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Standardizzazione della emoglobina glicata HbA 1c. Gestione in caso di catastrofe delle persone con diabete. Il fallimento secondario degli ipoglicemizzanti orali nel diabete mellito di tipo 2: Standard italiani per la cura del diabete mellito. La terapia dietetica nella gravidanza diabetica — Raccomandazioni. Documento di consenso internazionale sul Piede Diabetico. Raccomandazioni per la terapia medica nutrizionale del diabete mellito. Linee-guida per la prevenzione cardiovascolare del paziente diabetico. Linee-guida per lo screening, la diagnostica e il trattamento della retinopatia diabetica in Italia.
Manuale di accreditamento delle strutture diabetologiche. Manuale del disease management applicato alla diabetologia. As to gear lost due to adverse climactic conditions e. Farmers in Wadi Fukin have again come under attack from Israeli settlers and the Israeli army. The inhabitants of Wadi Fukin, a Palestinian farming village near Bethlehem, have courageously resisted Israeli attacks designed to deprive them of a livelihood and seize the land for Israeli settlers.
The land seized by the Israeli authorities is often used to extend settlements or create new ones. The opinion was ratified by the United Nations. How much longer will Israel be permitted to violate international law with impunity? While we have a clear position on settlements, endorsed by all Member States and the European Parliament that Israeli settlements in the occupied Palestinian territory are illegal and constitute an obstacle to peace, we are not contemplating the use of sanctions in the context of bilateral EU-Israel relations, since sanctions should only be considered when there is no other instrument at reach, which is not the case on bilateral EU-IL relations.
Alimenti a lunghissima conservazione per i militari. Ritiene che questo genere di alimenti possa essere in qualche modo nocivo per la salute umana? This food product remains edible up to three years without refrigeration or freezing. The project arose from the need for substitutes for the conventional tinned foods used by US soldiers on foreign assignments. The scientists undertook to develop a method of preventing mould growth.
This prevents the pasta dough from absorbing the moisture in the tomato sauce or cheese, which feeds the growth of bacteria or mould which inevitably causes the pizza to rot. Their solution uses humectants such as sugar, salt and various types of syrup as ingredients which bind to water and keep it from getting to the dough.
Does it believe that this type of nutrition can have side-effects on military operational capability? The Commission is not aware of the experiment on very long-life foods for military consumption. The Commission does not have information to judge on the harmfulness of the food in question. Inquinamento atmosferico e complicanze prenatali e neonatali. Il confronto dei dati ha mostrato che una pesante esposizione a monossido di carbonio, biossido di zolfo e anidride solforosa ha portato a un significativo aumento del rischio di sviluppare il disturbo caratterizzato da alta pressione sanguigna durante la gravidanza.
L'esame fa inoltre riferimento a studi recenti che dimostrano l'esistenza di interrelazioni tra vari inquinanti atmosferici e altri effetti, compresi il basso peso alla nascita e la nascita prematura. According to a recent American study, fumes from atmospheric pollution can have even more harmful effects on pregnant women than cigarette smoke. They exacerbate potentially fatal complications such as pre-eclampsia. The data comparison revealed that severe exposure to carbon monoxide and sulphur dioxide significantly increased the risk of developing high blood pressure as a disorder during pregnancy.
As foetal growth is highly sensitive to ambient factors, hypertension in the mother influences rates of foetal morbidity and mortality. The WHO review established that there is a causal relationship between particulate matter exposure and increased risk for lung cancer and cardiovascular diseases mortality and morbidity.
It also identified recent studies which have shown links between various air pollutants and other effects, including low birth weight and preterm birth as well as with pre-eclampsia. Nei giorni scorsi l'Ucraina ha registrato un forte inasprimento delle violenze di strada.
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I media italiani riportano la notizia della morte di un giornalista, che era in taxi quando lo hanno fermato, gli hanno lanciato contro una molotov e lo hanno trascinato fuori e crivellato di colpi, poco lontano da Piazza Maidan. A ucciderlo sarebbe stato un commando di uomini mascherati. Il giornale per cui la vittima lavorava accoglie spesso posizioni filo-governative, ma secondo alcuni testimoni l'uomo sarebbe stato vittima di una formazione militare filo-governativa che da tempo combatte sulla piazza protetta dalle forze di polizia. La Commissione ha avviato programmi o intrapreso azioni volte a garantire il rispetto dei diritti fondamentali in Ucraina, a norma di quanto stabilito dall'articolo 21, paragrafo 1, del TUE?
L'UE condanna tutte le forme di violenza, indipendentemente dagli autori, ed esprime profonda simpatia per le vittime delle recenti violenze in Ucraina. L'UE ritiene di fondamentale importanza che si indaghi con la debita efficacia su tutti i casi di decessi, intimidazioni, torture, sparizioni e trattamenti inumani o degradanti, compresi quelli riguardanti giornalisti. L'Unione ha reagito immediatamente agli eventi straordinari verificatisi in Ucraina, anche individuando e introducendo misure restrittive contro le persone responsabili di violazioni dei diritti umani o di appropriazione indebita di fondi dello Stato nel paese.
The past few days have seen a severe escalation of violence on the streets of Ukraine. The Italian media have released news reports concerning the death of a journalist, who was in a taxi when the vehicle was stopped and a petrol bomb thrown at it. The journalist was dragged out of the vehicle and beaten to death, not far from Independence Square. He was apparently killed by a group of masked men. The EU condemns all forms of violence perpetrated by any party and expresses deep sympathy for victims of recent violence in Ukraine. The EU attaches the utmost importance to the proper investigation of all cases involving death, intimidation, torture, disappearances, and inhumane or degrading treatment of any individual, including journalists.
In this regard, ensuring that law-enforcement bodies and the judicial system are efficient and transparent, and respect human rights, are top priorities. Reform of judiciary is a main feature of EU assistance to Ukraine. The EU responded immediately to extraordinary circumstances in Ukraine, including by pointing to and introducing restrictive measures against persons identified as responsible for human rights violations or misappropriation of State funds in Ukraine.
The EU urges all sides to de-escalate the situation, including in Crimea, and allow the media to report freely in accordance with international commitments. The experts reached these figures by analysing the mortality rate in several areas close to the power station in question.
The rate in areas most affected by pollutants, after excluding other factors such as road traffic, other companies in the area or fumes from ships in port, was markedly higher than in the least affected areas. The company, which is owned by a well-known Italian industrial group, has sought to dismiss the connection by challenging the assessment method used. Whether it is aware of similar situations to the one described here in other EU Member States? The Commission has no specific figures on the health impact of individual coal-fired power plants.
It is the responsibility of the competent authorities in the Member States to ensure that the plants are permitted and operated in line with the requirements set out in those Directives. Un'azienda di telecomunicazioni tedesca da circa quattro anni ha vietato l'invio di e-mail e messaggi di lavoro fuori dagli orari d'ufficio. In seguito anche altre imprese hanno adottato questa politica, anche in altri settori industriali. Un'altra azienda ha stabilito che tutta la posta elettronica che arrivi dopo che qualcuno ha attivato la risposta automatica in cui informa della sua assenza temporanea dalla scrivania, venga cancellata.
Un ministro tedesco ha addirittura ammesso di essere a favore di una norma che vietasse messaggi di lavoro nel tempo libero, pur senza proporre mai alcun testo. Sono disponibili dati che confermino che lo stress da lavoro possa essere provocato da richieste fuori orario? Sono disponibili dati relativi alla diffusione dello stress da lavoro tra i cittadini europei?
