The role of serum osteoprotegerin and receptor-activator of nuclear factor-κB ligand in metabolic bone disease of women after obesity surgery.

Metabolic bone disease may appear as a complication of obesity surgery. Because an imbalance in the osteoprotegerin and receptor-activator of nuclear factor-κB ligand system may underlie osteoporosis, we aimed to study this system in humans in the metabolic bone disease occurring after obesity surgery. In this study we included sixty women with a mean age of 47 ± 10 years studied 7 ± 2 years after bariatric surgery. The variables studied were bone mineral density, ß-isomer of C-terminal telopeptide of type I collagen cross-links (a bone resorption marker), the bone formation markers osteocalcin and N-terminal propeptide of procollagen 1, serum osteoprotegerin and receptor-activator of nuclear factor-κB ligand. Serum osteoprotegerin inversely correlated with the bone remodeling markers osteocalcin, ß-isomer of C-terminal telopeptide of type I collagen cross-links and N-terminal propeptide of procollagen 1. The osteoprotegerin and receptor-activator of nuclear factor-κB ligand ratio also correlated inversely with serum parathormone and osteocalcin. Bone mineral density at the lumbar spine was associated with age (ß = -0.235, P = 0.046), percentage of weight loss (ß = 0.421, P = 0.001) and osteoprotegerin and receptor-activator of nuclear factor-κB ligand ratio (ß = 0.259, P = 0.029) in stepwise multivariate analysis (R 2 = 0.29, F = 7.49, P < 0.001). Bone mineral density at the hip site was associated only with percentage of weight loss (ß = 0.464, P < 0.001) in stepwise multivariate regression (R 2 = 0.21, F = 15.1, P < 0.001). These data show that the osteoprotegerin and receptor-activator of nuclear factor-κB ligand system is associated with bone markers and bone mineral density at the lumbar spine after obesity surgery.

Changes in Soluble TWEAK Concentrations, but Not Those in Amyloid-ß(1-40), Are Associated with a Decrease in Carotid Intima-Media Thickness after Bariatric Surgery in Obese Women.

BACKGROUND/AIM: Soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) and amyloid-ß(1-40) (Aß40) emerged as markers of cardiovascular risk because of their actions in the endothelium and their role in atherosclerotic progression. The aim of this study was to analyze the association of these two factors with the decrease in carotid intima-media thickness (cIMT) after bariatric surgery in obese women. METHODS: We studied 60 severely obese women, of whom 20 were submitted to laparoscopic Roux-en-Y gastric bypass (RYGB), 20 to sleeve gastrectomy (SG), and 20 to lifestyle modification therapy. Circulating sTWEAK, Aß40, high-sensitivity C-reactive protein, plasminogen activator inhibitor type 1, insulin resistance (HOMA-IR), and cIMT were measured at baseline and after 1 year of follow-up. RESULTS: sTWEAK increased similarly after both surgical procedures, whereas the increase observed after lifestyle intervention did not reach statistical significance. Aß40 showed no differences between groups of women, nor did it change during follow-up. The decrease in cIMT at 12 months correlated with the decrease in body mass index (BMI) (r = 0.45; p < 0.001) and fasting insulin (r = 0.30; p = 0.038), and also with the increase in sTWEAK (r = -0.43; p = 0.002). Multivariate linear regression showed that only the changes in BMI (ß = 0.389; p = 0.005) and sTWEAK (ß = -0.358; p = 0.009) were associated with the decrease in cIMT (R2 = 0.313; F = 9.348; p < 0.001). CONCLUSIONS: One year after bariatric surgery, RYGB and SG induced a similar increase in circulating sTWEAK that occurred in parallel to the decrease observed in cIMT.

Effects of oral nutritional supplements in normally nourished or mildly undernourished geriatric patients after surgery for hip fracture: a randomized clinical trial.

