Risk of bias and certainty of evidence on the association between obesity and mortality in patients with SARS-COV-2: An umbrella review of meta-analyses.

BACKGROUND & AIMS: This umbrella review of systematic reviews with meta-analysis (SR-MAs) aimed to evaluate the risk of bias and the certainty of the evidence of SR-MAs on the association between obesity and mortality in patients with SARS-CoV-2. METHODS: We conducted a comprehensive literature search until April 22, 2022, in several databases and assessed the risk of bias of SR-MAs according to AMSTAR-2 and the certainty of evidence using the GRADE approach. The degree of overlap between meta-analyses was based on the corrected covered area (CCA) index. The results of each MA [relative risk (RR), hazard ratio (HR), or odds ratio (OR)] were extracted to evaluate the magnitude of the association between obesity and mortality. RESULTS: A total of 24 SR-MAs were eligible, and the association between obesity and mortality was not statistically significant in eight (33.3%) of them, while the OR/HR/RR ranged from 1.14 to 3.52 in the other SR-MAs. The overlap was slight (CCA = 4.82%). The majority of SR-MAs presented critically low quality according to AMSTAR-2 (66.7%), and the certainty of the evidence for most of them (83.4%) was "very low". CONCLUSIONS: Obesity was associated with an increased risk of death in patients with SARS-CoV-2 infection in most SR-MAs; however, a critical appraisal pointed to a high risk of bias, and the certainty of their evidence was not well graded. The dissemination of poor SR-MAs may limit the interpretation of findings, and we should always aspire to trustworthy scientific evidence. PROSPERO: PROSPERO 2021 CRD42021253142.

Inferior vena cava syndrome and morbid obesity.

A case is reported of inferior vena cava syndrome in a patient with extreme obesity (BMI: >70 kg/m(2)), treated at a public hospital. The inferior vena cava obstruction was diagnosed during an attempt at inferior vena cava filter percutaneous insertion, in prebariatric surgery period. The diagnosis occurred after a hepatic scintillography, and was confirmed with a femoral venography and celiac trunk arteriography. The patient underwent a biliopancreatic diversion-duodenal switch and has lost weight. A venography 7 months after the surgery did not show any inferior vena cava rechanneling evidence.

Functional vascular endothelial growth factor -634G>C SNP is associated with proliferative diabetic retinopathy: a case-control study in a Brazilian population of European ancestry.

OBJECTIVE: The purpose of this study was to evaluate the effect of the single nucleotide polymorphism (SNP) -634G>C at the 5' regulatory region of the vascular endothelial growth factor (VEGF) in the risk of proliferative diabetic retinopathy (PDR) in the Brazilian population of European ancestry with type 2 diabetes. RESEARCH DESIGN AND METHODS: A case-control study was conducted in 501 type 2 diabetic patients of European ancestry. Patients underwent a standardized clinical, ophthalmological, and laboratory evaluation. Of these, 167 patients had PDR (case patients), and 334 were considered as control subjects (patients without PDR) for PDR. A reference population (110 individuals of European ancestry) was also evaluated. RESULTS: No evidence of association between -634G>C/VEGF and the presence of diabetic retinopathy or type 2 diabetes was observed (P > 0.05). However, CC homozygous for the SNP -634G>C was significantly more frequent in patients with PDR (37 of 167; 22.2%) than in the corresponding control group (40 of 334; 12%) in accordance with a recessive model (P = 0.003). This effect was further observed when creatinine, BMI, sex, duration of type 2 diabetes, HDL cholesterol, and systolic blood pressure were taken into account (odds ratio 1.9 [95% CI 1.01-3.79], P = 0.04). CONCLUSIONS: The presence of the allele -634C/VEGF in homozygosity is an independent risk factor for the development of PDR in type 2 diabetic patients of European ancestry.

Nonalcoholic fatty liver disease in patients with different baseline glucose status undergoing bariatric surgery: analysis of intraoperative liver biopsies and literature review.

