What are we measuring? Considerations on subjective ratings of perceived exertion in obese patients for exercise prescription in cardiac rehabilitation programs.

We sought to describe the differences in exercise prescription in obese subjects using attained METs as compared to the subjective perception of the effort using the Borg scale ratings of perceived exertion (Borg RPE). We studied 552 obese patients who underwent an exercise stress test in the setting of a rehabilitation program. Exercise was prescribed at 70% of peak attained METS. This method was compared to an exercise level prescription that induces a subjective perception of mild fatigue (13 on the 20 points Borg scale). Attained METS were 6.2+/-2.5 and Borg RPE was 15.2+/-1.7. Borg RPE was negatively related to intensity and duration of exercise. Females, patient with a lower level of education and patients on diuretics perceived higher efforts. Patients who stopped exercising because of dyspnea or angina reached a lower level of METs (4.7+/-1.7 vs 6.3+/-2.7 METs; P<0.001) but the perceived effort was similar (15.5+/-1.7 vs 15.2+/-1.7; P=0.252). The subjective method would have yielded a significantly higher training workload: 5.4+/-2.3 vs 4.3+/-1.8 (P<0.001). In conclusion, in obese patients, Borg RPE is not equivalent to attained METs in exercise prescription and it influenced by educational level.

Short-term effects of a hypocaloric diet and a physical activity programme on weight loss and exercise capacity in obese subjects with chronic ischaemic heart disease: a study in everyday practice.

OBJECTIVE: The objective of this paper is to describe the effects of a rehabilitation programme in obese patients affected with chronic ischaemic heart disease; to identify the factors that influence weight loss and improvement in exercise capacity in everyday practice. METHODS AND RESULTS: We studied 562 white patients (381 men) who followed a 23.3 +/- 3.9 days in-hospital programme. They attended daily sessions of aerobic activity (cycloergometer, walking, and strength exercise); a low-calorie diet was set at approximately 80% of resting energy expenditure. By the end of the programme BMI decreased from 38.0 +/- 4.9 to 36.7 +/- 4.8 kg/m2 (P < 0.001 ). Attained metabolic equivalents (METs) increased from 6.2 +/- 2.5 METs to 7.3 +/- 2.7 (P < 0.001). Age, sex, presence of diabetes and education level were significantly related to the outcomes. Patients who took beta-blockers and statins had less BMI improvement: -1.2 +/- 0.7 kg/m2 vs. -1.4 +/- 0.6 (P = 0.013) and -1.3 +/- 0.6 vs. -1.4 +/- 0.7 (P = 0.023), respectively. Patients that took diuretics and angiotensin receptor blockers (ARB) had less improvement in exercise capacity: 0.9 +/- 1.0 METS vs. 1.3 +/- 1.3 (P < 0.001) and 0.8 +/- 1.3 vs. 1.2 +/- 1.3 (P = 0.011 ), respectively. After a median interval of 358 days, 152 patients were seen at a follow-up visit: their BMI increased by 1.0 +/- 2.4 kg/m2 and only 21% of patients lost weight. CONCLUSIONS: Rehabilitation improves exercise capacity and induces significant weight loss in obese patients with stable IHD, but women, diabetic, elderly and poorly educated subjects obtained unsatisfactory results. Use of diuretics and ARB seem to worsen the results. At follow-up only a small percentage of patients further improves BMI.

Type 2 deiodinase polymorphism (threonine 92 alanine) predicts L-thyroxine dose to achieve target thyrotropin levels in thyroidectomized patients.