La Commissione non dispone di cifre relative agli effetti del lavoro fuori orario. I rispettivi dati dell'IFS saranno disponibili alla fine del For about four years now, a German telecommunications company has banned the sending of work messages and emails outside office hours. Other companies, including in other industries, have since adopted this policy. Another company has arranged for the deletion of any electronic mail that arrives after someone has activated the automatic response saying that they are temporarily away from their desk.
A German minister has even said that he is in favour of a regulation banning work messages during free time, though without actually proposing a text. Are any figures available on the incidence of work-related stress among European citizens? Are any figures available on the connection between suicides and work-related stress in Europe? Implementation Reports show that the Agreement has contributed to raising awareness, promoting principles and rules and building consensus on the structural nature of work-related stress and the need for concerted responses. The Commission has no figures on the effect of out-of-hours demands.
Similar data from the LFS should be available end Una nuova droga sintetica in polvere ha ucciso 15 persone in Europa: Dispone di dati aggiornati sui casi di decesso o rischio di decesso causati dal citato prodotto? Intende adottare misure volte a ridurne la distribuzione sul mercato europeo?
Al consumo di questa sostanza sono associati sei casi d'intossicazione non mortali e 15 decessi in tre paesi. Il comitato scientifico dell'Osservatorio sta conducendo una valutazione dei rischi legati all'AH The deaths caused by this product have been reported by the European Monitoring Centre for Drugs and Drug Addiction and the product has been seized in the United Kingdom, Germany and France. Can the Commission state which Member States have classed this product as an illegal narcotic substance so far? Does it have up-to-date information on the number of fatal or life-threatening cases caused by this product?
Does it plan to adopt measures to curb its distribution on the European market? Its consumption has been associated with six non-fatal intoxications and 15 deaths in three countries. The proposals are currently being negotiated by the European Parliament and the Council. Negli Stati Uniti sono disponibili sul mercato test genetici a prezzi facilmente accessibili. Questi sono in genere effettuati da coloro che vogliono scoprire se sono a rischio di determinate patologie ereditarie, scandagliando il proprio patrimonio genetico.
Non guardare a tutte le varianti in gioco significa, infatti, avere solo una visione parziale. Tra le modifiche figura inoltre la proposta che i dispositivi per test genetici possano essere forniti soltanto su prescrizione medica. Genetic tests are available on the market in the United States at readily affordable prices.
They are generally done by people who want to find out if they are at risk of certain hereditary diseases by probing their own genetic make-up. Such tests are not yet always reliable, and sometimes similar tests may even give opposite results. There are in fact many different tests, some requiring a medical prescription and aimed at identifying the likelihood of developing certain diseases deriving from mutations in a specific gene, while others aimed at consumers analyse numerous genes and provide less definite results.
Not looking at all the variables involved results in only having a partial view. Can the Commission say whether these kinds of tests are also being carried out in the European Union? How many European citizens are taking these kinds of tests? Is the number growing? The Commission has no information on which genetic tests are carried out in individual Member States, and under which conditions.
The Commission proposal also aims at ensuring the proper regulation of devices offered by means of information society services, as well as devices that are not placed on the market, but are used in the context of a commercial activity for the provision of a diagnostic or therapeutic service offered by means of information society services, or by other means of communication, to a natural or legal person established in the Union.
The amendments also propose that devices for genetic testing may only be supplied on medical prescription. Nuove tecniche e farmaci per la cura della depressione. Per trattare la depressione vengono generalmente utilizzati psicofarmaci come quelli che agiscono sull'inibizione dei neurotrasmettitori, ma non sempre i risultati di questo genere di trattamenti sono soddisfacenti.
Gli scienziati hanno infatti osservato che in condizioni di stress cronico sono le cellule nervose dell'ippocampo a soffrirne, iniziando ad atrofizzarsi. Queste cifre riguardano la depressione autovalutata, non necessariamente quella diagnosticata da operatori sanitari.
L'indagine IES viene effettuata ogni 5 anni. Depression is usually treated with psychotropic drugs, such as those that act on neurotransmitter inhibition, but the results of this kind of treatment are not always satisfactory. A study carried out by a university in Ohio, United States, suggests that there are other drugs and other techniques for treating depression. The most common alternatives appear to be electrical and magnetic brain stimulation, long-term cognitive-behavioural therapy for stress management, or even a new generation of drugs that do not target neurotransmitters.
The reason why neurotransmitter-targeting drugs were developed was that for many years depression was thought to be caused by a lack of these chemical messengers. In contrast, the new theories about depression are focusing on differences in neuron density in various regions of the brain, the effects of stress on the birth and death of brain cells, alterations in brain feedback pathways and the role of brain inflammation caused by the response to stress. It is thought that chronic stress itself may be intimately involved in the development of depression, since over the long term stress damages cells in both the body and the brain.
Scientists have in fact observed that nerve cells in the hippocampus suffer under chronic stress conditions and begin to atrophy. The prevalence levels varied significantly, from 0. These figures are on self-reported depression, not necessarily diagnosed by a health professional. The next wave is foreseen for Nuove pillole contro i dolori da artrite.
Questa scoperta potrebbe portare alla creazione di nuovi farmaci contro questo genere di dolori. I ricercatori hanno rilevato che il rimedio riduce in modo significativo i dolori, anche forti, nel 90 per cento dei casi e in particolare i dolori alle mani. L'osteoartrite, infatti, colpisce proprio le articolazioni rendendo spesso difficile compiere le normali azioni quotidiane come aprire un barattolo, tenere le posate in mano o allacciarsi le scarpe. I test hanno poi dimostrato che l'estratto ha un effetto a lungo termine. A Danish research team has been examining the therapeutic properties of rose hips for arthritic pain.
This discovery could lead to the development of new drugs to treat this kind of pain. The study was conducted on 30 osteoarthritis patients with problems in either their upper or their lower limbs. Another component of interest is lycopene, an antioxidant that helps to reduce LDL cholesterol levels and fight ageing and inflammation. The tests showed that the extract has a long-term effect. Is the Commission aware of the study in question and does it plan to allow rose hip pills to be marketed in the European Union?
Applications for an authorisation for a medicine containing rosehip as active substance to relieve arthritic pain have to be submitted to the Competent Authority of a Member State. An authorisation is only granted if the benefit-risk balance is favourable. Applicants must demonstrate the quality, safety and efficacy of his product.
Applications for a registration are also submitted to and evaluated by the Competent Authority of a Member State. In addition to demonstrating the quality of the product, the applicant has to provide data on the traditional use of the product, in particular it proves not to be harmful and its efficacy is plausible on the basis of long-standing use and experience. However, the labelling, presentation and advertising must not attribute to food supplements the property of preventing, treating or curing a human disease, or refer to such properties.
The classification of a product as food or medicine is the responsibility of the Member States, taking into account all the characteristics of the final product, not only of the ingredients it contains. Ritiene che la riduzione dell'aliquota sul latte di soia possa incentivare un'economia a basso impatto ambientale? I prodotti alimentari, comprese le bevande e quindi il latte di soia, rientrano in tale opzione. In view of this, can the Commission clarify whether soya milk is also taxed as a luxury good in other Member States?
Does it consider that a reduction in the rate on soya milk could incentivise an economy with low environmental impact? Does it consider that Europe-wide coordination action is necessary in this matter? Foodstuffs, including beverages and therefore soya milk, are covered by such an option. VAT is not primarily designed to incentivise or favour a particular sector but rather to efficiently collect revenue in a simple and neutral way.
