Resilient Older Subjects with Heterozygous Familial Hypercholesterolemia, Baseline Differences and Associated Factors

Despite elevated low-density lipoprotein (LDL) cholesterol levels, some older subjects with heterozygous familial hypercholesterolemia (HeFH) do not develop atherosclerotic cardiovascular disease (ACVD) during their lifetime. The factors related to this resilient state have not been fully established. The aim of this study was to evaluate differential characteristics between older HeFH subjects with and without ACVD and factors associated with the presence of ACVD. Subjects were part of the Spanish Atherosclerosis Society Dyslipidemia Registry, and those ≥ 70 years old and with HeFH were included. Baseline characteristics of these subjects with and without ACVD were compared. A multivariate analysis was performed to assess factors associated with the presence of ACVD. A total of 2148 subjects with HeFH were included. Resilient subjects were mostly female, younger and presented fewer comorbidities with respect to the ACVD group. Subjects without ACVD had higher baseline high-density lipoprotein (HDL) cholesterol (55.8 ± 17.1 vs. 47.9 ± 15.4 mg/dL; p < 0.001) and lower lipoprotein(a) [Lp(a)] (53.4 ± 67.9 vs. 66.6 ± 85.6 mg/dL; p < 0.001) levels with respect to those in the ACVD group. Lp(a) and the presence of ≥3 risk factors were associated with the presence of ACVD.

Effects of Preoperative Quadruple Therapy for Helicobacter pylori on Bariatric Surgery Metabolic Outcomes

PURPOSE

To assess the effects of Helicobacter pylori (HP) eradication with an omeprazole, clarithromycin, amoxicillin, and metronidazole (OCAM) regimen on the metabolic profile and weight loss 12 months after bariatric surgery (BS).

METHODS

Retrospective analysis of a prospective cohort of patients with morbid obesity undergoing BS. HP presence was tested preoperatively by gastric biopsy and treated with OCAM when positive. Short-term metabolic outcomes and weight loss were evaluated.

RESULTS

HP infection was detected in 75 (45.7%) of the 164 patients included. OCAM effectiveness was 90.1%. HP-negative patients had a greater reduction in glucose levels at 3 (-14.6 ± 27.5 mg/dL HP-treated vs -22.0 ± 37.1 mg/dL HP-negative, p=0.045) and 6 months (-13.7 ± 29.4 mg/dL HP-treated vs -26.4 ± 42.6 mg/dL HP-negative, p= 0.021) and greater total weight loss (%TWL) at 6 (28.7 ± 6.7% HP-treated vs 30.45 ± 6.48% HP-negative, p= 0.04) and 12 months (32.21 ± 8.11% HP-treated vs 35.14 ± 8.63% HP-negative, p= 0.023).

CONCLUSIONS

Preoperative treatment with OCAM has been associated to poorer glycemic and weight loss outcomes after BS. More research is needed on the influence of OCAM on gut microbiota, and in turn, the effect of the latter on metabolic and weight loss outcomes after BS.

One abnormal value or vomiting after oral glucose tolerance test in pregnancy: incidence and impact on maternal-fetal outcomes

OBJECTIVE

To analyze pregnancy outcomes of women with one abnormal value (OAV) during oral glucose tolerance test (OGTT) or OGTT-intolerance, compared with gestational diabetes mellitus (GDM) and normal glucose tolerance (NGT) pregnant women, according to whether they received any health intervention or not.

METHODS

An observational retrospective study was designed including pregnant women who gave birth at Hospital del Mar, Barcelona (Spain) during December/2014-July/2018. Baseline characteristics, pregnancy outcomes and health interventions were obtained from a database collected previously for other study. Inclusion criteria were singleton pregnancies with OAV or OGTT-intolerants who gave birth at the Hospital. GDM screening followed a two-step approach: 50 g O'Sullivan test and 100 g 3-hour OGTT if the former was abnormal.

RESULTS

From a total of 2,662 pregnancies, 326 (12.2%) had GDM, 87 OAV (3.3%), 65 OGTT intolerance (2.4%) and 2,184 were NGT women. First trimester HbA1c in both OAV and OGTT-intolerant women was significantly higher than in NGT group, and significantly lower than in GDM pregnants. No differences in obstetric outcomes were found between OGTT-intolerants and NGT/GDM groups. Treated OGTT-intolerants had greater gestational age at delivery than non-treated ones (weeks, 39.6 ± 1.2 vs 38.0 ± 4.0, respectively). In OAV women, significant differences were observed in newborns' birthweight (g, 3227.3 ± 500.8 vs 3351.1 ± 436.7, vs GDM) and gestational age at birth (weeks, 38.7 ± 1.8 vs 39.3 ± 1.9, vs NGT), but not in macrosomia/pre-eclampsia. No differences were found according to treatment in OAV.

CONCLUSIONS

OAV and OGTT-intolerants account for a third of pregnant women referred to Diabetes Unit. Their rates of preterm birth, pre-eclampsia and macrosomia were not different from NGT or GDM women.

Validity and Applicability of the Global Leadership Initiative on Malnutrition (GLIM) Criteria in Patients Hospitalized for Acute Medical Conditions

(1) Background: The objectives of this study were to evaluate the concurrent and predictive validity and the applicability of the global leadership initiative on malnutrition (GLIM) criteria in patients hospitalized for acute medical conditions. (2) Methods: prospective cohort study with patients hospitalized for acute medical conditions. For validation, the methodology proposed by the GLIM group of experts was used. Sensitivity and specificity values greater than 80% with respect to those for the subjective global assessment (SGA) were necessary for concurrent validation. The time necessary to complete each nutritional assessment test was determined. (3) Results: A total of 119 patients were evaluated. The SGA was applied to the entire cohort, but the GLIM criteria could not be applied to 3.4% of the patients. The sensitivity and specificity of the GLIM criteria with respect to those for the SGA to detect malnutrition were 78.0 and 86.2%, respectively. The GLIM predictive validity criterion was fulfilled because patients with malnutrition more frequently had a hospital stay >10 days (odds ratio of 2.98 (1.21-7.60)). The GLIM criteria required significantly more time for completion than did the SGA (p = 0.006). (4) Conclusion: The results of this study do not support the use of the GLIM criteria over the SGA for the diagnosis of malnutrition in patients hospitalized for acute medical conditions.

Use of phytosterol-fortified foods to improve LDL cholesterol levels: A systematic review and meta-analysis

AIMS

The main objective was to assess if foods fortified with phytosterols (PS), including plant sterols and plant stanols, reduce low-density lipoprotein cholesterol (LDL-C) concentrations. The secondary objective was to determine the impact of different factors related to PS administration.

DATA SYNTHESIS

The search was carried out in MEDLINE, EMBASE, Web of Science, Scopus and The Cochrane Central Register of Controlled Trials (CENTRAL) databases up to March 2023. The meta-analysis was registered in the PROSPERO database (CRD42021236952). From a total of 223 studies, 125 were included. On average, PS lowered LDL-C 0.55 mmol/L [95% confidence interval (CI) = 10.82-12.67], and this decrease was significantly maintained for all analysed subgroups. A greater reduction in LDL-C levels was detected in relation to a higher daily PS dosage. The food format "Bread, biscuits, cereals", conditioned a lower decrease of 0.14 mmol/L (95%CI -8.71 to -2.16) in LDL-C levels, compared to the predominant food format group of "butter, margarine, spreads". No significant differences were detected with the other subgroups (treatment duration, intake pattern, number of daily intakes and concomitant statin treatment).

CONCLUSION

The present meta-analysis supported that the use of PS-fortified foods had a beneficial effect on LDL-C lowering. In addition, it was observed that the factors that influence a decline LDL-C levels were PS dose as well as the food format in which they were consumed.

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

Objective

Increasing evidence indicates that the telehealth (TH) model is noninferior to the in-person approach regarding metabolic control in type 1 diabetes (T1D) and offers advantages such as a decrease in travel time and increased accessibility for shorter/frequent visits. The primary aim of this study was to compare the change in glycated hemoglobin (HbA1c) at 6 months in T1D care in a rural area between TH and in-person visits.

