Does self-efficacy in diabetes management differ by type of diabetes and gender? Results from network analysis.

This study aims to analyze the correlations and relevance of self-efficacy items in 411 patients with diabetes using network analysis. We found that the self-efficacy items structure is consistent between genders and types of diabetes. However, the strength of item correlations was significantly higher in type 2 diabetes. The items central to the network were following a regular diet in type 2 diabetes and adjusting diet when ill in type 1 diabetes. No significant gender differences were found. Knowledge of the most central aspects of self-efficacy and their interconnections can help clinicians to target psychoeducational interventions aimed at empowering patients.

Assessing self-efficacy in type 2 diabetes management: validation of the Italian version of the Diabetes Management Self-Efficacy Scale (IT-DMSES).

BACKGROUND: Being highly self-efficacious is a key factor in successful chronic disease self-management. In the context of measuring self-efficacy in type 2 diabetes management, the Diabetes Management Self-Efficacy Scale (DMSES) is the most widely used scale. The aim of this study was to adapt the English version of the scale to Italian and to evaluate the psychometric properties of the Italian version of DMSES in type 2 diabetes (IT-DMSES). METHODS: We conducted a cross-sectional study of people with type 2 diabetes attending the Endocrine-Metabolic Disease Care Unit of the Internal Medicine Department of San Marino State Hospital between October 2016 and February 2017. Patients completed a socio-demographic and clinical data form, the IT-DMSES and 3 self-report questionnaires measuring diabetes distress (PAID-5), psychological well-being (WHO-5) and depression (PHQ-9). Psychometric testing included construct validity (principal component analysis), internal consistency (Cronbach's α coefficient) and convergent/discriminant validity (Spearman's correlation coefficient). Decision tree analysis was performed to classify patients into homogeneous subgroups of self-efficacy based on their demographic and clinical characteristics. RESULTS: Participants were 110 males and 55 females, mean age of 65.2 years (SD ± 9), 56.9% had been diagnosed for 1-15 years, 63% had HbA1c level > 53 mmol/mol. Two main factors underlain the construct of self-efficacy in diabetes management: 'Disease Management' and "Lifestyles Management". Disease Management had a good reliability (α = .849) and Lifestyle Management had an excellent reliability (α = .902) indicating that the instrument is internally consistent. A negative and weak correlation was found between Lifestyle management, PAID-5 (r = - 0.258, p = < 0.01) and PHQ-9 (r = - 0.274, p = < 0.01) and a positive one with WHO-5 (r = 0.325, p < 0.01) supporting convergent validity. Disease management was uncorrelated with PAID-5 (r = - 0.142, p = 0.083), PHQ-9 (r = - 0.145, p = 0.076) and weekly correlated with WHO-5 (r = 0.170, p = 0.037) confirming discriminant validity. Higher levels of self-efficacy in lifestyle management were found in patients diagnosed for at least 1 year up to 15 years and aged > 65 years and the poorest self-efficacy was found in males < 65 years. CONCLUSIONS: Results support the validity and reliability of IT-DMSES. The scale can be used in research and clinical practice to monitor type 2 diabetes self-management over time.

Vertebral fractures in males with prolactinoma.

Data on osteoporotic fractures in hyperprolactinemia are limited. An increased prevalence of radiological vertebral fractures was recently observed in women with prolactin (PRL)-secreting adenoma, whereas it is unknown whether this observation may reflect a more general increased risk of fractures in this disease and whether the prevalence of fractures in males is affected by gonadal status. Thirty-two males (median age 47 years, range: 22-79) with PRL-secreting pituitary adenoma (10 with microadenoma and 22 with macroadenoma) and 64 control males, with normal PRL values and with comparable age to patients with hyperprolactinemia, were evaluated for vertebral fractures by a morphometric approach and for bone mineral density (BMD) by a dual-energy X-ray absorptiometry at lumbar spine. Vertebral fractures were shown in 12 patients with PRL-secreting adenoma (37.5%) and in 5 controls (7.8%, P < 0.001). Fractured patients had lower BMD T-score (P = 0.007) and longer duration of disease (P < 0.001) as compared to patients who did not fracture. Fractures occurred more frequently (P = 0.03) in patients with untreated hyperprolactinemia versus patients treated with cabergoline whose frequency of vertebral fractures was still higher than control subjects. The prevalence of vertebral fractures was not significantly different between eugonadal and hypogonadal patients (33.3% vs. 38.5%; P = 0.8). Moreover, no significant (P = 0.4) difference in serum testosterone values was found between fractured and not fractured males. Hyperprolactinemia is associated with high prevalence of radiological vertebral fractures in men with PRL-secreting adenoma. These findings would also suggest that PRL excess may produce negative skeletal effects independently of hypogonadism.

High prevalence of radiological vertebral fractures in women with prolactin-secreting pituitary adenomas.

