Aims/HypothesisDiabetes treatments were related with either an increased or reduced risk of cancer. There is ongoing debate about a potential protective action of metformin. To summarize evidence on the association between metformin and risk of cancer and cancer mortality in patients with diabetes.MethodsData source: MEDLINE and EMBASE (January 1966-April 2012). We selected randomized studies comparing metformin and other hypoglycaemic agents and observational studies exploring the association between exposure to metformin and cancer. Outcomes were cancer mortality, all malignancies and site-specific cancers.ResultsOf 25307 citations identified, 12 randomized controlled trials (21,595 patients) and 41 observational studies (1,029,389 patients) met the inclusion criteria. In observational studies there was a significant association of exposure to metformin with the risk of cancer death [6 studies, 24,410 patients, OR:0.65, 95%CI: 0.53-0.80], all malignancies [18 studies, 561,836 patients, OR:0.73, 95%CI: 0.61-0.88], liver [8 studies, 312,742 patients, OR:0.34; 95%CI: 0.19-0.60] colorectal [12 studies, 871,365 patients, OR:0.83, 95%CI: 0.74–0.92], pancreas [9 studies, 847,248 patients, OR:0.56, 95%CI: 0.36–0.86], stomach [2 studies, 100701 patients, OR:0.83, 95%CI: 0.76–0.91], and esophagus cancer [2 studies, 100694 patients, OR:0.90, 95%CI: 0.83–0.98]. No significant difference of risk was observed in randomized trials. Metformin was not associated with the risk of: breast cancer, lung cancer, ovarian cancer, uterus cancer, prostate cancer, bladder cancer, kidney cancer, and melanoma.Conclusions/InterpretationResults suggest that Metformin might be associated with a significant reduction in the risk of cancer and cancer-related mortality. Randomized trials specifically designed to evaluate the efficacy of metformin as an anticancer agent are warranted.

OBJECTIVE -Within the context of a large, nationwide outcomes research program in type 2 diabetes, we assess the prevalence of self-reported erectile dysfunction and evaluate its impact on quality of life.RESEARCH DESIGN AND METHODS -The study involved 1,460 patients enrolled by 114 diabetes outpatient clinics and 112 general practitioners. Patients were asked to complete a questionnaire investigating their ability to achieve and maintain an erection. Various aspects of quality of life were also assessed depressive using the following instruments: SF-36 Health Survey, diabetes health distress, psychological adaptation to diabetes, depressive symptoms (CES-D scale), and quality of sexual life.RESULTS -Overall, 34% of the patients reported frequent erectile problems, 24% reported occasional problems, and 42% reported no erectile problems. After adjusting for patient characteristics, erectile dysfunction was associated with higher levels of diabetes-specific health distress and worse psychological adaptation to diabetes, which were, in turn, related to worse metabolic control. Erectile problems were also associated with a dramatic increase in the prevalence of severe depressive symptoms, lower scores in the mental components of the SF-36, and a less satisfactory sexual life. A total of 63% of the patients reported that their physicians had never investigated their sexual problems.CONCLUSIONS -Erectile dysfunction is extremely common among type 2 diabetic patients and is associated with poorer quality of life, as measured with generic and diabetes-specific instruments. Despite their relevance, sexual problems are seldom investigated by general practitioners and specialists. Diabetes Care 25:284 -291, 2002E rectile dysfunction (ED) is a common complication of diabetes; the reported prevalence ranges from 35 to 70% (1-8). In the Massachusetts Male Aging Study (9), the age-adjusted probability of complete impotence was three times greater (28%) in patients with treated diabetes than in those without diabetes (9.6%). In addition to its higher frequency, ED also occurs at an earlier age in the diabetic population as compared with the general population (1-10) and is often related to duration and severity of diabetes (4,5,8).Although psychogenic factors, such as performance distress, can contribute to its etiology, ED in diabetic patients is mainly related to organic causes, such as vasculogenic and neurological abnormalities (11,12). The presence of a normal sexual desire and the inability to physically act on that desire can affect patients' lives in different ways, including disorders in interpersonal relationships, interference with sexual life, problems with partners, and increase in mental stress, making ED a major quality of life (QoL) issue (13). Recent pharmacological advances have stimulated a great interest in ED, generating new data concerning its prevalence (4,5,(7)(8)(9)14), treatment (15,16), and costs (17,18). Nevertheless, even in randomized clinical trials, little attention has been given to QoL. Instead...

