Comment on Grimaldi et al. Association of Obstructive Sleep Apnea in Rapid Eye Movement Sleep With Reduced Glycemic Control in Type 2 Diabetes: Therapeutic Implications. Diabetes Care 2014;37:355–363

We read with great interest the article by Grimaldi et al. (1) focusing on how rapid eye movement (REM) sleep deprivation due to obstructive sleep apnea affects glycemic control in type 2 diabetes. The study meritoriously investigates the effect of continuous positive airway pressure (CPAP) on HbA1c levels. However, selected limitations deserve to be cited. Indeed, the authors aimed at determining the metabolic effect of reversing apneas by calculating the mean profiles of cumulative minutes of REM and non-REM (NREM)

Surgery in older patients with diabetes

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Treating diabetes in the very old: an intersocietary consensus document

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A thrombotic snake in the thoracic aorta

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Mechanisms of atherothrombosis in chronic obstructive pulmonary disease

Patients affected by chronic obstructive pulmonary disease (COPD) have an increased risk of atherothrombotic acute events, independent of smoking and other cardiovascular risk factors. As a consequence, myocardial ischemia is a relevant cause of death in these patients. We reviewed studies concerning the potential mechanisms of atherothrombosis in COPD. Bronchial inflammation spreads to the systemic circulation and is known to play a key role in plaque formation and rupture. In fact, C-reactive protein blood levels increase in COPD and provide independent prognostic information. Systemic inflammation is the first cause of the hypercoagulable state commonly observed in COPD. Furthermore, hypoxia is supposed to activate platelets, thus accounting for the increased urinary excretion of platelet-derived thromboxane in COPD. The potential metabolic risk in COPD is still debated, in that recent studies do not support an association between COPD and diabetes mellitus. Finally, oxidative stress contributes to the pathogenesis of COPD and may promote oxidation of low-density-lipoproteins with foam cells formation. Retrospective observations suggest that inhaled corticosteroids may reduce atherothrombotic mortality by attenuating systemic inflammation, but this benefit needs confirmation in ongoing randomized controlled trials. Physicians approaching COPD patients should always be aware of the systemic vascular implications of this disease

Assessing Nephrological Competence among Geriatricians: A Proof of Concept Internet Survey

Chronic kidney disease (CKD) is highly prevalent in the elderly and negatively impacts survival and health status. Thus, nephrological competence is mandatory for a skilled geriatrician. The present study aimed to assess nephrological competence in a sample of geriatricians recruited through a web survey. To this aim, a 12-items questionnaire was produced by an expert panel of nephrologists and geriatricians and was available online for members of the Italian Society of Gerontology and Geriatrics (SIGG). Two-hundred-eighty-seven geriatricians volunteered to fill in the questionnaire. The majority of them indirectly estimated the glomerular filtration rate (GFR) using mainly the Cockroft-Gault (C-G) formula. Selected nephrological exams, such as urinary Na and serum D-vitamin measurements, did not qualify as routine exams although the majority of geriatricians supplemented their patients with fat-soluble secosteroids. Ten percent of geriatricians asked for nephrological consultation only for stage 5 CKD patients and 30,9% only for stage 4 or 5. Erythropoietin supplementation was common practice for the majority of geriatricians, while only one third of them systematically used a procedure intended to prevent the contrast induced nephropathy (CIN). Finally, an alleged 50% adherence to the international guidelines for the management of CKD patients emerged from the questionnaire. Overall, results from this survey strongly recommend promoting nephrological education among geriatricians. Didactic standards for in training geriatricians need to be updated and the cooperation between geriatrics and nephrological societies promoted

