[Nasogastric tube obstruction due to enteral feeding bezoar]. / Obstrucción de sonda nasogástrica por molde de nutrición enteral.

Introduction: Introduction: the administration of enteral nutrition through a nasogastric tube can cause potentially serious complications. We present a case of esophageal obstruction due to an enteral nutrition bezoar. Case report: the 77-year-old patient was admitted to our center in the intensive care unit for COVID pneumonia. The patient received enteral nutrition through a nasogastric tube (NGT), presenting difficulty passing it after a month of follow-up. After removal of the tube and attached to it, an esophageal mold for enteral nutrition was extracted. Later, a solvent solution is administered through a new SNG and the formula is modified for a hydrolyzed one. Discussion: enteral nutrition bezoars are a rare but can be a life-threatening complication.

Introducción: Introducción: la administración de nutrición enteral por sonda nasogástrica puede presentar complicaciones potencialmente graves. Presentamos un caso de obstrucción esofágica por un bezoar de nutrición enteral. Caso clínico: el paciente de 77 años ingresó en nuestro centro en la unidad de cuidados intensivos por neumonía COVID. El paciente recibía nutrición enteral por sonda nasogástrica (SNG) presentando al mes del seguimiento dificultad para el paso de la misma. Tras retirada de la sonda y unida a ella se extrajo un molde esofágico de nutrición enteral. Posteriormente se administra a través de una nueva SNG una solución disolvente y se modifica la fórmula por una hidrolizada. Discusión: los bezoar de nutrición enteral son una complicación rara pero potencialmente mortal.

Xanthogranuloma of the sellar region: a systematic review.

Knowledge of xanthogranuloma (XG) of the sellar region comes from short series or single cases. We performed a systematic review, using the PubMed, Web of Science, Embase, Scopus, eLibrary, and BIOSIS Preview databases, of all cases reported from 2000 to the present. We also describe one unreported patient treated in our institution. A search of the literature revealed that of 71 patients 50.7% were male and that mean age at diagnosis was 34.7 ± 19.2 years old. Median time from clinical onset until diagnosis was 7 (3-21) months. Hypopituitarism (70.4%), visual disorders (64.7%), headache (53.5%), and polyuria-polydipsia (28.2%) were the most common symptoms. On MRI, median tumor size was 20 (16-29) mm, while 71.8% were sellar/suprasellar and less frequently exclusively suprasellar (15.5%) or sellar (12.7%). On T1-weighted imaging, XG was hyperintense in 76.3% of patients, while it showed variable appearance on T2-weighted imaging. The tumor showed cystic features in 50.7%, gadolinium enhancement in 45.1%, and calcification in 22.5% of patients. All patients underwent surgery (77.4% transphenoidal approach and 18.3% craniotomy), with hypopituitarism (56.4%), diabetes insipidus (34.5%), and visual defects (7.3%) being the most common complications. Total/subtotal resection was achieved in 93.5%, while the tumor was partially removed in 6.6%. Median follow-up was 24 (6-55) months and no tumor recurrence or remnant growth was reported in 97.5% of cases. In conclusion, XG affects the younger population, manifested by hormonal deficit and mass effect symptoms. Surgery is safe and offers excellent outcomes, though hypopituitarism is frequent post-surgery. Tumor recurrence or remnant growth is rare and radiological surveillance is a good option for patients with remnant lesions.

A specific gut microbiota signature is associated with an enhanced GLP-1 and GLP-2 secretion and improved metabolic control in patients with type 2 diabetes after metabolic Roux-en-Y gastric bypass.

