Cytokine profiles in adults with imported malaria.

The increase in worldwide travel is making imported malaria a growing health concern in non-endemic countries. Most data on the pathophysiology of malaria come from endemic areas. Little is known about cytokine profiles during imported malaria. This study aimed at deciphering the relationship between cytokine host response and malaria severity among imported cases in France. This study reports cytokine profiles in adults with Plasmodium falciparum malaria included in the PALUREA prospective study conducted between 2006 and 2010. The patients were classified as having uncomplicated malaria (UM) or severe malaria (SM), with this last further categorized as very severe malaria (VSM) or less severe malaria (LSM). At hospital admission, eight blood cytokines were assayed in duplicate using Luminex® technology: interleukin (IL)-1α, IL-1ß, IL-2, IL-4, IL-10, tumor necrosis factor (TNF)α, interferon (IFN)γ, and macrophage migration inhibitory factor (MIF). These assays were repeated on days 1 and 2 in the SM group. Of the 278 patients, 134 had UM and 144 SM. At hospital admission, over half the patients had undetectable levels of IL-1α, IL-1ß, IL-2, IL-4, IFNγ, and TNFα, while IL-10 and MIF were significantly higher in the SM vs. the UM group. Higher IL-10 was significantly associated with higher parasitemia (R = 0.32 [0.16-0.46]; P = 0.0001). In the SM group, IL-10 elevation persisting from admission to day 2 was significantly associated with subsequent nosocomial infection. Of eight tested cytokines, only MIF and IL-10 were associated with disease severity in adults with imported P. falciparum malaria. At admission, many patients had undetectable cytokine levels, suggesting that circulating cytokine assays may not be helpful as part of the routine evaluation of adults with imported malaria. Persisting high IL-10 concentration was associated with subsequent nosocomial infection, suggesting its possible interest in immune monitoring of most severe patients.

Relationship between serotypes, disease characteristics and 30-day mortality in adults with invasive pneumococcal disease.

PURPOSE: Invasive pneumococcal disease (IPD) is responsible for substantial mortality and morbidity worldwide. We aimed to identify host and bacterial factors associated with 30-day mortality in 18-year-old patients hospitalized with IPD in France from 2013 to 2015. METHODS: This study analyzed data collected from consecutives IPD cases included in two parallel multi-center cohort studies: COMBAT study (280 patients with pneumococcal community-acquired bacterial meningitis) and SIIP study (491 patients with non-meningitis IPD). Factors associated with 30-day mortality were identified using logistic regression. RESULTS: Among the 771 enrolled patients (median age 66 years, IQR [52.0-79.7]), 592/767 (77.2%) had at least one chronic disease. Patients with meningitis were younger (60.2 vs 70.9 years; p < 0.001) and had fewer chronic diseases than those with non-meningitis IPD (73.3% vs 79.4%; p = 0.05). Non-vaccine serotypes were more frequent in meningitis patients than in those with other IPD (36.1% vs 23.1%; p < 0.001). The overall 30-day mortality was 16.7% and patients with concurrent meningitis and extra-cerebral IPD had the highest 30-day mortality rate (26.5%). On multivariate analyses, older age, history of malignant solid tumor, meningeal IPD and serotypes previously identified with high mortality potential were independently associated with 30-day mortality. Of the serotypes with high mortality potential, 80% were included in licensed (PCV13 or PPV23) vaccines. CONCLUSION: We observed an effect of both host factors and pneumococcal serotypes on 30-day mortality in IPD. This highlights the need for a focused strategy to vaccinate at-risk patients. CLINICAL TRIAL: ClinicalTrial. Gov identification number: NCT01730690.

[Impact of a coordinated regional organization to secure the management of patients on oral anticancer drugs: CHIMORAL, a comparative trial]. / Impact d'une organisation régionale coordonnée pour sécuriser la prise en charge des patients sous anticancéreux oraux : CHIMORAL, une étude comparative.

INTRODUCTION: Oral anticancer drugs have disrupted hospital and community practices. A better coordination and patient support for medication and adverse events management by primary care providers (general practitioner, community pharmacist and liberal nurse) could improve the situation. The CHIMORAL study evaluated a model of coordination by territorial health networks. METHODS: A here and elsewhere, prospective and multicentric study, comparing coordinated care with standard care. Primary outcome was the use of the hospital structure for adverse events within 6 months of initiating treatment. RESULTS: In all, 283 patients were included. 92% had at least one adverse event, with a higher median number in the coordinated group (12.5 vs. 9.0, P=0.02). No difference in hospital use by arm (P=0.502). Increase in the use of community care for adverse events in the coordinated group (27% vs. 16%, P=0.009). No observed impact on progression rates, quality of life and treatment adherence. The overall survival rate at 6 months is numerically higher in the coordinated group (87% vs. 76%, P=0.064). DISCUSSION: This model does not show any difference on the primary endpoint. The lack of randomization, patient selection, power loss, and local initiatives to monitor these patients may have biased the analysis. A large number of uses of the healthcare system were observed. These results confirm the need for a dedicated care pathway for the patient with oral anticancer drugs.

Perip7lakin is a target for autoimmunity in asthma.

