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Aims: Neurodegeneration and glial activation are primary events in the pathogenesis of diabetic retinopathy. Serum glial fibrillary acidic protein (GFAP) and neurofilament light chain (NfL) are biomarkers of underlying neuroinflammatory and neurodegenerative disease processes. The aim of the present study was to assess the usefulness of these serum biomarkers for the identification and monitoring of retinal neurodysfunction in subjects with type 2 diabetes., Methods: A case-control study was designed including 38 patients from the placebo arm of the EUROCONDOR clinical trial: 19 with and 19 without retinal neurodysfunction assessed by multifocal electroretinography. GFAP and NfL were measured by Simoa., Results: Serum levels of GFAP and NfL directly correlated with age (r = 0.37, p = 0.023 and r = 0.54, p < 0.001, respectively). In addition, a direct correlation between GFAP and NfL was observed (r = 0.495, p = 0.002). Serum levels of GFAP were significantly higher at baseline in those subjects in whom neurodysfunction progressed after the 2 years of follow-up (139.1 ± 52.5 pg/mL vs. 100.2 ± 54.6 pg/mL; p = 0.04)., Conclusions: GFAP could be a useful serum biomarker for retinal neurodysfunction. Monitoring retinal neurodysfunction using blood samples would be of benefit in clinical decision-making. However, further research is needed to validate this result as well as to establish the best cutoff values., (© 2023. Springer-Verlag Italia S.r.l., part of Springer Nature.)

Objectives: To provide quantitative anatomical parameters in patients with and without non-traumatic multidirectional instability using MR arthrography (MR-a)., Materials and Methods: One hundred and seventy-six MR-a performed from January 2020 to March 2021 were retrospectively evaluated. Patients were divided according to the presence of clinically diagnosed multidirectional shoulder instability (MDI). Each MR-a was performed immediately after intra-articular injection of 20 ml of gadolinium using the anterior approach. The width of the axillary recess, the width of the rotator interval, and the circumference of the glenoid were measured by three independent radiologists, choosing the average value of the measurements. The difference between the mean values of each of the three parameters between the two study groups was then assessed., Results: Thirty-seven patients were included in the study (20 in the MDI group, 17 in the control group). The mean axillary recess width in the MDI group was significantly greater than in the control group (t(33) = 3.15, p = .003); rotator interval width and glenoid circumference measurements were not significantly different (t(35) = 1.75, p = .08 and t(30) = 0,51, p = .6, respectively)., Conclusions: Inferior capsular redundancy may be an important predisposing factor in MDI, while glenoid circumference is not related to MDI. The relationship between the width of the rotator interval and shoulder instability remains debated., (© 2022. The Author(s).)

The first reports of a link between thiamine and diabetes date back to the 1940s. Some years later, a role for thiamine deficiency in diabetic neuropathy became evident, and some pilot studies evaluated the putative effects of thiamine supplementation. However, the administration of thiamine and its lipophilic derivative benfotiamine for the treatment of this complication gained consensus only at the end of the '90 s. The first evidence of the beneficial effects of thiamine on microvascular cells involved in diabetic complications dates to 1996: from then on, several papers based on in vitro and animal models have addressed the potential use of this vitamin in counteracting diabetic microangiopathy. A few pilot studies in humans reported beneficial effects of thiamine administration on diabetic nephropathy, but, despite all promising proofs-of-concept, the possible role of thiamine in counteracting development or progression of retinopathy has not been addressed until now. Thiamine is a water-soluble vitamin, rapidly expelled from the body, with no issues of over-dosage or accumulation; unfortunately, it is non-patentable, and neither industry nor independent donors are interested in investing in large-scale randomized controlled clinical trials to investigate its potential in diabetes and its complications. Consequently, science will not be able to disprove a promising hypothesis and, more importantly, diabetic people remain deprived of a possible way to ameliorate their condition., (© 2021. The Author(s).)

Diabetes and sepsis are important causes of morbidity and mortality worldwide, and diabetic patients represent the largest population experiencing post-sepsis complications and rising mortality. Dysregulated immune pathways commonly found in both sepsis and diabetes contribute to worsen the host response in diabetic patients with sepsis. The impact of diabetes on mortality from sepsis is still controversial. Whereas a substantial proportion of severe infections can be attributed to poor glycemic control, treatment with insulin, metformin and thiazolidinediones may be associated with lower incidence and mortality for sepsis. It has been suggested that chronic exposure to high glucose might enhance immune adaptation, leading to reduced mortality rate in septic diabetic patients. On the other hand, higher risk of acute kidney injury has been extensively documented and a suggested lower risk of acute respiratory distress syndrome has been recently questioned. Additional investigations are ongoing to confirm the protective role of some anti-diabetic treatments, the occurrence of acute organ dysfunction, and the risk/benefit of less stringent glycemic control in diabetic patients experiencing sepsis. Based on a MEDLINE/PubMed search from inception to December 31, 2020, the aim of this review is therefore to summarize the strengths and weaknesses of current knowledge on the interplay between diabetes and sepsis., (© 2021. The Author(s).)

The objective of this study is to evaluate the prognostic features of multiple myeloma (MM) using whole-body low-dose computed tomography (WBLDCT). One hundred three patients with biopsy-proven MM who underwent WBLDCT were retrospectively enrolled. The evolution of osteolytic lesions overtime was performed by measuring the maximum axial diameter at the baseline (T 0 ) and the end of follow-up (T e ), by using a cut-off value of 10 mm. The location and dimension of up to three lesions were registered. The time-to-fracture (TTF) was recorded. Sixty-three percent of patients presented a focal pattern, 22% a diffuse pattern, and 15% a combined one. Seventy-two percent of patients with lesions ≤ 10 mm presented stability, 27% a dimensional increase, and 1% a decrease. Patients with lesions >10 mm showed a statistically significant difference regarding the mean difference of axial diameter between T 0 and T e (p = 0.015). Patients with lesions >10 mm showed an odds ratio (OR) of 29.8 (95%CIs 3.8-230.5) to develop at least one fracture. Mean TTF was significantly lower in patients with lesions >10 mm in comparison with lesions ≤ 10 mm (9 ± 3 vs 23 ± 7 months, respectively, p = 0.011). WBLDCT represents a reliable imaging-based tool for proper management of MM patients, showing that diffuse form or small lytic lesions may deserve a less frequent follow-up.

