Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: A narrative literature review

Diabetes mellitus is a chronic disease characterized by high social, economic and health burden, mostly due to the high incidence and morbidity of diabetes complications. Numerous studies have shown that optimizing metabolic control may reduce the risk of micro and macrovascular complications related to the disease, and the algorithms suggest that an appropriate and timely step of care intensification should be proposed after 3 months from the failure to achieve metabolic goals. Nonetheless, many population studies show that glycemic control in diabetic patients is often inadequate. The phenomenon of clinical inertia in diabetology, defined as the failure to start a therapy or its intensification/de-intensification when appropriate, has been studied for almost 20 years, and it is not limited to diabetes care, but also affects other specialties. In the present manuscript, we have documented the issue of inertia in its complexity, assessing its dimensions, its epidemiological weight, and its burden over the effectiveness of care. Our main goal is the identification of the causes of clinical inertia in diabetology, and the quantification of its social and health-related consequences through the adoption of appropriate indicators, in an effort to advance possible solutions and proposals to fight and possibly overcome clinical inertia, thus improving health outcomes and quality of care

Early Detection of Microvascular Changes in Patients with Diabetes Mellitus without and with Diabetic Retinopathy: Comparison between Different Swept-Source OCT-A Instruments

Optical coherence tomography angiography (OCT-A) has recently improved the ability to detect subclinical and early clinically visible microvascular changes occurring in patients with diabetes mellitus (DM). The aim of the present study is to evaluate and compare early quantitative changes of macular perfusion parameters in patients with DM without DR and with mild nonproliferative DR (NPDR) evaluated by two different swept-source (SS) OCT-A instruments using two scan protocols (3 73 mm and 6 76 mm). One hundred eleven subjects/eyes were prospectively evaluated: 18 healthy controls (control group), 73 eyes with DM but no DR (no-DR group), and 20 eyes with mild NPDR (DR group). All quantitative analyses were performed using ImageJ and included vessel and perfusion density, area and circularity index of the FAZ, and vascular complexity parameters. The agreement between methods was assessed according to the method of Bland-Altman. A significant decrease in the majority of the considered parameters was found in the DR group versus the controls with both instruments. The results of Bland-Altman analysis showed the presence of a systemic bias between the two instruments with PLEX Elite providing higher values for the majority of the tested parameters when considering 6 76 mm angiocubes and a less definite difference in 3 73 mm angiocubes. In conclusion, this study documents early microvascular changes occurring in the macular region of patients at initial stages of DR, confirmed with both SS OCT-A instruments. The fact that early microvascular alterations could not be detected with one instrument does not necessarily mean that these alterations are not actually present, but this could be an intrinsic limitation of the device itself. Further, larger longitudinal studies are needed to better understand microvascular damage at very early stages of diabetic retinal disease and to define the strengths and weaknesses of different OCT-A devices

An integrated care pathway for cancer patients with diabetes: A proposal from the Italian experience

Diabetes and cancer frequently coexist in the same subject, often with relevant clinical effects on the management and prognosis of the comorbid patient. The existing guidelines, however, do not appropriately address many clinical issues in this setting. Although collaboration between diabetologists and oncologists should play an important role in achieving appropriate levels of care, close coordination or agreement between these specialists is seldom offered. There is an urgent need for greater interdisciplinary integration between all specialists involved in this setting, for a shared approach ensuring that organisational silos are overcome. To this end, the Italian Associations of Medical Diabetologists (AMD) and the Italian Association of Medical Oncology (AIOM) recently established a dedicated Working Group on 'Diabetes and Cancer'. The working group outlined a diagnostic and therapeutic clinical pathway dedicated to hospitalised patients with diabetes and cancer. In this article, we describe the Italian proposal including some suggested measures to assess, monitor and improve blood glucose control in the hospital setting, to integrate different specialists from both areas, as well as to ensure discharge planning and continuity of care from the hospital to the territory

Portal vein thrombosis following laparoscopic cholecystectomy complicated by dengue viral infection: a case report

<p>Abstract</p> <p>Introduction</p> <p>Portal vein thrombosis is an uncommon post-operative complication following abdominal surgery. Although therapeutic anticoagulation is recommended, this treatment may be questionable when the patient has an associated bleeding diathesis.</p> <p>Case presentation</p> <p>We report a case of a 63-year-old woman of Asian Indian ethnicity who developed portal vein thrombosis following an uneventful laparoscopic cholecystectomy for symptomatic gallstones. Her condition was further complicated by dengue viral infection in the post-operative period, with thrombocytopenia immediately preceding the diagnosis of portal vein thrombosis. The etiological connections between dengue viral infection with thrombocytopenia, laparoscopic cholecystectomy, portal vein thrombosis as well as the treatment dilemmas posed in treating a patient with portal vein thrombosis with a bleeding diathesis are discussed.</p> <p>Conclusion</p> <p>When portal vein thrombosis occurs in patients with contraindications to anticoagulation, there is a role for initial conservative management without aggressive anticoagulation therapy and such patients must be approached on an individualized basis.</p

Trans-arterial radioembolization for intermediate-advanced hepatocellular carcinoma: a budget impact analysis

