Efficacy in type 2 diabetes mellitus remission in patients undergoing bariatric surgery | Endocrinología, Diabetes y Nutrición (English ed.)

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"identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "José Enrique" "apellidos" => "Palacio Abizanda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General y Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eficacia en la remisión de la diabetes mellitus tipo 2 en pacientes sometidos a cirugía bariátrica en nuestro medio" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2264 "Ancho" => 2158 "Tamanyo" => 748384 ] ] "descripcion" => array:1 [ "en" => "Predictors of type 2 diabetes mellitus remission after bariatric surgery." ] ] ] "textoCompleto" => "IntroductionObesity and type 2 diabetes mellitus (DM2) are leading public health problems due to their high and increasing prevalence and important associated healthcare costs.<a class="elsevierStyleCrossRefs" href="#bib0100">1,2</a>. In Spain, the Di@bet.es study confirmed the high prevalence of DM2 (13.8%), as well as the clear link between both disorders (>50% of all diabetics were obese).<a class="elsevierStyleCrossRef" href="#bib0110">3</a> The Canary Islands heads the Spanish national ranking for the prevalence of both disorders, as well as for mortality attributable to diabetes.<a class="elsevierStyleCrossRef" href="#bib0115">4</a>The optimal approach to both disease conditions remains a challenge for clinicians. Lifestyle modifications and drug treatments afford modest weight reductions (usually <10%), but the reversal of DM2 is not achieved. Even adequate metabolic control is often not reached. The possibility of using bariatric surgery (BS) as a treatment strategy for reverting or improving DM2 is attracting increasing interest. Many data show metabolic surgery to afford improved glycemic control and to reduce the cardiovascular risk factors in patients with obesity and DM2 as compared to different medical interventions.<a class="elsevierStyleCrossRef" href="#bib0120">5</a>Bariatric surgery exerts potent action at different levels simultaneously. Apart from the restrictive and/or malabsorptive component of the different procedures, which limits nutrient intake or absorption, respectively, BS is characterized by an endocrine and biochemical regulatory component that facilitates dramatic weight loss, and this in turn results in important improvements in carbohydrate metabolism. The known underlying mechanisms include increased levels of peptide YY (anorexigenic action) and decreased ghrelin levels (orexigenic action). In turn, the incretin effect of surgery, with increased circulating levels of GLP-1 and GIP, stimulates insulin secretion, lowers glucagon secretion, and increases the sensation of satiety at the level of the central nervous system.<a class="elsevierStyleCrossRef" href="#bib0125">6</a> Although no studies are available in our setting, a number of trials<a class="elsevierStyleCrossRefs" href="#bib0130">7–10</a> have demonstrated a significant increase in DM2 remission as compared to conventional therapy up to 5 years following surgery, even in patients with grade 1 obesity or overweight.It is difficult to establish comparisons among the existing studies, since the DM2 remission criteria used are different. This has obliged the main scientific bodies to position themselves on this matter. The most commonly used criteria in our setting are those of the SEEN-SECO-SEEDO-SED consensus of 2013<a class="elsevierStyleCrossRef" href="#bib0150">11</a> and those of the American Diabetes Association (ADA) of 2009<a class="elsevierStyleCrossRef" href="#bib0155">12</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The present study was designed to analyze the potential benefit of BS in patients with DM2 in our setting, as well as to identify the factors associated with an improved response, with a view to allowing the selection of those patients who stand to benefit most from BS. Lastly, an analysis was made of the correlation between the DM2 remission classifications of the Spanish national and American consensuses.Material and methodsA retrospective study was made of diabetic patients monitored at nutrition clinics following Roux-en-Y gastric bypass surgery (RYGB) between January 2009 and November 2015 (n=106). A variant of RYGB adjusted to the body mass index (BMI) is performed at our center. It involves the creation of a small gastric reservoir with a capacity of about 15–30ml, a 100-cm biliopancreatic loop, and a feed loop with a length conditioned to the BMI:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Patients with a BMI 40–45kg/m2: 170cm feed loop.</li><li class="elsevierStyleListItem" id="lsti0010">-Patients with a BMI 45–50kg/m2: 260cm feed loop.</li><li class="elsevierStyleListItem" id="lsti0015">-Patients with a BMI 50–55kg/m2: 350cm feed loop.</li><li class="elsevierStyleListItem" id="lsti0020">-Patients with a BMI 55–60kg/m2: 440cm feed loop.</li><li class="elsevierStyleListItem" id="lsti0025">-Patients with a BMI >60kg/m: 530cm feed loop.</li></ul>We always check that there is at least 180cm of common loop.The following variables were recorded: age, gender, years from diabetes onset, antidiabetic treatment, the type and dose of insulin, the date of surgery, the surgical procedure, weight and the BMI (maximum, presurgery and at each annual visit), the percentage of overweight lost, DM progression after surgery (according to Spanish national and American consensus criteria), HbA1c and glycemia at each annual visit. A descriptive analysis of the above variables was made, and correlations were established between the classifications of both consensuses. In order to identify possible predictors of DM remission in the patients operated on, we divided the sample into two groups: (a) patients in complete remission; and (b) the remainder of the sample. The following variables were compared between the two groups: age, time from DM onset, insulin treatment before surgery, and the BMI before surgery.Statistical analysisQualitative variables were reported with their frequency distribution. Quantitative variables were reported as the mean±standard deviation (SD). Continuous variables were compared using the Student t-test, while categorical variables were contrasted with the chi-squared test. Statistical significance was considered for p<0.05. The SPSS version 24 statistical package (IBM, 2016) was used throughout.ResultsPatients undergoing RYGB in the period January 2009 and November 2015 were included in the study. