Risk of underdiagnosis of hypertension in schizophrenia patients.

AIM: Arterial hypertension requires proper screening and management, and its underdiagnosis in patients with schizophrenia (SZ) and/or antipsychotic treatment has been postulated. The objective of the study is to assess whether there are differences in the proportion of screened patients with a blood pressure >140/90 mmHg that are undiagnosed or not confirmed later (risk of underdiagnosis). METHODS: Cross-sectional study of clinical records from SIDIAPQ (Spain) during the 2006-2011 period. Three groups were studied: SZ, no SZ but under antipsychotic treatment, and control groups. Patients with established hypertension, cardiovascular disease, dementia, or diagnosis of SZ or starting with antipsychotic treatment during this period were excluded. RESULTS: The SZ group had a lower risk of underdiagnosis than the control group (OR 0.91; 95% CI: 0.83-0.99; p < 0.05), at the expense of men (OR 0.8; 95% CI: 0.71-0.9; p < 0.001) and patients younger than 50 years of age (OR: 0.84; 95% CI: 0.74-0.93; p < 0.003). In the no SZ but under antipsychotic treatment group there were some differences, but not in the overall results. CONCLUSION: Preventive management of hypertension seemed to be sufficient for SZ and antipsychotic treatment patients. The lower prevalence of hypertension found in these groups may be due to other factors (blood pressure-lowering effect of psychoactive drugs or smoking) but these hypotheses must be evaluated with specific studies.

Mechanisms of the Development of Allergy (MeDALL): Introducing novel concepts in allergy phenotypes.

Asthma, rhinitis, and eczema are complex diseases with multiple genetic and environmental factors interlinked through IgE-associated and non-IgE-associated mechanisms. Mechanisms of the Development of ALLergy (MeDALL; EU FP7-CP-IP; project no: 261357; 2010-2015) studied the complex links of allergic diseases at the clinical and mechanistic levels by linking epidemiologic, clinical, and mechanistic research, including in vivo and in vitro models. MeDALL integrated 14 European birth cohorts, including 44,010 participants and 160 cohort follow-ups between pregnancy and age 20 years. Thirteen thousand children were prospectively followed after puberty by using a newly standardized MeDALL Core Questionnaire. A microarray developed for allergen molecules with increased IgE sensitivity was obtained for 3,292 children. Estimates of air pollution exposure from previous studies were available for 10,000 children. Omics data included those from historical genome-wide association studies (23,000 children) and DNA methylation (2,173), targeted multiplex biomarker (1,427), and transcriptomic (723) studies. Using classical epidemiology and machine-learning methods in 16,147 children aged 4 years and 11,080 children aged 8 years, MeDALL showed the multimorbidity of eczema, rhinitis, and asthma and estimated that only 38% of multimorbidity was attributable to IgE sensitization. MeDALL has proposed a new vision of multimorbidity independent of IgE sensitization, and has shown that monosensitization and polysensitization represent 2 distinct phenotypes. The translational component of MeDALL is shown by the identification of a novel allergic phenotype characterized by polysensitization and multimorbidity, which is associated with the frequency, persistence, and severity of allergic symptoms. The results of MeDALL will help integrate personalized, predictive, preventative, and participatory approaches in allergic diseases.

Screening of cardiovascular risk factors in patients with schizophrenia and patients treated with antipsychotic drugs: are we equally exhaustive as with the general population?

Many studies have previously shown increased cardiovascular risk factors related to schizophrenia independently from the use of antipsychotic drugs. However, a poorer effort in clinical detection and management of cardiovascular risk in patients with severe mental illness could also explain these results. To test this hypothesis, we analyzed the differences in screening and incidence of cardiovascular risk factors between schizophrenia, non-schizophrenic patients on treatment with antipsychotic drugs (NS-TAD) and the general population. Data from adult subjects assessed by high-quality register general practitioners from 2006 to 2011 were extracted from the Catalonian SIDIAP database. The schizophrenia, NS-TAD, and control groups were compared in terms of measurements and incidence of diabetes, dyslipidemia, obesity, hypertension, and smoking. A total of 4911 patients in the schizophrenia group, 4157 in NS-TAD group, and 98644 in the control group were included. Schizophrenia patients were screened for dyslipidemia and diabetes more frequently than the control group, while for obesity or hypertension, they were screened equal to controls. Also, as compared to the control group, the NS-TAD group was more frequently screened for obesity with no differences in dyslipidemia and diabetes and less frequently for hypertension. Smoking was less frequently screened in both study groups. The incidence of all risk factors studied in both study groups was higher than or equal to the control group, except for hypertension, which had lower incidence. The lack of screening of risk factors does not appear decisive in the increased cardiovascular risk of patients diagnosed with schizophrenia seen in primary care. Studies evaluating the possible under diagnosis of the risk factors are required. ABBREVIATIONS: Schizophrenia (SZ); Treatment with antipsychotic drugs (TAD); Cardiovascular risk factor/s (CVRF); Without schizophrenia but on therapy with antipsychotic drugs (NS-TAD); Defined Daily Dose (DDD).

