"Arterial stiffness is not associated with changes in the circadian pattern of blood pressure in patients with type 1 diabetes mellitus and cardiovascular autonomic dysfunction".

INTRODUCTION: Cardiovascular autonomic neuropathy (CAN) associates an abnormal circadian pattern in blood pressure (BP) regulation that might be aggravated by the coexistence of arterial stiffness. We aimed to evaluate the effect of arterial stiffness in the circadian rhythm of BP in patients with type 1 diabetes and CAN. METHODS: Cross-sectional study including 56 consecutive patients with type 1 diabetes and CAN, with (n = 28) or without (n = 24) arterial stiffness as defined by an ankle-brachial index above 1.2. CAN was diagnosed by BP and heart rate responses to active standing and cardiovascular autonomic reflex tests. Absence of nocturnal decrease in BP-"non-dipping" pattern- was defined by a daytime to nighttime decrease in mean BP smaller than 10%. RESULTS: The study's subjects mean age was 40 ± 11 years-old, their mean duration of diabetes was 22 ± 10 years, and their mean A1c was 7.9 ± 1.5%. A "non-dipping" pattern was observed in 28 patients (54%) regardless of the presence or absence of arterial stiffness. Age, waist circumference, body mass index, and A1c, were introduced as independent variables into a multiple regression analysis. The stepwise model (R2: 0.113, p = 0.016) retained only A1c levels (ß: ‒ 0.333, 95% confidence interval [CI]: -3.10 to -0.33) as significant predictor of the percentage of nighttime decrease in mean BP. CONCLUSIONS: A non-dipping pattern in BP is very common in patients with type 1 diabetes presenting with subclinical CAN and is associated with a poorer metabolic control. On the contrary, coexistence of arterial stiffness is not associated with abnormalities in circadian BP regulation.

Sex differences and sex steroids influence on the presentation and severity of cardiovascular autonomic neuropathy of patients with type 1 diabetes.

BACKGROUND: Sex differences characterize cardiovascular outcomes in patients with type 1 diabetes. Cardioautonomic neuropathy is a common complication of type 1 diabetes that associates increased morbi-mortality. Data regarding the interplay between sex and cardiovascular autonomic neuropathy are scarce and controversial in these patients. We aimed to address sex-related differences in the prevalence of seemingly asymptomatic cardioautonomic neuropathy in type 1 diabetes, and their associations with sex steroids. METHODS: We conducted a cross-sectional study including 322 consecutively recruited patients with type 1 diabetes. Cardioautonomic neuropathy was diagnosed using Ewing's score and power spectral heart rate data. We assessed sex hormones by liquid chromatography/tandem mass spectrometry. RESULTS: When considering all subjects as a whole, asymptomatic cardioautonomic neuropathy prevalence was not significantly different between women and men. When age was taken into account, the prevalence of cardioautonomic neuropathy was similar among young men and those > 50 years. However, in women > 50 years, the prevalence of cardioautonomic neuropathy doubled that of young women [45.8% (32.6; 59.7) vs. 20.4% (13.7; 29.2), respectively]. The OR of having cardioautonomic neuropathy was 3.3 higher in women > 50 years than in their younger counterparts. Furthermore, women presented more severe cardioautonomic neuropathy than men. These differences were even more marked when women were classified according their menopausal status instead of age. Peri- and menopausal women had an OR 3.5 (1.7; 7.2) of having CAN compared with their reproductive-aged counterparts [CAN prevalence: 51% (37; 65) vs. 23% (16; 32), respectively]. A binary logistic regression model (R2: 0.161; P = 0.001) displayed age > 50 years as a significant determinant of cardioautonomic neuropathy only in women. Androgens were positively associated with heart rate variability in men, and negatively in women. Accordingly, cardioautonomic neuropathy was associated with increased testosterone/estradiol ratio in women but to decreased testosterone concentrations in men. CONCLUSIONS: Menopause in women with type 1 diabetes is accompanied by an increase in the prevalence of asymptomatic cardioautonomic neuropathy. This age-related excess risk of cardioautonomic neuropathy is not observed in men. Men and women with type 1 diabetes have opposite associations between circulating androgens and indexes of cardioautonomic function. Trial registration ClinicalTrials.gov Identifier: NCT04950634.

Effect of Iron Depletion by Bloodletting vs. Observation on Oxidative Stress Biomarkers of Women with Functional Hyperandrogenism Taking a Combined Oral Contraceptive: A Randomized Clinical Trial.