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the baseline characteristics of the patients.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The mean duration of follow-up was 3.5 years (range: 1–8). <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the evolutive changes of the anthropometric and metabolic parameters and of DM in the first 5 years after surgery. A very good correlation was observed between the Spanish national and American classifications of DM remission after BS (rho=0.974; p<0.001) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>The identified markers of a lesser probability of achieving DM remission after surgery (according to national criteria) were: age >50 years (54.4% vs. 88.2%; p=0.001), DM2 duration >10 years (26.3% vs. 81.8%; p<0.001), HbA1c≥8% before surgery (40% vs. 77%; p=0.001) and treatment with insulin before surgery (31.3% vs. 87.9%; p<0.001). By contrast, no association with DM2 remission was observed for the BMI before surgery (p=0.729) or for the percentage overweight lost after BS (p=0.710) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The behavior with the ADA criteria was identical, the markers of a lesser probability of achieving DM remission after surgery being: age >50 years (49.1% vs. 79.4%; p=0.004), DM2 duration >10 years (26.3% vs. 72.7%; p<0.001), HbA1c≥8% before surgery (36% vs. 68.9%; p=0.005) and treatment with insulin before surgery (21.9% vs. 82.8%; p<0.001). Similarly, no association with DM2 remission was observed for the BMI before surgery (p=0.343) or for the percentage overweight lost after BS (p=0.440). In patients receiving insulin, high insulin doses (>80U/day) were associated with poorer remission rates according to the national criteria (7.7% vs 46.7%; p=0.023).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>DiscussionType 2 diabetes mellitus has traditionally been considered a chronic disease, because fewer than 15% of all patients achieved remission with conventional treatment (lifestyle modifications and drug therapy).<a class="elsevierStyleCrossRefs" href="#bib0160">13,14</a> In our study, 65.9% of the patients achieved complete remission of DM2 at one year. This figure is in the upper range of the DM2 remission rates documented in the clinical trials published to date (30–63%).<a class="elsevierStyleCrossRef" href="#bib0120">5</a>The percentage of patients in remission in our sample remained constant at 5 years, though a decrease in this figure was seen in the third year of follow-up. We find no explanation for this observation. A slow but progressive increase was seen in HbA1c (without reaching >6.5%). In concordance with our results, the available data show a decrease in percentage DM2 remission over time (with a reappearance of the disease in 35–50% of all cases over the longer term). However, the median disease-free period after RYGB is 8.3 years,<a class="elsevierStyleCrossRefs" href="#bib0170">15,16</a> and most patients subjected to BS maintain substantial improvements in glycemic control for at least 5 years.<a class="elsevierStyleCrossRef" href="#bib0130">7</a>In coincidence with our own observations, a younger age, a shorter time from the onset of DM2, no prior insulin treatment, and better prior metabolic control are consistently associated in the literature with higher DM2 remission rates after BS.<a class="elsevierStyleCrossRefs" href="#bib0135">8,17,18</a> The explanation for this is probably that the benefit upon the pancreatic islets of the hormonal changes occurring after the reconstruction of gastrointestinal transit depends on the mass of beta-cells present at the time of BS (the more evolved the disease, the smaller the beta-cell mass and the lesser the probability of DM2 remission). The practical consequence of this should be the avoidance of surgical delays in obese diabetic patients in which BS is indicated.The third objective of our study was to analyze the correlation between the Spanish national and the American criteria, which proved to be very good. We even found the association between the predictors of BS success and DM2 remission to be greater with the national criteria<a class="elsevierStyleCrossRef" href="#bib0150">11</a> than with the American criteria.<a class="elsevierStyleCrossRef" href="#bib0155">12</a> This suggests that our consensus criteria have at least the same consistency and external validity as those of the ADA. The mentioned criteria also offer the advantage of including a fourth category (“improvement”), which includes patients who have adequate metabolic control even if they are unable to discontinue drug treatment for DM2. This allows for a more exhaustive evaluation of BS success in terms of improved glycemic control.The main strengths of our study are the large sample size and data compilation consistent with the main clinical trials conducted to date in the “real-life” clinical practice setting. By contrast, the most significant limitations of our study were its retrospective design and the short follow-up time (3.5 years on average), which possibly precluded the detection of more DM relapses. In any case, in the subgroup of patients with 5 years of follow-up, the remission levels remained virtually unchanged. This indicates that BS affords at least 5 years of good metabolic control, with the expected associated benefits in terms of a decrease in micro- and macrovascular complications over the long term. Another limitation of our study is the fact that C peptide was not measured before surgery, this peptide having been shown to be an important marker of DM2 remission after BS.<a class="elsevierStyleCrossRef" href="#bib0190">19</a>In conclusion, our results show BS to be associated with high DM2 remission rates in morbidly obese individuals subjected to surgery at our center, with a very good correlation between the Spanish national and ADA disease remission criteria. A patient age of over 50 years, long-evolving DM2, poorer initial metabolic control (HbA1c≥8%) and prior insulin treatment are indicators of a poorer response to BS in terms of DM2 remission.