Severe Hypocalcemia due to Vitamin D Deficiency after Extended Roux-en-Y Gastric Bypass

Vitamin D deficiency is a well-known comorbidity of obesity that can be exacerbated after bariatric surgery and can predispose the patient for hypocalcemia. Vitamin D and calcium doses to prevent and treat vitamin D deficiency after weight loss surgery are not well defined. We describe a patient who developed severe hypocalcemia due to vitamin D deficiency 5 years after an extended Roux-en-Y gastric bypass for a type II obesity. No precipitating factors were present and malabsorption induced by the bypass was considered to be the main causative factor. High doses of vitamin D and calcium were needed to reach and maintain normal calcium and vitamin D concentrations. This case emphasises the importance of routine screening for vitamin D deficiency in obese individuals and reflects that while consensus does not exist regarding optimal dosage, vitamin D replacement should be tittered based on calcidiol levels

Meeting individualized glycemic targets in primary care patients with type 2 diabetes in Spain

Information about the achievement of glycemic targets in patients with type 2 diabetes according to different individualization strategies is scarce. Our aim was to analyze the allocation of type 2 diabetic patients into individualized glycemic targets according to different strategies of individualization and to assess the degree of achievement of adequate control. Cross-sectional analysis on 5382 type 2 diabetic patients in primary care setting in Spain between 2011 and 2012. Targets of HbA1c were assigned based on different strategies of individualization of glycemic targets: 1) the ADA/EASD consensus 2) The Spanish Diabetes Society (SED) consensus 3) a strategy that accounts for the risk of hypoglycemia (HYPO) considering the presence of a hypoglycemia during the last year and type of hypoglycemic treatment. Concordance between the different strategies was analyzed. A total of 15.9, 17.1 and 67 % applied to ADA/EASD recommendation of HbA1c target of <6.5, < 7 and <8 % (48, 53 and 64 mmol/mol), and 31.9 and 67.4 % applied to the SED glycemic target of <6.5 and <7.5 % (<48 and 58 mmol/mol). Using the HYPO strategy, 53.5 % had a recommended HbA1c target <7 % (53 mmol/mol). There is a 94 % concordance between the ADA/EASD and SED strategies, and a concordance of 41-42 % between these strategies and HYPO strategy. Using the three different strategies, the overall proportion of patients achieving glycemic targets was 56-68 %. Individualization of glycemic targets increases the number of patients who are considered adequately controlled. The proposed HYPO strategy identifies a similar proportion of patients that achieve adequate glycemic control than ADA/EASD or SED strategies, but its concordance with these strategies in terms of patient classification is bad

Evaluation of motivational stages and processes of change for weight management in obesity and after bariatric surgery

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Divergent Effects of Glycemic Control and Bariatric Surgery on Circulating Concentrations of TMAO in Newly Diagnosed T2D Patients and Morbidly Obese

High circulating concentrations of the gut microbiota-derived metabolite trimethylamine N-oxide (TMAO) are significantly associated with the risk of obesity and type 2 diabetes (T2D). We aimed at evaluating the impact of glycemic control and bariatric surgery on circulating concentrations of TMAO and its microbiota-dependent intermediate, γ-butyrobetaine (γBB), in newly diagnosed T2D patients and morbidly obese subjects following a within-subject design. Based on HbA1c concentrations, T2D patients achieved glycemic control. However, the plasma TMAO and γBB concentrations were significantly increased, without changes in estimated glomerular filtration rate. Bariatric surgery was very effective in reducing weight in obese subjects. Nevertheless, the surgery reduced plasma γBB concentrations without affecting TMAO concentrations and the estimated glomerular filtration rate. Considering these results, an additional experiment was carried out in male C57BL/6J mice fed a Western-type diet for twelve weeks. Neither diet-induced obesity nor insulin resistance were associated with circulating TMAO and γBB concentrations in these genetically defined mice strains. Our findings do not support that glycemic control or bariatric surgery improve the circulating concentrations of TMAO in newly diagnosed T2D and morbidly obese patients

Assessing motivational stages and processes of change for weight management around bariatric surgery: A multicenter study

