Cardiovascular Risk Factors in Transgender People after Gender-Affirming Hormone Therapy.

INTRODUCTION: In the last decade, healthcare for the transgender population has increased considerably in many countries thanks to depathologization movements and the easier accessibility of medical assistance. The age at which they request to start gender-affirming hormones (GAHs) is increasingly younger. The cardiovascular risk associated with hormonal treatment is a novel research field, and the published studies are heterogeneous and inconclusive. Our objective is to determine the metabolic impact of GAHs in the transgender people treated in our Gender Identity Treatment Unit. METHODS: We designed a pre-post study to analyze changes in anthropometric parameters (weight and body mass index), analytical determinations (fasting blood glucose, glycated hemoglobin, and lipoproteins), and blood pressure control in the transgender population treated with GAHs in Puerta del Mar University Hospital. These variables were collected before and one year after hormonal therapy. RESULTS: A total of 227 transgender people were recruited between 2017 and 2020, 97 (40.09%) transwomen and 136 (59.91%) transmen. The average age at which GAHs began was 18 years. Weight, body mass index, and blood pressure increased significantly in both genders. Transmen showed a more atherogenic lipid profile, with a decrease in cholesterol LDL (p < 0.001) and an increase in triglycerides (p < 0.001). The risk of developing prediabetes or diabetes did not increase one year after treatment, although non-specific alterations in carbohydrate metabolism were detected, such as an increase in glycated hemoglobin in transmen (p = 0.040) and fasting blood glucose in transwomen (p = 0.008). No thromboembolic processes or cardiovascular events were reported during the first year of treatment. CONCLUSION: In our setting, transgender people developed changes in their metabolic profiles in the first year after hormonal treatment. Both transmen and transwomen showed early alterations in lipid and carbohydrate metabolism, slight elevations in blood pressure, and a tendency to gain weight. This makes lifestyle interventions necessary from the beginning of GAHs.

Factors associated with knowledge and vaccination intention for human papillomavirus on trans girls by their main caregiver: A cross-sectional study.

Introduction: Trans women are highly affected by the human papillomavirus (HPV) and are at risk of suffering from HPV-related diseases such as oropharyngeal, anal, penile, or neovaginal neoplasia. HPV vaccination seems to be a good strategy to reduce HPV-related diseases, mainly during the early age before the first sexual intercourse, but only cisgender girls are covered by the National Health Services, while some high-risk groups such as trans girls are not included. Achieving a high vaccination rate is important in the adolescent population, but there are many factors that could affect it, such as lack of knowledge about HPV or fear of side effects by patients and main caregivers. The aim of our study is to analyze the knowledge of trans girls' main caregivers about HPV-related diseases in the general population and, in particular, in trans women, as well as factors associated with HPV vaccination intention. Methods: A cross-sectional study was performed with the collaboration of main caregivers of adolescent trans girls, between 9 and 16 years old, assisted in two reference centers' multidisciplinary Gender Diversity Units. Information was requested through a self-completed questionnaire: HPV-related diseases Knowledge Transwomen questionnaire (HPV-TQ) was elaborated based on a 19-item self-administered questionnaire and score was standardized from 0 to 19 points. Percentage of correct answers was calculated and defined by the group of high scores that showed over 70% correct answers. Results: A total of 65 main caregivers were included. Almost all main caregivers were mothers with a Caucasian ethnicity. The HPV-TQ average score was 11 (3.7) with an average correct answer of 58.1% (19.6). Only 17/65 (26.1%) of main caregivers were highly knowledgeable in HPV. Of 65 trans girls, 14 were already vaccinated (29.8% of trans girls over 12 years old); 78.5% were not vaccinated and only 21.5% had intentions to be vaccinated. The group with a high score in HPV-TQ had a longer follow-up at the transgender unit, a higher maternal vaccination rate, and a positive family history of HPV-related disease, especially in mothers. Conclusion: Adolescent trans girls attended to in our units had a low rate and a low intention of vaccination against HPV. Education on and promotion and prevention of transgender HPV-related diseases should probably be implemented to achieve a higher knowledge and vaccination coverage in adolescent trans girls.

Dual effect of RYGB on the entero-insular axis: How GLP-1 is enhanced by surgical duodenal exclusion.