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1142695" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1073334" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1142694" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1073333" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-09" "fechaAceptado" => "2018-08-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1073334" "palabras" => array:4 [ 0 => "Type 2 diabetes mellitus remission" 1 => "Metabolic surgery" 2 => "Bariatric surgery" 3 => "Type 2 diabetes mellitus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1073333" "palabras" => array:4 [ 0 => "Remisión diabetes mellitus tipo 2" 1 => "Cirugía metabólica" 2 => "Cirugía bariátrica" 3 => "Diabetes mellitus tipo 2" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo assess remission of type 2 diabetes mellitus (T2DM) after bariatric surgery, to analyze potential conditioning factors, and to compare Spanish and American remission criteria. Material and methodsA retrospective study of diabetic patients undergoing Roux-en-Y gastric bypass from 2009 to 2015. Data collected included age, sex, time since T2DM diagnosis, antidiabetic drugs, insulin (type and dose), weight and BMI, percent excess weight lost, HbA1c, blood glucose levels, and course of T2DM after surgery according to Spanish and American criteria, including a descriptive analysis and correlation between both. ResultsThe study sample consisted of 106 patients. Outcomes one year after surgery was as follows (Spanish criteria): complete remission 65.9%, partial remission 5.5%, improvement 18.9%, no change 9.7% (at 5 years: 68.4, 5.3, 10.5, and 15.8%, respectively). Outcomes according to ADA criteria were as follows: complete remission 61.5%, partial remission 5.3%, and no remission 28.6% (after 5 years, complete remission 68.4%). There was a good correlation between both classifications (rho=0.974; p<0.001). Mean HbA1c levels: 7.3±1.8% at baseline; 5.7±1% at one year; 6.3±1.2% at 5 years. Chance of remission was lower in patients aged over 50 years (54.4% vs. 88.2%; p=0.001), with T2DM diagnosed more than 10 years before (26.3% vs. 81.8%; p<0.001), on insulin treatment (31.3% vs. 87.9%; p<0.001), and with HbA1c levels ≥8% (40% vs. 77%; p=0.001). ConclusionsAt our hospital, bariatric surgery is associated to a high remission rate of T2DM in patients with morbid obesity, with a good correlation between Spanish and American criteria. Age over 50 years old, long T2DM duration, poorer baseline metabolic control, and previous insulin treatment are markers of poorer response." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosEvaluar la remisión de la diabetes mellitus tipo 2 (DM-2) tras cirugía bariátrica; analizar potenciales factores condicionantes y comparar criterios de remisión nacionales y americanos. Material y métodosEstudio retrospectivo de pacientes diabéticos sometidos a bypass gástrico en Y de Roux entre 2009-2015. Variables recogidas: edad, sexo, años de evolución de DM-2, antidiabéticos, insulina (tipo y dosis), peso e IMC, porcentaje de sobrepeso perdido, HbA1c, glucemia y evolución de la DM-2 tras cirugía según criterios nacionales y americanos. Análisis descriptivo y correlación entre ambos consensos. ResultadosSe incluyeron 106 pacientes. Al año de la intervención (criterios nacionales): remisión completa 65,9%, remisión parcial 5,5%, mejoría 18,9% y sin cambios 9,7% (a los 5 años: 68,4; 5,3; 10,5 y 15,8%, respectivamente). Según criterios ADA: remisión completa 61,5%, remisión parcial 5,3% y sin remisión 28,6% (a los 5 años, remisión completa 68,4%). Buena correlación entre ambas clasificaciones (Rho=0,974; p<0,001). HbA1c media inicial: 7,3±1,8%; al año: 5,7±1%; a 5 años: 6,3±1,2%. Resultaron marcadores de peor probabilidad de remisión: edad superior a 50 años (54,4 vs. 88,2%; p=0,001), DM-2 de más de 10 años (26,3 vs. 81,8%; p<0,001), tratamiento con insulina (31,3 vs. 87,9%; p<0,001) y HbA1c≥8% (40 vs. 77%; p=0,001). ConclusionesEn nuestro centro, la cirugía bariátrica se asocia a una elevada tasa de remisión de DM-2 en pacientes con obesidad mórbida intervenidos, existiendo una buena correlación entre los criterios nacionales y los americanos. La edad superior a 50 años, una larga evolución de la DM-2, un peor control metabólico inicial y el tratamiento previo con insulina son marcadores de peor respuesta." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pereyra-García Castro FM, Oliva García JG, García Nuñez MA, García Bray BF, Suarez Llanos JP, Moneva Arce ME, et al. Eficacia en la remisión de la diabetes mellitus tipo 2 en pacientes sometidos a cirugía bariátrica en nuestro medio. Endocrinol Diabetes Nutr. 2019;66:56–61." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2434 "Ancho" => 1505 "Tamanyo" => 683921 ] ] "descripcion" => array:1 [ "en" => "Correlation of remission criteria for type 2 diabetes mellitus after bariatric surgery (Spanish national vs. American) one year after surgery." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2264 "Ancho" => 2158 "Tamanyo" => 748384 ] ] "descripcion" => array:1 [ "en" => "Predictors of type 2 diabetes mellitus remission after bariatric surgery." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ADA: American Diabetes Association; HbA1c: glycosylated hemoglobin; SECO: Sociedad Española de Cirugía de la Obesidad; SED: Sociedad Española de Diabetes; SEEDO: Sociedad Española para el Estudio de la Obesidad; SEEN: Sociedad Española de Endocrinología y Nutrición." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Consensus criteria</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">SEEN-SECO-SEEDO-SED (2013)</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Complete remission</td><td class="td" title="table-entry " align="left" valign="top">HbA1c<6.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glycemia<100mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Partial remission</td><td class="td" title="table-entry " align="left" valign="top">HbA1c<6.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glycemia=100–125mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Improvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HbA1c<7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged remission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">At least 5 years of complete remission \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1950030.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No changes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Remaining cases \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">ADA (2009) consensus criteria</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Complete remission</td><td class="td" title="table-entry " align="left" valign="top">HbA1c<6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood glucose<100mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Partial remission</td><td class="td" title="table-entry " align="left" valign="top">HbA1c<6.