Indici di funzione tiroidea in gravidanza: variazioni fisiologiche e relazione con il diabete gestazione

Background. Il diabete gestazionale (GDM) è la più frequente patologia meta-bolica in gravidanza ed è associata a importanti complicanze materno-fetale. Alcuni recenti studi hanno osservato un’associazione fra GDM e alterazioni della funzionalità tiroidea. I dati sono però limitati e contrastanti. Obiettivi dello studio. Preliminarmente definire intervalli di riferimento trime-stre-specifici in gravidanza di TSH, fT4 e fT3 in un campione di donne caucasiche e valutare l’andamento fisiologico del rapporto fT3/fT4, come indicatore dell’attività deiodasica, durante la gestazione. Valutare poi l’associazione fra gli indici di funzionalità tiroidea e lo sviluppo di GDM, anche al fine di individuare possibili nuovi predittori di tale patologia. Materiali e metodi. I dati sono stati ricavati dalla coorte dello studio Trilogy, uno studio prospettico in gravidanza condotto presso l'AOUI di Verona. Le donne in-cluse nel progetto, reclutate su base volontaria e con unico criterio di esclusione la diagnosi precedente di diabete, sono state sottoposte a visite e a raccolta di infor-mazioni cliniche e campioni biologici in ciascun trimestre di gravidanza e a di-stanza di circa sei mesi dal parto. Sono stati effettuati test da carico orale di gluco-sio tra la 14-16esima e la 24-26esima settimana di gestazione mentre tra la 30-32esima settimana è stata rivalutata la glicemia basale. Per la diagnosi di GDM sono stati usati i criteri IADPSG 2010. Per definire gli intervalli di riferimento degli indici di funzione tiroidea sono stati preliminarmente studiati soggetti sani con gravidanza fisiologica, escludendo quelli che presentavano valori francamente alterati di TSH o positività per gli anticorpi anti-tiroide. Successivamente, i dati di 92 donne con GDM sono stati confrontati con quelli di 149 controlli, dopo esclu-sione dei soggetti trattati per patologie tiroidee. In tutti questi soggetti è stata valu-tata la funzionalità tiroidea in ciascun trimestre misurando TSH, fT4 e fT3 ed è stato calcolato il rapporto fT3/fT4. Inoltre anticorpi anti-TPO e ioduria sono stati misurati al primo controllo. Risultati. I valori di TSH non presentavano sostanziali modificazioni in corso di gravidanza. I valori di fT4 e di fT3 mostravano invece una chiara riduzione pro-gressiva nel corso della gestazione, mentre il rapporto fT3/fT4 presentava un lieve ma significativo aumento. Il valore medio della ioduria indicava uno stato di lieve carenza iodica. I valori di fT3 e del rapporto fT3/fT4 nelle fasi iniziali di gravi-danza correlavano positivamente con il BMI pregravidico, mentre quelli di fT4 correlavano negativamente con questo parametro. Nella fase finale di gravidanza si osservavano invece correlazioni analoghe, in particolare per fT4 e rapporto fT3/fT4, con l’incremento ponderale materno durante la gestazione. Le donne con GDM mostravano valori di fT3 nella fase iniziale di gestazione si-gnificativamente superiori rispetto ai valori dei controlli sani, ma tali differenze non si confermavano all’analisi multivariata, una volta considerati i potenziali fat-tori confondenti. Il peso assoluto neonatale, infine, era simile nei due gruppi, ma il corrispondente valore di SDS, era significativamente maggiore nel gruppo GDM. Conclusioni. Il TSH presenta fisiologicamente valori sostanzialmente stabili nel corso della gestazione, quantomeno a partire dalla 14esima settimana di gestazio-ne. I valori di fT4 e di fT3 si modificano invece in modo progressivo con il proce-dere della gestazione, riducendosi. Nella valutazione degli ormoni tiroidei in corso di gravidanza è quindi indispensabile l’adozione di intervalli di riferimento trime-stre-specifici. I valori del rapporto fT3/fT4, indicatore dell’attività deiodasica, aumentano leggermente ma significativamente nel corso della gestazione. Nelle donne con GDM i livelli di fT3 sono significativamente più alti rispetto a quelli misurati nei controlli sani. Questa differenza è presente nelle fasi iniziali e centrali della gestazione. Il rapporto fT3/fT4 non mostra invece differenze nei due gruppi. All’analisi multivariata, tuttavia, nessuno dei parametri di funzione tiroidea risulta associato in modo indipendente alla diagnosi di GDM. Nell’insieme queste os-servazioni suggeriscono un significato adattativo di questi fenomeni e rendono poco verosimile un ruolo patogenetico degli ormoni tiroidei nello sviluppo del GDM, almeno nell’ambito di valori normali o quanto meno non francamente patologici di questi ormoni