Women with functional hyperandrogenism show both increased markers of oxidative stress and a mild iron overload. Combined oral contraceptives (COC) may worsen redox status in the general population. Since iron depletion ameliorates oxidative stress in other iron overload states, we aimed to address the changes in the redox status of these women as a consequence of COC therapy and of bloodletting, conducting a randomized, controlled, parallel, open-label clinical trial in 33 adult women with polycystic ovary syndrome or idiopathic hyperandrogenism. After three months of treatment with a COC, participants were randomized (1:1) to three scheduled bloodlettings or observation for another nine months. After taking a COC, participants showed a mild decrease in their plasma electrochemical antioxidant capacity, considering fast-acting antioxidants [MD: −1.51 (−2.43 to −0.60) µC, p = 0.002], and slow-acting antioxidants [MD: −1.90 (−2.66 to −1.14) µC, p < 0.001]. Women submitted to bloodletting showed a decrease in their non-enzymatic antioxidant capacity levels (NEAC) throughout the trial, whereas those individuals in the control arm showed a mild increase in these levels at the end of the study (Wilks' λ: 0.802, F: 3.572, p = 0.041). Decreasing ferritin and plasma hemoglobin during the trial were associated with worse NEAC levels. COC may impair redox status in women with functional hyperandrogenism. Decreasing iron stores by scheduled bloodletting does not override this impairment.

Point-of-care sural nerve conduction could predict the presence of cardiovascular autonomic neuropathy in type 1 diabetes mellitus.

AIMS: Assessment for cardiovascular autonomic neuropathy (CAN) in patients with type 1 diabetes mellitus remains time-consuming in the clinical setting. We aimed to examine the diagnostic performance of a portable point-of-care diagnostic tool (POCD) for assessing sural nerve conduction during the screening of CAN. METHODS: Nerve amplitude (AMPPOCD ) and conduction velocity (CVPOCD ) were measured in a cross-sectional study including 198 asymptomatic patients with type 1 diabetes. CAN was diagnosed by the Ewing score and power spectral heart rate [low-frequency (LF) and high-frequency (HF) activity]. Diagnostic accuracy was determined by ROC curves. RESULTS: CVPOCD and AMPPOCD showed positive correlations with LF and HF, and a negative correlation with age. Overall, AMPPOCD had an 81.7% accuracy in identifying CAN [AUC = 0.817 (95% CI 0.692-0.942)] with an AMPPOCD ≤6 µV showing 90% sensitivity and 73% specificity. In a stepwise binary logistic regression analysis, the model (R2 : 0.297; P < 0.001) retained the duration of type 1 diabetes [ß: 1.131 (95% CI: 1.051-1.216); P = 0.001) and A1c [ß: 2.131 (95% CI: 1.060-4.283); P = 0.034) as significant predictors of CAN. The combination of AMPPOCD ≤6 µV + a type 1 diabetes duration of ≥8 years maximized the sensitivity, showing a diagnostic performance of 87% [AUC = 0.867 (95% CI 0.769-0.965)] with 90%, 76%, and 99%, sensitivity, specificity, and NPV, respectively. Adding A1c ≥ 7% to this model maintained accuracy [AUC = 0.867 (95% CI: 0.788-0.963) and NPV (99%), while increasing specificity to 84%. CONCLUSIONS: The combination of AMPPOCD with A1c and the duration of type 1 diabetes mellitus showed a good performance for the detection of asymptomatic CAN, making POCD an easy and rapid test for its routine screening in the clinical setting.

Impact of excluding hyperglycemia from international diabetes federation metabolic syndrome diagnostic criteria on prevalence of the syndrome and its association with microvascular complications, in adult patients with type 1 diabetes.

