Assessment of plasma dexamethasone levels after 1-mg dexamethasone suppression test in adults with obesity.

BACKGROUND: The 1-mg overnight dexamethasone suppression test is the most frequently used screening test for Cushing's syndrome. It has been proposed that people with obesity may have insufficient plasma dexamethasone levels for the test which may result in false positives. We sought to compare the plasma dexamethasone levels after 1-mg dexamethasone suppression test in healthy obese participants and in optimal-weight participants. METHODS: A total of 30 optimal-weight participants (BMI ≤ 25 kg/m2 ) and 62 obese participants (BMI > 25 kg/m2 ) were enroled in the study. Obese participants were further divided into class 1 (25-29.9 kg/m2 ) and class 2 (>30 kg/m2 ). After a standard overnight 1-mg dexamethasone suppression test, blood samples were obtained for serum cortisol and plasma dexamethasone levels. Plasma dexamethasone levels were quantified using liquid chromatography - mass spectrometry (LC-MS/MS). RESULTS: No significant difference in plasma dexamethasone levels were found between obese and optimal-weight participants (3.31 ± 1.35 vs. 2.82 ± 1.11 nmol/L, mean ± SD; p = .09 respectively). There were also no correlations found between sex, BMI, body surface area and plasma dexamethasone levels. There was also no significant difference in the proportion of participants who achieved a plasma dexamethasone level >3.3 nmol/L in comparison between obesity class 1, obesity class 2, and optimal-weight groups. CONCLUSION: Our results suggest that obesity does not affect plasma dexamethasone levels. However, dexamethasone measurement may still be helpful in patients who are being investigated for Cushing's syndrome and suspected to have a false-positive DST.

Effect of canagliflozin in non-diabetic obese patients with albuminuria: A randomized, double-blind, placebo-controlled trial.

BACKGROUND: Sodium-glucose co-transporter 2 inhibitor (SGLT2i) has been shown to improve renal outcomes in both diabetic and non-diabetic kidney disease. However, the effect of SGLT2i on renal outcomes in patients with non-diabetic obesity is still not established. MATERIALS AND METHODS: In this double-blind, randomized controlled trial, we assigned non-diabetic patients with body mass index (BMI) ≥ 25 kg/m2, persistent 24-hour urine albumin-creatinine ratio (UACR) ≥ 10 mg/gCr, and estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73m2, who had been treated with renin-angiotensin system blockade, to canagliflozin 100 mg daily or placebo for 24 weeks. The reduction in UACR and eGFR at 12 and 24 weeks were explored. (Thai Clinical Trials Registry 20190203003). RESULTS: Of 247 non-diabetic obese patients screened, 32 patients met inclusion criteria and underwent randomization. The median baseline of UACR was 69.1 mg/gCr. There were no statistically significant differences in albuminuria reduction between the groups at 12 weeks and 24 weeks. The estimated GFR in the canagliflozin group decreased significantly from baseline at 12 weeks (-5.39 mL/min/1.73m2; 95% CI -9.81 to -0.97; p = 0.017) but not at 24 weeks (-1.16 mL/min/1.73m2; 95% CI -5.58 to 3.26; p = 0.66), and there was no significant change from baseline in the placebo group at both 12 and 24 weeks. CONCLUSION: Canagliflozin 100 mg daily was well tolerated but did not significantly reduce UACR in non-diabetic obese patients with microalbuminuria. However, a significant temporary decline in eGFR might reflect a subtle reduction in glomerular hyperfiltration.

Outcomes of a multidisciplinary transition clinic for youth with type 1 diabetes.

