Obesity and type 1 diabetes mellitus management.

Patients with type 1 diabetes mellitus (T1DM) traditionally had a low body mass index and microangiopathic complications were common. The Diabetes Control and Complications Trial, published in 1993, demonstrated that therapy aimed at maintaining HbA1c levels as close to normal as feasible reduced the incidence of microangiopathy. Since then, the use of intensive insulin therapy to optimise metabolic control became generalised, with two main side effects: a higher rate of severe hypoglycaemia and increased weight gain. Approximately 50% of patients with T1DM are currently obese or overweight, which reduces or nullifies the benefits of good metabolic control, and which has other negative consequences; therefore, strategies to achieve weight control in patients with T1DM are necessary. At present, treatment with GLP-1 and SGLT-2 inhibitors has yielded promising short-term results that need to be confirmed in studies with larger numbers of patients and long-term follow-up. It is possible that, in coming years, the applicability of bariatric surgery in obese patients with T1DM will be similar to that of the general population or T2DM.

Bariatric surgery: to whom and when?

Bariatric surgery is the most effective treatment for obesity. Its effects go beyond weight loss, in a high percentage of cases achieving remission of comorbidities associated with obesity and reducing mortality. However, not all patients achieve satisfactory weight loss or resolution of comorbidities and perioperative complications are a constant risk. Correct preoperative evaluation is essential to predict the likelihood of success and choose the most appropriate surgical technique for this purpose. The aim of this review was to ascertain which obese subjects will benefit from bariatric surgery taking into account body mass index, age, comorbidities, risk of complications and the impact of different bariatric surgery techniques.

Different clinical presentation of Klinefelter's syndrome in monozygotic twins.

There is a wide variability in the clinical presentation of Klinefelter's syndrome. We report the case of a 45-year-old man who was incidentally diagnosed a 47,XXY/46,XY karyotype in a bone marrow aspiration (case 1). He presented hypogonadic features with undetectable testosterone levels and a height in accordance with mid-parental height. He had a monozygous sibling (case 2) who did not show clinical signs of hypogonadism and whose height exceeded mid-parental height. Both patients had presented language disorders since childhood. The karyotype of lymphocytes in peripheral blood of both subjects was compatible with mosaic Klinefelter's syndrome (46,XY/47,XXY). Testosterone replacement was initiated in case 1. Lack of testicular involvement due to mosaicism and the overexpression of the SHOX gene in case 2 could explain the marked differences in phenotype in these homozygous twins.

Role of A1c in the postpartum screening of women with gestational diabetes.

OBJECTIVE: This study aimed to determine whether A1c detects a different prediabetes prevalence in women with a history of gestational diabetes mellitus (GDM) compared to those diagnosed with oral glucose tolerance test (OGTT) and the influence of haemoglobin concentrations on A1c levels. DESIGN AND PATIENTS: We evaluated carbohydrate metabolism status by performing OGTT and A1c tests in 141 postpartum women with prior GDM in the first year post-delivery. RESULTS: The overall prevalence of prediabetes was 41.8%. Prevalence of isolated A1c 5.7-6.4%, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) was 10.6%, 7.1%, and 9.2%, respectively. Isolated A1c 5.7-6.4% was associated with Caucasian origin (66.7% versus 32.6%, p = 0.02) and with higher LDL cholesterol concentrations (123 ± 28.4 mg/dl versus 101.6 ± 19.2 mg/dl, p = 0.037) compared with patients diagnosed by OGTT (IFG or IGT). Women with postpartum anaemia had similar A1c levels to those with normal haemoglobin concentrations (5.5% ± 0.6% versus 5.4% ± 0.4%, p = 0.237). CONCLUSIONS: Use of A1c in postpartum screening of women with GDM detected an additional 10.6% of patients with prediabetes and a more adverse lipid profile. Haemoglobin concentrations did not influence A1c values.

[Chronic complications in type 1 diabetes mellitus. Analysis of a cohort of 291 patients with a mean evolution time of 15 years]. / Complicaciones crónicas en la diabetes mellitus tipo 1. Análisis de una cohorte de 291 pacientes con un tiempo medio de evolución de 15 años.

