Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients.

BACKGROUND: Bariatric operations achieve a high remission rate of type 2 diabetes in patients with morbid obesity. Malabsorptive operations usually are followed by a higher rate of metabolic improvement, though complications and secondary effects of these operations are usually higher. OBJECTIVES: Analyze the results of a simplified duodenal switch, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) on patients with obesity and type 2 diabetes mellitus (T2 DM). SETTING: University Hospital, Madrid, Spain. METHODS: Ninety-seven T2 DM patients with a mean body mass index (BMI) of 44.3 kg/m(2) were included. Mean preoperative glycated hemoglobin was 7.6%, and mean duration of the disease was 8.5 years. Forty patients were under insulin treatment. SADI-S was completed with a sleeve gastrectomy performed over a 54 French bougie and a 200 cm common limb in 28 cases and 250 cm in 69. RESULTS: Follow up was possible for 86 patients (95.5%) in the first postoperative year, 74 (92.5%) in the second, 66 (91.6%) in the third, 46 (86.7%) in the fourth and 25 out of 32 (78%) in the fifht postoperative year. Mean glycemia and glycated hemoglobin decreased immediately. Control of the disease, with HbA1c below 6%, was obtained in 70 to 84% in the long term, depending on the initial antidiabetic therapy. Most patients abandoned antidiabetic therapy after the operation. Absolute remission rate was higher for patients under oral therapy than for those under initial insulin therapy, 92.5% versus 47% in the first postoperative year, 96.4% versus 56% in the third and 75% versus 38.4% in the fifth. A short diabetes history and no need for insulin were related to a higher remission rate. Three patients had to be reoperated for recurrent hypoproteinemia. CONCLUSION: SADI-S is an effective therapeutic option for obese patients with diabetes mellitus.

Prevalence of diabetes, prediabetes, and stress hyperglycemia: insulin therapy and metabolic control in patients on total parenteral nutrition (prospective multicenter study).

OBJECTIVE: The prevalence of carbohydrate metabolism disorders in patients who receive total parenteral nutrition (TPN) is not well known. These disorders can affect the treatment, metabolic control, and prognosis of affected patients. The aims of this study were to determine the prevalence in noncritically ill patients on TPN of diabetes, prediabetes, and stress hyperglycemia; the factors affecting hyperglycemia during TPN; and the insulin therapy provided and the metabolic control achieved. METHODS: We undertook a prospective multicenter study involving 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included, and data were collected on demographic, clinical, and laboratory variables (glycated hemoglobin, C-reactive protein [CRP], capillary blood glucose) as well as insulin treatment. RESULTS: The study included 605 patients. Before initiation of TPN, the prevalence of known diabetes was 17.4%, unknown diabetes 4.3%, stress hyperglycemia 7.1%, and prediabetes 27.8%. During TPN therapy, 50.9% of patients had at least one capillary blood glucose of >180 mg/dL. Predisposing factors were age, levels of CRP and glycated hemoglobin, the presence of diabetes, infectious complications, the number of grams of carbohydrates infused, and the administration of glucose-elevating drugs. Most (71.6%) patients were treated with insulin. The mean capillary blood glucose levels during TPN were: known diabetes (178.6 ± 46.5 mg/dL), unknown diabetes (173.9 ± 51.9), prediabetes (136.0 ± 25.4), stress hyperglycemia (146.0 ± 29.3), and normal (123.2 ± 19.9) (P<.001). CONCLUSION: The prevalence of carbohydrate metabolism disorders is very high in noncritically ill patients on TPN. These disorders affect insulin treatment and the degree of metabolic control achieved.

Nutrition-related risk indexes and long-term mortality in noncritically ill inpatients who receive total parenteral nutrition (prospective multicenter study).

BACKGROUND: Malnutrition in hospitalized patients is associated with an increased risk of death, in both the short and the long term. AIMS: The purpose of this study was to determine which nutrition-related risk index predicts long-term mortality better (three years) in patients who receive total parenteral nutrition (TPN). METHODS: This prospective, multicenter study involved noncritically ill patients who were prescribed TPN during hospitalization. Data were collected on Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), body mass index, albumin and prealbumin, as well as long-term mortality. RESULTS: Over the 1- and 3-year follow-up periods, 174 and 244 study subjects (28.8% and 40.3%) respectively, died. Based on the Cox proportional hazards survival model, the nutrition-related risk indexes most strongly associated with mortality were SGA and albumin (<2.5 g/dL) (after adjustment for age, gender, C-reactive protein levels, prior comorbidity, mean capillary blood glucose during TPN infusion, diabetes status prior to TPN, diagnosis, and infectious complications during hospitalization). CONCLUSIONS: The SGA and very low albumin levels are simple tools that predict the risk of long-term mortality better than other tools in noncritically ill patients who receive TPN during hospitalization.

Fat-soluble vitamin deficiencies after bariatric surgery could be misleading if they are not appropriately adjusted.

OBJECTIVE: To evaluate the differences in frequency of fat-soluble vitamin deficiencies if we adjust their levels by its main carriers in plasma in patients undergoing Biliopancreatic diversion (BPD) and Roux-en-Y gastric bypass (RYGB). RESEARCH METHODS & PROCEDURES: We recruited 178 patients who underwent RYGB (n = 116 patients) and BPD (n = 62 patients) in a single centre. Basal data information and one-year after surgery included: anthropometric measurements, fat-soluble vitamins A, E and D, retinol binding protein (RBP) and total cholesterol as carriers of vitamin A and E respectively. Continuous data were compared using T-Student and proportions using chisquare test. RESULTS: There was a vitamin D deficiency of 96% of all patients, 10% vitamin A deficiency and 1.2% vitamin E deficiency prior to surgery. One year after surgery, 33% of patients were vitamin A deficient but the frequency reduced to 19% when we adjusted by RBP. We found a vitamin E deficiency frequency of 0% in RYGB and 4.8% in DBP one year after surgery. However, when we adjusted the serum levels to total cholesterol, we found an increased frequency of 8.7% in RYGB group for vitamin E deficiency and 21.4% in DBP (p = 0.04). CONCLUSION: We have found a different frequency of deficit for fat-soluble vitamin both in BPD and RYGB once we have adjusted for its main carriers. This is clinically relevant to prevent from overexposure and toxicity. We suggest that carrier molecules should be routinely requested when we assess fat-soluble vitamin status in patients who undergo malabsorptive procedures.