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood glucose=100–125mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged remission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">At least 5 years of complete remission \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No changes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Remaining cases \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1950031.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Type 2 diabetes mellitus remission criteria." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "GLP-1 A: glucagon-like peptide-1 analog; OADs: oral antidiabetic drugs; SD: standard deviation; DM2: type 2 diabetes mellitus; HbA1c: glycosylated hemoglobin; BMI: body mass index." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cohort (n=106) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51.8±9.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female gender, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88 (83) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of DM2 (years), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.6±5.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Pharmacological treatment</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">OADs, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 (89.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A-GLP-1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (9.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insulin, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 (34.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (10.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mixtures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bolus-basal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (9.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Daily insulin dose (U/day), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86.2±47.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maximum weight (kg), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">129.5±21.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maximum BMI (kg/m2), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49.6±6.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight before surgery (kg), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">119.9±20.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI before surgery (kg/m2), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45.7±5.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HbA1c(%), mean±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.3±1.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1950029.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of the study sample." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "DM (1): evolution of type 2 diabetes mellitus according to Spanish national consensus criteria; DM (2): evolution of type 2 diabetes mellitus according to American Diabetes Association (ADA) consensus criteria; BMI: body mass index; I: improvement; POL: percentage overweight lost; CR: complete remission; PR: partial remission.Source: Rubio et al.<a class="elsevierStyleCrossRef" href="#bib0150">11</a> and Buse et al.<a class="elsevierStyleCrossRef" href="#bib0155">12</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5 years \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.3±4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.9±4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.7±3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.9±3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.9±4.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">POL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.4±22.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.5±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.6±17.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.4±13.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.5±15.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glucose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.8±30.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103.8±37.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">109.1±36.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106.6±36.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">107.6±34.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HbA1c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.7±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.8±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.2±1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.2±1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.3±1.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">DM (1)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">DM (2)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1950028.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Evolution of anthropometric and metabolic parameters." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K.M. 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Original article

Efficacy in type 2 diabetes mellitus remission in patients undergoing bariatric surgery

Eficacia en la remisión de la diabetes mellitus tipo 2 en pacientes sometidos a cirugía bariátrica en nuestro medio

Francisca María Pereyra-García Castroa,

Corresponding author

francispereyra@telefonica.net

Corresponding author.

, José Gregorio Oliva Garcíaa, María Araceli García Nuñeza, Bruno Francisco García Braya, José Pablo Suarez Llanosa, Modesto Enrique Moneva Arceb, José Enrique Palacio Abizandaa

a Servicio de Endocrinología y Nutrición, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain

b Servicio de Cirugía General y Digestivo, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Obesity and type 2 diabetes mellitus &#40;DM2&#41; are leading public health problems due to their high and increasing prevalence and important associated healthcare costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; In Spain&#44; the Di&#64;bet&#46;es study confirmed the high prevalence of DM2 &#40;13&#46;8&#37;&#41;&#44; as well as the clear link between both disorders &#40;&#62;50&#37; of all diabetics were obese&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> The Canary Islands heads the Spanish national ranking for the prevalence of both disorders&#44; as well as for mortality attributable to diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The optimal approach to both disease conditions remains a challenge for clinicians&#46; Lifestyle modifications and drug treatments afford modest weight reductions &#40;usually &#60;10&#37;&#41;&#44; but the reversal of DM2 is not achieved&#46; Even adequate metabolic control is often not