Efectes metabòlics de la cirurgia bariàtrica : comparació del bypass gàstric en Y de Roux laparoscòpic i la gastrectomia tubular laparoscòpica /

INTRODUCCIÓ: El bypass gàstric en Y de Roux laparoscòpies (BGYRL) és la tècnica de cirurgia bariàtrica més utilitzada i la que ofereix un millor perfil de risc-benefici. La gastrectomia tubular laparoscòpica (GTL) és una nova tècnica restrictiva que ha mostrat resultats postoperatoris equiparables a BGYRL en termes de pèrdua de pes i remissió de la Diabetis Mellitus tipus 2 (DM2). Hi ha poques dades dels efectes de la GTL en comparació amb el BGYRL sobre altres aspectes del metabolisme. OBJECTIU GENERAL: Comparar els efectes metabòlics de la GTL i el BGYRL. OBJECTIUS ESPECÍFICS: Estudiar l'efecte de la cirurgia bariàtrica sobre les escales de risc cardiovascular generals (Framingham) i les adaptades a població mediterrània (REGICOR). Comparar els efectes de 2 tècniques de cirurgia bariàtrica sobre: 1) El risc cardiovascular estimat 2) La taxa de remissió i de milloria de les comorbiditats, 3) El perfil lipídic, i estudiar els factors predictors de milloria de la concentració de lípids 4) La taxa de remissió de la resistència a la insulina, 5) La taxa de remissió total de DM2 amb els nous criteris de la American Diabetes Association, i estudiar els factors associats amb aquesta remissió. MATERIAL I MÈTODES: Estudi de cohorts prospectiu de subjectes amb obesitat greu intervinguts de cirurgia bariàtrica mitjançant BGYRL o GTL. Els pacients van ser seguits fins a un màxim de 2 anys després de la cirurgia. RESULTATS: Efectes sobre el risc cardiovascular: s'inclouen 95 subjectes intervinguts de BGYRL i 45 de GTL. El percentatge de pèrdua d'excés de pes als 12 mesos és similar entre les 2 tècniques(80.9%±16.7% BGYRL i 82.7%±18% GTL,p=0.632). El risc cardiovascular disminueixals 12 mesos del 6.6% al 3.4% amb l'equació Framingham i del 3.7% al 1.9% amb REGICOR. No s'observen diferències en la disminució del risc cardiovascular, ni el la taxa de remissió de la hipertensió arterial, ni de la DM2. La taxa de milloria de la dislipèmia és ser superior per al BGYRL (100%) que per la GTL (75%, p=0.014). Efectes sobre el perfil lipídic:51 subjectes en cada grups'aparellen per edat, sexe i índex de massa corporal.No es detecten diferències el descens del triglicèrids. El colesterol LDL disminueix de forma significativa després de BGYRL(125.9±29.3mg/dl fins 100.3±26.4mg/dl,p 0.001), però no ho fa amb GTL (118.6±30.7mg/dlfins 114.6±33.5mg/dl,p=0.220). El colesterol HDL augmentade forma més intensa després de GTL (15.4±13.1mg/dl GTL vs. 9.4±14.0mg/dl BGYRL, p=0.032). S'associen amb la milloria del perfil lipídic: una major A1c inicial per als triglicèrids, la realització d'un BGYRL per al colesterol LDL i una major edat i la GTL per al colesterol HDL. Efectes sobre la resistència a la insulina: s'inclouen 115 subjectes intervinguts de BGYRL i 78 de GTL, dels quals 29 i 20 respectivament presenten DM2. Als 24 mesos no es detecten diferències en la taxa de remissió de resistència a la insulina (92.9% LRYGB i 87.5% LSG,p=0.355) ni en la taxa de remissió complerta de DM2 segons els criteris de 2009 de l'American Diabetes Association (92.9% LRYGB i 87.5% LSG, p=0.355). El descens del HOMA-IR als 3 mesos s'associa amb la remissió total de la DM2. CONCLUSIONS: La GTL tot i ser una tècnica restrictiva es mostra igual d'eficaç que el BGYRL en termes de: pèrdua de pes, remissió de la hipertensió arterial i de la DM2, disminució del risc cardiovascular