Therefore other more targeted policy measures will be more effective. Sperimentazione di un nuovo farmaco contro diverse malattie autoimmuni. Si tratta di globuli bianchi che esprimono il gene FOXA1, responsabile dello sviluppo delle cellule con funzioni soppressive nei confronti delle cellule T. Il team di ricercatori ha esaminato il sangue dei pazienti con sclerosi multipla prima e dopo due anni di trattamento con il farmaco interferone-beta. I risultati dei test hanno mostrato che i pazienti trattati con questo farmaco avevano visto aumentare il numero di questo nuovo tipo di cellule del sangue che combattono la malattia.
La fase attuale di ricerca prevede una serie di test con cui valutare se i nuovi linfociti FOXA1 possano impedire il deterioramento dello strato di mielina delle cellule nervose e la degenerazione cerebrale in un modello di sclerosi multipla progressiva. Inoltre, questa terapia potrebbe avere risvolti importanti anche nella cura di altre malattie autoimmuni come il diabete di tipo 1 o l'artrite reumatoide. Non sono disponibili dati o registri ufficiali sull'incidenza delle malattie autoimmuni in Europa. Due terzi dei pazienti sono donne. Si riportano in allegato i dati relativi alle dimissioni ospedaliere per casi di sclerosi multipla registrate nel e ripartite per sesso.
Some pathologies, such as multiple sclerosis, are marked by a chronic inflammation of the brain, which is believed to be caused by hyperactivity of the immune system involving the immune cells known as T cells. A Danish research team has discovered some blood cells which are able to combat hyperactive T cells and, consequently, the cerebral inflammation they cause. These are white cells which emit the gene FOXA1, responsible for the development of cells which can suppress T cells. By stimulating the activity of these regulatory cells, the scientists have been able to reduce significantly the level of cerebral inflammation and illness.
The research team has examined the blood of multiple sclerosis patients before and after two years of treatment with the drug interferon beta. The test results showed that patients treated with this drug had experienced an increase in the number of this new type of blood cell which combats the disease. The current stage of the research provides for a series of tests to evaluate whether the new FOXA1 lymphocytes can prevent the deterioration of the myelin layer of the nerve cells and cerebral degeneration in a progressive multiple sclerosis model.
Also, this therapy could also have significant implications for the treatment of other autoimmune diseases such as type 1 diabetes or rheumatoid arthritis. There are no official available data or registries on the incidence of auto immune diseases in Europe. The report includes best estimates on prevalence and incidence of Multiple Sclerosis by gender and age group in Europe.
In annex, data is provided on hospital discharges for multiple sclerosis in by gender. Tre ragazzini intossicati in una piscina a Roma. I tre minori sono ricoverati in gravi condizioni e sottoposti a un trattamento in camera iperbarica. Sono intervenuti i carabinieri della stazione Madonna del Riposo, che sono in attesa di una relazione dei vigili del fuoco che hanno ispezionato la struttura e per verificare con esattezza la causa del malore dei tre ragazzini.
Chi deve essere considerato responsabile dell'incidente in casi simili a quello descritto? La regolamentazione delle strutture per il tempo libero, come le piscine, compresi anche gli aspetti legati all'enforcement, rientrano nelle competenze degli Stati membri. Non esistono attualmente norme europee. The three children were taken to hospital in a serious condition and treated in a hyperbaric chamber.
In view of this incident, can the Commission clarify whether any specific European standards exist in relation to safety in premises of this kind? Who should be held responsible for the incident in cases similar to the one described? The regulation of safety of leisure services such as swimming pools, including the enforcement falls into the competence of Member States.
There are currently no European standards in place. Liability is determined in accordance with the applicable national rules. Utilizzo dei semi di uva per ridurre gli effetti collaterali della chemioterapia. La ricerca effettuata ha anche mostrato che il vinacciolo assunto per via orale ha ridotto in modo significativo l'infiammazione e i danni ai tessuti causati dalla chemioterapia nel piccolo intestino, senza danneggiare le cellule non tumorali, agendo quindi selettivamente sulle cellule tumorali.
In linea di principio, la Commissione europea non valuta progetti di ricerca che non siano direttamente legati ai suoi finanziamenti. I finanziamenti unionali per la ricerca sono erogati in base a concorsi in forma di inviti a presentare proposte ed in seguito a una valutazione indipendente tra pari. L'azione dell'UE in materia di cancro si basa sulle migliori evidenze scientifiche disponibili. La Commissione non intende tuttavia promuovere specificamente lo studio menzionato dall'Onorevole deputato. A medical study carried out by an Australian university has been looking at how to reduce the side effects of chemotherapy by analysing grape seeds, which contain active substances that are particularly useful in this case.
These are tannins and polyphenols, anti-inflammatory agents that can reduce side effects and increase the efficacy of chemotherapy used in the treatment of bowel cancer, one of the most common forms of cancer and one that is rather difficult to treat. Is it aware of similar studies carried out by European universities or research centres? Does it intend to promote this study, given that the incidence of cancer is still rather high among Europeans?
As a matter of policy, the European Commission does not assess research projects that do not directly relate to its funding activities. EU action on cancer is based on the best available scientific evidence.
The Commission does not however intend to specifically promote the study referred to by the Honourable Member. Vitamina C e rischio di ictus emorragico. I ricercatori francesi alla guida dello studio hanno coinvolto 65 persone che avevano subito un ictus emorragico intracerebrale, ossia una rottura dei vasi sanguigni all'interno del cervello, per poi confrontare i dati relativi alla loro condizione con quelli di 65 persone sane.
Alla luce di quanto esposto, si chiede alla Commissione se intende promuovere campagne di sensibilizzazione a favore del consumo di cibi contenti vitamina C, al fine di garantire un apporto vitaminico sufficiente a ridurre il rischio di ictus e altre patologie legate alla carenza di tale vitamina. Spetta agli Stati membri monitorare la situazione nutrizionale della popolazione e decidere se desiderano o meno introdurre misure per ovviare a un'assunzione insufficiente di nutrienti essenziali.
Per quanto concerne le campagne di sensibilizzazione, l'educazione alla salute rientra nelle competenze degli Stati membri. La Commissione sostiene gli sforzi condotti a livello nazionale. In cooperazione con gli Stati membri la Commissione si adopera per promuovere il consumo di frutta e verdura. A very recent study has shown that eating foods rich in vitamin C may help to reduce the risk of the most common type of haemorrhagic stroke, and that on the other hand a deficiency may increase the risk significantly.
The French researchers leading the study recruited 65 people who had suffered an intercerebral haemorrhagic stroke, that is, a rupture of the blood vessels in the brain, and compared the data relating to their condition with those of 65 healthy people. The study has also shown that vitamin C appears to offer other benefits such as the production of collagen, a protein found in bones, skin and tissues. In view of the above, does the Commission intend to promote awareness campaigns to encourage consumption of foods containing vitamin C, so as to ensure a vitamin intake sufficient to reduce the risk of stroke and other pathologies associated with a deficiency of this vitamin?
The European Food Safety Authority acts as a risk assessor and provides independent scientific advice. With regard to the recommended levels of vitamin C intake, the Commission has asked the European Food Safety Authority to advice on population reference intakes of micronutrients in the diet, which includes advice on vitamin C, in the context of a balanced diet which, when part of an overall healthy lifestyle, contributes to good health through optimal nutrition.
It is the responsibility of Member States to monitor the nutritional situation of the population, and to decide whether or not they wish to introduce measures to address insufficient intake of essential nutrients. Regarding awareness campaigns, health education is within the competence of Member States. The Commission is supporting national efforts. In cooperation with the Member States the Commission works on promoting the consumption of fruits and vegetables.
