Publications by authors named "Francisco Botella Romero"

26 Publications

  • Page 1 of 1

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project.

Endocrinol Diabetes Nutr (Engl Ed) 2021 Jun 1. Epub 2021 Jun 1.

Unidad de Nutrición Clínica y Dietética, Hospital General Universitario Gregorio Marañón, Madrid, España.

Background: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs.

Objective: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program.

Methods: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis.

Results: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition.

Conclusion: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.
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http://dx.doi.org/10.1016/j.endinu.2021.02.005DOI Listing
June 2021

RECALSEEN. Subgroup: Patient care in the clinical nutrition units of the Spanish National Health System.

Endocrinol Diabetes Nutr (Engl Ed) 2021 May 10;68(5):354-362. Epub 2020 Aug 10.

Hospital General Universitario de Albacete, Albacete, España. Electronic address:

Introduction: Artificial nutrition (AI) is one of the most representative examples of coordinated therapeutic programs, and therefore requires adequate development and organization. The first clinical nutrition units (CNUs) emerged in the public hospitals of the Spanish National Health System (NHS) in the 80s and have gradually been incorporated into the departments of endocrinology and nutrition (DENs). The purpose of our article is to report on the results found in the RECALSEEN study as regards the professional and organizational aspects relating to CNUs and their structure and operation.

Materials And Methods: Data were collected from the RECALSEEN study, a cross-sectional, descriptive study of the DENs in the Spanish NHS in 2016. The survey was compiled from March to September 2017. Qualitative variables were reported as frequency distributions (number of cases and percentages), and quantitative variables as the mean, median, and standard deviation (SD).

Results: A total of 88 (70%) DENs, out of a total of 125 general acute hospitals of the NHS with 200 or more installed beds, completed the survey. CNUs were available in 83% of DENs (98% in hospitals with 500 or more beds). As a median, DENs had one nurse dedicated to nutrition (35% did not have this resource). Fifty-three percent of DENs with nutrition units had dieticians integrated into the unit (median: 1). DENs located in hospitals with 500 or more beds are more complex and have a wide portfolio of monographic unit services (morbid obesity, 78.3%; artificial home nutrition, 87%; chronic diseases, 65.2%) and specific techniques (impedanciometry, 78%). However, only 14% of the centers perform universal screening tests for malnutrition, and a secondary diagnosis of malnutrition only appears in 12.3 reports per 1000 hospital discharges.

Discussion: After the 1997 and 2003 studies, the results of 2017 show a marked growth and consolidation of CNUs within the DENs in most hospitals. Today, the growth of this specialty is largely due to the care demand created by hospital clinical nutrition. CNUs still have an insufficient nursing staff and dietitians/nutritionists, and in the latter case, atypical contracts or grants funded by research projects or the pharmaceutical industry are common. Units for specific nutritional diseases and participation in multidisciplinary groups, quite heterogeneous, are concentrated in hospitals with 500 or more beds and represent an excellent opportunity for CNU development.

Conclusions: Many DENs of Spanish hospitals include CNUs where care is provided by endocrinologists, who devote most of their time to clinical nutrition in more than half of the hospitals. This is most common in large centers with a high workload in relation to staffing. There is considerable heterogeneity between hospitals in terms of both the number and type of activity of the CNUs.
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http://dx.doi.org/10.1016/j.endinu.2020.03.013DOI Listing
May 2021

Prevalence of severe hypoglycemia in a cohort of patients with type 1 diabetes.

Endocrinol Diabetes Nutr (Engl Ed) 2021 Jan 26;68(1):47-52. Epub 2020 Apr 26.

Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Servicio de Salud de Castilla-La Mancha, Albacete, España; Facultad de Medicina de Albacete, Universidad de Castilla-La Mancha, Albacete, España.

Introduction: Hypoglycemia is the major limiting factor in the glycemic management of type 1 diabetes. Severe hypoglycemia puts patients at risk of injury and death. Recurrent hypoglycemia leads to impaired awareness of hypoglycemia and this increases the risk of severe hypoglycemia. Recent studies have reported rates for severe hypoglycemia of 35% in type 1 diabetic patients.

Objectives: To assess the prevalence of severe hypoglycemia in type 1 diabetes mellitus patients and to evaluate the relationship between this and impaired awareness of hypoglycemia according to the Clarke test.

Patients And Methods: The following data were collected from a cohort of type 1 diabetic patients: age, gender, duration of type 1 diabetes, treatment (multiple daily insulin injection or continuous subcutaneous insulin infusion), glycemia self-control, HbA1c, episodes of severe hypoglycemia and impaired awareness of hypoglycemia.

Results: Of the participants, 39.8% had had at least one episode of severe hypoglycemia (in the previous 6 months), 11.4% with loss of consciousness (in the previous 12 months). According to the Clark test, 40.9% had impaired awareness of hypoglycemia. Older age and longer duration of diabetes were associated with a higher prevalence of severe hypoglycemia with unconsciousness; older age and a lower level of HbA1c were associated with impaired awareness of hypoglycemia.