BACKGROUND: Oral nutritional supplements have been recommended after orthopedic surgery in geriatric patients to reduce postoperative complications. However, tolerability of supplements could be a limitation, and their universal use is not supported by the heterogeneity of previous studies, especially in patients without malnutrition. METHODS: This study is a randomized, controlled, open, parallel, 3-arm clinical trial comparing supplementation with protein powder dissolved in liquids to aim at 36 g of protein per day, energy and protein supplements to aim at 37.6 g of protein and 500 kcal per day, or no intervention in normally nourished or mildly undernourished patients. Outcomes were serum albumin, prealbumin, retinol-binding globulin, and body mass index, among others. Postoperative complications were also recorded. RESULTS: Ninety patients aged 83.8 +/- 6.6 years were included. The mean ingested amount of supplements was 41.1% +/- 20.6% in the protein powder supplement group and 51.4% +/- 13.2% in the energy protein supplement group (t = 2.278, P = .027). Postoperative supplements had no effect on the nutrition status during in-hospital follow-up, as assessed by serum albumin (P = .251), prealbumin (P = .530), retinol-binding globulin (P = .552), or body mass index (P = .582). Multivariate analysis showed that length of hospital stay with an established complication until its resolution (beta = .230, P = .031), total hospital stay (beta = .450, P < .001), baseline body mass index (beta = .204, P = .045), and total daily ingested proteins per body weight (beta = .252, P = .018) were predictive variables on the change in serum albumin (R2 = 0.409, F = 11.246, P < .001). CONCLUSIONS: Oral nutritional supplements in normally nourished or only mildly undernourished geriatric patients with hip fracture submitted to surgery may be of interest for patients with postoperative complications and long hospital stays.

[Prevalence of psychiatric cases in overweight or obese patients attended in a hospital outpatient clinic]. / Prevalencia de casos psiquiátricos en pacientes con sobrepeso u obesidad atendidos en consultas externas de un centro hospitalario.

BACKGROUND AND AIMS: It has been recently shown that psychiatric disorders are associated with obesity. However this association has not been studied in overweight/obese patients at a hospital setting in our country. PATIENTS AND METHODS: We have studied 333 consecutive patients who were referred to our hospital outpatient clinic with overweight or obesity. Individuals with prior diagnosis of psychiatric disease were excluded from the study. Well validated auto-administered questionnaires were employed to identify psychiatric cases (Goldberg Health Questionnaire, GHQ, with a cut-off point of 5/6) and eating disorders (Eating Disorders Inventory, EDI, bulimia subscales with a cut-off point of 6/7). RESULTS: The prevalence of pathologic results in the GHQ was 47.1%, and the prevalence of pathologic results in the EDI was 5.8%. There were no differences after subgroup analysis when patients were classified according to their grade of obesity, but women presented a higher prevalence of psychiatric cases than men (p < 0.001). Multivariate analysis showed an influence of female gender on the scores of the administered questionnaires (p < 0,01 in all of them) and of body mass index on the depression subscale of GHQ and on EDI (p < 0,001 in both). CONCLUSION: The prevalence of psychiatric cases in overweight/obese patients referred to a hospital setting is high, and higher in women than in men.

Circulating adiponectin increases in obese women after sleeve gastrectomy or gastric bypass driving beneficial metabolic changes but with no relationship with carotid intima-media thickness.

BACKGROUND & AIMS: Obesity surgery induces beneficial effects in metabolic and cardiovascular parameters. Adiponectin increase might be associated with some of these changes. However, direct comparison between different surgical techniques has not been extensively performed. METHODS: We studied 20 obese women submitted to laparoscopic Roux en Y gastric bypass (RYGB) and 20 to sleeve gastrectomy (SG). Twenty control women matched for age and baseline metabolic profiles were also included. Both patients and controls were followed up for one year after surgery or conventional treatment with diet and exercise, respectively. Serum adiponectin was measured at baseline, 6 months and 1 year after, as well as lipid profiles, sex hormone binding globulin (SHBG), fasting glucose and insulin. Carotid intima-media thickness was measured by ultrasonography at baseline and after 1 year. RESULTS: Circulating adiponectin increased after obesity surgery (more markedly following RYGB than after SG), whereas no changes were observed in the controls (Wilks' λ = 0.659, P < 0.001 for the interaction, P < 0.001 for RYGB vs. controls, P = 0.016 for SG vs. controls, P = 0.040 for RYGB vs. SG). The percentage increment in adiponectin correlated positively with changes in SHBG (r = 0.404, P = 0.002) and negatively with changes in weight (r = -0.531, P < 0.001), waist circumference (r = -0.426, P = 0.001), fasting glucose (r = -0.356, P = 0.006), and insulin (r = -0.496, P < 0.001). No correlation was found with carotid intima-media thickness (r = -0.055, P = 0.679). CONCLUSIONS: RYGB induces a higher increase in adiponectin than SG, which parallels SHBG, the reduction of fasting insulin and insulin resistance. On the other hand, no association was found with carotid intima-media, lipid profiles or blood pressure.

