LOCAL USE OF GRANULOCYTE-MACROPHAGES COLONY STIMULATING FACTOR IN TREATMENT OF CHRONIC DIABETIC NEUROPATHIC ULCER (CASE REVIEW).

One of the main causes of amputations in patients with Diabetes Mellitus patients is a chronic diabetic foot ulcer. The authors present a clinical case and discussion of a successful use of Granulocyte-Macrophages Colony Stimulating Factor (GM-CSF) treatment for the promotion of healing of a chronic diabetic foot ulcer. A 65 year-old woman was admitted to the Diabetes Center with complaints of a deep non-healing chronic foot ulcer for the last 18 months. At the examination a 5 cm ulcer on the plantar surface of the right foot was revealed. The patient had a 15-year history of Diabetes Mellitus type 2, complicated by neuropathy (peripheral and autonomic), retinopathy, nephropathy and Charcot joints in both legs and the right 4th toe had been amputation. She also had a history of heart failure. Healing of the ulcer could not be achieved with prior administered treatment. The decision was made to use GM-CSF treatment option in the area of the ulcer. Patient received local intradermal injections of GM-CSF (400 mcg twice a week) into the ulcerated foot for the duration of two months. The ulcer healed completely after one year of treatment with GM-CSF. Osteomyelitis was ruled out by scintigraphy. The patient did not develop any clinical side-effects or peripheral blood cell count abnormalities to the treatment. GM-CSF is a safe and effective treatment for chronic non-healing diabetic foot ulcers.

Peripheral blood monocytes can differentiate into efficient insulin-producing cells in vitro.

BACKGROUND: Recent studies provide evidence that peripheral blood monocytes have the ability to differentiate into mesenchymal-like cells. The ability of cultured monocytes to differentiate and produce insulin in vitro is analysed in the present study. METHODS: Peripheral blood monocytes were isolated from healthy donors and cultivated for fourteen days. Growth factors and liraglutide were used to induce pancreatic differentiation in most of the cultures. The growth factors were: monocyte colony-stimulating factor, interleukin-3, hepatocyte growth factor and epidermal growth factor. The rest of the cultures were cultivated only with nutrient medium and human serum. Insulin levels were measured by an enzyme-linked immunosorbent assay. Cellular morphology was observed using optical and electron microscopy. Cell membrane receptors were detected by flow cytometry. RESULTS: Monocytes were able to synthesize and excrete high levels of insulin after seven days in culture. A further increase in the excretion of insulin was observed after fourteen days. Cells were also able to differentiate and synthesize insulin, even if no growth factors were added to the culture medium. Some of the cultures were able to excrete insulin in a glucose-dependent manner. Differentiated monocytes were connected to neighbouring cells with axons and resembled the morphology of mesenchymal, dendritic and myeloid-progenitor cells. Cells retained their mature receptors and simultaneously developed immature receptors on their membrane. CONCLUSIONS: Monocytes can acquire morphological properties of multipotent cells when they are cultivated under specific conditions in vitro. Differentiated monocytes are able to synthesize and excrete insulin. Hippokratia 2015; 19 (4): 344-351.

TNF-α and microalbuminuria in patients with type 2 diabetes mellitus.

AIM: Recent evidence suggests that chronic subclinical inflammation plays a key role in the pathogenesis and progression of diabetic nephropathy. Aim of the present study was to investigate possible correlation between the presence and degree of microalbuminuria and markers of inflammation in patients with type 2 diabetes mellitus (DM). PATIENTS-METHODS: Eighty patients were enrolled and clinical and laboratory data were recorded. Albumin-creatinine ratio (ACR) was calculated in first-morning urine samples. Serum and urinary tumor necrosis factor-α (TNF-α) levels were determined by ELISA. RESULTS: Forty-five patients had normoalbuminuria, 33 microalbuminuria, and 2 macroalbuminuria. Patients with microalbuminuria were older, with higher glycosylated hemoglobin levels (HbA1c) and they more frequently had diabetic retinopathy, neuropathy, and cardiovascular disease and were on treatment with angiotensin converting enzyme inhibitors (ACEi) and/or angiotensin receptor blockers (ARBs). ACR was significantly correlated with the presence of cardiovascular disease, hypertension, and HbA1c levels and the administration of clopidogrel and ACEi or ARBs. ACR was not correlated with C-reactive protein, fibrinogen, or serum TNF-α levels but had a strong correlation with urinary TNF-α levels. CONCLUSIONS: In patients with type 2 DM, urinary, but not serum, TNF-α levels are associated with the presence and severity of microalbuminuria.