Research design and methods

Randomized controlled, open-label, parallel-arm study among adults with T1D. Participants were submitted to in-person visits at baseline and at months 3 and 6 (conventional group) or teleconsultation in months 1 to 4 plus 2 in-person visits (baseline and 6 months) (TH group). Mixed effects models estimated differences in HbA1c changes.

Results

Fifty-five participants were included (29 conventional/26 TH). No significant differences in HbA1c between groups were found. Significant improvement in time in range (5.40, 95% confidence interval (CI): 0.43-10.38; p < 0.05) and in time above range (-6.34, 95% CI: -12.13- -0.55;p < 0.05) in the TH group and an improvement in the Diabetes Quality of Life questionnaire (EsDQoL) score (-7.65, 95% CI: -14.67 - -0.63; p < 0.05) were observed. In TH, the costs for the participants were lower.

Conclusions

The TH model is comparable to in-person visits regarding HbA1c levels at the 6-month follow-up, with significant improvement in some glucose metrics and health-related quality of life. Further studies are necessary to evaluate a more efficient timing of the TH visits.

Gut microbiota in nonalcoholic fatty liver disease: a PREDIMED-Plus trial sub analysis

To evaluate the changes in the gut microbiota associated with changes in the biochemical markers of nonalcoholic fatty liver disease (NAFLD) after a lifestyle intervention with the Mediterranean diet. Participants (n = 297) from two centers of PREDIMED-Plus trial (Prevención con Dieta Mediterránea) were divided into three different groups based on the change tertile in the Hepatic Steatosis Index (HSI) or the Fibrosis-4 score (FIB-4) between baseline and one year of intervention. One-year changes in HSI were: tertile 1 (T1) (-24.9 to -7.51), T2 (-7.5 to -1.86), T3 (-1.85 to 13.64). The most significant differences in gut microbiota within the year of intervention were observed in the T1 and T3. According to the FIB-4, participants were categorized in non-suspected fibrosis (NSF) and with indeterminate or suspected fibrosis (SF). NSF participants showed higher abundances of Alcaligenaceae, Bacteroidaceae, Bifidobacteriaceae, Clostridiaceae, Enterobacteriaceae, Peptostreptococcaceae, Verrucomicrobiaceae compared to those with SF. Then, participants were divided depending on the FIB-4 tertile of change: T1 (-89.60 to -5.57), T2 (-5.56 to 11.4), and T3 (11.41 to 206.24). FIB-4 T1 showed a decrease in Akkermansia and an increase in Desulfovibrio. T2 had an increase in Victivallaceae, Clostridiaceae, and Desulfovibrio. T3 showed a decrease in Enterobacteriaceae, and an increase in Sutterella, Faecalibacterium, and Blautia. A relation between biochemical index changes of NAFLD/NASH (HSI and FIB-4) and gut microbiota changes were found. These observations highlight the importance of lifestyle intervention in the modulation of gut microbiota and the management of metabolic syndrome and its hepatic manifestations.

Ethnic differences in the impact of gestational diabetes on macrosomia

BACKGROUND

Previous studies reported an ethnic disparity in gestational diabetes mellitus-associated birth outcomes, with some suggesting that macrosomia increases to a lesser extent in groups at high risk, the opposite of the pattern observed by others. Our aim was to evaluate ethnic variation in the impact of gestational diabetes mellitus (GDM).

METHODS

A case-control study evaluating pregnancy outcomes was conducted in women with and without GDM from five ethnic groups. Data on GDM were collected between January 2004 and July 2017. Women giving birth between May 2013 and July 2017 in whom pre-existing diabetes had been ruled out served as controls. A multivariate logistic regression analysis was performed to determine factors independently associated with macrosomia.

RESULTS

Overall, 852 GDM women and 3,803 controls were included. In Caucasian and East-Asian women excessive gestational weight gain (OR 2.273, 95% CI 1.364-3.788 and OR 3.776, 95% CI 0.958-14.886) was an independent predictor of macrosomia. In Latin-American and Moroccan women, obesity (OR 1.774, 95% CI 1.219-2.581 and OR 1.656, 95% CI 1.054-2.601), GDM (OR 2.440; 95% CI 1.048-5.679 and OR 3.249, 95% CI 1.269-8.321) and gestational weight gain but only for Latin-American women (OR 2.365, 95% CI 1.039-5.384) were associated with macrosomia. In South-Central Asian women, only GDM was associated with macrosomia (OR 3.701, 95% CI 1.437-9.532).

CONCLUSIONS

GDM is an independent predictor of macrosomia in Latin-American, South-Central Asian and Moroccan women but not in Caucasian or East-Asian women in whom other factors play a more important role.

Mid- and long-term changes in satiety-related hormones, lipid and glucose metabolism, and inflammation after a Mediterranean diet intervention with the goal of losing weight: A randomized, clinical trial

Background

Obesity is produced by the enlargement of the adipose tissue. Functioning as an endocrine organ, it releases and receives information through a complex network of cytokines, hormones, and substrates contributing to a low-chronic inflammation environment. Diet and healthy habits play key roles in the prevention of obesity and its related pathologies. In this regard, there is a need to switch to healthier and more appetizing diets, such as the Mediterranean one.

Objective

To compare the mid-and long-term effects of two Mediterranean diet (MedDiet) interventions, one energy-reduced plus physical activity promotion versus a non-restrictive diet, on peripheral satiety-related hormones, weight loss, glucose/lipid metabolism, and pro-inflammatory markers in subjects with obesity/overweight and metabolic syndrome.

Materials and methods

A randomized, lifestyle intervention was conducted in 23 Spanish centers, with a large cohort of patients presenting metabolic syndrome. Our study is a subproject set in IMIM (Hospital del Mar Research Institute). Participants were men and women, aged 55–75 and 60–75, respectively, who at baseline met at least three metabolic syndrome components. Subjects were assigned to two intervention groups: (1) an intensive lifestyle intervention with an energy-reduced MedDiet and physical activity promotion (intervention group) with the aim of weight loss; and (2) a normocaloric MedDiet (control). We quantified in a subsample of 300 volunteers from Hospital del Mar Research Institute (Barcelona), following analytes at baseline, 6 months, and 1 year: glucose, HbA1c, triglycerides, total cholesterol, high-density lipoprotein cholesterol, LDL cholesterol, C-peptide, ghrelin, GLP-1, glucagon, insulin, leptin, PAI-1, resistin, and visfatin. Anthropometric and classical cardiovascular risk factors were also determined. A multivariate statistical model was employed to compare the two groups. Linear mixed-effect models were performed to compare changes in risk factors and biomarkers between intervention groups and over time.

Results

Compared to participants in the control group, those in intervention one showed greater improvements in weight, waist circumference, insulin (P &lt; 0.001), glucose metabolism-related compounds (P &lt; 0.05), triglyceride-related lipid profile (P &lt; 0.05), leptin, blood pressure, and pro-inflammatory markers such as PAI-1 (P &lt; 0.001) at mid-and/or long-term. High-sensitivity C-reactive protein, resistin, and vifastin also decreased in both groups.

Conclusion

A weight loss intervention employing a hypocaloric MedDiet and physical activity promotion has beneficial effects on adiposity, glucose metabolism, lipid profile, leptin, and pro-inflammatory markers, such as PAI-1 in both mid-and long-term.

Level of understanding and consumption of ultra-processed food in a Mediterranean population: A cross-sectional study

BACKGROUND AND AIMS

Since the population may not be aware of ultra-processed food (UPF) consumption as a result of ignorance or non-recognition, this study aimed to ascertain the main characteristics of subjects regarding their knowledge of different easily acquired foods through a questionnaire in Google Forms format with 52 questions. Secondary objectives were to determine whether the profile of UPF consumers can be defined based on sex, age, sociodemographic factors, and lifestyle.