Rivalutazione del capitale della Banca d'Italia. La legge italiana n. Il capitale di BI passa da milioni di lire definito nel a un valore attuale di 7,5 miliardi di Euro. La riforma ha anche provocato la modifica degli art. Se le riserve di BI sono da considerare risorse pubbliche o utili liberamente distribuibili ai soci di BI o destinabili ad aumenti di capitale di BI? Any unsold shares may be bought back by BI. An important step in this event is the privatisation of the public banks which in substantially allowed the transfer of Banca d'Italia shares from public sector bodies to bodies in the process of privatisation.
In the period leading up to privatisation no proper revaluation of BI shares took place. Since we are unaware of any voluntary notification by the Italian State, can the European Commission verify:. Whether the ability to sell shares in BI and for BI to buy back its own shares where shareholdings to be sold to third parties remain unsold may be considered state aid, incompatible with the rules of the Union? The Commission has already sent a request for information to the Italian authorities in order to verify whether there might be elements of state aid in the revaluation of Italy's Central Bank, Banca d'Italia, and, if so, whether they would seem compatible with the internal market.
On that basis, the Commission will decide whether or not to conduct a preliminary examination. Secondo alcune fonti giornalistiche in Pakistan il ventiquattrenne cristiano, Sabir Masih, sarebbe stato torturato ed ucciso dalla polizia. Gli agenti avrebbero dichiarato la morte del ragazzo per suicidio, ma i referti medici rilasciati dopo l'autopsia indicherebbero che il decesso sarebbe sopraggiunto in seguito a gravi ferite interne, causate da torture e abusi.
Secondo la famiglia, il ragazzo non poteva essere l'artefice del reato, in quanto avrebbe passato tutta la giornata al lavoro. Va ricordato che la tortura sarebbe una pratica usata spesso in questo paese e secondo alcune testimonianze, i cristiani arrestati sarebbero vittime di abusi particolarmente violenti. Pare che la polizia, per non far emergere dettagli della violenza, avrebbe intimato alla famiglia di celebrare il funerale il giorno stesso della sua morte e che non sono stati ancora presi provvedimenti verso i presunti responsabili.
Intende far luce sulla vicenda a seguito di questo ennesimo episodio nei confronti dei cristiani che in tutto il mondo vengono perseguitati?
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Sono frequenti le denunce in relazione a torture e maltrattamenti di detenuti e a decessi verificatisi durante la detenzione preventiva in Pakistan. L'associazione non governativa per i diritti umani e l'assistenza ai detenuti ha segnalato 69 decessi avvenuti in carcere nel L'Unione europea ha costantemente ribadito, nel dialogo sui diritti politici e umani con il Pakistan, che lo Stato deve garantire il rispetto dei diritti umani fondamentali e la protezione di tutti i cittadini, compresi quelli appartenenti a minoranze religiose.
Some news sources in Pakistan are reporting that a twenty-four year old Christian, Sabir Masih, has been tortured and killed by police. It is said that the officers reported that the young man had committed suicide, but medical records released after the autopsy show that death occurred following serious internal injuries, caused by torture and abuse. According to his family, the young man could not have been responsible for the offence, since he spent the whole day at work. It is recalled that torture is a practice frequently used in that country, and according to some witnesses, any Christians who are arrested are subjected to particularly violent abuse.
It appears that in order to prevent the details of the violence emerging, the police pressured the family to hold the funeral on the same day as the death, and no action has yet been taken against the suspects. Is the High Representative aware of this event, and of the many other cases occurring in the country in recent years? Does the Commission intend to look into this issue, following this latest of many episodes against Christians who are persecuted throughout the world?
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Allegations of torture and mistreatment of detainees as well as deaths in police custody are frequent in Pakistan. According to reports the police often state that these occur when suspects attempt to escape or commit suicide. The incidents affect both Muslims and religious minorities, but many minority advocates contend that minorities are more often subject to mistreatment by the police than Muslims. Uzgoj industrijske konoplje i njezinih nusproizvoda. The European hemp industry depends in large part on the political and economic framework of the European Union.
Aspects of greening can make a significant contribution to the cultivation of hemp as an environmentally friendly crop. Additionally, more and more requirements must now be met to obtain certificates for all types of biomass. All of this should help to expand hemp production in the near future, given the increased demand for it in the construction, automotive and food industries. Producers are forced to securely destroy the remainder of this highly valuable plant.
What would the Commission recommend in terms of European greening policy and the greening of industry? Besides the oil that is obtained from hemp seeds, multiple new uses have been developed for its fibres and shives. The fibre is mainly used for cigarette paper, insulation material and bio-based composites, while the shives are mainly used for animal bedding and construction. For the purpose of direct payments, only varieties which have tetrahydrocannabinol content not exceeding 0.
Member States are obliged to introduce a system to verify the tetrahydrocannabinol content of the hemp crops. Croatian authorities can get in contact with the authorities of the main producer Member States France, UK and the Netherlands to be informed on how they implement the corresponding EU legislation.
Linee-guida e Raccomandazioni
The Commission has highlighted the potential of sustainable bio-based products in the context of efforts to promote the transition towards a green economy, including in the Roadmap to a Resource Efficient Europe, the Bioeconomy Strategy and the communication for a European Industrial Renaissance. Namjerava li Komisija poduzeti konkretne korake u tom smjeru? Furthermore, Parliament has adopted a report on the maritime dimension of the Common Security and Defence Policy calling for EU funds to be used to finance naval dockyards.
Does the Commission intend to take specific steps in that direction? Zbog toga je Komisija They faced multiple bureaucratic barriers and had to have a variety of documents verified. If public documents were to be standardised, how much could EU citizens expect to save in the first year of standardisation? A recent meta-analysis of prospective and retrospective clinical trials demonstrated that severe hypoglycemia doubled the risk of cardiovascular events [EL 2; MNRCT] , while an observational trial showed that, over a period of 5 years, mortality was 3.
The proposed mechanism for these effects posits that hypoglycemia reduces baroreceptor sensitivity and increases sympathoadrenal system activity, which can trigger a fatal ventriculararrhythmia in the setting of reduced baroreflex sensitivity [EL 4; NE]. Other short- and long-term consequences of severe hypoglycemia include neurologic conditions ranging from temporary cognitive impairment to dementia as well as major vascular events such as stroke, myocardial infarction, acute cardiac failure, ventricular arrhythmias, and sudden death [EL 4; NE]; [EL 4; NE]; [EL 4; NE].
The complications of hypoglycemia are also associated with short-term disability and higher healthcare costs [EL 4; NE]. Hypoglycemia is the primary limiting factor in the treatment of both T1D and T2D. It remains a significant barrier in terms of treatment adherence and achievement of glycemic goals [EL 4; NE]. Long-term management of hypoglycemia depends on appropriate adjustment of therapy to prevent hypoglycemia or reduce its frequency and severity in patients prone to hypoglycemia e.
In T2D, hypoglycemia typically occurs in association with use of exogenous insulin, sulfonylureas especially glyburide [EL 1; MRCT] , and glinides; symptoms may be mild, moderate, or severe. The risk of hypoglycemia may be further increased by the addition of other antihyperglycemic agents to sulfonylureas or insulin. Therefore, in adults with T2D, treatment strategies should emphasize classes of pharmaceutical agents that are not associated with severe hypoglycemia, many of which are available Table 9.