Objective: To determine changes in incretins, systemic inflammation, intestinal permeability and microbiome modifications 12 months after metabolic RYGB (mRYGB) in patients with type 2 diabetes (T2D) and their relationship with metabolic improvement. Materials and methods: Prospective single-center non-randomized controlled study, including patients with class II-III obesity and T2D undergoing mRYGB. At baseline and one year after surgery we performed body composition measurements, biochemical analysis, a meal tolerance test (MTT) and lipid test (LT) with determination of the area under the curve (AUC) for insulin, C-peptide, GLP-1, GLP-2, and fasting determinations of succinate, zonulin, IL-6 and study of gut microbiota. Results: Thirteen patients aged 52.6 ± 6.5 years, BMI 39.3 ± 1.4 kg/m2, HbA1c 7.62 ± 1.5% were evaluated. After mRYGB, zonulin decreased and an increase in AUC after MTT was observed for GLP-1 (pre 9371 ± 5973 vs post 15788 ± 8021 pM, P<0.05), GLP-2 (pre 732 ± 182 vs post 1190 ± 447 ng/ml, P<0.001) and C- peptide, as well as after LT. Species belonging to Streptococaceae, Akkermansiacea, Rickenellaceae, Sutterellaceae, Enterobacteriaceae, Oscillospiraceae, Veillonellaceae, Enterobacterales_uc, and Fusobacteriaceae families increased after intervention and correlated positively with AUC of GLP-1 and GLP-2, and negatively with glucose, HbA1c, triglycerides and adiposity markers. Clostridium perfringens and Roseburia sp. 40_7 behaved similarly. In contrast, some species belonging to Lachnospiraceae, Erysipelotricaceae, and Rumnicocaceae families decreased and showed opposite correlations. Higher initial C-peptide was the only predictor for T2D remission, which was achieved in 69% of patients. Conclusions: Patients with obesity and T2D submitted to mRYGB show an enhanced incretin response, a reduced gut permeability and a metabolic improvement, associated with a specific microbiota signature.

The Spanish Scientific Societies before the ESC 2021 guidelines on vascular disease prevention: Generalizing the measurement of albuminuria to identify vascular risk and prevent vascular disease.

The 2021 guidelines on the prevention of vascular disease (VD) in clinical practice published by the European Society of Cardiology (ESC) and supported by 13 other European scientific societies recognize the key role of screening for chronic kidney disease (CKD) in the prevention of VD. Vascular risk in CKD is categorized based on measurements of estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (ACR). Thus, moderate CKD is associated with a high vascular risk and severe CKD with a very high vascular risk requiring therapeutic action, and there is no need to apply other vascular risk scores when vascular risk is already very high due to CKD. Moreover, the ESC indicates that vascular risk assessment and the subsequent decision algorithm should start with measurement of eGFR and ACR. To optimize the implementation of the ESC 2021 guidelines on the prevention of CVD in Spain, we consider that: 1) Urine testing for albuminuria using ACR should be part of the clinical routine at the same level as blood glucose, cholesterolemia, and GFR estimation when these are used to make decisions on CVD risk. 2) Spanish public and private health services should have the necessary means and resources to optimally implement the ESC 2021 guidelines for the prevention of CVD in Spain, including ACR testing.

Review of SGLT2i for the Treatment of Renal Complications: Experience in Patients with and Without T2D.

The management of type 2 diabetes (T2D) involves decreasing plasma glucose levels and reducing cardiovascular and microvascular complications. Diabetic kidney disease (DKD), defined as presence of albuminuria, impaired glomerular filtration, or both, is an insidious microvascular complication of diabetes that generates a substantial personal and clinical burden. The progressive reduction in renal function and increased albuminuria results in an increase of cardiovascular events. Thus, patients with DKD require exhaustive control of the associated cardiovascular risk factors. People with diabetes and renal impairment have fewer options of antidiabetic drugs because of contraindications, adverse effects, or altered pharmacokinetics. Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) reduce blood glucose concentrations by blocking the uptake of sodium and glucose in the proximal tubule and promoting glycosuria, and these agents now have an important role in the management of T2D. The results of several cardiovascular outcomes trials suggested that SGLT2i are associated with improvements in renal endpoints in addition to their reduction in cardiovascular events and mortality, which represents a major advance in the care of this population. The dedicated kidney outcomes trials have confirmed the renoprotective action of SGLT2i across different glomerular filtration and albuminuria values, even in patients with non-diabetic chronic kidney disease. Notably, this improvement in kidney function may indirectly benefit cardiac function through multifaceted interorgan cross talk, which can break the cardiorenal vicious circle linked to T2D. In this article, we briefly review the different mechanisms of action that may explain the renal beneficial effects of SGLT2i and disclose the results of the key renal outcome trials and the subsequent update of related clinical guidelines.