reached&#46; The possibility of using bariatric surgery &#40;BS&#41; as a treatment strategy for reverting or improving DM2 is attracting increasing interest&#46; Many data show metabolic surgery to afford improved glycemic control and to reduce the cardiovascular risk factors in patients with obesity and DM2 as compared to different medical interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Bariatric surgery exerts potent action at different levels simultaneously&#46; Apart from the restrictive and&#47;or malabsorptive component of the different procedures&#44; which limits nutrient intake or absorption&#44; respectively&#44; BS is characterized by an endocrine and biochemical regulatory component that facilitates dramatic weight loss&#44; and this in turn results in important improvements in carbohydrate metabolism&#46; The known underlying mechanisms include increased levels of peptide YY &#40;anorexigenic action&#41; and decreased ghrelin levels &#40;orexigenic action&#41;&#46; In turn&#44; the incretin effect of surgery&#44; with increased circulating levels of GLP-1 and GIP&#44; stimulates insulin secretion&#44; lowers glucagon secretion&#44; and increases the sensation of satiety at the level of the central nervous system&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> Although no studies are available in our setting&#44; a number of trials<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#8211;10</span></a> have demonstrated a significant increase in DM2 remission as compared to conventional therapy up to 5 years following surgery&#44; even in patients with grade 1 obesity or overweight&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is difficult to establish comparisons among the existing studies&#44; since the DM2 remission criteria used are different&#46; This has obliged the main scientific bodies to position themselves on this matter&#46; The most commonly used criteria in our setting are those of the SEEN-SECO-SEEDO-SED consensus of 2013<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> and those of the American Diabetes Association &#40;ADA&#41; of 2009<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The present study was designed to analyze the potential benefit of BS in patients with DM2 in our setting&#44; as well as to identify the factors associated with an improved response&#44; with a view to allowing the selection of those patients who stand to benefit most from BS&#46; Lastly&#44; an analysis was made of the correlation between the DM2 remission classifications of the Spanish national and American consensuses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective study was made of diabetic patients monitored at nutrition clinics following Roux-en-Y gastric bypass surgery &#40;RYGB&#41; between January 2009 and November 2015 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>106&#41;&#46; A variant of RYGB adjusted to the body mass index &#40;BMI&#41; is performed at our center&#46; It involves the creation of a small gastric reservoir with a capacity of about 15&#8211;30<span class="elsevierStyleHsp" style=""></span>ml&#44; a 100-cm biliopancreatic loop&#44; and a feed loop with a length conditioned to the BMI&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients with a BMI 40&#8211;45<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#58; 170<span class="elsevierStyleHsp" style=""></span>cm feed loop&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients with a BMI 45&#8211;50<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#58; 260<span class="elsevierStyleHsp" style=""></span>cm feed loop&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with a BMI 50&#8211;55<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#58; 350<span class="elsevierStyleHsp" style=""></span>cm feed loop&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients with a BMI 55&#8211;60<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#58; 440<span class="elsevierStyleHsp" style=""></span>cm feed loop&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with a BMI &#62;60<span class="elsevierStyleHsp" style=""></span>kg&#47;m&#58; 530<span class="elsevierStyleHsp" style=""></span>cm feed loop&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">We always check that there is at least 180<span class="elsevierStyleHsp" style=""></span>cm of common loop&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The following variables were recorded&#58; age&#44; gender&#44; years from diabetes onset&#44; antidiabetic treatment&#44; the type and dose of insulin&#44; the date of surgery&#44; the surgical procedure&#44; weight and the BMI &#40;maximum&#44; presurgery and at each annual visit&#41;&#44; the percentage of overweight lost&#44; DM progression after surgery &#40;according to Spanish national and American consensus criteria&#41;&#44; HbA<span class="elsevierStyleInf">1c</span> and glycemia at each annual visit&#46; A descriptive analysis of the above variables was made&#44; and correlations were established between the classifications of both consensuses&#46; In order to identify possible predictors of DM remission in the patients operated on&#44; we divided the sample into two groups&#58; &#40;a&#41; patients in complete remission&#59; and &#40;b&#41; the remainder of the sample&#46; The following variables were compared between the two groups&#58; age&#44; time from DM onset&#44; insulin treatment before surgery&#44; and the BMI before surgery&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Qualitative variables were reported with their frequency distribution&#46; Quantitative variables were reported as the mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#46; Continuous variables were compared using the Student <span class="elsevierStyleItalic">t</span>-test&#44; while categorical variables were contrasted with the chi-squared test&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; The SPSS version 24 statistical package &#40;IBM&#44; 2016&#41; was used throughout&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">Patients undergoing RYGB in the period January 2009 and November 2015 were included in the study&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the baseline characteristics of the patients&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The mean duration of follow-up was 3&#46;5 years &#40;range&#58; 1&#8211;8&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the evolutive changes of the anthropometric and metabolic parameters and of DM in the first 5 years after surgery&#46; A very good correlation was observed