Aims: Although diabetic retinopathy has long been considered a microvascular complication, retinal neurodegeneration and inflammation may precede its clinical manifestations. Despite all research efforts, the primary treatment options remain laser photocoagulation and anti-vascular endothelial growth factor (VEGF) intravitreal injections, both aggressive and targeting the late stages of the disease. Medical treatments addressing the early phases of diabetic retinopathy are therefore needed. We aimed at verifying if thiamine and fenofibrate protect the cells of the inner blood-retinal barrier from the metabolic stress induced by diabetic-like conditions., Methods: Human microvascular endothelial cells (HMECs), retinal pericytes (HRPs) and Müller cells (MIO-M1) were cultured in intermittent high glucose (intHG) and/or hypoxia, with addition of fenofibrate or thiamine. Modulation of adhesion molecules and angiogenic factors was addressed., Results: Integrins β1/αVβ3 and ICAM1 were upregulated in HMECs/HRPs cultured in diabetic-like conditions, as well as metalloproteases MMP2/9 in HRP, with a reduction in their inhibitor TIMP1; MMP2 increased also in HMEC, and TIMP1 decreased in MIO-M1. VEGF and HIF-1α were strongly increased in HMEC in intHG + hypoxia, and VEGF also in HRP. Ang-1/2 augmented in HMEC/MIO-M1, and MCP-1 in HRP/MIO-M1 in intHG + hypoxia. Thiamine was able to normalize all such abnormal modulations, while fenofibrate had effects in few cases only., Conclusions: We suggest that endothelial cells and pericytes are more affected than Müller cells by diabetic-like conditions. Fenofibrate shows a controversial behavior, potentially positive on Müller cells and pericytes, but possibly detrimental to endothelium, while thiamine confirms once more to be an effective agent in reducing diabetes-induced retinal damage.

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Diabetic retinopathy (DR), diabetic macular edema (DME), and cardiovascular disease (CVD) resulting from vascular damage from persistently elevated blood glucose levels are among the serious secondary pathologies associated with long-standing diabetes mellitus. The established link between DR and CVD suggests the need for appropriate and early management of patients with diabetes to minimize CV risk. This is of particular importance in patients with recent, or a history of, major CV events. Early management of DR is a complex task that requires comprehensive evaluation and a multidisciplinary approach to manage complications, risk factors, and interactions between different aspects of the disease. Anti-vascular endothelial growth factor (VEGF) agents have become an important therapeutic modality in ophthalmology. However, their use is contraindicated in patients with DR and/or DME with a CV event in the previous 3 months. In patients with DME, corticosteroids target the multifaceted inflammatory pathways involved in the pathogenesis of DR, with a broader spectrum of action than anti-VEGF agents. In this context, recent guidelines suggest the use of corticosteroids, and in particular dexamethasone intravitreal implant, as a well-tolerated and efficacious first-line treatment in patients with high CV risk, such as a history of or recent major CV events. This review focuses on the subset of diabetic patients with a prior CV event, DR, and DME and discusses the need for a holistic approach in evaluating the optimal therapeutic choice for the care of the individual patient, supported by real-world clinical experience on long-term dexamethasone intravitreal implant therapy.

Aims: Diabetic retinopathy remains asymptomatic until its late stages but remains a leading cause of vision impairment and blindness. We studied quality of life and the ability to deal with the discomfort deriving from the presence of a chronic disease in patients with type 1 diabetes and different stages of retinopathy., Methods: Multicenter collaborative observational study involving nine centers screening for retinopathy in different areas of Italy. The National Eye Institute 25-item visual functioning questionnaire and the locus of control tool were administered to 449 people with type 1 diabetes between February 2016 and March 2018. Socio-demographic and clinical data were collected., Results: On multivariable analysis, severe retinopathy is associated with worse scores for general vision, ocular pain, near vision activities, distance vision activities, driving, color vision, peripheral vision and lower values of internal control, independently of visual acuity. Women had a perception of worse general health, distance vision activities and driving, and lower internal control and trust in others. Worse scores for visual-specific social functioning, visual-specific mental health, visual-specific role difficulties, visual-specific dependency and peripheral vision were associated with higher HbA1c levels. Fatalism increased with rising HbA1c levels., Conclusions: These results confirm that a gap exists between patients' knowledge and expectations on retinopathy and providers' expertise and assumptions. To bridge this gap, patient-centered education and engaging approaches may be more effective than simple information given during consultations.

Aims: We used data from the GUIDANCE Study to determine the care of people with type 2 diabetes according to age and accompanying cardiovascular diseases and to assess indicators of overtreatment of glycaemia., Methods: The GUIDANCE study was a retrospective, cross-sectional study from 2009-2010 based on the records of 7597 people in France, Belgium, Italy, the Netherlands, Sweden, UK, Ireland and Germany. We analysed the level of metabolic control achieved and blood glucose-lowering medication used in different age groups and in relation to accompanying diseases., Results: 4.459 patients (59.1%) were 65 years or older. Their HbA1c levels were similar to those with <65 years. 44.7% of patients ≥65 years had an HbA1c ≤7% (53 mmol/mol) and were treated with insulin or sulfonylureas, and 27.1% of them had ischaemic heart disease or congestive heart failure. Significantly more patients with heart disease had HbA1c values ≤7% (53 mmol/mol) and were treated more often with insulin or sulfonylureas compared to patients of the same age without heart disease., Conclusions: Most patients were treated according to guidelines valid at the time this large international patient sample was surveyed. Older and younger patients were at a similar level of metabolic control, and almost half of the patients with an age of ≥65 years and treated with insulin or sulfonylurea had HbA1c levels below the target range (≤7%) for younger patients. However, these patients have an increased risk of severe hypoglycaemic events with potentially dangerous complications, particularly in those with cardiovascular diseases.

Aims: Diabetic retinopathy is considered a microvascular disease, but recent evidence has underlined early involvement of the neuroretina with interactions between microvascular and neural alterations. Topical administration of somatostatin (SST), a neuroprotective molecule with antiangiogenic properties, prevents diabetes-induced retinal neurodegeneration in animals. The α 2 -adrenergic receptor agonist brimonidine (BRM) decreases vitreoretinal vascular endothelial growth factor and inhibits blood-retinal barrier breakdown in diabetic rats. However, SST and BRM effects on microvascular cells have not yet been studied. We investigated the behaviour of these drugs on the crosstalk between microvasculature and neuroretina., Methods: Expression of SST receptors 1-5 in human retinal pericytes (HRP) was checked. We subsequently evaluated the effects of diabetic-like conditions (high glucose and/or hypoxia) with/without SST/BRM on HRP survival. Endothelial cells (EC) and photoreceptors were maintained in the above conditions and their conditioned media (CM) used to culture HRP. Vice versa, HRP-CM was used on EC and photoreceptors. Survival parameters were assessed., Results: HRP express the SST receptor 1 (SSTR1). Glucose fluctuations mimicking those occurring in diabetic subjects are more damaging for pericytes and photoreceptors than stable high glucose and hypoxic conditions. SST/BRM added to HRP in diabetic-like conditions decrease EC apoptosis. However, neither SST nor BRM changed the response of pericytes and neuroretina-vascular crosstalk under diabetic-like conditions., Conclusions: Retinal pericytes express SSTR1, indicating that they can be a target for SST. Exposure to SST/BRM had no adverse effects, direct or mediated by the neuroretina, suggesting that these molecules could be safely evaluated for the treatment of ocular diseases.

