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Aim To determine if patients with heart failure and preserved ejection fraction (HFpEF) and type 2 diabetes mellitus (T2DM) have a higher comorbidity burden than those without T2DM, if other comorbidities are preferentially associated with T2DM and if these conditions confer a worse patient prognosis. Methods and results Cohort study based on the RICA Spanish Heart Failure Registry, a multicentre, prospective registry that enrols patients admitted for decompensated HF and follows them for 1 year. We selected only patients with HFpEF, classified as having or not having T2DM and performed an agglomerative hierarchical clustering based on variables such as the presence of arrhythmia, chronic obstructive pulmonary disease, dyslipidemia, liver disease, stroke, dementia, body mass index, haemoglobin levels, estimated glomerular filtration rate and systolic blood pressure. A total of 1934 patients were analysed: 907 had T2DM (mean age 78.4 +/- 7.6 years) and 1027 did not (mean age 81.4 +/- 7.6 years). The analysis resulted in four clusters in patients with T2DM and three in the reminder. All clusters of patients with T2DM showed higher BMI and more kidney disease and anaemia than those without T2DM. Clusters of patients without T2DM had neither significantly better nor worse outcomes. However, among the T2DM patients, clusters 2, 3 and 4 all had significantly poorer outcomes, the worst being cluster 3 (HR 2.0, 95% CI 1.36-2.93,P = .001). Conclusions Grouping our patients with HFpEF and T2DM into clusters based on comorbidities revealed a greater disease burden and prognostic implications associated with the T2DM phenotype, compared with those without T2DM.

Aim To assess the efficacy of sodium-glucose cotransporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptors agonist (GLP-1RA) therapy on liver steatosis measured by fatty liver index (FLI) and hepatic steatosis index (HSI) at 26 weeks in outpatients with diabetes and obesity. Methods Observational, prospective, multicenter study. Patients with steatosis determined by FLI (values 60 indicate steatosis) and HIS (values 36 indicate steatosis) who received combination therapy were included. Patients were stratified into three groups according to the sequential order of treatment. We used robust statistical methods. Results In our final report we included 174 patients (58.6% males), mean age 61.9 (10) years. Baseline body mass index, waist circumference and weight were 36.5 (6.8) kg/m(2), 117.5 (15.1) cm and 99.4 (20.5) kg, respectively. One hundred percent of patients had altered biomarkers of fatty liver scores (FLI 96 [13] and HSI 49.2 [8.5]). At 26 weeks, significant reductions in FLI (-4.5 [95% CI 3.5-5.9] p < .001) and HSI (-2.4 [95% CI 1.6-3.2] p < .001) were found in the total sample and pre-specified treatment and FLI cut-off point subgroups. Conclusion Our results show a beneficial effect of the combination of GLP-1RAs plus SGLT2is on liver steatosis that goes beyond glucose control, and it is related mainly to weight loss, a decline in biomarkers and reductions in abdominal circumference. For many patients, early detection is essential to improving outcomes in NAFLD and could allow us to select the most efficient treatment options.

Type 2 diabetes mellitus is a major health problem with high prevalence, morbidity and mortality, and its medical treatment is growing in complexity due to patients' diverse clinical conditions. This article presents a consensus document by the Diabetes, Obesity and Nutrition Group of the Spanish Society of Internal Medicine, with recommendations for the medical treatment of type 2 diabetes mellitus. The main objective of this article is to facilitate the therapeutic decision-making process to improve the care of patients with diabetes. The document prioritises treatments with cardiovascular benefits, especially those that benefit patients with heart and renal failure. (C) 2020 Elsevier Espana, S.L.U. and Sociedad Espanola de Medicina Interna (SEMI). All rights reserved.