Information and consensus document for the detection and management of chronic kidney disease.

Chronic kidney disease (CKD) is a major public health problem worldwide that affects more than 10% of the Spanish population. CKD is associated with high comorbidity rates, poor prognosis and major consumption of health system resources. Since the publication of the last consensus document on CKD seven years ago, little evidence has emerged and few clinical trials on new diagnostic and treatment strategies in CKD have been conducted, apart from new trials in diabetic kidney disease. Therefore, CKD international guidelines have not been recently updated. The rigidity and conservative attitude of the guidelines should not prevent the publication of updates in knowledge about certain matters that may be key in detecting CKD and managing patients with this disease. This document, also prepared by 10 scientific associations, provides an update on concepts, clarifications, diagnostic criteria, remission strategies and new treatment options. The evidence and the main studies published on these aspects of CKD have been reviewed. This should be considered more as an information document on CKD. It includes an update on CKD detection, risk factors and screening; a definition of renal progression; an update of remission criteria with new suggestions in the older population; CKD monitoring and prevention strategies; management of associated comorbidities, particularly in diabetes mellitus; roles of the Primary Care physician in CKD management; and what not to do in Nephrology. The aim of the document is to serve as an aid in the multidisciplinary management of the patient with CKD based on current recommendations and knowledge.

Role of Gastrointestinal Hormones as a Predictive Factor for Long-Term Diabetes Remission: Randomized Trial Comparing Metabolic Gastric Bypass, Sleeve Gastrectomy, and Greater Curvature Plication.

PURPOSE: Long-term studies comparing the mechanisms of different bariatric techniques for T2DM remission are scarce. We aimed to compare type 2 diabetes (T2DM) remission after a gastric bypass with a 200-cm biliopancreatic limb (mRYGB), sleeve gastrectomy (SG), and greater curvature plication (GCP), and to assess if the initial secretion of gastrointestinal hormones may predict metabolic outcomes at 5 years. MATERIAL AND METHODS: Forty-five patients with mean BMI of 39.4(1.9)kg/m2 and T2DM with HbA1c of 7.7(1.9)% were randomized to mRYGB, SG, or GCP. Anthropometric and biochemical parameters, fasting concentrations of PYY, ghrelin, glucagon, and AUC of GLP-1 after SMT were determined prior to and at months 1 and 12 after surgery. At 5-year follow-up, anthropometrical and biochemical parameters were determined. RESULTS: Total weight loss percentage (TWL%) at year 1 and GLP-1 AUC at months 1 and 12 were higher in the mRYGB than in the SG and GCP. TWL% remained greater at 5 years in mRYGB group - 27.32 (7.8) vs. SG - 18.00 (10.6) and GCP - 14.83 (7.8), p = 0.001. At 5 years, complete T2DM remission was observed in 46.7% after mRYGB vs. 20.0% after SG and 6.6% after GCP, p < 0.001. In the multivariate analysis, shorter T2DM duration (OR 0.186), p = 0.008, and the GLP-1 AUC at 1 month (OR 7.229), p = 0.023, were prognostic factors for complete T2DM remission at 5-year follow-up. CONCLUSIONS: Long-term T2DM remission is mostly achieved with hypoabsortive techniques such as mRYGB. Increased secretion of GLP-1 after surgery and shorter disease duration were the main predictors of T2DM remission at 5 years.

Changes in Bone Mineral Density in Patients with Type 2 Diabetes After Different Bariatric Surgery Procedures and the Role of Gastrointestinal Hormones.