BACKGROUND: Bariatric surgery has been investigated as a treatment option for obese patients with nonalcoholic fatty liver disease (NAFLD). Because patients with NAFLD and type 2 diabetes show accelerated progression from liver disease to cirrhosis, it has been suggested that surgery could be indicated for patients with lower degrees of obesity and type 2 diabetes. OBJECTIVE: To analyze the degree of tissue damage in liver biopsies obtained from patients undergoing bariatric surgery, correlating histopathologic findings with their baseline glucose status. SETTING: General hospital in the public health system. METHODS: Intraoperative liver biopsies were obtained from 521 obese patients undergoing bariatric surgery. Patients were divided into 3 study groups according to their preoperative glucose levels: 167 (32.05%) type 2 diabetic, 132 (25.33%) prediabetic, and 222 (42.61%) normoglycemic patients. Tissue samples were classified in accordance with Brunt and Clinical Research Network Nonalcoholic Steatohepatis criteria. RESULTS: Prevalence of NAFLD was 95%. Higher rates of hepatic fibrosis were observed in diabetic patients (56.4%) compared with prediabetic (29.2%), and normoglycemic patients (28.6%) (P<.001). Nonalcoholic steatohepatitis was diagnosed in 59.4% of the diabetics, in 49.2% of the prediabetics, and in 36% of the normoglycemic obese (P<.001). Only 1.5% of the diabetics had no histologic hepatic alterations. CONCLUSION: NAFLD is markedly more severe in diabetic patients. Our data suggest that intraoperative liver biopsy should be considered for diabetic patients undergoing bariatric surgery. Early bariatric surgery should be investigated as a means to prevent progression of NAFLD.

Revisional Malabsorptive Bariatric Surgery: 29-Year Follow-up in a Brazilian Public Hospital.

BACKGROUND: This study aimed to evaluate the outcomes of 67 patients who underwent revisional bariatric surgeries over a 29-year period in a Brazilian public hospital. METHODS: The records of all patients who underwent revisional bariatric surgery from January 1987 to December of 2016 at our hospital were analyzed for weight loss and complications. Descriptive statistics and paired t tests were computed. RESULTS: Sixty-seven patients were included in the study. The primary surgeries previously performed on these patients were biliopancreatic diversion with duodenal switch (BPD-DS) (37 cases, 55.2%), jejunoileal bypass (JIB) (24 cases, 35.8%), sleeve gastrectomy (4 cases, 5.9%), Roux-en-Y gastric bypass (RYGB) (1 case, 1.5%), and laparoscopic adjustable gastric band (1 case, 1.5%). The indications for revisional surgery were as follows: malnutrition in 29 cases (43.3%), failure to lose weight in 27 cases (40.3%), weight regain in 5 cases (7.5%), and untreatable diarrhea in 6 cases (9.2%). Most revisional surgeries were performed using JIB or BPD-DS. Operative mortality was higher after the revisional procedures compared with that following the primary bariatric surgeries. CONCLUSIONS: Most patients requiring a revisional surgery had undergone a primary BPD-DS or JIB. Severe and untreatable malnutrition and diarrhea were the main indications for the revisional procedures. RYGB produced significant and sustainable weight loss and exhibited a low risk of malnutrition or requiring revisional surgery.

Entrevista com Fernando Pigatto - Presidente do Conselho Nacional de Saúde (25/06/2021) / Interview with Fernando Pigatto - President of National Health Council (06/25/2021)

RESUMO Entrevista realizada com Fernando Pigatto, atual presidente do Conselho Nacional de Saúde (CNS), por via remota, em 25 de junho de 2021, quando o País chegava a 500 mil mortos pela pandemia de Covid-19. Nela, os entrevistadores objetivaram, por meio de perguntas abertas, levantar informações que: i) apresentassem a atuação do CNS no contexto pandêmico, em especial, seus desafios e avanços; e ii) promovessem a reflexão do entrevistado sobre aspectos fundamentais da democracia e da participação social, sobretudo a relação do Conselho com a sociedade civil e a sociedade política, o papel do CNS no processo decisório das políticas de saúde (ator e/ou arena?) e a interação Conselho-Conferência.

ABSTRACT Interview with Fernando Pigatto, President of National Health Council (CNS), carried out remotely, on 25/06/2021, when the country reached the mark of 500,000 deaths from the COVID-19 pandemic. The interviewers aimed, through open questions, to collected information that would: i) present the performance of the CNS in the pandemic context, in special its challenges and advances; and ii) promote the interviewee's reflection on fundamental aspects of democracy and social participation, especially the relationship between the Council and civil society and political society, the role of CNS in the decision-making process of health policies (actor and/or arena?), and the Council-Conference interaction.

