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

Prognostic Value of the Acute-to-Chronic Glycemic Ratio at Admission in Heart Failure: A Prospective Study

Acute hyperglycemia has been associated with worse prognosis in patients hospitalized for heart failure (HF). Nevertheless, studies evaluating the impact of glycemic control on long-term prognosis have shown conflicting results. Our aim was to assess the relationship between acute-to-chronic (A/C) glycemic ratio and 4-year mortality in a cohort of subjects hospitalized for acute HF. A total of 1062 subjects were consecutively included. We measured glycaemia at admission and estimated average chronic glucose levels and the A/C glycemic ratio were calculated. Subjects were stratified into groups according to the A/C glycemic ratio tertiles. The primary endpoint was 4-year mortality. Subjects with diabetes had higher risk for mortality compared to those without (HR 1.35 [95% CI: 1.10-1.65]; p = 0.004). A U-shape curve association was found between glucose at admission and mortality, with a HR of 1.60 [95% CI: 1.22-2.11]; p = 0.001, and a HR of 1.29 [95% CI: 0.97-1.70]; p = 0.078 for the first and the third tertile, respectively, in subjects with diabetes. Additionally, the A/C glycemic ratio was negatively associated with mortality (HR 0.76 [95% CI: 0.58-0.99]; p = 0.046 and HR 0.68 [95% CI: 0.52-0.89]; p = 0.005 for the second and third tertile, respectively). In multivariable analysis, the A/C glycemic ratio remained an independent predictor. In conclusion, in subjects hospitalized for acute HF, the A/C glycemic ratio is significantly associated with mortality, improving the ability to predict mortality compared with glucose levels at admission or average chronic glucose concentrations, especially in subjects with diabetes

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

Efficacy of treatment for hyperglycemic crisis in elderly diabetic patients in a day hospital

The purpose of this prospective cohort study was to compare the costs of day hospital (DH) care for hyperglycemic crisis in elderly diabetic patients with those of conventional hospitalization (CH). Secondary objectives were to compare these two clinical scenarios in terms of glycemic control, number of emergency and outpatient visits, readmissions, hypoglycemic episodes, and nosocomial morbidity. The study population comprised diabetic patients aged >74 years consecutively admitted to a tertiary teaching hospital in Spain for hyperglycemic crisis (sustained hyperglycemia [>300 mg/dL] for at least 3 days with or without ketosis). The patients were assigned to DH or CH care according to time of admission and were followed for 6 months after discharge. Exclusion criteria were ketoacidosis, hyperosmolar crisis, hemodynamic instability, severe intercurrent illness, social deprivation, or Katz index >D. Sixty-four diabetic patients on DH care and 36 on CH care were included, with no differences in baseline characteristics. The average cost per patient was 1,345.1±793.6 € in the DH group and 2,212.4±982.5 € in the CH group (P <0.001). There were no differences in number of subjects with mild hypoglycemia during follow-up (45.3% DH versus 33.3% CH, P =0.24), nor in the percentage of patients achieving a glycated hemoglobin (HbA) <8% (67.2% DH versus 58.3% CH, P =0.375). Readmissions for hyperglycemic crisis and pressure ulcer rates were significantly higher in the CH group. DH care for hyperglycemic crises is more cost-effective than CH care, with a net saving of 1,418.4 € per case, lower number of readmissions and pressure ulcer rates, and similar short-term glycemic control and hypoglycemia rates

Diabetes mellitus gestacional: control glicémico intraparto e hipoglicemia neonatal