Thromboembolic disease: a geriatric syndrome

The incidence of thrombotic cardiovascular disease increases with age. Several potential reasons can explain the association between thrombosis risk and age, such as the high prevalence of predisposing illnesses among older people and age-related changes in hemostasis pathways, including endothelial dysfunction, alterations in platelet function, coagulation and fibrinolytic factors, that contribute to create a hypercoagulability of the blood. Furthermore, some components of this procoagulant status may also support the inflammatory processes that characterize advancing age, promoting an increased risk of a thrombo-inflammatory disease. However, despite the increased thrombotic risk make the older patient a theoretical target for anticoagulant therapy, the concomitant risk of major bleeding make the use of this drugs problematic, with consequent underuse. This review summarizes the physiological changes of hemostasis pathways in older people in the context of thromboembolic disease as a geriatric syndrome. The balance between thrombotic and hemorrhagic risk and therefore the therapeutic efficacy of anticoagulant medications are also discussed

Ultrasound assisted great saphenous vein ligation and division: an office procedure

The aim of this proof of concept study is to describe an ultrasound (US) assisted simplified surgical procedure for pre-terminal great saphenous vein (GSV) high ligation/division avoiding groin dissection and tributary interruption, in an office setting, in association to varices phlebectomy and saphenous vein foam occlusion treatment. Inclusion criteria: primary GSV reflux due to terminal valve, vein diameter >6 mm. By ultrasonography in standing position, the point GSV passing over the adductor longus muscle (about 3 cm from the junction) is identified. This E (easy) point, relatively superficial, free from tributaries and other structures, allows an easy grasping and extraction of the GSV vein through a 3 mm stab incision provided an ultrasonography assistance. The vein is divided/ligated about 2 cm distal from the ostium, the distal stump is cannulated and foam is injected on the distal segment from the E-point incision in a retrograde fashion, varices are avulsed by phlebectomy. Twenty procedures in 18 patients (venous clinical severity score: mean 3.15 - GSV diameter: mean 7.34) were performed, all the cases without inconveniences, with a duration not exceeding 10 min in addition to the phlebectomy procedure time. No complications as hemorrhage, infection, nerve lesion, lymphatic leak or thrombosis have been registered. At one month the residual saphenous stump length was in average 2.16 cm with complete closure of GSV in all. Three patients have been controlled at 6 months showing GSV complete closure. The procedure described is a simple office US assisted method for GSV ligationdivision, leaving the 2 last cm of the saphenofemoral junction. It could be associated to most of the procedures in use with limited additional time and resources required

Distancing Measures in COVID-19 Pandemic: Loneliness, More than Physical Isolation, Affects Health Status and Psycho-Cognitive Wellbeing in Elderly Patients with Chronic Obstructive Pulmonary Disease.

Since the outbreak of the SARS-CoV-2 pandemic in 2020, many governments have been imposing confinement and physical distancing measures. No data exist on the effects of lockdowns on the health status of patients affected by chronic pathologies, specifically those with Chronic Obstructive Pulmonary Disease (COPD). Our study aims to establish variations across the psychological and cognitive profile of patients during the isolation period in Italy, in a cohort of patients affected by COPD, between February and May 2020. Forty patients with established COPD were comprehensively evaluated by geriatric multidimensional assessment before the spread of the epidemic in Italy, and submitted to a second evaluation during the subsequent lockdown. We assessed functional ability, basic and instrumental Activities of Daily Living (ADL and IADL), cognition and mood status. We compared the scores obtained at baseline against those obtained during the pandemic, and used mean differences for correlation with major clinical and functional indexes. The score differences from MMSE, ADL and IADL were statistically significant. Such differences were correlated to the presence of a caregiver and to the total number of family members living together. Remarkably, the loneliness dimension, more than the restrictions themselves, seemed to represent the major determinant of altered health status and depressed psycho-cognitive profile in our population. Also remarkably, we detected no correlation between the score variation and the respiratory function indexes of disease severity. The isolation measures adopted during the SARS-CoV-2 pandemic have triggered the classic clinical string associated to geriatric isolation, which leads to a deterioration of cognitive functions, independence and frailty levels in a population affected by a chronic degenerative disease, such as COPD. If considered from a multidimensional geriatric point of view, the individual benefit of isolation measures could be small or non-existent