BACKGROUND: We aimed to determine, in patients with type 1 diabetes (T1DM), the impact of excluding hyperglycemia as a criterion from the International Diabetes Federation (IDF) definition of the metabolic syndrome (MetS), both on its prevalence and on its association with micro and macrovascular complications and markers of subclinical inflammation. METHODS: A cross-sectional design, including 280 patients with T1DM. We defined MetS by three different models: (i) the standard IDF criteria, (ii) a modification consisting of excluding of hyperglycemia as a criterion (modified IDF criteria) and (iii) a modification consisting in changing the hyperglycemia by insulin resistance (MetS + IR model) defined by the estimated glucose disposal rate. Microvascular complications and cardioautonomic neuropathy were assessed. We measured an inflammatory panel including high sensitivity C reactive protein, erythrocyte sedimentation rate, homocysteine, and fibrinogen concentrations. RESULTS: After excluding hyperglycemia, the prevalence of MetS was 6.4% (95%CI: 4.1 to 9.9) compared with 20.7% (95%CI: 16.3 to 25.8) using standard IDF criteria. After adjusting for duration of diabetes, all three MetS definitions increased the odds for having microvascular complications [OR: 6.012 (2.208-16.307) for modified definition; OR: 5.176 (2.555-10.486) for standard definition and [OR: 3.374 (1.649-8.456) for MetS+IR model]. However, the both modified IDF models for MetS showed better predictive performance than standard criteria for suffering from neuropathy, nephropathy, cardiovascular disease and were associated with markers of subclinical inflammation. CONCLUSIONS: The prevalence of MetS significantly varies as a function whether or not hyperglycemia is included as a diagnostic criterion. The subset of patients fulfilling the modified MetS definitions may reflect better the concept of metabolic syndrome in T1DM. These modified definitions were accompanied by a poorer metabolic control and lipid profile, showing the worse inflammatory biomarker profiles and higher odds for micro- and macrovascular complications. In patients with T1DM, the inclusion of insulin resistance instead of hyperglycemia as a criterion of MetS may be of interest in routine clinical practice.

High serum copeptin may be a marker of an increased carotid intima-media thickness in asymptomatic patients with type 1 diabetes.

We aimed to study the association of copeptin with carotid intima-media thickness in 60 patients with type 1 diabetes (T1DM-patients). Our results suggest that copeptin might improve the stratification of cardiovascular risk in T1DM-patients. Further research is needed to determine the value in identifying carotid disease of this biochemical marker.

Bloodletting has no effect on the blood pressure abnormalities of hyperandrogenic women taking oral contraceptives in a randomized clinical trial.

Normoferritinemic women with functional hyperandrogenism show a mild iron overload. Iron excess, hyperandrogenism, and cardioautonomic dysfunction contribute to blood pressure (BP) abnormalities in these patients. Furthermore, combined oral contraceptives (COC) prescribed for hyperandrogenic symptoms may worse BP recordings. Iron depletion by phlebotomy appears to lower BP in other acquired iron overload conditions. We aimed to determine the effect of iron depletion on the office BP, ambulatory BP monitoring, and frequency of hypertension in patients with functional hyperandrogenism submitted to standard therapy with COC. We conducted a phase 2 randomized, controlled, parallel, open-label clinical trial (NCT02460445) in adult women with functional hyperandrogenism including hyperandrogenic polycystic ovary syndrome and idiopathic hyperandrogenism. After a 3-month run-in period of treatment with 35 µg ethinylestradiol plus 2 mg cyproterone acetate, participants were randomized (1:1) to three scheduled bloodlettings or observation for another 9 months. Main outcome measures were the changes in office BP, 24-h-ambulatory BP, and frequency of hypertension in both study arms. From June 2015 to June 2019, 33 women were included in the intention-to-treat analyses. We observed an increase in mean office systolic BP [mean of the differences (MD): 2.5 (0.3-4.8) mmHg] and night-time ambulatory systolic BP [MD 4.1 (1.4-6.8) mmHg] after 3 months on COC. The percentage of nocturnal BP non-dippers also increased, from 28.1 to 92.3% (P < 0.001). Office and ambulatory BP did not change throughout the experimental period of the trial, both when considering all women as a whole or as a function of the study arm. The frequency of the non-dipping pattern in BP decreased during the experimental period [OR 0.694 (0.577-0.835), P < 0.001], regardless of the study arm. Decreasing iron stores by scheduled bloodletting does not override the BP abnormalities caused by COC in women with functional hyperandrogenism.

Iron Overload in Functional Hyperandrogenism: In a Randomized Trial, Bloodletting Does Not Improve Metabolic Outcomes.

