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Steatosi epatica non alcolica e diabete mellito tipo 2: studio dell'associazione tra grado di steatosi, fattori metabolici e alterazioni vascolari
Full text linkNAFLD (non alcoholic fatty liver disease) is defined by the presence of hepatic steatosis not associated with a significant alcohol intake nor to the assumption of specific drugs. It is frequently associated with diabetes, obesity and metabolic syndrome. Many authors support the concept that NAFLD is the hepatic manifestation of the metabolic syndrome, and that the insulin-resistance is the common soil in the pathogenesis. Although the natural history of this disease seems to be benign, an evolution toward steatohepatitis and cirrhosis, and a link between NAFLD and cardiovascular (clinical and subclinical) diseases, have been demonstrated. The objectives of this research were to evaluate prevalence and degree of steatosis in patients with type 2 diabetes and the metabolic syndrome (defined by ATP III criteria); to search for metabolic factors which are predictive for the degree of steatosis, and to evaluate the possible link between hepatic steatosis and anatomic vasculopathy (intima-media thickness – IMT and carotid plaques) and endothelial function (flow mediated dilation - FMD).
An observational study was performed among 60 type 2 diabetic patients (M/F 25/35) with metabolic syndrome afferent to our Diabetes Center. Steatosis was evaluated by means of semi-quantitative ecography (4 grades) as well as by an “objective quantitative” method based on the determination of liver/kidney ratio (6 grades). The presence of carotid plaques and the IMT measurement were evaluated by means of ecocolordoppler of the supra-aortic arteries. The endothelial function was evaluated by means of ecography as the vasodilatation induced by ischemia in the brachial artery (FMD). We measured anthropometric variables (body mass index, waist circumference), metabolic parameters (lipids, HbA1c, HOMA), inflammation markers
(hs-PCR, IL-6, TNFα), thrombogenic factors (fibrinogen) and an adipokine (leptin). We applied a statistical program (Ordered Probit) to evaluated the probability to predict the degree of steatosis by the combination of metabolic parameters. The prevalence of steatosis was 88% (33% mild steatosis, 33% moderate e 22% severe). IMT was 0.88 ± 0.23mm; 63% of patients had carotid plaques. FMD (calculated in 45 patients) was reduced with respect to normal values (5.02 ± 1.81%). We demonstrated a correlation between the degree of steatosis and BMI, waist, the number of metabolic syndrome’s factors, sex, diastolic pressure, insulinemia, HOMA, Hb1Ac, HDL-cholesterol (inverse), hs-PCR, fibrinogen, leptin. We didn’t demonstrate any correlation between steatosis, and medium and maximum IMT, the presence of carotid plaques and FMD. With multiple regression analysis HOMA and BMI levels were indipendent factors which predict hepatic steatosis (p 0.033). Using the combination of HbA1c, waist and insulinemia, a prediction of the exact grade of steatosis (± one steatosis grade) (evaluated by ecography) was obtained in 96.5% of cases. This study confirms that, in this population of diabetic patients with metabolic myndrome, NAFLD can be considered the hepatic manifestation of the syndrome since it correlates with HOMA and obesity. A high prevalence of increased IMT and of presence of carotid plaques, as well as a reduced FMD compared to general population, are also demonstrated, although they are not apparently linked with steatosis.La steatosi epatica non alcolica (NAFLD) si definisce come la presenza di steatosi epatica in soggetti con modesto o assente consumo di alcol e mancata assunzione/esposizione a determinati farmaci o sostanze; è frequentemente associata al diabete, all’obesità e alla sindrome metabolica, tanto da essere considerata da molti autori come la manifestazione epatica della sindrome metabolica, avendo come fattore patogenetico comune l’insulino-resistenza. La storia naturale della NAFLD sembra benigna anche se può evolvere in steatoepatite e in cirrosi ed è stata dimostrata una correlazione tra NAFLD e patologie cardiovascolari (cliniche e subcliniche). Lo scopo dello studio è stato di valutare la prevalenza ed il grado di steatosi epatica in un gruppo di pazienti affetti da diabete mellito tipo 2 e sindrome metabolica (definita in base ai criteri dell’ATP III), di ricercare i fattori metabolici predittivi del grado di steatosi e di valutare l’eventuale relazione esistente tra steatosi epatica e vasculopatia anatomica (spessore medio-intimale carotideo [IMT] e placche carotidee) e funzionale (dilatazione flusso mediata [FMD]).