Conclusions: Our study allows us to confirm the high rate of severe hypoglycemia and impaired awareness of hypoglycemia in patients with type 1 diabetes.
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http://dx.doi.org/10.1016/j.endinu.2020.01.002DOI Listing
January 2021

[Nutritional status in older adults admitted to an acute geriatric unit].

Nutr Hosp 2020 Apr;37(2):260-266

Complejo Hospitalario Universitario de Albacete.

Introduction: Objective: to describe the nutritional status of older adults hospitalized in an acute geriatric unit (AGU) and its association with mortality and days of hospitalization. Material and methods: a retrospective study in 1,084 adults older than 65 years, hospitalized in an AGU. The Mini Nutritional Assessment®-Short Form (MNA®-SF) and subjective global assessment (SGA) were used. The association between nutritional status, mortality, and long hospital stay (> 7 days) was analyzed using regression models and Cox hazard models. Results: mean age was 86.5 years: 58.7% were women. Mean MNA®-SF score was 8.9 (20.0%, well nourished; 48.2%, at nutritional risk, and 31.7% with malnutrition). Using the SGA, 22.1% were well nourished, 54.7% had moderate malnutrition, and 23.2% had severe malnutrition. Agreement between SGA and MNA®-SF was good (kappa, 0.654; p < 0.001), and correctly classified 78.5% of participants. Malnutrition was associated with poorer cognitive status, greater disability, worse ambulation, and lower levels of total protein, albumin, cholesterol, and transferrin. Patients with malnutrition in the MNA®-SF assessment had a higher adjusted mortality risk than those who were well nourished (HR, 1.80; 95% CI, 1.01-3.20), same as those with SGA C versus A (HR, 1.66; 95% CI, 0.96-2.86). Patients with SGA B and C presented a higher adjusted risk of long hospitalization as compared to well nourished subjects (OR, 1.42; 95% CI, 1.04-1.96 and OR, 1.73; 95% CI, 1.18-2.54, respectively. Patients with malnutrition per the MNA-SF® presented a higher adjusted risk of long hospitalization as compared to well nourished subjects (OR, 1.59; 95% CI, 1.09-2.33). Conclusions: nutritional risk and malnutrition are very common in older adults in AGUs, and are associated with higher mortality and longer hospital stay.
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http://dx.doi.org/10.20960/nh.03005DOI Listing
April 2020

Trends on Diabetes Mellitus's healthcare management in Spain 2007-2015.

Diabetes Res Clin Pract 2019 Oct 22;156:107824. Epub 2019 Aug 22.

Sociedad Española de Endocrinología y Nutricion (SEEN), Spain; Gerencia de Atención Integrada de Albacete, Albacete, Spain.

Aims: To analyze the trends on diabetes mellitus (DM) healthcare management in Spain.

Methods: Retrospective observational study between January 1st 2007 and 31th December 2015 with DM as the principal diagnosis. The main clinical outcome measures were all-cause, in-hospital mortality and 30-day readmissions. We also analyze three Prevention Quality Indicators (PQI) for DM.

Results: The number of hospitalization episodes decreased significantly as well as the frequentation rate and average length of stay (Incidence Rate Ratio [IRR] = 0.963, p < 0.001; 0.91, p < 0.001 and 0.986, p < 0.001, respectively). Crude in-hospital mortality and readmissions rates and risk-standardized in-hospital mortality rates (RSMR), however, remained stable (IRR = 0.988, p = 0.073; IRR = 1.003, p = 0.334 and IRR = 0.997, p = 0.116, respectively). A relevant variability in RSMR, both at hospital (Median Odds Ratio 1.49) and regional level, was found. High volume hospitals (≥105 DM discharges at year) showed better outcomes. High variability was also found in PQI indicators al regional level.

Conclusion: The present analysis shows an improvement in hospitalizations related to DM in Spain in the period 2007-2015. There was also a decrease in the frequentation rate and in the average length of stay. These findings are probably explained by quality improvements in the healthcare management of the DM at the ambulatory level. However, there were important differences in the management of diabetic inpatients both at the hospital and the regional level.
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http://dx.doi.org/10.1016/j.diabres.2019.107824DOI Listing
October 2019

[So doctor, what could I eat then?]

Nutr Hosp 2019 Aug;36(4):898-904

Gerencia de Atención Integrada de Albacete.

