Association of kidney disease measures with risk of renal function worsening in patients with type 1 diabetes

Background: Albuminuria has been classically considered a marker of kidney damage progression in diabetic patients and it is routinely assessed to monitor kidney function. However, the role of a mild GFR reduction on the development of stage 653 CKD has been less explored in type 1 diabetes mellitus (T1DM) patients. Aim of the present study was to evaluate the prognostic role of kidney disease measures, namely albuminuria and reduced GFR, on the development of stage 653 CKD in a large cohort of patients affected by T1DM. Methods: A total of 4284 patients affected by T1DM followed-up at 76 diabetes centers participating to the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD) initiative constitutes the study population. Urinary albumin excretion (ACR) and estimated GFR (eGFR) were retrieved and analyzed. The incidence of stage 653 CKD (eGFR < 60 mL/min/1.73 m2) or eGFR reduction > 30% from baseline was evaluated. Results: The mean estimated GFR was 98 \ub1 17 mL/min/1.73m2 and the proportion of patients with albuminuria was 15.3% (n = 654) at baseline. About 8% (n = 337) of patients developed one of the two renal endpoints during the 4-year follow-up period. Age, albuminuria (micro or macro) and baseline eGFR < 90 ml/min/m2 were independent risk factors for stage 653 CKD and renal function worsening. When compared to patients with eGFR > 90 ml/min/1.73m2 and normoalbuminuria, those with albuminuria at baseline had a 1.69 greater risk of reaching stage 3 CKD, while patients with mild eGFR reduction (i.e. eGFR between 90 and 60 mL/min/1.73 m2) show a 3.81 greater risk that rose to 8.24 for those patients with albuminuria and mild eGFR reduction at baseline. Conclusions: Albuminuria and eGFR reduction represent independent risk factors for incident stage 653 CKD in T1DM patients. The simultaneous occurrence of reduced eGFR and albuminuria have a synergistic effect on renal function worsening

Il margine del parco agricolo del terrente San Vincenzo su Corso Italia, Carini

To the west of Palermo, at the foot of Mount Saraceno and Mount Ceresia, surrounded by mounts Pecoraro, Montagna Longa, Tre Pizzi, Colombrina, stands Carini, on a hill 181 m above sea level. The area, cut lengthwise from south to north by some roads, among which corso Italia, extends, crossing the railway line and the SS 113, to the coast and the homonymous gulf. Along the strip to the west of the town (with an area of about 100 ha), among citrus orchards, olive groves, orchards, semicultivated or neglected fields, there is an area (about 240 ha) crossed by stream San Vincenzo. The railway line (north), corso Italia (east), Rocca del Castello with the adjacent walls (south), the cemetery (south-west), an archaeological site (west), define the almost inaccessible closed area. In this area, adjacent to the above-mentioned corso Italia, the new urban realities are represented by scattered built fabric juxtaposed to stretches of countryside. The indefinite margins towards corso Italia, the shapeless spaces among the buildings, the lack of continuity between built and open areas, the missing connection with the nearby agricultural area bring out the need for a design action. The project idea is based on the preservation of an open area where the countryside emerges with great potentials, and on its discovery through an easy access. To give a shape1 to the countryside through a redefinition of its margins, leads to a continuity of open spaces within new relationships to be established between built fabric and agricultural area

