Increased Urinary Albumin Excretion, Insulin Resistance, and Related Cardiovascular Risk Factors in Patients With Type 2 Diabetes

OBJECTIVE—While the relevant role of insulin resistance in the pathogenesis of increased urinary albumin excretion (UAE) is well established in type 1 diabetes, its contribution in type 2 diabetes is controversial. Our aim was to investigate whether insulin resistance was associated with increased UAE in a large cohort of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS— A total of 363 men and 349 women, aged 61 ± 9 years, with a disease duration of 11 ± 9 years and HbA1c levels of 8.6 ± 2.0% were included. Insulin resistance was derived from the homeostasis model assessment of insulin resistance (HOMAIR), and UAE was derived from the albumin-to-creatinine ratio (ACR) defined as increased if the value was ≥2.5 mg/mmol in men and ≥3.5 mg/mmol in women. ACR was correlated with HOMAIR (r = 0.15, P = 0.0001), independently of age, disease duration, blood pressure, HbA1c, triglycerides, waist circumference, and smoking. RESULTS—When the two sexes were investigated separately, a significant correlation between ACR and HOMAIR was reached in men (n = 363; r = 0.21, P = 0.0001) but not women (n = 349; r = 0.08, P = 0.14), suggesting that insulin resistance and sex may interact (P for interaction = 0.04) in determining UAE. When men were subgrouped into quartiles of HOMAIR, those of the third and fourth quartile (i.e., the most insulin resistant) were at higher risk to have increased ACR than patients of the first quartile (third quartile: odds ratio 2.2 [95% CI 1.2–4.2], P = 0.01) (fourth quartile: 4.1 [2.2–7.9], P = 0.00002). Finally, ACR was significantly higher in men with two or more insulin resistance–related cardiovascular risk factors (i.e., abdominal obesity, dyslipidemia, and arterial hypertension) than in men with fewer than two insulin resistance–related cardiovascular risk factors (0.90 [0.2–115.1] vs. 1.56 [0.1–1367.6], respectively, P = 0.005). CONCLUSIONS—In type 2 diabetic patients, increased UAE is strongly associated with insulin resistance and related cardiovascular risk factors. This association seems to be stronger in men than in women

Copernicus Ocean State Report, issue 6

The 6th issue of the Copernicus OSR incorporates a large range of topics for the blue, white and green ocean for all European regional seas, and the global ocean over 1993–2020 with a special focus on 2020

Prescription appropriateness of anti-diabetes drugs in elderly patients hospitalized in a clinical setting: evidence from the REPOSI Register

Diabetes is an increasing global health burden with the highest prevalence (24.0%) observed in elderly people. Older diabetic adults have a greater risk of hospitalization and several geriatric syndromes than older nondiabetic adults. For these conditions, special care is required in prescribing therapies including anti- diabetes drugs. Aim of this study was to evaluate the appropriateness and the adherence to safety recommendations in the prescriptions of glucose-lowering drugs in hospitalized elderly patients with diabetes. Data for this cross-sectional study were obtained from the REgistro POliterapie-Società Italiana Medicina Interna (REPOSI) that collected clinical information on patients aged ≥ 65 years acutely admitted to Italian internal medicine and geriatric non-intensive care units (ICU) from 2010 up to 2019. Prescription appropriateness was assessed according to the 2019 AGS Beers Criteria and anti-diabetes drug data sheets.Among 5349 patients, 1624 (30.3%) had diagnosis of type 2 diabetes. At admission, 37.7% of diabetic patients received treatment with metformin, 37.3% insulin therapy, 16.4% sulfonylureas, and 11.4% glinides. Surprisingly, only 3.1% of diabetic patients were treated with new classes of anti- diabetes drugs. According to prescription criteria, at admission 15.4% of patients treated with metformin and 2.6% with sulfonylureas received inappropriately these treatments. At discharge, the inappropriateness of metformin therapy decreased (10.2%, P < 0.0001). According to Beers criteria, the inappropriate prescriptions of sulfonylureas raised to 29% both at admission and at discharge. This study shows a poor adherence to current guidelines on diabetes management in hospitalized elderly people with a high prevalence of inappropriate use of sulfonylureas according to the Beers criteria