between the Spanish national and American classifications of DM remission after BS &#40;rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;974&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The identified markers of a lesser probability of achieving DM remission after surgery &#40;according to national criteria&#41; were&#58; age &#62;50 years &#40;54&#46;4&#37; vs&#46; 88&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; DM2 duration &#62;10 years &#40;26&#46;3&#37; vs&#46; 81&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>8&#37; before surgery &#40;40&#37; vs&#46; 77&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and treatment with insulin before surgery &#40;31&#46;3&#37; vs&#46; 87&#46;9&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; By contrast&#44; no association with DM2 remission was observed for the BMI before surgery &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;729&#41; or for the percentage overweight lost after BS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;710&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The behavior with the ADA criteria was identical&#44; the markers of a lesser probability of achieving DM remission after surgery being&#58; age &#62;50 years &#40;49&#46;1&#37; vs&#46; 79&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; DM2 duration &#62;10 years &#40;26&#46;3&#37; vs&#46; 72&#46;7&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>8&#37; before surgery &#40;36&#37; vs&#46; 68&#46;9&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; and treatment with insulin before surgery &#40;21&#46;9&#37; vs&#46; 82&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Similarly&#44; no association with DM2 remission was observed for the BMI before surgery &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;343&#41; or for the percentage overweight lost after BS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;440&#41;&#46; In patients receiving insulin&#44; high insulin doses &#40;&#62;80<span class="elsevierStyleHsp" style=""></span>U&#47;day&#41; were associated with poorer remission rates according to the national criteria &#40;7&#46;7&#37; vs 46&#46;7&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;023&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Type 2 diabetes mellitus has traditionally been considered a chronic disease&#44; because fewer than 15&#37; of all patients achieved remission with conventional treatment &#40;lifestyle modifications and drug therapy&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">13&#44;14</span></a> In our study&#44; 65&#46;9&#37; of the patients achieved complete remission of DM2 at one year&#46; This figure is in the upper range of the DM2 remission rates documented in the clinical trials published to date &#40;30&#8211;63&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The percentage of patients in remission in our sample remained constant at 5 years&#44; though a decrease in this figure was seen in the third year of follow-up&#46; We find no explanation for this observation&#46; A slow but progressive increase was seen in HbA<span class="elsevierStyleInf">1c</span> &#40;without reaching &#62;6&#46;5&#37;&#41;&#46; In concordance with our results&#44; the available data show a decrease in percentage DM2 remission over time &#40;with a reappearance of the disease in 35&#8211;50&#37; of all cases over the longer term&#41;&#46; However&#44; the median disease-free period after RYGB is 8&#46;3 years&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">15&#44;16</span></a> and most patients subjected to BS maintain substantial improvements in glycemic control for at least 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In coincidence with our own observations&#44; a younger age&#44; a shorter time from the onset of DM2&#44; no prior insulin treatment&#44; and better prior metabolic control are consistently associated in the literature with higher DM2 remission rates after BS&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8&#44;17&#44;18</span></a> The explanation for this is probably that the benefit upon the pancreatic islets of the hormonal changes occurring after the reconstruction of gastrointestinal transit depends on the mass of beta-cells present at the time of BS &#40;the more evolved the disease&#44; the smaller the beta-cell mass and the lesser the probability of DM2 remission&#41;&#46; The practical consequence of this should be the avoidance of surgical delays in obese diabetic patients in which BS is indicated&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The third objective of our study was to analyze the correlation between the Spanish national and the American criteria&#44; which proved to be very good&#46; We even found the association between the predictors of BS success and DM2 remission to be greater with the national criteria<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> than with the American criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> This suggests that our consensus criteria have at least the same consistency and external validity as those of the ADA&#46; The mentioned criteria also offer the advantage of including a fourth category &#40;&#8220;improvement&#8221;&#41;&#44; which includes patients who have adequate metabolic control even if they are unable to discontinue drug treatment for DM2&#46; This allows for a more exhaustive evaluation of BS success in terms of improved glycemic control&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The main strengths of our study are the large sample size and data compilation consistent with the main clinical trials conducted to date in the &#8220;real-life&#8221; clinical practice setting&#46; By contrast&#44; the most significant limitations of our study were its retrospective design and the short follow-up time &#40;3&#46;5 years on average&#41;&#44; which possibly precluded the detection of more DM relapses&#46; In any case&#44; in the subgroup of patients with 5 years of follow-up&#44; the remission levels remained virtually unchanged&#46; This indicates that BS affords at least 5 years of good metabolic control&#44; with the expected associated benefits in terms of a decrease in micro- and macrovascular complications over the long term&#46; Another limitation of our study is the fact that C peptide was not measured before surgery&#44; this peptide having been shown to be an important marker of DM2 remission after BS&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results show BS to be associated with high DM2 remission rates in morbidly obese individuals subjected to surgery at our center&#44; with a very good correlation between the Spanish national and ADA disease remission criteria&#46; A patient age of over 50 years&#44; long-evolving DM2&#44; poorer initial metabolic control &#40;HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>8&#37;&#41; and prior insulin treatment are indicators of a poorer response to BS in terms of DM2 remission&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-03-09"