CONTEXT: Functional hyperandrogenism may be associated with a mild increase in body iron stores. Iron depletion exerts a beneficial effect on metabolic endpoints in other iron overload states. OBJECTIVES: (i) To determine the effect of iron depletion on the insulin sensitivity and frequency of abnormal glucose tolerance in patients with functional hyperandrogenism submitted to standard therapy with combined oral contraceptives (COC). ii) To assess the overall safety of this intervention. DESIGN: Randomized, parallel, open-label, clinical trial. SETTING: Academic hospital. PATIENTS: Adult women with polycystic ovary syndrome or idiopathic hyperandrogenism. INTERVENTION: After a 3-month run-in period of treatment with 35 µg ethinylestradiol plus 2 mg cyproterone acetate, participants were randomized (1:1) to 3 scheduled bloodlettings or observation for another 9 months. MAIN OUTCOME MEASURES: Changes in insulin sensitivity index and frequency of prediabetes/diabetes, and percentage of women in whom bloodletting resulted in plasma hemoglobin <120 g/L and/or hematocrit <0.36. RESULTS: From 2015 to 2019, 33 women were included by intention-to-treat. During the follow-up, insulin sensitivity did not change in the whole group of women or between study arms [mean of the differences (MD): 0.0 (95%CI: -1.6 to 1.6)]. Women in the experimental arm showed a similar odds of having prediabetes/diabetes than women submitted to observation [odds ratio: 0.981 (95%CI: 0.712 to 1.351)]. After bloodletting, 4 (21.1%) and 2 women (10.5%) in the experimental arm had hemoglobin (Hb) levels <120 g/L and hematocrit (Hct) values <0.36, respectively, but none showed Hb <110 g/L or Hct <0.34. CONCLUSIONS: Scheduled bloodletting does not improve insulin sensitivity in women with functional hyperandrogenism on COC.

Fasting serum copeptin and asymptomatic peripheral artery disease: No association in patients with type 1 diabetes mellitus.

OBJECTIVE: As copeptin is associated with lower-extremity amputation in patients with type 1 diabetes mellitus (T1DM), our study aimed to address the putative association between copeptin and asymptomatic peripheral artery disease (aPAD) in those patients. DESIGN AND METHODS: This observational cross-sectional study included 112 patients with T1DM from a larger cohort (ClinicalTrials.gov: NCT02910271), selected (1:2) as per the presence of aPAD (n = 37) or not (n = 75). aPAD was evaluated by ankle-brachial index (ABI), toe-brachial index (TBI), and peripheral Doppler ultrasound. The two groups of patients were matched by age, gender distribution and duration of T1DM. Fasting serum copeptin was measured by high-sensitivity ELISA, and its relationships with clinical and biochemical variables as well as aPAD were evaluated too. RESULTS: The study population was aged 42 ± 8 years, duration of T1DM was 27 ± 7 years, and mean HbA1c was 7.7 ± 1.1%. No significant differences in copeptin concentrations were found between patients with or without aPAD (16.9 ± 10.8 vs 17.3 ± 14.7 pmol/L, respectively; P = 0.462). Considering all patients as a whole, copeptin correlated with systolic blood pressure (SBP; ρ = -0.209, P = 0.027), eGFR ρ = -0.271, P = 0.004), and serum sodium (ρ = -0.208, P = 0.027), but not with ABI (ρ = -0.068, P = 0.476). Stepwise multiple linear regression analysis (R2: 0.059; P = 0.035) retained SBP (ß: -0.219, 95% CI: -1.391; -0.089) as the only significant predictor of copeptin concentration. CONCLUSION: As serum copeptin does not appear to be associated with aPAD in patients with T1DM, further studies are now needed to elucidate whether it has any other potential role to play in the subclinical vascular disease of this patient population.

2D Diffusion-Ordered 1 H-NMR Spectroscopy Lipidomic Profiling after Oral Single Macronutrient Loads: Influence of Obesity, Sex, and Female Androgen Excess.

SCOPE: Postprandial dysmetabolism plays a major role in the pathogenesis of metabolic disorders such as obesity and the polycystic ovary syndrome (PCOS). The aim is to characterize the circulating lipoprotein particle profiles in response to oral glucose, lipid, and protein challenges. METHODS AND RESULTS: 17 women with PCOS, 17 control women, and 19 healthy men selected to have similar age and body mass index are studied. Blood samples are collected following the ingestion of 300 kcal in the form of glucose, lipids, or proteins, and they are submitted to two-dimensional (2D) diffusion-ordered 1 H-NMR spectroscopy. Regardless of macronutrient administered, the number of very low-density (VLDL) particles increases whereas low density-lipoprotein (LDL) decreases. High density-lipoprotein (HDL) particles increase only after lipid ingestion. Obese subjects show an increase in the number of large VLDL particles and a decrease in large LDL particles, with a significant reduction in the average particle size of LDL. Patients with PCOS show a particularly unfavorably smaller LDL particle size response to oral lipid intake, regardless of obesity. CONCLUSIONS: Oral macronutrient challenges induce immediate class-specific postprandial changes in particle number and size of lipoproteins, with lipids inducing a more pro-atherogenic lipoprotein profile compared to glucose and proteins, particularly in obese subjects and women with PCOS.