Bone histomorphometry in acromegaly patients with fragility vertebral fractures

CONTEXT: The high risk of vertebral fractures (VFs) in acromegaly patients despite normal bone mineral density (BMD) is well known. The reasons for this paradoxical finding of skeleton fragility are poorly understood due to the limited data on bone histomorphometry in acromegaly. OBJECTIVE: This study aimed to analyze histomorphometric parameters including bone microarchitecture in acromegaly patients with VFs and normal BMD compared to normal subjects, and also to evaluate the differences between active and controlled acromegaly patients. PATIENTS AND METHODS: Forty-seven acromegaly patients (17 active, 30 controlled), median (range) age 57 years (30-88) were evaluated for bone turnover, morphometric VFs and BMD by dual-energy X-ray absorptiometry at lumbar spine and hip; 12 patients with VFs and normal BMD underwent iliac crest bone biopsy; 12 biopsies were taken at the autopsy in healthy sex and age-matched control subjects. RESULTS: The histomorphometric evaluation of acromegaly fractured patients was compared with that of normal controls and showed significantly reduced median (range) levels of bone volume/tissue volume (BV/TV: 15.37% (7.93-26.75) vs. 18.61% (11.75-27.31), p\u2009=\u20090.036), trabecular thickness (TbTh: 77.6 \ub5m (61.7-88.3) vs. 82.7 \ub5m (72.3-92.0) p\u2009=\u20090.045), with increased trabecular separation (TbSp: 536.4 \ub5m (356.2-900.6) vs. 370.3 \ub5m (377.1-546.3) p\u2009=\u20090.038) and increased cortical thickness (1268 \u3bcm (752-2521) vs. 1065 \u3bcm (851-1205) p\u2009=\u20090.025) and porosity (11.9% (10.2-13.3) vs. 4.8% (1.6-8.8) p\u2009=\u20090.0008). While active acromegaly patients showed histomophometric features of increased bone turnover, patients with controlled disease presented normal bone turnover with significantly lower osteoblastic activity, expressed as osteoblast number (p\u2009=\u20090.001), active osteoblasts and vigor (p\u2009=\u20090.014) in the presence of reduced osteocyte number (p\u2009=\u20090.008) compared to active disease. CONCLUSIONS: The apparent paradox of bone fragility in acromegaly patients with a normal BMD can be explained by increased cortical thickness and porosity and reduced trabecular thickness with increased trabecular separation. These structural and microarchitectural abnormalities persist in the controlled phase of acromegaly despite bone turnover normalization. The main determinant of bone disease after hormonal control is severe osteoblastic dysfunction

Hyperinsulinemic hypoglycemia associated with ectopic Cushing's syndrome due to a pancreatic endocrine tumor in a Type 2 diabetes mellitus patient: clinical implications of a rare association.

The coexistence of insulin and ACTH hypersecretion in the same patient is extremely rare. A diabetic patient with a pancreatic endocrine tumor (PET) co-secreting insulin and ACTH is even rarer and has never been described. The combination of these two endocrine syndromes results in a peculiar clinical picture. AIM: To determine the cause of glycemic variations in a patient with previously stable diabetes mellitus. SUBJECTS AND METHODS: This is a clinical case report from the Endocrinology Unit of Aosta Hospital and Internal Medicine and Surgical Unit of Verona University. A 69-yr-old diabetic patient was hospitalized for recurrent severe hypoglycemic events persistent after withdrawal of anti-diabetic drugs. The causes of hypoglycemia and subsequent resumption of hyperglycemia were investigated. RESULTS: An insulin-secreting PET was diagnosed. Diazoxide and octreotide therapy initially was able to control hypoglycemic symptoms, then, a Cushing's syndrome occurred resulting in worsening of diabetes control. ACTH was found to be released by the PET previously diagnosed as an insulin-secreting tumor. The tumor was removed and the histology was consistent with a well differentiated endocrine carcinoma. After surgery, adrenal function was normal and insulin therapy was again necessary to control diabetes. CONCLUSIONS: A single PET may be responsible for both a hyperinsulinemic and a Cushing's syndrome. When this rare association occurs, each of the two syndromes may affect the other resulting in a peculiar clinical course. Finally, an insulin-secreting PET has to be kept in mind as a rare cause of hypoglycemia in diabetic patients

Hyperinsulinemic hypoglycemia associated with ectopic Cushing's syndrome due to a pancreatic endocrine tumor in a Type 2 diabetes mellitus patient: Clinical implications of a rare association.

The coexistence of insulin and ACTH hypersecretion in the same patient is extremely rare. A diabetic patient with a pancreatic endocrine tumor (PET) co-secreting insulin and ACTH is even rarer and has never been described. The combination of these two endocrine syndromes results in a peculiar clinical picture.To determine the cause of glycemic variations in a patient with previously stable diabetes mellitus.This is a clinical case report from the Endocrinology Unit of Aosta Hospital and Internal Medicine and Surgical Unit of Verona University. A 69-yr-old diabetic patient was hospitalized for recurrent severe hypoglycemic events persistent after withdrawal of anti-diabetic drugs. The causes of hypoglycemia and subsequent resumption of hyperglycemia were investigated.An insulin-secreting PET was diagnosed. Diazoxide and octreotide therapy initially was able to control hypoglycemic symptoms, then, a Cushing's syndrome occurred resulting in worsening of diabetes control. ACTH was found to be released by the PET previously diagnosed as an insulin-secreting tumor. The tumor was removed and the histology was consistent with a well differentiated endocrine carcinoma. After surgery, adrenal function was normal and insulin therapy was again necessary to control diabetes.A single PET may be responsible for both a hyperinsulinemic and a Cushing's syndrome. When this rare association occurs, each of the two syndromes may affect the other resulting in a peculiar clinical course. Finally, an insulin-secreting PET has to be kept in mind as a rare cause of hypoglycemia in diabetic patients