Cutaneous squamous carcinoma in a patient with diabetic foot: an unusual evolution of a frequent complication

After basal cell carcinoma, the cutaneous squamous cell carcinoma (cSCC) is the second most frequent non-melanoma skin cancer worldwide, and, classically, arises from the upper coats of the epidermis of sun-exposed areas or from skin areas constantly exposed to a chronic inflammatory stimulus. The occurrence of cSCC seems to be linked to several factors, including exposure to sunlight (or other ultraviolet radiations), immunosuppression, chronic scarring conditions and some familial cancer syndromes. Although the majority of cSCCs are adequately eradicated by surgical excision, a subgroup of cSCC may be linked with an increased risk of recurrence, metastasis and death. The incidence of type 2 diabetes mellitus is constantly increasing worldwide. Importantly, diabetes mellitus is a strong risk factor for cancers (including cutaneous tumors) and is highly related with poor cancer outcomes. At present, in the literature, squamous cell carcinoma developing in association with diabetic foot ulcers has been already reported in some reports; however, additional data are needed to make the clinicians aware of this rare, although possible, complication. Therefore, we herein report an unusual case of an elderly man with T2DM and a positive oncological history, presenting a cSCC involving the skin overlying the first toe of left foot. The growing cSCC appeared approximately 3 years after the appearance of a diabetic ulcer

nonalcoholic fatty liver disease is independently associated with an increased incidence of chronic kidney disease in patients with type 1 diabetes

OBJECTIVE There is no information about the role of nonalcoholic fatty liver disease (NAFLD) in predicting the development of chronic kidney disease (CKD) in type 1 diabetes. RESEARCH DESIGN AND METHODS We studied 261 type 1 diabetic adults with preserved kidney function and with no macroalbuminuria at baseline, who were followed for a mean period of 5.2 years for the occurrence of incident CKD (defined as estimated glomerular filtration rate [eGFR] 2 and/or macroalbuminuria). NAFLD was diagnosed by ultrasonography. RESULTS At baseline, patients had a mean eGFR of 92 ± 23 mL/min/1.73 m 2 ; 234 (89.7%) of them had normoalbuminuria and 27 (10.3%) microalbuminuria. NAFLD was present in 131 (50.2%) patients. During follow-up, 61 subjects developed incident CKD. NAFLD was associated with an increased risk of incident CKD (hazard ratio [HR] 2.85 [95% CI 1.59–5.10]; P P P P = 0.002). CONCLUSIONS This is the first study to demonstrate that NAFLD is strongly associated with an increased incidence of CKD. Measurement of NAFLD improves risk prediction for CKD, independently of traditional cardio-renal risk factors, in patients with type 1 diabetes