Introduction: Introduction: the strict dietary recommendations we impose on patients with advanced chronic kidney disease (ACKD) have negative impact on quality of life. Objective: determine whether such restrictions are justified and if an educational program can improve health-related quality of life (HRQL) parameters. Methods: we carried out an educational intervention, single center, randomized, controlled clinical trial on ACKD outpatients in Albacete. Seventy-five patients were included, 35 in the control group and 40 in the intervention group. Nutritional assessment was based on the Subjetive Global Assessment (SGA) and body mass index (BMI). We used the SF-36 health questionnaire to measure HRQL. In the intervention group we carried out individual, collective and telephone nutritional interventions, adapting diet advice and restrictions in a personalized way. Results: malnutrition measured by Subjective Global Assessment (SGA) in the control group was 20%; meanwhile, in the intervention group it was 29.3% and it improved at the end of the study, but not significantly. BMI showed overweight with a mean of 28.83 kg/m² (DE: 5.4) and 26.96 kg/m² (DE: 4.09), respectively, and did not change throughout the study. The nutritional intervention improved the score in all the subscales except for body pain score. Besides, mental and physical components also improved their scores in the intervention group and worsened them in the control group (p < 0.001). Conclusions: quality of life can be improved in ACKD patients applying an educational nutrition program.
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http://dx.doi.org/10.20960/nh.02576DOI Listing
August 2019

Present and future of postgraduate training in Clinical Nutrition.

Endocrinol Diabetes Nutr (Engl Ed) 2019 Jun - Jul;66(6):343-345. Epub 2019 May 18.

Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, España. Electronic address:

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http://dx.doi.org/10.1016/j.endinu.2019.04.002DOI Listing
January 2020

Quo vadis, Endocrinology and nutrition?

Endocrinol Diabetes Nutr (Engl Ed) 2019 May 7;66(5):291-296. Epub 2019 Apr 7.

Servicio Endocrinología y Nutrición, Hospital General Universitario de Albacete, Albacete, España.

Introduction: In Spain, the system used to select a medical specialty is the MIR (internal resident physician) exam. The MIR selection number may reflect the interest in a given specialty. Our study objective was to confirm the increase in the selection number and to analyze possible factors influencing the decision.

Material And Method: To analyze change over time in the MIR number with which this specialty is chosen and to compare it with other related specialties, as well as the reasons why it is preferred using an anonymous survey to 108 MIRs of endocrinology.

Results: The average number of MIR for Endocrinology and Nutrition has gradually increased to 2336 in year 2018, a trend that coincides with an increase in the number of places offered but is more marked as compared to other medical specialties. Respondents weighed different factors when choosing specialty. When asked about the most positive aspects of the specialty, the highest rated was that day to day activity was "less intense". The most commonly mentioned negative aspect was the low number of techniques. When asked if the specialty had met their expectations, respondents gave an average score of 8.7, although the perceived prestige of the specialty scored only 6.7 points.

Conclusions: There is an obvious deterioration of the MIR selection number of our specialty that it is not so marked in other specialties.
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http://dx.doi.org/10.1016/j.endinu.2019.03.003DOI Listing
May 2019

[Comprehensive approach for malnourished patients: aiming for continuity in nutritional support].

Nutr Hosp 2018 Apr 3;35(Spec no2):34-38. Epub 2018 Apr 3.

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days of hospitalization, a greater number of complementary tests, the need for artificial nutritional support and / or drugs to treat complications, which is a very important economic burden. Most patients who are malnourished, or at risk, can benefit from oral nutritional support, which includes dietary modifications (fortification, extra snacks, etc.), prescription of a personalized diet by a registered dietitian and the use of oral nutritional supplements (ONS). The use of ONS has shown benefits, in several meta-analysis, in weight recovery, reduction in the number of complications or hospital readmissions and functional improvement, without a reduction in the usual food intake. The use of ONS is particularly cost-effective in certain subgroups of age (frail elderly), nutritional status (previous malnutrition) and underlying disease (hip fracture, abdominal surgery, etc.).On the other hand, there are additional difficulties to evaluate the effect of nutritional support in different healthcare settings (community, nursing home, hospital) since the economic burden in one environment often has an impact on another (for example: hospital readmissions). This circumstance makes it difficult for regulators to control the prescription and generates debate about the continuity of treatments in different settings. The repercussion of an episode of hospitalization on functional status, 30 days after discharge ("post hospital syndrome"), constitutes a transitory period of special vulnerability for comorbidity and hospital readmission risk. The nutritional support (dietary counselling + use of ONS) generates savings of around 5% of the health cost in the intervention group vs "usual practice", together with a significant decrease in the number of hospital readmissions. The nutritional support throughout the different scenarios where the patient is found has proven to be cost-effective, does not involve extra costs per unit of improvement, both clinical and functional, and can be defended from a health economic perspective. These results highlight the need to pay attention to the detection of malnutrition and its treatment as part of standard medical care in the transition process between the hospital and the patient's home. It is the responsibility of the health managers to ensure that the detection and treatment of malnutrition is routinely carried out in their centers, as well as integrating clinical nutrition into standardized medical care. of any patient, which raises the importance of including clinical nutrition in the training plans of the health personnel.
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http://dx.doi.org/10.20960/nh.1958DOI Listing
April 2018

Development of hyponatremia in non-critical patients receiving total parenteral nutrition: A prospective, multicenter study.