BACKGROUND: Emerging adults with type 1 diabetes (T1D) have several challenges regarding diabetes management and care transition from pediatric to adult services. In this study we aimed to assess the effectiveness of the newly established transition clinic for emerging adults with T1D. METHODS: We conducted an observational study of emerging adults with T1D treated in a transition clinic jointly operated by a pediatric and adult multidisciplinary care team during 2019-2021. A retrospective chart review of hemoglobin A1c (HbA1c), frequency of clinic attendance, acute diabetes-related complications, assessment of gaps in knowledge and behavior, and psychosocial outcomes was analyzed. RESULTS: A total of 21 patients with T1D were included. Median age at the transfer to the transition clinic was 24 years (range 21-34). Fifteen patients (71%) were successfully transferred to adult services; mean duration of follow-up at the transition clinic was 9.2 months (SD 3.9). None of the patients was lost to follow-up or experienced serious diabetes related complications. Mean (95% confidence interval) HbA1c levels decreased from 8.97% (7.87-10.07) at baseline to 8.25% (7.45-9.05) at the most recent visit (p = 0.01). A proportion of patients achieving the glycemic target (HbA1c < 7.5%) was increased from 24% at the first visit to 38% at the most recent visits. Patients' HbA1c levels at the adult clinic continued a favorable trend. Seven patients (33%) were identified as having symptoms of depression. Knowledge and behavioral gaps were identified and counselled by clinical care team. CONCLUSION: The multidisciplinary transition clinic has shown to be beneficial in terms of improving glycemic control, maintaining continuity of care and clinic attendance.

Changes in plasma aldosterone level after weight loss by bariatric surgery in morbidly obese patients.

BACKGROUND: Overactivation of renin-aldosterone-angiotensin system (RAS) is part of the pathogenesis of obesity-associated hypertension. Evidences have shown that weight loss can result in reduction in blood pressure and RAS. This study was aim to investigate changes of plasma aldosterone concentration (PAC) after bariatric surgery. METHODS: A prospective study was done in 14 morbidly obese patients undergoing bariatric surgery. Patients who were taking medications that can interfere with PAC and renin levels were excluded. Collection of blood samples were done at baseline and at 3 and 6-month post-bariatric surgery. RESULTS: Four out of 14 patients had hypertension at baseline. Mean body mass index (BMI) was 56.7 ± 13.5 kg/m2. PAC were significantly decreased at 3-and 6-month post-bariatric surgery from 14.3 ± 8.0 to 7.5 ± 5.5 [reduction of 36% from baseline (P < 0.01)] and 8.0 ± 6.6 ng/dl [reduction of 32% from baseline (P < 0.05)] respectively. The reduction of PAC at 3-month post-surgery was correlated with the reduction of body weight (r = 0.46, P < 0.05), waist circumference (r = 0.73, P < 0.05) and percent of body fat (r = 0.58, P < 0.05). CONCLUSIONS: Maximal reduction of PAC in obese patients underwent bariatric surgery occurred during the first 3 months after bariatric surgery. The reduction of PAC was associated with the reduction of body weight, waist circumference and percent of body fat suggesting the link between RAS and obesity-mediated hypertension.

Immediate return of fertility function following a bariatric surgery: A case report.

Obesity in women of childbearing age is linked to lower fertility rates due to chronic oligoovulation and anovulation. Effective weight loss treatment such as bariatric surgery can improve fertility potential. However, pregnancy during the first 12 months after bariatric surgery should be avoided due to an active catabolic state and may increase the potential risk of fetal growth restriction. Here, we report a case with an immediate return of fertility function following a bariatric surgery with favorable outcomes. A 30-year-old woman with obesity, history of polycystic ovarian syndrome and infertility become pregnant within 2-month period following bariatric surgery. She first recognized her pregnancy at the gestational age of 8 weeks. Micronutrient laboratory results at baseline were normal except for low 25-OH vitamin D level of 18.7 ng/dL. She continued to lose her weight during the first trimester but was able to gain some weight during the second and third trimesters. Close fetal ultrasonography monitoring was done during each trimester. The fetal ultrasonography showed an appropriate fetal weight, a normal Doppler study and no abnormality detected in the fetus. Finally, at 36 weeks of gestation, a 2380-g female baby was delivered successfully.

Metabolically healthy obesity--does it exist?