BPCO istruzioni per l\u2019uso: buone pratiche per persone con BPCO e i loro familiari ai tempi del COVID-19

Introduzione: La pandemia del COVID- 19 \ue8 esplosa in Italia dal 21 febbraio 2020 e ha colpito soprattutto le persone in et\ue0 anziana e portatori di comorbidit\ue0, tra cui anche pazienti con BPCO (Broncopneumopatia Cronico Ostruttiva). A causa dell\u2019emergenza sanitaria ci si \ue8 dovuti assestare su nuove tipologie di rapporto medico-paziente e in particolar modo sull\u2019esigenza della promozione di consulti telefonici / telematici web per la valutazione della progressione della malattia, per le complicanze ad essa connesse, per la necessit\ue0 di rideterminare le condizioni e le abitudini di vita del paziente stesso. Le visite in presenza erano quindi sospese e di vitale importanza risultava continuare un\u2019educazione alla salute per i pazienti con BPCO, e i loro caregivers attraverso un manuale mirato che li raggiungesse direttamente. Le Associazioni dei pazienti, assieme alla Societ\ue0 Italiana di Pneumologia, si sono preoccupate di colmare questo gap attraverso la stesura di un libro che si occupasse del benessere fisico psichico e sociale delle persone con BPCO e dei loro familiari in un\u2019epoca di profondo sconvolgimento per le persone di malattia polmonare. Metodi: Il manuale BPCO istruzioni per l\u2019uso: buone pratiche per persone con BPCO e i loro familiari ai tempi del COVID-19 \ue8 stato redatto da competenze esperte sulla BPCO, sulla gestione dei Traumi psichici e sul miglioramento del tono dell\u2019umore, in epidemiologia e sull\u2019organizzazione di Sistemi sanitari proprio per considerare la salute come un sistema integrato di interventi. Ogni capitolo \ue8 stato illustrato con immagini e con linguaggio laico e chiaro ai pazienti con BPCO per trasmettere come gestire al meglio la propria patologia e migliorare la qualit\ue0 di vita durante l\u2019esperienza del lock down. I temi trattati sono: le informazioni sulla BPCO, I fattori di rischio, la diagnosi e le cure, la Cessazione del fumo lo Stile di vita la Terapia farmacologica, l\u2019importanza dell\u2019aderenza terapeutica, consigli per \u201cconvivere\u201d con la pandemia COVID-19, come convivere con l\u2019isolamento sociale a cura di Delia Duccoli, le attivit\ue0 da svolgere per aumentare il proprio benessere, hobby e passatempi, arte e cultura, tecniche di rilassamento. Il manuale in formato ebook \ue8 presente, gratuito e copyleft, in due lingue, Italiano e Inglese, per portare questa Buona Pratica di informazione mirata anche agli altri paesi. Risultati e conclusioni: In un tempo (primavera e estate 2020) in cui le informazioni sulla salute erano diffuse quasi esclusivamente dai media e in modo confuso, questo manuale \ue8 giunto ad aiutare le associazioni di pazienti nel rispondere ai loro associati con un manuale concreto ed esaustivo, anzich\ue9 con informazioni parcellizzate e focalizzate solo ad un aspetto del bisogno di salute. La multidisciplinariet\ue0 di questo lavoro di avanguardia sulla BPCO mette in luce come il benessere della persona con BPCO ai tempi del COVID- 19 ma anche in altri settori, sia il pilastro per cui il campo clinico, debba essere arricchito con quello comunicazionale e psicologico. Il manuale a dicembre 2020 sar\ue0 anche aggiornato dalla ricerca in corso \u201cNarrarsi al tempo del COVID-19\u201d, il punto di vista di persone con BPCO, i familiari e professionisti sanitari, includenti anche una casistica affetta da COVID-19: le testimonianze porteranno miglioramenti organizzativi per la qualit\ue0 dei servizi e promuoveranno la resilienza in pazienti, caregiver e operatori