Clin Nutr 2019 12 30;38(6):2639-2644. Epub 2018 Nov 30.

Endocrinology and Nutrition Department, Hospital Clínico Universitario de Valladolid-IEN, Universidad de Valladolid, Valladolid, Spain.

Background & Aims: Hyponatremia is frequent in hospitalized patients, especially in those receiving total parenteral nutrition (TPN). Furthermore, the presence of hyponatremia is associated with increased morbimortality in both groups. The goal of this study is to describe the prevalence of hyponatremia developing during TPN in non-critical patients, and identify risk factors for its appearance.

Methods: This prospective multicenter study involved 19 Spanish hospitals. Noncritically-ill patients prescribed TPN over a 9-month period were studied. Variables analyzed demographic characteristics, prior comorbidities, drug therapy, PN composition, additional iv fluids, and serum sodium levels.

Results: A total of 543 patients were recruited, 60.2% males. Age: 67 (IR 57-76). Of 466/543 who were eunatremic when starting TPN, 18% developed hyponatremia (serum sodium < 135 mmol/L) during TPN. Independent risk factors identified by logistic regression analysis: female (OR 1.74 [95% CI = 1.04-2.92], p = 0.036); severe malnutrition (OR 2.15 [95% CI = 1.16-4.35], p = 0.033); opiates (OR 1.97 [95% CI = 1.10-3.73], p = 0.036); and nausea/vomiting (OR 1.75 [95% CI = 1.04-2.94], p = 0.036).

Conclusions: Previously eunatremic patients frequently develop hyponatremia while receiving TPN. In this group, severe malnutrition is an independent risk factor for hyponatremia, as well as previously described risk factors: opiates, nausea/vomiting, and female gender.
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http://dx.doi.org/10.1016/j.clnu.2018.11.014DOI Listing
December 2019

Patient care in the Endocrinology and Nutrition Units of the National Health System. The RECALSEEN study.

Endocrinol Diabetes Nutr (Engl Ed) 2019 Aug - Sep;66(7):425-433. Epub 2018 Nov 30.

Hospital Universitario Gregorio Marañón, Madrid, España.

Objectives: To elaborate a diagnosis of the situation regarding the assistance in the Services and Units of Endocrinology and Nutrition (S°EyN) of the National Health System of Spain (SNHS) and to develop, based on the results obtained, proposals for improvement policies in the S°EyN.

Material And Methods: Cross-sectional descriptive study of the patients treated in the S°EyN departments of acute general hospitals of the SNHS in 2016. Data were obtained through RECALSEEN 2017, an "ad hoc" survey designed specifically for this purpose, and the Minimum Basic Data Set of discharges given by the S°EN of the SNHS (2015).

Results: 88 responses of S°EyN have been obtained forma total of 125 acute general hospitals of more than 200 beds installed in the SNHS (70% answers). 47% of the S°EyN respondents were services and 31% sections. The average of endocrinologists by S°EyN was 7.4±4.4, and the average rate of endocrinologists per 100,000 inhabitants was 2.3±1. The most relevant care activities were the consultation (average of 12.3 first consultations per thousand inhabitants and year), day hospital (median of 2,000 sessions/year) and in-hospital consultations (median of 900 in-hospital consultations/year). 83% of S°EyNhad a Clinical Nutrition Unit. The number of dietitians, nutrition technicians and nutritionists in the Clinical Nutrition Unit was low. In relation to quality management, a large margin for improvement was detected; only 35% of S°EyN had a responsible of quality and 38% had implemented process management for those most frequent processes in the unit. There were notable differences in structure, resources and activity of S°EyN between Autonomous Communities.

Conclusions: RECALSEEN 2017 survey is a useful tool for the analysis of S°EyN. The remarkable variability found in the structure, activity and management indicators probably indicates significant differences and, therefore, a wide margin for improvement.
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http://dx.doi.org/10.1016/j.endinu.2018.10.002DOI Listing
April 2020

Terms, concepts and definitions in clinical artificial nutrition. The ConT-SEEN Project.

Endocrinol Diabetes Nutr (Engl Ed) 2018 Jan 8;65(1):5-16. Epub 2017 Dec 8.

Grupo de trabajo ConTSEEN del Área de Nutrición de la SEEN.

Background: Imprecision in terms used in the field of clinical nutrition may lead to misinterpretations among professionals.

Objective: For this reason, the Spanish Society of Endocrinology and Nutrition (SEEN) promoted this document on the terms and definitions used in clinical artificial nutrition (enteral and parenteral), establishing an agreement between Spanish experts of this specialty.