The prevalence of obesity has been increasing worldwide over the past 30 years and is a major public health concern. Obesity is known to be associated with metabolic disturbances including insulin resistance and inflammation; however, there is a subset of obese subjects who have normal metabolic profiles, and they have been identified as the metabolically healthy obese (MHO). Several studies have described MHO as obese individuals who have high levels of insulin sensitivity and the absence of diabetes, dyslipidemia, or hypertension. The prevalence of MHO varies from 20 to 30% among obese individuals. This review will discuss the MHO phenotype; the differences between MHO and metabolically unhealthy obese (MUO) individuals; and the possible underlying mechanisms including adipocyte differentiation, immune regulation, and cellular energy metabolism.

Comparison of long-term outcomes after laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most bariatric procedures in Asia. However, a comparison of long-term outcomes is still limited. OBJECTIVES: To compare the degree of long-term weight loss, remission of comorbidities and complication rates after LRYGB and LSG procedures. METHODS: A retrospective analysis was conducted for all patients who underwent LSG or LRYGB between May 2005 and May 2018 at a single institute with at least 1-5 years of follow up. Demographic data were collected. RESULTS: Of the total 342 patients, 159 underwent primary LSG and 183 patients underwent LRYGB. Preoperative BMI in the LSG group was significantly higher than the LRYGB group (54.7 ± 12.6 kg/m2 vs 48.2 ± 8.2 kg/m2, P = 0.001). Comorbidities between LSG and LRYGB groups were similar. Mean percentage of total weight loss (%TWL) at 5 years after was 23.6 ± 1.7 % in the LSG group vs. 29.9 ± 1.3 % in the LRYGB group (P = 0.005) and LRYGB resulted in greater weight loss than LSG at all time points. The remission of comorbidities were similar in both groups, except that dyslipidemia was significantly better in the LRYGB group. Overall complications were 35.2 % in the LSG group vs. 20.8 % in the LRYGB group (P = 0.003). CONCLUSIONS: Our center revealed that LRYGB had better results than LSG in terms of percentage total weight loss at all time points. In the long term, LSG showed a higher overall complication rate compared to LRYGB.

Comparison of enoxaparin 40 mg versus 60 mg dosage for venous thromboprophylaxis in patients undergoing bariatric surgery: A randomized controlled trial.

BACKGROUND: Venous thromboembolism (VTE) is a common cause of morbidity and mortality after bariatric surgery. Morbid obesity is an independent risk factor for VTE, with goals of prophylactic anti-factor Xa levels within 0.2-0.5 IU/mL. The recommended dosing regimen of enoxaparin for VTE prophylaxis in patients with morbid obesity is lacking in available guidelines. OBJECTIVES: To evaluate the achieving prophylactic anti-factor Xa levels with different dosages of enoxaparin for morbid obesity patients. SETTING: We conducted a study at Chulalongkorn Bariatric and Metabolic Institute, King Chulalongkorn Memorial Hospital. METHODS: We conducted a randomized controlled trial comparing anti-factor Xa levels 4 h after the administration of enoxaparin. All recruited patients randomly received 40 mg or 60 mg of enoxaparin 12 h before the operation. Blood specimens were collected 4 h after the administration of enoxaparin. RESULTS: In total, 56 patients who presented between April 2019 and March 2020 at King Chulalongkorn Memorial Hospital were recruited. Of these patients, 28 received 40 mg and 28 received 60 mg of enoxaparin. In both groups, the rates of achieving target levels were 53.57% and 78.57%, respectively (p-value = 0.048). The mean anti-factor Xa levels were 0.19 IU/mL ± 0.06 IU/mL and 0.28 and 0.28 ± 0.10 IU/mL, respectively (p < 0.001). No significant difference was found in the estimated blood loss between the groups. No patient obtained anti-factor Xa levels exceeding 0.5 IU/mL. In both groups, no symptomatic VTE occurred. CONCLUSIONS: A 60 mg of enoxaparin regimen achieved more prophylactic anti-factor Xa levels than 40 mg in obese patients undergoing bariatric surgery without any adverse events.

Effect of Preoperative Very Low-Calorie Diets on Hepatic Steatosis, Fibrosis, and Perioperative Outcomes of Bariatric Surgery.