BACKGROUND: The role of the ileum and Glucagon Like Peptide-1 (GLP-1) secretion in the pathophysiological processes underlying the effects of Roux-en-Y gastric bypass (RYGB) on type 2 Diabetes mellitus (T2DM) improvement has been previously determined. However, the roles of duodenal exclusion and Glucose Insulinotropic Peptide (GIP) secretion change is not clear. To clarify this aspect, we compared the pathophysiological mechanisms triggered by RYGB, which implies the early arrival of food to the ileum with duodenal exclusion, and through pre-duodenal ileal transposition (PdIT), with early arrival of food to the ileum but without duodenal exclusion, in a nondiabetic rodent model. METHODS: We compared plasma and insulin, glucose (OGTT), GIP and GLP-1 plasma levels, ileal and duodenal GIP and GLP-1 tissue expression and beta-cell mass for n = 12 Sham-operated, n = 6 RYGB-operated, and n = 6 PdIT-operated Wistar rats. RESULTS: No surgery induced changes in blood glucose levels after the OGTT. However, RYGB induced a significant and strong insulin response that increased less in PdIT animals. Increased beta-cell mass was found in RYGB and PdIT animals as well as similar GLP-1 secretion and GLP-1 intestinal expression. However, differential GIP secretion and GIP duodenal expression were found between RYGB and PdIT. CONCLUSION: The RYGB effect on glucose metabolism is mostly due to early ileal stimulation; however, duodenal exclusion potentiates the ileal response within RYGB effects through enhanced GIP secretion.

Somatostatin: From a supporting actor to the protagonist to explain the long-term effect of sleeve gastrectomy on glucose metabolism.

BACKGROUND: Bariatric/metabolic surgery has become the most effective treatment against type 2 Diabetes mellitus (T2DM). The role of many gastrointestinal hormones in T2DM has been proposed, but the pathophysiological models described vary greatly depending on the anatomical rearrangements after surgery. We focus on somatostatin as a common factor in two of the most commonly performed surgical procedures in a healthy rodent model. We performed sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) and also an experimental surgery without gastric involvement (intestinal resection of 50 % jejunum-ileum portion -IR50 %). METHODS: We used five groups of Wistar rats: fasting control, sham-operated, SG-operated, RYGB-operated and IR50-operated. We analysed several parameters 4 and 23 weeks after surgery: plasma SST-14/28 fractions, plasma glucose, insulin release and SST-producing cell expression in the duodenum and pancreatic islets. RESULTS: Numerous SST-producing cells in the duodenum but a low number in the pancreas and a long-term loss of glucose tolerance were observed in SG and RYGB animals. Additionally, a high plasma SST-28 fraction was found in animals after SG but not after RYGB. Finally, IR50 animals showed no differences versus controls. CONCLUSIONS: In our SG model the amplitude of insulin response after metabolic surgeries, is mediated by SST-28 plasma levels derived from the proportional compensatory effect of gastric SST-producing tissue ablation. In addition, a strong compensatory response to the surgical loss of gastric SST-producing cells, leads to long-term loss of insulin production after SG but not in the others.

The long-term failure of RYGB surgery in improving T2DM is related to hyperinsulinism.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is the gold standard method for bariatric surgery and leads to substantial improvements in Type 2 Diabetes mellitus. However, many patients experience relapses in diabetes five years after undergoing this aggressive surgical procedure. We focus on beta-cell population changes and absorptive intestinal consequences after RYGB in a healthy nonobese animal model after a long survival period. METHODS: For our purpose, we use three groups of Wistar rats: RYGB-operated, surgical control (Sham) and fasting control. We measure alpha-, beta-cell mass; transcription (Arx, and Pdx-1) and proliferation (Ki67) factors; glucose tolerance and insulin release after oral glucose tests; histological adaptive changes in the jejunum; and intestinal glucose transporters. RESULTS: Our results showed an early increase in insulin secretion after surgery, that decrease at the end of the study. The beta-cell mass reduces twenty-four weeks after RYGB, which coincides with decrease of Pdx-1 transcription promoter factor. These was coincident with an increase in alpha-mass and a high expression of Arx in RYGB group. CONCLUSIONS: The analysis of all data showed beta-cell mass transdifferentiation into alpha-cell mass in RYGB rats. Due to long-term exhaustion of the beta-cell population by hyperinsulinism derived from digestive tract adaptation to surgery.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017).