Vitamin D deficiency is associated with the metabolic syndrome in morbid obesity.

BACKGROUND & AIMS: Vitamin D deficiency has been recently associated with the metabolic syndrome. However, it is not known whether this possible association of vitamin D deficiency with the metabolic syndrome is still present at very high degrees of obesity, as in morbidly obese patients. METHODS: Transversal, observational study that included 73 consecutive morbidly obese patients (body mass index 40 kg/m(2)). In every patient, anthropometric variables were recorded, fasting blood was assayed for 25-hydroxyvitamin D concentrations, lipid profiles, glucose and insulin levels, and insulin resistance was estimated by homeostasis model assessment. RESULTS: Vitamin D deficiency was present in 37 of the 73 patients (50.7%). As defined by revised Adult Treatment Panel III criteria, 46 of the 73 obese patients (63%) had the metabolic syndrome. Vitamin D deficiency was more prevalent in morbidly obese patients presenting with the metabolic syndrome, compared with those who did not achieve the criteria for this syndrome (60.9% vs. 33.3% respectively, P = 0.023). When serum concentrations of 25-hydroxyvitamin D were categorized in tertiles, there was an association of the prevalence of the metabolic syndrome with the former (P = 0.038). Serum high-density lipoprotein cholesterol concentrations were lower (37.0+/-7.8 mg/dl vs. 44.9+/-8.7 mg/dl, P = 0.003), and triglycerides levels were higher (163.3+/-81.5 mg/dl vs. 95.1+/-24.2 mg/dl, P = 0.001) in the vitamin D-deficient group. CONCLUSION: Vitamin D deficiency is associated with the metabolic syndrome in morbidly obese patients.

Improvement in cardiovascular risk in women after bariatric surgery as measured by carotid intima-media thickness: comparison of sleeve gastrectomy versus gastric bypass.

BACKGROUND: Bariatric surgery may diminish cardiovascular risk (CVR) and its associated mortality. However, studies that compare these effects with different techniques are scarce. OBJECTIVE: To evaluate the changes in CVR as estimated by carotid intima-media thickness (IMT) after obesity surgery in women with high CVR as defined by the presence of metabolic syndrome. SETTING: Academic hospital. METHODS: We studied 40 severely obese women, of whom 20 received laparoscopic Roux en Y gastric bypass (RYGB) and 20 received sleeve gastrectomy (SG). Twenty control women matched for age and cardiovascular risk were also included. Patients and controls were evaluated at baseline and 1 year after surgery or conventional treatment with diet and exercise, respectively. Only 18 of the 20 women in the control group were available for analysis after 1 year. None of the women who had bariatric surgery was lost to follow-up. RESULTS: Mean carotid IMT decreased 1 year after surgery irrespective of the surgical technique used, whereas no changes were observed in the control women who had conventional therapy (Wilks´ λ = .802, P = .002 for the interaction, P = .011 for RYGB versus controls, P = .002 for SG versus controls, P = .349 for RYGB versus SG). CONCLUSION: Both RYGB and SG decrease CVR as measured by carotid IMT in obese women.

Role of peripherally inserted central catheters in home parenteral nutrition: a 5-year prospective study.