OBJETIVO: Evaluar las diferencias en la frecuencia de las deficiencias de vitaminas liposolubles si ajustamos sus concentraciones mediante sus principales transportadores plasmáticos en pacientes sometidos a derivación biliopancreática (DBP) y derivación gástrica en Y de Roux (DGYR). MÉTODOS DE INVESTIGACIÓN Y PROCEDIMIENTOS: Reclutamos a 178 pacientes sometidos a DGYR (n = 116 pacientes) y DBP (n = 62 pacientes) en un único centro. Los datos de información basal y al año de la cirugía incluyeron: mediciones antropométricas, vitaminas liposolubles A, E y D, proteína de unión al retinol (PUR) y el colesterol total como transportadores de las vitaminas A y E, respectivamente. Los datos continuos se compararon utilizando la t de Student y para las proporciones el test chi cuadrado. RESULTADOS: Hubo una deficiencia de vitamina D en el 96% de todos los pacientes, de vitamina A en el 10% y de vitamina E en el 1,2% antes de la cirugía. Un año después de la cirugía, el 33% de los pacientes tenía deficiencia de vitamina A pero la frecuencia se redujo al 19% cuando ajustamos para la PUR. Encontramos una frecuencia de deficiencia de vitamina E en el 0% de los pacientes con DGYR y en el 4,8% de aquellos con DBP un año después de la cirugía. Sin embargo, cuando ajustamos las concentraciones séricas de colesterol total, encontramos un aumento de la frecuencia de hasta el 8,7% de deficiencia de vitamina E en el grupo con DGYR y del 21,4% en el grupo con DBP (p = 0,04). CONCLUSIÓN: Encontramos una frecuencia diferente de déficit de vitaminas liposolubles tanto en DBP como en DGYR una vez que ajustamos para sus principales transportadores. Esto es clínicamente relevante para evitar la sobreexposición y la toxicidad. Sugerimos que se deberían solicitar de forma rutinaria las moléculas transportadoras a la hora de evaluar el estado de vitaminas liposolubles en pacientes sometidos a procedimientos que entrañan malabsorción.

Fat-soluble vitamin deficiencies after bariatric surgery could be misleading if they are not appropriately adjusted / Las deficiencias de vitaminas liposolubles tras la cirugía bariátrica pueden ser perjudiciales si no se ajustan adecudadamente

Objective: To evaluate the differences in frequency of fat-soluble vitamin deficiencies if we adjust their levels by its main carriers in plasma in patients undergoing Biliopancreatic diversion (BPD) and Roux-en-Y gastric bypass (RYGB). Research Methods & Procedures: We recruited 178 patients who underwent RYGB (n = 116 patients) and BPD (n = 62 patients) in a single centre. Basal data information and one-year after surgery included: anthropometric measurements, fat-soluble vitamins A, E and D, retinol binding protein (RBP) and total cholesterol as carriers of vitamin A and E respectively. Continuous data were compared using T-Student and proportions using chisquare test. Results: There was a vitamin D deficiency of 96% of all patients, 10% vitamin A deficiency and 1.2% vitamin E deficiency prior to surgery. One year after surgery, 33% of patients were vitamin A deficient but the frequency reduced to 19% when we adjusted by RBP. We found a vitamin E deficiency frequency of 0% in RYGB and 4.8% in DBP one year after surgery. However, when we adjusted the serum levels to total cholesterol, we found an increased frequency of 8.7% in RYGB group for vitamin E deficiency and 21.4% in DBP (p = 0.04). Conclusion: We have found a different frequency of deficit for fat-soluble vitamin both in BPD and RYGB once we have adjusted for its main carriers. This is clinically relevant to prevent from overexposure and toxicity. We suggest that carrier molecules should be routinely requested when we assess fat-soluble vitamin status in patients who undergo malabsorptive procedures (AU)

Objetivo: Evaluar las diferencias en la frecuencia de las deficiencias de vitaminas liposolubles si ajustamos sus concentraciones mediante sus principales transportadores plasmáticos en pacientes sometidos a derivación biliopancreática (DBP) y derivación gástrica en Y de Roux (DGYR). Métodos de investigación y procedimientos: Reclutamos a 178 pacientes sometidos a DGYR (n = 116 pacientes) y DBP (n = 62 pacientes) en un único centro. Los datos de información basal y al año de la cirugía incluyeron: mediciones antropométricas, vitaminas liposolubles A, E y D, proteína de unión al retinol (PUR) y el colesterol total como transportadores de las vitaminas A y E, respectivamente. Los datos continuos se compararon utilizando la t de Student y para las proporciones el test chi cuadrado. Resultados: Hubo una deficiencia de vitamina D en el 96% de todos los pacientes, de vitamina A en el 10% y de vitamina E en el 1,2% antes de la cirugía. Un año después de la cirugía, el 33% de los pacientes tenía deficiencia de vitamina A pero la frecuencia se redujo al 19% cuando ajustamos para la PUR. Encontramos una frecuencia de deficiencia de vitamina E en el 0% de los pacientes con DGYR y en el 4,8% de aquellos con DBP un año después de la cirugía. Sin embargo, cuando ajustamos las concentraciones séricas de colesterol total, encontramos un aumento de la frecuencia de hasta el 8,7% de deficiencia de vitamina E en el grupo con DGYR y del 21,4% en el grupo con DBP (p = 0,04). Conclusión: Encontramos una frecuencia diferente de déficit de vitaminas liposolubles tanto en DBP como en DGYR una vez que ajustamos para sus principales transportadores. Esto es clínicamente relevante para evitar la sobreexposición y la toxicidad. Sugerimos que se deberían solicitar de forma rutinaria las moléculas transportadoras a la hora de evaluar el estado de vitaminas liposolubles en pacientes sometidos a procedimientos que entrañan malabsorción (AU)

Statistical models to predict type 2 diabetes remission after bariatric surgery.