Introducción: Varios estudios en pacientes con diabetes mellitus tipo 1 han demostrado la importancia del control glicémico estricto durante el parto en el desarrollo de hipoglicemia neonatal. Sin embargo, faltan estudios que evalúen la importancia del control glicémico intraparto y los factores asociados al desarrollo de hipoglicemia neonatal en pacientes con diabetes gestacional (DG). Objetivo general: Conocer la evolución de las glicemias durante el periodo de parto de mujeres afectas de DMG mediante la aplicación de un protocolo de tratamiento específico para estas pacientes y estudiar los factores que influyen en el desarrollo de las hipoglicemias neonatales. Objetivos específicos: 1/Control glicémico intraparto obtenido mediante la aplicación de un protocolo específico para mujeres con DMG y su relación con factores maternos y gestacionales, 2/Evaluar las glicemias de los recién nacidos hijos de madres con DMG durante las primeras 24 horas de vida y analizar la relación entre desarrollo de hipoglicemia neonatal y distintos factores maternos, gestacionales, periparto y neonatales. Material y métodos: Estudio prospectivo observacional en mujeres afectas de DMG que fueron atendidas durante la gestación y el parto en el Hospital del Mar entre Octubre-2006 y Enero-2011. Se recogieron las características maternas y gestacionales, las glicemias durante el parto y las características de los recién nacidos y sus glicemias durante las primeras 24 horas de vida. Resultados: El 86% de las glicemias capilares maternas se mantuvieron entre los objetivos de control (70-130mg/dl) sin necesidad de tratamiento con insulina. No hubo hipoglicemias maternas ni casos de cetosis grave. La hiperglicemia durante el parto se asoció con los niveles de HbA1c del tercer trimestre (p=0.02) y con la falta de adscripción al seguimiento endocrinológico (p=0.04). De los 190 neonatos estudiados, 48 (25.2%) tuvieron una glicemia inferior a 45mg/dl. De estos, 23 (12.1%) presentaron una hipoglicemia leve, 20 (10.5%) moderada y sólo 5 (2.6%) un episodio grave. Los factores asociados al desarrollo de hipoglicemia neonatal fueron la condición de grande para edad gestacional (29.3% vs 11.3%, p=0.003), el pH de cordón umbilical (7.28 vs 7.31, p=0.03) y la hiperglicemia materna durante el parto (18.8% vs 8.5%, p=0.04). El análisis multivariante identificó el origen pakistaní (OR: 2.94; 95% CI: 1.14-7.55) y el pH de cordón umbilical (OR: 0.04, 95% CI: 0.261-0.99) como factores asociados significativa e independientemente con el desarrollo de hipoglicemia. Conclusiones: El control glicémico intraparto en mujeres con DMG se consigue en la mayoría de los casos sin necesidad de tratamiento con insulina. Los factores relacionados con hiperglicemia materna durante el parto fueron la HbA1c del tercer trimestre y la falta de adscripción al seguimiento endocrinológico durante la gestación. Las hipoglicemias neonatales son habituales pero los episodios graves son poco habituales. Los factores asociados independientemente con el desarrollo de hipoglicemia neonatal son el origen pakistaní y el pH de cordón umbilical.Introduction: Previous studies in women with type 1 diabetes show that strict intrapartum glycemic control reduces the rate of neonatal hypoglycemia. However, there is a lack of clinical studies that evaluate the importance of intrapartum glycemic control and risk factors associated with the development of neonatal hypoglycemia in women with gestational diabetes mellitus (GDM). General objetive: To evaluate peripartum glycemic control in women with GDM and to analyze factors associated with the development of neonatal hypoglycemia. Specific objectives: 1/To evaluate peripartum glycemic control obtained with a specific treatment protocol designed for these patients and its relationship with maternal and gestational factors. 2/ To analyze newborn glycemias on the first 24 hours of life and the association of hypoglycemia with different maternal, gestational, peripartum and neonatal factors. Results: 86% of intrapartum maternal capillary blood glucose (CBG) values fell within target range (70-130mg/dl) without need of insulin treatment. There were no cases of maternal hypoglycemia or severe ketosis. Intrapartum maternal CBG values >130mg/dl was associated with third-trimester HbA1c levels (p=0.02) and with non-compliance of endocrinological follow-up (p=0.04). 190 newborns were evaluated and 48 (25.2%) had a CBG value of less than 45mg/dl. Of these, 23 (12.1%) had mild hypoglycemia, 20 (10.5%) moderate and only 5 (2.6%) a severe episode. Hypoglycaemic infants were more frequently large-for-gestational-age (29.3% vs 11.3%, p=0.003), had lower umbilical cord pH (7.28 vs 7.31, p=0.03) and their mothers had more frequently been hyperglycaemic during labour (18.8% vs 8.5%, p=0.04). In multivariate analyses, Pakistani origin (OR: 2.94; 95% CI: 1.14-7.55) and umbilical cord venous pH (OR: 0.04, 95% CI: 0.261-0.99) were significantly and independently associated with hypoglycaemia. Conclusions: Peripartum metabolic control in GDM patients was achieved without insulin in most cases. Intrapartum glycemic control was related with third-trimester HbA1c and with non-compliance of endocrinologic follow-up. Neonatal hypoglycemia is frequent although severe episodes are unusual. Factors independently associated with the development of neonatal hypoglycaemia were Pakistani origin and umbilical cord venous pH