BACKGROUND: Home parenteral nutrition (HPN) has become a common therapy, with tunneled central venous catheters (CVCs) being preferred for its administration. Peripherally inserted central catheters (PICCs) are not currently recommended for long-term HPN, although evidence to support this statement is scarce. The authors aimed to evaluate the outcomes of HPN, focusing on CVC-related complications. MATERIALS AND METHODS: All patients attended at the authors' center for HPN from 2007-2011 were prospectively included. HPN composition aimed at 20-35 kcal/kg/d, 3-6 g/kg/d of glucose, 1.0 g/kg/d of amino acids, and <1 g/kg/d of lipids. HPN was infused in an intermittent schedule, mostly at night. Catheter-related bloodstream infections (CRBSIs) were confirmed with positive semi-quantitative or quantitative culture of the catheter or simultaneous differential blood cultures drawn through the CVC and peripheral vein. RESULTS: Seventy-two patients received HPN, with 79 implanted CVCs (48 PICCs, 10 Hickman, and 21 ports). Mean catheter-days were 129.1 for PICCs, 98.5 for Hickman, and 67.7 for ports (P = .685). When analyzing CRBSIs, ports had 44, Hickman had 20, and PICC had 0 episodes per 1000 catheter-days (P = .078). Only PICCs showed less incidence of CRBSIs vs ports (P = .043). Multivariate logistic regression, correcting by catheter-days, patients' age and sex, underlying disease, and type of catheter, showed that only catheter-days (P = .031) was a predictor for CRBSIs (P = .007, Nagelkerke R= = 0.246). CONCLUSION: PICCs are similar in terms of catheter-related complications to other CVCs for the administration of HPN, especially for oncology patients with HPN lasting <6 months.

Copper and zinc serum levels after derivative bariatric surgery: differences between Roux-en-Y Gastric bypass and biliopancreatic diversion.

BACKGROUND: There are limited data on the prevalence of copper and zinc deficiency in the long term after bariatric surgery. METHODS: We analysed copper and zinc serum levels in a cohort of 141 patients, 52 who underwent Roux-en-Y gastric bypass (RYGB) and 89 biliopancreatic diversion (BPD), with a follow-up of 5 years. RESULTS: Mean copper level was significantly lower in the BPD group (P < 0.0001 vs. RYGB). Forty-five (50.6%) BPD patients had, at least once, a low copper level, and half of them, 27 (30.3%) patients, had repeatedly low levels. In this group, serum copper level correlated positively with total leukocyte and granulocyte count (r = 0.14, P = 0.002, and r = 0.17, P < 0.001, respectively). However, no patient had clinical evidence of haematological or neurological disorders. Only two RYGB patients (3.8%) had copper deficiency. Mean zinc level was also significantly lower in the BPD group (P < 0.0001). All but one BPD patient had hypozincaemia at least once, and the percentage of patients with hypozincaemia ranged from 44.9% to 74.2%. In RYGB patients, zinc deficiency peaked at 48 and 60 months (15.4% and 21.2%, respectively). The zinc level was determined by the alimentary limb length in this group, but the common channel length had no influence on copper and zinc levels in the BPD group. CONCLUSIONS: Hypocupremia, and especially hypozincaemia, are frequent findings in BPD patients, but rarely found in patients who underwent RYGB, particularly short RYGB. Our data also suggest that a long-standing and severe hypocupremia is required to develop neurological and haematological disorders after bariatric surgery.

Vitamin D receptor polymorphisms in secondary hyperparathyroidism after Scopinaro's biliopancreatic diversion.

BACKGROUND: Secondary hyperparathyroidism is a frequent metabolic complication of bariatric surgery. Individual differences in calcium absorption determine chronic secondary hyperparathyroidism after biliopancreatic diversion in half of the patients who have normal levels of 25-hydroxyvitamin D. We aimed to evaluate if certain vitamin D receptor polymorphisms may be responsible for the latter. Cases and controls study including 57 patients after biliopancreatic diversion with a mean serum 25-hydroxyvitamin D above 20 ng/mL, separated into those with secondary hyperparathyroidism (n = 26, cases) and those without it (n = 31, controls). METHODS: Genotyping for restriction-length-fragment polymorphisms of the vitamin D receptor gene was carried out for FOK1, BSM1, APA1, and TAQ1, and haplotype structure was also constructed. RESULTS: There were no differences in the allelic or genotypes distribution of the four studied polymorphisms between patients and controls (P = 0.352 and P = 0.301 for FOK1, P = 0.733 and P = 0.924 for BSM1, P = 0.974 and P = 0.992 for APA1, and P = 0.995 and P = 0.928 for TAQ1, respectively). Haplotype analysis showed no differences between patients and controls (P = 0.495 for BAT, P = 1.000 for BAt, P = 0.508 for Bat and P = 0.924 for bAT haplotypes, respectively). Furthermore, haplotypes were not associated with serum PTH levels or with the ratio between serum PTH and 25-hydroxyvitamin D levels. CONCLUSION: Chronic secondary hyperparathyroidism after biliopancreatic diversion in patients with normal levels of 25-hydroxyvitamin D is not dependent on vitamin D receptor gene polymorphisms.