BACKGROUND AND OBJECTIVE: Micro- and macrovascular complications are the main cause of morbidity and mortality in type 1 diabetes mellitus (T1D). Given the scarcity of data on the subject in our population, we have analyzed the prevalence of vascular complications and possible risk factors in a cohort of T1D patients. PATIENTS AND METHODS: A cross-sectional study including patients aged 18 and over diagnosed of T1D with at least 6 months' evolution, seen in the Hospital del Mar, Barcelona and Hospital de Granollers during 2008 was carried out. RESULTS: We recruited 291 patients (166 men) with a mean age of 38 years and a T1D duration of 15.3 years. There was one or more diabetes-related vascular complications in 110 (37.8%) patients. Of these, 104 (35.7%) had microvascular complications, 22 (7.6%) macrovascular, and 16 (5.5%) both. Patients with microvascular complications had a higher prevalence of tobacco use (57% smokers Vs. 47.5%, P<.05), dyslipidemia (65.4% Vs. 28.3%, P <.05), hypertension (43.3% Vs. 23.5%, P <.05) and metabolic syndrome (41.3% Vs. 18.7%, P<.001). Moreover, they were older, had a longer duration of diabetes and higher values of glycosylated hemoglobin, triglycerides and systolic blood pressure. In the logistic regression analysis, diabetes duration (OR: 1.19 [95%CI: 1.07-1.32], P=.002), glycosylated hemoglobin levels (OR: 3.33 [95%CI: 1.58-7.03], P=.002) and the absence of metabolic syndrome (OR: 0.04 [95% CI:0.002-0.72], P=.03) showed an independent association with microangiopathy. Patients with T1D and macroangiopathy had longer diabetes duration (23.3±12.6 years Vs. 14.7±10.9 years, in patients without complications, P <.001), higher prevalence of metabolic syndrome (50% Vs. 24.9%, in patients without complications, P=.011) and were more frequently receiving lipid lowering treatment (59.1% Vs. 27.1%, in patients without complications, P=.002). In the multiple regression model, only diabetes duration (OR: 1.047 [95% CI: 1.01-1.09], P=.019) remained independently associated with macroangiopathy. CONCLUSIONS: More than 1/3 of the T1D patients suffered a diabetes-related complication, mainly microvascular, at the time of the study. Diabetes duration and metabolic syndrome are the two mostly strongly related factors to chronic complications of DM1.

Mid- and long-term changes in satiety-related hormones, lipid and glucose metabolism, and inflammation after a Mediterranean diet intervention with the goal of losing weight: A randomized, clinical trial.

Background: Obesity is produced by the enlargement of the adipose tissue. Functioning as an endocrine organ, it releases and receives information through a complex network of cytokines, hormones, and substrates contributing to a low-chronic inflammation environment. Diet and healthy habits play key roles in the prevention of obesity and its related pathologies. In this regard, there is a need to switch to healthier and more appetizing diets, such as the Mediterranean one. Objective: To compare the mid-and long-term effects of two Mediterranean diet (MedDiet) interventions, one energy-reduced plus physical activity promotion versus a non-restrictive diet, on peripheral satiety-related hormones, weight loss, glucose/lipid metabolism, and pro-inflammatory markers in subjects with obesity/overweight and metabolic syndrome. Materials and methods: A randomized, lifestyle intervention was conducted in 23 Spanish centers, with a large cohort of patients presenting metabolic syndrome. Our study is a subproject set in IMIM (Hospital del Mar Research Institute). Participants were men and women, aged 55-75 and 60-75, respectively, who at baseline met at least three metabolic syndrome components. Subjects were assigned to two intervention groups: (1) an intensive lifestyle intervention with an energy-reduced MedDiet and physical activity promotion (intervention group) with the aim of weight loss; and (2) a normocaloric MedDiet (control). We quantified in a subsample of 300 volunteers from Hospital del Mar Research Institute (Barcelona), following analytes at baseline, 6 months, and 1 year: glucose, HbA1c, triglycerides, total cholesterol, high-density lipoprotein cholesterol, LDL cholesterol, C-peptide, ghrelin, GLP-1, glucagon, insulin, leptin, PAI-1, resistin, and visfatin. Anthropometric and classical cardiovascular risk factors were also determined. A multivariate statistical model was employed to compare the two groups. Linear mixed-effect models were performed to compare changes in risk factors and biomarkers between intervention groups and over time. Results: Compared to participants in the control group, those in intervention one showed greater improvements in weight, waist circumference, insulin (P < 0.001), glucose metabolism-related compounds (P < 0.05), triglyceride-related lipid profile (P < 0.05), leptin, blood pressure, and pro-inflammatory markers such as PAI-1 (P < 0.001) at mid-and/or long-term. High-sensitivity C-reactive protein, resistin, and vifastin also decreased in both groups. Conclusion: A weight loss intervention employing a hypocaloric MedDiet and physical activity promotion has beneficial effects on adiposity, glucose metabolism, lipid profile, leptin, and pro-inflammatory markers, such as PAI-1 in both mid-and long-term.

Clinical Value of Thyrotropin Receptor Antibodies for the Differential Diagnosis of Interferon Induced Thyroiditis.