Also, the role of hypoglycemia must be considered in determining ideal A1C goals for each patient. SMBG is an important tactic to help patients document hypoglycemia, although it is essential that the glucose meter meet accuracy standards. Patients who have marked swings in glucose levels are particularly susceptible to hypoglycemia unawareness. The majority of persons with T2D either have uncontrolled hypertension or are on treatment for elevated blood pressure [EL 3; SS]. Hypertension is not only more prevalent in persons with T2D than in the general population, it also predicts progression to DM.
Once diagnosed with hypertension, an individual is 2. The combination of hypertension and DM magnifies the risk of DM-related complications. Numerous other studies have also demonstrated decreased nephropathy and retinopathy progression. Once the diagnosis of hypertension is established, the data are clear that blood pressure lowering prevents both micro- and macrovascular complications associated with DM. Analysis of the UKPDS data suggests that blood pressure lowering should be the first priority in managing a patient presenting with newly diagnosed hypertension and DM. While glucose and lipid management remain important, blood pressure lowering will have the greatest and most immediate impact on morbidity and mortality [EL 1; RCT]; [EL 1; RCT, questionnaires and other variables may have confounded].
Accurate measurement of blood pressure remains fundamental to the diagnosis and effective management of hypertension 8 [EL 4; NE]. The equipment, which can be aneroid, mercury, or electronic, should be inspected and validated on a regular maintenance schedule. Initial training and regularly scheduled retraining in the standardized technique provides consistency in measurements. The patient must be properly prepared and positioned; blood pressure should be measured after being seated quietly for at least 5 minutes in a chair rather than on an exam table , with feet on the floor and arm supported at heart level.
Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement. Measurement of blood pressure in the standing position is indicated periodically, especially in those at risk for postural hypotension. At least 2, and preferably 3, measurements should be made and the average recorded. While hour ambulatory blood pressure monitoring ABPM is not included as part of the diagnostic criteria for hypertension, it has become an important tool for guiding patient management.
Routine use of ABPM, at least annually, should be considered for the evaluation of white coat hypertension, masked hypertension, and nighttime nondipping status, all of which are associated with increased long-term morbidity and mortality. Blood pressure targets are based upon the combination of data from clinical trials and epidemiology studies and should be individualized for patients with consideration of their anticipated lifespan and risk factors for heart disease and stroke e.
Frequent reassessment is needed to ensure that the blood pressure goal is maintained without unacceptable adverse effects. The selection of medications can be guided by disease and ethnic-specific considerations. Whether any class is superior to another is no longer considered when choosing therapy because most patients with DM will need at least 2 to 4 drugs to achieve target blood pressure. The choice of pharmacologic agents is guided by additional considerations such as the presence of albuminuria, CVD, heart failure, or postmyocardial infarction status; possible metabolic side effects; number of pills per day; and cost.
Early in the disease process, the primary concerns will be slowing of nephropathy and retinopathy while minimizing impact on triglycerides Table As heart disease develops, consideration of cardiovascular benefits factor into the choice of agents for blood pressure lowering; given that diastolic heart disease develops early in T2D, the use of ARBs could be considered earlier, before the diagnosis of systolic heart failure. However, the combination of multiple RAAS blockers i. The UKPDS study group performed a year post trialmonitoring observational study that demonstrated a loss of benefit within 2 years if tight blood pressure control was not maintained [EL 1; RCT, questionnaires and other variables may have confounded].
These data reinforce the imperative to initiate blood pressure-lowering therapy with continued reinforcement to maintain compliance with therapy. The introduction of fixed-dose combination tablets combining 2 or 3 agents in 1 pill has facilitated patient compliance and adherence with multidrug regimens and should be encouraged as part of initial therapy. The use of multiple fixed-dose combination tablets can provide a 4-drug regimen with just 2 tablets, thus allowing a patient to reach their blood pressure goal while optimizing compliance with therapy. Risk stratification in this manner can guide management strategies.
In prediabetes and DM, multiple disturbances in lipoprotein metabolism result from the combined effects of insulin deficiency, insulin resistance, and hyperglycemia. T2D dyslipidemia is characterized by increased levels of triglyceride-rich lipoproteins very low-density lipoprotein, intermediate-density lipoprotein, and remnant particles , low levels of HDL-C, and increased levels of small, dense LDL-P [EL 4; review NE].
Patients who have T1D with persistent proteinuria are at particularly increased risk of premature atherosclerosis [EL 4; NE]. However, the rising prevalence of overweight and obesity may contribute to increased rates of the lipid and lipoprotein pattern related to insulin resistance among prediabetic individuals and those with T2D [EL 1; RCT]. All patients should receive information about physical activity recommendations, a meal plan designed to improve glucose and lipids, and cardiovascular risk reduction strategies.
Lipids should be rechecked within 12 weeks. The combination of a statin with another lipid-lowering agent may be required to achieve these targets. In such patients, treatment should begin with therapeutic lifestyle changes for an initial 6- to 8-week trial. In patients younger than 40 years, initiation of statin therapy for primary prevention of CVD in both males and females needs to be individualized, based on other risk factors and comorbidities. The use of various year or life-time risk calculators is an option to decide the intensity of treatment, but currently available risk calculators lack sufficient accuracy and are limited by discrepancies between predicted and observed event rates [EL 4; NE]; [EL 4; NE].
No study has yet been designed to investigate the cardiovascular outcomes benefit of adding bile acid sequestrants, niacin, or cholesterol absorption inhibitors to statins in patients whose atherogenic markers LDL-C, non-HDL-C, ApoB, and LDL-P are not already at target levels. Such patients should be monitored closely to determine whether statin dose adjustment is necessary depending on comorbidities, drug interactions, and renal status [EL 4; NE]; [EL 4; NE].
Two separate RCTs tested the HDL-C-raising hypothesis in patients with coronary artery disease optimally treated with statins with or without ezetimibe. However, in other settings, where the goals of these atherogenic markers have not been met, niacin remains a viable treatment option. The principles and goals of lipid management in prediabetes are the same as those for DM described previously Table 7.
No randomized intervention trials dedicated to patients with prediabetes use ASCVD events as outcome measures. Diet, exercise, and weight loss or maintenance should be emphasized for all prediabetes patients. Low HDL-C is also common in prediabetes. Niacin is effective in raising HDL-C, but it also increases insulin resistance and may accelerate the appearance of overt DM.
Fibrates may be considered, but the use of gemfibrozil is discouraged owing to its interaction with statin clearance and the risk for severe rhabdomyolysis. Meta-analyses of statin RCTs indicate that statin use is associated with significant increases in the risk of progression to T2D among patients with prediabetes: Patients with prediabetes should be warned of the potential added risk of conversion to DM with statin use.
Diabetic nephropathy is represented histologically by the presence of basement membrane thickening, mesangial expansion, podocyte loss, and nodular or diffuse glomerulosclerosis [EL 4; NE]. The pathologic changes, which modestly correlate with the degree of kidney injury as measured by blood and urine tests, are typically present before functional tests are positive [EL 4; NE].
Consequently, prevention of microvascular complications such as nephropathy should be started upon diagnosis of DM and be intensified in those with evidence of kidney damage. The AACE concurs with both guidelines in general. The KDIGO guidelines recommend phasing out the term microalbuminuria and replacing it with the term albuminuria.
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Testing for the presence of albuminuria can be done using a spot urine sample or a timed collection. Urinary albumin may be seen in the setting of urinary tract or systemic infection, after exercise, or in the presence of hematuria, so confirmation is necessary to establish the diagnosis of diabetic nephropathy. Sudden onset or rapidly increasing AER should prompt additional tests to rule out other kidney diseases.