BACKGROUND: To compare changes in bone mineral density (BMD) in patients with morbid obesity and type 2 diabetes (T2D) a year after being randomized to metabolic gastric bypass (mRYGB), sleeve gastrectomy (SG), and greater curvature plication (GCP). We also analyzed the association of gastrointestinal hormones with skeletal metabolism. METHODS: Forty-five patients with T2D (mean BMI 39.4 ± 1.9 kg/m2) were randomly assigned to mRYGB, SG, or GCP. Before and 12 months after surgery, anthropometric, body composition, biochemical parameters, fasting plasma glucagon, ghrelin, and PYY as well as GLP-1, GLP-2, and insulin after a standard meal were determined. RESULTS: After surgery, the decrease at femoral neck (FN) was similar but at lumbar spine (LS), it was greater in the mRYGB group compared with SG and GCP - 7.29 (4.6) vs. - 0.48 (3.9) vs. - 1.2 (2.7)%, p < 0.001. Osteocalcin and alkaline phosphatase increased more after mRYGB. Bone mineral content (BMC) at the LS after surgery correlated with fasting ghrelin (r = - 0.412, p = 0.01) and AUC for GLP-1 (r = - 0.402, p = 0.017). FN BMD at 12 months correlated with post-surgical fasting glucagon (r = 0.498, p = 0.04) and insulin AUC (r = 0.384, p = 0.030) and at LS with the AUC for GLP-1 in the same time period (r = - 0.335, p = 0.049). However, in the multiple regression analysis after adjusting for age, sex, and BMI, the type of surgery (mRYGB) remained the only factor associated with BMD reduction at LS and FN. CONCLUSIONS: mRYGB induces greater deleterious effects on the bone at LS compared with SG and GCP, and gastrointestinal hormones do not play a major role in bone changes.

Long-Term Effects in Bone Mineral Density after Different Bariatric Procedures in Patients with Type 2 Diabetes: Outcomes of a Randomized Clinical Trial.

There is scant evidence of the long-term effects of bariatric surgery on bone mineral density (BMD). We compared BMD changes in patients with severe obesity and type 2 diabetes (T2D) 5 years after randomization to metabolic gastric bypass (mRYGB), sleeve gastrectomy (SG) and greater curvature plication (GCP). We studied the influence of first year gastrointestinal hormone changes on final bone outcomes. Forty-five patients, averaging 49.4 (7.8) years old and body mass index (BMI) 39.4 (1.9) kg/m2, were included. BMD at lumbar spine (LS) was lower after mRYGB compared to SG and GCP: 0.89 [0.82;0.94] vs. 1.04 [0.91;1.16] vs. 0.99 [0.89;1.12], p = 0.020. A higher percentage of LS osteopenia was present after mRYGB 78.6% vs. 33.3% vs. 50.0%, respectively. BMD reduction was greater in T2D remitters vs. non-remitters. Weight at fifth year predicted BMD changes at the femoral neck (FN) (adjusted R2: 0.3218; p = 0.002), and type of surgery (mRYGB) and menopause predicted BMD changes at LS (adjusted R2: 0.2507; p < 0.015). In conclusion, mRYGB produces higher deleterious effects on bone at LS compared to SG and GCP in the long-term. Women in menopause undergoing mRYGB are at highest risk of bone deterioration. Gastrointestinal hormone changes after surgery do not play a major role in BMD outcomes.

Real-world outcomes of treatment with insulin glargine 300 U/mL versus standard-of-care in people with uncontrolled type 2 diabetes mellitus.

Objective: To compare real-world outcomes with newer (insulin glargine 300 U/mL; Gla-300) versus standard of care (SoC) basal insulins (BIs) in the REACH (insulin-naïve; NCT02967224) and REGAIN (basal insulin-treated; NCT02967211) studies in participants with uncontrolled type 2 diabetes (T2DM) in Europe and Brazil.Methods: In these open-label, parallel-group, pragmatic studies, patients (HbA1c > 7.0%) were randomized to Gla-300 or SoC BI for a 6-month treatment period (to demonstrate non-inferiority of Gla-300 vs SoC BIs for HbA1c change [non-inferiority margin 0.3%]) and a 6-month extension period (continuing with their assigned treatment). Insulin titration/other medication changes were at investigator/patient discretion post-randomization.Results: Overall, 703 patients were randomized to treatment in REACH (Gla-300, n = 352; SoC, n = 351) and 609 (Gla-300, n = 305, SoC, n = 304) in REGAIN. The primary outcome, non-inferiority of Gla-300 versus SoC for HbA1c change from baseline to month 6, was met in REACH (least squares [LS] mean difference 0.12% [95% CI -0.046 to 0.281]) but not REGAIN (LS mean difference 0.17% [0.015-0.329]); no between-treatment difference in HbA1c change was shown after 12 months in either study. BI dose increased minimally from baseline to 12 months in REACH (Gla-300, +0.17 U/kg; SoC, +0.15 U/kg) and REGAIN (Gla-300, +0.11 U/kg; SoC, +0.07 U/kg). Hypoglycemia incidence was low and similar between treatment arms in both studies.Conclusions: In both REACH and REGAIN, no differences in glycemic control or hypoglycemia outcomes with Gla-300 versus SoC BIs were seen over 12 months. However, the suboptimal insulin titration in REACH and REGAIN limits comparisons of outcomes between treatment arms and suggests that more titration instruction/support may be required for patients to fully derive the benefits from newer basal insulin formulations.