OBJECTIVE: The clinical value of thyrotropin receptor antibodies for the differential diagnosis of thyrotoxicosis induced by pegylated interferon-alpha remains unknown. We analyzed the diagnostic accuracy of thyrotropin receptor antibodies in the differential diagnosis of thyrotoxicosis in patients with chronic hepatitis C (CHC) receiving pegylated interferon-alpha plus ribavirin. METHODS: Retrospective analysis of 274 patients with CHC receiving pegylated interferon-alpha plus ribavirin. Interferon-induced thyrotoxicosis was classified according to clinical guidelines as Graves disease, autoimmune and non- autoimmune destructive thyroiditis. RESULTS: 48 (17.5%) patients developed hypothyroidism, 17 (6.2%) thyrotoxicosis (6 non- autoimmune destructive thyroiditis, 8 autoimmune destructive thyroiditis and 3 Graves disease) and 22 "de novo" thyrotropin receptor antibodies (all Graves disease, 2 of the 8 autoimmune destructive thyroiditis and 17 with normal thyroid function). The sensitivity and specificity of thyrotropin receptor antibodies for Graves disease diagnosis in patients with thyrotoxicosis were 100 and 85%, respectively. Patients with destructive thyroiditis developed hypothyroidism in 87.5% of autoimmune cases and in none of those with a non- autoimmune etiology (p<0.001). CONCLUSION: Thyrotropin receptor antibodies determination cannot replace thyroid scintigraphy for the differential diagnosis of thyrotoxicosis in CHC patients treated with pegylated interferon.

Efficacy of treatment for hyperglycemic crisis in elderly diabetic patients in a day hospital.

BACKGROUND: The purpose of this prospective cohort study was to compare the costs of day hospital (DH) care for hyperglycemic crisis in elderly diabetic patients with those of conventional hospitalization (CH). Secondary objectives were to compare these two clinical scenarios in terms of glycemic control, number of emergency and outpatient visits, readmissions, hypoglycemic episodes, and nosocomial morbidity. METHODS: The study population comprised diabetic patients aged >74 years consecutively admitted to a tertiary teaching hospital in Spain for hyperglycemic crisis (sustained hyperglycemia [>300 mg/dL] for at least 3 days with or without ketosis). The patients were assigned to DH or CH care according to time of admission and were followed for 6 months after discharge. Exclusion criteria were ketoacidosis, hyperosmolar crisis, hemodynamic instability, severe intercurrent illness, social deprivation, or Katz index >D. RESULTS: Sixty-four diabetic patients on DH care and 36 on CH care were included, with no differences in baseline characteristics. The average cost per patient was 1,345.1±793.6 € in the DH group and 2,212.4±982.5 € in the CH group (P<0.001). There were no differences in number of subjects with mild hypoglycemia during follow-up (45.3% DH versus 33.3% CH, P=0.24), nor in the percentage of patients achieving a glycated hemoglobin (HbA(1c)) <8% (67.2% DH versus 58.3% CH, P=0.375). Readmissions for hyperglycemic crisis and pressure ulcer rates were significantly higher in the CH group. CONCLUSION: DH care for hyperglycemic crises is more cost-effective than CH care, with a net saving of 1,418.4 € per case, lower number of readmissions and pressure ulcer rates, and similar short-term glycemic control and hypoglycemia rates.

Impact of different criteria on type 2 diabetes remission rate after bariatric surgery.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) achieve similar type 2 diabetes mellitus (T2DM) remission rates. Since a great variability exists in defining T2DM remission, an expert panel proposed partial and complete remission criteria that include the maintenance of fasting plasma glucose (FPG) and glycosylated hemoglobin (A1c) objectives for at least 1 year. The 2-year T2DM remission rate and time needed to reach it after LSG or LRYGB were compared using different remission criteria. METHODS: This was a prospective cohort study of 55 T2DM subjects operated on with LSG (n = 21) or LRYGB (n = 34). Four models for defining remission were used: Buchwald criteria (FPG <100 mg/dl or A1c <6 %), American Diabetes Association (ADA) complete (FPG <100 mg/dl plus A1c <6 % maintained for at least 1 year), ADA partial (FPG <125 mg/dl with A1c <6.5 % maintained for at least 1 year), and ADA complete without time requirement. RESULTS: Both groups were comparable, except for higher A1c levels in the LSG group. The remission rate ranged from 43.6 % using ADA complete remission to 92.7 % with Buchwald criteria, with no differences between surgical procedures. Differences were found in the time to achieve remission only when ADA complete remission criteria (5.1 ± 2.9 months LRYGB and 9.0 ± 3.8 months LSG, p = 0.014) and ADA without time requirement criteria (4.9 ± 2.7 months LRYGB and 8.4 ± 3.9 months LSG, p = 0.005) were used. CONCLUSIONS: T2DM remission rate varies widely depending on the criteria used for its definition. Remission occurred sooner after LRYGB when the strictest criteria to define remission were used.