    "fechaAceptado" => "2018-08-02"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Type 2 diabetes mellitus remission"
            1 => "Metabolic surgery"
            2 => "Bariatric surgery"
            3 => "Type 2 diabetes mellitus"
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            0 => "Remisi&#243;n diabetes mellitus tipo 2"
            1 => "Cirug&#237;a metab&#243;lica"
            2 => "Cirug&#237;a bari&#225;trica"
            3 => "Diabetes mellitus tipo 2"
          ]
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess remission of type 2 diabetes mellitus &#40;T2DM&#41; after bariatric surgery&#44; to analyze potential conditioning factors&#44; and to compare Spanish and American remission criteria&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study of diabetic patients undergoing Roux-en-Y gastric bypass from 2009 to 2015&#46; Data collected included age&#44; sex&#44; time since T2DM diagnosis&#44; antidiabetic drugs&#44; insulin &#40;type and dose&#41;&#44; weight and BMI&#44; percent excess weight lost&#44; HbA<span class="elsevierStyleInf">1c</span>&#44; blood glucose levels&#44; and course of T2DM after surgery according to Spanish and American criteria&#44; including a descriptive analysis and correlation between both&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study sample consisted of 106 patients&#46; Outcomes one year after surgery was as follows &#40;Spanish criteria&#41;&#58; complete remission 65&#46;9&#37;&#44; partial remission 5&#46;5&#37;&#44; improvement 18&#46;9&#37;&#44; no change 9&#46;7&#37; &#40;at 5 years&#58; 68&#46;4&#44; 5&#46;3&#44; 10&#46;5&#44; and 15&#46;8&#37;&#44; respectively&#41;&#46; Outcomes according to ADA criteria were as follows&#58; complete remission 61&#46;5&#37;&#44; partial remission 5&#46;3&#37;&#44; and no remission 28&#46;6&#37; &#40;after 5 years&#44; complete remission 68&#46;4&#37;&#41;&#46; There was a good correlation between both classifications &#40;rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;974&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Mean HbA<span class="elsevierStyleInf">1c</span> levels&#58; 7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&#37; at baseline&#59; 5&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#37; at one year&#59; 6&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#37; at 5 years&#46; Chance of remission was lower in patients aged over 50 years &#40;54&#46;4&#37; vs&#46; 88&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; with T2DM diagnosed more than 10 years before &#40;26&#46;3&#37; vs&#46; 81&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; on insulin treatment &#40;31&#46;3&#37; vs&#46; 87&#46;9&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and with HbA<span class="elsevierStyleInf">1c</span> levels &#8805;8&#37; &#40;40&#37; vs&#46; 77&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">At our hospital&#44; bariatric surgery is associated to a high remission rate of T2DM in patients with morbid obesity&#44; with a good correlation between Spanish and American criteria&#46; Age over 50 years old&#44; long T2DM duration&#44; poorer baseline metabolic control&#44; and previous insulin treatment are markers of poorer response&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la remisi&#243;n de la diabetes mellitus tipo 2 &#40;DM-2&#41; tras cirug&#237;a bari&#225;trica&#59; analizar potenciales factores condicionantes y comparar criterios de remisi&#243;n nacionales y americanos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de pacientes diab&#233;ticos sometidos a bypass g&#225;strico en Y de Roux entre 2009-2015&#46; Variables recogidas&#58; edad&#44; sexo&#44; a&#241;os de evoluci&#243;n de DM-2&#44; antidiab&#233;ticos&#44; insulina &#40;tipo y dosis&#41;&#44; peso e IMC&#44; porcentaje de sobrepeso perdido&#44; HbA<span class="elsevierStyleInf">1c</span>&#44; glucemia y evoluci&#243;n de la DM-2 tras cirug&#237;a seg&#250;n criterios nacionales y americanos&#46; An&#225;lisis descriptivo y correlaci&#243;n entre ambos consensos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 106 pacientes&#46; Al a&#241;o de la intervenci&#243;n &#40;criterios nacionales&#41;&#58; remisi&#243;n completa 65&#44;9&#37;&#44; remisi&#243;n parcial 5&#44;5&#37;&#44; mejor&#237;a 18&#44;9&#37; y sin cambios 9&#44;7&#37; &#40;a los 5 a&#241;os&#58; 68&#44;4&#59; 5&#44;3&#59; 10&#44;5 y 15&#44;8&#37;&#44; respectivamente&#41;&#46; Seg&#250;n criterios ADA&#58; remisi&#243;n completa 61&#44;5&#37;&#44; remisi&#243;n parcial 5&#44;3&#37; y sin remisi&#243;n 28&#44;6&#37; &#40;a los 5 a&#241;os&#44; remisi&#243;n completa 68&#44;4&#37;&#41;&#46; Buena correlaci&#243;n entre ambas clasificaciones &#40;Rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;974&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; HbA<span class="elsevierStyleInf">1c</span> media inicial&#58; 7&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;8&#37;&#59; al a&#241;o&#58; 5&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#37;&#59; a 5 a&#241;os&#58; 6&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2&#37;&#46; Resultaron marcadores de peor probabilidad de remisi&#243;n&#58; edad superior a 50 a&#241;os &#40;54&#44;4 vs&#46; 88&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; DM-2 de m&#225;s de 10 a&#241;os &#40;26&#44;3 vs&#46; 81&#44;8&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; tratamiento con insulina &#40;31&#44;3 vs&#46; 87&#44;9&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>8&#37; &#40;40 vs&#46; 77&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestro centro&#44; la cirug&#237;a bari&#225;trica se asocia a una elevada tasa de remisi&#243;n de DM-2 en pacientes con obesidad m&#243;rbida intervenidos&#44; existiendo una buena correlaci&#243;n entre los criterios nacionales y los americanos&#46; La edad superior a 50 a&#241;os&#44; una larga evoluci&#243;n de la DM-2&#44; un peor control metab&#243;lico inicial y el tratamiento previo con insulina son marcadores de peor respuesta&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Pereyra-Garc&#237;a