Aims: Diabetic retinopathy (DR) is characterized by early dropout of capillary pericytes, leading to loss of control on endothelial proliferation and, subsequently, angiogenesis. We have demonstrated that extracellular vesicles (EV) derived from mesenchymal stem cells (MSC) maintained in diabetic-like conditions may play a role in vessel destabilization, thus contributing to angiogenesis through paracrine signalling. In particular, a role for MMP-2 was described. This study was aimed at further investigating the molecular mechanisms of EV-induced vessel destabilization., Methods: We evaluated miR-126 expression, the subsequent HIF-1α and VEGF modulation, Ang-2 and PDGF signalling pathways in human retinal pericytes (HRP) after exposure to MSC-derived EV obtained in diabetic-like conditions (high glucose and/or hypoxia)., Results: HRP express miR-126, and this expression is down-regulated in intermittent high glucose. MSC-derived EV obtained in hyperglycaemic/hypoxic conditions down-regulate miR-126 expression in pericytes, leading to increased expression of angiogenic molecules, such as VEGF and HIF-1α. No modulation of Ang-2 and PDGF signalling pathways in pericytes was observed following EV exposure., Conclusions: HRP express miR-126, and this expression is down-regulated in diabetic-like conditions. Exposure of HRP to EV obtained in diabetic-like conditions is able to decrease miR-126 expression, consistently with previous observations of its involvement in DR and providing further insights into the role of EV in vessel destabilization. In contrast, PDGF and Ang-2 signalling pathways do not seem to be involved in these mechanisms.

Aims: Since depression, anxiety and cognitive function may be impaired in type 2 diabetes, we investigated the relationships between clinical and socioeconomic variables and these psychological dimensions., Methods: For an 8-year prospective observational study of 498 patients, 249 were not insulin-treated (NIT) and 249 were insulin-treated (IT). Demographic, socioeconomic and clinical data were monitored along with depression and anxiety (assessed by Zung questionnaire) and cognitive function by Mini Mental State Examination (MMSE)., Results: After 8 years, 131 patients remained NIT (NIT-NIT), 179 remained IT (IT-IT), 47 switched to insulin (NIT-IT), 111 were lost to follow-up and 30 were died. In all groups, HbA1c remained stable, BMI, glucose and lipid profile improved, and foot ulcers and retinopathy worsened. Mild worsening in depression and anxiety scores was observed in the IT-IT patients only. On multivariate analysis, worsening of depression was associated with female gender, disease duration and being IT-IT, and worsening of anxiety with disease duration. Decreased MMSE was associated inversely with smoking and directly with being IT-IT., Conclusions: Patients with type 2 diabetes are at relatively low risk of psycho-cognitive decline. However, being female and on long-term insulin treatment may be risk factors for psychological distress, suggesting that special attention is required for these patients.

Aims: Loss of pericytes in the early phases of diabetic retinopathy (DR) may disrupt their stable association with endothelial cells (EC), leading to EC proliferation and, eventually, angiogenesis. Extracellular vesicles (EV) are small membrane particles derived from different cells which contain biologically active proteins and RNA and are known to promote phenotypic changes in target cells. In diabetic-like conditions, EV derived from MSC may play a role in vessel destabilization by interfering with the strict interactions between EC/pericytes and pericyte/extracellular matrix., Methods: We examined the behaviour of retinal pericytes exposed to EV derived from MSC cultured in physiological and diabetic-like conditions (high glucose and/or hypoxia)., Results: MSC-derived EV are able to enter the pericytes, cause their detachment and migration from the substrate, and increase blood-barrier permeability. Moreover, EV added to EC/pericytes co-cultures in Matrigel promote in vitro angiogenesis. These effects may be mediated by matrix metalloproteinase-2, expressed by both EV and EV-stimulated pericytes, and are exacerbated if MSC are previously cultured in conditions (high glucose and/or hypoxia) mimicking the diabetic microvascular milieu., Conclusions: We confirm that MSC-derived EV contribute to angiogenesis, showing that they may not only exert a direct stimulus to EC proliferation, but also induce pericyte detachment, thus leaving EC free to proliferate. In addition, we demonstrate a possible link between EV and the early stages of the pathogenesis of DR. Diabetic-like conditions may influence vessel remodelling during angiogenesis through EV paracrine signalling.

Aims: There is conflicting evidence to support the concept that the years with diabetes preceding puberty may not contribute to the development of vascular complications. In this paper, duration-related prevalence of retinopathy was compared in patients who developed type 1 diabetes before and after pubertal age., Methods: Retrospective analysis of prospectively collected data of 1,483 patients was screened for retinopathy in 1991-2010, with diabetes onset at age ≤29, who were on insulin treatment and aged ≤60. Prepubertal age was defined as 0-12 in males and 0-11 in females., Results: A total of 647 patients had developed diabetes before and 836 after puberty. Cumulative prevalence of retinopathy was initially lower among those with prepubertal onset diabetes but rates became superimposable after 20-year duration. Patients with prepubertal onset diabetes had higher lifetime HbA1c and lower blood pressure than those who became diabetic after puberty., Conclusions/interpretation: Retinopathy is infrequent during childhood and develops later than in patients with post-pubertal onset diabetes. After 20-year duration, however, retinopathy becomes just as prevalent suggesting that, in the long term, prepubertal years do contribute to the development of retinopathy. In this series, higher blood pressure may have played a role in the earlier appearance of retinopathy in patients with diabetes onset after puberty, whereas worse metabolic control may have contributed to the late "catch-up" effect in those with prepubertal onset disease.

Aims/hypothesis: Mesenchymal stem cells (MSCs) have been shown to abrogate in vitro the proinflammatory response in type 1 diabetes. The mechanism involves paracrine factors, which may include microvesicles (MVs). We evaluated whether MVs derived from heterologous bone-marrow MSCs exert an immunomodulatory effect on T cell responses against GAD (glutamic acid decarboxylase) antigen in type 1 diabetes., Methods: MVs were purified from heterologous human MSCs by differential centrifugation. Peripheral blood mononuclear cells (PBMCs) were obtained from patients with type 1 diabetes at disease onset, and responses to GAD65 stimulation were assessed by IFN-γ enzyme-linked immunosorbent spot analysis. Levels of cytokines and prostaglandin E2 (PGE2) were measured in the supernatant fraction, and T helper 17 (Th17) and regulatory T cell analysis was performed., Results: MVs were internalised by PBMCs, as assessed by confocal microscopy and flow cytometry analyses. MVs significantly decreased IFN-γ spots and levels in GAD65-stimulated PBMCs, and significantly increased transforming growth factor-β (TGF-β), IL-10, IL-6 and PGE2 levels. Furthermore, MVs decreased the number of Th17 cells and the levels of IL-17, and increased FoxP3(+) regulatory T cells in GAD65-stimulated PBMCs., Conclusions/interpretation: These results provide evidence that MSC-derived MVs can inhibit in vitro a proinflammatory response to an islet antigenic stimulus in type 1 diabetes. The action of MVs involves PGE2 and TGF-β signalling pathways and IL-10 secretion, suggesting a switch to an anti-inflammatory response of T cells.