CONTEXT: Type 2 deiodinase (D2) converts T4 in T3 in several human tissues, including hypothalamus and pituitary, and, therefore, plays a pivotal role in the negative feedback regulation of TSH secretion. A common variant of the gene, threonine (Thr) 92 alanine (Ala), has been identified and associated with decreased D2 enzymatic activity. OBJECTIVE: Our objective was to investigate whether this polymorphism predicts the T4 dosage needed to obtain target TSH levels in thyroidectomized patients. SETTING: Ambulatory patients were included in the study. PATIENTS: A total of 191 consecutive thyroid cancer patients, previously treated by near total thyroidectomy and radioiodine ablation, were studied. They were on stable T4 dose treatment aimed at obtaining either suppressed (supp) (n=117, <0.1 mU/liter) or near-supp (n=74, >or=0.1<0.5 mU/liter) serum TSH levels. MAIN OUTCOME MEASURES: DNA genotyping for D2 Thr92Ala variant and evaluation of T4 dose (microg/kg) needed to obtain target TSH levels were determined. RESULTS: Ala/Ala homozygous patients needed a higher T4 dose as compared with patients carrying the Thr92 variant (X/Thr patients) according to a recessive genetic model (2.08+/-0.43 vs. 1.90+/-0.35 microg/kg; P<0.05). This difference was observable in the near-supp group (P=0.002), but not in the supp group (P=0.4). CONCLUSIONS: D2 Thr92Ala polymorphism seems to predict the need for higher T4 intake in thyroidectomized patients. If this finding is confirmed in additional studies, it may predict the T4 requirement to suppress TSH on the basis of the individual genetic background.

Evaluation of a multisensor armband in estimating energy expenditure in obese individuals.

OBJECTIVE: To examine the reliability and validity of the SenseWear Pro 2 Armband (SWA; Body Media, Pittsburgh, PA) during rest and exercise compared with indirect calorimetry (IC) in obese individuals. RESEARCH METHODS AND PROCEDURES: Energy expenditure was assessed during rest with the SWA and IC in 142 obese adults (37 men and 105 women, BMI = 42.3 +/- 7.0) and in 25 lean and overweight adults (BMI = 25.3 +/- 3.2) who were used as a comparison group. Twenty-nine of the obese adults also participated in three separate short exercise sessions including cycle ergometry, stair stepping, and treadmill walking. RESULTS: The repeatability of SWA estimates in obese subjects was high (r = 0.88, p < 0.001). The SWA generally underestimated the resting energy expenditure (REE) (1811 +/- 346 vs. 1880 +/- 382 kcal/d) and highly overestimated the energy expenditure during the exercise sessions in obese individuals. REE estimations by SWA were significantly correlated with fat-free mass (r = 0.88, p < 0.001). Bland-Altman plots based statistical analysis for the estimated REE, and measured IC showed a low agreement (Total Error > 20% but Systematic Error < 5%) between the two methods in obese subjects, although they showed a high correlation and a very good agreement in lean and overweight patients. DISCUSSION: The SWA is an easy to handle, practical, new portable device for measuring energy expenditure. The accuracy of the SWA appeared to be poor in the obese subjects we examined, especially those with high REE both in rest and exercise. We believe that it is necessary to incorporate new, obesity-specific algorithms in the relative software.

Impaired caspase-3 expression by peripheral T cells in chronic autoimmune thyroiditis and in autoimmune polyendocrine syndrome-2.

CONTEXT: Activation-induced cell death (AICD) is a major mechanism in the regulation of peripheral tolerance, and caspase-3 represents its major executioner. AICD impairment contributes to the persistence of autoreactive T cells, and defective AICD has been reported in autoimmune thyroiditis as well as in type 1 diabetes mellitus. OBJECTIVE: The objective of this study was to evaluate the involvement of caspase-3 in the regulation of AICD resistance in thyroid and polyendocrine autoimmunity. DESIGN/SETTINGS/PATIENTS/INTERVENTION: Caspase-3 expression was analyzed in peripheral blood lymphocytes from 26 adults (A-AT) and 25 children (Y-AT) affected by autoimmune thyroiditis and 13 individuals affected by chronic autoimmune thyroiditis plus Addison's disease [autoimmune polyendocrine syndrome-2 (APS-2)] in comparison with 32 age-matched normal control subjects (NC). OUTCOME MEASURES: Caspase-3 mRNA expression in peripheral T cells was evaluated by quantitative real-time PCR; protein expression of both procaspase-3 and activated caspase-3 by Western blot analysis was followed by scanning densitometry. RESULTS: Caspase-3 mRNA expression was significantly reduced in resting lymphocytes from both A-AT (P = 0.001) and Y-AT (P = 0.016) compared with NC. After lymphocyte activation, protein levels of caspase-3 active form were significantly reduced in A-AT (P = 0.023) and Y-AT (P = 0.001) compared with NC. The APS-2 group displayed characteristics similar to the A-AT group because both caspase-3 mRNA and protein active form levels were significantly reduced compared with NC (P = 0.004 and 0.002, respectively). CONCLUSION: Our data show that peripheral lymphocytes of subjects affected by thyroid autoimmunity or APS-2 show defective expression of the major executioner of AICD, thus potentially contributing to AICD resistance and to the development of autoimmunity.

