Effectiveness of an educational intervention on the management of type 2 diabetic patients hospitalized in Internal Medicine: results from the FADOI-DIAMOND study.

Appropriate management of hyperglycemia is crucial for patients with type 2 diabetes. Aim of the FADOI-DIAMOND study was to evaluate real-world management of type 2 diabetic patients hospitalized in Internal Medicine wards (IMW) and the effects of a standardized educational intervention for IMW staff. DIAMOND has been carried out in 53 Italian IMW, with two cross-sectional surveys interspersed with an educational program (PRE phase and POST phase). In PRE phase, each center reviewed the charts of the last 30 hospitalized patients with known type 2 diabetes. An educational program was conducted in each center by means of the "outreach visit," a face-to-face meeting between IMW staff and a trained external expert. Six months after, each center repeated the data collection (POST phase), specular to the PRE. A total of 3,167 patients were enrolled (1,588 PRE and 1,579 POST). From PRE phase to POST, patients with registered anthropometric data (54.1 vs. 74.9 %, p < 0.001) and in-hospital/recent measurement of glycated hemoglobin (48.2 vs. 61.4 %, p < 0.005) increased significantly. After educational program, more patients received insulin during hospitalization (68.3 vs. 63.6 %, p = 0.005). A more relevant variation in glycemia during hospitalization was observed in POST phase than PRE (-22.2 vs. -15.5 mg/dL, p < 0.001), without differences as for occurrence of hypoglycemia (12.3 vs. 11.9 %). A one-shot educational intervention led to persistent improvement in the management of hospitalized patients with type 2 diabetes and to significant better glycemic control. Further studies might evaluate the effectiveness of a more aggressive educational program, on both management and outcomes.

Lung function changes in older people with metabolic syndrome and diabetes.

AIM: Restrictive lung dysfunction (RLD; defined as reduced forced vital capacity [FVC] in the presence of normal forced expiratory volume in 1 s [FEV1]/FVC ratio) is highly prevalent in the elderly, and is associated with diabetes, metabolic syndrome (MetS) and abdominal obesity. The aim of this study was to assess the relative contribution of diabetes, MetS and abdominal obesity in characterizing RLD in the elderly. METHODS: This was cross-sectional analysis of 192 consecutive, community-dwelling persons (mean age 70.8 ± 8 years). The participants were grouped according to the number of MetS components (i.e. 0, 1, 2, 3 or 4) and the presence of diabetes. According to the Adult Treatment Panel-III criteria, participants with three or four components were considered to be affected by MetS. Independent correlates of RLD and obstructive lung dysfunction (OLD; FEV1/FVC < 0.70) were assessed by logistic regression models. RESULTS: The mean age of the sample population was 70.8 years. FVC expressed as percent of the predicted value declined for an increasing number of MetS components (P < 0.0001), but diabetes did not account for further ventilatory decline. Consistently, MetS (OR 3.03, 95% CI 1.16-7.89) and abdominal obesity (OR 4.89, 95% CI 1.17-20.3), but not diabetes, were independently associated with RLD. OLD did not worsen for an increasing number of MetS components and was only related to age (OR 1.07, 95% CI 1.01-1.13) and smoking (OR 1.04, 95% CI 1.01-1.06). CONCLUSIONS: MetS and abdominal obesity, two conditions of prediabetes, but not diabetes itself, are closely associated with RLD. These conditions might be implicated in the pathogenesis of the RLD, which is frequently observed in diabetic patients.

Erlotinib-induced hepatitis complicated by fatal lactic acidosis in an elderly man with lung cancer.

OBJECTIVE: To report a case of erlotinib-induced hepatitis complicated by fatal lactic acidosis in an elderly patient with lung adenocarcinoma and diabetes mellitus. CASE SUMMARY: A 77-year-old man with stage IIIB lung adenocarcinoma was treated with erlotinib 100 mg/day, an epidermal growth factor receptor inhibitor, after failure of chemotherapy and radiotherapy. The patient also had type 2 diabetes mellitus; metformin therapy had been initiated 5 years before presentation. Twelve days after the start of erlotinib therapy, he developed drug-related acute hepatitis complicated by renal deterioration (aspartate aminotransferase 1400 U/L, alanine aminotransferase 1299 U/L, creatinine 4.4 mg/dL, urea nitrogen 55 mg/dL). Viral causes of hepatitis were excluded and a recent computed tomography scan had ruled out liver metastases. According to the Roussel-Uclaf causality assessment method, the erlotinib-related hepatitis was classified as probable. The patient's condition was soon complicated by the onset of lactic acidosis, which caused death 2 hours after admission. DISCUSSION: In this patient, lactic acidosis was promoted by erlotinib-related hepatitis with initial liver failure (decreased lactate clearance), concomitant metformin treatment (increased lactate production), and acute renal deterioration (metformin accumulation). This is the second case of fatal erlotinib-induced liver toxicity in a patient with lung cancer. In the previous case, death occurred after about 11 days and was entirely due to fulminant hepatitis, whereas in our patient, the liver injury only initiated a drug-disease interaction that caused fatal lactic acidosis within a few hours. CONCLUSIONS: Liver function should be carefully monitored during erlotinib treatment, particularly in elderly and frail patients on multiple medications. Further studies are therefore needed for better testing the safety of erlotinib in such people, commonly encountered in the real world, but often excluded from participation in randomized trials of cancer treatment.

The association between metabolic syndrome and restrictive ventilatory dysfunction in older persons.

BACKGROUND: The restrictive, but not the obstructive respiratory dysfunction, is associated with an increased risk of developing type 2 diabetes mellitus. Our aim was to verify in an elderly nondiabetic population whether a restrictive respiratory pattern was associated with a higher prevalence of metabolic syndrome and increased insulin resistance than were obstructive and normal respiratory patterns. METHODS: We performed a cross-sectional study of 159 consecutive nondiabetic elderly persons attending two social centers. According to their spirometric pattern, volunteers were classified into the following categories: normal spirometry, obstructive (forced expiratory volume in 1 second/forced vital capacity<0.70), and restrictive pattern (forced vital capacity<80% predicted, forced expiratory volume in 1 second/forced vital capacity>or=0.70). Independent correlates of the metabolic syndrome were identified. RESULTS: The prevalence of metabolic syndrome was higher in restrictive (56%) than in both normal (21.4%, p=.001) and obstructive volunteers (12.9%, p=.001). Insulin resistance, as assessed by the log transformation of the HOmeostasis Model Assessment (HOMA), was higher in restrictive than in obstructive and normal volunteers (1+/-0.6 vs 0.3+/-0.6 and 0.5+/-0.5, p<.001). Restriction was an independent correlate of metabolic syndrome, also after adjustment for waist circumference and body mass index (odds ratio=3.23, 95% confidence interval, 1.23-8.48; p=.01). CONCLUSION: Restrictive, but not obstructive respiratory pattern, is associated with metabolic syndrome and insulin resistance, and does not only reflect a limitation of ventilation due to visceral obesity. Metabolic abnormalities likely mediate cardiovascular risk in patients with restrictive respiratory impairment.