Methods: Forty-seven specialists in endocrinology and nutrition, members of the Nutrition Area of the SEEN, participated between April and September 2016. After a systematic literature review, 52 concepts were proposed. The coordinators included two additional concepts, and 57were finally selected by the working group: 13 of a general nature, 30 referring to enteral nutrition and 14 to parenteral nutrition. The degree of agreement was subsequently determined using a two-round Delphi process. It was finally ratified by consistency and concordance analysis.

Results: Fifty-four of the 57 terms had a very consistent agreement and were concordant. Only three showed no concordance, of whom two were very consistent and one inconsistent. In conclusion, there was consensus in the definition of 54 basic terms in the practice of clinical nutrition.
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http://dx.doi.org/10.1016/j.endinu.2017.10.008DOI Listing
January 2018

Evidence-based recommendations and expert consensus on enteral nutrition in the adult patient with diabetes mellitus or hyperglycemia.

Nutrition 2017 Sep 27;41:58-67. Epub 2017 Mar 27.

UGC Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga/Universidad de Málaga, CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases (Instituto de Salud Carlos III: CB07/08/0019), Spain.

Objective: The aim of this study was to develop evidence-based recommendations for glycemic control of patients with diabetes mellitus or stress hyperglycemia who are receiving enteral nutrition (EN).

Methods: A Delphi survey method using Grading Recommendations Assessment, Development and Evaluation criteria was utilized for evaluation of suitable studies.

Results: In patients with diabetes or stress hyperglycemia who were on EN support, the following results were found: CONCLUSIONS: These recommendations and suggestions regarding enteral feeding in patients with diabetes and hyperglycemia have direct clinical applicability.
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http://dx.doi.org/10.1016/j.nut.2017.02.014DOI Listing
September 2017

Prognostic value of obesity on both overall mortality and cardiovascular disease in the general population.

PLoS One 2015 20;10(5):e0127369. Epub 2015 May 20.

Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain; Research Unit, Elda General Hospital, Elda, Spain.

Background: Obesity represents an important health problem and its association with cardiovascular risk factors is well-known. The aim of this work was to assess the correlation between obesity and mortality (both, all-cause mortality and the combined variable of all-cause mortality plus the appearance of a non-fatal first cardiovascular event) in a general population sample from the south-east of Spain.

Materials And Methods: This prospective cohort study used stratified and randomized two-stage sampling. Obesity [body mass index (BMI) ≥ 30 kg/m(2)] as a predictive variable of mortality and cardiovascular events was assessed after controlling for age, sex, cardiovascular disease history, high blood pressure, diabetes mellitus, hypercholesterolemia, high-density lipoprotein/triglycerides ratio, total cholesterol and smoking with the Cox regression model.

Results: The mean follow-up time of the 1,248 participants was 10.6 years. The incidence of all-cause mortality during this period was 97 deaths for every 10,000 person/years (95% CI: 80-113) and the incidence of all-cause mortality+cardiovascular morbidity was 143 cases for every 10,000 person/years (95% CI: 124-163). A BMI ≥ 35 kg/m(2) yielded a hazard ratio for all-cause mortality of 1.94 (95% CI: 1.11-3.42) in comparison to non-obese subjects (BMI <30 kg/m(2)). For the combination of cardiovascular morbidity plus all-cause mortality, a BMI ≥ 35 kg/m(2) had a hazard ratio of 1.84 (95% CI: 1.15-2.93) compared to non-obese subjects.

Conclusions: A BMI ≥ 35 kg/m(2) is an important predictor of both overall mortality and of the combination of cardiovascular morbidity plus all-cause mortality.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0127369PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438865PMC
April 2016

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

Clin Nutr 2015 Oct 13;34(5):962-7. Epub 2014 Nov 13.

Endocrinology and Nutrition Service, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain.

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.
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http://dx.doi.org/10.1016/j.clnu.2014.10.008DOI Listing
October 2015

Hypoglycemia in noncritically ill patients receiving total parenteral nutrition: a multicenter study. (Study group on the problem of hyperglycemia in parenteral nutrition; Nutrition area of the Spanish Society of Endocrinology and Nutrition).

Nutrition 2015 Jan 10;31(1):58-63. Epub 2014 May 10.

Endocrinology and Nutrition Service, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain.

Objective: Hypoglycemia is a common problem among hospitalized patients. Treatment of hyperglycemia with insulin is potentially associated with an increased risk for hypoglycemia. The aim of this study was to determine the prevalence and predictors of hypoglycemia (capillary blood glucose <70 mg/dL) in hospitalized patients receiving total parenteral nutrition (TPN).

Methods: This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill adults who were prescribed TPN were included, thus enabling us to collect data on capillary blood glucose and insulin dosage.