INTRODUCTION: Obesity is a chronic, complex and multifactorial metabolic disease involved in the development of chronic noncommunicable diseases such as type 2 diabetes mellitus, cardiovascular disease and cancer. The care of individuals with obesity is an essential part of the holistic approach provided by internal medicine to patients. MATERIAL AND METHODS: Between September 2019 and January 2020, we distributed an online survey to the members of the Spanish Society of Internal Medicine. We prepared a Strengths, Weaknesses, Opportunities, and Threats analysis using the responses and, using the nominal group technique, developed the recommendations. RESULTS: We obtained 599 responses. The respondents mean age was 44.4±11 years, and 52.1% were women. Some 91.8% of the internists evaluate their patients to rule out the comorbidities associated with obesity, mainly type 2 diabetes mellitus (96.2%), cardiovascular disease (88.9%) and obesity-associated hypoventilation syndrome (73%), among others. Some 79.9% provided indications on lifestyle changes. Some 64.1% and 74.9% of the respondents knew the indications for the drugs and bariatric surgery, respectively. Some 93.8% and 83% of the respondents considered obesity and excess weight a chronic disease, and 88.7% considered it a disease of specific interest to internists, who should take an active and leading role in its treatment (85.3%). CONCLUSIONS: The objective of the present document is to determine the degree of understanding and sensitivity of internists regarding the management of obesity and to develop a consensus of recommendations for the Spanish Society of Internal Medicine based on the scientific evidence and the opinion of its members.

OBJECTIVE: To evaluate the use of therapy with cardiovascular benefit in patients with type 2 diabetes mellitus admitted to internal medicine departments. METHODS: One day, cross-sectional study of patients with type 2 diabetes mellitus hospitalised in internal medicine departments. We recorded demographic and anthropometric variables, laboratory data and use of antihyperglycaemic drugs. The endpoint was the proportion and determinants of the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). RESULTS: We included 928 patients belonging to 74 hospitals, with a mean age of 78.9 years (SD, 10.86 years), 50% of whom were men. A total of 557 (60%) patients had ischaemic heart disease, 189 (20.4%) had cerebrovascular disease, 293 (31.6%) had heart failure, 274 (29.5%) had chronic kidney disease, and 129 (13.9%) had peripheral arterial disease. Prior to their hospital admission, the patients were taking sulfonylureas (5.7%), biguanides (49.1%), alpha-glucosidase inhibitors (0.2%), pioglitazone (0%), dipeptidyl peptidase 4 inhibitors (39%), SGLT2i (5.8%), GLP1-RA (2.6%) and basal insulin analogues (24%). An age over 75 years was the main determinant for not taking SGLT2i (adjusted OR, 0.28; 95% CI 0.10-0.74; P=.039) or GLP1-RA (adjusted OR, 0.09; 95% CI 0.02-0.46; P=.006). DISCUSSION: A large proportion of elderly patients with type 2 diabetes mellitus at very high cardiovascular risk are not treated with antihyperglycemic drugs with proven cardiovascular benefit. The most commonly used drugs were metformin and DPP4i. There is room for improvement in the treatment of this very high-risk population.

Aims We aimed to determine the efficacy and safety of sodium-glucose cotransporter type 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists to prevent worsening urinary albumin-to-creatinine ratio as an early biomarker of diabetes kidney disease. Methods A total of 178 patients with type 2 diabetes and obesity received combination treatment with SGLT2i added to GLP1ra (n = 76), GLP1ra added to SGLT2i (n = 50) or GLP1ra plus SGLT2i from start (n = 52), according to investigators ' best clinical judgement. Major outcomes assessed at 26 weeks were changes in urine albumintocreatinine-ratio (UACR), estimated glomerular filtration rate (eGFR), glycated haemoglobin, body weight and systolic blood pressure. Results All patients (58.6% men, mean age 61.9 +/- 10.0 years) completed the study. Baseline HbA1c, weight and eGFR levels were 8.2 +/- 0.9%, 109.9 +/- 19 kg and 83.3 +/- 19.6 mL/min/m(2), respectively. At 26 weeks, we found significant reductions in HbA1c (1.16%), weight (5.17 kg) and systolic blood pressure (8.13 mmHg). The reduction in UACR was 15.14 mg/g (95% CI 8.50-22.4) (-24.6 +/- 64.7%), which was greatest in the group of patients with SGLT2i added on to GLP1ra therapy (116.7 mg/g; 95% CI: 54-296.5 mg/g;P < .001. Patients with urinary albumin-to-creatinine ratio >= 30 mg/g, showed a higher declines (63.18 mg/g [95% CI 44.5-104.99]) (-56 +/- 65.9%). The greatest reduction in urinary albumin-to-creatinine ratio was obtained when SGLT2i was added to GLP1ra (116.7 mg/g). The eGFR did not significantly change along the study period. Conclusion Our results show the beneficial effect of GLP1ra and SGLT2i combination therapy on early biomarkers of diabetes kidney disease such as albuminuria and in other significant outcomes for diabetes control.