Glomerular filtration rate estimation in patients with type 2 diabetes: creatinine- or cystatin C-based equations?

AIMS/HYPOTHESIS: It is argued that GFR estimation (eGFR) using cystatin C-based equations (eGFRcys) is superior to that using creatinine-based equations (eGFRcre). We investigated whether eGFRcys are superior to eGFRcre in patients with type 2 diabetes. METHODS: GFR was measured in 448 type 2 diabetic patients using (51)Cr-EDTA-measured GFR (mGFR) as the reference standard. Bias, precision and accuracy of eGFRcys and eGFRcre were compared. RESULTS: The most accurate eGFRcre equation (Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]), which produced the highest proportion of estimates that were within 30% and 10% of the reference standard (80.7% and 38.0% of samples, respectively) had a bias of 7.1 and precision of 12.0 ml min(-1) 1.73 m(-2). The calibrated eGFRcys with the highest accuracy (Tan-C), which produced the highest proportion of estimates that were within 30% (78.8%) and within 10% (39.0%) of the reference standard had a bias of -3.5 and precision of 18.0 ml min(-1) 1.73 m(-2). Moreover, the areas under the receiver operating curve were higher with eGFRcre (CKD-EPI and Modification of Diet in Renal Disease [MDRD]) than with eGFRcys for the diagnosis of mild (mGFR <90 ml min(-1) 1.73 m(-2)) and moderate (mGFR <60 ml min(-1) 1.73 m(-2)) chronic kidney disease. In patients with mGFR ≥90 ml min(-1) 1.73 m(-2), CKD-EPI was the least biased, the most precise and the most accurate equation. CONCLUSIONS/INTERPRETATION: In patients with type 2 diabetes, eGFRcys do not currently provide better eGFR than eGFRcre. At present, compared with eGFRcys, eGFRcre are better at predicting the stage of chronic kidney disease. In addition, CKD-EPI seems to be the best equation for eGFR in patients with normal renal function.

Myocardial perfusion scintigraphy in asymptomatic diabetic patients: a critical review.

The increasing prevalence of diabetes mellitus and the associated high cardiovascular risk has made the non-invasive identification of silent coronary heart disease in diabetic individuals an important issue. This strategy could identify higher risk asymptomatic patients with diabetes mellitus in whom coronary revascularization may improve the outcome beyond that achieved by currently recommended medical management. Stress myocardial perfusion imaging has been shown to be effective in detecting coronary heart disease and predicting adverse cardiac events in asymptomatic diabetic patients. However, the clinical utility of myocardial perfusion scintigraphy is debated intensively due to the paucity of prospective and outcome based evidence. The controversy stems from several observational studies, epidemiologic data and cost-effectiveness analyses. Thus, although several authors and professional organizations advocate the use of stress imaging for screening higher risk asymptomatic diabetic patients, others are cautious in recommending any kind of stress testing in that population. This review is based on a broad survey of the literature and discusses the potential role of stress myocardial perfusion scintigraphy in screening asymptomatic diabetic subjects for coronary heart disease in the current era and in relation with other non-invasive screening tools.

Initiative for a new diabetes therapeutic approach in a Mediterranean country: the INDEED study.

AIM: To assess the efficacy of a strategy to improve vascular risk management in patients with type 2 diabetes mellitus (T2DM). METHODS: This was a pilot best practice implementation enhancement programme that enrolled 578 patients with T2DM. A baseline visit was followed by a concerted effort from previously trained physicians to improve adherence to lifestyle advice and optimise drug treatment for all vascular risk factors. The patients were followed-up for 6 months. The UKPDS risk engine was used to estimate vascular risk in patients without established coronary heart disease (CHD) (n = 279). RESULTS: There was an improvement in compliance to lifestyle measures and increased prescription of evidence-based medication. In patients without established CHD there was a 37% reduction in estimated risk for CHD, 44% for fatal CHD, 10% for stroke and 25% for fatal stroke (p < or = 0.003 for all comparisons vs. baseline). There was also a substantial increase in the proportion of patients with established CHD who achieved their vascular risk factor targets. CONCLUSIONS: This is the first study to increase the adherence to multiple interventions in patients with T2DM in both primary care and hospital settings. Education of physicians and patients, distribution of guidelines/brochures, and the completion of a one-page form, motivated both physicians and patients to achieve multiple vascular risk factor goals.

The ORLIstat and CArdiovascular risk profile in patients with metabolic syndrome and type 2 DIAbetes (ORLICARDIA) Study.