Table 14 lists correlations between AER, urine dipstick, and tests of total protein excretion. Intensive glucose control has not been shown to diminish the progression of diabetic nephropathy or cardiovascular mortality in patients with advanced CKD, but these patients have an increased risk of hypoglycemia, so glycemic targets and therapies may need to be modified as diabetic nephropathy progresses.
How is hypertension managed in patients with diabetes? Patients with DM and CKD up to stage 4, including posttransplant patients, benefit from lipid lowering with statins. Slowing the progression of kidney dysfunction is critical for patient survival and quality of life. The RAAS-blocking drugs may potentiate hyperkalemia and may cause harm when used with nonsteroidal anti-inflammatory drugs NSAIDs or in patients with renovascular hypertension or dehydration. They are not safe for use in pregnancy. Data on the use of aldosterone antagonists with ACE inhibitors or ARB classes is limited, but the same cautions apply.
If the GFR continues to decline despite excellent glycemic and blood pressure control, protein restriction may be of some benefit. KDIGO recommends limiting protein intake to 0. Additional dietary restrictions may be required to control potassium and phosphorus levels. Salt intake should be limited to 2 g per day in all patients with DM who require antihypertensive medications. Obesity is a risk factor for hypertension and incident CKD, so weight loss along with exercise is recommended for patients with DM without evidence of kidney disease as well as patients with category G2 to G4 CKD.
Unintended weight loss is associated with poorer outcomes in dialysis patients. Patients with CKD are at risk for drug toxicity and acute kidney injury. Antihyperglycemic therapies should be modified to reduce excessive drug exposure and hypoglycemia [EL 3; CSS]. Many other drugs should be avoided or used with caution in patients with CKD. Patients should be informed of their CKD diagnosis and should avoid dehydration and imaging that requires gadolinium, high phosphate-containing bowel preparations, or high doses of iodinated contrast dyes.
Patients with diabetic nephropathy should undergo annual or more frequent assessment of electrolytes to assess potassium and acid-base status; blood counts to assess anemia status; and calcium, phosphorus, vitamin D, and parathyroid hormone PTH measurements to assess mineral metabolism [EL 4; NE]. Hyperkalemia is managed by dietary restriction and adjustment of antihypertensive medications.
Iron given intravenously may produce better results than oral replacement. Active vitamin D preparations may be necessary to keep the PTH level from increasing as kidney function declines. Hyperphosphatemia should be corrected into the normal range with dietary modification and judicious use of phosphate binders. Referral to a nephrologist is appropriate when the presentation is atypical, progression of albuminuria or decline in eGFR is rapid, or when secondary manifestations of CKD require expert advice.
Referral of patients with stage 4 CKD to a nephrologist allows time for sufficient planning to accommodate individual patient needs [EL 4; opinion NE]. Renal transplantation is the preferred replacement therapy for patients with DM and ESRD because long-term outcomes are superior to those achieved with dialysis. For patients with T1D, the possibility of combined kidney-pancreas transplantation allows for considerably better outcomes [EL 2; PCS]. Diabetic retinopathy is the leading cause of blindness in adults. The lesions of diabetic retinopathy include background or nonproliferative retinopathy, macular edema, preproliferative retinopathy, and proliferative retinopathy.
Higher levels of glucose and blood pressure, as well as the presence of nerve and renal diabetic complications, are associated with greater likelihood of developing retinopathy [EL 3; SS]. The goal is to detect clinically significant retinopathy before vision is threatened. Funduscopy performed by internists or endocrinologists is often suboptimal; therefore, referral to an experienced ophthalmologist for an annual dilated eye examination is recommended [EL 2; MNRCT].
The complete ophthalmologic examination can also detect other common conditions such as cataracts, glaucoma, and macular degeneration. The use of nonmydriatic fundus cameras equipped with digital transmission technology enables large-scale, POC screening for retinopathy [EL 3; SS]. Patients with abnormal retinal photographs are then triaged to full examination by an ophthalmologist. This 2-step approach can be an efficient strategy for retinopathy screening at the population level, particularly in remote areas [EL 3; SS].
However, the system is still under development and does not replace the current recommendation for an annual dilated eye examination by an ophthalmologist from the time of diagnosis because of the lag between onset and diagnosis of T2D [EL 3; CSS]. As retinopathy develops over a period of 5 or more years from initial hyperglycemia, screening should be initiated within 5 years of diagnosis in patients with T1D [EL 3; SS]. Pregnancy is a risk factor for progression of retinopathy, and ophthalmologic examinations should be performed repeatedly during pregnancy and for 1 year postpartum [EL 2; PCS, longitudinal follow-up study].
Patients with active lesions may be followed up more frequently, while those who have had repeatedly normal eye findings can be seen less frequently. Good control of glycemia and blood pressure are also effective in slowing the progression of pre-existing background retinopathy. Research into other novel pharmacologic agents with potential benefits may lead to additional medical treatments [EL 1; RCT, small sample size]. Panretinal scatter laser photocoagulation is the treatment of choice for high-risk proliferative retinopathy [EL 4; review NE]. For macular edema, the combination of focal laser photocoagulation with intravitreal antivascular endothelial growth factor modalities appears to offer optimal benefit [EL 1; MRCT].
Vitrectomy is reserved for patients with persistent vitreous hemorrhage or significant vitreous scarring and debris [EL 4; review NE]. It is a major cause of falls in older patients that lead to lacerations, fractures, and traumatic brain injuries [EL 4; NE]. Diabetic neuropathy is a set of clinical syndromes that affect distinct regions of the nervous system, singly or in combination. It may be silent and go undetected while exercising its ravages, or it may present with clinical symptoms and signs that, although nonspecific and insidious with slow progression, also mimic those seen in many other diseases.
Diabetic neuropathy is, therefore, diagnosed by exclusion. Unfortunately neither endocrinologists nor nonendocrinologists have been trained to recognize the condition, and even when diabetic neuropathy is symptomatic, less than one-third of physicians recognize the cause or discuss this with their patients [EL 1; RCT].
Diabetic neuropathy encompasses multiple different disorders involving proximal, distal, somatic, and autonomic nerves. It may be acute and self-limiting or a chronic, indolent condition. It may be focal such as a mononeuritis involving single nerves or entrapment neuropathies e.
Proximal lumbosacral, thoracic, and cervical radiculoplexus neuropathies involving the proximal limb girdle are, for the most part, inflammatory demyelinating conditions requiring immunotherapy and, if caught early, are reversible [EL 4; NE]; [EL 4; review NE]; [EL 4; position NE]; [EL 4; NE]. They may be acute or chronic. Because of the lack of agreement on the definition and diagnostic assessment of neuropathy, several consensus conferences were convened to overcome the current problems. Several reviews discuss useful approaches to the treatment of the common forms of diabetic neuropathy, as well as algorithms for pain management, diagnosis, and treatment of the manifestations of autonomic neuropathy [EL 4; review NE]; [EL 4; review NE].
However, no treatments have been approved for the prevention or reversal of diabetic neuropathy. Once large-fiber diabetic neuropathy has been diagnosed, therapy should be initiated to reduce symptoms and prevent further progression. It is vitally important to institute measures to prevent foot ulcers that lead to amputations.
In general these are daily inspection, protective socks, appropriate footwear, and avoidance of injury. Patients with DM who have large-fiber neuropathies are uncoordinated and ataxic and are 17 times more likely to fall than their counterparts without neuropathy [EL 2; RCCS]. Low-impact activities that emphasize muscular strength and coordination and challenge the vestibular system such as a Bosu ball; use of rubber bands to strengthen lower limb muscles; and Pilates, yoga, and Tai Chi to strengthen the body core, may also be particularly helpful [EL 2; PCS, small sample size]; [EL 2; PCS, small sample size].