Analysis of the characteristics of patients with diabetes mellitus who attend a tertiary hospital emergency department for a hypoglycemic event. / Análisis de las características de los pacientes con diabetes mellitus que consultan por hipoglucemia en el servicio de urgencias de un hospital terciario.

INTRODUCTION AND OBJECTIVE: Hypoglycemia associated to insulin or other glucose-lowering agents is one of the most common causes of visits to the emergency department for adverse drug reactions. The study objective was to analyze the characteristics of patients with diabetes mellitus (DM) who attend a tertiary hospital emergency department for a hypoglycemic event. PATIENTS AND METHODS: A 3-year retrospective analysis was conducted of patients with DM who attended the emergency department of Hospital Universitari de Bellvitge for a hypoglycemic event. An analysis was made of epidemiological and diabetes-related characteristics, prevalence of chronic diabetic complications and other comorbidities, the glucose-lowering treatment and the result of the hypoglycemic episode. RESULTS: Of the 149 hypoglycemic events analyzed, 81.9% occurred in patients with type 2 DM. Mean age of patients with type 2 DM was 75.4 years. DM duration was longer than 10 years in 69.4% of patients. The prevalence rates of chronic kidney disease and cognitive decline were 38.5% and 19.7% respectively in patients with type 2 DM. Insulin with or without other concomitant glucose-lowering agents was associated to 78.7% of episodes in type 2 DM patients. The remaining 21.3% were associated to oral hypoglycemic agents, mainly glibenclamide. After the event, 13.4% of patients required hospital admission, and in 36.8% of these hypoglycemia was associated to use of glibenclamide. CONCLUSIONS: A majority of hypoglycemic events occurred in elderly patients with type 2 DM, with a high prevalence of associated comorbidities and treated with insulin and sulfonylureas, particularly glibenclamide.

Diagnostic Accuracy of 18F-FDG PET/CT in Patients With Biochemical Evidence of Recurrent, Residual, or Metastatic Medullary Thyroid Carcinoma.

OBJECTIVE: Medullary thyroid carcinoma (MTC) is a rare malignancy. Location of residual, recurrent, or metastatic disease is crucial to treatment management and outcome. We aimed to evaluate the use of F-FDG PET/CT in localizing MTC foci in patients with biochemical relapse. METHODS: This is a retrospective cohort study. Review of 51 FDG PET/CT studies of 45 patients referred to restage MTC due to increased calcitonin (Ctn) and carcinoembryonic antigen (CEA) values at follow-up. FDG PET/CT diagnostic accuracy was determined through a patient-based analysis, using histology as criterion standard when available, or other imaging studies and clinical follow-up otherwise (mean, 4 years). RESULTS: There were 25 positive scans. Sensitivity, specificity, positive and negative predictive values, diagnostic accuracy, and positive likelihood ratio were 66.7%, 83.3%, 88.0%, 57.7%, 72.5%, and 4.0, respectively. Using a Ctn cutoff of 1000 pg/mL, sensitivity increased to 76.9%. There were significant differences of Ctn and CEA values between positive and negative FDG PET/CT (P < 0.05). Regarding true-positive studies, average SUVmax comparing locoregional and metastatic disease was at the limit of significance (P = 0.046). CONCLUSIONS: PET/CT can be useful to restage patients with biochemical relapse of MTC, with a better performance in higher Ctn levels. Its high positive predictive value (88%) may impact in the therapeutic management, although its low negative predictive value (57.7%) makes strict follow-up mandatory in examinations without pathologic findings.