Progressive adaptation to disease is paramount to improve quality of life (QoL) and other psychological dimensions in type 1 diabetes (T1DM). This study aimed at identifying possible correlations between QoL, locus of control (LoC) and clinical variables in patients with T1DM followed up for 16 years. Fifty-nine patients (27 women) with T1DM, part of a cohort of 112 followed since 1996, accepted to participate. Patients were divided into those in whom onset of T1DM had been during the first 5 years of life (n = 16) or later. They were also stratified into worsened, stable and improved, based on whether their HbA1c had increased/decreased by 1 percentage point between baseline and last follow-up visit. QoL was measured by the Diabetes Quality of Life questionnaire (DQOL), translated into Italian and re-validated. The LoC was measured by the Peyrot- and Rubin-specific questionnaire. Patients who developed T1DM before age 5 had a better total DQOL score than those who developed it later in life, mainly due to the satisfaction dimension and a tendency to decreased fatalism in adult age. All subjects whose HbA1c had worsened from baseline had had their diagnosis after age 5 and reported more frequent episodes of hypoglycemia. Onset of diabetes after age 5 and more frequent hypoglycemia was more likely in subjects with worsened HbA1c (ORs 7.6, p < 0.10 and 20.3, p < 0.01, respectively, from a multivariate logistic model with HbA1c, dichotomized in 'worsened' vs all others, as dependent variable). Onset of T1DM during the first 5 years of life may result in better QoL and less fatalism in the long term. Presumably, these patients have no memory of disease onset, which may reduce trauma and facilitate adaptation to managing life with diabetes.

Diabetic retinopathy may induce visual impairment. We evaluated vision-related quality of life in patients with visual acuity <5/10 in the better eye induced by retinopathy using the 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25). The NEI VFQ-25 was self-administered to 196 patients in 3 Italian centres (A, B and C; n = 64, 61 and 71, respectively) dedicated to DR screening and treatment. Patients in the 3 centres did not differ by age, gender, occupation and diabetes duration. Multivariate analysis demonstrated that reduced visual acuity was associated with decreased scores for General Vision, Near Activities, Distance Activities, Visual-Specific Social Functioning, Mental Health, Role Difficulties and Dependency, Driving, Colour Vision and Peripheral Vision (p < 0.01, all). Treatment by photocoagulation was associated with reduced scores in General Health (-8.3; p = 0.002), General Vision (-7.2; p = 0.001), Visual-Specific Role Difficulties (-8.8; p = 0.015) and Driving (-13.7; p = 0.003). Centre affiliation was associated with different scores for General Health, Ocular pain, Distance Activities, Visual-Specific Social Functioning and Role Difficulties and Peripheral Vision. Women had higher scores for General Vision (p = 0.015), Near Activities (p = 0.005), Distance Activities (p = 0.006), Visual-Specific Social Functioning (p = 0.03), Visual-Specific Mental Health (p = 0.035) and Colour Vision (p = 0.012). Diabetic retinopathy and vision loss modify the way people perceive their own ability to function autonomously. More data should be collected to confirm this interpretation and to guide the development of more appropriate settings to improve approach and support to patients.

Aims/hypothesis: Most guidelines recommend annual screening for diabetic retinopathy (DR) but limited resources and the slow progression of DR suggest that longer recall intervals should be considered if patients have no detectable lesions. This study aimed to identify the cumulative incidence and time of development of referable DR in patients with no DR at baseline, classified by clinical characteristics., Methods: Analysis was performed of data collected prospectively over 20 years in a screening clinic based in a teaching hospital according to a consensus protocol. The cumulative incidence, time of development and relative risk of developing referable retinopathy over 6 years following a negative screening for DR were calculated in 4,320 patients, stratified according to age at onset of diabetes (<30 or ≥ 30 years), being on insulin treatment at the time of screening and known duration of diabetes (<10 or ≥ 10 years)., Results: The 6 year cumulative incidence of referable retinopathy was 10.5% (95% CI 9.4, 11.8). Retinopathy progressed within 3 years to referable severity in 6.9% (95% CI 4.3, 11.0) of patients with age at onset ≥ 30 years, who were on insulin treatment and had a known disease duration of 10 years or longer. The other patients, especially those with age at onset <30 years, on insulin and <10 years duration, progressed more slowly., Conclusions/interpretation: Screening can be repeated safely at 2 year intervals in any patient without retinopathy. Longer intervals may be practicable, provided all efforts are made to ensure adherence to standards in procedures and to trace and recall non-attenders.

Self-monitoring of blood glucose (SMBG) is a core component of diabetes management. However, the International Diabetes Federation recommends that SMBG be performed in a structured manner and that the data are accurately interpreted and used to take appropriate therapeutic actions. We designed a study to evaluate the impact of structured SMBG on glycemic control in non-insulin-treated type 2 diabetes (T2DM) patients. The Prospective, Randomized Trial on Intensive SMBG Management Added Value in Non-insulin-Treated T2DM Patients (PRISMA) is a 12-month, prospective, multicenter, open, parallel group, randomized, and controlled trial to evaluate the added value of an intensive, structured SMBG regimen in T2DM patients treated with oral agents and/or diet. One thousand patients (500 per arm) will be enrolled at 39 clinical sites in Italy. Eligible patients will be randomized to the intensive structured monitoring (ISM) group or the active control (AC) group, with a glycosylated hemoglobin (HbA1c) target of <7.0%. Intervention will comprise (1) structured SMBG (4-point daily glucose profiles on 3 days per week [ISM]; discretionary, unstructured SMBG [AC]); (2) comprehensive patient education (both groups); and (3) clinician's adjustment of diabetes medications using an algorithm targeting SMBG levels, HbA1c and hypoglycemia (ISM) or HbA1c and hypoglycemia (AC). The intervention and trial design build upon previous research by emphasizing appropriate and collaborative use of SMBG by both patients and physicians. Utilization of per protocol and intent-to-treat analyses facilitates assessment of the intervention. Inclusion of multiple dependent variables allows us to assess the broader impact of the intervention, including changes in patient and physician attitudes and behaviors.