Hyperprolactinemia may cause bone loss but data on fractures are scanty. The aim of this study was to evaluate the prevalence of vertebral fractures in women with prolactin (PRL)-secreting adenoma. In this cross-sectional study, 78 women (median age 45.5 years, range: 20-81) with PRL-secreting pituitary adenoma (66 with microadenoma and 12 with macroadenoma) and 156 control subjects, with normal PRL values and with comparable age to patients with hyperprolactinemia, were evaluated for vertebral fractures by a morphometric approach and for bone mineral density (BMD) by a dual-energy X-ray absorptiometry at lumbar spine. Vertebral fractures were shown in 25 patients with PRL-secreting adenoma (32.6%) and in 20 controls (12.8%, P < 0.001). Fractured patients were significantly older (P < 0.001) and had lower BMD T-score (P < 0.001), longer duration of disease (P < 0.001), higher serum PRL (P = 0.004) and lower serum IGF-I (P < 0.001) values as compared to patients who did not fracture. The prevalence of vertebral fractures was significantly (P < 0.001) higher in post-menopausal women with PRL-secreting adenoma as compared to pre-menopausal patients. Fractures occurred more frequently (P = 0.01) in patients with untreated hyperprolactinemia versus patients treated with cabergoline. Logistic regression analysis demonstrated that duration of disease maintained a significant correlation with vertebral fractures (odds ratio 1.16, C.I. 95% 1.02-1.33) even after correction for age, menopausal status, treatment with cabergoline, BMD, serum IGF-I and serum PRL values. Hyperprolactinemia is associated with high prevalence of radiological vertebral fractures in women with PRL-secreting adenoma.

Treatment of Cushing disease: overview and recent findings.

Endogenous Cushing syndrome is an endocrine disease caused by excessive secretion of adrenocorticotropin hormone in approximately 80% of cases, usually by a pituitary corticotroph adenoma (Cushing disease [CD]). It is a heterogeneous disorder requiring a multidisciplinary and individualized approach to patient management. The goals of treatment of CD include the reversal of clinical features, the normalization of biochemical changes with minimal morbidity, and long-term control without recurrence. Generally, the treatment of choice is the surgical removal of the pituitary tumor by transsphenoidal approach, performed by an experienced surgeon. Considering the high recurrence rate, other treatments should be considered. Second-line treatments include more radical surgery, radiation therapy, medical therapy, and bilateral adrenalectomy. Drug treatment has been targeted at the hypothalamic or pituitary level, at the adrenal gland, and also at the glucocorticoid receptor level. Frequently, medical therapy is performed before surgery to reduce the complications of the procedure, reducing the effects of severe hypercortisolism. Commonly, in patients in whom surgery has failed, medical management is often essential to reduce or normalize the hypercortisolemia, and should be attempted before bilateral adrenalectomy is considered. Medical therapy can be also useful in patients with CD while waiting for pituitary radiotherapy to take effect, which can take up to 10 years or more. So far, results of medical treatment of CD have not been particularly relevant; however, newer tools promise to change this scenario. The aim of this review is to analyze the results and experiences with old and new medical treatments of CD and to reevaluate medical therapies for complications of CD and hypopituitarism in patients with cured CD.

Vertebral fractures in males with type 2 diabetes treated with rosiglitazone.

OBJECTIVE: To investigate the relationship between osteoporotic vertebral fractures and rosiglitazone treatment and the influence on this association of bone mineral density (BMD) and duration of diabetes. RESEARCH DESIGN AND METHODS: In this cross-sectional study, we evaluated BMD by DXA and the prevalence of radiological vertebral fractures identified by a quantitative morphometric analysis in 43 males with type 2 diabetes under metformin alone (22 cases) or associated with rosiglitazone (21 cases) and in 22 control non-diabetic subjects attending an out-patient bone clinic. RESULTS: Vertebral fractures were found in 46.5% of diabetic males (p=0.06 vs. control subjects) with higher prevalence in patients treated with rosiglitazone plus metformin as compared with those under treatment with metformin alone (66.7% vs. 27.3%; p=0.01). The patients on rosiglitazone plus metformin were significantly younger and with greater body mass index (BMI). Multivariate logistic regression analysis demonstrated that rosiglitazone plus metformin treatment maintained the significant correlation with the occurrence of vertebral fractures (odds ratio 6.5, C.I. 1.3-38.1, p=0.03) even after correction for age and BMI. Within the rosiglitazone-exposed group, the occurrence of vertebral fractures was not correlated with BMD, age, duration of diabetes, duration of medical treatment, dose of rosiglitazone, serum glycosylated hemoglobin and total testosterone values. CONCLUSIONS: The use of rosiglitazone is associated with an increased prevalence of vertebral fractures in males with type 2 diabetes. These findings call for a wide screening of bone status in diabetic patients treated with rosiglitazone and the use of spine X-ray in combination with DXA in this assessment.