Results: The study included 605 patients of whom 6.8% (n = 41) had at least one capillary blood glucose <70 mg/dL and 2.6% (n = 16) had symptomatic hypoglycemia. The total number of hypoglycemic episodes per 100 d of TPN was 0.82. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes, a lower body mass index (BMI), and treatment with intravenous (IV) insulin. Patients with hypoglycemia also had a significantly longer hospital length of stay, PN duration, higher blood glucose variability, and a higher insulin dose. Multiple logistic regression analysis showed that a lower BMI, high blood glucose variability, and TPN duration were risk factors for hypoglycemia. Use of IV insulin and blood glucose variability were predictors of symptomatic hypoglycemia.

Conclusions: The occurrence of hypoglycemia in noncritically ill patients receiving PN is low. A lower BMI and a greater blood glucose variability and TPN duration are factors associated with the risk for hypoglycemia. IV insulin and glucose variability were predictors of symptomatic hypoglycemia.
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http://dx.doi.org/10.1016/j.nut.2014.04.023DOI Listing
January 2015

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

Endocr Pract 2015 Jan;21(1):59-67

Endocrinology and Nutrition Service, Hospital Universitario Gregorio Marañón, Madrid, Spain.

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.
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http://dx.doi.org/10.4158/EP13441.ORDOI Listing
January 2015

[Integration of a software for hospital nutritional support prescription and the electronic medical record].

Nutr Hosp 2013 Sep-Oct;28(5):1696-701

Servicio de Endocrinología y Nutrición.

Introduction: The prescription of parenteral nutrition is a medical procedure that should be properly documented and that requires adequate communication between physicians, pharmacists and nurses. Prescription may be made by orders and paper forms or with software applications, in which case their integration with the rest of the hospital information systems may be difficult. We present our experience with a software for prescribing artificial nutrition integrated with the electronic medical record.

Methods: In order to develop a software application for artificial nutrition prescription, meetings between the Clinical Nutrition Unit and the Computing Service staff were held, which set the needs of the clinical services and features that should have the application. DESCRIPTION OF THE SOFTWARE: The software allows the prescription of parenteral nutrition component by component or using predesigned templates, generates alerts if extreme value of components or possible physical- chemical incompatibility, imports and stores the results of the labs of patients and records the composition of parenteral nutrition formula in the electronic medical record, among other features.

Discussion: Our experience shows that collaboration between clinical services and hospital Computing permits to develop useful applications for the clinical teams and that can be integrated with other hospital software.
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http://dx.doi.org/10.3305/nh.2013.28.5.6669DOI Listing
September 2014

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

Diabetes Care 2013 May 6;36(5):1061-6. Epub 2012 Dec 6.

Carlos Haya University Hospital, Malaga, Spain.

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.
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http://dx.doi.org/10.2337/dc12-1379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3631871PMC
May 2013

Importance of clinical variables in the diagnosis of MODY2 and MODY3.

Endocrinol Nutr 2011 Aug-Sep;58(7):341-6. Epub 2011 Jul 6.

Sección de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, España.

Aims: MODY (maturity onset diabetes of the young) is a group of well-defined diseases clinically characterised by onset before age 25 years that does not require insulin treatment (at least initially) to prevent the formation of ketone bodies and autosomal dominant inheritance. Despite the importance of accurate classification, it is not always simple to catalogue the diagnosis of a young patient with diabetes, and genetic studies are often improperly used.

Methods: We describe the clinical features of patients negative for MODY2 and MODY3 and compared them to patients positive for these subtypes.

Results: All patients with MODY3 had been diagnosed before age 25 years and required drug therapy for blood glucose control. MODY2 patients were diagnosed at the first laboratory workup either incidentally or as part of gestational diabetes screening. The clinical description of the 19 patients negative for MODY2 and MODY3 showed that only two patients presented a clinical picture consistent with MODY3 and one patient with MODY2.

Conclusions: Clinical features can be used for early exclusion of a MODY2 or MODY3 diagnosis and may reduce the need for genetic testing.
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http://dx.doi.org/10.1016/j.endonu.2011.05.002DOI Listing
January 2012

[Bariatric surgery in duodenal switch procedure: weight changes and associated nutritional deficiencies].

Endocrinol Nutr 2011 May 27;58(5):214-8. Epub 2011 Apr 27.

Sección de Endocrinología y Nutrición, SESCAM, Hospital General Universitario de Albacete, Albacete, España.

Introduction: Bariatric surgery using the technique of duodenal switch is considered as one of the most effective treatments to lose weight and decrease comorbidity in morbidly obese patients. However, we have to be familiar with and adequately manage the various nutritional deficiencies that may occur as a consequence of its practice.

Objectives: To assess weight loss and development of nutritional deficiencies in morbidly obese patients undergoing bariatric surgery through the duodenal switch procedure.

Material And Methods: One hundred and twenty-eight morbidly obese patients underwent a duodenal switch procedure at Hospital General Universitario in Albacete. Weight changes and the most important nutritional deficiencies occurring after surgery were recorded.