Prefrontal Cortex Neuromodulation Enhances Frontal Asymmetry and Reduces Caloric Intake in Patients with Morbid Obesity.

OBJECTIVE: The objective of this study was to test the feasibility of a combined intervention involving transcranial direct current stimulation (tDCS) on the dorsolateral prefrontal cortex (dlPFC) and cognitive training (CT). Short-term effects on food consumption, cognition, endocannabinoid (eCB) levels, and electroencephalogram (EEG) markers of future weight loss were explored. METHODS: Eighteen healthy volunteers with morbid obesity were randomized in a double-blind, placebo-controlled, parallel trial. Participants received sham or active tDCS plus CT for four consecutive days. Cognitive performance, daily food intake, and eCB blood samples were collected before and after the intervention; EEG data were gathered before and after daily training. RESULTS: The active tDCS + CT group reversed left-dominant frontal asymmetry and increased frontal coherence (FC) in the γ-band (30-45 Hz) after the intervention. The strength of the latter predicted BMI reduction. Additionally, a large intervention effect on food intake was shown in the active tDCS + CT group at follow-up (-339.6 ± 639 kcal on average), and there was a decrease of plasma eCB concentrations. CONCLUSIONS: dlPFC modulation through tDCS + CT is an effective tool to restore right dominance of the dlPFC and enhance FC in patients with morbid obesity. Moreover, the effect of the strength of FC on BMI suggests that the interhemispheric FC at the dlPFC is functionally relevant for the efficient regulation of food choice.

Pharmacokinetics in Morbid Obesity: Influence of Two Bariatric Surgery Techniques on Paracetamol and Caffeine Metabolism.

PURPOSE: The purpose of the study was to study the impact of the two most common bariatric surgery techniques on paracetamol pharmacokinetics (a marker of gastric emptying) and caffeine metabolism (a marker of liver function). MATERIALS AND METHODS: In the present prospective study, we studied 24 morbid obese patients before, at 4 weeks, and 6 months after having undergone sleeve gastrectomy (n = 10) or Roux-en-Y gastric bypass (n = 14). For comparative purposes, 28 healthy controls (14 normal weights and 14 overweights) were also included in the study. RESULTS: Paracetamol pharmacokinetics was altered in the obese participants leading to lower bioavailability. Bariatric surgery resulted in faster absorption and normalized pharmacokinetic parameters, prompting an increase in paracetamol bioavailability. No differences were found between surgical procedures. In the case of caffeine, the ratio paraxanthine/caffeine did not differ between morbid obese and healthy individuals. This ratio remained unmodified after surgery, indicating that the liver function (assessed by cytochrome P450 1A2 activity) was unaffected by obesity or bariatric surgery. CONCLUSIONS: Paracetamol pharmacokinetics and caffeine plasma levels are altered in severely obese patients. The two studied bariatric surgical techniques normalize paracetamol oral bioavailability without impairing the liver function (measured by cytochrome P450 1A2 activity).

Virological, immunological, and clinical impact of switching from protease inhibitors to nevirapine or to efavirenz in patients with human immunodeficiency virus infection and long-lasting viral suppression.

Seventy-seven subjects infected with human immunodeficiency virus were randomized to switch from protease inhibitor (PI) therapy to nevirapine therapy (group A; n=26) or to efavirenz therapy (group B; n=25) or to continue PI therapy (group C; n=26). At month 12, viral suppression had been maintained in 96% of patients in group A, 92% of patients in group B, and 92% of patients in group C. A significant increase in the CD4(+) level was observed in all 3 groups. In group A, lipid profiles improved, whereas levels of gamma-glutamiltransferase and alanine aminotransferase significantly increased; 1 subject interrupted treatment because of hepatotoxicity. In group B, an increase in gamma-glutamiltransferase levels was also observed, and 3 patients interrupted treatment because of central nervous system symptoms. Two patients in group C withdrew therapy. Quality of life significantly improved for groups A and B. In patients receiving effective PI-based therapy, the replacement of the PI with either nevirapine or efavirenz is safe and virologically effective.

[Psychosis, cardiovascular risk and associated mortality: are we on the right track?]. / Psicosis, riesgo cardiovascular y mortalidad asociada: ¿vamos por el buen camino?