Hyperprolactinemia and prolactinomas.

Any process interfering with dopamine synthesis, its transport to the pituitary gland, or its action at the level of lactotroph dopamine receptors can cause hyperprolactinemia. As described in this article, considering the complexity of prolactin regulation, many factors could cause hyperprolactinemia, and hyperprolactinemia can have clinical effects not only on the reproductive axis. Once any drug effects are excluded, prolactinomas are the most common cause of hyperprolactinemia. The most frequent symptom is hypogonadism in both genders. Medical and surgical therapies generally have excellent results, and most prolactinomas are well controlled or even cured in some cases.

Functional effects of nitric oxide-releasing aspirin on vein conduits of diabetic patients undergoing CABG.

BACKGROUND: Type 2 diabetes mellitus (DM) is known to negatively affect biological properties of venous vasculature, and, particularly, to reduce endothelium-derived nitric oxide release. This condition might influence venous graft function following coronary artery bypass surgery (CABG). The aim of this study was to evaluate the functional effects of a NO-releasing aspirin (NORA) on vein grafts (VG) of diabetics and control patients undergoing elective CABG. METHODS: In 40 consecutive ischemic heart disease patients, the effects of NORA were tested on segments of saphenous vein conduits harvested during elective CABG. Twenty patients had type-2 DM (mean age 69+/-2), whereas 20 patients had no DM (NDM) and represented the control group (mean age 67+/-4). Functional responses were tested by exposing VGs to NORA and to standard vasoactive agents in an organ-bath preparation. Histological features of VGs were also assessed by light and electronic microscopy. RESULTS: Significant impairment of endothelial-dependent vasodilation (acetylcholine induced) was documented in VGs of DM subjects. NORA induced a significant and comparable vascular relaxation in all venous segments of NDM and DM patients (56+/-12% of maximal relaxation vs 61+/-11% in the control group, respectively). Histology showed variable extent of vascular layer and cellular abnormalities in VGs of diabetics (intimal hyperplasia, calcific deposition, endothelial cell degeneration) likely responsible of the endothelial functional impairment, whereas control group VG showed preserved structures. CONCLUSIONS: This preliminary study confirms the impairment of endothelium-dependent vasodilative property of VGs in DM patients. It also indicates that NORA effectively induces vasodilation of VGs which was effective also in DM patients thereby representing a promising therapy for diabetics undergoing CABG with the use of VGs, although further studies are mandatory to conclusively assess the safety and benefits of this pharmacological agent.

Expression of growth hormone-releasing hormone receptor splicing variants in human primary adrenocortical tumours.

OBJECTIVE: Several splice variants (SVs) of GHRH receptor (GHRH-R) have been identified in various human cancers through which GHRH antagonists may exert their IGF-II-mediated antiproliferative action. Because the overexpression of the IGF-II gene is a frequent feature of adrenal carcinoma, we searched for the presence of GHRH-R SVs in these tumours. METHODS AND RESULTS: The expression of GHRH-R SVs was assessed by nested PCR in 45 human adrenocortical tumours. We have amplified 720-, 566- and 335-bp PCR products only in carcinomas. Their sequence revealed three open reading frames, corresponding to SV1, SV2 and SV4 of GHRH-R. SV2 was detected in five of 24 cancers examined, whereas the incidence of SV1 and SV4 was lower. Their simultaneous expression was observed in one carcinoma. No PCR products for SV3 or wild-type GHRH-R were found in carcinomas; mRNA for wild-type GHRH-R or SVs of GHRH-R were not observed either in adenomas or in normal adrenal or in NCI-H295R cells. Interestingly, all carcinomas which expressed SVs were also positive for the presence of GHRH mRNA. CONCLUSION: This is the first time that the expression of splice variants of GHRH-R has been demonstrated in human adrenal carcinoma. This study raises the possibility that splice variants might play a role in adrenal carcinogenesis and might offer the possibility for new therapeutic strategies at least in a subgroup of adrenal carcinomas.

High cardiovascular risk in patients with Cushing's syndrome according to 1999 WHO/ISH guidelines.