Diabetes mellitus gestacional : control glicémico intraparto e hipoglicemia neonatal /

Varios estudios en pacientes con diabetes mellitus tipo 1 han demostrado la importancia del control glicémico estricto durante el parto en el desarrollo de hipoglicemia neonatal. Sin embargo, faltan estudios que evalúen la importancia del control glicémico intraparto y los factores asociados al desarrollo de hipoglicemia neonatal en pacientes con diabetes gestacional (DG). Objetivo general: Conocer la evolución de las glicemias durante el periodo de parto de mujeres afectas de DMG mediante la aplicación de un protocolo de tratamiento específico para estas pacientes y estudiar los factores que influyen en el desarrollo de las hipoglicemias neonatales. Objetivos específicos: 1/Control glicémico intraparto obtenido mediante la aplicación de un protocolo específico para mujeres con DMG y su relación con factores maternos y gestacionales, 2/Evaluar las glicemias de los recién nacidos hijos de madres con DMG durante las primeras 24 horas de vida y analizar la relación entre desarrollo de hipoglicemia neonatal y distintos factores maternos, gestacionales, periparto y neonatales. Material y métodos: Estudio prospectivo observacional en mujeres afectas de DMG que fueron atendidas durante la gestación y el parto en el Hospital del Mar entre Octubre-2006 y Enero-2011. Se recogieron las características maternas y gestacionales, las glicemias durante el parto y las características de los recién nacidos y sus glicemias durante las primeras 24 horas de vida. Resultados: El 86% de las glicemias capilares maternas se mantuvieron entre los objetivos de control (70-130mg/dl) sin necesidad de tratamiento con insulina. No hubo hipoglicemias maternas ni casos de cetosis grave. La hiperglicemia durante el parto se asoció con los niveles de HbA1c del tercer trimestre (p=0.02) y con la falta de adscripción al seguimiento endocrinológico (p=0.04). De los 190 neonatos estudiados, 48 (25.2%) tuvieron una glicemia inferior a 45mg/dl. De estos, 23 (12.1%) presentaron una hipoglicemia leve, 20 (10.5%) moderada y sólo 5 (2.6%) un episodio grave. Los factores asociados al desarrollo de hipoglicemia neonatal fueron la condición de grande para edad gestacional (29.3% vs 11.3%, p=0.003), el pH de cordón umbilical (7.28 vs 7.31, p=0.03) y la hiperglicemia materna durante el parto (18.8% vs 8.5%, p=0.04). El análisis multivariante identificó el origen pakistaní (OR: 2.94; 95% CI: 1.14-7.55) y el pH de cordón umbilical (OR: 0.04, 95% CI: 0.261-0.99) como factores asociados significativa e independientemente con el desarrollo de hipoglicemia. Conclusiones: El control glicémico intraparto en mujeres con DMG se consigue en la mayoría de los casos sin necesidad de tratamiento con insulina. Los factores relacionados con hiperglicemia materna durante el parto fueron la HbA1c del tercer trimestre y la falta de adscripción al seguimiento endocrinológico durante la gestación. Las hipoglicemias neonatales son habituales pero los episodios graves son poco habituales. Los factores asociados independientemente con el desarrollo de hipoglicemia neonatal son el origen pakistaní y el pH de cordón umbilical.Previous studies in women with type 1 diabetes show that strict intrapartum glycemic control reduces the rate of neonatal hypoglycemia. However, there is a lack of clinical studies that evaluate the importance of intrapartum glycemic control and risk factors associated with the development of neonatal hypoglycemia in women with gestational diabetes mellitus (GDM). General objetive: To evaluate peripartum glycemic control in women with GDM and to analyze factors associated with the development of neonatal hypoglycemia. Specific objectives: 1/To evaluate peripartum glycemic control obtained with a specific treatment protocol designed for these patients and its relationship with maternal and gestational factors. 2/ To analyze newborn glycemias on the first 24 hours of life and the association of hypoglycemia with different maternal, gestational, peripartum and neonatal factors. Results: 86% of intrapartum maternal capillary blood glucose (CBG) values fell within target range (70-130mg/dl) without need of insulin treatment. There were no cases of maternal hypoglycemia or severe ketosis. Intrapartum maternal CBG values >130mg/dl was associated with third-trimester HbA1c levels (p=0.02) and with non-compliance of endocrinological follow-up (p=0.04). 190 newborns were evaluated and 48 (25.2%) had a CBG value of less than 45mg/dl. Of these, 23 (12.1%) had mild hypoglycemia, 20 (10.5%) moderate and only 5 (2.6%) a severe episode. Hypoglycaemic infants were more frequently large-for-gestational-age (29.3% vs 11.3%, p=0.003), had lower umbilical cord pH (7.28 vs 7.31, p=0.03) and their mothers had more frequently been hyperglycaemic during labour (18.8% vs 8.5%, p=0.04). In multivariate analyses, Pakistani origin (OR: 2.94; 95% CI: 1.14-7.55) and umbilical cord venous pH (OR: 0.04, 95% CI: 0.261-0.99) were significantly and independently associated with hypoglycaemia. Conclusions: Peripartum metabolic control in GDM patients was achieved without insulin in most cases. Intrapartum glycemic control was related with third-trimester HbA1c and with non-compliance of endocrinologic follow-up. Neonatal hypoglycemia is frequent although severe episodes are unusual. Factors independently associated with the development of neonatal hypoglycaemia were Pakistani origin and umbilical cord venous pH