Introduction/Purpose: The assessment of the patients' motivation as a predictor of behavioral change via five stages (pre- contemplation, contemplation, preparation, action, and maintenance) and four processes (emotional re-evaluation, weight management actions, environmental restructuring, and weight consequences evaluation) of change. Materials/Methods: A total of 542 participants (251 waiting for bariatric surgery (BS), 90 undergoing BS, and 201 controls) completed the Stages (S-Weight) and Processes (P-Weight) of Change in Overweight and Obese People questionnaires in a multicenter cross-sectional study. Results: A higher percentage of subjects seeking BS (31.7%) were in the action stage (16.7% of post-BS patients, p < 0.001; 14.9% of controls, p < 0.001). The referred body mass index (BMI) reduction was higher in subjects in active stages (3.6 ± 4.4 kg/ m2 in maintenance versus 1.4 ± 1.4 kg/m2 in contemplation, p < 0.001). In the P-Weight questionnaire, patients looking for BS scored significant higher in the four processes of change than controls. In addition, a positive and significantly correlation between BMI and the four processes was observed. In the stepwise multivariate analysis, BMI and the S-Weight allocation were constantly associated with the four processes of change. Conclusion: Obesity is accompanied by a modifying behavioral stage, suggesting that subjects before BS are seriously thinking about overcoming excess weight. To identify subjects on the waiting list for BS who will be more receptive to weight lost interventions remains a challenge

Role of biomarkers in early infectious complications after lung transplantation

Background Infections and primary graft dysfunction are devastating complications in the immediate postoperative period following lung transplantation. Nowadays, reliable diagnostic tools are not available. Biomarkers could improve early infection diagnosis. Methods Multicentre prospective observational study that included all centres authorized to perform lung transplantation in Spain. Lung infection and/or primary graft dysfunction presentation during study period (first postoperative week) was determined. Biomarkers were measured on ICU admission and daily till ICU discharge or for the following 6 consecutive postoperative days. Results We included 233 patients. Median PCT levels were significantly lower in patients with no infection than in patients with Infection on all follow up days. PCT levels were similar for PGD grades 1 and 2 and increased significantly in grade 3. CRP levels were similar in all groups, and no significant differences were observed at any study time point. In the absence of PGD grade 3, PCT levels above median (0.50 ng/ml on admission or 1.17 ng/ml on day 1) were significantly associated with more than two- and three-fold increase in the risk of infection (adjusted Odds Ratio 2.37, 95% confidence interval 1.06 to 5.30 and 3.44, 95% confidence interval 1.52 to 7.78, respectively). Conclusions In the absence of severe primary graft dysfunction, procalcitonin can be useful in detecting infections during the first postoperative week. PGD grade 3 significantly increases PCT levels and interferes with the capacity of PCT as a marker of infection. PCT was superior to CRP in the diagnosis of infection during the study period

Association between Use of Enhanced Recovery after Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery after Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2)

Importance: The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery. Objective: To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Design, Setting, and Participants: This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019. Exposures: Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not. Main Outcomes and Measures: The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality. Results: During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P =.22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P =.02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P <.001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P <.001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P <.001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P <.001). Conclusions and Relevance: An increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes

ABHD4-dependent developmental anoikis safeguards the embryonic brain

During embryonic development, neural progenitor cells undergo numerous cell divisions. Here, the authors show that ABHD4-mediated developmental anoikis distinguishes the physiological delamination and the pathological detachment of progenitor cells with relevance to fetal alcohol-induced apoptosis

Meeting individualized glycemic targets in primary care patients with type 2 diabetes in Spain

BACKGROUND: Information about the achievement of glycemic targets in patients with type 2 diabetes according to different individualization strategies is scarce. Our aim was to analyze the allocation of type 2 diabetic patients into individualized glycemic targets according to different strategies of individualization and to assess the degree of achievement of adequate control. METHODS: Cross-sectional analysis on 5382 type 2 diabetic patients in primary care setting in Spain between 2011 and 2012. Targets of HbA1c were assigned based on different strategies of individualization of glycemic targets: 1) the ADA/EASD consensus 2) The Spanish Diabetes Society (SED) consensus 3) a strategy that accounts for the risk of hypoglycemia (HYPO) considering the presence of a hypoglycemia during the last year and type of hypoglycemic treatment. Concordance between the different strategies was analyzed. RESULTS: A total of 15.9, 17.1 and 67 % applied to ADA/EASD recommendation of HbA1c target of <6.5, < 7 and <8 % (48, 53 and 64 mmol/mol), and 31.9 and 67.4 % applied to the SED glycemic target of <6.5 and <7.5 % (<48 and 58 mmol/mol). Using the HYPO strategy, 53.5 % had a recommended HbA1c target <7 % (53 mmol/mol). There is a 94 % concordance between the ADA/EASD and SED strategies, and a concordance of 41–42 % between these strategies and HYPO strategy. Using the three different strategies, the overall proportion of patients achieving glycemic targets was 56–68 %. CONCLUSIONS: Individualization of glycemic targets increases the number of patients who are considered adequately controlled. The proposed HYPO strategy identifies a similar proportion of patients that achieve adequate glycemic control than ADA/EASD or SED strategies, but its concordance with these strategies in terms of patient classification is bad