Juan J. Chillarón

Type 1 diabetes, metabolic syndrome and cardiovascular risk

Patients with type 1 diabetes mellitus (T1DM) traditionally had a low body mass index and microangiopathic complications were common, while macroangiopathy and the metabolic syndrome were exceptional. The Diabetes Control and Complications Trial, published in 1993, demonstrated that therapy aimed at maintaining HbA1c levels as close to normal as feasible reduced the incidence of microangiopathy. Since then, the use of intensive insulin therapy to optimize metabolic control became generalized. Improved glycemic control resulted in a lower incidence of microangiopathy; however, its side effects included a higher rate of severe hypoglycemia and increased weight gain. Approximately 50% of patients with T1DM are currently obese or overweight, and between 8% and 40% meet the metabolic syndrome criteria. The components of the metabolic syndrome and insulin resistance have been linked to chronic T1DM complications, and cardiovascular disease is now the leading cause of death in these patients. Therefore, new therapeutic strategies are required in T1DM subjects, not only to intensively lower glycemia, but to control all associated metabolic syndrome traits.

Laparoscopic sleeve gastrectomy: More than a restrictive bariatric surgery procedure?

Sleeve gastrectomy (SG) is a restrictive bariatric surgery technique that was first used as part of restrictive horizontal gastrectomy in the original Scopinaro type biliopancreatic diversion. Its good results as a single technique have led to a rise in its use, and it is currently the second most performed technique worldwide. SG achieves clearly better results than other restrictive techniques and is comparable in some aspects to the Roux-en-Y gastric bypass, the current gold standard in bariatric surgery. These benefits have been associated with different pathophysiologic mechanisms unrelated to weight loss such as increased gastric emptying and intestinal transit, and activation of hormonal mechanisms such as increased GLP-1 hormone and decreased ghrelin. The aim of this review was to highlight the salient aspects of SG regarding its historical evolution, pathophysiologic mechanisms, main results, clinical applications and perioperative complications.

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

BackgroundPatients 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.MethodsIn 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.ResultsThere 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.ConclusionsUndiagnosed 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.

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.

Síndrome metabólico y diabetes mellitus tipo 1: prevalencia y factores relacionados

Introduccion y objetivos. Numerosas evidencias han puesto de relieve la importancia clinica y epidemiologica del sindrome metabolico como precursor de la enfermedad cardiovascular. El sindrome metabolico se asocia en general a la diabetes tipo 2, pero son escasos los datos en la diabetes tipo 1. En el presente estudio se evalua la prevalencia de sindrome metabolico en pacientes con diabetes tipo 1 y los factores relacionados. Metodos. Estudio transversal que incluyo a los pacientes mayores de 18 anos de edad con diabetes tipo 1 autoinmune de mas de 6 meses de evolucion atendidos consecutivamente en la Consulta Externa de Endocrinologia del Hospital del Mar de Barcelona durante el ano 2008. La identificacion del sindrome metabolico se establecio segun los criterios modificados del Panel III del National Cholesterol Education Program. Resultados. Tenia sindrome metabolico el 31,9% (intervalo de confianza [IC] del 95%, 22,3%-41,5%) de los pacientes con diabetes tipo 1. La edad (odds ratio [OR] = 1,09; IC del 95%, 1,029-1,154), el indice de masa corporal (OR = 1,389; IC del 95%, 1,134-1,702) y la glucohemoglobina (OR = 1,745; IC del 95%, 1,081-2,815) fueron los factores que se asociaron de forma independiente y significativa con la presencia de sindrome metabolico en los pacientes con diabetes tipo 1. Se constato una relacion directa entre el numero de componentes de sindrome metabolico y la prevalencia de microangiopatia, que llego a ser del 100% en los pacientes que cumplian todos los criterios diagnosticos. Conclusiones. El sindrome metabolico es frecuente en los pacientes con diabetes tipo 1 y se asocia con las complicaciones microvasculares

Insulin resistance and hypertension in patients with type 1 diabetes

AIM The aims of this study were to determine the prevalence of hypertension in type 1 diabetes patients and to analyze its relationship with insulin resistance and other associated factors. DESIGN AND METHODS A cross-sectional study on 291 patients with type 1 immune-mediated diabetes managed at two outpatient endocrinology clinics was performed. All participants were Caucasian, 18 years or older with type 1 diabetes duration of more than 6 months, who had completed the study protocol. Hypertension was defined as blood pressure ≥130/80 mmHg or use of antihypertensive medication, excluding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers when used as treatment for micro- or macroalbuminuria. RESULTS Hypertension was found in 87 [29.9% (95% confidence interval, or CI): 24.6%-35.2%] patients with type 1 diabetes. Hypertensive patients presented older age, male predominance, higher body mass index and overweight/obesity prevalence, and longer diabetes duration compared with normotensive patients. Insulin sensitivity quantified by estimated glucose disposal rate (eGDR) was lower in patients with hypertension compared with normotensives (5.2±1.4 vs. 9.1±1.2 mg kg(-1) min(-1), P<.001) and showed a negative correlation with systolic blood pressure level (r=-0.612, P<.01). In multivariate logistic regression analysis, eGDR, besides nephropathy, emerged significantly and independently associated with hypertension. An increment of 1 unit in insulin sensitivity assessed by eGDR was associated with a 5.7% decrease in hypertension prevalence (95% CI: 0.018-0.175) and the absence of nephropathy with an 88.2% decrease (95% CI: 0.15-0.92). CONCLUSIONS Hypertension was present in approximately one third of patients with type 1 diabetes, especially in men, those with microangiopathy, overweight or obesity, older age and longer diabetes duration. Hypertension prevalence increased in parallel to the degree of renal impairment and was inversely related to insulin sensitivity.