Role of adipose tissue GLP-1R expression in metabolic improvement after bariatric surgery in patients with type 2 diabetes.

We aimed to explore the relationship between GLP-1 receptor (GLP-1R) expression in adipose tissue (AT) and incretin secretion, glucose homeostasis and weight loss, in patients with morbid obesity and type 2 diabetes undergoing bariatric surgery. RNA was extracted from subcutaneous (SAT) and visceral (VAT) AT biopsies from 40 patients randomized to metabolic gastric bypass, sleeve gastrectomy or greater curvature plication. Biochemical parameters, fasting plasma insulin, glucagon and area under the curve (AUC) of GLP-1 following a standard meal test were determined before and 1 year after bariatric surgery. GLP-1R expression was higher in VAT than in SAT. GLP-1R expression in VAT correlated with weight (r = -0.453, p = 0.008), waist circumference (r = -0.494, p = 0.004), plasma insulin (r = -0.466, p = 0.007), and systolic blood pressure (BP) (r = -0.410, p = 0.018). At 1 year, GLP-1R expression in VAT was negatively associated with diastolic BP (r = -0.361, p = 0.039) and, following metabolic gastric bypass, with the increase of GLP-1 AUC, (R2 = 0.46, p = 0.038). Finally, GLP-1R in AT was similar independently of diabetes outcomes and was not associated with weight loss after surgery. Thus, GLP-1R expression in AT is of limited value to predict incretin response and does not play a role in metabolic outcomes after bariatric surgery.

Obstrucción de sonda nasogástrica por molde de nutrición enteral / Nasogastric tube obstruction due to enteral feeding bezoar

Introducción: la administración de nutrición enteral por sonda nasogástrica puede presentar complicaciones potencialmente graves. Presentamos un caso de obstrucción esofágica por un bezoar de nutrición enteral. Caso clínico: el paciente de 77 años ingresó en nuestro centro en la unidad de cuidados intensivos por neumonía COVID. El paciente recibía nutrición enteral por sonda nasogástrica (SNG) presentando al mes del seguimiento dificultad para el paso de la misma. Tras retirada de la sonda y unida a ella se extrajo un molde esofágico de nutrición enteral. Posteriormente se administra a través de una nueva SNG una solución disolvente y se modifica la fórmula por una hidrolizada. Discusión: los bezoar de nutrición enteral son una complicación rara pero potencialmente mortal. (AU)

Introduction: the administration of enteral nutrition through a nasogastric tube can cause potentially serious complications. We present a case of esophageal obstruction due to an enteral nutrition bezoar. Case report: the 77-year-old patient was admitted to our center in the intensive care unit for COVID pneumonia. The patient received enteral nutrition through a nasogastric tube (NGT), presenting difficulty passing it after a month of follow-up. After removal of the tube and attached to it, an esophageal mold for enteral nutrition was extracted. Later, a solvent solution is administered through a new SNG and the formula is modified for a hydrolyzed one. Discussion: enteral nutrition bezoars are a rare but can be a life-threatening complication (AU)

Artículo especial por el Día Mundial del Riñón: Las sociedades científicas españolas ante la guía ESC 2021 de prevención de la enfermedad vascular: generalizar la medida de la albuminuria para identificar el riesgo vascular y prevenir la enfermedad vascular / The Spanish Scientific Societies before the ESC 2021 guidelines on vascular disease prevention: Generalising the measurement of albuminuria to identify vascular risk and prevent vascular disease