METHODS AND RESULTS

Responses were received from 1037 participants from a convenience sample; of these, 83 (8.0%) were sporadic or non-users, and 954 (92.0%) were frequent UPF consumers. The participants of the upper tertile correctly matched >12 food items, those of the medium tertile matched 12-9 items, and those of the lower tertile matched <9 items. Factors independently associated with participants who better identified UPF (upper tertile) compared to those of the lower tertile (reference) were female sex (OR: 2.54, 95%CI: 1.70-3.79; p < 0.001), age between 21 and 50 (OR: 3.63, 95% CI: 2.56-5.15; p < 0.001), living with family (OR: 0.64, 95% CI: 0.41-9.96; p = 0.033), and eating more fruit (≥3 pieces/day, OR: 2.30, 95% CI: 1.61-3.27; p < 0.001).

CONCLUSIONS

These findings highlight the high consumption and low degree of awareness of UPF among consumers based mainly on food composition.

Acute-to-Chronic Glycemic Ratio as a Predictor of COVID-19 Severity and Mortality

OBJECTIVE

To evaluate the association between acute-to-chronic (A/C) glycemic ratio and mortality and severity outcomes for patients with type 2 diabetes (T2D) hospitalized with coronavirus disease 2019 (COVID-19).

RESEARCH DESIGN AND METHODS

A total of 91 patients were included. We measured glycemia at admission and estimated the average chronic glucose levels to calculate the A/C glycemic ratio. The primary outcome was a composite of in-hospital mortality, intensive care unit admission, and mechanical ventilation.

RESULTS

Thirty-five patients had a primary outcome event, presenting a significant association with the A/C glycemic ratio (hazard ratio [HR] 1.57 [95% CI 1.14-2.15], P = 0.005). In comparisons with the 2nd tertile, the 3rd tertile of the A/C glycemic ratio was associated with the primary outcome (HR 3.39 [95% CI 1.31-8.75], P = 0.012). In the multivariate analysis, after additional adjustment for age, sex, comorbidities, inflammatory markers, and corticosteroid therapy, the association for the 3rd tertile (HR 3.96 [95% CI 1.35-11.59], P = 0.012) remained significant.

CONCLUSIONS

In patients with T2D hospitalized with COVID-19, the imbalance between acute glycemia at admission and chronic metabolic control is associated with worse prognosis.

Bariatric Surgery and Hypertension

A clear pathogenetic association exists between obesity and arterial hypertension, becoming even more evident in subjects with severe obesity. Bariatric surgery has proved to be the most effective treatment for severe obesity, with its benefits going beyond weight loss. The present review aimed to determine the effects of bariatric surgery on arterial hypertension evident in short- and long-term follow-ups. Moreover, the differences between surgical techniques regarding hypertension remission are described as well as the possible pathophysiologic mechanisms involved. In addition, the effects of bariatric surgery beyond blood pressure normalization are also analyzed, including those on target organs and cardiovascular morbidity and mortality.

Abstract P166: Kidney Changes In Patients With Morbid Obesity After Bariatric Surgery: Looking For The Mechanisms

Morbid obesity (MO) carries an increased risk of kidney damage. Albuminuria and hyperfiltration decrease after bariatric surgery (BS). The relationships between kidney changes obesity-associated are not fully understood.

Aim: to analyze renal changes (Δ) and their determinants at 3-mths after BS (3m-postBS) in patients with MO.

Methods: In a cohort of patients with MO, we analyzed changes in renal function at 3m-postBS and possible associations with anthropometric parameters, ambulatory blood pressure, glucose metabolism, adipocytokine profile, and components of both renin-angiotensin-aldosterone and endocannabinoid systems.

Results: 59 patients were included, 76% women; age (mean ± SD): 42.3 ± 9.5 years; body weight (mean ± SD): 117.8 ± 19.2 Kg. At 3m-postCxB, significant reductions in body weight and waist circumference were observed (p <0.001), but not in blood pressure. Biochemical changes (mean, 95% CI); eGFR-CKDEPI: -4.6 mL/min/1.73m 2 (-8.6; -0.6), p = 0.024; Na + : 2.5 mmol/L (1.9; 3.0), p <0.001; K + : -0.2 mmol/L (-0.3; -0.1), p = 0.006; HbA1c: -0.47% (-0.63; -0.31), p <0.001 and HOMA-IR-Index: -3.13 (-4.19; -2.06), p <0.001. Δ of Albuminuria: Z-1.8 (p = 0.069). The Δ of eGFR-CKDEPI indirectly correlated only with the Δ of plasma renin activity (PRA), p = 0.026. The Δ of albuminuria indirectly correlated with the Δ of leptin (p = 0.039) and directly with the Δ of HbA1c (0.019), HOMA-index (p = 0.013), ACE2 (p = 0.032) and resistin (p = 0.005), as well as with the Δ of the endocannabinoids N-palmitoyl ethanolamine (p = 0.028) and N-stearoyl ethanolamine (p = 0.022). None of the factors analyzed was associated with changes in sNa + . The reduction in sK + was significantly correlated with the Δ of leptin (p = 0.028) and with the Δ of aldosterone (p = 0.025). In multivariate analyzes, no factor was independently associated with the different markers of renal function.

Conclusions: patients with MO experience a decrease in eGFR-CKDEPI associated with an increase in PRA 3m-postBS, indicating that the hyperfiltration present in MO has a hemodynamic origin. On the other hand, the variation in albuminuria is related to the improvement of the carbohydrate metabolism and probably certain cytokines and endocannabinoids have a role, although the latter needs to be confirmed.

Bariatric surgery improves metabolic and nonalcoholic fatty liver disease markers in metabolically healthy patients with morbid obesity at 5 years

BACKGROUND

No studies have evaluated the effect of metabolic and bariatric surgery (MBS) on nonalcoholic fatty liver disease (NAFLD) and cardiometabolic markers in metabolically healthy patients with morbid obesity (MHMO) at midterm.

OBJECTIVES

To assess the effect of MBS on NAFLD and cardiometabolic markers in MHMO patients and ascertain whether metabolically unhealthy patients with morbid obesity (MUMO) remain metabolically healthy at 5 years after MBS.

SETTING

University hospital.

METHODS

A total of 191 patients with a body mass index >40 kg/m² and at least 5 years of follow-up were retrospectively analyzed. Lost to follow-up were 37.6% (151 of 401 patients). Patients were classified as MHMO if 1 or 0 of the cardiometabolic markers were present using the Wildman criteria. The degree of liver fibrosis was assessed using the NAFLD fibrosis score (NFS).

RESULTS

Forty-one patients (21.5%) fulfilled the criteria for MHMO. They showed significant improvements in blood pressure (from 135.1 ± 22.1 and 84.2 ± 14.3 mm Hg to 117.7 ± 19.2 and 73.0 ± 10.9 mm Hg), plasma glucose (from 91.0 ± 5.6 mg/dL to 87.2 ± 5.2 mg/dL), homeostatic model assessment for insulin resistance (from 2.2 ± .9 to 1.0 ± .8), triglycerides (from 88.0 [range, 79.5-103.5] mg/dL to 61.0 [range, 2.0-76.5] mg/dL), alanine aminotransferase, gamma-glutamyl transpeptidase NFS (from -1.0 ± 1.0 to -1.9 ± 1.2), and high-density lipoprotein cholesterol (from 56.9 ± 10.5 mg/dL to 77.9 ± 17.4 mg/dL) at 5 years after surgery. A total of 108 MUMO patients (84.4%) who became metabolically healthy after 1 year stayed healthy at 5 years.

CONCLUSIONS

MBS induced a midterm improvement in cardiometabolic and NAFLD markers in MHMO patients. Seventy-six percent of MUMO patients became metabolically healthy at 5 years after MBS.

Familial Hypercholesterolemia: Do HDL Play a Role?