Diabetic retinopathy is the leading cause of blindness in adults, and oxidative stress has been pathogenically associated with retinal neurodegeneration. Cellular stresses induce expression of heat shock proteins (HSPs) and this results in cytoprotection. Our aim was to assess retinal expression of HSP25 in early experimental diabetes. Mice were rendered diabetic by streptozotocin injection. Ten weeks after diabetes onset retinal HSP25 expression were studied by real-time PCR, immunoblotting and immunohistochemistry (IHC). Expression of nitrotyrosine and Cu/Zn superoxide dismutase (SOD), was assessed by IHC and apoptosis by TUNEL. Retinal HSP25 mRNA and protein expression was significantly increased in diabetic as compared to non-diabetic animals and localised predominantly within the retinal ganglion cells (RGC) layer. This was paralleled overexpression of nitrotyrosine and SOD and enhanced apoptosis. In early experimental diabetes, HSP25 is overexpressed in the RGC layer in parallel with markers of oxidative stress and apoptosis.

Pericytes regulate vascular tone, perfusion pressure and endothelial cell (EC) proliferation in capillaries. Thiamine and benfotiamine counteract high glucose-induced damage in vascular cells. We standardized two human retinal pericyte (HRP)/EC co-culture models to mimic the diabetic retinal microvascular environment. We aimed at evaluating the interactions between co-cultured HRP and EC in terms of proliferation/apoptosis and the possible protective role of thiamine and benfotiamine against high glucose-induced damage. EC and HRP were co-cultured in physiological glucose and stable or intermittent high glucose, with or without thiamine/benfotiamine. No-contact model: EC were plated on a porous membrane suspended into the medium and HRP on the bottom of the same well. Cell-to-cell contact model: EC and HRP were plated on the opposite sides of the same membrane. Proliferation (cell counts and DNA synthesis), apoptosis and tubule formation in Matrigel were assessed. In the no-contact model, stable high glucose reduced proliferation of co-cultured EC/HRP and EC alone and increased co-cultured EC/HRP apoptosis. In the contact model, both stable and intermittent high glucose reduced co-cultured EC/HRP proliferation and increased apoptosis. Stable high glucose had no effects on HRP in separate cultures. Both EC and HRP proliferated better when co-cultured. Thiamine and benfotiamine reversed high glucose-induced damage in all cases. HRP are sensitive to soluble factors released by EC when cultured in high glucose conditions, as suggested by conditioned media assays. In the Matrigel models, addition of thiamine and benfotiamine re-established the high glucose-damaged interactions between EC/HRP and stabilized microtubules.

To evaluate the prevalence of depression in outpatients with type 2 diabetes and its possible correlation with anxiety, cognitive function, and clinical variables. The Zung Self-Rating Depression and Anxiety Scales and the Mini-Mental-State Examination were administered to 249 non-insulin-treated (NIT) and 249 insulin-treated (IT) outpatients with type 2 diabetes, aged 40-80, in a cross-sectional survey. Compared with a reported prevalence of 6-13% in the general population, 104 (20.9%) patients had either a score indicative of depression or were on anti-depressant medication. Assuming that medication might modify the responses to questionnaires, the latter patients were excluded from further analysis. IT patients had higher age, known duration of diabetes, HbA1c, more foot ulcers, retinopathy, microalbuminuria and practised more self-monitoring of blood glucose (P < 0.01 all) but a slightly lower mean depression score (P = 0.004) and similar anxiety or cognitive function. At multivariate analysis, depression was associated with anxiety (P < 0.001), age (P < 0.001), gender (men having lower scores than women, P = 0.042), and insulin treatment, IT patients being less depressed than NIT (P < 0.001), but none of the clinical variables. Anxiety correlated with age (P < 0.001). The association between depression and anxiety became progressively weaker with increasing age. These data confirm increased prevalence of depression in a population of patients with type 2 diabetes who did not show impaired cognitive function. The lack of correlation with disease duration, metabolic control, and complications suggests that depression may not appear/worsen with diabetes and/or its complications but rather supports suggestions that it might predate both.

Aims/hypothesis: The teratogenic consequences of angiotensin-converting enzyme inhibitors angiotensin receptor blockers (ARBs) during the second and third trimesters of pregnancy are well described. However, the consequences of exposure during the first trimester are unclear, especially in diabetes. We report the experience from DIRECT (DIabetic REtinopathy and Candesartan Trials), three placebo-controlled studies designed to examine the effects of an ARB, candesartan, on diabetic retinopathy., Methods: Over 4 years or longer, 178 normotensive women with type 1 diabetes (86 randomised to candesartan, 32 mg once daily, and 92 assigned to placebo) became pregnant (total of 208 pregnancies)., Results: More than half of patients were exposed to candesartan or placebo prior to or in early pregnancy, but all discontinued it at an estimated 8 weeks from the last menstrual period. Full-term pregnancies (51 vs 50), premature deliveries (21 vs 27), spontaneous miscarriages (12 vs 15), elective terminations (15 vs 14) and other outcomes (1 vs 2) were similar in the candesartan and placebo groups. There were two stillbirths and two 'sick babies' in the candesartan group, and one stillbirth, eight 'sick babies' and one cardiac malformation in the placebo group., Conclusions/interpretation: The risk for fetal consequences of ARBs in type 1 diabetes may not be high if exposure is clearly limited to the first trimester. Long-term studies in fertile women can be conducted with ARBs during pregnancy, provided investigators diligently stop their administration upon planning or detection of pregnancy., Trial Registration: ClinicalTrials.gov DIRECT-Prevent 1 NCT00252733; DIRECT-Protect 1 NCT00252720; DIRECT-Protect 2 NCT00252694., Funding: The study was funded jointly by AstraZeneca and Takeda.

Pericyte survival in diabetic retinopathy depends also on interactions with extracellular matrix (ECM) proteins, which are degraded by matrix metalloproteinases (MMP). Elevated glucose influences ECM turnover, through expression of MMP and their tissue inhibitors, TIMP. We reported on reduced pericyte adhesion to high glucose-conditioned ECM and correction by thiamine. We aimed at verifying the effects of thiamine and benfotiamine on MMP-2, MMP-9 and TIMP expression and activity in human vascular cells with high glucose. In HRP, MMP-2 activity, though not expression, increased with high glucose and decreased with thiamine and benfotiamine; TIMP-1 expression increased with high glucose plus thiamine and benfotiamine; MMP-9 was not expressed. In EC, MMP-9 and MMP-2 expression and activity increased with high glucose, but thiamine and benfotiamine had no effects; TIMP-1 expression was unchanged. Neither glucose nor thiamine modified TIMP-2 and TIMP-3 expression. TIMP-1 concentrations did not change in either HRP or EC. High glucose imbalances MMP/TIMP regulation, leading to increased ECM turnover. Thiamine and benfotiamine correct the increase in MMP-2 activity due to high glucose in HRP, while increasing TIMP-1.