Small-nerve fiber dysfunction usually occurs early and is often present without objective signs or electrophysiologic evidence of nerve damage [EL 3; SS]. Skin punch biopsy, a minimally invasive procedure, allows morphometric quantification of intraepidermal nerve fibers. Intraepidermal nerve fiber density inversely correlates with both cold and heat detection thresholds [EL 3; CSS].
Intraepidermal nerve fiber density is also reduced in painful neuropathy compared with that observed in painless neuropathy [EL 3; SS]. These data suggest that intraepidermal nerve fiber loss is an early feature of the metabolic syndrome, prediabetes, and established DM, and the loss progresses with increasing neuropathic severity. There may be nerve regeneration with treatment. Noninvasive tests of small nerve fiber function have recently been recognized. Corneal confocal microscopy may be used to detect small nerve fiber loss in the cornea.
This technique correlates with neuropathy severity and can be used to monitor responses to transplantation and other procedures [EL 3; CSS]. Contact heat-evoked potentials use nociceptive heat as a stimulus, and the response is recorded through electroencephalographic readings. Sudomotor function assesses the sweat response by analyzing sweat production or sweat chloride concentrations and detects early neurophysiologic abnormalities in peripheral autonomic function [EL 2; PCS]. Strategies for management of SFN include simple measures that can protect the foot deficient in functional C fibers from developing ulceration, and therefore, from gangrene and amputation.
Patients should inspect the plantar surface of their feet with a mirror on a daily basis and test bathwater with a part of the body that is not insensate before submerging a numb foot. Patients should also be cautioned against falling asleep in front of the fireplace with their insensate feet close to the fire. Emollient creams can moisturize dry skin and prevent cracking and infection.
Symptoms are usually associated with clinical signs of peripheral neuropathy, although occasionally in acute neuropathic pain, symptoms may occur in the absence of signs. A number of simple numeric rating scales can be used to assess the frequency and severity of painful symptoms [EL 4; review NE] , and other causes of neuropathic pain must be excluded. Outcome measures to assess response to therapy should include patient-reported improvements in the measures and numeric rating scales [EL 4; review NE] , including the Neuropathic Pain Symptoms Inventory, the Brief Pain Inventory, and the Neuropathic Pain Questionnaire.
Physicians must be able to differentiate painful diabetic neuropathy from other unrelated or coexisting conditions. The algorithm provided Fig. The FDA has approved only the serotonin and norepinephrine reuptake inhibitor duloxetine, the anticonvulsant pregabalin, and the opioid tapentadol for neuropathic pain, but level 1 evidence also exists to support the use of tricyclic antidepressants e.
Recent studies have highlighted metformin-associated B12 deficiency, which can lead to neuropathy-like symptoms. Cardiovascular autonomic neuropathy is significantly associated with overall mortality [EL 4; review NE]; [EL 2; MNRCT] and in some studies, but not all, with morbidity including silent myocardial ischemia, coronary artery disease, stroke, diabetic neuropathy progression, and perioperative morbidity.
Some pathogenetic mechanisms may link cardiovascular autonomic neuropathy to cardiovascular dysfunction and diabetic complications [EL 4; review NE]. Cardiovascular autonomic neuropathy assessment may be used for cardiovascular risk stratification in patients with and without established CVD, as a marker for patients requiring more intensive monitoring during the perioperative period and other physiological stresses, and as an indicator for more or less intensive pharmacotherapeutic and lifestyle management of comorbid conditions. Cardiovascular autonomic neuropathy may be useful for prediction of cardiovascular risk, and a combination of cardiovascular autonomic neuropathy [EL 3; SS] and symptoms of peripheral neuropathy increase the odds ratio to 4.
Indeed, this is the strongest predictor of CVD risk, far greater than blood pressure, lipoprotein profile, and even adenosine scans [EL 4; NE]. The reported prevalence of diabetic autonomic neuropathy varies widely 7. All the manifestations of autonomic nerve dysfunction, along with suggested testing, the symptom complex, and possible therapies, are listed in Table 15 [EL 3; CSS]. Cardiovascular reflex tests are the criterion standard in clinical autonomic testing [EL 4; position NE]. The most widely used tests assessing cardiac parasympathetic function are based on the time-domain heart rate response to deep breathing, a Valsalva maneuver, and postural change.
Valsalva maneuvers must not be performed in patients with proliferative retinopathy. Cardiovascular sympathetic function is assessed by measuring the blood pressure response to orthostatic change and a Valsalva maneuver. The combination of cardiovascular autonomic tests with sudomotor function tests may allow a more accurate diagnosis of diabetic autonomic neuropathy [EL 4; NE].
Frequency domain measurements of the total spectral power, the standard deviation of normal R-R intervals, and the root means squared of the standard deviation of R-R intervals have recently been shown to be the most sensitive indicator of autonomic imbalance. Patients with DM and features of cardiac autonomic dysfunction such as unexplained tachycardia, bradycardia, orthostatic hypotension, and poor exercise tolerance or those with other symptoms of autonomic dysfunction should be evaluated for the presence of cardiovascular autonomic neuropathy. Screening for cardiovascular autonomic neuropathy should be performed at diagnosis of T2D and 5 years after the diagnosis of T1D.
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Retrospective and prospective studies have suggested a relationship between hyperglycemia and the development and severity of diabetic neuropathy, as well as significant effects of intensive insulin treatment on prevention of neuropathy [EL 4; review NE]. Older adults taking statins show a greater benefit than younger adults because of their higher attributable risk of CVD [EL 4; review NE].
A modest association between statin use and peripheral neuropathy was found in a review of the National Health and Nutrition Examination Survey NHANES data, but the authors cautioned not to overinterpret the findings, which may be explained by many uncontrolled, confounding factors, so no causal inference can be made [EL 3; SS]. Small studies in patients with DM have shown that aerobic exercise improved quantitative test results for peripheral nerve function and cardiac autonomic neuropathy [EL 2; PCS].
CVD is increased two- to threefold in patients with DM. In a meta-analysis involving , patients, the rate of fatal coronary heart disease in patients with DM was reported to be 5. Diabetic females had a significantly higher relative fatal cardiovascular risk than males 3. The original 7-year East-West Study in a Finnish population showed that the incidence of myocardial infarction in patients with DM and no preceding myocardial infarction at baseline was equivalent to that of persons without DM who had had a previous myocardial infarction at baseline.
The incidence of myocardial infarction in the diabetic population was almost sixfold greater than the incidence in nondiabetic persons with no previous myocardial infarction at baseline [EL 3; SS]. A subsequent year follow-up of the same cohort confirmed that the patients with DM without evidence of any ischemic heart disease at baseline had as great or a greater risk for CVD-related death and total CVD as persons without DM who had had previous ischemic heart disease at baseline [EL 3; SS]. A nationwide study of 3. It is difficult to quantitatively define the factors responsible for DM being a CVD risk factor because insulin resistance, hypertension, lipid abnormalities, endothelial dysfunction, inflammation, and procoagulant factors are all present in patients with T1D and T2D, as well as in those with less severe forms of hyperglycemia.