Cardiovascular disease (CVD) in heterozygous familial hypercholesterolemia (HeFH), the most frequent monogenic disorder of human metabolism, is largely driven by low-density lipoprotein (LDL) cholesterol concentrations. Since the CVD rate differs considerably in this population, beyond the lifetime LDL cholesterol vascular accumulation, other classical risk factors are involved in the high cardiovascular risk of HeFH. Among other lipoprotein disturbances, alterations in the phenotype and functionality of high-density lipoproteins (HDL) have been described in HeFH patients, contributing to the presence and severity of CVD. In fact, HDL are the first defensive barrier against the burden of high LDL cholesterol levels owing to their contribution to reverse cholesterol transport as well as their antioxidant and anti-inflammatory properties, among others. In this context, the present narrative review aimed to focus on quantitative and qualitative abnormalities in HDL particles in HeFH, encompassing metabolic, genetic and epigenetic aspects.

Hydrophilic or Lipophilic Statins?

Drugs can be classified as hydrophilic or lipophilic depending on their ability to dissolve in water or in lipid-containing media. The predominantly lipophilic statins (simvastatin, fluvastatin, pitavastatin, lovastatin and atorvastatin) can easily enter cells, whereas hydrophilic statins (rosuvastatin and pravastatin) present greater hepatoselectivity. Although the beneficial role of statins in primary and secondary cardiovascular prevention has been unequivocally confirmed, the possible superiority of one statin or other regarding their solubility profile is still not well-established. In this respect, although some previously published observational studies and clinical trials observed a superiority of lipophilic statins in cardiovascular outcomes, these results could also be explained by a greater low-density lipoprotein cholesterol reduction with this statin type. On the other hand, previous studies reported conflicting results as to the possible superiority of one statin type over the other regarding heart failure outcomes. Furthermore, adverse events with statin therapy may also be related to their solubility profile. Thus, the aim of the present review was to collect clinical evidence on possible differences in cardiovascular outcomes among statins when their solubility profile is considered, and how this may also be related to the occurrence of statin-related adverse effects.

Impact of statin therapy on LDL and non-HDL cholesterol levels in subjects with heterozygous familial hypercholesterolaemia

BACKGROUND AND AIMS

Cardiovascular risk in heterozygous familial hypercholesterolaemia (HeFH) is driven by LDL cholesterol levels. Since lipid response to statin therapy presents individual variation, this study aimed to compare mean LDL and non-HDL cholesterol reductions and their variability achieved with different types and doses of the most frequently prescribed statins.

METHODS AND RESULTS

Among primary hypercholesterolaemia cases on the Spanish Arteriosclerosis Society registry, 2894 with probable/definite HeFH and complete information on drug therapy and lipid profile were included. LDL cholesterol reduction ranged from 30.2 ± 17.0% with simvastatin 10 mg to 48.2 ± 14.7% with rosuvastatin 40 mg. After the addition of ezetimibe, an additional 26, 24, 21 and 24% reduction in LDL cholesterol levels was obtained for rosuvastatin, 5, 10, 20 and 40 mg, respectively. Subjects with definite HeFH and a confirmed genetic mutation had a more discrete LDL cholesterol reduction compared to definite HeFH subjects with no genetic mutation. A suboptimal response (<15% or <30% reduction in LDL cholesterol levels, respectively with low-/moderate-intensity and high-intensity statin therapy) was observed in 13.5% and, respectively, 20.3% of the subjects.

CONCLUSION

According to the LDL cholesterol reduction in HeFH patients, the ranking for more to less potent statins was rosuvastatin, atorvastatin and simvastatin; however, at maximum dosage, atorvastatin and rosuvastatin were nearly equivalent. HeFH subjects with positive genetic diagnosis had a lower lipid-lowering response. Approximately 1 in 5 patients on high-intensity statin therapy presented a suboptimal response.

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.

LDL Cholesterol Reduction Variability with Different Types and Doses of Statins in Monotherapy or Combined with Ezetimibe. Results from the Spanish Arteriosclerosis Society Dyslipidaemia Registry

PURPOSE

Low-density lipoprotein (LDL) cholesterol reduction by statin therapy is dose-dependent, varies among different statins, and has wide inter-individual variability. The present study aimed to compare mean LDL cholesterol reduction and its variability achieved with different doses of the three statins most frequently used in monotherapy or combined with ezetimibe in a real clinical setting.

METHODS

Of 5620 cases with primary hypercholesterolemia on the Spanish Arteriosclerosis Society Registry, 1004 with non-familial hypercholesterolemia and complete information on drug therapy and lipid profile were included.

RESULTS

The lowest mean percentage LDL cholesterol reduction was observed with simvastatin 10 mg (32.5 ± 18.5%), while the highest mean percentage LDL reduction was obtained with rosuvastatin 40 mg (58.7 ± 18.8%). As to combined treatment, the lowest and highest mean percentage LDL cholesterol reductions were obtained with simvastatin 10 mg combined with ezetimibe (50.6 ± 24.6%) and rosuvastatin 40 mg combined with ezetimibe (71.6 ± 11.1%), respectively. Factors associated with a suboptimal response were male sex, lower age, body mass index, and baseline LDL cholesterol levels. Combined treatment was associated with less variability in LDL cholesterol reduction (OR 0.603, p < 0.001).

CONCLUSION

In a real clinical setting, rosuvastatin was superior to the other statins in lowering LDL cholesterol, both as monotherapy or combined with ezetimibe. Factors associated with a suboptimal response in LDL cholesterol decline were male sex, age, body mass index, and baseline LDL cholesterol levels. Combined treatment was associated with less variability in LDL cholesterol improvement.

Ethnic differences in the impact of gestational diabetes on macrosomia

BACKGROUND

Previous studies reported an ethnic disparity in gestational diabetes mellitus-associated birth outcomes, with some suggesting that macrosomia increases to a lesser extent in groups at high risk, the opposite of the pattern observed by others. Our aim was to evaluate ethnic variation in the impact of gestational diabetes mellitus (GDM).

METHODS

A case-control study evaluating pregnancy outcomes was conducted in women with and without GDM from 5 ethnic groups. Data on GDM were collected between January 2004 and July 2017. Women giving birth between May 2013 and July 2017 in whom pre-existing diabetes had been ruled out served as controls. A multivariate logistic regression analysis was performed to determine factors independently associated with macrosomia.

RESULTS

852 GDM women and 3,803 controls were included. In Caucasian and East-Asian women excessive gestational weight gain (OR 2.273, 95% CI 1.364-3.788 and OR 3.776, 95% CI 0.958-14.886) was an independent predictor of macrosomia. In Latin-American and Moroccan women, obesity (OR 1.774, 95% CI 1.219-2.581 and OR 1.656, 95% CI 1.054-2.601), GDM (OR 2.440; 95% CI 1.048-5.679 and OR 3.249, 95% CI 1.269-8.321) and gestational weight gain but only for Latin-American women (OR 2.365, 95% CI 1.039-5.384) were associated with macrosomia. In South-Central Asian women, only GDM was associated with macrosomia (OR 3.701, 95% CI 1.437-9.532).

CONCLUSIONS

GDM is an independent predictor of macrosomia in Latin-American, South-Central Asian and Moroccan women but not in Caucasian or East-Asian women in whom other factors play a more important role.

