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Recommendations and management of hyperglycaemia in pregnancy during COVID-19 pandemic in Italy.
Torlone, E, Sculli, MA, Bonomo, M, Di Benedetto, A, Di Cianni, G, Festa, C, Formoso, G, Lapolla, A, Mannino, D, Napoli, A, et al
Diabetes research and clinical practice. 2020;:108345
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Abstract
Many specialists use the remote management of people with chronic disease as diabetes, but structured management protocols have not been developed yet. The COVID-19 pandemic has given a big boost to the use of telemedicine, as it allows to maintain the physical distance, essential to the containment of contagion having regular health contact. Encouraging results related to the use of telemedicine in women with hyperglycaemia in pregnancy, have been recently published. It is well known that hyperglycaemia alters the immune response to infections, that inflammation, in turn, worsens glycaemic control and that any form of hyperglycaemia in pregnancy (HIP) has effects not only on the mother but also on development of the foetus. Therefore, the Italian Diabetes and Pregnancy Study Group, together with a group of experts, developed these recommendations in order to guide physicians in the management of HIP, providing specific diagnostic, therapeutic and assistance pathways (PDTAs) for the COVID-19 emergency. Three detailed PDTAs were developed, for type 1, type 2 and gestational diabetes.
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Glucose homeostasis, nutrition and infections during critical illness.
Ingels, C, Vanhorebeek, I, Van den Berghe, G
Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2018;(1):10-15
Abstract
Critical illness is a complex life-threatening disease characterized by profound endocrine and metabolic alterations and by a dysregulated immune response, together contributing to the susceptibility for nosocomial infections and sepsis. Hitherto, two metabolic strategies have been shown to reduce nosocomial infections in the critically ill, namely tight blood glucose control and early macronutrient restriction. Hyperglycaemia, as part of the endocrine-metabolic responses to stress, is present in virtually all critically ill patients and is associated with poor outcome. Maintaining normoglycaemia with intensive insulin therapy has been shown to reduce morbidity and mortality, by prevention of vital organ dysfunction and prevention of new severe infections. The favourable effects of this intervention were attributed to the avoidance of glucose toxicity and mitochondrial damage in cells of vital organs and in immune cells. Hyperglycaemia was shown to impair macrophage phagocytosis and oxidative burst capacity, which could be restored by targeting normoglycaemia. An anti-inflammatory effect of insulin may have contributed to prevention of collateral damage to host tissues. Not using parenteral nutrition during the first week in intensive care units, and so accepting a large macronutrient deficit, also resulted in fewer secondary infections, less weakness and accelerated recovery. This was at least partially explained by a suppressive effect of early parenteral nutrition on autophagic processes, which may have jeopardized crucial antimicrobial defences and cell damage removal. The beneficial impact of these two metabolic strategies has opened a new field of research that will allow us to improve the understanding of the determinants of nosocomial infections, sepsis and organ failure in the critically ill.
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Insulin resistance - "the good or the bad and ugly".
Szosland, K, Lewinski, A
Neuro endocrinology letters. 2018;(5):355-362
Abstract
Insulin resistance (IR) is a state of decreased sensitivity or responsiveness of target tissues to metabolic actions of circulating insulin. IR can be selective, involving only certain aspects of insulin action, i.e. only its impact on hepatic glucose disposal. Plasma insulin concentration is a continuous variable, dependent upon several physiological stimuli, thus the thresholds used to diagnose IR are arbitrary. Insulin resistance (impaired insulin action) may occur due to derangements on three levels: pre-receptor (antibodies against insulin, defected insulin molecule), receptor (defects of insulin receptor, anti-receptor antibodies) and post-receptor (disregulated intracellular pathways). The aim of the study has been promoting the opinion that IR itself cannot be considered only a harmful phenomenon. Detrimental effect is rather chronic hyperinsulinemia related to IR. IR appears important physiological mechanism responsible for adaptation to various stresses: physical, as well as emotional/physiological. Diurnal, seasonal, age-related, pregnancy-associated, and illness-induced fluctuations in food intake and energy expenditure necessitate homeostatic versatility, including the capacity to vary insulin sensitivity, so as to optimize partitioning between tissues of a variable nutrient supply. IR has positively been selected during evolution for the short-lived energy-consuming activation of the brain or immune system. Physiologic situations that require organisms to reserve priority nutrient access for an emerging metabolic requirement, for example immune system activation or foetal development, promote the decrease of systemic insulin sensitivity, reducing nutrient uptake by non-priority tissues and reserving glucose for priority cells. It has been suggested that IR is a mechanism of antioxidant defence in conditions of nutrient energy excess.
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DIABETIC KETOACIDOSIS: A COMMON DEBUT OF DIABETES AMONG AFRICAN AMERICANS WITH TYPE 2 DIABETES.
Vellanki, P, Umpierrez, GE
Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2017;(8):971-978
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Abstract
OBJECTIVE More than half of African Americans (AA) with a new diagnosis of diabetic ketoacidosis have clinical and metabolic features of type 2 diabetes during follow-up. This particular presentation of diabetes has been termed as ketosis-prone type 2 diabetes (KPDM) or atypical diabetes. METHODS We review the epidemiology, diagnosis, pathophysiology, and acute and long-term management of AA with KPDM and compare these similarities to patients with type 2 diabetes. RESULTS In contrast to the long-term insulin requirement of auto-immune type 1 diabetes, patients with KPDM are able to discontinue insulin after a few months of therapy and maintain acceptable glycemic control for many years on either diet or oral agents. Patients with KPDM have significant impairment of both insulin secretion and insulin action at presentation; however, at the time of near-normoglycemia remission, insulin secretion and action improve to levels similar to hyperglycemic patients with ketosis-resistant type 2 diabetes. In the long term, however, patients with KPDM have a decline in β-cell function similar to patients with type 2 diabetes. Recent studies indicate that treatment with metformin and dipeptidyl peptidase-4 inhibitors can prolong the period of near-normoglycemia remission for several years compared to placebo therapy. CONCLUSION KPDM is a unique but common presentation of newly diagnosed African Americans with type 2 diabetes. ABBREVIATIONS A(+/-) = auto-antibody positive/negative AA = African Americans DKA = diabetic ketoacidosis FFA = free fatty acids G6PD = glucose-6-phosphate dehydrogenase GAD-65 = 65-kDA glutamic acid decarboxylase HBA1c = glycated hemoglobin A1c HHV8 = human herpes virus 8 HLA = human leukocyte antigen KPDM = ketosis-prone type 2 diabetes.