Objectives: Scientific literature about the combination of glucagon-like peptide-1 receptor agonists (GLP-1ra) and sodium-glucose cotransporter 2 (SGLT2) inhibitors in older patients is scarce. We sought to assess the real-world efficacy and safety of SGLT2 inhibitors and GLP-1ra combination therapy in older patients (>65 years of age). Methods: This was an observational, prospective, multicenter study based on clinical practice. Patients were stratified according to tertiles of baseline glycated hemoglobin (A1C) levels and to treatment schedule. Results: We included 113 patients (65.5% men, mean age 70.4 +/- 8.8 years). The body mass index was 36.5 (+/- 6.6) kg/m(2). The baseline A1C level was 8.0% (+/- 1.2%). At the 6-month follow up, we found a significant reduction in A1C levels (-1.1%; p= 8.4%) showed greater improvement in A1C levels (p= 5% without hypoglycemia. Conclusions: This study's findings provide evidence of clinically meaningful reductions in A1C level, body weight and systolic blood pressure in older patients with type 2 diabetes who are taking combined regimens. The dropout and hypoglycemia rates were minimal, and treatment was tolerated well. (C) 2018 Canadian Diabetes Association.

Aims: Hospital complications and hyperglycemia are common in elderly patients during hospitalization. Our aim was to analyze the relationship between hyperglycemia and hospital complications in an ageing population. Methods: We conducted an observational study to evaluate the association between maximum blood glucose (MBG) levels and hospital complications. Patients were stratified according to the quartiles of MBG levels. Diabetes mellitus (DM) was determined by patient history and/or admission glycated hemoglobin (HbA1c) level >= 6.5%. Hyperglycemia in patients without DM was defined as stress-induced hyperglycemia (SH). The composite primary end-point included frequent complications and/or all-cause hospital mortality. Results: Among 461 patients, mean age 80 +/- 7.5 years, 238 (51.6%) patients had DM, 20 had undiagnosed DM, and 162 (35.1%) developed hospital complications. Patients with complications had higher mean daily BG levels (215 +/- 84 vs 195 +/- 85 mg/d1, P 250 mg/dl, 60%; P=.002), but not in patients with DM (< 140 mg/dl, 26.3%; 140-185 mg/d1, 40.4%; 186-250 mg/dl, 35.6%; > 250 mg/dl, 37.4%; P=.748). In the multivariate analyses, SH was independently associated with complications: OR 2.60 (CI 95%: 1.2-5.6), 2.82 (CI 95%: 1.2-6.5), 5.50 (CI 95%: 1.4-20.8) for the second, third and fourth quartile respectively (P=.01), as compared to the first quartile. We found no association with readmissions and all-cause mortality. Conclusions: SH in elderly patients is associated with hospital complications, but not with all cause mortality, compared to patients with diabetes or normoglycennia. (C) 2018 Elsevier Espana, S.L.U. and Sociedad Espanola de Medicina Interna (SEMI). All rights reserved.

Background: An objective and simple prognostic model for hospitalized patients with hypoglycemia could be helpful in guiding initial intensity of treatment. Methods: We carried out a derivation rule for hypoglycemia using data from a nationwide retrospective cohort study of patients with diabetes or hyperglycemia carried out in 2014 (n = 839 patients). The rule for hypoglycemia was validated using a second data set from a nationwide retrospective cohort study carried out in 2016 (n = 561 patients). We derived our prediction rule using logistic regression with hypoglycemia (glucose less than 70 mg/dL) as the primary outcome. Results: The incidence of hypoglycemia in the derivation cohort was 10.3%. Patient's characteristics independently associated with hypoglycemia included episodes of hypoglycemia during the previous three months (odds ratio [OR]: 6.29, 95% confidence interval [95% CI]: 3.37-11.79, p < 0.001) estimated glomerular filtration rate lower than 30 mL/min/1.73 m(2) (OR: 2.32, 95% CI: 1.23-4.35, p = 0.009), daily insulin dose greater than 0.3 units per Kg (OR: 1.74, 95% CI: 1.06-2.85, p = 0.028), and days of hospitalization (OR: 1.03, 95% CI: 1.01-1.04, p = 0.001). The model showed an area under the curve (AUC): 0.72 (95% CI: 0.66-0.78, p < 0.001). The AUC in the validation cohort was: 0.71 (95% CI: 0.63-0.79, p < 0.001). Conclusions: The rule showed fair accuracy to predict hypoglycemia. Implementation of the rule into computer systems could be used in guiding initial insulin therapy. (C) 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Recent evidence suggests that obese people are hypohydrated and that water consumption may be a useful indicator for the prevention and treatment of obesity. Nevertheless, there is no agreement regarding the best hydration status indicators and there are few data about the relationship between hydration and body weight. In the present study, we aim to analyze the correlation among hydration status with obesity measured by three different methods (plasma osmolarity, urinary specific gravity (USG) and urinary osmolarity) in a hospital-based outpatient population. We have carried out a cross-sectional study to evaluate the association between obesity and hydration status in 260 patients, average 56.5 +/- 15.7 years. Hydration status was estimated by means of plasma osmolarity, urine osmolarity and USG. We did show significant trend of higher urine osmolarity (P=0.03), USG (P=0.000) and plasma osmolarity (P=0.000) with an increase of weight status categories, more accurate in the case of plasma osmolarity. In a multivariate analysis, after controlled by confounders, we found that obesity was associated with plasma osmolarity (OR 1.09; 95%CI 1.02 to 1.17, P=0.009), urine osmolarity (OR 1.00; 95%CI 1.00 to 1.01, P=0.05) and USG (OR 1.02; 95%CI 1.00 to 1.04, P=0.05). Our results have shown a more accurate relationship between plasma osmolarity with all body mass index categories. This finding may have clinical implications that must be confirmed in further studies.