Results: Median follow-up time was 30 months (interquartile range, 18 months). Body weight markedly decreased, with mean body mass index (BMI) decreasing from a preoperative value of 52.9±7.7kg/m(2) to 30.8±5.2kg/m(2) 18 months after surgery. The percentage of excess weight lost (% EWL) was 81.4±16.4% in this period. Weight loss slowed down subsequently, reaching its lowest value 30 months after surgery (% EWL 82.1%±16.8, BMI 30.2±4.3kg/m(2)) and tended to stabilize in patients with longer follow-up times. Significant nutritional deficiencies requiring replacement therapy were detected in some micronutrients with iron (42.9%), zinc (38.3%), vitamin A (55.5%), and vitamin D (57.8%) deficiencies being most relevant.

Conclusions: Duodenal switch is a very effective surgical procedure for treating morbidly obese patients because it allows for achieving a significant and sustained weight loss.Close lifetime monitoring is required in these patients because of the high prevalence of nutritional deficiencies during follow-up.
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http://dx.doi.org/10.1016/j.endonu.2011.02.008DOI Listing
May 2011

[Prevalence of known diabetes mellitus and unknown diabetes in adults from Castilla-La Mancha, Spain].

Med Clin (Barc) 2011 Oct 1;137(11):484-90. Epub 2011 Mar 1.

Fundación para la Diabetes de Castilla La-Mancha (FUCAMDI), Ciudad Real, Spain.

Background And Objective: To estimate the prevalence of known diabetes mellitus (KD), unknown diabetes (UD), and carbohydrate metabolism disturbances in a population of Castilla-La Mancha (CLM) older than 30 years old; To study the cardiovascular risk factors related with diabetes.

Patients And Methods: A transversal study was performed in order to determine these prevalence data. Reference date: 2007/06/01. 3,092 subjects were selected, and 1,181 of them (38.1%) participated in the study. A questionnaire, physical exploration and glucose tolerance test were performed. The diagnostic criteria of diabetes were those established by the American Association of Diabetes (ADA) and were compared with the World Health Organization criteria (WHO).

Results: Prevalence of diabetes in individuals younger than 30 years: 17.9% (DM 10.7%, DO 7.2%). Ratio UD/KD: 0.7. Prevalence of impaired glucose tolerance (IGT) 5.6% and impaired fasting glucose (IFG) 22.3% based on ADA criteria and 7.2% if WHO criteria applied. KD, IFT and IFG increased with age. Global prevalence was higher in males (20.9%) than females (14.5%), but the prevalence was higher in females older than 74 years. A positive relationship was found with obesity, male sex, age and familiar history of diabetes.

Conclusions: Prevalence of diabetes in the adult population of CLM is very high, higher in males and increase with age. A great percentage of diabetic people or with carbohydrate metabolism alterations do not know that condition. This situation makes necessary to create early detection strategies.
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http://dx.doi.org/10.1016/j.medcli.2010.11.019DOI Listing
October 2011

[Influence of previous psychiatric disorders on postoperative course in patients undergoing bariatric surgery].

Endocrinol Nutr 2010 Jan;57(1):9-15

Sección de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, España.

Introduction: Presurgical evaluation of patients undergoing bariatric surgery includes, among others, a psychological/psychiatric evaluation. Psychiatric disorders that did not contraindicate surgery may persist and influence on weight loss and postoperative clinical course, hindering the success of the procedure. The aim of our study was to analyze the postoperative evolution of our series of patients with and without psychiatric symptoms before surgery.

Patients And Methods: Retrospective analysis of 109 patients undergoing bariatric surgery with duodenal switch from 2003 to 2008 (follow up > 6 months). We studied weight changes, immediate and delayed complications of surgery and nutritional deficiencies in post-surgical follow-up in patients with previous psychiatric disorders (group 1, n = 17) compared with patients without psychiatric disorders (group 2, n = 92).

Results: Patients in group 1 showed a greater tendency for weight gain. They regained a 9.4% of the initial excess weight lost between 18 months after surgery and 36 months after surgery, while patients in group 2 regained only 0.2% in the same period (p < 0.05). There was no difference in immediate surgical complications (5/17 vs 25/92 patients). The mean incidence of late surgical complications was 0.71 per patient in group 1 and 0.22 complications per patient in group 2 (p = 0.02). 52.9% of patients in group 1 had at least one late complication compared to 19.6% of patients in group 2 (p = 0.003). The three most common complications in patients with previous psychiatric disorders were chronic diarrhea, vomits and malnutrition. The presence of nutritional deficiencies were common in both groups, mainly soluble vitamins, iron and zinc. During postoperative follow-up, we found 3.1 +/- 1.6 nutritional deficiencies per patient in group 1 and 2.5 +/- 1.7 in group 2 (p = 0.04). More than three nutritional deficiencies were found in 8 patients in group 1 (52.9%) compared to 23 patients in group 2 (25%) (p = 0.03).