i remissió de la resistència a la insulina. La GTL a diferència del BGYRL no produeix un descens del colesterol LDL, però en canvi s'associa a un major ascens del colesterol HDL.BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) is the most accepted bariatric surgery technique with the best risk-benefit profile. Laparoscopic Sleeve Gastrectomy (LSG) is a new restrictive technique that achieves similar results as those of LRYGB in terms of weight loss and type 2 Diabetes mellitus (T2DM) remission. Few studies have compared the effects of LRYGB and LSG on other metabolic factors. GENERAL OBJECTIVE: To compare the impact of LRYGB and LSG on different metabolic factors. SPECIFIC OBJECTIVES: To study the effects of bariatric surgery on cardiovascular risk using general cardiovascular risk scores (Framingham) and those specific to the Mediterranean population (REGICOR). To compare the impact of both techniques on: 1) estimated cardiovascular risk, 2) improvement/resolution of comorbidities 3) lipid profile, and predictive factors for dyslipidemia improvement 4) insulin resistance remission rate, 5) T2DM total remission rate with the new American Diabetes Association criteria and predictive factors for remission. METHODS: Non-randomized, prospective cohort study of severe obese patients undergoing LRYGB or LSG with a mean follow-up of 12-24 months. RESULTS: Effects on cardiovascular risk: 95 subjects operated on LRYGB and 45 on LSG were included. Percentage of excess weight loss at 12 months was similar between groups (80.9%±16.7% LRYGB vs 82.7%±18% LSG,p=0.632). At 12 months, cardiovascular risk decreased from 6.6% to 3.4% using the Framingham risk score and from 3.7% to 1.9% using the REGICOR score. No differences were observed between groups in cardiovascular risk improvement, nor in the resolution of T2DM or hypertension. Hypercholesterolemia improvement was lower in the LSG group (75%) compared with the LRYGB group (100%,p=0.014). Effects on lipids profile: 51 patients undergoing LRYGB and 51 underwent LSG were matched for age, sex and body mass index. During the first year after surgery, no differences in triglyceride reduction were found between groups. After LRYGR, LDL cholesterol concentration fell significantly (125.9±29.3 to 100.3±26.4 mg/dl, p 0.001), whereas no significant changes were observed in the LSG group (118.6±30.7 to 114.6±33.5 mg/dl, p=0.220). HDL cholesterol increase was significantly greater after LSG (15.4±13.1 mg/dl) compared with LRYGB (9.4±14.0 mg/dl, p=0.032). Factors independently associated with LDL cholesterol reduction were higher baseline total cholesterol and LRYGB. A greater increase in HDL cholesterol was associated with LSG, older age and higher baseline HDL cholesterol. Effects on insulin resistance: At baseline, 29 (25.2%) of the 115 LRYGB group and 20 (25.6%) of the 78 LSG group had T2DM. No differences were detected in insulin resistance remission rate (92.9% LRYGB and 87.5% LSG, p=0.355) nor in T2DM complete remission at 2 years (62.1 vs. 60% respectively, p=0.992). The main predictor factor for T2DM complete remission was a greater decrease in 3-month HOMA-IR index. CONCLUSIONS: LSG, a restrictive technique, is equally effective as LRYGB in terms of: weight loss, T2DM and hypertension remission, cardiovascular risk improvement and insulin resistance remission. Although LSG does not improve LDL cholesterol levels, its effects on HDL cholesterol are comparable to or greater than those obtained with malabsorptive techniques