BACKGROUND: Metabolic syndrome (MetSyn) is associated with a marked increase in the risk of cardiovascular disease, especially in patients with type 2 diabetes mellitus (DM). AIM: To investigate the effect of orlistat plus hypocaloric diet (HCD) vs HCD alone on the cardiovascular risk profile in patients with both MetSyn (National Cholesterol Educational Program--NCEP--Adult Treatment Panel III definition) and type 2 DM. METHODS: This was a prospective, multicentre, open-label, randomized, controlled study. One hundred and twenty-six patients, free of cardiovascular disease at baseline, were included in the final analysis. Ninety-four (73%) patients were treated with orlistat (360 mg/day) and HCD for a 6-month period, while 34 (27%) were on HCD alone. Analysis of covariance was used to assess differences between the treatment groups over time. MAIN OUTCOME MEASURES: Components of the MetSyn criteria assessed were: waist circumference; systolic and diastolic blood pressure; fasting glucose, triglycerides; high-density lipoprotein cholesterol (HDL-C) plus body mass index; glycosylated haemoglobin (HbA1C); homeostasis model for assessment of insulin resistance (HOMA) index; and total and low-density lipoprotein cholesterol (LDL-C). RESULTS: By protocol, all patients had MetSyn at baseline. After a 6 month treatment period there were significant differences between the orlistat plus HCD vs the HCD-alone groups in body weight (p = 0.0001), waist circumference (p < 0.0001), fasting glucose (p < 0.0001), HbA(1C) (p < 0.0001), systolic blood pressure (p = 0.024), total cholesterol (p < 0.0001), LDL-C (p = 0.034), and HOMA index (p = 0.022), while there were no significant differences in triglycerides and HDL-C. Orlistat was well tolerated. By the end of the study, 65% of the patients on orlistat plus HCD were still meeting the MetSyn criteria and 41% had four to five MetSyn components vs 91% (p < 0.0001) and 53% (p = 0.017), respectively, of those on HCD alone. CONCLUSIONS: Orlistat plus HCD favourably modified several cardiovascular risk factors in patients with both MetSyn and type 2 DM. These effects might partly offset the excess cardiovascular risk and improve outcome in this patient population.

Long-term effect of converting enzyme inhibition on circadian sympathetic and parasympathetic modulation in patients with diabetic autonomic neuropathy.

OBJECTIVE: Autonomic nervous system function in patients with diabetes mellitus (DM), especially those with diabetic autonomic neuropathy (DAN), displays an abnormal circadian pattern compared to normal subjects; this probably plays an important role in the onset of acute cardiovascular syndromes, which display a similar pattern of occurrence with a blunted late morning peak, and an increase of episodes during the night, in comparison to non-diabetic subjects. This study was undertaken to investigate the effect of an angiotensin-converting enzyme inhibitor, quinapril, on the circadian pattern of heart rate variability (HRV), a reliable index of sympathovagal interactions, in patients with definite DAN. METHODS & RESULTS: Normalised HRV frequency domain indices [high frequency power (HFP), reflecting vagal tone, low frequency power (LFP), reflecting both vagal and sympathetic (predominantly) modulation, and their ratio (LFP/HFP), indicative of sympathovagal balance] were assessed in 60 patients with DAN at baseline and one year after therapy with quinapril (n = 30), or placebo (n = 30) on a 24-hour 2-channel electrocardiogram with a solid state Holter monitor. Normal subjects (n = 30) and patients with DM without DAN (n = 30), were used as controls. The baseline circadian variation of fractional normalised power in DAN patients was abolished, with pronounced dominance of LFP over HFP during the whole 24-hour period. After one year of treatment, quinapril increased HFP, decreased LFP and improved their ratio, in the morning (07.00 a.m. to 15.00 p.m.) and night (23.00 p.m. to 07.00 a.m.) time intervals, with maximal effect in the night time interval (HFP = 20%, LFP = -8%, LFP/HFP = -31%; for all comparisons p < 0.05 vs baseline values and p < 0.001 vs one year of placebo). CONCLUSIONS: Quinapril increased HFP and decreased LFP as well as their ratio, all indicative of sympathetic predominance reduction, in patients with DAN at time intervals these indices were most adversely affected (morning and night). Since autonomic function is an important contributor in the pathogenesis of acute coronary events, malignant arrhythmias and sudden cardiac death, improvement of indices related to autonomic function in DAN patients in these time intervals may prove beneficial in clinical practice.

Effect of aldose reductase inhibition on cardiovascular reflex tests in patients with definite diabetic autonomic neuropathy over a period of 2 years.

