Bariatric surgery is associated with a reduction in major macrovascular and microvascular complications in moderately to severely obese patients with type 2 diabetes mellitus.

Bariatric surgery (BAR) has been established as an effective treatment for type 2 diabetes mellitus (T2DM) in obese patients. However, few studies have examined the mid- to long-term outcomes of bariatric surgery in diabetic populations. Specifically, no comparative studies have broadly examined major macrovascular and microvascular complications in bariatric surgical patients vs similar, nonbariatric surgery controls. We conducted a large, population-based, retrospective cohort study of adult obese patients with T2DM, from 1996 to 2009, using UB-04 administrative data and vital records. Eligible patients undergoing bariatric surgery (BAR [n = 2,580]) were compared with nonbariatric surgery controls (CON [n = 13,371]) for the outcomes of any first major macrovascular event (myocardial infarction, stroke, or all-cause death) or microvascular event (new diagnosis of blindness, laser eye or retinal surgery, nontraumatic amputation, or creation of permanent arteriovenous access for hemodialysis), assessed in combination and separately, as well as other vascular events (carotid, coronary or lower extremity revascularization or new diagnosis of congestive heart failure or angina pectoris). Bariatric surgery was associated with favorable unadjusted 5-year event-free survival estimates for the combined primary outcome (95% ± 1% vs 81% ± 1%, log-rank p < 0.01) and each secondary outcome (log-rank p < 0.01). Multivariate-adjusted and propensity-based relative risk estimates showed BAR to be associated with a 60% to 70% reduction (adjusted hazard ratio [HR] 0.36, 95% CI 0.27 to 0.47) in the combined primary outcome and 60% to 80% risk reductions for each secondary outcome (macrovascular events [adjusted HR 0.39, 95% CI 0.29 to 0.51]; microvascular events [adjusted HR 0.22, 95% CI 0.09 to 0.49]; and other vascular events [adjusted HR 0.25, 95% CI 0.19 to 0.32]). Bariatric surgery is associated with a 65% reduction in major macrovascular and microvascular events in moderately and severely obese patients with T2DM.

Johnson BL ，Blackhurst DW ，Latham BB ，Cull DL ，Bour ES ，Oliver TL ，Williams B ，Taylor SM ，Scott JD ... -  《-》

Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications.

Sjöström L ，Peltonen M ，Jacobson P ，Ahlin S ，Andersson-Assarsson J ，Anveden Å ，Bouchard C ，Carlsson B ，Karason K ，Lönroth H ，Näslund I ，Sjöström E ，Taube M ，Wedel H ，Svensson PA ，Sjöholm K ，Carlsson LM ... -  《-》

Eye complications and markers of morbidity and mortality in long-term type 1 diabetes.