Background: Trans-arterial radio-embolization (TARE) is an emerging treatment for the management of hepatocellular carcinoma (HCC). TARE may compete with systemic chemotherapy, sorafenib, in intermediate stage patients with prior chemoembolization failure or advanced patients with tumoral macrovascular invasion with no extra-hepatic spread and good liver function. We performed a budget impact analysis (BIA) evaluating the expected changes in the expenditure for the Italian Healthcare Service within scenarios of increased utilization of TARE in place of sorafenib over the next five years. Methods: Starting from patient level data from three oncology centres in Italy, a Markov model was developed to project on a lifetime horizon survivals and costs associated to matched cohorts of intermediate-advanced HCC patients treated with TARE or sorafenib. The initial model has been integrated with epidemiological data to perform a BIA comparing the current scenario with 20 and 80% utilization rates for TARE and sorafenib, respectively, with increasing utilization rates of TARE of 30, 40 and 50% over the next 1, 3 and 5 years. Results: Compared to the current scenario, progressively increasing utilization rates of TARE over sorafenib in the next 5 years is expected to save globally about 7 million Euros. Conclusions: Radioembolization can be considered a valuable treatment option for patients with intermediate-advanced HCC. These findings enrich the evidence about the economic sustainability of TARE in comparison to standard systemic chemotherapy within the context of a national healthcare servic

Tc-99m labelled bone scintigraphy in suspected cardiac amyloidosis

Aims: To perform evaluation of widely embraced bone scintigraphy-based non-biopsy diagnostic criteria (NBDC) for ATTR amyloid cardiomyopathy (ATTR-CM) in clinical practice, and to refine serum free light chain (sFLC) ratio cut-offs that reliably exclude monoclonal gammopathy (MG) in chronic kidney disease. Methods and results: A multi-national retrospective study of 3354 patients with suspected or histologically proven cardiac amyloidosis (CA) referred to specialist centres from 2015 to 2021; evaluations included radionuclide bone scintigraphy, serum and urine immunofixation, sFLC assay, eGFR measurement and echocardiography. Seventy-nine percent (1636/2080) of patients with Perugini grade 2 or 3 radionuclide scans fulfilled NBDC for ATTR-CM through absence of a serum or urine monoclonal protein on immunofixation together with a sFLC ratio falling within revised cut-offs incorporating eGFR; 403 of these patients had amyloid on biopsy, all of which were ATTR type, and their survival was comparable to non-biopsied ATTR-CM patients (p = 0.10). Grade 0 radionuclide scans were present in 1091 patients, of whom 284 (26%) had CA, confirmed as AL type (AL-CA) in 276 (97%) and as ATTR-CM in only one case with an extremely rare TTR variant. Among 183 patients with grade 1 radionuclide scans, 122 had MG of whom 106 (87%) had AL-CA; 60/61 (98%) without MG had ATTR-CM. Conclusion: The NBDC for ATTR-CM are highly specific [97% (95% CI 0.91-0.99)] in clinical setting, and diagnostic performance was further refined here using new cut-offs for sFLC ratio in patients with CKD. A grade 0 radionuclide scan all but excludes ATTR-CM but occurs in most patients with AL-CA. Grade 1 scans in patients with CA and no MG are strongly suggestive of early ATTR-type, but require urgent histologic corroboration

Early-stage rifting of the northern Tyrrhenian Sea Basin: Results from a combined wide-angle and multichannel seismic study

Extension of the continental lithosphere leads to the formation of rift basins and ultimately may create passive continental margins. The mechanisms that operate during the early stage of crustal extension are still intensely debated. We present the results from coincident multichannel seismic and wide-angle seismic profiles that transect across the northern Tyrrhenian Sea Basin. The profiles cross the Corsica Basin (France) to the Latium Margin (Italy) where the early-rift stage of the basin is well preserved. We found two domains, each with a distinct tectonic style, heat flow and crustal thickness. One domain is the Corsica Basin in the west that formed before the main rift phase of the northern Tyrrhenian Sea opening (∼8–4 Ma). The second domain is rifted continental crust characterized by tilted blocks and half-graben structures in the central region and at the Latium Margin. These two domains are separated by a deep (∼10 km) sedimentary complex of the eastern portion of the Corsica Basin. Travel-time tomography of wide-angle seismic data reveals the crustal architecture and a subhorizontal 15–17 ± 1 km deep Moho discontinuity under the basin. To estimate the amount of horizontal extension we have identified the pre-, syn-, and post-tectonic sedimentary units and calculated the relative displacement of faults. We found that major faults initiated at angles of 45°–50° and that the rifted domain is horizontally stretched by a factor of β ∼ 1.3 (∼8–10 mm/a). The crust has been thinned from ∼24 to ∼17 km indicating a similar amount of extension (∼30%). The transect represents one of the best imaged early rifts and implies that the formation of crustal-scale detachments, or long-lived low-angle normal faults, is not a general feature that controls the rift initiation of continental crust. Other young rift basins, like the Gulf of Corinth, the Suez Rift or Lake Baikal, display features resembling the northern Tyrrhenian Basin, suggesting that half-graben formations and distributed homogeneous crustal thinning are a common feature during rift initiation