Objetivo: Estudiar las características de la enfermedad tromboembólica venosa (ETV) en un área rural del sur de Extremadura (España). Material y métodos: Estudio observacional prospectivo de todos los pacientes diagnosticados mediante métodos objetivos de ETV en el único hospital de nuestro área entre noviembre de 2002 y noviembre de 2004. Resultados: Se diagnosticaron 76 casos de ETV: 35 (46,1%) con tromboembolismo pulmonar (TEP) y 41 (53,9%) con trombosis venosa profunda (TVP) aislada. La edad media fue 72,4 años (rango 35-94 años), 51 (67,1%) tuvieron más de 70 años, y 43 (56,6%) fueron mujeres. La incidencia anual de ETV fue de 0,63 por 1.000 habitantes (0,74 por 1.000 habitantes en mujeres y 0,54 por 1.000 habitantes en hombres). Treinta y siete pacientes (48,7%) presentaron ETV "idiopática". Tras un seguimiento medio de 5,5 meses con tratamiento anticoagulante, 13 pacientes (17,1%) habían fallecido. La existencia de comorbilidad y ETV no "idiopática" fueron significativamente más frecuentes en los pacientes fallecidos. Tres pacientes (3,9%) tuvieron una probable recidiva, y todos fallecieron. Hubo 4 casos (5,3%) de hemorragia grave no fatal. Nueve pacientes con TVP aislada no precisaron ingreso hospitalario, y no hubo ningún evento en el seguimiento. Conclusiones: La incidencia de ETV puede ser menor en nuestro área que en otras zonas geográficas. La ETV afecta más frecuentemente a ancianos y a mujeres, y casi la mitad de los casos son "idiopáticos". La mortalidad es elevada, y se relaciona con la existencia de comorbilidad y ETV no "idiopática". Las recidivas y las hemorragias graves no son excepcionales durante el tratamiento anticoagulante. El tratamiento ambulatorio de la TVP aislada puede ser una opción en pacientes seleccionados. Objective: To study the characteristics of the venous thromboembolic disease (VTD) in a rural area of Southern Extremadura (Spain). Material and methods: Prospective observational study of all patients diagnosed by objective methods of VTD in the only hospital in our area from November 2002 to November 2004. Results: Seventy-six patients were diagnosed of VTD: 35 (46.1%) with pulmonary thromboembolism and 41 (53.9%) with isolated deep vein thrombosis (DVT). The median age was 72.4 years (range 35-94 years), 51 (67.1%) were older than 70 years, and 43 (56.6%) were women. The annual incidence of VTD was 0.63 per 1,000 persons (0.74 per 1,000 persons in women and 0.54 per 1,000 persons in men). Thirty-seven patients (48.7%) had "idiopathic" VTD. After a median follow-up of 5.5 months with anticoagulant therapy, 13 patients (17.1%) had dead. Comorbidity and non "idiopathic" VTD were significantly more frequent in the dead patients. Three patients (3.9%) presented probable recurrence, and all of them died. There were 4 cases (5.3%) of non-fatal severe hemorrhage. Nine patients with isolated DVT did not require hospitalization, and there was no event in the follow-up. Conclusions: The incidence of VTD may be lower in our area than in other geographical areas. VTD affects more frequently to elderly and women, and almost half of cases are "idiopathic". The mortality is high, and it is related to the existence of comorbidity and non "idiopathic" VTD. The recurrences and the severe hemorrhages are not exceptional during the anticoagulant therapy. The ambulatory treatment of isolated DVT may be an option in selected patients.