Sleep disturbances may be associated with impaired glucose metabolism. The aim of this study was to evaluate sleep duration and quality in relation to glycemic control in patients with type 2 diabetes. In a cross-sectional study, sleep duration and quality were assessed in 47 middle-aged patients with type 2 diabetes treated with oral agents and without sleep disturbing complications and 23 healthy control subjects similar by age, sex, body mass index, occupation and schooling. Sleep was recorded by wrist-actigraphy for three consecutive days under free-living conditions. Univariate analysis showed lower sleep maintenance (P = 0.002) and sleep efficiency (P = 0.005), and higher fragmentation index (P < 0.0001), total activity score (P = 0.05) and moving time (P < 0.0001) in patients with type 2 diabetes. After adjusting for age, gender and schooling, fragmentation index and moving time remained significantly higher in the patients with diabetes (P < 0.05, both). HbA1c correlated inversely with sleep efficiency (r = -0.29; P = 0.047) and positively with moving time (r = 0.31; P = 0.031). These findings suggest that type 2 diabetes is associated with sleep disruptions even in the absence of complications or obesity. The relevance of sleep abnormalities to metabolic control and possible strategies to improve sleep quality in type 2 diabetes deserve further investigation.

Thiamine (vitamin B1) is an essential cofactor in most organisms and is required at several stages of anabolic and catabolic intermediary metabolism, such as intracellular glucose metabolism, and is also a modulator of neuronal and neuro-muscular transmission. Lack of thiamine or defects in its intracellular transport can cause a number of severe disorders. Thiamine acts as a coenzyme for transketolase (TK) and for the pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase complexes, enzymes which play a fundamental role for intracellular glucose metabolism. In particular, TK is able to shift excess fructose-6-phosphate and glycerhaldeyde-3-phosphate from glycolysis into the pentose-phosphate shunt, thus eliminating these potentially damaging metabolites from the cytosol. Diabetes might be considered a thiamine-deficient state, if not in absolute terms at least relative to the increased requirements deriving from accelerated and amplified glucose metabolism in non-insulin dependent tissues that, like the vessel wall, are prone to complications. A thiamine/TK activity deficiency has been described in diabetic patients, the correction of which by thiamine and/or its lipophilic derivative, benfotiamine, has been demonstrated in vitro to counteract the damaging effects of hyperglycaemia on vascular cells. Little is known, however, on the positive effects of thiamine/benfotiamine administration in diabetic patients, apart from the possible amelioration of neuropathic symptoms. Clinical trials on diabetic patients would be necessary to test this vitamin as a potential and inexpensive approach to the prevention and/or treatment of diabetic vascular complications.

Aims/hypothesis: We recently reported associations of some persistent organic pollutants (POPs) with both prevalence of type 2 diabetes and insulin resistance in a US population with background exposure to POPs. Restricted to non-diabetic participants, we now investigate the relationship between POPs and the metabolic syndrome, a prediabetic state., Materials and Methods: Cross-sectional associations were investigated in 721 non-diabetic participants aged > or =20 years. Nineteen POPs in five subclasses were selected because they were detectable in > or =60% of participants., Results: Among five POPs subclasses, organochlorine (OC) pesticides were most strongly and consistently associated with metabolic syndrome: adjusted odds ratios (ORs) of 1.0, 1.5, 2.3 and 5.3 across OC pesticide quartiles (p for trend <0.01). Dioxin-like polychlorinated biphenyls (PCBs) were also positively associated with adjusted ORs of 1.0, 1.1, 2.2 and 2.1 (p for trend = 0.01). However, non-dioxin-like PCBs showed an inverted U-shaped association with adjusted ORs of 1.0, 1.3, 1.8 and 1.0 (p for quadratic term <0.01). Associations of specific POPs varied across five components of the metabolic syndrome. OC pesticides were positively and significantly associated with four of the five components, especially elevated triacylglycerol and high fasting glucose, but not high blood pressure. PCBs were significantly associated with waist circumference, triacylglycerol and impaired fasting glucose. Polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans showed small but significant associations only with high blood pressure., Conclusions/interpretation: This study suggests that the prevalence of a cluster of cardiovascular risk factors relates to background exposure to a mixture of POPs, several of which are also related to the prevalence of diabetes. POPs associated differentially with different components of the metabolic syndrome.

Aims/hypothesis: Thickening of the basement membrane and selective loss of pericytes occur early in diabetic retinopathy. As we showed previously that pericyte adhesion is impaired on extracellular matrix produced by endothelial cells in high hexose concentrations, we aimed to verify if altered adhesion could influence pericyte viability and replication., Methods: Conditioned extracellular matrices were obtained by growing human umbilical vein endothelial cells in media containing 28 mmol/l D-glucose, with or without the inhibitors of protein glycation thiamine or aminoguanidine, and D-galactose or L-glucose up to 28 mmol/l. Having removed the endothelium, bovine retinal pericytes were grown on these matrices and, in separate experiments, on laminin, fibronectin or type IV collagen. Pericyte viability and replication were measured by cell counts and DNA synthesis after 7 days, cell cycle traversal after 2 days and apoptosis after 18 h, 2 days and 7 days., Results: Pericyte counts and DNA synthesis were reduced on matrices produced in high D-glucose and D-galactose, whilst matrix obtained in L-glucose reduced DNA synthesis but not counts. Both thiamine and aminoguanidine corrected reduced pericyte viability when added to high D-glucose. Cell cycle and apoptosis were not affected by growing pericytes on different conditioned matrices. Laminin, fibronectin and type IV collagen did not modify pericyte replication., Conclusions/interpretations: Reduced pericyte counts could depend on impaired initial adhesion to the extracellular matrix produced by endothelium in high hexose concentrations, rather than impaired replication or viability. Altered cell-matrix interactions might facilitate pericyte dropout in diabetic retinopathy, independently of the effects of high glucose on pericyte replication.