The potential of the aldose reductase inhibitor tolrestat to ameliorate definite diabetic autonomic neuropathy (DAN), as defined by standard cardiovascular autonomic function tests, was evaluated in 35 patients over a period of 2 years, with repeated measurements at 3-month intervals. The effect of tolrestat (200 mg a day) was compared with that of placebo on 35 controls with diabetes mellitus, of similar age, gender, and glycemic control. In the placebo group, a significant deterioration of the indices, with the exception of Valsalva ratio, was recorded, while tolrestat induced a significant beneficial change in the values of most standard cardiovascular reflex tests, in comparison to baseline and placebo. The deep breathing tests (expiration-inspiration ratio, standard deviation, and mean circular resultant of R-R intervals), postural index, and postural hypotension were favorably affected. Three of 35 patients on tolrestat (8.6%) developed high transaminases levels (more than threefold the upper normal limit) and were withdrawn from the study. In conclusion, tolrestat improved autonomic nervous system function in patients with definite DAN, in comparison to baseline and placebo. The clinical importance of this finding needs further investigation.

The natural history of recently diagnosed autonomic neuropathy over a period of 2 years.

BACKGROUND: Patients with diabetic autonomic neuropathy (DAN) have an increased cardiovascular mortality rate compared with normals or diabetic patients without DAN. Indices of standard cardiovascular autonomic function tests and heart rate variability (HRV) are reliable markers of the presence and severity of DAN. OBJECTIVE: The present prospective study investigated the natural history of values of HRV indices and cardiovascular reflex tests in patients with recently diagnosed asymptomatic DAN, over a period of 2 years, at 3 month intervals. PATIENTS AND METHODS: A total of 30 consecutive patients (nine men and 21 women), of median age 51 (range 25-65) years, eight with type 1 and 22 with Type 2 diabetes mellitus, were included in the study, at the time that the presence of DAN was confirmed, as this was established if at least two of cardiovascular autonomic function tests became abnormal. The expiration/inspiration (E/I) ratio. S.D. and mean circular resultant of R-R intervals, the Valsalva index, the 30:15 ratio, and the blood pressure response to standing as well as normalised spectral power indices of HRV were used. RESULTS: All measured indices, except the Valsalva index, deteriorated in all 30 patients during the 2 year follow-up. Most of HRV indices values deteriorated significantly in comparison to baseline at month 12, while the values of cardiovascular reflex tests displayed significant deterioration, in comparison to baseline, between months 15 and 21. Fourteen patients developed symptoms of DAN during the 2 year period. Patients with better glycemic control exhibited deterioration of DAN markers at the same time period with those with poor glycemic control. CONCLUSIONS: Our data suggest that the progression of DAN is significant during the 2 years subsequent to its discovery. This was defined by the deterioration of the mean values of HRV indices and standard cardiovascular autonomic function tests, and by the development of autonomic symptoms in some patients. HRV indices are the earlier markers of DAN deterioration.

Effect of aldose reductase inhibition on heart rate variability in patients with severe or moderate diabetic autonomic neuropathy.

Patients with diabetic autonomic neuropathy (DAN) have an increased cardiovascular mortality rate compared with diabetic patients without DAN. Heart rate variability (HRV) time and frequency domain indices are strong predictors of malignant arrhythmias and sudden cardiac death. This prospective, randomised, double-blind, placebo-controlled study analysed the long-term effect of an aldose reductase inhibitor, tolrestat, on HRV time and frequency domain variables in 45 patients with diabetes mellitus (DM) and DAN. Patients were randomised into tolrestat (n = 22) and placebo (n = 23) groups. Tolrestat (200 mg/day) or placebo were administered, respectively, for a period of 12 months. HRV was assessed at months 0, 3, 6, 9 and 12. The HRV level of the 45 patients was compared with that of 20 patients with DM, with analogous glycaemic control, without DAN and 20 healthy controls, of similar age and gender. At the twelfth month, tolrestat, compared with placebo, had a beneficial effect on HRV indices related to vagal tone. Compared with baseline, HRV time and frequency domain indices showed no significant improvement. Moreover, at the twelfth month of tolrestat administration, HRV indices remained less than that of patients with DM but without DAN, and healthy controls. The 12 patients of the 22 with moderate DAN benefited more than the 10 patients of the 22 with severe DAN. At the twelfth month no patient showed deterioration in HRV indices with tolrestat as was seen with placebo. Our data suggest that tolrestat slows down the progression of DAN compared with placebo. This effect of an aldose reductase inhibitor may contribute to a reduction in risk for malignant ventricular arrhythmias. The early detection of DAN is imperative for successful intervention.