BACKGROUND: Type 2 diabetes (T2D) remission may be achieved after bariatric surgery (BS), but rates vary according to patients' baseline characteristics. The present study evaluates the relevance of several preoperative factors and develops statistical models to predict T2D remission 1 year after BS. METHODS: We retrospectively studied 141 patients (57.4% women), with a preoperative diagnosis of T2D, who underwent BS in a single center (2006-2011). Anthropometric and glucose metabolism parameters before surgery and at 1-year follow-up were recorded. Remission of T2D was defined according to consensus criteria: HbA1c <6%, fasting glucose (FG) <100 mg/dL, absence of pharmacologic treatment. The influence of several preoperative factors was explored and different statistical models to predict T2D remission were elaborated using logistic regression analysis. RESULTS: Three preoperative characteristics considered individually were identified as the most powerful predictors of T2D remission: C-peptide (R2 = 0.249; odds ratio [OR] 1.652, 95% confidence interval [CI] 1.181-2.309; P = 0.003), T2D duration (R2 = 0.197; OR 0.869, 95% CI 0.808-0.935; P < 0.001), and previous insulin therapy (R2 = 0.165; OR 4.670, 95% CI 2.257-9.665; P < 0.001). High C-peptide levels, a shorter duration of T2D, and the absence of insulin therapy favored remission. Different multivariate logistic regression models were designed. When considering sex, T2D duration, and insulin treatment, remission was correctly predicted in 72.4% of cases. The model that included age, FG and C-peptide levels resulted in 83.7% correct classifications. When sex, FG, C-peptide, insulin treatment, and percentage weight loss were considered, correct classification of T2D remission was achieved in 95.9% of cases. CONCLUSION: Preoperative characteristics determine T2D remission rates after BS to different extents. The use of statistical models may help clinicians reliably predict T2D remission rates after BS.

C-peptide levels predict type 2 diabetes remission after bariatric surgery.

BACKGROUND: C-peptide (Cp) serves as a surrogate of pancreatic beta-cell reserve. This study evaluates the clinical significance of basal Cp as a predictor of type 2 diabetes (T2D) remission after bariatric surgery (BS). RESEARCH DESIGN AND METHODS: Retrospective study of 22 patients with BMI > 35 kg/m² and T2D who underwent BS. Evaluation of anthropometric and glucose metabolism parameters before BS and at one-year follow-up. Analysis of patients with T2D remission (HbA1c < 6%, fasting glucose (FG) < 100 mg/dl, absence of pharmacologic treatment) and preoperative characteristics associated (logistic binary regression model). ROC curve to estimate an optimal Cp value to predict T2D remission. RESULTS: Preoperativeley (mean ± SD): age 53.3 ± 9.4 years, BMI 42.9 ± 6.8 kg/m², T2D duration 6.9 ± 5.2 years, FG 159.6 ± 56.6 mg/dL, HbA1c 7.5 ± 1.1%, Cp 4.0 ± 2.0 (median 3.8, range 0.1-8.9) ng/mL. At one year follow-up, remission of T2D in 12 cases (54.5%). Preoperative Cp correlated with 12-month HbA1c (r = -0.519, p = 0.013). Preoperative Cp was higher in those who achieved remission: 5.0 ± 1.7 vs 3.0 ± 1.7 ng/ml, p = 0,013. A Cp concentration > 3.75 ng/mL provided a clinically useful cut-off for prediction of T2D remission. T2D remission rates were different according to median preoperative Cp: 27.3% if Cp < 3.8 ng/mL and 81.7% if Cp > 3.8 ng/mL (p = 0.010). CONCLUSIONS: Patients with elevated preoperative Cp levels achieve higher rates of T2D remission one year after BS. A Cp concentration > 3.75 ng/mL seems clinically useful.

Introducción: La determinación del péptido C (pC) suele emplearse como un indicador de la reserva betapancreática. El objetivo de este estudio es evaluar si el pC basal, es un parámetro predictor de remisión de diabetes mellitus tipo 2 (DM2) tras cirugía bariátrica (CB). Material y métodos: Estudio retrospectivo de 22 pacientes con DM2 e IMC > 35 kg/m2, intervenidos mediante CB. Recogida de datos clínicos, antropométricos y analíticos relativos al metabolismo de la glucosa, antes de la CB y al año. Análisis de pacientes en remisión completa de DM2 al año de la CB (glucosa basal [GB] < 100 mg/dl, HbA1c < 6%, sin tratamiento farmacológico) y las variables preoperatorias asociadas a remisión (regresión logística binaria). Estimación del mejor valor umbral de pC para predecir la remisión de DM2 con curva ROC. Resultados: Características pre-CB (media ± DE): edad 53,3 ± 9,4 años, IMC 42,9 ± 6,8 kg/m2, duración DM2 6,9 ± 5,2 años, GB 159,6 ± 56,6 mg/dl, HbA1c 7,5 ± 1,1%, pC 4,0 ± 2,0 (mediana 3,8, rango 0,1-8,9) ng/ml. 12 pacientes (54,5%) presentaron remisión de DM2. El pC preoperatorio se correlacionó con la HbA1c a los 12 meses (r = - 0,519, p = 0,013). Los valores de pC pre-CB fueron más elevados en los pacientes que alcanzaron remisión de DM2 (5,0 ± 1,7 vs 3,0 ± 1,7 ng/ml, p = 0,013). Un valor de pC > 3,75 ng/ml supuso una sensibilidad y especificidad para remisión de DM2 de 75% y 80%, respectivamente. La tasa de remisión de DM2 fue de 27,3% si el pC basal pre-CB < 3,8 ng/ml, y 81,7% si > 3,8 ng/ml (p = 0,010). Conclusiones: Los pacientes con pC basal preoperatorio elevado son los que mayores tasas de remisión alcanzan al año de la CB. Una concentración de pC basal > 3,75 ng/dL parece un buen predictor de remisión completa de DM2 al año de la CB.