Early epidemiologic studies indicated that the age-adjusted cardiovascular event rate for patients with DM was twofold greater than that of the nondiabetic individual at each identical level of systolic blood pressure from to mm Hg [EL 4; review NE]. Patients with DM not only have an increase in risk factors for CVD, but the risk factors cause more disease in a hyperglycemic environment. Comprehensive risk reduction programs have decreased the incidence of acute myocardial infarction in patients with DM by However, Ridker and Cook presented analyses from several large studies suggesting that the new risk prediction algorithm significantly overpredicts event rates [EL 4; NE].
How is dyslipidemia managed in patients with diabetes? Hyperglycemia increases CVD both by its direct effects and indirectly via effects on other cardiovascular risk factors. Intensive glycemic control reduces micro- and macrovascular complications in patients with DM. While neither showed a decrease in myocardial infarction during the trial, both showed reductions in macrovascular events in the intensively treated cohort in long-term extension studies 49 [EL 1; RCT, posttrial monitoring]; [EL1; RCT].
The beneficial effects of intensive glycemic control in reducing vascular complications appear to be inversely related to the extent of vascular disease at the time it is initiated. The duration of the trials was 3. All 3 trials failed to show a significant benefit of intensive glycemic control in reducing new cardiovascular events. A randomized controlled substudy in the VADT trial investigated the utility of measuring coronary artery calcification in predicting subsequent clinical cardiovascular events [EL 1; RCT, posthoc analysis with other methodological limitations]. At the end of the 6-year study, the extent of baseline coronary artery calcification was found to correlate very well with the development of clinical cardiovascular events.
In contrast, there is no such legacy effect of blood pressure control on cardiovascular risk [EL 1; RCT, questionnaires and other variables may have confounded]. The use of aspirin for primary prevention has become controversial owing to recent data showing little to no benefit in certain patient populations 9 [EL 1; MRCT but small sample sizes and event rates]. Adjuvant therapies such as adenosine diphosphate receptor antagonists may also be helpful, especially if peripheral vascular disease is present.
Data from the many clinical trials and observational studies on the use of low-dosage aspirin in the primary prevention of CVD in patients with DM continue to be controversial [EL 1; RCT]. Several recent meta-analyses show no statistically significant benefit on either total cardiovascular outcomes or individual events such as death, myocardial infarction, or stroke 10 [EL 1; MRCT]. Observational studies such as The Fremantle Diabetes Study reported beneficial reductions in all-cause and CVD-related mortality with regular low-dosage aspirin use, particularly in males older than 65 years 12 [EL 2; PCS].
These conflicting findings may reflect the results of studies showing that patients with DM have an increased resistance to the effects of aspirin [EL 1; MRCT]. Although screening for asymptomatic coronary artery disease in patients with T2D does not improve cardiac outcomes, the measurement of coronary artery calcification may be useful in assessing whether some patients with long-standing DM are reasonable candidates for intensification of glycemic control and or lipid lowering. The impression in the past was that diagnosing asymptomatic CVD in patients with DM would result in improved care and better long-term clinical outcomes; however, findings from well-conducted clinical trials have not supported this idea [EL 1; RCT].
The use of coronary calcification scores might help to identify those patients who will receive the most benefit from intensive glycemic control [EL 1; RCT, posthoc analysis with other methodological limitations]. A large prospective study is necessary to validate such an approach. Meanwhile, in those patients with long-standing DM, coronary artery calcification scores could separate those who already have extensive disease from those with significantly less severe disease. The natural history of obesity reflects a small positive energy balance over a prolonged period of time, which produces excess fat storage and adipose tissue mass.
BMI weight in kilograms divided by height in meters squared is used to differentiate normal weight Clinical correlation is required since BMI may not reflect adipose tissue mass in muscular athletes, sarcopenic obesity, paraplegia, frailty, and other conditions. Also, lower BMI criteria for obesity have been recommended for some ethnicities e. While insulin resistance can exist independent of obesity, excess weight gain, particularly with accumulation of fat in ectopic compartments such as visceral adipose tissue, can exacerbate insulin resistance and increase risk for the development of metabolic syndrome, nonalcoholic fatty liver disease NAFLD , hypertension, prediabetes, and T2D.
Whether individuals are insulin sensitive or resistant, increased adiposity can also lead to biomechanical complications of obesity including osteoarthritis, OSA, gastroesophageal reflux disease GERD , urinary stress incontinence, and disability. Thus, primary prevention is needed to prevent obesity, and secondary treatment and prevention is required to stabilize or decrease body weight and prevent the emergence of complications in patients who are overweight or obese without complications. When excess adiposity adversely impacts health by causing obesity-related complications, more aggressive interventions are needed to induce and sustain weight loss and treat the complications [EL 4; NE].
Lifestyle change is a cornerstone for weight management in the patient with or without DM, and includes 3 components: Therefore, healthy meal plans such as the Mediterranean, low carbohydrate, low fat with an emphasis on high-water content, low-energy-dense foods , low glycemic index, DASH Diet which emphasizes fruits, vegetables, and low-fat dairy products , and vegetarian diets have been advocated to take into account personal and cultural preferences that accommodate nutrition guidelines [EL 4; NE]. Caloric reduction is critical for weight loss regardless of the meal plan. Increased physical activity is important for maintaining weight loss.
However, it is important to individualize the prescription for physical activity. Reduction in sedentary behavior can be helpful. The third component of lifestyle focuses on behavior modification [EL 4; NE]. The components of a lifestyle program include education and behavior modification including self-monitoring of food intake and physical activity, learning to cope with negative thoughts by means other than eating, portion control, and consuming meals at regular times and in places where one can focus on the act of eating.
A mental health professional is commonly needed to address issues such as disordered eating and depression, which, if not treated proactively, can jeopardize the effectiveness of lifestyle therapy. The first step in evaluating medications for the overweight patient is to determine whether the patient is taking drugs that produce weight gain, including some antihyperglycemic agents Table 9 , antidepressants, and antiseizure medications [EL 4; NE]; [EL 4; NE]; [EL 1; RCT].
If such agents are identified and there are acceptable weight-neutral or weight loss-inducing alternatives, the healthcare professional should consider changing the medication [EL 4; NE]. Five medicines are approved for long-term use and, therefore, are more useful in the treatment of obesity as a chronic if not lifelong disease. All weight-loss medications are approved for patients with BMI 27 to These drugs vary with respect to efficacy as defined by weight loss in RCTs and differ regarding adverse effect profile, cautions, and warnings. However, these differences enable individualized treatment.
On any treatment program there are patients who do very well and for whom the medication should be continued; for others, the treatment may be ineffective, and the patient may lose little weight or even gain weight. At that point, an alternative weight-loss medication may be prescribed. All weight-loss medications serve as an adjunct to lifestyle modification therapy. Except for orlistat, these medications act to decrease appetite and enhance compliance with a reduced-calorie meal plan.
Therefore, maximal benefit is achieved in conjunction with lifestyle therapy, and all clinical trials demonstrated greater weight loss when the medication was added to lifestyle modification than that achieved with lifestyle modification plus placebo. Bariatric surgery is an effective approach for attaining significant and durable weight loss in severely obese patients with and without DM. Because metabolic as well as weight-related comorbidities are often improved or resolved through weight loss due in part to neuroendocrine mechanisms, the term metabolic surgery is often used instead of bariatric surgery.
In general, metabolic operations alter the GI tract by reducing stomach capacity gastric restrictive operations ; rerouting nutrient flow, leading to some degree of malabsorption bypass procedures ; or combining both concepts. Metabolic procedures have evolved since the jejunoileal bypass was abandoned in the s. A meta-analysis of mostly short-term studies in more than 22, patients showed an overall loss of