INTRODUCTION: Diabetes mellitus (DM) is one of the most prevalent chronicdiseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease (VD) reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models. OBJECTIVE: To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM). PATIENTS AND METHODS: A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model. RESULTS: During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level < 8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction (AMI) and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (P = .001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14 ± 1.73%; 95% CI: 0.73-1.55; P = .0001) and cholesterol (11.28 ± 40 mg/dL; 95% CI: 2.07-20.48; P = .012). CONCLUSIONS: This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

Evaluation of Clinical Factors Predictive of Diabetes Remission Following Bariatric Surgery.

Bariatric surgery is an effective treatment for achieving significant weight loss and improving metabolic comorbidities such as type 2 diabetes mellitus (T2DM). The aim of our study was to investigate clinical factors related to T2DM remission in obese patients who had undergone bariatric surgery. METHODS: A cohort of patients with T2DM and a minimum of class II obesity undergoing bariatric surgery had their clinical and anthropometric variables assessed. The statistical evaluation included multivariate analyses of clinical factors predicting a T2DM remission two years post-surgery. RESULTS: 83 patients were included (mean age 44.13 ± 10.38 years). Two years post-surgery, the percentage of excess weight lost was 63.43 ± 18.59%, and T2DM was resolved in 79.5% of the patients. T2DM remission was directly related to a high body mass index (BMI) (OR: 1.886; p = 0.022) and the absence of macro-vascular complications (OR: 34.667; p = 0.002), while it was inversely associated with T2DM with a duration longer than 5 years (OR: 0.022; p = 0.040) and baseline insulin treatment (OR: 0.001; p = 0.009). 15.6% of the patients presented early complications and 20.5% developed late complications. CONCLUSION: In our study sample, bariatric surgery proved to be an effective and safe technique for sustained medium-term weight loss and the resolution of T2DM. A higher baseline BMI, a shorter T2DM duration, non-insulin treatment, and the absence of macro-vascular complications are factors predictive of T2DM remission.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017). / Modelo específico de coordinación entre atención primaria y hospitalaria para la atención a pacientes con diabetes mellitus. Evaluación de resultados a dos años (2015-2017).

INTRODUCTION: Diabetes mellitus (DM) is one of the most prevalent chronic diseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models. OBJECTIVE: To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM). PATIENTS AND METHODS: A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model. RESULTS: During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level<8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (p=0.001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14±1.73%; 95% CI: 0.73-1.55; p=0.0001) and cholesterol (11.28±40mg/dL; 95% CI: 2.07-20.48; p=0.012). CONCLUSIONS: This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

The histomorphometric parameters of endocrine pancreas after bariatric surgery in healthy animal models.

BACKGROUND: The aim of this study is to describe in depth how different bariatric surgeries affect to the cellularity of ß-cells in the pancreatic islet. There are much data regarding the possible physiological mechanisms involved in resolution of type 2 diabetes after bariatric surgery. But these data usually are controversial. We reported a direct influence of bariatric surgical technique on endocrine pancreas cellular turnover. Some surgeries increase proliferation processes of the ß-cells. Our objective is to report the histomorphometric mechanism that these techniques stimulate over the cellularity of pancreatic islet. METHOD: To this purpose, we used adult male Wistar rats to undergo the different techniques. We developed three surgical techniques (Sleeve gastrectomy and Y-Roux Gastric bypass as the most usual bariatric techniques, and a purely malabsorptive technique); moreover two control groups were performed (Sham and fasting controls). RESULTS: We completed a sequence of morphometric studies to conclude the behaviour of endocrine pancreatic ß-cell islet, correlating several histomorphometry parameters. CONCLUSION: Our purpose was to show a comprehensive interpretation to the consequences that bariatric surgeries had on the pancreatic islets cellularity. Moreover, we included the main tests to report the cellularity in histological samples.

Apoplejía hipofisaria como forma de presentación de un tumor teratoide/rabdoide atípico en el adulto / Pituitary apoplexy as presentation of atypical teratoid/rhabdoid tumor in an adult

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Nocturnal blood pressure is associated with the progression of microvascular complications and hypertension in patients with type 1 diabetes mellitus.