Antidiabetic Drug Prescription Pattern in Hospitalized Older Patients with Diabetes

Objective: To describe the prescription pattern of antidiabetic and cardiovascular drugs in a cohort of hospitalized older patients with diabetes. Methods: Patients with diabetes aged 65 years or older hospitalized in internal medicine and/or geriatric wards throughout Italy and enrolled in the REPOSI (REgistro POliterapuie SIMI—Società Italiana di Medicina Interna) registry from 2010 to 2019 and discharged alive were included. Results: Among 1703 patients with diabetes, 1433 (84.2%) were on treatment with at least one antidiabetic drug at hospital admission, mainly prescribed as monotherapy with insulin (28.3%) or metformin (19.2%). The proportion of treated patients decreased at discharge (N = 1309, 76.9%), with a significant reduction over time. Among those prescribed, the proportion of those with insulin alone increased over time (p = 0.0066), while the proportion of those prescribed sulfonylureas decreased (p < 0.0001). Among patients receiving antidiabetic therapy at discharge, 1063 (81.2%) were also prescribed cardiovascular drugs, mainly with an antihypertensive drug alone or in combination (N = 777, 73.1%). Conclusion: The management of older patients with diabetes in a hospital setting is often sub-optimal, as shown by the increasing trend in insulin at discharge, even if an overall improvement has been highlighted by the prevalent decrease in sulfonylureas prescription

The “Diabetes Comorbidome”: A Different Way for Health Professionals to Approach the Comorbidity Burden of Diabetes

(1) Background: The disease burden related to diabetes is increasing greatly, particularly in older subjects. A more comprehensive approach towards the assessment and management of diabetes’ comorbidities is necessary. The aim of this study was to implement our previous data identifying and representing the prevalence of the comorbidities, their association with mortality, and the strength of their relationship in hospitalized elderly patients with diabetes, developing, at the same time, a new graphic representation model of the comorbidome called “Diabetes Comorbidome”. (2) Methods: Data were collected from the RePoSi register. Comorbidities, socio-demographic data, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), and functional status (Barthel Index), were recorded. Mortality rates were assessed in hospital and 3 and 12 months after discharge. (3) Results: Of the 4714 hospitalized elderly patients, 1378 had diabetes. The comorbidities distribution showed that arterial hypertension (57.1%), ischemic heart disease (31.4%), chronic renal failure (28.8%), atrial fibrillation (25.6%), and COPD (22.7%), were the more frequent in subjects with diabetes. The graphic comorbidome showed that the strongest predictors of death at in hospital and at the 3-month follow-up were dementia and cancer. At the 1-year follow-up, cancer was the first comorbidity independently associated with mortality. (4) Conclusions: The “Diabetes Comorbidome” represents the perfect instrument for determining the prevalence of comorbidities and the strength of their relationship with risk of death, as well as the need for an effective treatment for improving clinical outcomes

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Influence of stress on wild Marsican brown bear chemical immobilization.

Capture of wild bears with leg holding snares causes fear, anxiety, excitement, muscular activity and resistance to holding which in turn elicit in an acute stress response: neuro-hormonal responses are then activated, but these may interfere with anaesthetics efficacy and safety. Hormonal and physiological parameters have been used to evaluate stress level in bears after chemical immobilization; to our knowledge however, behavioral indicators prior to drug injection have never been used to evaluate it. The aim of this study was to evaluate if stress induced using Aldrich snare\u2019s restraint influenced anesthetics requirements for chemical immobilization and physiological parameters. Data sheets collected during 43 adult Marsican brown bear (Ursus arctos marsicanus) captures (27 males and 16 females) in the Abruzzo, Lazio and Molise National Park (Italy) were reviewed. Before chemical immobilization, a stress score (0 - 4) was assigned to each bear by an experienced veterinarian (LG) based on the behavioral reactions to leg-holding snare entrapment. A medetomidine-ketamine combination was administered intramuscularly by remote injection: supplemental doses were injected until a safe approach to the animal was possible. Dose used, induction time (time from injection to recumbency), approach time (time from injection to safe handling) and physiological parameters collected within 15 \ub1 5 minutes of chemical immobilization were analyzed by Spearmann correlation test. Stress score showed a positive correlation with the total dose of medetomidine (r=0.0030) and ketamine used (r=0.0008): more stressed bears required greater dosages then less stressed animals. Stress score positively correlated with rectal temperature (r=0.015) and heart rate (r=0.044). Time to approach was correlated to stress only in female, not in male bears. Other slight differences were observed between male and female bears. This is the first study evaluating the level of stress induced by physical restraint in Marsican brown bears and it showed that stress influenced not only physiological parameters but also anaesthetics needs, thus the anaesthetic protocol should be tailored to the bear\u2019s stress state