Perioperative oral nutritional supplements in normally or mildly undernourished geriatric patients submitted to surgery for hip fracture: a randomized clinical trial.

BACKGROUND: Oral nutritional supplements have been recommended after orthopedic surgery in geriatric patients. This has been shown to be effective even in normally nourished or mildly undernourished geriatric patients. Whether perioperative administration of these products is also effective and suitable is not known. METHODS: Randomized, controlled, open, paralleled two-arms clinical trial, comparing energy-protein supplements (40 g of protein and 400 kcal per day), with no intervention in normally nourished or mildly undernourished patients. Outcomes were serum proteins, body mass index, postoperative complications among others. RESULTS: 60 Elderly patients were included. Patients in the intervention group (n = 30) ingested 52.2 ± 12.1% of the prescribed supplements per day for 5.8 ± 1.8 days before surgery and until hospital discharge. There was a significant change in serum albumin at follow-up (F = 22.536, P < 0.001), and between the two groups (F = 5.763, P = 0.002), favouring the intervention. The same was observed for serum prealbumin (F = 6.654, P = 0.001 within subjects, F = 2.865, P = 0.045 for interaction). Logistic regression showed that only supplemented proteins per day (OR[95%CI] = 0.925[0.869-0.985]) were associated with less postoperative complications (R(2) = 0.323, χ(2) = 11.541, P = 0.003). CONCLUSION: Perioperative supplements in geriatric patients with hip fracture submitted to surgery showed better recovery of plasma proteins. Higher daily protein intakes were associated with less postoperative complications.

Retinol and alpha-tocopherol in morbid obesity and nonalcoholic fatty liver disease.

BACKGROUND: We aimed to study serum retinol and alpha-tocopherol in a cohort of obese patients and their possible association with several obesity-related conditions, given that the former may be implicated in a diminished capacity of anti-inflammatory and antioxidant potential in obese patients. METHODS: Eighty patients with morbid obesity participated in the study. Many clinical and biochemical variables were measured including serum retinol, alpha-tocopherol, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) concentrations. Fatty liver was detected by ultrasonography. RESULTS: Both serum retinol and alpha-tocopherol inversely correlated with body mass index (r = -0.334, P = 0.002 and r = -0.299, P = 0.007, respectively). Serum retinol inversely correlated with AST (r = -0.236, P = 0.036) and ALT (r = -0.241, P = 0.032). Multivariate regression analyses confirmed these results after correcting for the effects of other variables. Eighty-five percent of patients had fatty liver. When restricting the analysis to them, multivariate regression identified male sex (beta = 0.451, P = 0.003), age (beta = -0.275, P = 0.039), and serum retinol concentrations (beta = -0.414, P = 0.005) as predictive variables on serum AST (R (2) = 0.230, F = 3.408, P = 0.009) and male sex (beta = 0.448, P = 0.003), age (beta = -0.236, P = 0.046), insulin resistance determined by homeostasis model assessment (beta = 0.243, P = 0.050), and serum retinol concentrations (beta = -0.305, P = 0.022) as predictive variables on serum ALT (R (2) = 0.296, F = 5.817, P = 0.001). CONCLUSION: Serum retinol and alpha-tocopherol concentrations are inversely associated with body mass index in morbid obesity, and serum retinol is also inversely associated with serum concentrations of transaminases in those patients with nonalcoholic fatty liver disease.