AIMS: To evaluate relationships between early alterations in blood pressure and the progression of microvascular complications of diabetes in clinically-normotensive patients with type 1 diabetes (T1DM). METHODS: In a prospective observational study of 85 normotensive T1DM patients without microalbuminuria, blood pressure (BP) was monitored over 24h using the ambulatory blood pressure monitoring (ABPM) system at baseline and 7years later. Development or progression of microalbuminuria, retinopathy and hypertension was evaluated. RESULTS: Initially, 20 patients (24%) were diagnosed with masked hypertension and 31 (37%) with non-dipper pattern as the only pathological findings. At 7years: 1) twenty-seven patients (32%) had progression of retinopathy related to the nocturnal diastolic blood pressure (BPD) (OR:1.122; p=0.034) and final non-dipper pattern (OR:5.857; p=0.005); 2) seven patients (10%) developed microalbuminuria for which nocturnal systolic blood pressure (BPS) was a risk factor (OR:1.129; p=0.007); 3) five of the normotensive patients (9%) progressed to hypertension; historic HbA1c (OR:2.767; p=0.046) and nocturnal BPD (OR:1.243; p=0.046) being the related risk factors. BPD level ≥65mmHg was associated with an increase in progression of retinopathy and hypertension. CONCLUSIONS: In T1DM patients there is an elevated prevalence of BP alterations, detected using ABPM. Alterations in nocturnal BP predispose to development/progression of microvascular complications and overt hypertension.

¿Deberían modificarse los protocolos diagnóstico-terapéuticos de los incidentalomas suprarrenales? / Should the diagnostic and therapeutic protocols for adrenal incidentalomas be changed?

ANTECEDENTES: La prevalencia de los incidentalomas suprarrenales está aumentando por el envejecimiento de la población y el empleo de técnicas de imagen de alta resolución. Los protocolos actuales proponen un seguimiento de su estado funcional y morfológico exhaustivos, sin una evidencia clínica concluyente que lo avale MÉTODO: Estudio retrospectivo de 96 pacientes diagnosticados de incidentaloma adrenal entre 2008 y 2012. Se evalúan características clínicas, funcionales y de imagen, basales y durante el seguimiento. RESULTADOS: Inicialmente, 4 casos fueron intervenidos por hiperfunción (2 síndromes de Cushing y 2 feocromocitomas) y 5 por tamaño superior a 4 cm. Durante el seguimiento, tan solo se diagnosticó un caso de feocromocitoma y otro creció más de 1 cm, indicándose cirugía. En el 98,86% de los incidentalomas diagnosticados inicialmente como benignos y no funcionantes, no se objetivaron modificaciones funcionales y/o morfológicas en la evaluación final. CONCLUSIONES: Los resultados de nuestra serie cuestionan la validez de los protocolos de seguimiento de los incidentalomas adrenales vigentes en la actualidad, que deberían ser revaluados atendiendo a características de eficiencia mediante estudios prospectivos

BACKGROUND: The prevalence of adrenal incidentalomas is increasing with the aging of the population and the use of high resolution imaging technics. Current protocols propose a comprehensive monitoring of their functional and morphological state, but with no conclusive clinical evidence that endorses it. METHOD: Retrospective study of 96 patients diagnosed with adrenal incidentaloma between 2008 and 2012. We evaluated clinical, functional and imaging at baseline and during follow-up. RESULTS: Initially, 9 cases were surgically removed: 4 due to hyperfunction (2 Cushing syndromes and 2 pheochromocytomas) and 5 due to size larger than 4 cm. During follow-up one case of pheochromocytoma was diagnosed and another grew more than 1 cm, needing surgery. In 98.86% of nonfunctional and benign lesions, there was no functional and/or morphological changes in the final evaluation. CONCLUSIONS: The results of our study challenge the validity of current diagnostic-therapeutic protocols of incidentalomas, which should be reassessed in prospective studies taking into account efficiency characteristics

Should the diagnostic and therapeutic protocols for adrenal incidentalomas be changed?

BACKGROUND: The prevalence of adrenal incidentalomas is increasing with the aging of the population and the use of high resolution imaging technics. Current protocols propose a comprehensive monitoring of their functional and morphological state, but with no conclusive clinical evidence that endorses it. METHOD: Retrospective study of 96 patients diagnosed with adrenal incidentaloma between 2008 and 2012. We evaluated clinical, functional and imaging at baseline and during follow-up. RESULTS: Initially, 9 cases were surgically removed: 4 due to hyperfunction (2 Cushing syndromes and 2 pheochromocytomas) and 5 due to size larger than 4cm. During follow-up one case of pheochromocytoma was diagnosed and another grew more than 1cm, needing surgery. In 98.86% of nonfunctional and benign lesions, there was no functional and/or morphological changes in the final evaluation. CONCLUSIONS: The results of our study challenge the validity of current diagnostic-therapeutic protocols of incidentalomas, which should be reassessed in prospective studies taking into account efficiency characteristics.