Introduction: Preoperative weight loss through a very low-calorie diet (VLCD) has been shown to reduce liver volume and technical difficulty in patients undergoing metabolic and bariatric surgery (MBS). However, the effect of preoperative VLCD on liver histology and other outcomes is not well demonstrated. Our study aimed to explore the effect of a 2-week preoperative VLCD, compared with no-dietary intervention, on hepatic steatosis, fibrosis, weight loss, and other postoperative outcomes of MBS. Materials and Methods: This retrospective study was conducted at the Chulalongkorn Bariatric and Metabolic Institute, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. The medical records of patients with severe obesity (body mass index ≥50 kg/m2) attending the clinic from January 2005 to December 2020 were reviewed. Clinical data and laboratory investigations were collected at baseline and at each follow-up visit, up to 5 years postoperatively. Hepatic steatosis and fibrosis were assessed by liver biopsy intraoperatively. Results: A total of 181 patients were included in this study. Preoperative VLCD was prescribed in 65 patients (VLCD group) and 116 patients received their usual diet (control group). Mean preoperative weight loss was 9.1 ± 6.1 kg in the VLCD group versus 0.0 ± 0.0 kg in the control group (P = .000). The VLCD group had significantly less number of patients with moderate and severe liver steatosis from the liver biopsy specimens (16.2% versus 46.3%; P = .008). However, there was no significant difference in fibrosis grade between those with VLCD and control (≥F2-fibrosis; 2.7% versus 7.5%; P = .118). Moreover, preoperative VLCD could reduce operating time in patients who underwent both laparoscopic Roux-en-Y gastric bypass (LRYGB; VLCD 163.4 ± 38.2 minutes versus control 215.1 ± 67.4 minute, P = .000) and laparoscopic sleeve gastrectomy (LSG; VLCD 110.8 ± 20.0 minutes versus control 131.0 ± 38.1 minutes, P = .004). During the 5-year follow-up, there were a significant difference of HbA1C between the VLCD and the control group (coefficient: -0.24 with 95% confidence interval [CI]: -0.44 to -0.04, P = .019), particularly in patients who underwent LRYGB (Coefficient: -0.26 with 95% CI: -0.49 to -0.03, P = .028), but not LSG. However, long-term weight loss outcomes and other biochemical outcomes were not different between the VLCD and the control group. Conclusion: Preoperative VLCD was associated with reduced liver steatosis and operative time in patients who underwent LRYGB and LSG. Moreover, preoperative VLCD significantly decreased HbA1C during a 5-year follow-up period. Therefore, it should be considered in patients with severe obesity, who will undergo MBS.

Towards a major methodological shift in depression research by assessing continuous scores of recurrence of illness, lifetime and current suicidal behaviors and phenome features.

BACKGROUND: The binary major depressive disorder (MDD) diagnosis is inadequate and should never be used in research. AIMS: The study's objective is to explicate our novel precision nomothetic strategy for constructing depression models based on adverse childhood experiences (ACEs), lifetime and current phenome, and biomarker (atherogenicity indices) scores. METHODS: This study assessed recurrence of illness (ROI: namely recurrence of depressive episodes and suicidal behaviors, SBs), lifetime and current SBs and the phenome of depression, neuroticism, dysthymia, anxiety disorders, and lipid biomarkers including apolipoprotein (Apo)A, ApoB, free cholesterol and cholesteryl esters, triglycerides, high density lipoprotein cholesterol in 67 normal controls and 66 MDD patients. We computed atherogenic and reverse cholesterol transport indices. RESULTS: We were able to extract one factor from a) the lifetime phenome of depression comprising ROI, and traits such as neuroticism, dysthymia and anxiety disorders, and b) the phenome of the acute phase (based on depression, anxiety and quality of life scores). PLS analysis showed that 55.7 % of the variance in the lifetime + current phenome factor was explained by increased atherogenicity, neglect and sexual abuse, while atherogenicity partially mediated the effects of neglect. Cluster analysis generated a cluster of patients with major dysmood disorder, which was externally validated by increased atherogenicity and characterized by increased scores of all clinical features. CONCLUSIONS: The outcome of depression should not be represented as a binary variable (MDD or not), but rather as multiple dimensional scores based on biomarkers, ROI, subclinical depression traits, and lifetime and current phenome scores including SBs.