Effect of bariatric surgery on cardiac structure and function in obese patients: Role of the renin-angiotensin system

Echocardiographic alterations have been described in obesity, but their modifications after bariatric surgery (BS) and mechanisms are little known, mostly in normotensive patients. We aimed to analyze cardiac changes 1 year post‐BS and to explore possible mechanisms. A cohort of patients with severe obesity (58% normotensives) were prospectively recruited and examined before surgery and after 12 months. Clinical and echocardiographic data, 24 h BP, renin‐angiotensin‐aldosterone system (RAAS) components, cytokines, and inflammatory markers were analyzed at these two time points. Overall reduction in body weight was mean (IQR) = 30.0% (25.9–33.8). There were statistically significant decreases in left ventricle mass index^2.7(LVMI)^2.7, septum thickness (ST), posterior wall thickness (PWT), relative wall thickness (RWT), and E/e’, both in the whole cohort and in patients without RAAS blockers (p ≤ .04 for all). Plasma renin activity (PRA) decreased from (median, IQR) = 0.8 (0.3;1.35) to 0.4 (0.2;0.93) ng/ml/h, plasma aldosterone from 92 (58.6;126) to 68.1 (56.2;83.4) ng/dl, and angiotensin‐converting enzyme (ACE)‐2 activity from 7.7 (5.7;11.8) to 6.8 (5.3;11.2) RFU/µl/h, p < .05. The body weight loss correlated with a decrease in both 24 h SBP and 24 h DBP (Pearson's coefficient 0.353, p = .022 and 0.384, p = .012, respectively). Variation (Δ) of body weight correlated with ΔE/e’ (Pearson's coeff. 0.414, p = .008) and with Δ lateral e’ (Pearson's coeff. = −0.363, p = .018). Generalized linear models showed that ΔPRA was an independent variable for the final (12‐months post‐BS) LVMI^2.7 (p = .028). No other changes in cardiac parameters correlated with ΔBP. In addition to the respective baseline value, final values of PWT and RWT were dependent on 12‐month Δ of PRA, ACE, and ACE/ACE2 (p < .03 for all). We conclude that there are cardiac changes post‐BS in patients with severe obesity, normotensives included. Structural changes appear to be related to modifications in the renin‐angiotensin axis.

Additional Metabolic Effects of Bariatric Surgery in Patients with a Poor Mid-Term Weight Loss Response: A 5-Year Follow-Up Study

To ascertain the 5-year metabolic effects of bariatric surgery in poor weight loss (WL) responders and establish associated factors. Methods: Retrospective analysis of a non-randomised prospective cohort of bariatric surgery patients completing a 5-year follow-up. Mid-term poor WL was considered when 5-year excess weight loss was <50%. Results: Forty-three (20.3%) of the 212 included patients were mid-term poor WL responders. They showed an improvement in all metabolic markers at 2 years, except for total cholesterol. This improvement with respect to baseline was maintained at 5 years for plasma glucose, HbA1c, HOMA, HDL and diastolic blood pressure; however, LDL cholesterol, triglycerides and systolic blood pressure were similar to presurgical values. Comorbidity remission rates were comparable to those obtained in the good WL group except for hypercholesterolaemia (45.8% vs. poor WL, p = 0.005). On multivariate analysis, lower baseline HDL cholesterol levels, advanced age and lower preoperative weight loss were independently associated with poor mid-term WL. Conclusions: Although that 1 in 5 patients presented suboptimal WL 5 years after bariatric surgery, other important metabolic benefits were maintained.

Trends in prevalence of pre-existing diabetes and perinatal outcomes: a large, population-based study in Catalonia, Spain, 2006-2015

INTRODUCTION

This study aims to assess trends in the prevalence of pre-existing diabetes and whether the risk of adverse perinatal outcomes decreased in women between 2006 and 2015 in Catalonia, Spain.

RESEARCH DESIGN AND METHODS

A population-based study of 743 762 singleton deliveries between 2006 and 2015 in Catalonia, Spain, was conducted using data from the Spanish Minimum Basic Data Set. Cases of type 1 diabetes (T1DM) and 'type 2 diabetes and other pre-existing diabetes' ('T2DM and other PGD') were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Crude and age-adjusted annual prevalences were calculated. Poisson regression model was used to assess trends in prevalence and perinatal outcomes during the study period.

RESULTS

Overall prevalences of pre-existing diabetes, T1DM and 'T2DM and other PGD' were 0.52% (95% CI 0.51 to 0.54), 0.17% (95% CI 0.17 to 0.18) and 0.35% (95% CI 0.33 to 0.36), respectively. From 2006 to 2015, rates increased for pre-existing diabetes (from 0.43 (95% CI 0.39 to 0.48) to 0.56% (0.50 to 0.62), p<0.001), T1DM (from 0.14 (0.11 to 0.17) to 0.20% (0.17 to 0.23), p<0.001) and 'T2DM and other PGD' (from 0.29 (0.25 to 0.33) to 0.36% (0.31 to 0.40), p<0.001). Pre-eclampsia rose in women with pre-existing diabetes (from 4.38% to 8.97%, adjusted p<0.001), T1DM (from 3.85% to 12.88%, p=0.005) and 'T2DM and other PGD' (from 4.63% to 6.78%, adjusted p=0.01). Prevalence of prematurity, cesarean section and small for gestational age remained stable in all diabetes groups. However, the prevalence of macrosomia fell in women with pre-existing diabetes (from 18.18% to 11.9%, adjusted p=0.011) and 'T2DM and other PGD' (from 14.71% to 11.06%, non-adjusted p=0.022, adjusted p=0.305) and large for gestational age decreased in all diabetes groups (from 39.73% to 30.25% in pre-existing diabetes, adjusted p=0.004).

CONCLUSIONS

The prevalence of pre-existing diabetes increased significantly in Catalonia between 2006 and 2015. Despite improvements in outcomes related to excessive birth weight, pre-eclampsia rates are rising and overall perinatal outcomes in women with pre-existing diabetes continue to be markedly worse than in the population without diabetes.

Bariatric surgery and LDL cholesterol (BASALTO) trial study protocol: randomised controlled study evaluating the effect of gastric bypass versus sleeve gastrectomy on high LDL cholesterol

INTRODUCTION

Observational studies have shown gastric bypass to be superior to sleeve gastrectomy in terms of low-density lipoprotein (LDL) cholesterol improvement. If these results are confirmed in randomised controlled trials, presurgical LDL cholesterol status could be a relevant factor in surgical procedure election. Furthermore, it is also necessary to establish the mechanisms by which LDL cholesterol improves after surgery and whether qualitative and quantitative changes occur in the different lipoprotein subclasses. The first objective is to ascertain whether high LDL cholesterol levels before surgery can be considered an additional factor when selecting the most appropriate surgical procedure for each patient (gastric bypass or sleeve gastrectomy). Hence, the 1-year remission rates of high LDL cholesterol after gastric bypass and sleeve gastrectomy in patients with morbid obesity will be compared. Secondary objectives were (1) to compare changes in other lipoproteins and LDL composition and (2) to study the pathophysiologic mechanisms related to LDL cholesterol remission.

METHODS AND ANALYSIS

A randomised clinical trial, with intention-to-treat analysis, will be conducted to compare LDL cholesterol remission between gastric bypass and sleeve gastrectomy, with a 12-month follow-up. Inclusion criteria will be patients between 18 and 60 years of age with body mass index ≥40 kg/m² or ≥35 kg/m² with significant obesity-related comorbidity and high LDL cholesterol levels. Patients will be evaluated preoperatively and at 3, 6 and 12 months after bariatric surgery. Examinations will include routine blood chemistry, anthropometric measurements, food intake recall, physical activity questionnaires and serum samples for lipidomic and lipoprotein characterisation.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Parc de Salut Mar Ethics Committee (2019/8471/I). The study and its conclusions regarding the primary and secondary objectives will be presented as manuscripts submitted for peer-reviewed journal publication.

TRIAL REGISTRATION NUMBER

NCT03975478.

Atherosclerosis and inflammation. New therapeutic approaches

The recognition of atherogenesis as an active process rather than a passive cholesterol storage disease has underlined key inflammatory mechanisms. Hence, innate and adaptive immune responses play an important role in the onset and progression of atherosclerosis. More recently, some clinical studies were designed to address the impact of anti-inflammatory intervention strategies in reducing risk of cardiovascular disease beyond the management of classic risk factors. Therefore, we review first the pathophysiological contribution of inflammation to atherosclerosis and the effect of lipid-lowering drugs on inflammatory biomarkers. Next, we address the effect of classic anti-inflammatory drugs, pharmacological therapies targeting specific inflammatory mediators and vaccines in cardiovascular prevention.