Effects of Lanreotide Autogel on Growth Hormone, Insulinlike Growth Factor 1, and Tumor Size in Acromegaly : A 1-Year Prospective Multicenter Study

Objective: To evaluate the safety and effectiveness of lanreotide Autogel on growth hormone and insulinlike growth factor 1 (IGF-1) concentrations and tumor size in patients with acromegaly. Methods: Between September 2004 and March 2006, patients with active acromegaly who had not previously been treated with somatostatin analogues or received irradiation were enrolled in a 1-year, prospective, open, multicenter study. Lanreotide Autogel was injected subcutaneously starting with 90 mg every 4 weeks for 2 cycles and then individually titrated, aiming for safe growth hormone concentrations (<2.5 ng/mL) and normal age-matched IGF-1 concentrations. Tumor shrinkage, clinical score, pituitary function, and safety parameters were evaluated. Results: Twenty-seven patients (15 women, 12 men) were enrolled. One patient withdrew because of treatment intolerance, and 5 proceeded to neurosurgery 6 months into the study. Lanreotide Autogel was the primary treatment in 19 patients (4 with microadenoma, 15 with macroadenoma) and the adjuvant treatment in 8 patients in whom it followed a previous unsuccessful neurosurgery. In the 26 patients, safe growth hormone values were achieved in 11 (42%), normal IGF-1 values in 14 (54%), and both targets were achieved in 10 (38%). Tumors shrank in 16 of the 22 patients (73%) in whom tumor shrinkage could be evaluated. The maximal vertical diameter of the tumor decreased by a mean of 24% (range, 0% to 50%), from 14.4 \ub1 8.4 mm to 10.4 \ub1 7 mm, and tumor volume decreased by a mean of 44% (range, 0% to 76%), from 2536 mm3 (range, 115-7737 mm3) to 1461 mm3 (range, 63-6217 mm3) (both P<.015). Symptom scores and lipid levels significantly improved. In the 26 patients, glucose metabolism deteriorated in 3 (12%) and improved in 4 (15%). New biliary alterations appeared in 26%. Pituitary function and safety parameters did not change. Conclusions: Lanreotide Autogel treatment, titrated for optimal hormonal control, effectively controls IGF-1 and growth hormone levels, shrinks tumors, reduces acromegalic symptoms, and is well tolerated

ACTH-secreting Pancreatic Neoplasms Associated With Cushing Syndrome: Clinicopathologic Study of 11 Cases and Review of the Literature

Adrenocorticotropic hormone (ACTH)-secreting pancreatic neuroendocrine tumors (PanNETs), although rare, are responsible for about 15% of ectopic Cushing syndrome (CS). They represent a challenging entity because their preoperatory diagnosis is frequently difficult, and clear-cut morphologic criteria useful to differentiate them from other types of PanNETs have not been defined. Ectopic ACTH secretion associated with CS can also be rarely due to pancreatic acinar cell carcinoma (ACC) and pancreatoblastoma, rare tumor types with morphologic features sometimes overlapping those of PanNETs and, for this reason, representing a diagnostic challenge for pathologists. We herein describe the clinicopathologic and immunohistochemical features of 10 PanNETs and 1 ACC secreting ACTH and associated with CS together with an extensive review of the literature to give the reader a comprehensive overview on ACTH-producing pancreatic neoplasms. ACTH-secreting PanNETs are aggressive neoplasms with an immunohistochemical profile that partially overlaps that of pituitary corticotroph adenomas. They are generally large and well-differentiated neoplasms without distinctive histologic features but with signs of aggressiveness including vascular and perineural invasion. They are more frequent in female individuals with a mean age of 42 years. At 5 and 10 years after diagnosis, 35% and 16.2% of patients, respectively, were alive. ACTH-secreting ACCs and pancreatoblastomas are very aggressive pediatric tumors with a poor prognosis. Using an appropriate immunohistochemical panel including ACTH, \u3b2-endorphin, trypsin, and BCL10 it is possible to recognize ACTH-secreting PanNETs and to distinguish them from the very aggressive ACTH-secreting ACCs