Comparison of Body Composition Variables between Post-Bariatric Surgery Patients and Non-Operative Controls.

Background: Since bariatric surgery results in massive weight loss, it may be associated with a disproportionate decrease in lean body mass. Objective: To evaluate body composition in post-bariatric surgery patients who had a successful weight loss at 12 months (>50% excess weight loss) with comparisons to healthy controls who were matched for age, sex and BMI. Methods: This is an observational analytic study using data from post-bariatric surgery patients who had laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (SG) at King Chulalongkorn Memorial Hospital. Patients who had percentage excessive weight loss (%EWL) >50% and achieved a BMI of <30 kg/m2 within 12 months after the surgery were included. Non-operative healthy controls matched for sex, age, and BMI (1:1) were recruited. The 12-month post-bariatric surgery BMI was used to match the BMI of the control subjects. A single bioelectrical impedance analysis (BIA) (Inbody 770) machine was used for the entire study. Results: Sixty participants were included in this study. There are 30 post-bariatric surgery patients (female n = 19, male n = 11) and 30 non-operative controls (female n = 19, male n = 11). The 12-month post-bariatric surgery patients had lower percentage of body fat (PBF) (30.6% vs 35.9%, P-value .001) and trunk fat mass (10.3 vs 12.4 kg, P-value .04) than non-operative controls. The 12-month post-bariatric surgery patients also were found to have more soft lean mass (SLM) (47.7 vs 39.9 kg, P-value .001), fat free mass (FFM) (51.1 vs 42.3 kg, P-value .001), skeletal muscle mass (SMM) (27.5 vs 23 kg, P-value .003), and trunk lean mass (21.2 vs 19 kg, P-value .02). Conclusion: Despite the significant reductions in all body composition variables in post-bariatric surgery patients at 12-month follow-up, both fat free mass and skeletal muscle mass were found to be higher in the surgical patients compared to the control group. Clinical trials: Thai Clinical Trials Registry, https://thaiclinicaltrials.org/ID:TCTR20200223003.

Sustained weight loss after duodenal-jejunal bypass liner treatment in patients with body mass index below, but not above 35 kg/m2 : A retrospective cohort study.

Previous data from short term studies have shown an efficacy of the duodenal-jejunal bypass liner (DJBL) for weight loss. However, less data is available regarding weight change after device removal and possible predictors for weight loss. This is a retrospective chart review of all patients who had DJBL inserted at the University Hospital Zurich between December 2012 and June 2015. A total of 27 patients had DJBL insertion. The median BMI at baseline was 38.5 (34.0-42.2) kg/m2 . In the 24 patients with DJBL treatment >3 months (failed implantation or early removal due to side effects in 3 patients), the mean duration of implantation was 42.9 ± 13.1 weeks. During the treatment, the mean total body weight loss (%TBWL) was 15.0 ± 8.3%. Fifteen patients had long-term follow-up data available (mean duration of follow-up 4.0 ± 0.9 years). The mean weight change was 12.7 ± 12.8 kg, corresponding with a mean % weight regain of 13.3 ± 13.3%. Five patients (33.3%) subsequently underwent bariatric surgery. In patients with class I obesity (BMI <35 kg/m2 at baseline), 4 out of 6 (66.7%) had a stable weight or only a weight regain <7%. In contrast, no patient with BMI >35 kg/m2 at baseline was able to keep weight regain below 7%. DJBL is an effective treatment for obesity, but substantial weight regain occurs during long-term follow up after the device removal, in particular in patients with BMI > 35 kg/m2 .

Skin manifestations and biophysical changes following weight reduction induced by bariatric surgery: A 2-year prospective study.