Morbid obesity and dyslipidaemia: The impact of bariatric surgery

Obesity prevalence has presented an exponential increase in the last decades, becoming a first order public health issue. Dyslipidemia of obesity, characterized by low levels of high density lipoprotein (HDL) cholesterol, hypertriglyceridemia and small and dense low-density lipoprotein (LDL) particles, is partly responsible for the high residual cardiovascular risk of this clinical situation. On the other hand, bariatric surgery (BS) is the most effective treatment for obesity, obtaining a greater weight loss than achieved with conventional medical therapy and favoring the improvement or remission of associated comorbidities. The most commonly used BS techniques nowadays are laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Both of these procedures have obtained similar results in terms of weight loss and comorbidity remission such as type2 diabetes mellitus or hypertension. A differential feature between both techniques could be the different impact on the lipoprotein profile. In this respect, previous studies with short and mid-term follow-up have proved LRYGB to be superior to LSG in total and LDL cholesterol reduction. Results regarding triglycerides and HDL cholesterol are contradictory. Therefore, we consider of interest to review the effects of BS at short and mid-term follow-up on lipoprotein profile, as well as the remission rates of the different lipid abnormalities and the possible related factors.

Most of qualitative dietary changes observed one year post-bariatric surgery can be achieved with a preoperative dietary intervention

BACKGROUND AND OBJECTIVES

Bariatric surgery (BS) leads to several changes in nutritional habits that can be attributed to different mechanisms. Some of these changes could be achievable with a preoperative nutritional intervention. The objective was to evaluate dietary modifications during the preoperative and postoperative periods of BS.

METHODS

Prospective observational study of patients who underwent BS between 2010 and 2014 at the Hospital del Mar; 60 consecutive patients were included. Food consumption was measured by a validated food-frequency questionnaire at inclusion in the bariatric surgery program, after preoperative nutritional intervention, and one year after surgery. Generalized estimating equation models were used to assess differences in food group intake during follow up.

RESULTS

Energy intake significantly decreased from inclusion to 1 year of surgery (p=0.003). After the preoperative intervention and prior to surgery, there was an increase in intake of nuts, vegetables, poultry and rabbit, fruit, fish and skimmed milk products and a decrease in bread, soft drinks and pastry. At one year post-surgery, a continued decrease in the consumption of bread and soft drinks and an increase in nuts was observed (linear non-quadratic trend). Consumption of fruit, pastry, fish and skimmed milk products remained stable showing a linear and quadratic trend. Vegetables and poultry and rabbit increased in the preoperative period and decreased after surgery, showing a quadratic but not linear trend.

CONCLUSIONS

a preoperative nutritional intervention in morbidly obese patients can associate favorable dietary changes that are mostly maintained one year after bariatric surgery.

Trends in prevalence of gestational diabetes and perinatal outcomes in Catalonia, Spain, 2006 to 2015: the Diagestcat Study

BACKGROUND

No recent epidemiologic studies on gestational diabetes mellitus (GDM) have been conducted in Spain. The present study aimed to explore trends in the prevalence of GDM and ascertain whether the risk of adverse perinatal outcomes changed between 2006 and 2015 in Catalonia.

METHODS

In this population-based study, all hospital admissions for singleton births in Catalonia for the period 2006 to 2015 were collected from the Spanish Minimum Basic Data Set. Cases of GDM were identified from hospital delivery discharge reports using ICD-9-CM codes. Data regarding maternal characteristics and perinatal outcomes were analysed. Crude and age-adjusted annual prevalences were calculated. The Poisson regression model was used to assess trends in prevalence and perinatal outcomes, adjusted for age and smoking habit; however, they could not be adjusted for body mass index (BMI) and ethnicity.

RESULTS

Data from 743 762 deliveries were collected. GDM prevalence over the study period was 4.80% (95% CI 4.75-4.85%). Crude GDM prevalence rose from 3.81% (95% CI 3.67-3.95%) in 2006 to 6.53% (95% CI 6.33-6.72%) in 2015 (P < 0.001). Women with GDM showed a stable trend in rates of preeclampsia (2.56%), prematurity (15.7%), and large-for-gestational age (LGA) newborns (18.3%), whereas a lower rate of macrosomia was observed during the study period (from 9.16% to 7.84%). Caesarean deliveries rose from 28% to 31%; however, significance was lost after adjustment.

CONCLUSIONS

The prevalence of GDM in Catalonia almost doubled between 2006 and 2015. During the study period, the frequency of macrosomia decreased whereas pre-eclampsia, prematurity, LGA, and age-adjusted Caesarean rates remained stable.

Muscle and statins: from toxicity to the nocebo effect

INTRODUCTION

Although statins have a satisfactory safety profile and are well tolerated, many statin-treated patients report muscle symptoms in clinical practice which contribute to drug discontinuation and, consequently, adverse cardiovascular outcomes.

AREAS COVERED

This narrative review will cover the definition and prevalence of statin intolerance, the clinical spectrum of statin-associated muscle symptoms (SAMS) with special focus on patients with only mild myalgias, the complexity of statin muscle intolerance diagnosis and provide an overview on the nocebo effect of particular importance for physicians.

EXPERT OPINION

Many patients are unable to tolerate statin therapy, with SAMS being the most common cause of statin intolerance. The reported incidence of SAMS was consistently lower in randomized placebo-controlled trials than in observational studies. These results strongly suggested that SAMS were not always due to by the pharmacologic effects of statin therapy. Convincing patients that their muscle symptoms might be due to causes other than statin treatment is sometimes difficult. Furthermore, clinicians should not prematurely discontinue statin therapy before considering other possible causes, including the nocebo effect.

Association of first-trimester HbA1c levels with adverse pregnancy outcomes in different ethnic groups

AIM

To determine, in a multi-ethnic cohort, the association of first-trimester HbA1c levels with the development of pregnancy complications.

METHODS

A prospective study between April 2013-October 2016. Participants were stratified in five ethnic groups. Women had an HbA1c measurement added to their first antenatal bloods. Primary outcome was macrosomia and secondary outcomes included preeclampsia and large-for-gestational age (LGA). A multivariate logistic regression analysis was performed to adjust for potential confounders in determining the association between different HbA1c cut-off points and obstetric outcomes on each ethnic group.

RESULTS

1,882 pregnancies were included. Analysis was limited to the three main ethnic groups: Caucasian (54.3%), South-Central Asian (19%) and Latin-American (12.2%). There was no association between HbA1c levels and obstetric outcomes among Caucasians. In Latin-Americans, an HbA1c ≥ 5.8% (40 mmol/mol) was associated with higher risk of macrosomia, whereas an HbA1c ≥ 5.9% (41 mmol/mol) was associated with LGA. In South-Central Asian, an HbA1c ≥ 5.7% (39 mmol/mol) was associated with increased risk of macrosomia and a continuous graded relationship between HbA1c levels and preeclampsia and LGA was detected starting at HbA1c levels of 5.4% (36 mmol/mol).

CONCLUSION

First-trimester HbA1c levels perform as a suitable predictor of pregnancy complications in South-Central Asian and Latin-American women whereas in Caucasian no significant associations were found.

Impact of overt diabetes diagnosed in pregnancy in a multi-ethnic cohort in Spain

Overt diabetes (ODM) is defined as women without diabetes meeting the criteria for diabetes at the first antenatal visit. The risk of obstetric complications increases linearly with maternal glycemia and poorer maternal-fetal outcomes than in gestational diabetes (GDM) may be expected. Studies focusing on ODM pregnancy outcomes are lacking. We aimed to analyze maternal characteristics and pregnancy outcomes in ODM women compared with those with GDM. A retrospective cohort study of women giving birth between January 2010 and April 2013 was conducted. Participants with pre-gestational diabetes were excluded. All women underwent screening for GDM at the 24th-28th weeks of gestation or at the first prenatal visit in those with risk factors. HbA1c and a fasting glucose were measured in GDM women to rule out ODM. Of the 5,633 women included, 572 (10%) were diagnosed with GDM and 50 (0.88%) with ODM. Almost 95% of ODM women were from ethnic minorities. After adjustment for confounding factors, ODM women showed increased rates of premature birth (23.1% vs. 6.7%, p < .001), emergent cesarean section (41.0% vs. 19.5%, p = .049), preeclampsia (22% vs. 3.7%, p < .001) and large-for-gestational-age babies (40.0% vs. 14.8%, p = .008) compared with GDM. In conclusion, ODM is associated with poorer obstetric outcomes than GDM and affects mainly women from ethnic minorities.