Aims/hypothesis: Drop-out of capillary pericytes occurs early and selectively in diabetic retinopathy. High glucose concentrations decrease replication and increase apoptosis of cultured pericytes. Since glucose activates protein kinase C, we investigated the effects of modulating this intracellular mediator on replication, cell cycle and apoptosis of cultured bovine retinal pericytes., Methods: Pericytes cultured in 5.6 or 28 mmol/l glucose were exposed to a protein kinase C activator (phorbol 12-myristate 13-acetate) and/or a selective inhibitor of its beta2 isoform (LY379196). Cells were counted after 7 days. Proliferation by the tetrazolium to formazan assay and DNA synthesis by 5-bromo-2'-deoxyuridine incorporation were measured at day 4. Cell cycle by flow cytometry and apoptosis by ELISA were assessed at day 2., Results: High glucose reduced pericyte replication and increased apoptosis. Protein kinase C activation increased proliferation, while inhibition of its beta2 isoform decreased it. Cell cycle was accelerated by protein kinase C activation and delayed by inhibition. Apoptosis was enhanced by protein kinase C inhibition and reduced by activation., Conclusions/interpretation: Protein kinase C inhibition amplifies the anti-proliferative and pro-apoptotic effects of high glucose on cultured pericytes, whereas stimulation reduces apoptosis and promotes proliferation both in physiological glucose and high glucose. Protein kinase C inhibition, proposed for the treatment of diabetic macular edema and proliferative retinopathy, might accelerate pericyte dropout in earlier stages when these cells are still present in retinal capillaries.

Easy observation of the fundus oculi makes retinopathy the most frequently reported chronic complication of diabetes and, consequently, the one we know best in terms of epidemiology and natural history. Achieving near-normal levels of blood glucose and blood pressure provides empirical though powerful tools for clinicians to delay the onset and progression of diabetic retinopathy. Even when these measures have failed and retinopathy becomes sight-threatening, laser photocoagulation has proven remarkably effective. Nonetheless, retinopathy remains a leading cause of blindness and there is little evidence that diabetes-related visual loss is decreasing in industrialized countries. This may result from the mixed blessing of prolonged survival of patients who had become diabetic when metabolic control was pursued less fastidiously than today. Screening for sight-threatening retinopathy is the most cost-effective medical procedure known and should help optimise the use of diagnostic and therapeutic resources, but its widest deployment still meets with inertia and lack of interest within most health care systems. Improving clinical skills and technology, however, allow us to take a more optimistic look at the future, as pathogenesis-targeted forms of treatment are being developed and tested through appropriately powered clinical trials.

Aims/hypothesis: Metabolic control worsens progressively in Type II (non-insulin-dependent) diabetes mellitus despite intensified pharmacological treatment and lifestyle intervention, when these are implemented on a one-to-one basis. We compared traditional individual diabetes care with a model in which routine follow-up is managed by interactive group visits while individual consultations are reserved for emerging medical problems and yearly checks for complications., Methods: A randomized controlled clinical trial of 56 patients with non-insulin-treated Type II diabetes managed by systemic group education and 56 control patients managed by individual consultations and education., Results: Observation times were 51.2+/-2.1 months for group care and 51.2+/-1.8 for control subjects. Glycated haemoglobin increased in the control group but not in the group of patients ( p<0.001), in whom BMI decreased ( p<0.001) and HDL-cholesterol increased ( p<0.001). Quality of life, knowledge of diabetes and health behaviours improved with group care ( p<0.001, all) and worsened among the control patients ( p=0.004 to p<0.001). Dosage of hypoglycaemic agents decreased ( p<0.001) and retinopathy progressed less ( p<0.009) among the group care patients than the control subjects. Diastolic blood pressure ( p<0.001) and relative cardiovascular risk ( p<0.05) decreased from baseline in group patients and control patients alike. Over the study period, group care required 196 min and 756.54 US dollars per patient, compared with 150 min and 665.77 US dollars for the control patients, resulting in an additional 2.12 US dollars spent per point gained in the quality of life score., Conclusion/interpretation: Group care by systemic education is feasible in an ordinary diabetes clinic and cost-effective in preventing the deterioration of metabolic control and quality of life in Type II diabetes without increasing pharmacological treatment.

Aims/hypothesis: Thickening of the basement membrane and selective loss of pericytes are early events in diabetic retinopathy. We aimed at checking whether pericyte interaction with extracellular matrix produced by endothelial cells is influenced by the hexose concentrations in which endothelial cells are cultured., Methods: Conditioned extracellular matrixes were obtained by growing human umbilical vein endothelial cells in media containing 28 mmol/l hexoses (D-glucose, D-galactose, L-glucose), which undergo different intracellular processing, before and after adding the inhibitors of protein glycation thiamine or aminoguanidine. Having removed the endothelium, bovine retinal pericytes were grown on such matrixes and, in separate experiments, on laminin, fibronectin or type IV collagen. Pericyte adhesion was determined by cell counts 18 h after seeding., Results: Reduced adhesion was observed on matrixes produced in high D-glucose, high D-galactose and high L-glucose. Both thiamine and aminoguanidine restored impaired pericyte adhesion when added to high D-glucose and high D-galactose, but not L-glucose. Laminin, fibronectin and type IV collagen did not consistently modify pericyte adhesion., Conclusions/interpretations: Pericyte adhesion is impaired on extracellular matrix produced by endothelium in high hexose concentrations. This could result from excess protein glycation, corrected by aminoguanidine and thiamine, rather than altered glycoprotein composition.

Aims/hypothesis: Proliferative diabetic retinopathy (PDR), a leading cause of blindness, cannot be totally prevented by optimizing metabolic and blood pressure control and responds to no specific treatment other than partially destructive retinal photocoagulation. Recognizing risk factors using large-scale epidemiological studies could help identify targets for treatment. The EURODIAB Prospective Complications Study (PCS) includes the largest cohort so far of patients with Type I (insulin-dependent) diabetes mellitus., Methods: Baseline data were collected between 1989 and 1991 on 3250 patients who were recalled for follow-up. Physical examination, biochemical tests and assessment of complications were done on both occasions. In particular, 1249 patients had retinal photographs taken both basally and after an average of 7.3 years., Results: Proliferative retinopathy had developed in 157 patients (cumulative incidence 17.3/1000 patient-years; 95%-CI: 13.6-21.1). HbA(1c) (standardized regression estimate--SRE = 3.03, CI 2.49-3.69), diabetes duration (1.71, 1.42-2.06), age at diagnosis < 12 (1.66, 1.11-2.50), diastolic blood pressure less than or equal to 83 (1.50, 1.03-2.20) and waist-to-hip ratio (1.50, 1.03-2.20) were all independent predictors for progression to PDR when entered simultaneously into a logistic regression model. Including retinopathy at baseline maintained the effects of metabolic control and pre-pubertal onset only. Including the albumin excretion rate maintained the effect of control but reduced SRE for pre-pubertal onset to 1.49 (0.94-2.33). There was no evidence for a threshold effect for HbA(1c)concentrations at baseline and progression to proliferative retinopathy., Conclusion/hypothesis: Metabolic control and duration of diabetes are strong indicators of progression to proliferative retinopathy. Onset of diabetes before puberty could be an additional independent risk factor.