E’ stato eseguito uno studio osservazionale su 60 pazienti (M/F 25/35) affetti da diabete mellito di tipo 2 e sindrome metabolica afferenti al nostro servizio di Diabetologia. La presenza di steatosi è stata valutata mediante ultrasonografia sia con metodica soggettiva semiquantitativa (4 gradi) sia con metodica oggettiva quantitativa mediante la determinazione del rapporto fegato/rene (6 gradi). La ricerca di placche aterosclerotiche carotidee e la misurazione dell’IMT sono stati eseguiti con ecocolordoppler dei tronchi sovraaortici; la funzione endoteliale è stata valutata mediante ultrasonografia con valutazione della vasodilatazione indotta dall’ischemia a
livello dell’arteria brachiale (FMD). Sono stati misurati i parametri antropometrici (indice di massa corporea e circonferenza addominale), metabolici (assetto lipidico, HbA1c, HOMA), citochine infiammatorie (hs-PCR, IL-6, TNFα), fattori trombogenici (fibrinogeno) e adipochine (leptina). E’ stato utilizzato inoltre un programma statistico (Ordered Probit) in cui associando alcuni parametri metabolici viene predetta la probabilità del soggetto di appartenere ad una determinata classe di steatosi. La prevalenza di steatosi è risultata dell’88% (33% steatosi lieve, 33% moderata e 22% grave); l’IMT medio pari a 0.88 ± 0.23 mm; il 63% dei pazienti presentavano placche carotidee; l’FMD (calcolato su 45 pazienti) è risultato ridotto e pari a 5.02 ± 1.81%. Dividendo i pazienti per classi di steatosi abbiamo evidenziato una correlazione tra steatosi e BMI, circonferenza addominale, numero dei fattori della sindrome metabolica, sesso, pressione diastolica, insulinemia, HOMA, HbA1c, colesterolo-HDL (inversa), hs-PCR, fibrinogeno e log leptinemia. Non abbiamo dimostrato invece alcuna correlazione tra grado di steatosi e IMT medio o massimo, presenza di placche aterosclerotiche e valore di FMD. Con il modello di regressione multipla HOMA e waist sono risultati fattori indipendenti che influenzano il grado di steatosi epatica (p 0.033). Associando HbA1c, waist, insulinemia il modello statistico Ordered Probit mi predice il grado esatto o con un errore di un grado di steatosi soggettiva (valutato all’ecografia) nel 96,5% dei casi.
Questo studio conferma che nei nostri pazienti diabetici con sindrome metabolica la NAFLD correla strettamente con obesità e insulino-resistenza, può essere quindi considerata la manifestazione epatica della sindrome metabolica. E’ stata dimostrata un’elevata prevalenza di aumentato IMT e di placche carotidee, così come di riduzione dell’FMD rispetto alla popolazione generale, sebbene non sembra esservi correlazione con la steatosi epatica
Decreased Homocysteine Trans-Sulfuration in Hypertension With Hyperhomocysteinemia: Relationship With Insulin Resistance
No full textHomocysteine is an independent cardiovascular risk factor and is elevated in essential hypertension. Insulin stimulates homocysteine catabolism in healthy individuals. However, the mechanisms of hyperhomocysteinemia and its relationship with insulin resistance in essential hypertension are unknown
Quality of care to institutionalized patients with diabetes in Italy: a national survey
No full textPurpose: To evaluate the epidemiology of diabetes and quality of care of institutionalized patients with diabetes in Italian nursing homes. More specifically, to evaluate the adherence to the national/international guidelines for the management of older people with diabetes. Methods: Data related to the epidemiology of diabetes and the quality of care were collected from questionnaires sent to 41 nursing homes. Data were extracted from papers, electronic medical records and validated operating protocols regulating the management of patients with diabetes in various homes. Completed questionnaires were returned in electronic format and centrally processed. Results: Out of 4692 residents, 906 (19.3%) had diabetes. Among these residents, excluding patients undergoing diet treatment, more than half were on insulin treatment (alone or in combination with oral antidiabetic agents). The critical findings can be summarized as follows: a lack of shared diagnostic-therapeutic protocols, specifically related to evaluation of frailty; the preparation of nutritional and physical activity plans; the clarification of the objectives of the treatment; the timing of insulin administration (frequent use of sliding scale); the frequency and timing of capillary blood glucose; metabolic control methods; hypoglycemia and hyperglycemia treatment; and the scant use of new drugs that do not cause hypoglycemia. Conclusion: Our data revealed substantial heterogeneity in the treatment of nursing home residents with diabetes in Italy with many discrepancies between what is recommended in the guidelines and real-world practice. The implementation of local diagnostic-therapeutic protocols shared by all caregivers should be encouraged and properly funded to overcome communication problems between doctors and nurses and eventually improve the quality of care for institutionalized patients with diabetes
Microangiopathy is independently associated with presence, severity and composition of carotid atherosclerosis in type 2 diabetes.
No full textBACKGROUND AND AIMS:
Common mechanisms for the development of micro- and macroangiopathic diabetic complications have been suggested. We aimed to cross-sectionally investigate strength and characteristics of the association between carotid atherosclerosis and microangiopathy in type 2 diabetic patients.