Peripartum metabolic control in gestational diabetes

OBJECTIVE We sought to evaluate intrapartum metabolic control in gestational diabetes mellitus (GDM) patients and maternal factors influencing intrapartum glycemic control and neonatal hypoglycemia risk. STUDY DESIGN A prospective observational study included 129 women with GDM admitted for delivery. Data collected included maternal intrapartum capillary blood glucose (CBG) and ketonemia, use of insulin, and neonatal hypoglycemia. RESULTS In all, 86% of maternal intrapartum CBG values fell within target range (3.3-7.2 mmol/L) without need for insulin use. There were no cases of maternal hypoglycemia or severe ketosis. Intrapartum CBG >7.2 mmol/L was associated with third-trimester glycated hemoglobin (P = .02) and lack of endocrinologic follow-up (P = .04). Risk of neonatal hypoglycemia was related with pregnancy insulin use compared with dietary control (60.5% vs 29.5%; P = .02). CONCLUSION Peripartum metabolic control in GDM patients was achieved without insulin in most cases. Intrapartum glycemic control was related with third-trimester glycated hemoglobin and with no endocrinologic follow-up. Neonatal hypoglycemia was associated with insulin use during pregnancy.

A prospective evaluation of neonatal hypoglycaemia in infants of women with gestational diabetes mellitus

OBJECTIVE To analyse first-day-of-life glucose levels in infants of women with gestational diabetes (GDM) and the influence of maternal, gestational and peripartum factors on the development of neonatal hypoglycaemia. STUDY DESIGN Prospective cohort study including newborns of GDM mothers. Capillary blood glucose (CBG) was measured serially on the first day of life. CBG values were defined as normal (≥ 2.5 mmol/l), mild hypoglycaemia (2.2-2.4 mmol/l), moderate hypoglycaemia (1.6-2.1 mmol/l) and severe hypoglycaemia (<1.6 mmol/l). RESULTS One hundred and ninety infants were included: 23 (12.1%) presented mild, 20 (10.5%) moderate and only 5 (2.6%) severe hypoglycaemia. 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 analysis 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 Mild and moderate neonatal hypoglycaemias were common although severe episodes were unusual in infants of women with GDM. Hypoglycaemia is mainly influenced by ethnicity and cord blood pH, although maternal peripartum glycaemic control and large-for-gestational-age condition may also play a role.

High prevalence of cardiovascular co-morbidities in patients with symptomatic knee or hand osteoarthritis

Objectives: To evaluate the frequency of cardiovascular events (CVEs) and metabolic syndrome (MetS) in patients with symptomatic knee or hand osteoarthritis (OA). Method: A cross-sectional study conducted by rheumatologists in a primary care setting. Consecutive symptomatic patients with primary knee or hand OA were included and patients with soft tissue conditions served as the control group. Hypertension, diabetes mellitus, obesity, dyslipidaemia, and CVEs consisting of myocardial infarction, angina, or cerebrovascular disease were recorded. Results: A total of 254 OA patients (184 with knee OA and 70 with hand OA) and 254 control patients were included. The frequency of obesity was higher in all OA groups and hypertension was more frequent in knee OA. MetS was significantly more frequent in patients with OA as a whole group and in knee or hand OA groups separately (p < 0.001, p = 0.002, and p = 0.007, respectively, vs. control group), with odds ratio (OR) 2.4, 95% confidence interval (CI) 1.26–4.55 in the OA group, OR 2.29, 95% CI 1.15–4.54 in the knee OA group, and OR 2.67, 95% CI 1.15–6.19 in the hand OA group. A higher prevalence of CVEs in the three OA groups was observed compared with the control group. Conclusions: A high frequency of MetS and CVEs was observed in OA patients in a primary care setting.

Gestational diabetes in a multiethnic population of Spain: Clinical characteristics and perinatal outcomes☆

AIMS To compare clinical characteristics and perinatal outcomes between immigrant and Spanish women with gestational diabetes mellitus (GDM) in a multiethnic population of Barcelona and to identify factors independently associated with the development of large-for-gestational-age (LGA) infants. METHODS Prospective study of women with GDM from five ethnic groups (Caucasian, South-Central Asian, Latin American, East Asian and Moroccan) at a single institution in Barcelona between 2004 and 2011. Maternal, gestational and newborn characteristics were recorded. RESULTS The cohort included 456 patients. In univariate analyses, Moroccan women had more frequently a pre-gestational body mass index (BMI)>25 kg/m(2) (76.4%, P=0.012), while East Asian women had lower BMI (23.41 ± 2.79 kg/m(2), P<0.001), less need for insulin therapy (14.3%, P=0.013) and the highest rate of spontaneous labor (69.8%, P=0.014) and eutocic delivery (63.8%, P=0.032). Also, Latin American women had a higher rate of Cesarean section (52.9%, P<0.001) and LGA infants (28.6%, P=0.004), and their newborns had lower umbilical cord pH (7.23 ± 0.06, P=0.005) and Apgar scores (9 [4-10], P<0.01) and a higher incidence of neonatal hypoglycemia (51.4%, P=0.045). Logistic regression analysis identified pre-gestational BMI (OR: 1.18; 95% CI: 1.09-1.27), pregnancy weight gain (OR: 1.19; 95% CI: 1.1-1.28) and insulin use during gestation (OR: 2.29; 95% CI: 1.09-4.82) as predictors of LGA infants. CONCLUSIONS Significant ethnic differences were found in clinical characteristics and perinatal outcomes of women with GDM. Latin American women had a higher frequency of adverse perinatal outcomes. Pregestational BMI, pregnancy weight gain and insulin use during pregnancy were independent predictors of LGA.