C-peptide levels predict type 2 diabetes remission after bariatric surgery / El péptido C predice la remisión de la diabetes mellitus tipo 2 tras cirugía bariátrica

Background: C-peptide (Cp) serves as a surrogate of pancreatic beta-cell reserve. This study evaluates the clinical significance of basal Cp as a predictor of type 2 diabetes (T2D) remission after bariatric surgery (BS). Research design and methods: Retrospective study of 22 patients with BMI > 35 kg/m2 and T2D who underwent BS. Evaluation of anthropometric and glucose metabolism parameters before BS and at one-year follow-up. Analysis of patients with T2D remission (HbAlc < 6%, fasting glucose (FG) < 100 mg/dl, absence of pharmacologic treatment) and preoperative characteristics associated (logistic binary regression model). ROC curve to estimate an optimal Cp value to predict T2D remission. Results: Preoperativeley (mean ± SD): age 53.3 ± 9.4 years, BMI 42.9 ± 6.8 kg/m2, T2D duration 6.9 ± 5.2 years, FG 159.6 ± 56.6 mg/dL, HbAlc 7.5 ± 1.1%, Cp 4.0 ± 2.0 (median 3.8, range 0.1-8.9) ng/mL. At one year follow-up, remission of T2D in 12 cases (54.5%). Preoperative Cp correlated with 12-month HbA1c (r = -0.519, p = 0.013). Preoperative Cp was higher in those who achieved remission: 5.0 ± 1.7 vs 3.0 ± 1.7 ng/ml, p = 0,013. A Cp concentration > 3.75 ng/mL provided a clinically useful cut-off for prediction of T2D remission. T2D remission rates were different according to median preoperative Cp: 27.3% if Cp < 3.8 ng/mL and 81.7% if Cp > 3.8 ng/mL (p = 0.010). Conclusions: Patients with elevated preoperative Cp levels achieve higher rates of T2D remission one year after BS. A Cp concentration > 3.75 ng/mL seems clinically useful (AU)

Introducción: La determinación del péptido C (pC) suele emplearse como un indicador de la reserva beta-pancreática. El objetivo de este estudio es evaluar si el pC basal, es un parámetro predictor de remisión de diabetes mellitus tipo 2 (DM2) tras cirugía bariátrica (CB). Material y métodos: Estudio retrospectivo de 22 pacientes con DM2 e IMC > 35 kg/m2, intervenidos mediante CB. Recogida de datos clínicos, antropométricos y analíticos relativos al metabolismo de la glucosa, antes de la CB y al año. Análisis de pacientes en remisión completa de DM2 al año de la CB (glucosa basal [GB] < 100 mg/dl, HbAlc < 6%, sin tratamiento farmacológico) y las variables preoperatorias asociadas a remisión (regresión logística binaria). Estimación del mejor valor umbral de pC para predecir la remisión de DM2 con curva ROC. Resultados: Características pre-CB (media ± DE): edad 53,3 ± 9,4 años, IMC 42,9 ± 6,8 kg/m2, duración DM2 6,9 ± 5,2 años, GB 159,6 ± 56,6 mg/dl, HbAlc 7,5 ± 1,1%, pC 4,0 ± 2,0 (mediana 3,8, rango 0,1-8,9) ng/ml. 12 pacientes (54,5%) presentaron remisión de DM2. El pC preoperatorio se correlacionó con la HbA1c a los 12 meses (r = -0,519, p = 0,013). Los valores de pC pre-CB fueron más elevados en los pacientes que alcanzaron remisión de DM2 (5,0 ± 1,7 vs 3,0 ± 1,7 ng/ml, p = 0,013). Un valor de pC > 3,75 ng/ml supuso una sensibilidad y especificidad para remisión de DM2 de 75% y 80%, respectivamente. La tasa de remisión de DM2 fue de 27,3% si el pC basal pre-CB < 3,8 ng/ml, y 81,7% si > 3,8 ng/ml (p = 0,010). Conclusiones: Los pacientes con pC basal preoperatorio elevado son los que mayores tasas de remisión alcanzan al año de la CB. Una concentración de pC basal > 3,75 ng/dL parece un buen predictor de remisión completa de DM2 al año de la CB (AU)

Remission of type 2 diabetes mellitus should not be the foremost goal after bariatric surgery.