Castro FM&#44; Oliva Garc&#237;a JG&#44; Garc&#237;a Nu&#241;ez MA&#44; Garc&#237;a Bray BF&#44; Suarez Llanos JP&#44; Moneva Arce ME&#44; et al&#46; Eficacia en la remisi&#243;n de la diabetes mellitus tipo 2 en pacientes sometidos a cirug&#237;a bari&#225;trica en nuestro medio&#46; Endocrinol Diabetes Nutr&#46; 2019&#59;66&#58;56&#8211;61&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Correlation of remission criteria for type 2 diabetes mellitus after bariatric surgery &#40;Spanish national vs&#46; American&#41; one year after surgery&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ADA&#58; American Diabetes Association&#59; HbA<span class="elsevierStyleInf">1c</span>&#58; glycosylated hemoglobin&#59; SECO&#58; Sociedad Espa&#241;ola de Cirug&#237;a de la Obesidad&#59; SED&#58; Sociedad Espa&#241;ola de Diabetes&#59; SEEDO&#58; Sociedad Espa&#241;ola para el Estudio de la Obesidad&#59; SEEN&#58; Sociedad Espa&#241;ola de Endocrinolog&#237;a y Nutrici&#243;n&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Consensus criteria</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">SEEN-SECO-SEEDO-SED &#40;2013&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete remission</td><td class="td" title="table-entry  " align="left" valign="top">HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glycemia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Partial remission</td><td class="td" title="table-entry  " align="left" valign="top">HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glycemia<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>100&#8211;125<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prolonged remission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At least 5 years of complete remission&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Remaining cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">ADA &#40;2009&#41; consensus criteria</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete remission</td><td class="td" title="table-entry  " align="left" valign="top">HbA<span class="elsevierStyleInf">1c</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood glucose<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>100&#8211;125<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No antidiabetic drugs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At least 5 years of complete remission&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Remaining cases&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Type 2 diabetes mellitus remission criteria&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">GLP-1 A&#58; glucagon-like peptide-1 analog&#59; OADs&#58; oral antidiabetic drugs&#59; SD&#58; standard deviation&#59; DM2&#58; type 2 diabetes mellitus&#59; HbA<span class="elsevierStyleInf">1c</span>&#58; glycosylated hemoglobin&#59; BMI&#58; body mass index&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Pharmacological treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">OADs&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Insulin&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;10&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Mixtures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Bolus-basal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Daily insulin dose &#40;U&#47;day&#41;&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>47&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Maximum weight &#40;kg&#41;&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">129&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Maximum BMI &#40;kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">2</span></span><span class="elsevierStyleBold">&#41;&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Weight before surgery &#40;kg&#41;&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">119&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">BMI before surgery &#40;kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">2</span></span><span class="elsevierStyleBold">&#41;&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">HbA</span><span class="elsevierStyleInf"><span class="elsevierStyleBold">1c</span></span><span class="elsevierStyleBold">&#40;&#37;&#41;&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">DM &#40;1&#41;&#58; evolution of type 2 diabetes mellitus according to Spanish national consensus criteria&#59; DM &#40;2&#41;&#58; evolution of type 2 diabetes mellitus according to American Diabetes Association &#40;ADA&#41; consensus criteria&#59; BMI&#58; body mass index&#59; I&#58; improvement&#59; POL&#58; percentage overweight lost&#59; CR&#58; complete remission&#59; PR&#58; partial remission&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Rubio et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> and Buse et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a></p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">109&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">106&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 25300180
Original language: English

DOI:10.1016/j.endien.2018.08.003

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Year/Month	Html	Pdf	Total

2024 November	4	3	7
2024 October	24	7	31
2024 September	36	9	45
2024 August	28	3	31
2024 July	27	8	35
2024 June	38	9	47
2024 May	32	7	39
2024 April	39	9	48
2024 March	43	6	49
2024 February	22	3	25
2024 January	16	3	19
2023 December	22	4	26
2023 November	25	5	30
2023 October	24	4	28
2023 September	28	2	30
2023 August	8	4	12
2023 July	15	4	19
2023 June	23	4	27
2023 May	49	3	52
2023 April	48	0	48
2023 March	42	3	45
2023 February	23	3	26
2023 January	19	6	25
2022 December	23	5	28
2022 November	16	9	25
2022 October	23	10	33
2022 September	26	11	37
2022 August	21	7	28
2022 July	18	11	29
2022 June	18	10	28
2022 May	26	11	37
2022 April	16	9	25
2022 March	55	11	66
2022 February	28	10	38
2022 January	56	15	71
2021 December	34	15	49
2021 November	50	13	63
2021 October	39	17	56
2021 September	55	30	85
2021 August	42	19	61
2021 July	25	8	33
2021 June	25	13	38
2021 May	36	11	47
2021 April	69	19	88
2021 March	67	11	78
2021 February	33	8	41
2021 January	21	18	39
2020 December	21	14	35
2020 November	32	18	50
2020 October	21	9	30
2020 September	13	12	25
2020 August	24	6	30
2020 July	22	11	33
2020 June	16	6	22
2020 May	33	25	58
2020 April	10	4	14
2020 March	25	5	30
2020 February	17	11	28
2020 January	19	10	29
2019 December	24	19	43
2019 November	8	9	17
2019 October	11	11	22
2019 September	12	17	29
2019 August	15	4	19
2019 July	15	10	25

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