Enteroparasitosis en escolares, problema de salud pública. Intervención desde el Sistema Nacional Integrado de Salud de Uruguay / Intestinal parasites in schoolchildren, public health problem. Intervention from the National Integrated Health System of Uruguay

RESUMEN Objetivos Generar un modelo de intervención en promoción de salud, desde el Sistema Nacional Integrado de Salud (SNIS) de Uruguay, con promotores escolares de salud, recursos web y abordaje desde los centros educativos a la comunidad. Materiales y Métodos Estudio descriptivo transversal, de base poblacional, mediante un muestreo aleatorio, no agrupado, durante los meses de abril y diciembre de 2016. Se llevó a cabo una capacitación para escolares en promoción de salud, encuesta poblacional, herramientas web, exámenes parasitológicos y georreferenciación. Resultados Se observaron prevalencias de giardiasis, del 14% (IC95%: 11-17) (6,5 a 22%); y oxiurosis 26% (IC95: 22-30) (20 a 44%). Se visualizaron 45 conglomerados de geohelmintiasis (HTS), la mayoría en zonas con asentamientos poblacionales carentes de servicios básicos. Conclusiones La existencia de sectores poblacionales vulnerables con índices de contaminación fecal intradomiciliaria y ambientales hace necesario que el SNIS realice de forma sistemática actividades de promoción de salud que puedan aportar datos relevantes para intervenciones gubernamentales intersectoriales y para mejorar la salud de estos sectores desprotegidos.

ABSTRACT Objectives To generate a model of intervention, from the National Integrated Health System (NIHS, Uruguay), with school facilitators of health, web resources and approach from the schools to the community. Materials and Methods Descriptive cross-sectional study of population base using a random sampling, non-clustered, during the months of April and December 2016. This was based in the model of schoolchildren health promoters, the use of web resources and community approach with the school as the centre of actions. Results The prevalence of parasites was 14% for Giardiasis (6,5 and 22%) (IC95%: 11-17) and 26% for Oxiurosis (IC95%: 22-30) (20 and 44%). Soil transmitted helminthiases were geo-referenced: we found 45 clusters, mainly in slums without basic services. Conclusions These worrying results show that there are regions in Montevideo (Uruguay) with high levels of faecal home and environmental contamination. Community approaches with prevention activities from NIHS may have a positive impact on these vulnerable populations.

Postprandial inflammatory responses after oral glucose, lipid and protein challenges: Influence of obesity, sex and polycystic ovary syndrome.

BACKGROUND & AIMS: Most evidence linking the polycystic ovary syndrome (PCOS) with chronic low-grade inflammation has been obtained in the fasting state. We have studied the postprandial inflammatory response to oral glucose, lipid and protein challenges and the possible influences of obesity, sex and PCOS on these responses. METHODS: On alternate days, we submitted 17 women with PCOS (9 non-obese, 8 obese), 17 control women (9 non-obese, 8 obese) and 19 control men (10 non-obese, 9 obese) to isocaloric (300 Kcal) oral macronutrient loads. We assayed serum for TNF-α, IL-6, IL-18, IL-10, pentraxin-3 and galectin-3 concentrations and leukocytes for expression of TNF, IL6, IL10 and their receptors TNFRSF1B, IL6R and IL10RA. RESULTS: Circulating IL-6 levels decreased after glucose and protein ingestion but slightly increased after oral lipid intake. Leukocyte IL6 expression did not change after the ingestion of any macronutrient yet IL6R expression increased during all macronutrient challenges, the largest increase being observed after glucose ingestion. Serum TNF-α similarly decreased during either macronutrient load, whereas TNF expression increased after macronutrient ingestion, the highest increase observed after oral glucose. TNFRSF1B expression also increased after glucose intake but not after lipid or protein ingestion. No global effect of obesity or group on postprandial circulating IL-6, TNF-α, or IL6, IL6R, TNF and TNFRSF1B expression was found. Circulating IL-18 concentrations decreased during all oral challenges, whereas in case of galectin-3 and pentraxin-3 only the protein load caused a reduction in its concentrations. Of the genes studied here, IL10 showed the largest increase in expression throughout all the postprandial curves, particularly after glucose. Obesity blunted the increase in IL10 expression. IL10RA expression decreased after glucose ingestion but remained unchanged during lipid and protein loads. CONCLUSIONS: Glucose ingestion, as opposed to lipid and protein intake, results into the largest increase in leukocyte gene expression of inflammatory mediators. The expression of the anti-inflammatory cytokine IL10 was the largest observed here, suggesting a compensatory mechanisms against postprandial inflammation that may be blunted in obesity. However, these responses did not translate into the circulating concentrations of these inflammatory mediators during the immediate postprandial phase.