BACKGROUND: Remission of type 2 diabetes (T2D) is a desired outcome after bariatric surgery (BS). Even if this goal is not achieved, individuals who do not strictly fulfill remission criteria experience an overall improvement. The aim of this study was to evaluate the metabolic control status in patients considered as diabetes "non-remitters." METHODS: A retrospective study of 125 patients (59.2 % women) with preoperative diagnosis of T2D who underwent BS in a single center (2006-2011) was conducted. We collected anthropometric and metabolic parameters before surgery and at 1-year follow-up. T2D remission was defined according to the 2009 consensus statement: glycosylated hemoglobin (HbA1c) <6 %, fasting glucose (FG) <100 mg/dLs, and absence of pharmacologic treatment. We evaluated metabolic status of non-remitters, according to the American Diabetes Association's (ADA) target recommendations: HbA1c <7 %, LDL-c <100 mg/dL, triglycerides <150 mg/dL, and HDL-c >40 (male) or >50 mg/dL (female). STATISTICS: analysis of variance. RESULTS: Baseline characteristics (mean ± SD): age 53.5 ± 9.7 years, BMI 43.5 ± 5.6 kg/m(2), time since diagnosis of T2D 7.7 ± 7.9 years, FG 162.0 ± 56.3 mg/dL, HbA1c 7.7 ± 1.6 %. ADA's target recommendations were present in 12 patients (9.6 %) preoperatively, and in 45 (36.0 %) at 1-year follow-up (p <0.001). Sixty-two (49.6 %) patients did not achieve diabetes remission; 26 (41.9 %) had now diet treatment, 30 (48.4 %) oral medications, and 6 (9.7 %) required insulin. Of the non-remitters, 57 (91.9 %) had HbA1c <7 % and 18 (40.0 %) achieved ADA's target recommendations. There were no differences between remitters and non-remitters in the number of individuals reaching ADA's combined metabolic control. CONCLUSIONS: Although almost 50 % of the patients may not be classified as diabetes remitters, their significant improvement in metabolic control should be regarded as a success, according to most scientific societies' target recommendations.

Diagnosis of diabetes remission after bariatic surgery may be jeopardized by remission criteria and previous hypoglycemic treatment.

BACKGROUND: Controversy exists regarding type 2 diabetes (T2D) remission rates after bariatric surgery (BS) due to heterogeneity in its definition and patients' baseline features. We evaluate T2D remission using recent criteria, according to preoperative characteristics and insulin therapy (IT). METHODS: We performed a retrospective study from a cohort of 657 BS from a single center (2006-2011), of which 141 (57.4 % women) had T2D. We evaluated anthropometric and glucose metabolism parameters before surgery and at 1-year follow-up. T2D remission was defined according to 2009 consensus criteria: HbA1c <6%, fasting glucose (FG) <100 mg/dL, and absence of pharmacologic treatment. We analyzed diabetes remission according to previous treatment. RESULTS: Preoperative characteristic were (mean ± SD): age 53.9 ± 9.8 years, BMI 43.7 ± 5.6 kg/m2, T2D duration 7.4 ± 7.6 years, FG 160.0 ± 54.6 mg/dL, HbA1c 7.6 ± 1.6%. Fifty-six (39.7%) individuals had IT. At 1-year follow-up, 74 patients (52.5%) had diabetes remission. Percentage weight loss (%WL) and percentage excess weight loss (%EWL) were associated to remission (35.5 ± 8.1 vs. 30.2 ± 9.5 %, p = 0.001; 73.6 ± 18.4 vs. 66.3 ± 22.8%, p = 0.037, respectively). Duration of diabetes, age, and female sex were associated to nonremission: 10.3 ± 9.4 vs. 4.7 ± 3.8 years, p < 0.001; 55.1 ± 9.3 vs. 51.2 ± 9.9 years, p = 0.017; 58.9 vs. 33.3%, p = 0.004, respectively. Prior treatment revealed differences in remission rates: 67.1 % in case of oral therapy (OT) vs. 30.4% in IT, p < 0.001. OR for T2D remission in patients with previous IT, compared to those with only OT, were 0.157-0.327 (p < 0.05), adjusting by different models. CONCLUSIONS: Consensus criteria reveal lower T2D remission rates after BS than previously reported. Prior insulin use is a main setback for remission.

Which criteria should be used to define type 2 diabetes remission after bariatric surgery?

BACKGROUND: Comparison of diabetes remission rates after bariatric surgery using two different models of criteria. METHODS: Retrospective analysis of data from 110 patients with type 2 diabetes and morbid obesity who underwent bariatric surgery, preoperatively and at 18-month follow-up. Comparison of two models of remission: 1) 2009 consensus statement criteria; 2) simple criteria using ADA's HbA1c diabetes diagnostic cut-off values. RESULTS: Patients' mean ± SD preoperative characteristics were: age 53.3 ± 9.5 years, BMI 43.6 ± 5.5 kg/m(2), HbA1c 7.9 ± 1.8%, duration of diabetes 7.6 ± 7.5 years. 44.5% of patients with previous insulin therapy. With 2009 consensus statement criteria: complete, partial and no remission in 50%, 12.7% and 37.3%, respectively; with HbA1c criteria: 50%, 15% and 34.5% in the analogous categories (p=0.673). CONCLUSIONS: We suggest a simpler approach to evaluate diabetes remission after bariatric surgery, following the rationale of the definition of diabetes itself.

Single-anastomosis duodenoileal bypass with sleeve gastrectomy: metabolic improvement and weight loss in first 100 patients.

BACKGROUND: Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplified 1-loop duodenal switch with a 200-250 common channel. Our objective was to analyze the weight loss and metabolic results of the technique on a series of 100 consecutively operated patients at a tertiary center university hospital. METHODS: A total of 100 patients consecutively underwent surgery. The criteria of inclusion were morbid obesity or metabolic disease. In the first 50 cases, the common/efferent limb measured 200 cm. The length was changed to 250 cm to reduce the hypoproteinemia rate. RESULTS: No mortality and no severe complications developed. The mean excess weight loss was >95% maintained during the follow-up period. More than 90% of the patients experimented complete remission of type 2 diabetes mellitus. Two conversions to a standard duodenal switch with a longer alimentary channel were required because of recurrent hypoproteinemia. Hypertension was controlled in 98% of the patients, with a 58% remission rate. The mean number of bowel movements was 2.5/d. CONCLUSION: Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplified duodenal switch procedure that is safe and quicker to perform and offers good results for the treatment of both morbid obesity and its metabolic complications.

Parenteral nutrition-associated hyperglycemia in non-critically ill inpatients increases the risk of in-hospital mortality (multicenter study).