OBJECTIVE -The role of self-monitoring of blood glucose (SMBG) in type 2 diabetes is still a matter of debate. In the framework of a nationwide outcomes research program, we investigated the frequency of SMBG and its association with metabolic control and quality of life (QoL).RESEARCH DESIGN AND METHODS -The study involved 3,567 patients with type 2 diabetes who were recruited by 101 outpatient diabetes clinics and 103 general practitioners. Patients completed a questionnaire investigating SMBG practice and QoL (diabetes-related stress, diabetes health distress, diabetes-related worries, and Centers for Epidemiologic StudiesDepression scale).RESULTS -Data on SMBG were available for 2,855 subjects (80% of the entire study population). Overall, 471 patients (17%) stated that they tested their blood glucose levels at home Ն1 time per day, 899 patients (31%) tested their blood glucose levels Ն1 time per week, and 414 patients (14%) tested their blood glucose levels Ͻ1 time per week, whereas 1,071 patients (38%) stated that they never practiced SMBG. A higher frequency of SMBG was associated with better metabolic control among subjects who were able to adjust insulin doses, whereas no relationship was found in all other patients, irrespective of the kind of treatment. Multivariate analyses showed that an SMBG frequency Ն1 time per day was significantly related to higher levels of distress, worries, and depressive symptoms in non-insulin-treated patients.CONCLUSIONS -Our findings suggest that SMBG can have an important role in improving metabolic control if it is an integral part of a wider educational strategy devoted to the promotion of patient autonomy. In patients not treated with insulin, self-monitoring is associated with higher HbA 1c levels and psychological burden. Our data do not support the extension of SMBG to this group.

A self-monitoring disease management strategy, primarily led by diabetes nurses and allowing a timely and efficient use of self-monitoring readings, is able to improve metabolic control, primarily through lifestyle modifications leading to weight loss.

Pfizer of Italy.

OBJECTIVE -To evaluate an opportunistic screening strategy addressed to individuals with one or more cardiovascular risk factor, based on the Diabetes Risk Score (DRS) as the initial instrument, for the identification of individuals with type 2 diabetes or impaired glucose tolerance (IGT).RESEARCH DESIGN AND METHODS -The DRS, a simple self-administered questionnaire, was completed by individuals identified by general practitioners and presenting with one or more cardiovascular risk factor. All patients underwent a 2-h oral glucose tolerance test (OGTT). The optimal DRS cutoff was calculated by applying the receiver-operating characteristic curve.RESULTS -Overall, 1,377 individuals aged between 55 and 75 years received an OGTT and completed the DRS. Mean DRS values showed a marked variation according to glucose metabolism categories, as follows: 8.7 Ϯ 3.0 in normoglycemic individuals, 9.5 Ϯ 3.1 in individuals with impaired fasting glucose, 9.9 Ϯ 3.3 in individuals with IGT, and 12.0 Ϯ 3.5 in individuals with type 2 diabetes. The receiver-operating characteristic curve showed that, with a cutoff of 9, the sensitivity of DRS in detecting individuals with glucose abnormalities (type 2 diabetes or IGT) was 77% and the specificity 45%. The use of the DRS as an initial screening instrument, followed by the measurement of fasting blood glucose in individuals with a score Ն9 and by the OGTT in individuals with a fasting blood glucose between 5.6 and 6.9 mmol/l, would lead to the identification of 83% of the case subjects with type 2 diabetes and 57% of the case subjects with IGT, at a cost of an OGTT in 38% of the sample and a fasting blood glucose in 64%.CONCLUSIONS -The DRS can represent a valid inexpensive instrument for opportunistic screening and a useful alternative to indiscriminate fasting blood glucose measurement, not readily available in general practice. Diabetes Care 28:1187-1194, 2005T he prevalence of type 2 diabetes is rapidly growing worldwide (1,2). This condition exerts a pernicious effect on patient health and health care budgets, and early detection of subjects with undiagnosed diabetes might be important in reducing the burden of diabetic complications. This is of particular importance considering that diabetes is frequently not diagnosed until complications appear, and approximately onethird of all people with diabetes may be undiagnosed (3).Recent experimental evidence has shown that type 2 diabetes can be prevented or delayed by implementing lifestyle modifications (e.g., diet and exercise) or using pharmacological treatment (metformin or acarbose) in individuals with impaired glucose tolerance (IGT) (4 -7). These findings have provided the rationale for screening IGT. This condition is defined using a 2-h oral glucose tolerance test (OGTT), a kind of test that is often considered to entail enough discomfort to discourage its indiscriminate use. Identifying people at increased risk for undiagnosed diabetes or glucose intolerance, followed by blood glucose testing to establish diagnosis, is consid...

OBJECTIVE -The role of general practice and diabetes clinics in the management of diabetes is still a matter of debate. Methodological flaws in previous studies may have led to inaccurate conclusions when comparing the care provided in these different settings. We compared the care provided to type 2 diabetic patients attending diabetes outpatient clinics (DOCs) or being treated by a general practitioner (GP) using appropriate statistical methods to adjust for patient case mix and physician-level clustering. RESULTS -Differences for most process measures were statistically significantly in favor of DOCs. The differences were more marked for patients who were always treated by the same physician within a DOC and if that physician had a specialty in diabetology. Less consistent differences in process measures were detected when patients followed by GPs were compared with those followed by physicians with a specialty other than diabetology. As for the outcomes considered, patients attending DOCs attained better total cholesterol levels, whereas no major differences emerged in terms of metabolic control and blood pressure levels between DOCs and GPs. Physicians' specialties were not independently related to patient outcomes. RESEARCH DESIGN AND METHODSCONCLUSIONS -Being followed always by the same physician in a DOC, particularly if the physician had a specialty in diabetes, ensured better quality of care in terms of process measures. In the short term, care provided by DOCs was also associated with better intermediate outcome measures, such as total cholesterol levels.

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