OBJECTIVE: In patients with Cushing's syndrome (CS) cardiovascular complications determine a mortality rate four times higher than in an age- and gender-matched population. Therefore, we calculated the global cardiovascular risk in patients with CS. DESIGN AND PATIENTS: We applied the World Health Organization--International Society of Hypertension (WHO/ISH) 1999 guidelines for the estimation of cardiovascular risk in 38 females and 11 males with CS; 27 pituitary adenomas, 15 adrenal adenomas, four adrenal carcinomas and three ectopic ACTH-secreting tumours. The risk of major cardiovascular events was estimated considering the combined effect of several risk factors (hypertension, diabetes, etc.), organ damage (left ventricular hypertrophy (LVH), proteinuria, etc.) and associated pathologies. Four categories of absolute cardiovascular disease risk were defined (low, medium, high, very high). RESULTS: Eighty per cent of patients presented a 'high' or 'very high' cardiovascular risk; 85.1% of the patients were hypertensive with a mild-moderate hypertension (68%). Forty-seven per cent of patients were diabetics and 41.3% were obese. Hyperlipidaemia was less frequent (37.5%). Fasting glycaemia was the only cardiovascular risk factor that correlated with a degree of hypercortisolism. Duration of disease correlated with the presence of obesity (P < 0.0008) and hypertension (P < 0.03) but not with the presence of diabetes or dyslipidaemia and seemed to be the only significant predictor of cardiovascular risk (P = 0.03). CONCLUSIONS: Patients with active CS present a remarkably increased cardiovascular risk. Considering that the biochemical cure of hypercortisolism is often difficult to obtain, especially in Cushing's disease, and that cardiovascular risk could persist even after the 'cure', control of risk factors should be one of the primary goals of the therapy.

Cardiovascular risk in Cushing's syndrome.

Chronic cortisol hypersecretion causes central obesity, hypertension, insulin resistance, dyslipidemia, protrombotic state, manifestations which form a metabolic syndrome in all patients with Cushing's syndrome. These associated abnormalities determine an increased cardiovascular risk not only during the active phase of the disease but also long after the "biomedical remission". Clinical management of these patients should be particularly careful in identifying global cardiovascular risk. Considering that remission from hypercortisolism is often difficult to achieve care and control of all cardiovascular risk factors should be one of the primary goals during the follow up of these patients. Extending the indications of the recent consensus on Cushing's syndrome, we suggest to carry out an OGTT to avoid underestimation of diabetes mellitus, an echocardiography and Doppler ultrasonography of the epiaortic vessels in all patients at diagnosis and during follow-up.

Cushing's syndrome and bone.

Structural and functional impairment of skeletal system is a relevant cause of morbidity and disability in patients with Cushing's syndrome (CS). Approximately 30-50% of patients with CS experience fractures (particularly at the spinal level) consistent with the 50% incidence of osteoporosis. Growth failure, pubertal arrest are the hallmarks of CS in children and growing adolescents leading to reduced final adult height and peak bone mass. The decrease in osteoblast number and function, through different mechanisms, seems to play a central role in the bone loss in CS. Patients with CS have decreased serum levels of osteocalcin and alkaline phosphatase. Considering the preferential bone loss in the cancellous skeleton it is reasonable to measure BMD, possibly with Dual X-rays absorptiometry (DEXA) at lumbar spine, in all patients with CS. Patients cured from CS have increased prevalence of spine damage: therefore, a radiological follow-up of the skeleton should be included in the management of patients with CS not only during the active phase but also after cure. Glucocorticoid-induced osteoporosis is reversible. The recovery of bone loss in CS is slow, taking approximately ten years to become complete. In the meanwhile, patients with severe osteopenia are exposed to a high risk of fracture. Alendronate may induce a more rapid improvement in BMD than cortisol normalization alone and it could be useful in patients with persistent postsurgical hypercortisolism to prevent further bone loss. The decision to discontinue antiresorptive therapy should be based on clinical monitoring and DEXA measurements.

Functional and nonfunctional adrenocortical tumors demonstrate a high responsiveness to low-dose adrenocorticotropin.

Aldosterone-producing adenomas (APAs) demonstrate exquisite sensitivity to endogenous ACTH. We previously showed an ACTH receptor overexpression in APAs compared with the other adrenal tumors. To evaluate the meaning of such findings, we investigated the response of aldosterone, cortisol, and 17OH progesterone (17OHP) to 1 microg ACTH in 42 patients with adrenocortical tumors (23 NHAs, 9 APAs, and 10 CPAs) and 10 normal subjects (C). All 52 subjects were responsive to ACTH, and hormone peak levels were reached at 30 min. The aldosterone peak level was significantly higher in APAs [mean +/- SEM: 84.3 +/- 13.1 ng/dl (2335.1 +/- 362.9 pmol/liter)] than in other tumors and control (C). Cortisol peak levels was higher in CPAs [37.1 +/- 3.9 microg/dl (1023.9 +/- 107.6 nmol/liter)] than in NHAs (P < 0.01), in C (P < 0.01) and in APAs (P = n.s.). 17OHP peak levels were significantly higher in patients with adrenocortical tumors toward C. In summary: 1) low-dose ACTH induces an important stimulation in all tumors, suggesting preservation of high responsiveness to ACTH; 2) this is especially true for aldosterone in APA and could be of primary importance when performing diagnostic tests for hyperaldosteronism; and 3) 17OHP-hyperresponsiveness to low-dose ACTH is the most common alteration both in functional and nonfunctional tumors.