good results have been reported also for non-TPS surface (e.g., machined surface). More data about different designs (e.g., cylinders) or coatings (e.g., hydroxyapatite) are needed before any firm conclusions about immediate loading can be reached.

Bone reactions to early occlusal loading of two-stage titanium plasma-sprayed implants: a pilot study in monkeys

This pilot study analyzed the bone reactions to early loaded titanium plasma-sprayed implants. A total of 24 titanium plasma-sprayed implants (12 in the maxilla and 12 in the mandible) (Primary Healing Implant, Legnano) were inserted into four Macaca fascicularis monkeys with instruments specially designed to obtain a precise fit of the implant in the bone socket. A metal superstructure was cemented into 10 mandibular and 10 maxillary implants 15 days after implant insertion. The four remaining implants were used as controls. Eight months after implant placement, a block section was carried out, the defect was filled with nonresorbable hydroxyapatite, and all 24 implants were retrieved. The implants were treated to obtain thin ground sections that were examined under normal and polarized light. Histologic analysis showed that bone was observed around the implant surface in all implants. Morphometric analysis demonstrated that bone lined 67.2% (SD = 3.1%) of the maxillary implant surface, and 80.71% (SD = 4.6%) of the mandibular implant surface. No differences were found in the percentage of bone-implant contact in the control implants. In the loaded implants, however, the bone around the implants had a more compact appearance. The study demonstrated that it is possible to obtain a high percentage of bone-implant contact in early loaded titanium plasma-sprayed implants.

Presence of multinucleated giant cells around machined, sandblasted and plasma-sprayed titanium implants: a histological and histochemical time-course study in rabbit

A histological and histochemical evaluation was conducted in rabbit to study the presence of multinucleated giant cells (MGCs) at the interface with machined, sandblasted and plasma-sprayed titanium implants. No MGCs were observed, at any of the experimental times, around machined and sandblasted titanium surfaces. MGCs were, on the contrary, present at the interface with titanium plasma-sprayed implants at two weeks and at two months. At two weeks these cells were numerous, and in some areas, particularly around the spires, tended to line almost all the implant perimeter surface. MGCs were present in large numbers where bone was present at the interface, while, on the contrary, where there was no newly formed bone, they tended to be fewer in number and smaller in diameter. At four and eight weeks these cells tended to decrease in number. The histochemical staining for acid phosphatase (ACP) and alkaline phosphatase (ALP) showed that MGCs were negative to ACP, while many ALP-positive osteoblasts, actively secreting osteoid matrix, were in close and tight contact with the MGCs. In no case was an inflammatory infiltrate present in connection with the MGCs. The precise nature of MGCs is still not clear, but our histological and histochemical results could point to a priming effect on the activity of the osteoblasts in a similar way to the supposed role of the osteoclasts.

Microscopical observations of the osseous responses in early loaded human titanium implants: a report of two cases

The authors present the histological picture of the surrounding tissues of two screw-shaped titanium plasma-sprayed implants retrieved for a fracture of the abutment after 18 and 42 months, respectively. These two implants were loaded after two months. The microscopical examination showed that both implants were covered in a large part of the implant surface by compact, mature lamellar bone with the presence of many Haversian systems and osteons. With von Kossa staining it was possible to see that the bone at the interface with the implant was highly mineralised. No connective tissue or inflammatory cells were present at the interface.

Effects of alkaline phosphatase on bone healing around plasma-sprayed titanium implants: a pilot study in rabbits

Alkaline phosphatase (ALP) is an enzyme thought to be important in the process of biomineralization. ALP promotes hydrolysis of phosphate containing substrates, produces orthophosphate and increases the uptake of calcium. ALP has been demonstrated recently to induce mineralization of collagen sheets in the animal body. Many factors are being investigated to try to increase the quantity of bone around dental implants. The aim of this study was an evaluation of the bone formation around dental implants used in conjunction with ALP extracted from calf intestine. Titanium plasma-sprayed implants were put for 30 min in glasses containing 500 micrograms of ALP, and then inserted into the femoral articular surface of the knee joint. The implants were retrieved after 2, 3, 4 and 8 weeks, and treated to obtain thin ground sections. The histological examination showed a higher quantity of bone trabeculae, and at 2 and 3 weeks, the presence of plump, elongated, highly stained, very active ALP-positive osteoblasts around the treated specimens. ALP seems, in the experimental conditions of this pilot study, to have a positive effect on bone formation around titanium plasma-sprayed implants.

Comparison of bone regeneration with the use of mineralized and demineralized freeze-dried bone allografts: a histological and histochemical study in man

Mineralized (FDBA) and demineralized freeze-dried bone allografts (DFDBA) have been proposed as substitutes for autologous bone in oral surgery. The demineralization process has been shown, in rodents, to determine osteoinduction in tissues other than bone. Other investigators have reported poor clinical results, in man, with the use of DFDBA. The aim of the present study was a comparative light microscopical and histochemical analysis of bone regeneration processes, in man, with the use of FDBA and DFDBA. Our histological results showed that in DFDBA only the particles near the host bone were involved in the mineralization processes, while in FDBA even the particles that were farthest from the host bone were lined by osteoblasts, actively secreting osteoid matrix and newly formed bone. These results probably point to a more osteoconductive effect of FDBA. No osteoinduction was observed with FDBA or DFDBA.