Is thrombophilia a risk factor for placental vascular disorders?

First trimester recurrent fetal loss and severe second or third trimester placental vascular disorders are still frequently unexplained. Acquired biological thrombophilia (antiphospholipid syndrome, essential thrombocythemia) are known risk factors. Genetic thrombophilia may represent a new risk factor for placental vascular diseases, but reported data are conflicting. Combined hereditary thrombophilias are indeed a moderate risk factor, but even in these cases most pregnancies are normal giving healthy live birth children. Whether hereditary thrombophilia is associated with recurrent severe placental vascular disorders is unknown.     

Is diabetes mellitus a risk factor for pancreatic cancer?

The relationship between diabetes mellitus and the risk of pancreatic cancer has been a matter of study for a long period of time.The importance of this topic is due to two main causes:the possible use of recent onset diabetes as a marker of the disease and,in particular,as a specific marker of pancreatic cancer,and the selection of a population at risk for pancreatic cancer.Thus,we decided to make an in-depth study of this topic;thus,we carried out an extensive literature search in order to re-assess the current knowledge on this topic.Even if diabetes is found a decade before the appearance of pancreatic cancer as reported in meta-analytic studies,we cannot select those patients already having non detectable pancreatic cancer,at least with the imaging and biological techniques available today.We believe that more studies are necessary in order to definitively identify diabetes mellitus as a risk factor for pancreatic cancer taking into consideration that approximately 10 years are needed to diagnose symptomatic pancreatic cancer.At present,the answer to the as to whether diabetes and pancreatic cancer comes first similar to the adage of the chicken and the egg is that diabetes is the egg.     

C-reactive protein. Should it be considered a coronary risk factor?

C-reactive protein (CRP) is an acute phase reactant which is not associated with coronary atherosclerosis in many studies. However, it has been demonstrated in many, but not all, studies to predict cardiovascular events. Increased CRP levels may reflect tissue damage and inflammation not only in the arteries, but anywhere in the body. Elevated CRP levels may be induced by metabolic, infective, immunologic, or other processes. Increased CRP levels are probably an indirect marker of any increased cytokine response to inflammatory stimuli that are critical for atherosclerotic plaque progression and rupture. A large-scale prospective trial is needed to investigate whether reduction of elevated CRP will reduce cardiovascular events.     

Supine fluid redistribution: should we consider this as an important risk factor for obstructive sleep apnea?

Introduction

Obstructive sleep apnea (OSA) is a common medical disorder affecting at least 2 % of women and 4 % of men living in Western societies. Obesity, older age, male gender, alcohol and sedative use, smoking, craniofacial parameters, and volume overload are some of the risk factors for this disorder.

Discussion

OSA is a known risk factor complicating the course of arterial hypertension, heart failure, and chronic kidney disease. It is important to note that all of the aforementioned comorbid disorders are associated with volume overload. This explains why patients with OSA and comorbid disorders associated with fluid overload can benefit from treatment with diuretics and drugs modulating the renin–angiotensin–aldosterone system. Additionally, patients with heart failure and high sodium intake are at increased risk for OSA, further supporting the complex interrelationship.

Conclusions

Hemodialysis and renal transplantation can markedly improve the severity of OSA in patients with concomitant kidney disease. Finally, there is a potential of a vicious cycle between OSA and fluid overload disorders, whereby OSA can contribute to the pathogenesis of arterial hypertension, heart failure, and chronic kidney disease, which in turn will significantly contribute to the course OSA.     

Metformin therapy for gestational diabetes mellitus: are we there yet?

Metformin is an effective alternative to insulin for nonpregnant women with type 2 diabetes mellitus; however, it has not yet been studied in the setting of gestational diabetes mellitus (GDM). Concerns have been raised about the effect of metformin on fetal development, particularly because it crosses the placenta. In this Practice Point commentary, I discuss the findings of an open-label, multicenter, prospective trial conducted by Rowan et al., in which women with GDM were randomly allocated to receive metformin (plus insulin when necessary) or insulin alone. The rate of a composite neonatal outcome and the efficiency of glycemic control were not significantly different between the groups. Compared with the insulin group, the prevalence of severe neonatal hypoglycemia was lower but the rate of preterm birth was higher in the metformin group. Of note, 46% of metformin-treated women required supplemental insulin. Although the results of this study are encouraging, further data are needed on the long-term safety of metformin before it can be considered as first-line therapy for women with GDM.     

High cumulative insulin exposure: a risk factor of atherosclerosis in type 1 diabetes?

BACKGROUND: Since insulin therapy might have an atherogenic effect, we studied the relationship between cumulative insulin dose and atherosclerosis in type 1 diabetes. We have focused on patients with type 1 diabetes instead of type 2 diabetes to minimise the effect of insulin resistance as a potential confounder. METHODS: An observational study was performed in 215 subjects with type 1 diabetes treated with multiple insulin injection therapy. Atherosclerosis was assessed by measurement of carotid intima-media thickness (CIMT). RESULTS: The cumulative dose of regular insulin showed a positive and significant relation with CIMT: increase of 21 microm in CIMT per S.D. of insulin use (95% CI: 8-35 adjusted for gender and age), which remained unchanged after adjustment for duration of diabetes, HbA1c, BMI, pulse pressure, physical activity and carotid lumen diameter. A similar relation was found for intermediate-acting insulin: 15.5 microm per S.D. (2-29), which was no longer present after further adjustment. CONCLUSIONS: These findings provide evidence that a high cumulative dose of regular insulin is a risk factor for atherosclerosis.     

Should we consider heparin prophylaxis in COVID-19 patients? a systematic review and meta-analysis

Journal of Thrombosis and Thrombolysis -