The catalase -262C/T promoter polymorphism and diabetic complications in Caucasians with type 2 diabetes.

Catalase is a central antioxidant enzyme constituting the primary defense against oxidative stress. In this study, we investigated whether the functional -262C/T polymorphism in the promoter of catalase gene is associated with the presence of diabetic retinopathy (DR), diabetic nephropathy (DN) and ischemic heart disease (IHD) in 520 Caucasian-Brazilians with type 2 diabetes. The -262C/T polymorphism was also examined in 100 Caucasian blood donors. Patients underwent a clinical and laboratory evaluation consisting of a questionnaire, physical examination, assessment of diabetic complications and laboratory tests. Genotype analysis was performed using the polymerase chain reaction followed by digestion with restriction enzyme. The genotype and allele frequencies of the -262C/T polymorphism in patients with type 2 diabetes were very similar to those of blood donors (T allele frequency=0.20 and 0.18, respectively). Likewise, there were no differences in either genotype or allele frequencies between type 2 diabetic patients with or without DR, DN or IHD. Thus, our results do not support the hypothesis that the -262C/T polymorphism is related to the development of DR, DN or IHD in patients with type 2 diabetes. Further studies are necessary to elucidate the role of catalase gene polymorphisms in the pathogenesis of diabetic complications.

Hepatic outcomes after jejunoileal bypass: is there a publication bias?

BACKGROUND: One of the reasons why jejunoileal bypass (JIB) was abandoned were reports of liver failure. The aim of this study was to describe histological findings in the intraoperative and follow-up liver biopsies of a cohort of super-obese patients who had undergone JIB. METHODS: 50 consecutive patients underwent JIB. Samples of liver biopsies performed intraoperatively (41 patients) and in the follow-up (31 patients) were evaluated. Brunt's scale was used. RESULTS: Mean age at operation was 37.9 +/- 7.6 years, and 15 patients (30.6%) had diabetes type 2, 20 (40.8%) had dyslipidemia, 29 (59.2%) had high blood pressure, and one (0.5%) had hepatitis C. Mean BMI preoperatively was 52.8 +/- 7.5 kg/m(2). Mean follow-up time was 67.0 +/- 42.8 months. At the time of the latest liver biopsy, the mean BMI was 35.7 +/- 7.5 kg/m(2). The % excess weight loss (%EWL) was 62.4 +/- 20.0%. 8 deaths (16%) have occurred, none from liver-related complications. At liver biopsy during the JIB operation, NAFLD was confirmed in 36 patients (86.7%) and NASH in 13 (31.7%). In 25 patients with mean follow-up of 4.8 +/- 4.0 years, there was no statistically significant change in the liver histology regarding the extent of steatosis (P=0.20), steatohepatitis (P=0.74) and fibrosis (P=0.71). CONCLUSIONS: There was a significant metabolic improvement, maintenance of the %EWL, and no worsening of liver histology. There has possibly been a publication bias concerning liver outcomes, where the type of JIB and the concomitance of hepatitis C were not taken into account.

Familial history of type 2 diabetes in patients from Southern Brazil and its influence on the clinical characteristics of this disease.

OBJECTIVE: To investigate the presence of maternal and paternal history of type 2 diabetes mellitus (DM) in relatives of 644 type 2 diabetic patients from Southern Brazil, and also to evaluate its influence on the clinical characteristics of this disease. PATIENTS AND METHODS: Familial history of type 2 DM was investigated by a questionnaire. The maternal and paternal history was investigated over two generations. Complete data sets on familial history were obtained from 396 patients. RESULTS: In general, 76.6% of the patients reported at least one first-degree affected relative. Besides, 31.6% of the patients reported a maternal history of type 2 DM and 12.6% reported a paternal history. Patients with maternal and/or paternal history presented a lower age at type 2 DM diagnosis when compared to patients without familial history. In addition, patients with only paternal history presented a higher frequency of hypertension than patients with no familial history. CONCLUSIONS: This study suggests that there is a significant maternal effect in the transmission of type 2 DM in Southern Brazil, and that most of the clinical characteristics of this disease do not differ between patients with or without familial history of type 2 DM.