OBJECTIVE: Hyperglycemia may increase mortality in patients who receive total parenteral nutrition (TPN). However, this has not been well studied in noncritically ill patients (i.e., patients in the nonintensive care unit setting). The aim of this study was to determine whether mean blood glucose level during TPN infusion is associated with increased mortality in noncritically ill hospitalized patients. RESEARCH DESIGN AND METHODS: This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included prospectively, and data were collected on demographic, clinical, and laboratory variables as well as on in-hospital mortality. RESULTS: The study included 605 patients (mean age 63.2 ± 15.7 years). The daily mean TPN values were 1.630 ± 323 kcal, 3.2 ± 0.7 g carbohydrates/kg, 1.26 ± 0.3 g amino acids/kg, and 0.9 ± 0.2 g lipids/kg. Multiple logistic regression analysis showed that the patients who had mean blood glucose levels >180 mg/dL during the TPN infusion had a risk of mortality that was 5.6 times greater than those with mean blood glucose levels <140 mg/dL (95% CI 1.47-21.4 mg/dL) after adjusting for age, sex, nutritional state, presence of diabetes or hyperglycemia before starting TPN, diagnosis, prior comorbidity, carbohydrates infused, use of steroid therapy, SD of blood glucose level, insulin units supplied, infectious complications, albumin, C-reactive protein, and HbA1c levels. CONCLUSIONS: Hyperglycemia (mean blood glucose level >180 mg/dL) in noncritically ill patients who receive TPN is associated with a higher risk of in-hospital mortality.

Personality profiles between obese and control subjects assessed with five standardized personality scales.

BACKGROUND/AIM: Psychopathology may exert influence on developing and maintaining obesity. Studies of personality traits or psychopathology of personality in obesity are scarce and contradictory. The aim of this study was to compare personality profiles between obese and normal-weight subjects and to determine the most useful tool to detect differences, considering that psychological assessment and psychotherapeutical support should be included within the overall management of these patients.* METHOD: We examined 55 obese subjects (mean BMI=43kg/ m2) and 66 controls (mean BMI =21.7kg/m2). We used the personality assessment tools: MCMI-II, TCI-R, EPQ-A, BIS-111 and SSS. Factorial multivariate analysis of variance was applied; with factors BMI, Gender and Age as a covariate. RESULTS: Significant differences between groups were more marked in the clinical syndrome scales of MCMI-II, particularly in Major-Depression, Thought-Disorder, Anxiety, Somatoform and Alcohol-Dependence. Among obese, women scored higher than men in all scales but not significantly. We have found significant differences in normal personality dimensions between both groups in TCI-R. Obese showed higher scores in Harm Avoidance, and lower in Novelty Seeking, Persistence and Self-transcendence. The remaining tests have not been useful for differentiating personality traits between both groups. CONCLUSION: Obese subjects showed different personality profiles than control subjects. The most useful scales for determining these differences might be those designed to assess pathological personality such as MCMI-II. Less important would be those intended to measure normal personality traits, such as TCI-R and EPQ-A.

Perfiles de personalidad en sujetos obesos y control medidos con cinco escalas estandarizadas de personalidad / Personality profiles between obese and control subjects assessed with five standardized personality scales

Introducción. La psicopatología puede ejercer influencia en el desarrollo y mantenimiento de la obesidad. Los estudios sobre los rasgos de personalidad o la psicopatología de la personalidad en obesidad son escasos y contradictorios. El objetivo de este estudio fue la comparación de los perfiles de personalidad entre sujetos obesos y normo-peso y la determinación de la herramienta más útil para la detección de diferencias, considerando que la evaluación psicológica y el apoyo psicoterapéutico deberían incluirse en el manejo de estos pacientes. Metodología. Examinamos 55 sujetos obesos (IMC=43kg/m2) y 66 controles (IMC=21,7kg/m2). Empleamos las herramientas de valoración de la personalidad: MCMI-II, TCI-R,EPQ-A, BIS-111 y SSS. Aplicamos un análisis multivariado dela varianza incluyendo los factores IMC, sexo y edad como covariables. Resultados. Se encontraron diferencias significativas más marcadas entre los grupos fueron más marcadas en las escalas clínicas del MCMI-II, especialmente en la de Depresión Mayor, Pensamiento psicótico, Ansiedad, Histeriforme y Abuso de alcohol. Entre los obesos, las mujeres puntuaron más que los hombres en todas las escalas, aunque no fue significativo. Encontramos diferencias significativas en los rasgos normales de personalidad entre ambos grupos en el TCI-R. Los obesos presentaron mayores puntuaciones en Evitación del daño y menores en Búsqueda de novedad, Persistencia y Trascendencia. El resto de los test no presentaron utilidad para la diferenciación de los rasgos de personalidad entre ambos grupos. Conclusión. Los sujetos obesos presentaron distintos perfiles de personalidad que los sujetos control. Las escalas de mayor utilidad para la determinación de estas diferencias podrían ser aquellas diseñadas para la evaluación de la personalidad patológica, tales como el MCMI-II. De menor importancia serían aquellas dirigidas a medir los rasgos de personalidad normal, tales como el TCI-R y el EPQ-A (AU)

Background/aim. Psychopathology may exert influence on developing and maintaining obesity. Studies of personality traits or psychopathology of personality in obesity are scarce and contradictory. The aim of this study was to compare personality profiles between obese and normal-weight subjects and to determine the most useful tool to detect differences, considering that psychological assessment and psychotherapeutical support should be included within the overall management of these patients. Method. We examined 55 obese subjects (mean BMI=43kg/m2) and 66 controls (mean BMI =21.7kg/m2). We used the personality assessment tools: MCMI-II, TCI-R, EPQ-A, BIS-111and SSS. Factorial multivariate analysis of variance was applied; with factors BMI, Gender and Age as a covariate. Results. Significant differences between groups were more marked in the clinical syndrome scales of MCMI-II, particularly in Major-Depression, Thought-Disorder, Anxiety, Somatoform and Alcohol-Dependence. Among obese, women scored higher than men in all scales but not significantly. We have found significant differences in normal personality dimensions between both groups in TCI-R. Obese showed higher scores in Harm Avoidance, and lower in Novelty Seeking, Persistence and Self-transcendence. The remaining tests have not been useful for differentiating personality traits between both groups. Conclusion. Obese subjects showed different personality profiles than control subjects. The most useful scales for determining these differences might be those designed to assess pathological personality such as MCMI-II. Less important would be those intended to measure normal personality traits, such as TCI-R and EPQ-A (AU)

Liver upregulation of genes involved in cortisol production and action is associated with metabolic syndrome in morbidly obese patients.