Telehealth model versus in-person standard care for persons with type 1 diabetes treated with multiple daily injections: an open-label randomized controlled trial

ObjectiveIncreasing evidence indicates that the telehealth (TH) model is noninferior to the in-person approach regarding metabolic control in type 1 diabetes (T1D) and offers advantages such as a decrease in travel time and increased accessibility for shorter/frequent visits. The primary aim of this study was to compare the change in glycated hemoglobin (HbA1c) at 6 months in T1D care in a rural area between TH and in-person visits.Research design and methodsRandomized controlled, open-label, parallel-arm study among adults with T1D. Participants were submitted to in-person visits at baseline and at months 3 and 6 (conventional group) or teleconsultation in months 1 to 4 plus 2 in-person visits (baseline and 6 months) (TH group). Mixed effects models estimated differences in HbA1c changes.ResultsFifty-five participants were included (29 conventional/26 TH). No significant differences in HbA1c between groups were found. Significant improvement in time in range (5.40, 95% confidence interval (CI): 0.43-10.38; p < 0.05) and in time above range (-6.34, 95% CI: -12.13- -0.55;p < 0.05) in the TH group and an improvement in the Diabetes Quality of Life questionnaire (EsDQoL) score (-7.65, 95% CI: -14.67 - -0.63; p < 0.05) were observed. In TH, the costs for the participants were lower.ConclusionsThe TH model is comparable to in-person visits regarding HbA1c levels at the 6-month follow-up, with significant improvement in some glucose metrics and health-related quality of life. Further studies are necessary to evaluate a more efficient timing of the TH visits

Trends in Prevalence of Diabetes among Twin Pregnancies and Perinatal Outcomes in Catalonia between 2006 and 2015 : the DIAGESTCAT Study

The aims of our study were to evaluate the trends in the prevalence of diabetes among twin pregnancies in Catalonia, Spain between 2006 and 2015, to assess the influence of diabetes on perinatal outcomes of twin gestations and to ascertain the interaction between twin pregnancies and glycaemic status. A population-based study was conducted using the Spanish Minimum Basic Data Set. Cases of gestational diabetes mellitus (GDM) and pre-existing diabetes were identified using ICD-9-CM codes. Data from 743,762 singleton and 15,956 twin deliveries between 2006 and 2015 in Catalonia was analysed. Among twin pregnancies, 1088 (6.82%) were diagnosed with GDM and 83 (0.52%) had pre-existing diabetes. The prevalence of GDM among twin pregnancies increased from 6.01% in 2006 to 8.48% in 2015 (p < 0.001) and the prevalence of pre-existing diabetes remained stable (from 0.46% to 0.27%, p = 0.416). The risk of pre-eclampsia was higher in pre-existing diabetes (15.66%, p = 0.015) and GDM (11.39%, p < 0.001) than in normoglycaemic twin pregnancies (7.55%). Pre-existing diabetes increased the risk of prematurity (69.62% vs. 51.84%, p = 0.002) and large-for-gestational-age (LGA) infants (20.9% vs. 11.6%, p = 0.001) in twin gestations. An attenuating effect on several adverse perinatal outcomes was found between twin pregnancies and the presence of GDM and pre-existing diabetes. As a result, unlike in singleton pregnancies, diabetes did not increase the risk of all perinatal outcomes in twins and the effect of pre-existing diabetes on pre-eclampsia and LGA appeared to be attenuated. In conclusion, prevalence of GDM among twin pregnancies increased over the study period. Diabetes was associated with a higher risk of pre-eclampsia, prematurity and LGA in twin gestations. However, the impact of both, pre-existing diabetes and GDM, on twin pregnancy outcomes was attenuated when compared with its impact on singleton gestations

Exploring Renal Changes after Bariatric Surgery in Patients with Severe Obesity

Obesity-related hyperfiltration leads to an increased glomerular filtration rate (GFR) and hyperalbuminuria. These changes are reversible after bariatric surgery (BS). We aimed to explore obesity-related renal changes post-BS and to seek potential mechanisms. Sixty-two individuals with severe obesity were prospectively examined before and 3, 6 and 12 months post-BS. Anthropometric and laboratory data, 24 h-blood pressure, renin-angiotensin-aldosterone system (RAS) components, adipokines and inflammatory markers were determined. Both estimated GFR (eGFR) and albuminuria decreased from the baseline at all follow-up times (p -for-trend <0.001 for both). There was a median (IQR) of 30.5% (26.2-34.4) reduction in body weight. Plasma glucose, glycosylated hemoglobin, fasting insulin and HOMA-index decreased at 3, 6 and 12 months of follow-up (p -for-trend <0.001 for all). The plasma aldosterone concentration (median (IQR)) also decreased at 12 months (from 87.8 ng/dL (56.8; 154) to 65.4 (56.8; 84.6), p = 0.003). Both leptin and hs-CRP decreased (p < 0.001) and adiponectine levels increased at 12 months post-BS (p = 0.017). Linear mixed-models showed that body weight (coef. 0.62, 95% CI: 0.32 to 0.93, p < 0.001) and plasma aldosterone (coef. −0.07, 95% CI: −0.13 to −0.02, p = 0.005) were the independent variables for changes in eGFR. Conversely, glycosylated hemoglobin was the only independent variable for changes in albuminuria (coef. 0.24, 95% CI: 0.06 to 0.42, p = 0.009). In conclusion, body weight and aldosterone are the main factors that mediate eGFR changes in obesity and BS, while albuminuria is associated with glucose homeostasis