Política Nacional de Atenção Integral à Saúde da Mulher: protagonismo do movimento de mulheres / National Policy for Integral Attention to Women's Health: leading role of the women's movement

RESUMO O artigo aborda a trajetória de elaboração da Política Nacional de Atenção Integral à Saúde da Mulher a partir da participação social do movimento de mulheres, do Movimento da Reforma Sanitária Brasileira, das instâncias de diálogo construídas desde a década de 1980 até aprovação em 2004 e proposição de revisão em 2017 pelo Estado brasileiro. Apresenta o processo de participação social do movimento feminista, ao longo desse período, limites, recuos e avanços para a elaboração e implantação da política. O artigo traz elementos para reflexão a partir de uma abordagem de gênero e cita alguns pontos de intersecção e diferenças dos mecanismos institucionais de controle social, no campo das políticas para as mulheres e da construção do Sistema Único de Saúde.

ABSTRACT The article addresses the elaboration trajectory of the National Policy for Integral Attention to Women's Health from the social participation of the women's movement, the Brazilian Health Reform Movement, the instances of dialogue raised in the 1980s until its approval in 2004 and review in 2017 by the Brazilian State. It presents the process of social participation of the Feminist Movement, throughout this period, its limits, setbacks, and advances for the elaboration and implementation of the Policy. The article brings elements for reflection from a gender approach and mentions some points of intersection and divergence in institutional mechanisms of social control, both in the field of women's policies and in the development of the Unified Health System.

Relationship of p22phox C242T polymorphism with nephropathy in type 2 diabetic patients.

BACKGROUND: In this case-control study, we investigated the possible involvement of the p22phox C242T polymorphism in the development and progression of diabetic nephropathy (DN) in 535 Caucasian Brazilians with type 2 diabetes. We also evaluated the effects of the interaction of the C242T polymorphism with smoking and hypercholesterolemia on the susceptibility to nephropathy. METHODS: Genotype analysis was performed using polymerase chain reaction (PCR) followed by digestion with restriction enzyme. Logistic regression analysis was used to control for independent risk factors associated with nephropathy. RESULTS: The genotype frequencies in patients with overt DN (CC/CT/TT: 0.36/0.47/0.17) were not significantly different from those of diabetic individuals with normoalbuminuria (0.47/0.41/0.12) or microalbuminuria (0.42/0.48/0.10) (p=0.214). Likewise, there were no differences in the T allele frequency among patients with normoalbuminuria, microalbuminuria or overt DN (0.33, 0.34 and 0.40, respectively; p=0.111). However, the T allele was found to be more frequent among smokers with overt nephropathy (macroalbuminuria and/or in dialysis) than those who had normoalbuminuria (43 vs. 32%, p=0.045). The multiple logistic regression analysis confirmed that the CT+TT genotypes were independently associated with a higher risk of having overt nephropathy among smokers [odds ratio (OR)=6.76, 95% confidence interval (95% CI) 1.83-25.02]. CONCLUSIONS: Our study shows a gene-environment interaction associated with the increased risk of DN progression in Caucasian Brazilian smokers with type 2 diabetes. Further studies should be performed to clarify whether it exists, and to what extent there is a relationship between the p22phox C242T polymorphism and DN.

Impact of Bariatric Surgery on the Saliva of Patients with Morbid Obesity.

BACKGROUND: The oral condition of obese patients may change following bariatric surgery owing to adverse effects that cause alterations in the oral cavity. The aim of this study was to evaluate the impact of bariatric surgery on the saliva of patients with morbid obesity. METHODS: Whole saliva samples were collected from 27 patients with morbid obesity (BMI >40 kg/m(2)), prior to and 6 months after bariatric surgery. Stimulated salivary flow rate, pH, buffering capacity, and microbial levels of mutans streptococci, Lactobacillus spp., and Candida albicans were analyzed from saliva. RESULTS: Values of all salivary variables before and after bariatric surgery were within the normal range, except for the level of C. albicans, which was elevated at both times. An increase in the level of mutans streptococci was observed after bariatric surgery (p < 0.05). CONCLUSIONS: The results suggest that the salivary levels of mutans streptococci increase following bariatric surgery in morbidly obese patients.