Prevalence of postprandial hyperglycaemia in basal insulin-treated patients with type 2 diabetes mellitus with controlled fasting glycaemia and elevated glycosylated haemoglobin

Objective: To study the prevalence of postprandial hyperglycaemia (PPH) in type 2 diabetes mellitus (T2DM) patients treated with basal insulin, having fasting glucose 7.0% (53 mmol/mol). Methods: This was an observational prospective multicentric study conducted in Spain. During 2 weeks, patients recorded a 6-point self-measured blood glucose profile (before and 2 h after eating) every 2 days. PPH was defined according to IDF and ADA guidelines (> 160 and > 180 mg/dL, respectively). Results: We included 98 patients (males: 56.1%; mean age: 64.3 ± 10.4 years) who were treated with basal insulin for at least 1 year at stable doses in the last 2 months, 88.8% of them received concomitant oral antidiabetic drugs. Overall, 95.7% (95% CI 91.6-99.8) and 93.5% (95% CI 88.6-98.5) of patients showed ≥ 1 episode of PPH according to IDF and ADA criteria respectively. PPH was more frequently observed after lunch and dinner. The proportion of patients with ≥ 40% readings in range of PPH was 59.1% (95% CI 49.1-69.1) and 40.9% (95% CI 30.9-50.9), according to IDF and ADA criteria, respectively. Conclusions: PPH is very common and should be considered a priority target in basal insulin-treated T2DM patients with elevated HbA1c despite controlled fasting glucose

Randomized Clinical Trial : A Normocaloric Low-Fiber Diet the Day Before Colonoscopy Is the Most Effective Approach to Bowel Preparation in Colorectal Cancer Screening Colonoscopy