Seven-year mortality in heart failure patients with undiagnosed diabetes : an observational study

Background: Patients with type 2 diabetes mellitus and heart failure have adverse clinical outcomes, but the characteristics and prognosis of those with undiagnosed diabetes in this setting has not been established. Methods: In total, 400 patients admitted consecutively with acute heart failure were grouped in three glycaemic categories: no diabetes, clinical diabetes (previously reported or with hypoglycaemic treatment) and undiagnosed diabetes. The latter was defined by the presence of at least two measurements of fasting plasma glycaemia ≥ 7 mmol/L before or after the acute episode.Group differences were tested by proportional hazards models in all-cause and cardiovascular mortality during a 7-year follow-up. Results: There were 188 (47%) patients without diabetes, 149 (37%) with clinical diabetes and 63 (16%) with undiagnosed diabetes. Patients with undiagnosed diabetes had a lower prevalence of hypertension, dyslipidaemia, peripheral vascular disease and previous myocardial infarction than those with clinical diabetes and similar to that of those without diabetes. The adjusted hazards ratios for 7-year total and cardiovascular mortality compared with the group of subjects without diabetes were 1.69 (95% CI: 1.17-2.46) and 2.45 (95% CI: 1.58-3.81) for those with undiagnosed diabetes, and 1.48 (95% CI: 1.10-1.99) and 2.01 (95% CI: 1.40-2.89) for those with clinical diabetes. Conclusions: Undiagnosed diabetes is common in patients requiring hospitalization for acute heart failure. Patients with undiagnosed diabetes, despite having a lower cardiovascular risk profile than those with clinical diabetes, show a similar increased mortality

Study protocol of a randomized controlled trial to assess safety of teleconsultation compared with face-to-face consultation: the ECASeT study

BackgroundThe use of remote consultation modalities has exponentially grown in the past few years, particularly since the onset of the COVID-19 pandemic. Although a huge body of the literature has described the use of phone (tele) and video consultations, very few of the studies correspond to randomized controlled trials, and none of them has assessed the safety of these consultation modalities as the primary objective. The primary objective of this trial was to assess the safety of remote consultations (both video and teleconsultation) in the follow-up of patients in the hospital setting.MethodsMulticenter, randomized controlled trial being conducted in four centers of an administrative healthcare area in Catalonia (North-East Spain). Participants will be screened from all individuals, irrespective of age and sex, who require follow-up in outpatient consultations of any of the departments involved in the study. Eligibility criteria have been established based on the local guidelines for screening patients for remote consultation. Participants will be randomly allocated into one of the two study arms: conventional face-to-face consultation (control) and remote consultation, either teleconsultation or video consultation (intervention). Routine follow-up visits will be scheduled at a frequency determined by the physician based on the diagnostic and therapy of the baseline disease (the one triggering enrollment). The primary outcome will be the number of adverse reactions and complications related to the baseline disease. Secondary outcomes will include non-scheduled visits and hospitalizations, as well as usability features of remote consultations. All data will either be recorded in an electronic clinical report form or retrieved from local electronic health records. Based on the complications and adverse reaction rates reported in the literature, we established a target sample size of 1068 participants per arm. Recruitment started in May 2022 and is expected to end in May 2024.DiscussionThe scarcity of precedents on the assessment of remote consultation modalities using randomized controlled designs challenges making design decisions, including recruitment, selection criteria, and outcome definition, which are discussed in the manuscript.Trial registrationNCT05094180. The items of the WHO checklist for trial registration are available in Additional file 1. Registered on 24 November 2021