Las guías de 2021 sobre la prevención de la enfermedad vascular (EV) en la práctica clínica publicadas por la European Society of Cardiology (ESC) y apoyadas por otras 13 sociedades científicas europeas reconocen el papel clave de la detección de la enfermedad renal crónica (ERC) en la prevención de la EV. El riesgo vascular en la ERC se categoriza a partir de las medidas del filtrado glomerular estimado (FGe) y del cociente albúmina:creatinina en orina (ACRo). Así, la ERC moderada se asocia a un riesgo vascular alto y la ERC grave a un riesgo vascular muy alto, debiendo actuar en consecuencia desde el punto de vista terapéutico, sin que sea necesario aplicar otras puntuaciones de riesgo vascular cuando este ya es muy alto debido a la ERC. Es más, la ESC sitúa la medida del FGe y del ACRo en el inicio de la estimación del riesgo vascular y del algoritmo de decisión subsiguiente. A fin de optimizar la implementación de la guía 2021 de la ESC sobre la prevención de la EV en España, consideramos que: 1) El estudio de la orina para determinar la albuminuria mediante el ACRo debería formar parte de la rutina clínica al mismo nivel que el de la glucemia, la colesterolemia y la estimación del FG cuando estas se usan para tomar decisiones sobre el riesgo de EV. 2) Los servicios de salud públicos y privados españoles deberían disponer de los medios y recursos necesarios para implementar de forma óptima las Guías ESC 2021 de prevención de la EV en España, incluyendo la determinación del ACRo.(AU)

The 2021 guidelines on the prevention of vascular disease (VD) in clinical practice published by the European Society of Cardiology (ESC) and supported by 13 other European scientific societies, recognise the key role of screening for chronic kidney disease (CKD) in the prevention of VD. Vascular risk in CKD is categorised based on measurements of estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (ACR). Thus, moderate CKD is associated with a high vascular risk and severe CKD with a very high vascular risk requiring therapeutic action, and there is no need to apply other vascular risk scores when vascular risk is already very high due to CKD. Moreover, the ESC indicates that vascular risk assessment and the subsequent decision algorithm should start with measurement of eGFR and ACR. To optimise the implementation of the ESC 2021 guidelines on the prevention of CVD in Spain, we consider that: 1) Urine testing for albuminuria using ACR should be part of the clinical routine at the same level as blood glucose, cholesterolaemia, and GFR estimation when these are used to make decisions on CVD risk. 2) Spanish public and private health services should have the necessary means and resources to optimally implement the ESC 2021 guidelines for the prevention of CVD in Spain, including ACR testing. (AU)

Impact and characteristics of the non-Caucasian population in hospital admissions for diabetes onset during 2003-2010. / Impacto y características diferenciales de la población de origen no caucásico en los ingresos por inicio de diabetes durante el periodo 2003-2010.

AIMS: To assess the prevalence of non-Caucasian patients in hospital admissions for onset of symptomatic diabetes mellitus during the 2003-2010 period, and to analyze the characteristics differentiating them from the Caucasian population at diagnosis and 2 years later. MATERIAL AND METHODS: A retrospective, observational study. INCLUSION CRITERIA: Patients aged 18-40 years admitted for de novo symptomatic diabetes from January 2003 to October 2010. Prevalence of patients of non-Caucasian origin was analyzed, and clinical, biochemical, immunological, and beta-cell function of both populations were compared at diagnosis and 2 years later. RESULTS: Nineteen percent of patients admitted to hospital for de novo symptomatic diabetes were non-Caucasian, with a progressive increase in recent years. Non-Caucasian patients had milder decompensation (3.0% had ketoacidosis, as compared to 15.2% in the Caucasian group, P<.05), lower presence of autoimmunity (27.2 vs. 73.1%, P<.01) and higher stimulated C-peptide levels (0.70±0.56 vs. 0.42±0.39 nmol/l, P<.05), mainly because of the subgroup with negative autoimmunity (0.82 vs. 0.25). Two years after diagnosis, less non-Caucasian patients were on intensified treatment (39.1 vs. 93.8%). CONCLUSIONS: Non-Caucasian patients had a lower prevalence of autoimmunity, better beta-cell function at diagnosis, particularly due to the subgroup with negative autoimmunity, and less need for intensive treatment 2 years after diagnosis, features which are more characteristic of type 2 diabetes mellitus.