Several trials have suggested that intensive post-remission therapy may prolong the duration of complete remission (CR) in acute myeloid leukemia (AML). The purpose of this study was to evaluate the feasibility and the efficacy of high-dose cytarabine (HiDAC) consolidation chemotherapy followed by high-dose therapy and autologous infusion of peripheral blood progenitor cells (PBPC) mobilized by G-CSF in adult patients with AML in first CR. Fifteen consecutive AML patients underwent HiDAC consolidation chemotherapy, used as a method of in vivo purging, followed by G-CSF for the purpose of autologous PBPC collection. Eleven patients collected a median of 6.9x10(8)/kg peripheral blood mononuclear cells (MNC) (range 2.9-23) and a median of 6.67x10(6)/kg CD34+ cells (range 1.8-33.5) with a median of two aphereses (range 1-3). Two patients did not mobilize and two obtained an inadequate number of progenitor cells. The 11 patients with adequate collections received myeloablative chemotherapy followed by the infusion of PBPC. The median number of days to recover neutrophils and platelets was 12 and 13, respectively. After a median follow-up of 28.7 months (range 17.2-43.4), five out of 11 patients who underwent PBPC transplantation are still in CR, five have died in first relapse and one is alive in CR after relapse treated with salvage therapy and second PBPC infusion. These results demonstrate that HiDAC consolidation chemotherapy followed by autologous PBPC transplantation is a feasible procedure with minimal toxicity. Randomized studies should be performed to evaluate whether this form of consolidation may produce a significant improvement in leukemia-free survival.

We investigated the hypothesis that benfotiamine, a lipophilic derivative of thiamine, affects replication delay and generation of advanced glycosylation end-products (AGE) in human umbilical vein endothelial cells cultured in the presence of high glucose. Cells were grown in physiological (5.6 mM) and high (28.0 mM) concentrations of D-glucose, with and without 150 microM thiamine or benfotiamine. Cell proliferation was measured by mitochondrial dehydrogenase activity. AGE generation after 20 days was assessed fluorimetrically. Cell replication was impaired by high glucose (72.3%+/-5.1% of that in physiological glucose, p=0.001). This was corrected by the addition of either thiamine (80.6%+/-2.4%, p=0.005) or benfotiamine (87.5%+/-8.9%, p=0.006), although it not was completely normalized (p=0.001 and p=0.008, respectively) to that in physiological glucose. Increased AGE production in high glucose (159.7%+/-38.9% of fluorescence in physiological glucose, p=0.003) was reduced by thiamine (113.2%+/-16.3%, p=0.008 vs. high glucose alone) or benfotiamine (135.6%+/-49.8%, p=0.03 vs. high glucose alone) to levels similar to those observed in physiological glucose. Benfotiamine, a derivative of thiamine with better bioavailability, corrects defective replication and increased AGE generation in endothelial cells cultured in high glucose, to a similar extent as thiamine. These effects may result from normalization of accelerated glycolysis and the consequent decrease in metabolites that are extremely active in generating nonenzymatic protein glycation. The potential role of thiamine administration in the prevention or treatment of vascular complications of diabetes deserves further investigation.

Aims/hypothesis: To identify factors associated with early development of and late protection from microvascular complications in subjects with Type I (insulin-dependent) diabetes mellitus., Methods: The frequency of microvascular complications and their relation to risk factors were studied in 300 Type I diabetic subjects with short duration of disease (< or = 5 years) compared with 1062 subjects with long duration (> or = 14 years). Microvascular disease was defined as the presence of either retinopathy (assessed from centrally-graded retinal photographs) or urinary albumin excretion rate of more than 20 micrograms/min., Results: The prevalence of microvascular disease was 25% in the short duration group. In the long duration group 18% had no evidence of microvascular complications. In the short duration group factors associated with early development of complications were cigarette smoking and a family history of hypertension. Subjects free of microvascular complications in spite of long duration of diabetes had better glycaemic control, lower blood pressure, better lipid profile and lower von Willebrand factor levels., Conclusion/interpretation: At the early stages of Type I diabetes, cigarette smoking and genetic susceptibility to hypertension are important risk factors for microvascular complications. At a later stage, additional risk factors are poorer glycaemic control, higher blood pressure, and an unfavourable lipid profile possibly associated with endothelial dysfunction. Many of these factors are amenable to long-term intervention which should be started as soon as possible in the course of the disease.

Several conditions have been described to cause osteoporosis, including diabetes mellitus. While the relationship between type 1 diabetes and osteopenia is well documented in the literature, data on the presence of this complication in type 2 diabetes have not been well established. We studied a population composed of 66 post-menopausal women with type 2 diabetes and a control population. We examined bone mineral density with the dual-energy X-ray absorptiometry (DXA) technique at the lumbar and femoral levels and, in a subgroup of patients, we also measured the levels of markers of bone remodelling. We found significantly higher levels of bone mineral density at the femoral (but not lumbar) level in the diabetic subjects compared with the control population in all the examined subregions, except Ward's triangle. Moreover, we found higher levels of some markers of bone resorption (urinary calcium and hydroxyproline, telopeptide) in the patients with diabetes, while urinary crosslinks were higher in the controls. On the basis of these results, we suggest that osteoporosis cannot be considered a complication of type 2 diabetes and that, from a metabolic point of view, bone resorption is greater in diabetic patients than in normal subjects, as suggested by the high levels of most of the markers of osteoclastic activity.

This study aimed at verifying whether thiamine, a co-enzyme which decreases intracellular glycolysis metabolites by allowing pyruvate and glyceraldheyde 3-phosphate to enter the Krebs cycle and the pentose-phosphate shunt, respectively, corrects delayed replication caused by high glucose concentrations in cultured human umbilical vein (HUVEC) and bovine retinal endothelial cells (BREC). After incubation in physiological (5.6 mmol/l) or high (28.0 mmol/l) glucose with or without 150 mumol/l thiamine, cells were counted and proliferation assessed by mitochondrial dehydrogenase activity. Lactate was measured in both cell types as an index of glycolytic activity and fluorescent advanced glycosylation end-products (AGE) concentration was determined in the HUVEC lysate. Both cell counts and proliferation assays in either of the cell types confirmed the impairment to cell replication induced by high glucose. When thiamine was added to cells kept under high glucose conditions, the number of surviving cells was significantly increased and the reduced cell proliferation appeared to be corrected. Lactate assays confirmed the increased production of this metabolite by BREC and HUVEC in high glucose, which was reduced by thiamine. Fluorescent AGE determination showed that thiamine may prevent non-enzymatic glycation in HUVEC. Thiamine restores cell replication, decreases the glycolytic flux and prevents fluorescent AGE formation in endothelial cells cultured in high glucose, suggesting that abnormal levels of glycolytic metabolite(s) may damage cells.