Objetivo: Conocer en nuestro medio la seguridad de no anticoagular a largo plazo a pacientes con sospecha de tromboembolismo pulmonar (TEP) y una gammagrafía pulmonar de ventilación/perfusión (V/Q) de baja probabilidad. Material y métodos: Revisión retrospectiva de una serie de pacientes ambulatorios consecutivos con sospecha de TEP y una gammagrafía pulmonar V/Q de baja probabilidad, según los criterios PIOPED modificados, que no son anticoagulados a largo plazo. Resultados: De 38 pacientes con una gammagrafía pulmonar V/Q de baja probabilidad, 31 (81,6%) no recibieron anticoagulación a largo plazo. La edad media fue 69,1 años (rango 26-88 años), y 19 (61,3%) fueron mujeres. La probabilidad clínica de TEP fue moderada en 27 pacientes (87,1%). Veintidós pacientes (71%) tuvieron una ecografía-doppler venosa de miembros inferiores negativa para trombosis venosa profunda (TVP). El seguimiento medio fue de 6,3 meses (rango 3-12 meses). Hubo un caso (3,2%; intervalo de confianza del 95%, 0,1-16,7%) con TEP y TVP demostrados, y no hubo ningún fallecimiento. Conclusión: No anticoagular a largo plazo a pacientes ambulatorios con una probabilidad clínica moderada de TEP, una gammagrafía pulmonar V/Q de baja probabilidad y una ecografía-doppler venosa de miembros inferiores negativa para TVP puede ser seguro en nuestro medio. Objective: To know in our area the security of no long-term anticoagulation in patients with suspected pulmonary thromboembolism (PTE) and a low probability ventilation/perfusion (V/Q) lung scan. Material and methods: Retrospective review of a series of consecutive outpatients with suspected PTE and a low probability V/Q lung scan, according to the modified PIOPED criteria, who receive no long-term anticoagulation. Results: Among 38 patients with a low probability V/Q lung scan, 31 (81.6%) did not receive long-term anticoagulation. The median age was 69.1 years (range 26-88 years), and 19 (61.3%) were female. The clinical probability of PTE was moderate in 27 patients (87.1%). Twenty-two patients (71%) had a venous lower extremities echography-doppler negative for deep vein thrombosis (DVT). The median follow-up was 6.3 months (range 3-12 months). There was one case (3.2%; 95% confidence interval, 0.1-16.7%) with demonstrated PTE and DVT, and there was no death. Conclusion: No long-term anticoagulation in outpatients with a moderate clinical probability of PTE, a low probability V/Q lung scan and a venous lower extremities echography-doppler negative for DVT may be secure in our area.

Gastrointestinal adverse events; Obesity; Type 2 diabetes Esdeveniments adversos gastrointestinals; Obesitat; Diabetis tipus 2 Eventos adversos gastrointestinales; Obesidad; Diabetes tipo 2 Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are indicated in type 2 diabetes and obesity for their high efficacy in controlling glycaemia and inducing body weight loss, respectively. Patients may develop gastrointestinal adverse events (GI AEs), namely nausea, vomiting, diarrhoea and/or constipation. To minimize their severity and duration, healthcare providers (HCPs) and patients must be aware of appropriate measures to follow while undergoing treatment. An expert panel comprising endocrinologists, nephrologists, primary care physicians, cardiologists, internists and diabetes nurse educators convened across virtual meetings to reach a consensus regarding these compelling recommendations. Firstly, specific guidelines are provided about how to reach the maintenance dose and how to proceed if GI AEs develop during dose-escalation. Secondly, specific directions are set about how to avoid/minimize nausea, vomiting, diarrhoea and constipation symptoms. Clinical scenarios representing common situations in daily practice, and infographics useful to guide both HCPs and patients, are included. These recommendations may prevent people with T2D and/or obesity from withdrawing from GLP-1 RAs treatment, thus benefitting from their superior effect on glycaemic control and weight loss. This work has been funded by Novo-Nordisk.