Renoprotective effect of diltiazem in hypertensive type 2 diabetic patients with persistent microalbuminuria despite ACE inhibitor treatment.

The aim of the study was to evaluate the effects of the non-dihydropyridine calcium antagonist (NDCA) diltiazem on the development of urinary albumin excretion (UAE) in type 2 hypertensive diabetic patients with persistent microalbuminuria despite ACE inhibitor treatment. Thirty-six type 2 diabetic hypertensive patients with microalbuminuria persisting after at least 1 year of treatment with ACE inhibitors were randomized to receive captopril (n=22) or combined therapy with captopril and 120 mg diltiazem (n=14) for 2 years. Captopril dose was individualized according to blood pressure. Changes in UAE, blood pressure, and metabolic control were monitored to analyze the influence of the addition of diltiazem on progression of diabetic nephropathy. In patients treated with captopril and diltiazem, absolute UAE did not change during the study (baseline: 101 mg/24 h, range 39-298; 2 years after randomization: 74 mg/24 h, range 12-665). In contrast, UAE increased in patients treated with captopril monotherapy (baseline: 118 mg/24 h, range 32-282; 2 years after randomization: 164 mg/24 h, range 15-1161, p<0.05). In addition, fewer patients in the captopril/diltiazem group progressed to macroalbuminuria (eight patients in captopril group and one in captopril/diltiazem group, p<0.05). The beneficial effects of the addition of diltiazem were independent of blood pressure and metabolic control. We suggest that the combination of ACE inhibitors and NDCA should be considered in type 2 microalbuminuric patients at high risk for progression to established diabetic nephropathy.

[Dementia and diabetes: casual or causal relationship?]. / Demencia y diabetes: ¿relación casual o causal?

Several studies have reported the existence of an epidemiological association between diabetes mellitus (DM) and dementia. Although this association is more evident for vascular dementia, it is also described in Alzheimer's disease (AD). In this review we evaluate the different hypotheses that may explain the association between DM and dementia. We can consider the existence of a diabetes type 3 as the situation that occurs when hyperinsulinemia in response to insulin resistance leads to a decrease of the brain insulin and a poor regulation of insulin-degrading enzyme; thus, beta-amyloid accumulates, among other mechanisms, by the decline of its degradation by insulin-degrading enzyme. Consequently, AD may be related, at least in part, to a brain insulin resistance. There are several studies that prove the concept that a better metabolic control, especially in not very old people, is associated with an increased cognitive performance. It is not known whether the use of any specific drug for the treatment of DM is better than any other. It is important for physicians responsible for the metabolic control of diabetic patients to know this possible association, and to explore cognition in the control visits of patients with DM.

Hypoglycemic seizures and epilepsy in type I diabetes mellitus.

PURPOSE: (1) To determine the characteristics of seizures and/or epilepsy among patients with adult onset type 1 diabetes mellitus (T1DM), and (2) to determine glutamic acid decarboxylase antibody (antiGADab) titres and other autoimmune characteristics of T1DM patients with seizure and/or epilepsy. METHODS: Patients were recruited after reviewing the databases of one Diabetes Unit and two Epilepsy Units. Prevalence of suffering epilepsy and/or seizures was calculated in the group of adult onset T1DM patients seen consecutively in the Diabetes Unit. Serum antiGADab titres were determined in all patients. RESULTS: Among the 229 T1DM patients, two had suffered hypoglycemic seizures (0.87%) and two unprovoked seizures (0.87%). We recruited 11 of these T1DM patients. Five reported only hypoglycemic seizures, and 6 temporal lobe epilepsy (TLE). Mean antiGADab titres in patients with T1DM and hypoglycemic seizures were lower (18.42 IU) than in those with T1DM and TLE (29.200 IU), p: 0.006. Patients with T1DM and TLE suffered more other autoimmune diseases than those with T1DM and hypoglycemic seizures, p: 0.015. CONCLUSIONS: Hypoglycemic seizures are rare in T1DM patients. AntiGADab titres do not differ from the general diabetic population. Patients with high titres of antiGADab are more likely to develop TLE.