Clinical guidelines recommend either a clear-liquid diet or a low-fiber diet for colonoscopy preparation. Participants in a screening program are usually motivated healthy individuals in which a good tolerability is important to improve adherence to potential surveillance colonoscopies. Our aim was to assess whether or not a normocaloric low-fiber diet followed the day before a screening colonoscopy compromises the efficacy of bowel cleansing and may improve the tolerability of bowel preparation. This is a randomized, endoscopist-blinded, noninferiority clinical trial. The study was conducted at a tertiary care center. A total of 276 consecutive participants of the Barcelona colorectal cancer screening program were included. Participants were randomly assigned to a clear-liquid diet or a normocaloric low-fiber diet the day before the colonoscopy. Both groups received 4 L of polyethylene glycol in a split-dose regimen. Primary outcome was the adequate bowel preparation rate measured with the Boston bowel preparation scale. Secondary outcomes included tolerability, fluid-intake perception, hunger, side effects, and acceptability. Participants in both groups were similar in baseline characteristics. Adequate bowel preparation was achieved in 89.1% vs 95.7% in clear-liquid diet and low-fiber diet groups, showing not only noninferiority, but also superiority (p = 0.04). Low-fiber diet participants reported less fluid-intake perception (p = 0.04) and less hunger (p = 0.006), with no differences in bloating or nausea. The single-center design of the study could limit the external validity of the results. The present findings may not be comparable to other clinical settings. A normocaloric low-fiber diet the day before a screening colonoscopy achieved better results than a clear-liquid diet in terms of adequate colon preparation. Moreover, it also improved the perception of hunger and excessive fluid intake

Statins for primary cardiovascular prevention in the elderly

The elderly population is increasing worldwide, with subjects > 65 years of age constituting the fastest-growing age group. Furthermore, the elderly face the greatest risk and burden of cardiovascular disease mortality and morbidity. Although elderly patients, particularly those older > 75, have not been well represented in randomized clinical trials evaluating lipid-lowering therapy, the available evidence supporting the use of statin therapy in primary prevention in older individuals is derived mainly from subgroup analyses and post-hoc data. On the other hand, elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of statin therapy. The aim of this review was to present the relevant literature regarding statin use in the elderly for their primary cardiovascular disease, with the associated risks and benefits of treatment

Changes in the lipid profile 5 years after bariatric surgery: laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy

BACKGROUND: Few studies have compared mid-term results of laparoscopic Roux-en-Y gastric bypass (LRYGB) versus laparoscopic sleeve gastrectomy (LSG), and none have focused on lipid profile. OBJECTIVES: To compare LRYGB versus LSG with respect to lipid disturbance evolution and remission at mid-term after bariatric surgery (BS) and to assess associated factors with the remission of lipid disturbances at 5 years. SETTING: Hospital del Mar, Barcelona, from January 2005 to January 2012. METHODS: A retrospective analysis of a nonrandomized, prospective cohort was conducted on patients undergoing BS at Hospital del Mar, Barcelona, from January 2005 to January 2012 with ≥5 years' follow-up. RESULTS: Of 259 patients, 151 (58.3%) completed the 5-year follow-up. The proportion of patients who achieved normal low-density lipoprotein cholesterol levels at 5 years post-LRYGB was greater than after LSG (30/49 [61.2%] versus 6/23 [26.1%]; P = .005), being male sex, absence of statins treatment, and type of BS technique (LRYGB) the associated factors with remission. Hypertriglyceridemia remission was also higher after LRYGB (23/25 [92.0%] versus 10/15 [66.7%]; P = .041), although type of surgery was not an associated factor. No differences were found in remission rates of low high-density lipoprotein cholesterol between groups. Absence of fibrates treatment and 5-year percentage of excess weight loss were independently associated with hypertriglyceridemia remission, and only the latter was independently associated with low high-density lipoprotein cholesterol remission 5 years after surgery. CONCLUSIONS: Five-year outcome data showed that, among patients with severe obesity undergoing BS, LRYGB was associated with a higher total and low-density lipoprotein cholesterol reduction and remission in comparison to LSG, with no differences in hypertriglyceridemia and high-density lipoprotein cholesterol normalization