Safety and efficacy of long-term statin-fibrate combinations in patients with refractory familial combined hyperlipidemia.

No monotherapy is able to tackle effectively all atherogenic features of familial combined hyperlipidemia: high low-density lipoprotein (LDL) cholesterol, triglycerides (TG), and plasma fibrinogen, as well as low high-density lipoprotein (HDL) cholesterol. The present study investigated the safety and efficacy of combined pravastotin or simvastatin with gemfibrozil or ciprofibrate treatment on total cholesterol, LDL, TG, plasma fibrinogen, and apoproteins B and A-I in patients with refractory familial combined hyperlipidemia, with or without coronary artery disease. From the initial 420 patients included in the study, 389 (294 men and 95 women, mean age 51 years [range 30 to 65]) completed the study. These patients were followed for a mean period of 29 months (1 year [n = 107], 2 years [n = 102], 3 years [n = 95], and 4 years [n = 85]). Patients given a hypolipidemic diet were randomly assigned to pravastatin + gemfibrozil (n = 135, 20 and 1,200 mg/day, respectively), simvastatin + gemfibrozil (n = 130, 20 and 1,200 mg), or simvastotin + ciprofibrate (n = 124, 20 and 100 mg). Lipid parameters, apoproteins B and A-I, and plasma fibrinogen were assessed every 3 months. Physical and laboratory investigations for adverse effects were performed every month for the first 3 months and every 3 months thereafter. No patient exhibited myopathy or rhabdomyolysis. Five patients (1.3%) were withdrawn from the study because of high transaminases (more than threefold the upper normal limit). Five nonfatal coronary artery disease events were recorded. All 3 combination treatments were more effective in normalizing lipid profile than any monotherapy in the past. Simvastatin + ciprofibrate was more effective than pravastatin + gemfibrozil in reducing LDL, TG, and plasma fibrinogen levels. Simvastatin + gemfibrozil increased HDL levels more than the other 2. The apoprotein B decrease was analogous to the LDL reduction by all combinations, whereas apoprotein A-I was increased more with simvastatin + gemfibrozil. The data suggest that the statin-fibrate combinations used in the study are safe and have a favorable effect on all major coronary artery disease risk factors in patients with refractory familial combined hyperlipidemia with or without coronary artery disease. Early detection of the rare drug-induced reversible hepatotoxicity calls for close monitoring of patients.

Effect of chronic quinapril administration on heart rate variability in patients with diabetic autonomic neuropathy.

OBJECTIVE: Heart rate variability (HRV) time and frequency domain indexes are strong predictors of malignant arrhythmias and sudden cardiac death. Patients with diabetic autonomic neuropathy (DAN) have an increased cardiovascular mortality rate compared with diabetic patients without DAN. RESEARCH DESIGN AND METHODS: The present double-blind, randomized, and placebo-controlled study analyzed the effect of quinapril, an ACE inhibitor, on HRV time and frequency domain variables in patients with DAN. Forty patients (17 men and 23 women) of a mean age of 51 (range 19-68) years, free of coronary artery disease and arterial hypertension, were randomized into a quinapril or placebo group. HRV was recorded at months 0, 3, and 6. The parameters measured were 1) time domain indexes: SD of all 24-h R-R intervals (intervals between consecutive electrocardiogram R waves), or SDNN/24-h; mean of SD of R-R intervals of all 5-min segements (SDNN/5-min); root-mean-square of the differences of successive R-R intervals (RMSSD); and percentage of the R-R intervals differing more than 50 ms (pNN50); and 2) frequency domain indexes: total power (TP), high-frequency power (HFP), low-frequency power (LFP), and very-low-frequency power (VLFP). HRV level of the 40 patients were compared with one of 20 matched diabetic patients, of analogous glycemic control without DAN, and 20 healthy control subjects. RESULTS: Quinapril, compared with placebo, increased total HRV: SDNN/24-h (P < 0.05), TP (P < 0.05), and HRV parameters related to parasympathetic activity: pNN50 (P < 0.01). RMSSD (P < 0.05), and HFP in absolute and normalized units (P < 0.01). LFP/HFP ratio was decreased (P < 0.01). Despite the beneficial effect of quinapril on parasympathetic variables of HRV these remained less than those of diabetic patients without DAN and healthy control subjects. CONCLUSIONS: Our findings suggest that quinapril significantly increases parasympathetic activity in patients with DAN 3 months after treatment initiation and sustains this effect until the 6th month. This might contribute to the reduction of the risk for malignant ventricular arrhythmias in these patients.