Factors Associated with Adherence to Clinical Practice Guidelines for Patients with Type 2 Diabetes Mellitus: Results of a Spanish Delphi Consensus.

OBJECTIVE: To assess factors associated with adherence to clinical practice guidelines (CPGs) for type 2 diabetes mellitus (T2DM). METHODS: A cross-sectional multicenter study based on a two-round Delphi survey was designed. A total of 98 endocrinologists (mean age 45 years) involved in the care of T2DM patients completed a 43-item questionnaire assessing different aspects of adherence related to CPGs. RESULTS: Most participants worked in tertiary care public hospitals. All participants used CPGs, with ADA/EASD as the most common (99%). The lack of time, establishment of an individualized management of patients, insufficient human resources, and therapeutic inertia were scored as the main reasons for not following CPGs recommendations. Participants agreed that insufficient material resources and limitations established by the healthcare system prevent adherence to CPGs. The risk of hypoglycemia was considered to be limiting factor for the patients' integral control. Also, there was consensus on the need to have the support of nursing personnel with specific training in diabetes as well as dietitians and podiatrists. There was disagreement regarding the influence on adherence to CPGs of patient's characteristics not matching those of CPGs, patient's preferences, tolerability of the action recommended, concomitant comorbidities, or pluripathological conditions. Differences according to the participant's age (≤40 years vs. >40 years) were not found. Therapeutic inertia and lack of time did not show a significant correlation. CONCLUSIONS: Nonadherence to CPGs on T2DM is a multifactorial problem but the existence multiple CPGs, the lack of time, the therapeutic inertia, and insufficient human resources have been identified as factors limiting adherence. Hypoglycemia continues to be a barrier for achievement of targets recommended by CPGs.

Modificaciones anatomofuncionales del corazón en la obesidad mórbida. Cambios tras la cirugía bariátrica / Anatomical and functional alterations of the heart in morbid obesity. Changes after bariatric surgery

Introducción y objetivos. La adaptación cardiaca a la obesidad asocia anomalías estructurales y funcionales del corazón. El último escalón terapéutico en la obesidad mórbida lo ofrece la cirugía bariátrica. En este estudio se investigan los cambios anatomofuncionales del corazón en una cohorte española de obesos mórbidos y las modificaciones después de la cirugía bariátrica. Métodos. Inclusión prospectiva de pacientes referidos para cirugía bariátrica. En cada caso se realizó ecocardiograma transtorácico, electrocardiograma y analítica antes de la cirugía y 1 año después de la intervención. Resultados. Alcanzaron el seguimiento a 1 año 41 pacientes, con media de edad de 40,2±9,6 años, el 82,9% mujeres. El índice de masa corporal promedio era 47,41, y pasó a 30,43 después de la cirugía. Antes de la cirugía, el 70,7% presentaba remodelado ventricular, fundamentalmente por hipertrofia excéntrica (el 34,1% de los casos). Al año, el 58,5% tenía un patrón geométrico normal (p = 0,02). La relación E/A de llenado mitral pasó de 1,14 a 1,43 (p<0,001). Sin embargo, la velocidad del anillo mitral medida con Doppler tisular descendió ligeramente (p=0,06). Conclusiones. Los pacientes obesos mórbidos que se someten a cirugía bariátrica presentan con elevada frecuencia datos de remodelado ventricular, que es fundamentalmente de características excéntricas. La pérdida de peso conseguida mediante cirugía bariátrica se acompaña de significativas mejorías estructurales y en muchos casos lleva a la normalización completa del patrón geométrico ventricular. Sin embargo, es posible que la disfunción diastólica llegue a ser permanente (AU)

Introduction and objectives. Cardiac adaptation to obesity includes both structural and functional changes in the heart. The therapeutic option of last resort for morbidly obese patients is bariatric surgery. This study aims to assess the anatomical functional changes in the heart for a Spanish cohort of morbidly obese patients, as well as changes after bariatric surgery. Methods. Patients referred for bariatric surgery were prospectively included. In each case, a transthoracic echocardiography, electrocardiogram, and blood tests were performed before the procedure and repeated 1 year after surgery. Results. Forty-one patients completed the 1-year follow-up. Of these, 82.9% were female. Mean age was 40.2±9.6) years. Prior to surgery, mean body mass index was 47.41kg/m2, decreasing to 30.43kg/m2 after the procedure. Before surgery, cardiac remodeling was present in 70.7%, most frequently in the form of eccentric hypertrophy (34.1%). At 1-year follow-up, 58.5% showed a normal left ventricular geometric pattern (P=.02). Mitral inflow E/A ratio changed from 1.14 to 1.43 (P<.001). Nevertheless, early mitral velocity measured by Doppler tissue decreased (P=.06). Conclusions. In morbidly obese patients referred for bariatric surgery, cardiac remodeling is highly prevalent, in most cases in an eccentric manner. Weight loss achieved by bariatric surgery is accompanied by significant improvements in left ventricular structure. Nevertheless, the damage in diastolic function may be permanent despite weight loss (AU)

Anatomical and functional alterations of the heart in morbid obesity. Changes after bariatric surgery.

INTRODUCTION AND OBJECTIVES: Cardiac adaptation to obesity includes both structural and functional changes in the heart. The therapeutic option of last resort for morbidly obese patients is bariatric surgery. This study aims to assess the anatomical functional changes in the heart for a Spanish cohort of morbidly obese patients, as well as changes after bariatric surgery. METHODS: Patients referred for bariatric surgery were prospectively included. In each case, a transthoracic echocardiography, electrocardiogram, and blood tests were performed before the procedure and repeated 1 year after surgery. RESULTS: Forty-one patients completed the 1-year follow-up. Of these, 82.9% were female. Mean age was 40.2±9.6 years. Prior to surgery, mean body mass index was 47.41 kg/m(2), decreasing to 30.43 kg/m(2) after the procedure. Before surgery, cardiac remodeling was present in 70.7%, most frequently in the form of eccentric hypertrophy (34.1%). At 1-year follow-up, 58.5% showed a normal left ventricular geometric pattern (P=.02). Mitral inflow E/A ratio changed from 1.14 to 1.43 (P<.001). Nevertheless, early mitral velocity measured by Doppler tissue decreased (P=.06). CONCLUSIONS: In morbidly obese patients referred for bariatric surgery, cardiac remodeling is highly prevalent, in most cases in an eccentric manner. Weight loss achieved by bariatric surgery is accompanied by significant improvements in left ventricular structure. Nevertheless, the damage in diastolic function may be permanent despite weight loss.