BACKGROUND: Hepatic 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) activity, which converts cortisone (inactive) to cortisol, is downregulated in obesity. However, this compensation fails in obese with metabolic abnormalities, such as diabetes. To further characterize the tissue-specific cortisol regeneration in obesity, we have investigated the mRNA expression of genes related to local cortisol production, i.e., 11ß-HSD1, hexose-6-phosphate dehydrogenase (H6PDH) and cortisol action, glucocorticoid receptor (GR) and a cortisol target gene, phosphoenolpyruvate carboxykinase (PEPCK) in the liver, and visceral (VAT) and subcutaneous (SAT) adipose tissues from morbidly obese patients with and without metabolic syndrome (MS). METHODS: Fifty morbidly obese patients undergoing bariatric surgery, 14 men (mean age, 41.3 ± 3.5 years; BMI, 48.0 ± 3.6 kg/m(2)) and 36 women (mean age, 44.6 ± 1.9 years; BMI, 44.9 ± 1.2 kg/m(2)), were classified as having MS (MS+, n = 20) or not (MS-, n = 30). Tissue mRNA levels were measured by real-time polymerase chain reaction. RESULTS: Hepatic mRNA levels of these genes were higher in obese patients with MS (11ß-HSD1, P = 0.002; H6PDH, P = 0.043; GR, P = 0.033; PEPCK, P = 0.032) and positively correlated with the number of clinical characteristics that define the MS. The expression of the four genes positively correlated among them. In contrast to the liver, these genes were not differently expressed in VAT or SAT, when MS+ and MS- obese patients were compared. CONCLUSIONS: Coordinated liver-specific upregulation of genes involved in local cortisol regeneration and action support the concept that local hepatic hypercortisolism contributes to development of MS in morbidly obese patients.

Effectiveness and safety of air-filled balloon Heliosphere BAG® in 82 consecutive obese patients.

BACKGROUND: Intragastric balloon is a widely used technique to treat obesity that is considered to be more efficient than conservative treatment before bariatric surgery. To describe air-filled balloon (Heliosphere BAG®) effectiveness [absolute weight loss, body mass index (BMI) loss, percentage of body weight loss (BWL), percentage of excess weight loss (EWL)] and complications 6 months after its insertion. METHODS: Eighty-four consecutive intragastric balloons were placed endoscopically. Individualized nutritional counseling was given. The follow-up was carried out in an endocrinology outpatient clinic. Due to the weight or height data missed in two cases, only 82 patients were included in this report, 63 women with a mean age 39 years (SD, 11.1); mean BMI, 39.1 kg/m(2) (SD, 5.8). The median follow-up was 182 days. RESULTS: The mean weight loss and BMI loss were 14.5 kg (SD, 8.2); and 5.3 kg/m(2) (SD, 2.8), respectively (for difference, p < 0.001). The mean percentage of BWL was 13.4% (SD, 7.0). Of the sample, 70.4% achieved a percentage of BWL >10%. The percentage of EWL reached 33.2% (SD, 19.2). After adjusting by sex and initial BMI, absolute weight loss (p = 0.033), BMI loss (p = 0.034), percentage of BWL (p = 0.034), and percentage of EWL (p = 0.034) were inversely related to age. Absolute weight loss and BMI loss were greater in higher initial BMI, but the percentage of EWL was lower. Two spontaneous deflations occurred (3%), but only one surgical early removal (1.2%) was required. Nausea and vomiting developed in 7.4% of the patients during the first week. CONCLUSIONS: Air-filled Heliosphere BAG® has been effective in achieving a relevant loss of body weight.

[Cardiovascular risk factor control in a population with longstanding diabetes attending endocrinology departments]. / Grado de control metabólico en una población diabética atendida en servicios de endocrinología.

OBJECTIVE: To determine the degree of control of cardiovascular risk factors (CVRF) in a sample of patients with diabetes mellitus (DM) attending Endocrinology and Nutrition Departments in Spain. MATERIAL AND METHODS: An epidemiological, cross-sectional, multicenter and observational study involving 41 Departments of Endocrinology and Nutrition in Spain. Each department selected patients with DM with over 10 years of evolution, which were treated in outpatient settings. Demographic, anthropometric, clinical and biochemical data, including medication, were collected for each participant. RESULTS: 1159 patients who met the inclusion criteria were recruited. 52% of the participants were patients with type 2 DM. The mean duration of DM was 19.6 years. A proportion of 37%, 44%, 27.6% and 25.5% had good control of their blood pressure (BP), low density cholesterol (LDLc), lipids and glucose, respectively, and only 4.3% did well in all factors evaluated. The percentage of poorly controlled BP was four times higher in type 2 than in type 1 DM. Obesity, low cultural level and aggregation of cardiovascular risk factors were associated with poorer control. CONCLUSIONS: The degree of control of CVRF in diabetic patients with long disease duration is insufficient.