[Intestinal parasites in schoolchildren, public health problem. Intervention from the National Integrated Health System of Uruguay]. / Enteroparasitosis en escolares, problema de salud pública. Intervención desde el Sistema Nacional Integrado de Salud de Uruguay.

OBJECTIVES: To generate a model of intervention, from the National Integrated Health System (NIHS, Uruguay), with school facilitators of health, web resources and approach from the schools to the community. MATERIALS AND METHODS: Descriptive cross-sectional study of population base using a random sampling, non-clustered, during the months of April and December 2016. This was based in the model of schoolchildren health promoters, the use of web resources and community approach with the school as the centre of actions. RESULTS: The prevalence of parasites was 14% for Giardiasis (6,5 and 22%) (IC95%: 11-17) and 26% for Oxiurosis (IC95%: 22-30) (20 and 44%). Soil transmitted helminthiases were geo-referenced: we found 45 clusters, mainly in slums without basic services. CONCLUSIONS: These worrying results show that there are regions in Montevideo (Uruguay) with high levels of faecal home and environmental contamination. Community approaches with prevention activities from NIHS may have a positive impact on these vulnerable populations.

OBJETIVOS: Generar un modelo de intervención en promoción de salud, desde el Sistema Nacional Integrado de Salud (SNIS) de Uruguay, con promotores escolares de salud, recursos web y abordaje desde los centros educativos a la comunidad. MATERIALES Y MÉTODOS: Estudio descriptivo transversal, de base poblacional, mediante un muestreo aleatorio, no agrupado, durante los meses de abril y diciembre de 2016. Se llevó a cabo una capacitación para escolares en promoción de salud, encuesta poblacional, herramientas web, exámenes parasitológicos y georreferenciación. RESULTADOS: Se observaron prevalencias de giardiasis, del 14% (IC95%: 11-17) (6,5 a 22%); y oxiurosis 26% (IC95: 22-30) (20 a 44%). Se visualizaron 45 conglomerados de geohelmintiasis (HTS), la mayoría en zonas con asentamientos poblacionales carentes de servicios básicos. CONCLUSIONES: La existencia de sectores poblacionales vulnerables con índices de contaminación fecal intradomiciliaria y ambientales hace necesario que el SNIS realice de forma sistemática actividades de promoción de salud que puedan aportar datos relevantes para intervenciones gubernamentales intersectoriales y para mejorar la salud de estos sectores desprotegidos.

Association of Cardiovascular Autonomic Dysfunction With Peripheral Arterial Stiffness in Patients With Type 1 Diabetes.

CONTEXT: Cardiovascular autonomic neuropathy (CAN) appears to contribute to peripheral arterial stiffness (AS) in type 1 diabetes. Whether CAN in patients with AS is associated with concomitant asymptomatic peripheral arterial disease (aPAD) remains unclear. OBJECTIVE: To assess the risk of CAN in patients with type 1 diabetes and AS and its potential association with atherosclerosis. DESIGN: Cross-sectional study. SETTING: Type 1 diabetes clinic in an academic hospital. PATIENTS: Two hundred sixty-four patients with type 1 diabetes. INTERVENTION: AS was defined as an ankle-brachial index (ABI) >1.2, aPAD by the toe-brachial index and Doppler sonography, and CAN by blood pressure and heart rate responses to active standing and Ewing and Clarke tests. MAIN OUTCOME MEASURES: Odds of having CAN among patients with AS. Odds for CAN were also calculated as a function of the presence of AS and concomitant aPAD. RESULTS: The study population's mean age was 35 ± 11 years, with a duration of disease of 19 ± 10 years and mean hemoglobin A1c of 7.5% ± 1.3%. Seventy-three patients (28%) had peripheral AS, of whom 28 showed aPAD. The prevalence of CAN among patients with AS was 48% but it was only 23% in subjects with normal ABI (OR: 3.1 [1.7; 5.4]). Concomitant aPAD increased the OR for CAN (OR: 4.5 [2.0; 10.1]). After adjustments for aPAD and relevant cardiovascular risk factors, AS remained associated with parasympathetic dysfunction. CONCLUSIONS: In type 1 diabetes, both peripheral AS and atherosclerosis were associated with CAN. A simple method, such as the ABI, may identify a subset of patients with undiagnosed dysautonomia.