Patients with psychotic disorders have a higher risk of early mortality. In addition to unnatural causes (accidents, suicide), death due to cardiovascular (CV) reasons is two to four times more prevalent in these patients than in the general population. This non-systematic review of MEDLINE aims to clarify the role of all the determining factors are involved. Psychotic disorders are related to unhealthy life habits such as smoking, poor diet and physical inactivity. Neuroleptic drugs have also been studied as triggers of obesity and metabolic syndrome. Therefore, psychotic patients seem predisposed to suffer from several of the «classic¼ CV risk factors. It is not surprising that their scores on the CV risk scales (Framingham, SCORE) are higher than the general population. We also found publications that showed poorer management of primary and secondary prevention of CV disease. In addition, some biochemical factors (plasma levels of cortisol, ACTH, homocysteine, PCR) may indicate a vulnerability in psychosis per se, as well as the findings on hyperglycemia and insulin resistance in psychotic "drug naive" patients. These "non-classical" factors could alter the validity of CV risk scales designed for the general population. Furthermore, antipsychotic drugs could control intrinsic factors of psychosis (they have shown to reduce global mortality), and their role in CV mortality is not clear.

Caloric intake capacity as measured by a standard nutrient drink test helps to predict weight loss after bariatric surgery.

BACKGROUND: Instruments that enable to select individuals that will benefit most from bariatric surgery (BS) are necessary to increase its cost-efficiency. Our goal was to assess if intake capacity, measured with a standardized test, predicts response to BS. METHODS: Patients with criteria for BS were randomly allocated to laparoscopic gastric bypass (LRYGB) or sleeve gastrectomy (LSG). We measured caloric intake capacity before and 1 year after surgery using a standardized nutrient drink test. We evaluated if pre-surgery satiation could predict satiation and weight loss (%) 1 year after surgery using multiple regression modeling. Descriptive statistics are given as mean ± SD. RESULTS: Fourteen women (48 ± 9 years old, BMI 41 ± 3 kg/m(2)) were evaluated before and 11 ± 2.6 months after surgery (seven LRYGB, seven LSG). Caloric intake capacity diminished after surgery (-950 ± 85 kcal on average [70 ± 8 % decrease over basal intake capacity]; p=0.002) and similarly in both LRYGB (72 ± 7 % decrease) and LSG groups (68 ± 8 % decrease); p=0.5. There was a significant weight reduction after surgery (-32 ± 10 kg [30 ± 8 % of total basal weight]) with a mean post-surgery BMI of 29 ± 2 kg/m(2). The best predictive model of weight loss (%) after surgery (R (2)=89 %, p=0.0009) included: BMI (p=0.0004), surgery type (p=0.01) and pre-surgery intake capacity (p=0.006). Weight loss was higher in heavier patients and those undergoing LRYGB. Patients with higher intake capacity had a poorer outcome independently of basal BMI and surgery type. CONCLUSIONS: Caloric intake capacity, as measured by a standard nutrient drink test, helps to predict weight loss after bariatric surgery. This test might be useful in algorithms of obesity treatment decision.

The diabetic immigrant: cardiovascular risk factors and control. Contributions of the IDIME study.

INTRODUCTION AND OBJECTIVES: The aim of this study was to determine the clinical characteristics of diabetes and associated cardiovascular risk factors in immigrants with diabetes in Spain. METHODS: A multicenter, observational, cross-sectional study including a cohort of 605 diabetic immigrants and 307 native diabetics was conducted in patients diagnosed with diabetes and treated in primary and specialized care in Spain. A consecutive sampling method was followed. We studied epidemiological, clinical and laboratory variables related to diabetes and the presence of classical risk factors. RESULTS: The immigrant diabetic patient was younger (50.4 [11.5] vs 62.7 [13] years) and had fewer years of diabetes progression (5.8 [6.4] vs 10.5 [8.3] years) (P<.001) compared with native diabetic patients. Immigrants from South America with diabetes were more obese. No statistically significant differences were found in abdominal obesity or the waist/height ratio. Glycemic control was worse in immigrants than in the native Spaniard group (glycosylated hemoglobin, 7.8 [2.2] vs 7.1 [1.5%]), especially among South Asians (8.1[2.5%]) (P<.001), in whom insulin use was lower (12.8% vs 30.7% in other immigrants) (P<.001). However, the prevalence of chronic complications of diabetes was lower among immigrants, particularly that of macrovascular complications (7.7% vs 24.4%) (P<.01). CONCLUSIONS: In our study the profile of immigrant diabetics in Spain is one of a young diabetic without complications, but with worse metabolic control. These findings provide an excellent opportunity to implement preventive measures.

[Bariatric surgery for the treatment of type 2 diabetes mellitus]. / La cirugía bariátrica como tratamiento de la diabetes tipo 2.

Weight loss can improve metabolic control in patients with type 2 diabetes mellitus but the results of conventional therapy in this respect have been discouraging. Besides achieving significant and sustained weight loss, bariatric surgery can improve or resolve type 2 diabetes mellitus in the majority of patients. Anatomical modifications and changes in the secretion of intestinal hormones can explain the superiority of malabsorptive techniques. Currently, bariatric surgery offers a therapeutic alternative for type 2 diabetes patients with severe obesity and poor metabolic control under conventional therapy. Ongoing research will provide insights regarding the effect of intestinal hormones, new surgery techniques and the possible benefits of bariatric surgery in non-obese patients.