Diabetic foot complicated by vertebral osteomyelitis and epidural abscess

Vertebral osteomyelitis (or spondylodiscitis) is steadily increasing in Western countries and often results from hematogenous seeding, direct inoculation during spinal surgery, or contiguous spread from an infection in the adjacent soft tissue. We present the case of a 67-year-old white patient with type 2 diabetes who went to Hospital for high fever, back pain, and worsening of known infected ulcers in the left foot. Despite intravenous antibiotic treatment and surgical debridement of the foot infection, high fever and lower back pain continued. Bone biopsy and two consecutive blood cultures were positive for Staphylococcus aureus. A spinal magnetic resonance imaging (MRI) was performed, revealing serious osteomyelitis in L4 and L5 complicated by an epidural abscess. Contiguous or other distant focuses of infection were not identified. In this case, diabetic foot could be considered as a primary distant focus for vertebral osteomyelitis. Clinicians should consider vertebral osteomyelitis as a 'possible' diagnosis in patients with type 2 diabetes complicated by foot infection that is associated with fever and lower back pain. LEARNING POINTS: Vertebral osteomyelitis is increasing in Western countries, especially in patients with type 2 diabetes.The primary focus of infection is the genitourinary tract followed by skin, soft tissue, endocarditis, bursitis, septic arthritis, and intravascular access.Diabetic foot could be a rare primary focus of infection for vertebral osteomyelitis, and, however, vertebral osteomyelitis could be a serious, albeit rare, complication of diabetic foot.Clinicians should keep in mind the many potential complications of diabetic foot ulcerations and consider vertebral osteomyelitis as a "possible" diagnosis in patients with type 2 diabetes and foot ulcers associated with nonspecific symptoms such as lower back pain.Early diagnosis and correct management of vertebral osteomyelitis are crucial to improve clinical outcomes

Nonalcoholic fatty liver disease is associated with an increased prevalence of distal symmetric polyneuropathy in adult patients with type 1 diabetes

Presently, data on the association between nonalcoholic fatty liver disease (NAFLD) and distal symmetric polyneuropathy in people with diabetes are scarce and conflicting. The aim of this retrospective, cross-sectional study was to examine whether NAFLD was associated with an increased prevalence of distal symmetric polyneuropathy in type 1 diabetic adults

Nonalcoholic fatty liver disease is independently associated with an increased incidence of cardiovascular disease in adult patients with type 1 diabetes

Background: Recent studies suggested that nonalcoholic fatty liver disease (NAFLD) is associated with an increased prevalence of cardiovascular disease (CVD) in type 1 diabetes. Weassessed whether NAFLD also predicts the risk of incident CVD events in type 1 diabetic adults. Methods: We studied a retrospective cohort of 286 type 1 diabetic outpatients (mean age 43\ub114 years; median duration of diabetes 17 [10\u201330] years) without secondary causes of chronic liver diseases,who were followed for a mean period of 5.3 years for the occurrence of incident CVD events (a combined endpoint inclusive of nonfatal ischemic heart disease, nonfatal ischemic stroke or coronary/peripheral artery revascularizations). NAFLD was diagnosed by ultrasonography. Results: Overall, 150 patients (52.4%) had NAFLD at baseline. During a mean follow-up of 5.3\ub1 2.1 years, 28 patients developed incident CVD events. Patients with NAFLD had a higher incidence of CVD events than those without NAFLD (17.3% vs. 1.5%, p b 0.001). NAFLD was associated with an increased risk of CVD events (hazard ratio [HR] 8.16, 95% confidence interval [CI] 1.9\u201335.1, p b 0.005). Adjustments for age, sex, body mass index, smoking, diabetes duration, hemoglobin A1c, dyslipidemia, hypertension, chronic kidney disease, prior ischemic heart disease and serum gamma-glutamyltransferase levels did not appreciably attenuate the association between NAFLD and incident CVD (adjusted-HR 6.73, 95% CI 1.2\u201338.1, p = 0.031). Conclusions: This is the first observational study to demonstrate that NAFLD is associated with an increased risk of incident CVD events in type 1 diabetic adults, independently of established CVD risk factors and diabetes-related variables