Is fasting plasma glucose in early pregnancy a better predictor of adverse obstetric outcomes than glycated haemoglobin?

OBJECTIVES

To determine, in a multi-ethnic cohort, the suitability of first-trimester fasting plasma glucose and HbA1c levels in non-diabetic range to identify women without diabetes at increased pregnancy risk.

STUDY DESIGN

A retrospective analysis of a prospective cohort between April 2013 and September 2015. Universal testing for fasting plasma glucose and HbA1c levels at the first antenatal blood sampling was performed and women were screened for gestational diabetes mellitus at 24-28 weeks' gestation. Primary outcomes were macrosomia and pre-eclampsia, and secondary outcomes preterm delivery, Caesarean section and large-for-gestational age. Different fasting plasma glucose and HbA1c cut-off levels were assessed for associations with outcomes.

RESULTS

1,228 pregnancies were included for outcome analysis. After adjustment for potential confounders, no association was found between fasting plasma glucose levels and pregnancy outcomes. Women with an HbA1c ≥5.8% (39.9 mmol/mol) showed an increased risk of macrosomia (OR 2.69, 95% CI 1.16-6.24); an HbA1c ≥5.9% (41 mmol/mol) threshold was independently associated with a three-fold risk of pre-eclampsia (95% CI 1.03-9.9) and an HbA1c ≥6.0% (42.1 mmol/mol) with a four-fold risk of large-for-gestational age (95% CI 1.49-11.07).

CONCLUSIONS

In a multi-ethnic population, first-trimester fasting plasma glucose levels were not a better predictor of pregnancy complications than HbA1c. Further, an early HbA1c ≥5.8% (39.9 mmol/mol) threshold is already associated with an increased risk of macrosomia.

Gestational diabetes mellitus in a multiethnic population in Spain: Incidence and factors associated to impaired glucose tolerance one year after delivery

BACKGROUND AND AIM

Women with history of gestational diabetes mellitus (GDM) are at increased risk for diabetes. Ethnicity may modify such risk, but no studies have been conducted in our environment. The aim of this study was to assess the incidence of type 2 diabetes mellitus and prediabetes one year after delivery in women with GDM and in a multiethnic background and to identify the associated factors.

PATIENTS AND METHODS

A retrospective analysis of a prospective, observational cohort of women with GDM who attended annual postpartum follow-up visits at Hospital del Mar from January 2004 to March 2016.

RESULTS

Three hundred and five women attended postpartum follow-up visits. Of these, 47.2% were Caucasian, 22% from South-Central Asia, 12% from Latin America, and 10% from Morocco and East Asia. Incidence rates of type 2 diabetes mellitus and prediabetes in these patients were 5.2 and 36.6%, respectively. In a multivariate analysis, non-Caucasian origin (OR=3.15, 95% CI [1.85-5.39]), recurrent gestational diabetes (OR=2.26, 95% CI [1.11-4.59]), and pre-pregnancy body mass index (OR=1.09, 95% CI [1.04-1.15]) were independent predictors of impaired glucose tolerance.

CONCLUSIONS

In a multiethnic Spanish population of women with GDM, incidence of impaired glucose tolerance in the first year after delivery was 41.8%, with a three-fold increased risk for women of non-Caucasian ethnicity.

Influence of the microbiota and probiotics in obesity

Gut microbiota plays a key role in the control of body weight. In the present review the different ways in which it can modify the energy homeostasis of the host are exposed, based on its capacity to modify the metabolism of the individual and its contribution in the energy consumption regulation. With the current evidence, it is not clear what microbiota profile is associated with the presence of obesity, although in animal models it seems to be related to a higher proportion of bacteria of the Firmicutes phylum, to the detriment of those of the Bacteroidetes phylum. Other factors clearly involved would be the diversity in the gut microbiota or its possible functional changes. More studies in humans are needed to clarify how dysbiosis can influence weight control. On the other hand, probiotics directly affect the gut microbiota, modulating its composition and, possibly, its functionality. A large number of studies in humans have evaluated the impact of probiotics on obesity. Although this intervention may have a potentially beneficial effect, more effort is needed to clarify which strains of probiotics should be recommended, at what dose and for how long.

Previous Gestational Diabetes Increases Atherogenic Dyslipidemia in Subsequent Pregnancy and Postpartum

In a cohort of women with previous gestational diabetes mellitus (GDM), we aimed to ascertain whether women with abnormal glucose tolerance 1-year postdelivery had a more atherogenic lipid profile during and after pregnancy than those with normal glucose tolerance. A prospective cohort study with longitudinal design between January 2004 and March 2016 was conducted. Three hundred and six (56.8%) of 537 women diagnosed with GDM during the studied period attended a control visit during the first year after delivery. Of these, 112 (36.6%) had prediabetes and 16 (5.2%) had type 2 diabetes mellitus. No significant differences during pregnancy were found in total, low-density lipoprotein, high-density lipoprotein (HDL) cholesterol, and triacylglycerol (TAG) concentrations among the three groups. Only HDL cholesterol and TAG levels differed significantly among groups at 2 and 12 months after delivery. Logistic regression analysis revealed pregnancy HDL and glucose metabolism status to be associated with the HDL cholesterol concentration 1-year postdelivery. Furthermore, the only independent factor associated with TAG levels 1 year after delivery was the gestational TAG concentration. In summary, an overweight multiethnic group of women with prior GDM presented a high incidence of postpartum dysglycemia (41.8%). HDL-cholesterol and TAG levels, both components of the metabolic syndrome, differed significantly among the three study groups in the glucose-metabolism status at 2 and 12 months after delivery. Women with previous GDM must be followed up in the postpartum period for early detection and management of lipid and glucose disorders.

Is first-trimester HbA1c useful in the diagnosis of gestational diabetes?

AIMS

To evaluate the usefulness and efficacy of first-trimester HbA1c in the diagnosis of gestational diabetes (GDM).

METHODS

Prospective observational of consecutive pregnant women. All women had a first-trimester HbA1c determination and GDM screening at 24-28weeks of pregnancy using a two-step approach. A ROC curve was drawn to determine the sensitivity and specificity of HbA1c in detecting GDM and a rule-in rule-out diagnostic algorithm was proposed. The cost of the proposed algorithm was calculated.

RESULTS

152 (13.1%) of 1195 women were diagnosed of GDM. The area under the ROC curve for HbA1c to detect GDM was 0.679 (95%CI 0.631-0.727). A rule-out threshold for HbA1c of 4.8% (29mmol/mol) had 96.7% sensitivity (95%CI 93.9-99.5), 10.1% specificity (95%CI 8.3-12.0) and a negative predictive value of 95.3% (95%CI 91.3-99.3). A rule-in value of 5.6% (38mmol/mol) had a positive predictive value of 31.6% (95%CI 24.4-38.9), 89.3% specificity (95%CI 87.4-91.2) and 32.9% sensitivity (95%CI 25.4-40.4). The low positive predictive value of the rule-in threshold precludes its use for GDM diagnosis, but could be used to identify women at high risk of GDM in whom the diagnosis can be established using a one-step approach. The overall saving of the proposed algorithm would be 6.5% of the total cost with the standard strategy.

CONCLUSIONS

A first-trimester HbA1c does not have sufficient sensitivity or specificity to diagnose GDM, although the use of a higher and lower threshold could simplify the diagnostic process by reducing the number of oral glucose tolerance test, associated costs and patient inconvenience.

Laparoscopic Roux-en-Y gastric bypass vs. laparoscopic sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis of lipid effects at one year postsurgery

INTRODUCTION

Results of the effects of Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG) on triglyceride and high-density lipoprotein (HDL) cholesterol levels are controversial. Moreover, previous meta-analyses focused on global dyslipidemia remission, but did not include the separate remission rates of the different lipid fractions. Hence, the aim of the present meta-analysis was to compare the outcomes (concentration change and remission rates) of GB and SG on diverse lipid disorders one year postbariatric surgery (BS).