Skin manifestations and biophysical changes are observed in patients with morbid obesity. However, reports of changes after significant weight loss, particularly through post-bariatric surgery (BaS), are limited. The aim of this 2-year prospective study was to evaluate the prevalence of skin signs and their changes in patients with morbid obesity who underwent BaS. Thirty-one patients were recruited for the study, with a mean age of 38.35 (SD 10.61) years and a male preponderance (male = 19 [61.29%], female = 12 [38.71%]). Patients were scheduled for multiple visits at months 0, 3, 6, 12, 18, and 24 post-BaS. Each subject had a thorough skin examination, biophysical measurements, and laboratory tests at each visit. Striae, acanthosis nigricans (AN), and plantar hyperkeratosis were the most common skin findings (n = 30 [96.77%], 29 [93.55%], 29 [93.55%], respectively). BaS provided improvements in many skin manifestations, namely striae, AN, acrochordons, plantar hyperkeratosis, hirsutism, lymphedema, pruritus, acne, finger pebbles, and chronic venous insufficiency with varied cumulative rates of improvements. However, acute telogen effluvium was observed in 17 (54.84%) patients. Regarding skin biophysical properties, transepidermal water loss, skin hydration, and pH did not change, while sebum production on the face significantly decreased at months 3 and 6, and elasticity decreased at months 6 and 24. In conclusion, weight reduction by BaS provided improvements in various skin signs, although telogen effluvium was a common sequelae.

The Accuracy of Continuous Glucose Monitoring in the Medical Intensive Care Unit.

OBJECTIVE: To assess the accuracy of continuous glucose monitoring (CGM) in medical intensive care unit (MICU) patients. METHODS: A Medtronic Enlite® sensor accuracy was assessed versus capillary blood glucose (CBG) and plasma glucose (PG) using the mean absolute relative difference (MARD), surveillance error grid (SEG) analysis and modified Bland-Altman plots. RESULTS: Using CBG as a reference, MARD was 6.6%. Overall, 99.7% of the CGM readings were within the "no risk" zone. No significant differences in accuracy were seen within vasopressor subgroups. Using PG as the reference, MARD was 8.8%. The surveillance error grid analysis showed 95.2% of glucose readings were within the "no risk" zone. There were no device-related adverse events. CONCLUSION: The CGM sensor showed acceptable accuracy in MICU patients, regardless of vasopressor use.

Thyrotoxic Hypokalemic Periodic Paralysis Triggered by Dexamethasone Administration.

Thyrotoxic hypokalemic periodic paralysis (THPP) is a disease characterized by recurrent episodes of muscle weakness due to intracellular potassium shifting in the presence of high levels of thyroid hormone. It occurs more commonly amongst young Asian men with underlying Graves' disease. Attacks are commonly precipitated by ingestion of carbohydrate-rich meals or alcohols, stress or strenuous exercise. Herein, we describe an adult Thai man suffering from a hypokalemic periodic paralysis attack after receiving a dexamethasone injection. The diagnosis of Graves' disease was confirmed by his thyroid function test and a presence of thyrotropin-receptor antibody. His weakness and hypokalemia responded well to potassium supplement and a non-selective beta blocker, while his thyrotoxicosis was initially controlled by an anti-thyroid medication and subsequently with a subtotal thyroidectomy. Clinicians should beware of this manifestation when administering steroids in the thyrotoxic patients, especially of Asian male descent.

Diabetic muscle infarction: rare complication with a distinct clinical manifestation.

Diabetic muscle infarction is an unusual condition with distinctive clinical characteristics seen in patients with prolonged and uncontrolled diabetes. Clinical findings and imaging study are unique and challenging. Patients usually present with acute unilateral severe muscular pain and swelling, particularly in the lower extremities. The presentation is difficult to distinguish from other common conditions such as deep venous thrombosis and infectious myositis. However, early recognition of the clinical presentation and appropriate imaging selection can lead to the diagnosis and avoid unnecessary muscle biopsy. Here, we report a case of diabetic muscle infarction in a patient with poorly controlled type 1 diabetes who had a good clinical response after an early detection and appropriate treatment.

Carotid body paraganglioma.

Carotid body paraganglioma is commonly asymptomatic, slow-growing, and nonfunctioning. With its relative contraindication to biopsy due to its high vascularity in nature, imaging characteristics are the key to help making the diagnosis. Treatment modalities, ranging from an observation to definitive treatment with surgery, should be selected on an individual basis.