Evaluation of quality of life and metabolic improvement after jejunoileal bypass in a community of low socioeconomic status.

BACKGROUND: Bariatric operations are currently the only effective treatment for morbid obesity The first operation, jejunoileal bypass (JIB), has been superceded. However, JIB has left a heritage which must be followed. We report the long-term follow-up of a series of patients who had undergone JIB in south Brazil. METHODS: 49 super-obese patients (85% female) from a poor community were submitted to JIB from 1987 to 2001. 5 deaths occurred and 4 patients were lost during follow-up. Quality of life was evaluated by means of the Bariatric Analysis and Reporting Outcome System (BAROS) applied to 40 patients. RESULTS: Preoperatively, 11 patients (22.4%) were diabetic,13 (26.5%) were dyslipidemic, and 23 (46.9%) had high blood pressure. After a mean postoperative period of 64.3 +/- 40.0 months, there was complete resolution of co-morbidites in all patients. Mean preoperative BMI was 52.8 +/- 10.3 kg/m(2), and the postoperative mean excess weight loss was 58.9% +/- 18.9%. CONCLUSION: JIB was adequate in reduction of weight, resolution of co-morbidites, and improvement in the quality of life as measured by BAROS. Since February 2001, we perform biliopancreatic diversion with duodenal switch, but we continue to follow our patients with JIB.

Diabetic retinopathy in Euro-Brazilian type 2 diabetic patients: relationship with polymorphisms in the aldose reductase, the plasminogen activator inhibitor-1 and the methylenetetrahydrofolate reductase genes.

We investigated the relationship between diabetic retinopathy (DR) and three polymorphisms, C(-106)T in the aldose reductase (ALR2) gene, 4G/5G in the plasminogen activator inhibitor-1 (PAI-1) gene and C677T in the methylenetetrahydrofolate reductase (MTHFR) gene, in 210 Euro-Brazilian type 2 diabetic patients. Retinopathy was evaluated by funduscopic examination and genotype analysis was performed using the polymerase chain reaction and allele-specific restriction. Retinopathy was detected in 47% of the patients. There were no significant differences in allele or genotype distributions between patients with or without retinopathy for all polymorphisms. Thus, the three polymorphisms are not related to the presence of DR in Euro-Brazilian type 2 diabetic patients.

Impact of bariatric surgery on the oral health of patients with morbid obesity.

BACKGROUND: The present study assessed the impact of bariatric surgery on the oral health. METHODS: All of the patients who underwent Roux-en-Y gastric bypass at Nossa Senhora da Conceição Hospital between October 2009 and January 2011 were invited to participate. In this longitudinal study, oral examinations and interviews were conducted in two stages. A descriptive analysis, McNemar's test, Student's t test for paired samples, and the Wilcoxon test were performed. RESULTS: Thirty-nine patients completed the protocol. There was a statistically significant reduction in the number of medications taken daily, sensation of dry mouth, and increased stimulated salivary flow rate. CONCLUSIONS: The oral health of patients who underwent bariatric surgery improved; moreover, the sensation of dry mouth decreased.

Improvement of exercise capacity and peripheral metaboreflex after bariatric surgery.

BACKGROUND: Bariatric surgery is the only predictable method to obtain weight loss in severe obesity. Poor physical performance of obese individuals may be mediated by the peripheral metaboreflex, which controls blood flow redistribution to exercising muscles. Weight reduction improves exercise capacity through several possible mechanisms that are insufficiently understood. We hypothesized that the metaboreflex is one among the causes of improvement in exercise capacity after weight loss. This study thus aimed to examine the effect of bariatric surgery on exercise performance and metaboreflex. METHODS: Severely obese patients were assessed before and 3 months after bariatric surgery. Metaboreflex was evaluated by the technique of selective induction by post-exercise circulatory occlusion (PECO+) after isometric handgrip exercise at 30% of maximum voluntary contraction. The exercise capacity was assessed by 6-min walking test. RESULTS: Seventeen patients completed the protocol. Body mass index decreased from 46.4 ± 2 to 36.6 ± 2 kg/m2 (P < 0.001). The distance walked in 6 min increased from 489 ± 14 to 536 ± 14 m (P < 0.001). The peripheral metaboreflex activity, expressed by the area under the curve of vascular resistance, was lower after than before bariatric surgery (42 ± 5 to 20 ± 4 units, P = 0.003). Heart rate, blood pressure, and vascular resistance were also significantly decreased. The correlation between change in distance walked in 6 min and change in peripheral metaboreflex activity was not significant. CONCLUSIONS: Weight loss after bariatric surgery increases exercise capacity and reduces peripheral metaboreflex, heart rate, and blood pressure. Further investigation on the role of metaboreflex regarding mechanisms of exercise capacity of individuals with obesity is warranted.