Grado de control metabólico en una población diabética atendida en servicios de endocrinología / Cardiovascular risk factor control in a population with longstanding diabetes attending endocrinology departments

Objetivo Conocer el grado de control de los factores de riesgo cardiovascular (FRCV) en una muestra de pacientes con diabetes mellitus (DM) asistidos en servicios de endocrinología y nutrición (SEyN) en España. Material y métodos Estudio epidemiológico, transversal, multicéntrico y observacional en el que participaron 41 SEyN en España. Cada servicio incluyó a pacientes con DM de más de 10 años de evolución que fueron atendidos en consultas externas. Se recogieron datos de filiación, antropométricos y clínicos, incluida medicación y datos bioquímicos. Resultados Se reclutaron a 1.159 pacientes que cumplían los criterios de inclusión. El 52% de los participantes fueron pacientes con DM-2, y la duración de la DM fue de 19,6 años. El 37%, el 44%, el 27,6% y el 25,5% presentaron buen control de la presión arterial (PA), colesterol de las lipoproteínas de baja densidad (cLDL), lípidos y glucemia, respectivamente, y solo el 4,3% tuvo un buen control de todos los factores evaluados. Los pacientes con DM tipo 2 presentaron una PA no controlada con una frecuencia 4 veces superior a la de los pacientes con DM tipo 1 (p<0,0001). La obesidad, el bajo nivel educativo y la agregación de los FRCV se asociaron a peor control. Conclusiones El grado de control de los FRCV en los pacientes diabéticos de larga evolución es insuficiente (AU)

Objective To determine the degree of control of cardiovascular risk factors (CVRF) in a sample of patients with diabetes mellitus (DM) attending Endocrinology and Nutrition Departments in Spain. Material and methods An epidemiological, cross-sectional, multicenter and observational study involving 41 Departments of Endocrinology and Nutrition in Spain. Each department selected patients with DM with over 10 years of evolution, which were treated in outpatient settings. Demographic, anthropometric, clinical and biochemical data, including medication, were collected for each participant.Results1159 patients who met the inclusion criteria were recruited. 52% of the participants were patients with type 2 DM. The mean duration of DM was 19.6 years. A proportion of 37%, 44%, 27.6% and 25.5% had good control of their blood pressure (BP), low density cholesterol (LDLc), lipids and glucose, respectively, and only 4.3% did well in all factors evaluated. The percentage of poorly controlled BP was four times higher in type 2 than in type 1 DM. Obesity, low cultural level and aggregation of cardiovascular risk factors were associated with poorer control (AU)

Prevalence of distal diabetic polyneuropathy using quantitative sensory methods in a population with diabetes of more than 10 years’ disease duration

Objectives Results of studies on the prevalence of distal diabetic polyneuropathy (DPN) are contradictory. Conventional methods used for the diagnosis of DPN in clinical practice have limited effectiveness. The present study aimed to assess the prevalence of DPN in a population with long-standing diabetes (more than 10 years disease duration) by measuring vibratory, thermal and tactile sensitivities with quantitative sensory devices, as well as their relationship with associated clinical risk factors.Patients and methods A total of 1011 diabetic patients were evaluated in a multicenter, cross-sectional, observational study. The three sensitivities were assessed by ultrabiothesiometer, aesthesiometer and thermoskin devices, respectively. The prevalence of neuropathic pain was validated by the DN4 questionnaire. Results Of the 1011 cases included, 400 (39.6%) met the diagnostic criteria of DPN, while no DPN was found in the remaining 611 (60.4%). Of the 400 patients with DPN, 253 (63.2%) showed clinical manifestations, while 147 (36.8%) were diagnosed as subclinical DPN. The prevalence of DPN increased with disease duration. There was a progressive loss of the three sensitivities with increased disease duration, particularly thermal and vibratory sensitivities. This loss was statistically significant for the latter two sensitivities. Among patients with clinical DPN, 84.2% had painful neuropathic symptoms. The prevalence of DPN was positively related to micro- and macroangiopathic complications and with dyslipidemia. Conclusion This study reveals a high degree of underdiagnosis of DPN, most likely due to the asymptomatic nature of the disease in a considerable proportion of patients. Our observations provide evidence of the usefulness of specific equipment for quantitative and objective assessment of polyneuropathy (AU)

Objetivos Los resultados de los estudios sobre la prevalencia de la polineuropatía distal diabética (DPN) son discrepantes. Los métodos convencionales para su diagnóstico tienen una eficacia limitada. Por ello, el presente trabajo pretende estudiar su prevalencia en una población diabética con más de 10 años de evolución de la enfermedad, valorando las sensibilidades vibratoria, térmica y táctil con dispositivos que cuantifican el grado de sensibilidad, a la vez que su relación con los factores de riesgo asociados. Pacientes y métodos Se evaluaron 1.011 diabéticos en un estudio multicéntrico, transversal y observacional. Se valoraron las tres sensibilidades con un ultrabiotesiómetro, un estesiómetro y un termoskin. Se validó la prevalencia de dolor neuropático con el cuestionario DN4.Resultados Del total de 1011 casos, 400 (39,6%) cumplían criterios de DPN, mientras que los 611 restantes (60,4%) no los cumplían. De los 400 enfermos con DPN, 253 (63,2%) presentaban manifestaciones clínicas, mientras que los 147 restantes (36,8%) fueron diagnosticados de DPN subclínica. La prevalencia de DPN aumentaba al avanzar la enfermedad. Había una pérdida progresiva de las tres sensibilidades con el tiempo, sobre todo de la térmica y táctil, cuya pérdida era estadísticamente significativa. Un 84,2% de los casos con DPN clínica aquejaban dolor neuropático. La prevalencia de DPN guardaba una relación positiva con las complicaciones micro y macroangiopáticas, y con la dislipidemia. Conclusiones El presente estudio revela que hay un alto porcentaje de DPN sin diagnosticar, lo más probable por la ausencia de síntomas en buena parte de los pacientes. Los resultados muestran la utilidad de dispositivos específicos que valoren de manera objetiva y cuantitativa la presencia de polineuropatía (AU)