Diagnosis of disorders of glucose tolerance in women with polycystic ovary syndrome (PCOS) at a tertiary care center: fasting plasma glucose or oral glucose tolerance test?

BACKGROUND: The risk of developing prediabetes and type 2 diabetes (dysglycemia) may be increased in women with PCOS. Whether an oral glucose tolerance test (OGTT) should be performed routinely in all PCOS women at presentation or should be recommended only to a selected subset of patients is still controversial. BASIC PROCEDURES: At a tertiary care center, we conducted a retrospective, observational study including 400 women with PCOS submitted to an OGTT. Our primary objective was to assess the diagnostic agreement between two algorithms commonly used for the screening of dysglycemia in these women: i) relying only on fasting plasma glucose (FPG) or ii) considering both fasting and/or 120-min plasma glucose concentrations during an OGTT. We conducted the analysis considering all patients as a whole, and also after stratifying them by body weight, androgen concentrations and age. MAIN FINDINGS: The OGTT detected dysglycemia in 24.5% of patients, whereas only 14.3% women would have been diagnosed using FPG levels alone. The latter missed as many as 40% of women with dysglycemia in our series, including all cases of diabetes. Diagnostic agreement between both algorithms was only 0.55 (κ = 0.103; 95% CI: 0.05-0.16). Areas under the receiver operating characteristic curve for dysglycemia were 0.86 (95%CI: 0.81-0.91) for FPG and 0.91 (95%CI = 0.87-0.95) for 120-min plasma glucose during the OGTT. FPG was not accurate in predicting dysglycemia in women with PCOS regardless of the presence of insulin resistance, weight excess, hyperandrogenemia and age. PRINCIPAL CONCLUSIONS: Relying on FPG alone is not adequate for the screening of disorders of glucose tolerance in women with PCOS; such diagnosis should rely on the results of an OGTT regardless of age, weight and/or androgen concentrations.

Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning.

OBJECTIVE: To evaluate clarity, completeness, and impact on surgical planning of MRI reporting of perianal fistulizing disease using a structured disease-specific template versus narrative reporting for planning of disease treatment by colorectal surgeons. MATERIALS AND METHODS: In this HIPAA-compliant, IRB-approved study with waiver of informed consent, a structured reporting template for perianal fistulizing disease MRIs was developed based on collaboration between colorectal surgeons and abdominal radiologists. The study population included 45 consecutive patients who underwent pelvic MRI for perianal fistulizing disease prior to implementation of structured reporting, and 60 consecutive patients who underwent pelvic MRI for perianal fistulizing disease after implementation of structured reporting. Objective evaluation of the reports for the presence of 12 key features was performed, as also subjective evaluation regarding the clarity and completeness of reports, and impact on surgical planning. RESULTS: Significantly more key features were absent in narrative reports [mean: 6.3 ± 1.8 (range 3-11)] than in structured reports [mean: 0.3 ± 0.9 (range 1-5)] (p ≤ 0.001). The use of structured reporting also increased the percentage of completeness (72.5-88.3% for surgeon 1, and 61.2-81.3% for surgeon 2; p = 0.05 and 0.03, respectively), helpfulness in surgical planning (7.1 ± 1.5-7.6 ± 1.5 for surgeon 1, and 5.8 ± 1.4-7.1 ± 1.1 for surgeon 2; p = 0.05 and p < 0.001, respectively), and clarity (7.6 ± 1.3-8.3 ± 1.1 for surgeon 1, and 5.2 ± 1.4-7.1 ± 1.3 for surgeon 2; p = 0.006 and p < 0.001, respectively) of the reports. CONCLUSION: Structured MRI reports in patients with perianal fistulizing disease miss fewer key features than narrative reports. Moreover, structured reports were described as more complete and clear, and more helpful for treatment planning.

The peripheral atherosclerotic profile in patients with type 1 diabetes warrants a thorough vascular assessment of asymptomatic patients.