Avanços e desafios na implementação da Política Nacional de Saúde Integral LGBT / Advances and challenges in the implementation of the National Policy on Integral Health of the LGBT Population

: Este artigo apresenta a descrição dos avanços e desafios da implementação da Política Nacional de Saúde Integral LGBT, desde sua elaboração e aprovação no Conselho Nacional de Saúde até a implementação de seu Plano Operativo, nos anos de 2012 à 2015.

This article presents the advances and challenges of the implementation of the National Policy on Comprehensive LGBT Health, since its elaboration and approval by the National Health Council to the implementation of its Operational Plan (2012-2015). (AU)

Este artículo analiza los avances y desafíos de la implementación de la Política Nacional de Salud Integral LGBT, desde su elaboración y aprobación por parte del Consejo Nacional de Salud hasta la ejecución de su Plan de Acción (2012-2015).

Prevalence of upper digestive endoscopy and gastric histopathology findings in morbidly obese patients.

CONTEXT: The prevalence of obesity has been increasing in modern society. Roux-en-y gastric bypass is a bariatric surgery that involves the exclusion of significant part of the stomach. Atrophy, intestinal metaplasia and gastric cancer have been associated with infection by Helicobacter pylori. OBJECTIVES: To evaluate the presence of endoscopy findings and histological changes in morbid obese patients for the presence of inflammatory cells, inflammatory activity, lymphoid hyperplasia, H. pylori infection, atrophy and intestinal metaplasia in the gastric mucosa. METHODS: Upper digestive endoscopy and gastric histopathological were studied in 126 obese patients in the preoperative evaluation for bariatric surgery. RESULTS: Upper digestive endoscopy abnormalities were diagnosed in 73/126 (57.9%) patients. In three patients (2.4%) the upper gastrointestinal endoscopy diagnosed gastric ulcer and one patient (0.8%) had duodenal ulcer. The histopathological from gastric biopsies of these obese patients showed 65.1% of mucosa inflammation, inflammatory activity in 50.0%, infection by H. pylori in 53.2%, lymphoid hyperplasia in 50.0% and atrophy and/or intestinal metaplasia in 16.7%. CONCLUSIONS: In present study, with routine preoperative upper gastrointestinal endoscopy and histopathological examination, were detected 57.9% patients with endoscopy abnormalities, high prevalence of infection by H. pylori (53%) and 16.7% of gastric atrophy and/or intestinal metaplasia.

Estado e políticas de equidade em saúde: democracia participativa? / State and equity policies in health: participatory democracy?

RESUMO Estado, políticas de equidade e participação social: experiência de gestão participativa na construção e na implementação de políticas públicas. Pode a saúde tornar-se um espaço de construção de cidadania que contribua com a redução das desigualdades sociais? Os limites do Estado brasileiro podem ser impeditivos para o desenvolvimento de uma gestão participativa, na qual os movimentos sociais deveriam estar aptos, de fato, a opinar e participar sem perder sua autonomia? O presente ensaio traz elementos para essas reflexões e cita possíveis avanços em tais questões, a partir da implantação de políticas de equidade na saúde, apontando, ainda, potencialidades de articulação entre as esferas da gestão do Sistema Único de Saúde, como espaço, também, de gestão participativa.

ABSTRACT State, equity policies and social participation: participatory management experience in the construction and implementation of public policies. Can health become a space for construction of citizenship that contributes to the reduction of social inequalities? Can the limits of the Brazilian state be prohibitive for the development of a participative management, in which social movements should be able to, in fact, speak about and participate without losing their autonomy? This essay brings elements to this reflection and cites possible advances in such issues, from the implementation of equity policies in health, pointing out, also, potentialities of articulation between the Unified Health System management spheres, as a space, also, of participatory management.