The incidence of type 1 diabetes is rising all over the world. Furthermore, the increased life-expectancy of type 1 diabetic patients is likely to cause a higher number of diabetes-related micro- and macrovascular complications in the years to come. In order to examine the level of long-term complications in type 1 diabetes as well as potential markers of micro- and macroangiopathy, a population-based cohort of Danish type 1 diabetic patients was examined in order to achieve the following aims: 1. To evaluate diabetic retinopathy as a long-term marker of all-cause mortality in type 1 diabetes (Paper I). 2. To estimate the long-term incidence and associated risk factors of blindness (Paper II) and cataract surgery (Paper III) in type 1 diabetes. 3 To use retinal vascular analyses in order to investigate the associations of long-term micro- and macrovascular complications and retinal vascular diameters (Paper IV) and retinal fractals (Paper V) in type 1 diabetes. 4. To examine N-terminal pro brain natriuretic peptide (Paper VI) and osteoprotegerin (Paper VII) as non-invasive markers of micro- and macrovascular complications in type 1 diabetes. In Paper I it was a major finding that, despite a mean age of only 38.3 years at baseline, 44.7% of the patients died during the 25-year follow-up. Patients who had proliferative retinopathy as well as proteinuria at the baseline examination had a significantly higher mortality. For these, the 10-year survival was only 22.2%. As demonstrated in Paper II, blindness is an important issue in type 1 diabetes. The 25-year cumulative incidence of blindness was 7.5%. Glycaemic regulation and maculopathy at baseline were both identified as risk factors of blindness. Finally, mortality was higher in patients who went blind during the follow-up. Cataract surgery is quite common in type 1 diabetes. In Paper III a 25-year cumulative incidence of 20.8% was found. Adjusted for mortality, this was even higher (29.4%). As compared to patients without diabetes, cataract surgery takes place approximately 20 years earlier in type 1 diabetic patients. Age and maculopathy at baseline were both identified as predictors of cataract surgery. In Paper IV it was demonstrated that patients with retinal arteriolar narrowing were 2.17 and 3.17 times more likely to have nephropathy and macrovascular disease, respectively. This was an important finding that suggests that retinal fundus photos may be used in order to predict the risk of non-ophthalmological complications in type 1 diabetes. Retinal fractal analysis is another way to evaluate the vascular system of the retina. In Paper V we found associations between retinal fractal and microvascular - but not macrovascular--disease. For instance, patients with lower fractal dimensions were more likely to have proliferative retinopathy (OR 1.45, 95% CI 1.04-2.03) and neuropathy (OR 1.42, 95% CI 1.01-2.01). NT-proBNP is likely to be a future predictor of diabetes-related complications. In Paper VI higher levels of NT-proBNP were related to nephropathy (OR 5.03, 95% CI 1.77-14.25), neuropathy (OR 4.08, 95% CI 1.52-10.97) and macrovascular disease (OR 5.84, 95% CI 1.65-20.74). These associations should be confirmed in future prospective studies. As opposed to NT-proBNP, osteoprotegerin is less likely to be a predictor of either micro- or macrovascular disease in type 1 diabetes. As demonstrated in Paper VII, even though association between higher levels of OPG and nephropathy were found in an age- and sex-adjusted model (OR 2.54, 95% CI 1.09-5.90), this was no longer statistically significant when other factors were taken into account. Overall, it was demonstrated that various complications such as mortality, blindness and cataract surgery were high in type 1 diabetes. Furthermore, retinal arteriolar narrowing, decreased retinal fractals and plasma NT-proBNP were associated with various micro- and macrovascular complications. If confirmed by prospective studies, these modalities may be used in order to identify patients at risk of diabetes-related complications. This could, ultimately, lead to decreased mortality and morbidity in type 1 diabetic patients.

Grauslund J 《-》

Influence of diabetes mellitus on long-term survival in systematic off-pump coronary artery bypass surgery.

Marcheix B ，Vanden Eynden F ，Demers P ，Bouchard D ，Cartier R ... -  《-》

Does bariatric surgery reduce the risk of major cardiovascular events? A retrospective cohort study of morbidly obese surgical patients.

Morbid obesity is associated with the development of cardiovascular and cerebrovascular disease. Several studies have shown that bariatric surgery results in risk factor reduction; however, studies correlating bariatric surgery to the reduced rates of myocardial infarction, stroke, or death have been limited. We conducted a large retrospective cohort study of bariatric (BAR) surgical patients (n = 4747) and morbidly obese orthopedic (n = 3066) and gastrointestinal (n = 1327) surgical controls. Data were obtained for all patients aged 40-79 years, from 1996 to 2008, with a diagnosis code of morbid obesity and a primary surgical procedure of interest. The data sources were the statewide South Carolina Universal Billing Code of 1992 inpatient hospitalization database and death records. The primary study outcome was the time-to-occurrence of the composite outcome of postoperative myocardial infarction, stroke, or death (all-cause). The 5-year Kaplan-Meier life table estimate of the composite index of event-free survival in the BAR, orthopedic, and gastrointestinal cohorts was 84.8%, 72.8%, and 65.8%, respectively. After adjusting for baseline differences and potential confounders, the Cox proportional hazards ratio was .72 (95% confidence interval .58-.89) for BAR versus orthopedic and .48 (95% confidence interval .39-.61) for BAR versus gastrointestinal. Bariatric surgery was significantly associated with a 25-50% risk reduction in the composite index of postoperative myocardial infarction, stroke, or death compared with other morbidly obese surgical patients in South Carolina.

Scott JD ，Johnson BL ，Blackhurst DW ，Bour ES ... -  《-》