[Descriptive study on the improvement of quality perceived after the introduction of a clinical pathway by patients subjected to bariatric surgery]. / Estudio descriptivo de la mejora de la calidad percibida en los pacientes sometidos a cirugía bariátrica tras la implantación de una vía clínica.

OBJECTIVES: To evaluate the level of perceived satisfaction in patients undergoing bariatric procedures after implementing a clinical pathway, and to analyse factors related to a high degree of satisfaction. MATERIAL AND METHODS: A cohort of patients was invited to fulfil, anonymously and voluntarily, a SERVQHOS survey the day before hospital discharge. RESULTS: Seventy-one (53 female) out of 103 patients (70%) responded to the questionnaire. A total of 97.3% of patients who completed the survey answered to the questions "as expected" or "above expectations". Most (98.6%) of the patients were "very satisfied" or "satisfied" with the care received, and 97.2% would recommend the hospital to others. Questions better related to overall satisfaction were technology used (P=.008), staff appearance (P=.019), the interest of staff to fulfil a promise (P=.002), and to solve the problems of the patient (P=.021), information provided by the medical staff (P=.039) and waiting time until being seen by the doctor (P=.002). In the multivariate study, only the "personalized care" achieved the category of a predictive variable (r=0.52). Median hospital stay was 3 days, and 76% of patients considered it adequate. The percentage of highest satisfaction was significantly lower in female, singles, unemployed, and those with academic studies. CONCLUSIONS: Morbid obese patients included in a clinical pathway of bariatric surgery had a good perception with the care received.

Impact of restrictive (sleeve gastrectomy) vs hybrid bariatric surgery (Roux-en-Y gastric bypass) on lipid profile.

BACKGROUND: Few studies have evaluated the impact of hybrid versus purely restrictive bariatric surgery on lipid profile, with the results being contradictory. The effect of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) on lipid profile was compared. METHODS: A nonrandomized prospective cohort study was conducted on severely obese patients undergoing bariatric surgery. Indication for the type of surgical procedure was based on clinical criteria. Patients on lipid-lowering drugs and those that could not be matched for age, sex, and body mass index were excluded. Finally, 51 patients who underwent LSG and 51 undergoing LRYGB completed this study. RESULTS: During the first year post-surgery, no differences in percentage of excess weight loss and triglyceride reduction were found between groups. After LRYGR, low-density lipoprotein (LDL) cholesterol concentrations fell significantly (125.9 ± 29.3 to 100.3 ± 26.4 mg/dl, p < 0.001), whereas no significant changes were observed in the LSG group (118.6 ± 30.7 to 114.6 ± 33.5 mg/dl, p = 0.220). High-density lipoprotein (HDL) cholesterol increase was significantly greater after LSG (15.4 ± 13.1 mg/dl) compared with LRYGB (9.4 ± 14.0 mg/dl, p = 0.032). Factors independently associated with LDL cholesterol reduction were higher baseline total cholesterol and undergoing LRYGB. A greater increase in HDL cholesterol was associated with LSG, older age, and baseline HDL cholesterol. CONCLUSIONS: LRYGB produces an overall improvement in lipid profile, with a clear benefit in all lipid fractions. Although LSG does not alter LDL cholesterol levels, its effect on HDL cholesterol is comparable to or greater than that obtained with malabsorptive techniques.

[Multicenter evaluation of a diabetes program in primary care in Tarragona]. / Evaluación multicéntrica de un programa de diabetes en la atención primaria de Tarragona.

To evaluate a provincial diabetes program for primary care in Tarragona 14 months after its implementation, the data provided by all centers were evaluated. The participants were 8 CAPS and the professionals of a rural area, with a reference population of 170,159. A total of 1,766 diabetic patients were sensed. 131 were type I (7.4%) and 1,635 type II (90.6%). The health care variables of 1,197 patients (67.7%) and the rate of complications of 654 (54.6%) were assessed. A high prevalence of hypertension (50.0%) and dyslipemia (40.5%) were found associated with diabetes. Overall 868 individuals (72.5%) received individualized education in the clinic; 112 of these (12.9%) were included in collective education programs for groups. At the time of this evaluation, the proportion of patients treated with insulin (174/545) was significantly higher than that found before the program (79/402, p less than 0.0001). The practice of glycemic self assessment at home was also significantly increased (82/691 versus 440/1, 124; p less than 0.0001). The initial impact on the professional and diabetic patients of our area has been remarkable. Although the planning of multicentric evaluation systems in complex, it is possible to implement it if the data and recording system are coordinated.