METHODS AND RESULTS:
Common carotid artery intima-media thickness (cIMT), carotid plaque (CP) type and degree of stenosis were evaluated by ultrasound, along with the determination of anthropometric parameters, HbA1c, lipid profile, assessment of diabetic retinopathy and nephropathy, in 662 consecutive patients with type 2 diabetes mellitus (T2DM). Patients were divided according to high/low cIMT, presence/absence of CP and of retinopathy and nephropathy. Patients with CP were older, more prevalently males, past smokers, had longer diabetes duration, significantly lower HDL cholesterol and more prevalent ischemic heart disease (all p<0.05) as compared to those with cIMT < 1 mm. Microangiopathies were more prevalent in patients with CP than in those without. At multivariate logistic regression, factors independently associated with the presence of CP were age, past smoke, HDL cholesterol, retinopathy and retinopathy plus nephropathy. A significant independent correlation of CP stenosis with stage of retinopathy and nephropathy was found. Finally, echolucent CPs were associated with a lower prevalence of proliferative retinopathy than CP containing calcium deposits.
CONCLUSION:
In T2DM, retinopathy, alone or in combination with nephropathy, is independently associated to CP, and severity of microangiopathy correlates with severity of carotid atherosclerosis. These observations, together with the different prevalence of proliferative retinopathy according to CP types, point to possible common pathogenic mechanisms in micro- and macrovascular complications
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
No association between the degree of liver steatosis and early signs of vasculopathy in T2DM.
Full text linkNon alcoholic fatty liver disease (NAFLD) is both an independent and an associated risk factor for cardiovascular (CV) disease in the general population [1]. Whereas the association between NAFLD, and early signs of vasculopathy, such as an increased intima-media thickness (IMT) and a decreased flow-mediated vasodilation (FMD), has been reported in the general population, such an association in type 2 diabetes mellitus (T2DM) is controversial. In T2DM patients with NAFLD FMD was decreased [2], whereas IMT was not different, with respect to patients without liver steatosis [3]. Should a (causative) relationship between hepatic steatosis and early signs of vasculopathy exists, the degree of liver fat should be associated with a worse endothelial function and morphology. However, despite the bulk of data generated on this complex association, insufficient reports exist on T2DM.
To this aim, we measured the extent of liver fat, average IMT, the presence and type of carotid plaques, and FMD, in sixty consecutive T2DM patients largely affected by features of the MS. Liver steatosis, IMT, and presence and types of carotid plaques, were evaluated by ultrasonography (using an HDI 5000 Philips Medical Systems apparatus, Bothell, WA, USA), with a broad-band width phased array transducer (2–5 MHz). Steatosis was divided into four classes following the traditional US classification (class 0: absence; classes 1–3: increasing degrees, of steatosis) [4]. IMT was assessed using standard procedures [5]. FMD was evaluated in 45 patients using an internationally validated approach [6]. Only six patients were current smokers, and seven had a positive history for CV disease (five for ischemic heart disease, and two for cerebrovascular disease). No subject was positive for hepatitis C virus infection.
The overall prevalence of steatosis was 88% (34% mild, 34% moderate e 20% severe). Average IMT was 0.88 ± 0.03 mm (Mean ± SE), significantly greater (p < 0.0001) than the mean value of a healthy, age- and sex matched population at our Institution (0.72 ± 0.03 mm). Fifty-eight percent of patients had carotid plaques. Average FMD in the patients (5.02 ± 0.81%) was lower (p < 0.001) than the normal values of healthy, age- and sex matched individuals from our Institution (6.56 ± 0.60%). Nevertheless, there was no difference, among the four classes of steatosis, in either FMD (class 0: 5.10 ± 0.89%; class 1: 4.97 ± 0.46%; class 2: 4.73 ± 0.40%; class 3: 5.25 ± 0.17%) (p = 0.543 by ANOVA), average IMT (0.82 ± 0.08; 0.93 ± 0.05; 0.85 ± 0.05; and 0.85 ± 0.06 mm, respectively; p = 0.760 by ANOVA), or the prevalence of carotid plaques (43; 70; 60 and 69% respectively, p = 0.644).
In conclusion, in T2DM patients largely exhibiting features of the MS, the degree of liver steatosis is not associated with early signs of (sub)clinical atherosclerosis and altered vascular function. These data question the role of liver fat as a direct determinant of early signs of vasculopathy in T2DM. Alternatively, it is possible that the burden of cardiovascular risk factors already present in these T2DM patients, obscure the possible contribution given by the degree of steatosis, on early signs of arteriosclerosis
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Dispelling the Myths Behind First-author Citation Counts
Full text linkWe conducted a full-scale evaluative citation analysis study of scholars in the XML research field to explore just how different from each other author rankings resulting from different citation counting methods actually are, and to demonstrate the capability of emerging data and tools on the Web in supporting more realistic citation counting methods. Our results contest some common arguments for the continued
use of first-author citation counts in the evaluation of scholars, such as high correlations between author rankings by first-author citation counts and other citation
counting methods, and high costs of using more realistic citation counting methods that are not well-supported by the ISI databases. It is argued that increasingly available digital full text research papers make it possible for citation analysis studies to go beyond what the ISI databases have directly supported and to employ more
sophisticated methods
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