Tractament de les descompensacions agudes de la diabetis mellitus en règim d’hospital de dia al pacient ancià

Estudi de cohorts no randomitzat que compara la eficiencia i la eficacia del tractament de les descompensacions agudes de la diabetis a Hospital de Dia (n=64) i a l’Hospitalització convencional (n=36) en diabètics &74 anys. L’hospital de Dia suposa un estalvi mig de 1418,4€ per cas sense diferències en el control glicèmic i les hipoglucèmies a curt termini, i amb menys freqüència de reingressos per diabetis i úlceres per pressió

Efectes metabòlics de la cirurgia bariàtrica: comparació del Bypass Gàstric en Y de Roux Laparoscòpic i la Gastrectomia Tubular Laparoscòpica

INTRODUCCIÓ: El bypass gàstric en Y de Roux laparoscòpies (BGYRL) és la tècnica de cirurgia bariàtrica més utilitzada i la que ofereix un millor perfil de risc-benefici. La gastrectomia tubular laparoscòpica (GTL) és una nova tècnica restrictiva que ha mostrat resultats postoperatoris equiparables a BGYRL en termes de pèrdua de pes i remissió de la Diabetis Mellitus tipus 2 (DM2). Hi ha poques dades dels efectes de la GTL en comparació amb el BGYRL sobre altres aspectes del metabolisme. OBJECTIU GENERAL: Comparar els efectes metabòlics de la GTL i el BGYRL. OBJECTIUS ESPECÍFICS: Estudiar l’efecte de la cirurgia bariàtrica sobre les escales de risc cardiovascular generals (Framingham) i les adaptades a població mediterrània (REGICOR). Comparar els efectes de 2 tècniques de cirurgia bariàtrica sobre: 1) El risc cardiovascular estimat 2) La taxa de remissió i de milloria de les comorbiditats, 3) El perfil lipídic, i estudiar els factors predictors de milloria de la concentració de lípids 4) La taxa de remissió de la resistència a la insulina, 5) La taxa de remissió total de DM2 amb els nous criteris de la American Diabetes Association, i estudiar els factors associats amb aquesta remissió. MATERIAL I MÈTODES: Estudi de cohorts prospectiu de subjectes amb obesitat greu intervinguts de cirurgia bariàtrica mitjançant BGYRL o GTL. Els pacients van ser seguits fins a un màxim de 2 anys després de la cirurgia. RESULTATS: Efectes sobre el risc cardiovascular: s’inclouen 95 subjectes intervinguts de BGYRL i 45 de GTL. El percentatge de pèrdua d’excés de pes als 12 mesos és similar entre les 2 tècniques(80.9%±16.7% BGYRL i 82.7%±18% GTL,p=0.632). El risc cardiovascular disminueixals 12 mesos del 6.6% al 3.4% amb l’equació Framingham i del 3.7% al 1.9% amb REGICOR. No s’observen diferències en la disminució del risc cardiovascular, ni el la taxa de remissió de la hipertensió arterial, ni de la DM2. La taxa de milloria de la dislipèmia és ser superior per al BGYRL (100%) que per la GTL (75%, p=0.014). Efectes sobre el perfil lipídic:51 subjectes en cada grups’aparellen per edat, sexe i índex de massa corporal.No es detecten diferències el descens del triglicèrids. El colesterol LDL disminueix de forma significativa després de BGYRL(125.9±29.3mg/dl fins 100.3±26.4mg/dl,p<0.001), però no ho fa amb GTL (118.6±30.7mg/dlfins 114.6±33.5mg/dl,p=0.220). El colesterol HDL augmentade forma més intensa després de GTL (15.4±13.1mg/dl GTL vs. 9.4±14.0mg/dl BGYRL, p=0.032). S’associen amb la milloria del perfil lipídic: una major A1c inicial per als triglicèrids, la realització d’un BGYRL per al colesterol LDL i una major edat i la GTL per al colesterol HDL. Efectes sobre la resistència a la insulina: s’inclouen 115 subjectes intervinguts de BGYRL i 78 de GTL, dels quals 29 i 20 respectivament presenten DM2. Als 24 mesos no es detecten diferències en la taxa de remissió de resistència a la insulina (92.9% LRYGB i 87.5% LSG,p=0.355) ni en la taxa de remissió complerta de DM2 segons els criteris de 2009 de l’American Diabetes Association (92.9% LRYGB i 87.5% LSG, p=0.355). El descens