EVIDENCE ACQUISITION

An exhaustive electronic search carried out on MedLine, Embase and The Cochrane Central Register of Controlled Trials (Central) until July 2016 yielded 2621 records, of which 17, totaling 4699 obese patients with one-year follow-up after BS were included in the meta-analysis.

EVIDENCE SYNTHESIS

GB was superior to SG in terms of total cholesterol (mean difference= 19.77 mg/dL, 95% CI: 11.84-27.69) and low-density lipoprotein (LDL) cholesterol (mean difference: 19.29 mg/dL, 95% CI: 11.93-26.64) decreases as well as in hypercholesterolemia remission (RR: 1.43, 95% CI: 1.27-1.61). No differences were found between GB and SG in terms of HDL cholesterol increase or triglyceride concentration change after surgery, as well as in hypertriglyceridemia and low HDL remission rates.

CONCLUSIONS

The effect of GB on total and LDL cholesterol concentration decreases and remission was greater than that of SG, whereas no differences were observed with respect to HDL cholesterol and triglyceride concentration evolution. Conclusions cannot be drawn from hypertriglyceridemia and low HDL remission rates based on this meta-analysis.

Role of First-Trimester HbA1c as a Predictor of Adverse Obstetric Outcomes in a Multiethnic Cohort

CONTEXT

Risk of obstetric complications increases linearly with rising maternal glycemia. Testing hemoglobin A1c (HbA1c) is an effective option to detect hyperglycemia, but its association with adverse pregnancy outcomes remains unclear. Emerging data sustain that an early HbA1c ≥5.9% could act as a pregnancy risk marker.

OBJECTIVE

To determine, in a multiethnic cohort, whether an early ≥5.9% HbA1c could be useful to identify women without diabetes mellitus at increased pregnancy risk.

DESIGN AND SETTING

A prospective study was conducted at Hospital del Mar, Barcelona, between April 2013 and September 2015.

PATIENTS AND INTERVENTION

A total of 1631 pregnant women had an HbA1c measurement added to their first antenatal blood tests and were screened for gestational diabetes mellitus at 24 to 28 weeks' gestation.

OUTCOME MEASURES

Primary outcome was macrosomia. Secondary outcomes were preeclampsia, preterm birth, and cesarean section rate.

RESULTS

A total of 1228 pregnancies were included for outcome analysis. Women with HbA1c ≥5.9% (n = 48) showed a higher rate of macrosomia (16.7% vs 5.9%, P = 0.008) and a tendency toward a higher rate of preeclampsia (9.32% vs 3.9%, P = 0.092). There were no statistically significant differences in other pregnancy outcomes. After adjusting for potential confounders, an HbA1c ≥5.9% was independently associated with a 3-fold increased risk of macrosomia (95% confidence interval, 1.127 to 8.603, P = 0.028) and preeclampsia (95% confidence interval, 1.086 to 11.532, P = 0.036).

CONCLUSIONS

In a multiethnic population, an early HbA1c ≥5.9% measurement identifies women at high risk for poorer pregnancy outcomes independently of gestational diabetes mellitus diagnosis later in pregnancy. Further studies are required to establish cutoff points adapted to each ethnic group and to assess whether early detection and treatment are of benefit.

Current dilemmas in the diagnosis and management of follicular thyroid tumors

Follicular carcinoma (FTC) is a relatively uncommon type of differentiated thyroid carcinoma. Guidelines have often dealt with FTC and papillary thyroid cancer as a single disease. Over the last decade, however, a better understanding of these two types of thyroid cancer indicates that they cannot be analysed together. Neither ultrasonography nor fine-needle aspiration cytology can provide a clear distinction between FTC and follicular adenoma. New molecular diagnostic techniques may be used to identify a subpopulation of follicular neoplasms with a low probability of being malignant. Diagnostic surgery-usually hemithyroidectomy- is recommended for most thyroid follicular lesions without a certain preoperative diagnosis. If FTC is diagnosed most-perhaps not all- patients will require a completion thyroidectomy. While widely invasive FTC usually does not pose diagnostic or therapeutic doubts, consensus on the diagnosis of non-invasive follicular lesions is still lacking. Prognosis of FTC is mostly dependent on local invasion and distant metastasis that, in turn, correlate with tumor size.

Predictors of Hypertension Remission and Recurrence After Bariatric Surgery

BACKGROUND

Few data exist on factors associated with hypertension (HTN) remission post-bariatric surgery. No information on factors that may predict HTN relapse is available. The aims were to assess the HTN remission and relapse rates at 1 and 3 years, respectively, post-bariatric surgery, and determine predictive factors.

METHODS

A nonrandomized prospective cohort study on severely obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with a follow-up of 36 months was conducted between 2005 and 2011. Criteria for HTN diagnosis were current treatment with antihypertensive agents and/or systolic blood pressure (BP) >140 mm Hg and/or diastolic BP >90 mm Hg. HTN remission was defined as normalization of BP maintained after discontinuation of medical treatment.

RESULTS

A total of 197 patients were included in the study. HTN was present in 47.7%; 68.1% of hypertensive patients showed HTN remission 1 year after the surgical procedure, 21.9% of whom had relapsed at 3 years. The number of antihypertensive drugs prior to surgery was associated with a lower remission rate at the first year and a higher recurrence at 3 years. However, a smaller weight loss during the first year was associated with increased HTN recurrence at 3 years.

CONCLUSION

HTN relapses in 1 of 5 hypertensives who have achieved remission at the first year of follow-up. Weight loss during the first postoperative year should be encouraged to avoid HTN relapse at 3 years.

High-Dose Vitamin D Supplementation is Necessary After Bariatric Surgery: A Prospective 2-Year Follow-up Study

BACKGROUND

We assessed the need of vitamin D supplementation to achieve normal 25-hydroxyvitamin D (25[OH]D) levels after bariatric surgery and whether there were differences between laparoscopy sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

A total of 164 morbid obese patients undergoing bariatric surgery from January 2008 to June 2011 were followed for 2 years. Serum levels of 25(OH)D and intact parathyroid hormone (iPTH) were measured preoperatively and at 3, 6, 9, 12, 18, and 24 months after operation. All patients received 400 IU/day of 25(OH)D. Patients received additional supplementation with 16,000 IU of vitamin D3 (calcifediol) every 2 weeks if 25(OH)D serum levels were < 30 ng/mL (intervention group).

RESULTS

Ninety-six (58.5 %) patients underwent LSG and 68 (41.5 %) LRYGB. A total of 106 (64.6 %) patients received calcifediol supplementation (62 in the LSG group and 44 in the LRYGB group). Normal 25(OH)D levels at 24 months were recorded in 69 % of patients in the intervention group and in 48.3 % in the non-intervention group. At 24 months, mean 25(OH)D levels in the non-intervention group were significantly lower among LRYGB patients than among LSG patients (P = 0.009). In the intervention group, normal 25(OH)D levels were achieved in 60 % of patients treated with LSG and in 22.2 % of those treated with LRYGB. Secondary hyperparathyroidism was presented in 49 (29.9 %) patients preoperatively but without significant differences in iPTH levels between the two surgical procedures.

CONCLUSION

Patients undergoing bariatric surgery should receive high-dose vitamin D supplementation independently of the surgical technique.

[Cardiovascular prevention in diabetes mellitus: A multifactorial challenge]

Patients with type2 diabetes mellitus have a high to very high cardiovascular risk, and often have other associated risk factors, such as hypertension, obesity and dyslipidaemia. Cardiovascular disease is the leading cause of morbidity and mortality in this population. An integrated control of all risk factors in patients with diabetes is essential for minimising the risk of macrovascular complications. Given the benefits of the multifactorial intervention strategies for cardiovascular prevention in diabetic patients, a review is presented on the therapeutic goals established for each risk factor in diabetes and the benefits of their control.