AIMS: Epidemiological data on subclinical atherosclerotic disease in type 1 diabetes mellitus (DM1) are scarce. We aimed to estimate the subclinical atherosclerosis profile of asymptomatic patients with DM1 and an abnormal ankle-brachial index (ABI). MATERIAL AND METHODS: In a cross-sectional design (ClinicalTrials.gov Identifier: NCT02910271), we estimated ABI in 289 consecutive asymptomatic patients with DM1. An abnormal ABI led to measurements of toe-brachial index (TBI) and peripheral doppler ultrasound (DUS) to diagnose peripheral artery disease (PAD) and/or atherosclerotic carotid plaques (ACP). RESULTS: A reduced (≤0.9) or increased (>1.2) ABI was detected in 17 (6%) and 75 (26%) patients, respectively. PAD was confirmed by TBI and DUS in 9 (53%) patients with a reduced ABI and 28 (37%) patients with an increased ABI, resulting in a 12.8% (9.4-17.2) prevalence of asymptomatic PAD. Fourteen patients with an abnormal ABI also exhibited ACP [4.8% (2.9-7.9)], with 64% of these patients showing bilateral disease. Artery stenosis was mild or moderate in 21% and 29% of patients, respectively. Thus, 46 [16% (12-21)] patients showed asymptomatic PAD, ACP, or both. According to our data, we would have to explore three asymptomatic patients with DM1 and normal pulses to unmask one case of PAD, and seven asymptomatic patients showing abnormal ABI values to detect one carotid disease. CONCLUSIONS: Peripheral artery disease is often undiagnosed in asymptomatic patients with DM1. However, its presence may change medical management in a substantial percentage of cases, highlighting the potential benefit of a thorough vascular assessment on these patients.

Certified testosterone immunoassays for hyperandrogenaemia.

BACKGROUND: Testosterone (T) measurement in women is problematic leading to initiatives aiming to improve laboratory standardization of commercial assays. We assessed the impact on the clinical diagnosis of functional hyperandrogenic disorders of a total T immunoassay recently certified by the Centers for Diseases Control and Prevention (CDC). METHODS: We conducted a cross-sectional study including 263 consecutive adult premenopausal women presenting with functional ovarian hyperandrogenism-including polycystic ovary syndrome (PCOS)-and 73 nonhyperandrogenic female volunteers who served to define reference ranges. Total T was measured by a local routine direct radioimmunoassay and by a CDC-certified immunochemiluminescence assay. The main outcome measures were total and calculated free T concentrations and percentage of patients with hyperandrogenaemia. RESULTS: Both assays showed a poor concordance for total and calculated free T measurements. Hence, 147 (56%) and 109 (41%) of women had hyperandrogenaemia with the routine and CDC-certified assays, respectively [κ (95%CI): 0.538 (0.441-0.634)]. Free T levels calculated from total T using both assays showed similar correlations with metabolic variables. Women showing hyperandrogenaemia by both methods had the worst metabolic profiles, yet women presenting with hyperandrogenaemia only when using the CDC-certified assay did not show any significant difference compared to nonhyperandrogenic women in anthropometric or metabolic variables. Those women with hyperandrogenaemia only when using the routine assay were more obese and insulin resistant than normoandrogenaemic hirsute patients. CONCLUSIONS: An isolated androgen measurement, even a very specific one, is unlikely to identify the hyperandrogenic milieu that characterizes patients with functional ovarian hyperandrogenism and PCOS.

Gut Microbiota and the Polycystic Ovary Syndrome: Influence of Sex, Sex Hormones, and Obesity.

Context: Gut microbiota play a major role in health and disease by influencing physiology, metabolism, nutrition, and immune function. Objective: To evaluate the composition of gut microbiota in women with polycystic ovary syndrome (PCOS), focusing on the influence of sex, sex hormones and obesity on the associations found. Design: Cross-sectional study. Setting: Academic hospital. Participants: We recruited 15 women with PCOS, 16 nonhyperandrogenic control women, and 15 control men. Participants were classified as nonobese (<30 kg/m2) or obese (≥30 kg/m2) according to their body mass index. Interventions: Standardization of diet for 3 consecutive days (at least 300 g of carbohydrates per day) followed by fecal sampling and a standard 75-g oral glucose tolerance test. Main Outcome Measures: Analysis of bacterial abundance and composition of gut microbiota by massive sequencing of 16S ribosomal DNA amplicons in a MiSeq platform (Illumina). Results: α Bacterial diversity was reduced in women compared with men, and ß diversity was reduced particularly in obese patients with PCOS. Women with PCOS presented with specific abnormalities in gut microbiota consisting of an increased abundance of the Catenibacterium and Kandleria genera. When all participants as a whole were considered, indexes of bacterial diversity and the abundance of several bacterial genera correlated positively with serum androgen concentrations and negatively with estradiol levels. Conclusions: The diversity and composition of the gut microbiota of young adults are influenced by the combined effects of sex, sex hormone concentrations, and obesity, presenting with specific abnormalities in women with PCOS.