del HOMA-IR als 3 mesos s’associa amb la remissió total de la DM2. CONCLUSIONS: La GTL tot i ser una tècnica restrictiva es mostra igual d’eficaç que el BGYRL en termes de: pèrdua de pes, remissió de la hipertensió arterial i de la DM2, disminució del risc cardiovascular i remissió de la resistència a la insulina. La GTL a diferència del BGYRL no produeix un descens del colesterol LDL, però en canvi s’associa a un major ascens del colesterol HDL.BACKGROUND: Laparoscopic Roux en-Y gastric bypass (LRYGB) is the most accepted bariatric surgery technique with the best risk-benefit profile. Laparoscopic Sleeve Gastrectomy (LSG) is a new restrictive technique that achieves similar results as those of LRYGB in terms of weight loss and type 2 Diabetes mellitus (T2DM) remission. Few studies have compared the effects of LRYGB and LSG on other metabolic factors. GENERAL OBJECTIVE: To compare the impact of LRYGB and LSG on different metabolic factors. SPECIFIC OBJECTIVES: To study the effects of bariatric surgery on cardiovascular risk using general cardiovascular risk scores (Framingham) and those specific to the Mediterranean population (REGICOR). To compare the impact of both techniques on: 1) estimated cardiovascular risk, 2) improvement/resolution of comorbidities 3) lipid profile, and predictive factors for dyslipidemia improvement 4) insulin resistance remission rate, 5) T2DM total remission rate with the new American Diabetes Association criteria and predictive factors for remission. METHODS: Non-randomized, prospective cohort study of severe obese patients undergoing LRYGB or LSG with a mean follow-up of 12-24 months. RESULTS: Effects on cardiovascular risk: 95 subjects operated on LRYGB and 45 on LSG were included. Percentage of excess weight loss at 12 months was similar between groups (80.9%±16.7% LRYGB vs 82.7%±18% LSG,p=0.632). At 12 months, cardiovascular risk decreased from 6.6% to 3.4% using the Framingham risk score and from 3.7% to 1.9% using the REGICOR score. No differences were observed between groups in cardiovascular risk improvement, nor in the resolution of T2DM or hypertension. Hypercholesterolemia improvement was lower in the LSG group (75%) compared with the LRYGB group (100%,p=0.014). Effects on lipids profile: 51 patients undergoing LRYGB and 51 underwent LSG were matched for age, sex and body mass index. During the first year after surgery, no differences in triglyceride reduction were found between groups. After LRYGR, LDL cholesterol concentration fell significantly (125.9±29.3 to 100.3±26.4 mg/dl, p<0.001), whereas no significant changes were observed in the LSG group (118.6±30.7 to 114.6±33.5 mg/dl, p=0.220). HDL cholesterol increase was significantly greater after LSG (15.4±13.1 mg/dl) compared with LRYGB (9.4±14.0 mg/dl, p=0.032). Factors independently associated with LDL cholesterol reduction were higher baseline total cholesterol and LRYGB. A greater increase in HDL cholesterol was associated with LSG, older age and higher baseline HDL cholesterol. Effects on insulin resistance: At baseline, 29 (25.2%) of the 115 LRYGB group and 20 (25.6%) of the 78 LSG group had T2DM. No differences were detected in insulin resistance remission rate (92.9% LRYGB and 87.5% LSG, p=0.355) nor in T2DM complete remission at 2 years (62.1 vs. 60% respectively, p=0.992). The main predictor factor for T2DM complete remission was a greater decrease in 3-month HOMA-IR index. CONCLUSIONS: LSG, a restrictive technique, is equally effective as LRYGB in terms of: weight loss, T2DM and hypertension remission, cardiovascular risk improvement and insulin resistance remission. Although LSG does not improve LDL cholesterol levels, its effects on HDL cholesterol are comparable to or greater than those obtained with malabsorptive techniques