Comparative evaluation of recombinant human thyrotropin-stimulated thyroglobulin levels, 131I whole-body scintigraphy, and neck ultrasonography in the follow-up of patients with papillary thyroid microcarcinoma who have not undergone radioiodine therapy.

CONTEXT: Although the prognosis of papillary thyroid microcarcinoma (PTMC) is usually excellent, the optimal follow-up strategy has never been investigated. OBJECTIVE: The objective of the study was to investigate the role of neck ultrasonography (US), whole-body scintigraphy (WBS), and serum thyroglobulin levels (Tg) after recombinant human (rh) TSH in the follow-up of very low-risk PTMC patients. DESIGN: The study was a 5-yr observational study based on a 6- to 12-month follow-up after near total thyroidectomy. SETTING: The study population consisted of ambulatory patients. PATIENTS: Eighty consecutive patients diagnosed with PTMC, who had not undergone postoperative radioiodine treatment because of unifocal tumor without lymph node metastases and who did not have anti-Tg antibodies, were included. MAIN OUTCOME MEASURES: WBS and Tg after both rhTSH and neck US were measured. RESULTS: rhTSH-Tg was 1 ng/ml or less in 45 (Tg-) and more than 1 in 35 (Tg+) patients. WBS showed no pathological uptake in any patient. US identified node metastases in two Tg (+) and one Tg (-) patients. rhTSH-Tg levels positively correlated with thyroid bed iodine uptake (r = 0.40, P < 0.0001). To date (32 +/- 13 months after surgery), all node-negative patients have undetectable Tg levels on LT(4) treatment and negative US. CONCLUSIONS: For the initial follow-up of PTMC patients without risk factors and anti-Tg antibodies and who did not undergo radioiodine treatment: 1) WBS is useless; 2) US is highly sensitive in detecting node metastases; and 3) detectable rhTSH-Tg levels mainly depend on small normal tissue remnants. In this subgroup of PTMC patients, neck US might be regarded as a primary tool for the initial follow-up.

Association of subclinical hypercortisolism with type 2 diabetes mellitus: a case-control study in hospitalized patients.

OBJECTIVE: Subclinical hypercortisolism (SH) may play a role in several metabolic disorders, including diabetes. No data are available on the relative prevalence of SH in type 2 diabetes (T2D). In order to compare the prevalence of SH in T2D and matched non-diabetic control individuals, we performed a case-controlled, multicenter, 12-month study, enrolling 294 consecutive T2D inpatients (1.7% dropped out the study) with no evidence of clinical hypercortisolism and 189 consecutive age- and body mass index-matched non-diabetic inpatients (none of whom dropped out). DESIGN AND METHODS: Ascertained SH (ASH) was diagnosed in individuals (i) with plasma cortisol after 1 mg overnight dexamethasone suppression >1.8 microg/dl (50 nmol/l), (ii) with more than one of the following: (a) urinary free cortisol >60.0 microg/24 h (165.6 nmol/24 h), (b) plasma ACTH <10.0 pg/ml (2.2 pmol/l) or (c) plasma cortisol >7.5 microg/dl (207 nmol/l) at 24:00 h or >1.4 microg/dl (38.6 nmol/l) after dexamethasone-CRH (serum cortisol after corticotrophin-releasing hormone stimulus during dexamethasone administration) test, and (iii) in whom the source of glucocorticoid excess was suggested by imaging and by additional biochemical tests (for ACTH-dependent ASH). RESULTS: Prevalence of ASH was higher in diabetic individuals than in controls (9.4 versus 2.1%; adjusted odds ratio, 4.8; 95% confidence interval, 1.6-14.1; P = 0.004). In our population the proportion of T2D which is statistically attributable to ASH was approx. 7%. Among diabetic patients, the presence of severe diabetes (as defined by the coexistence of hypertension, dyslipidaemia and insulin treatment) was significantly associated with SH (adjusted odds ratio, 3.8; 95% confidence interval, 1.4-10.2; P = 0.017). CONCLUSIONS: In hospitalized patients, SH is associated with T2D.