Management of chemical immobilization of brown bear (Ursus arctos) in the Abruzzo, Lazio and Molise National Park on 235 cases from 1990 to 2013.

235 chemical immobilizations, 44 on captive and wild brown bears (Ursus arctos, n=5) and 171 on Marsican brown bears (Ursus arctos marsicanus, n=44) were recorded. Age and body weight (mean \ub1 standard deviation) of captured animals was 9.81\ub16.28 years and 149.25\ub162.29 kg and 9.68\ub16.15 years and 147.54\ub160.71 kg in brown bear and Marsican brown bears respectively. The following anesthetic combinations were injected intramuscular by a remote equipment: medetomidine 0.05-0.09 mg/kg and ketamine 3-7 mg/kg (group MK: n=209); xylazine 7-13 mg/kg and ketamine 3-8 mg/kg (group XK: n=17); tiletamine-zolazepam 4-8 mg/kg (group TZ: n=9). In MK and XK groups, atipamezol was administered at the end of the procedure. Bears were darted after physical restraint (Aldrich snares or tube trap) or in free ranging situations. Complete anesthetic record, including heart rate (HR), respiratory rate (RR), rectal body temperature (T) and saturimetry (SpO2), and biometric data form were filled in. The first physiologic parameters were recorded within 20 minutes from darting, as soon as adequate depth of anesthesia allowed safe handling of the animal, and were compared between groups with ANOVA test. Statistical significance was set at P<0.05. Anaesthesia induction time was similar between groups and ranged from 7 to 11minutes. HR was similar in groups MK and XK but higher in TZ group; HR was higher in wild than captive bears. RR was similar between groups. Recovery time was shorter in MK and XK than TZ group. Peri-operative complications were reported in 16/235 immobilizations and included vomiting and respiratory complications: 7,1%, 5% and 0% of complications were reported in group MK, XK and TZ respectively. All recoveries were uneventful. Knowledge of the target species biology, trained personnel, deep knowledge of advantages and disadvantages anesthetic drugs is mandatory during wildlife chemical immobilization

Influence of age, sex, season and living conditions on body weight in Marsican brown bear (Ursus arctos marsicanus) captured in Abruzzo, Lazio and Molise National Park.

The aim of this work is to define the physiological range of body weight in the Mariscan brown bear population in wild and captive living conditions. Data were extrapolated from selected anesthetic records collected during bear captures in the Abruzzo Lazio and Molise National Park from 1990 to 2013. Forty-four Marsican bears were chemically immobilized on 171 occasions and body weight recorded, for individual marking or for ecologic, genetic, and health reasons. Values were obtained from animals captured in wild (n=83) and captive situations (n=88). Weight data were analyzed by a linear model including the effects of class of age, sex, wild or captive environment and their interactions. The effects of period of the year and sex on body weight and their interactions were also analyzed by ANOVA tests. Statistical significance was set at P<0.05. Mean body weight was influenced by age class and sex. From juvenile and subadult age, weight gain is similar in both males and females; older male bears resulted heavier than females and this difference is statistically significant for both adult and mature age groups. Moreover, a significant difference in weight (least squares means\ub1standard error) was observed in captive adult males (188.41\ub16.04 kg, n=14) compared to wild adult males (157.89\ub13.99 kg, n= 32), but not in adult females. In adults, body weight was influenced by seasonality. Female animals constantly increased their weight from post-hibernation to pre-hibernation period (mean weight gain 7%); males showed a weight loss during the reproductive period (-8%, P<0.05) and a significant weight gain after this period of time (13%). During all the period of time, from the post-hibernation, females have a increase of their initial weight of 23%, males of 16%. In conclusion, in Marsican bears body weight depends on age, sex, seasonality and living conditions