Optimal therapy of type 2 diabetes: a controversial challenge

Type 2 diabetes mellitus (T2DM) is one of the most common chronic disorders in older adults and the number of elderly diabetic subjects is growing worldwide. Nonetheless, the diagnosis of T2DM in elderly population is often missed or delayed until an acute metabolic emergency occurs. Accumulating evidence suggests that both aging and environmental factors contribute to the high prevalence of diabetes in the elderly. Clinical management of T2DM in elderly subjects presents unique challenges because of the multifaceted geriatric scenario. Diabetes significantly lowers the chances of "successful" aging, notably it increases functional limitations and impairs quality of life. In this regard, older diabetic patients have a high burden of comorbidities, diabetes-related complications, physical disability, cognitive impairment and malnutrition, and they are more susceptible to the complications of dysglycemia and polypharmacy. Several national and international organizations have delivered guidelines to implement optimal therapy in older diabetic patients based on individualized treatment goals. This means appreciation of the heterogeneity of the disease as generated by life expectancy, functional reserve, social support, as well as personal preference. This paper will review current treatments for achieving glycemic targets in elderly diabetic patients, and discuss the potential role of emerging treatments in this patient population

Responses to supplementation by dairy cows given low pasture allowances in different seasons 2. Milk production

Two factorial experiments were designed to determine the effects of stage of lactation, and season of the year, on cow responses to supplementary feeding. These experiments were conducted over consecutive years with 128 high genetic merit multiparous Holstein-Friesian cows in early, mid and late lactation in spring, summer, autumn and winter. At each stage of lactation, and in each season of the year, cows were offered a restricted pasture allowance (25 to 35 kg dry matter (DM) per cow per day), either unsupplemented (control) or with supplement at 50 MJ metabolizable energy (ME) per cow per day in experiment 1 and 80 MJ ME per cow per day in experiment 2. The two supplements given in both years were rolled maize grain (MG) and a mixture of foods formulated to nutritionally balance the diet (BR). In experiment 2, another treatment, of a generous pasture allowance (60 to 75 kg DM per cow per day) (AP), was imposed on an additional group of early lactation cows during each season. Direct milk solids (MS) (milk fat plus milk protein) responses in experiment 1 to MG were 169, 279, 195 and 251 g MS per cow per day in spring, summer, autumn and winter, respectively, while those to BR were 107, 250, 192, 289 g MS per cow per day. In experiment 2, however, milk solids responses to both supplements during spring were slightly below the control treatment, with values similar to those in experiment 1 in summer and autumn for cows on the BR but not the MG supplement. Milk solids responses to supplementary foods were largest during seasons of the year when the quantity and quality of pasture on offer resulted in the lowest milk solids yield from unsupplemented cows. When carry-over effects of feeding MG and BR on milk solids production were detected, they were only about half the magnitude of the direct effects. Serum urea concentrations were higher in control cows than those offered MG with a similar effect for BR in all but summer in experiment 1, while serum glucose concentrations were highest in winter and lowest in summer. The most important factor influencing milk solids responses was the relative food deficit (RFD) represented by the decline in milk solids yield of the respective control groups after,changing from a generous pasture allowance to restricted allowance when the feeding treatments were imposed. Total milk solids responses (direct and carry-over) to supplements were greatest when severe food restrictions, relative to the cows' current food demand, resulted in large reductions in milk solids yield of the control groups. The RFD was the best predictor of milk solids response to supplementary foods. Therefore, it is likely that cows are most responsive to supplementary foods during or immediately after the imposition of a severe food restriction

Responses to supplementation by dairy cows given low pasture allowances in different seasons 1. Pasture intake and substitution

Two factorial experiments were designed to determine the effects of stage of lactation, and season of the year, on cow responses to supplementary feeding. These experiments were conducted over consecutive years with 128 high genetic merit multiparous Holstein-Friesian cows in early, mid and late lactation in spring, summer, autumn and winter. At each stage of lactation, and in each season of the year, cows were offered a restricted pasture allowance (25 to 35 kg dry matter (DM) per cow per day), either unsupplemented (control) or supplemented with 50 MJ metabolizable energy (ME) per cow per day in experiment 1 and 80 MJ ME per cow per day in experiment 2. Two different supplements were offered, namely, rolled maize grain (MG) and a mixture of foods (BR) formulated to nutritionally balance the diet. In experiment 2, a fourth treatment consisting solely of a generous pasture allowance (60 to 75 kg DM per cow per day, AP) was introduced. Offering MG and BR increased DM intake (DMI). At the restricted pasture allowance, increasing total ME allowance (MEA) by offering supplementary foods increased ME intake (MEI) by 0.68 (s.e. 0.047) MJ per extra MJ ME offered. This highly significant (P < 0.001) linear relationship was consistent across seasons, and did not diminish at higher MEA. In experiment 2, cows in early lactation had lower substitution rates than mid and late lactation cows irrespective of season. Substitution rate was higher when higher pasture allowance or quality of pasture on offer enabled the unsupplemented cows to achieve higher DMI from pasture than at other times of the year. These results suggest that one of the key factors determining the intake response to supplementary foods is pasture allowance. Within spring calving dairying systems, the largest increases in total DMI per kg of supplement offered is likely when offering supplements to early lactation cows grazing restricted allowances of high quality pasture

Independent association of atherogenic dyslipidaemia with all-cause mortality in individuals with type 2 diabetes and modifying effect of gender. a prospective cohort study

Atherogenic dyslipidaemia has been implicated in the residual risk for cardiovascular morbidity and mortality, which remains despite attainment of LDL cholesterol goals especially in individuals with type 2 diabetes. However, its relationship with all-cause death has not been sufficiently explored. This analysis evaluated the independent association of increased triglycerides and triglyceride:HDL cholesterol ratio (TG:HDL) and decreased HDL cholesterol with total mortality and the possible modifying effect of gender in a large cohort of patients with type 2 diabetes

A major electronics upgrade for the H.E.S.S. Cherenkov telescopes 1-4

The High Energy Stereoscopic System (H.E.S.S.) is an array of imaging atmospheric Cherenkov telescopes (IACTs) located in the Khomas Highland in Namibia. It consists of four 12-m telescopes (CT1-4), which started operations in 2003, and a 28-m diameter one (CT5), which was brought online in 2012. It is the only IACT system featuring telescopes of different sizes, which provides sensitivity for gamma rays across a very wide energy range, from ~30 GeV up to ~100 TeV. Since the camera electronics of CT1-4 are much older than the one of CT5, an upgrade is being carried out; first deployment was in 2015, full operation is planned for 2016. The goals of this upgrade are threefold: reducing the dead time of the cameras, improving the overall performance of the array and reducing the system failure rate related to aging. Upon completion, the upgrade will assure the continuous operation of H.E.S.S. at its full sensitivity until and possibly beyond the advent of CTA. In the design of the new components, several CTA concepts and technologies were used and are thus being evaluated in the field: The upgraded read-out electronics is based on the NECTAR readout chips; the new camera front- and back-end control subsystems are based on an FPGA and an embedded ARM computer; the communication between subsystems is based on standard Ethernet technologies. These hardware solutions offer good performance, robustness and flexibility. The design of the new cameras is reported here.Comment: Proceedings of the 34th International Cosmic Ray Conference, 30 July- 6 August, 2015, The Hague, The Netherland