Conclusions: The presence of previous psychiatric disorders may be a predictor of a less positive outcome in morbidly obese patients who undergo bariatric surgery.
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http://dx.doi.org/10.1016/S1575-0922(10)70003-6DOI Listing
January 2010

Clinical differences between patients with MODY-3, MODY-2 and type 2 diabetes mellitus with I27L polymorphism in the HNF1alpha gene.

Endocrinol Nutr 2010 Jan;57(1):4-8

Sección de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, España.

Objective: The aim of our study was to describe and evaluate the clinical and metabolic characteristics of patients with MODY-3, MODY-2 or type 2 diabetes who presented I27L polymorphism in the HNF1alpha gene.

Methods: The study included 31 previously diagnosed subjects under follow-up for MODY-3 (10 subjects from 5 families), MODY-2 (15 subjects from 9 families), or type 2 diabetes (6 subjects) with I27L polymorphism in the HNF1alpha gene. The demographic, clinical, metabolic, and genetic characteristics of all patients were analyzed.

Results: No differences were observed in distribution according to sex, age of onset, or form of diagnosis. All patients with MODY-2 or MODY-3 had a family history of diabetes. In contrast, 33.3% of patients with type 2 diabetes mellitus and I27L polymorphism in the HNF1alpha gene had no family history of diabetes (p < 0.05). No differences were observed in body mass index, prevalence of hypertension, or microvascular or macrovascular complications. Drug therapy was required by 100% of MODY-3 patients, but not required by 100% of MODY-2 patients or 16.7% of patients with type 2 diabetes mellitus and I27L polymorphism in the HNF1alpha gene (p < 0.05).

Conclusions: Occasional difficulties may be encountered when classifying patients with MODY-2, MODY-3 or type 2 diabetes of atypical characteristics, in this case patients who present I27L polymorphism in the HNF1alpha gene.
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http://dx.doi.org/10.1016/S1575-0922(10)70002-4DOI Listing
January 2010

Rhabdomyolysis due to primary hyperaldosteronism.

Endocrinol Nutr 2009 Oct;56(8):431-4

Sección de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Facultad de Medicina, Universidad de Castilla-La Mancha, Albacete, España.

Rhabdomyolysis may be secondary to trauma, excessive muscle activity, hereditary muscle enzyme defects and other medical causes. Primary hyperaldosteronism is characterised by hypertension, hypokalemia, suppressed plasma renin activity, and increased aldosterone excretion. Rhabdomyolysis is not common in primary hyperaldosteronism. We report here a 42-year-old woman presenting with rhabdomyolysis as heralding symptom of primary hyperaldosteronism. We also carried out a search of the literature to identify all cases of rhabdomyolysis as the first-recognized expression of a primary hyperaldosteronism. Sixteen cases met the criteria for inclusion. When rhabdomyolysis occurs in a patient with hypokalemia and metabolic alkalosis, primary hyperaldosteronism has to be suspected: if confirmed, an aldosterone-producing adenoma is the most probable cause.
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http://dx.doi.org/10.1016/S1575-0922(09)72715-9DOI Listing
October 2009

[Characterization of muscarinic receptors in undifferentiated thyroid cells in Fisher rats].

Endocrinol Nutr 2009 Mar 18;56(3):106-11. Epub 2009 May 18.

Sección de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Facultad de Medicina, Universidad de Castilla La Mancha, Albacete, España.

Introduction: The parasympathetic autonomous nervous system exerts control over thyroid function by activation of the muscarinic receptors in follicular cells. Various pharmacological and molecular subtypes of muscarinic receptors (M(1), M(2), M(3), M(4), M(5)) have been identified in central nervous system and peripheral tissues. Controversy surrounds receptor characterization in thyroid cells.

Materials And Methods: Undifferentiated Fisher rat thyroid epithelial cells (FRT) were cultured. Association and dissociation kinetics assays and antagonist competition studies of the binding of (3)H-N-methylscopolamine ((3)H-NMS) to muscarinic receptors were performed to demonstrate the presence of muscarinic receptors.

Results: Specific muscarinic receptors in the plasma membrane of FRT cells were observed with an equilibrium dissociation constant (K(d)) of 0.44 nmol. The order of affinities obtained fitting the data to one binding site model in competition experiments with the muscarinic receptor antagonist was: dicyclomine > hexahydrosiladifenidol (HHSD) = 4-diphenylacetoxy-N-methylpiperidine methiodide (4-DAMP) > pirenzepine > himbacine = 11-[[2-[(diethylamino)methyl]- 1-piperidinyl]acetyl]-5,11-dihydro-6H-pyrido (414)benzodiazepine (AF-DX 116).

Conclusions: The results obtained indicate the existence of specific (3)H-NMS muscarinic binding sites located in the plasma membrane of FRT cells. The results obtained in competition experiments suggest that the receptors present in FRT cells belong to the M(3) subtype.
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http://dx.doi.org/10.1016/S1575-0922(09)70839-3DOI Listing
March 2009