The role of autoimmunity targeting epithelial antigens in asthma has been suggested, in particular in non-atopic and severe asthma. Periplakin, a desmosomal component, is involved in epithelial cohesion and intracellular signaling. We detected anti-periplakin IgG antibodies in 47/260 (18 %) patients with asthma, with no association with severity or atopy. In addition, anti-periplakin IgE antibodies were detected in 12 of 138 tested patients (8.7 %) and were more frequently observed in patients with than without nasal polyposis. This study identifies a new autoimmune epithelial target in asthma. Whether periplakin autoimmunity (both IgG and IgE auto-antibodies) is involved in asthma pathogenesis remains to be studied during the disease course of these patients.

Increased volume of conducting airways in idiopathic pulmonary fibrosis is independent of disease severity: a volumetric capnography study.

Bronchiectasis, bronchiolectasis, and bronchiolisation of alveolar regions are salient features of idiopathic pulmonary fibrosis (IPF). We asked whether IPF was associated with physiological changes consistent with increases in the volume of conducting airways, and whether airway volume was related to the severity of lung fibrosis. Patients with IPF (N = 57, vital capacity-VC: 73 ± 20%), patients with non-IPF interstitial lung disease (non-IPF ILD, N = 24, VC = 78 ± 18%) and controls without lung disease (N = 51, VC = 112 ± 21%) underwent volumetric capnography for the determination of conducting airway volume using Fletcher's equal area method, reported to predicted total lung capacity to control for the effect of lung size (VDaw/TLCp, mL/L). VDaw/TLCp was higher in patients with IPF (45.3 ± 12.8 ml L(-1)) in comparison with controls (34.2 ± 11.0 ml L(-1), p < 0.0001) and patients with non-IPF ILD (39.5 ± 9.2 ml L(-1), p = 0.0496). The same differences were observed when analysis was restricted to subjects with moderate IPF (VC ⩾ 80% predicted). Among IPF patients, VDaw/TLCp was correlated with neither the mMRC dyspnea scale, nor VC, nor carbon monoxide transfer factor, nor computed tomography fibrosis scores. Volumetric capnography showed higher conducting airway volume in IPF patients in comparison with controls and non-IPF ILDs, independent of disease severity. This result is consistent with either anatomical predisposition or dilation/longitudinal growth of conducting airways in IPF.

Paradoxical anti-TNF-associated TB worsening: Frequency and factors associated with IRIS.

OBJECTIVES: Paradoxical tuberculosis (TB) worsening, an example of the immune reconstitution inflammatory syndrome (IRIS), is an increasing phenomenon now described in several settings, including anti-tumor necrosis factor (TNF) discontinuation during biotherapy-induced TB. To better recognize it, we analyzed the frequency and factors associated with anti-TNF-induced TB-IRIS. METHODS: Case-control study on anti-TNF-associated TB patients. IRIS cases, defined with the following consensus criteria, were matched to two controls (anti-TNF-associated TB without IRIS). IRIS frequency was based on the French RATIO registry. Conditional logistic-regression identified IRIS risk factors. RESULTS: Fourteen patients developed anti-TNF-associated TB-IRIS within medians of 45 [IQR 22-131] days after starting anti-TB therapy and 110 [IQR 63-164] days after the last anti-TNF infusion. Each case was matched to two controls by year of TB diagnosis. IRIS-associated factors were (odds ratio [95% CI]): disseminated TB (11.4 [1.4-92.2], P=0.03), history of Mycobacterium tuberculosis exposure (12.7 [1.6-103.0], P=0.02) and steroid use at the time of TB diagnosis (4.6 [1.2-17.2], P=0.02). The RATIO registry IRIS frequency was 7%. CONCLUSION: After stopping biotherapy, paradoxical anti-TNF-associated TB worsening occurred most often in patients with disseminated TB. Although diagnosis remains difficult, physicians must be aware of IRIS because prolonged anti-TB treatment is not needed but, paradoxically, immunosuppressant reintroduction may be.

Body mass index and response to infliximab in rheumatoid arthritis.

OBJECTIVES: Excess adipose tissue in obese individuals may have immunomodulating properties and pharmacokinetics consequences. Previous studies have suggested that obesity could negatively affect the response to anti-TNF-α agents, notably infliximab (IFX). We aimed to determine whether body mass index (BMI) is involved in the response to IFX in rheumatoid arthritis (RA). METHODS: We retrospectively examined data for 76 RA patients receiving IFX. BMI was calculated before treatment, and change from baseline in DAS28, pain on a visual analog scale, erythrocyte sedimentation rate, C-reactive protein level, tender and swollen joint count was analysed at 6 months after treatment. The primary outcome was decrease in DAS28 ≥1.2. Secondary outcomes were good response and remission according to EULAR. RESULTS: At baseline, the median [interquartile range] BMI was 26.6 [22.6-30.6] kg/m2. The number of patients with normal weight, overweight and obesity was 25, 29 and 22. In multivariable analyses, IFX treated patients with lower BMI showed a more frequent DAS28 decrease ≥1.2 (25.5 [22.3-28.3] vs. 28.0 [23.2-32.5], p=0.02, odds ratio [OR] 0.88 [95% confidence interval 0.79-0.98]), EULAR good response (25.3 [21.9-27.5] vs. 27.5 [24.3-31.2], p=0.03, OR 0.87 [0.76-0.99]) and EULAR remission, although not significant (25.3 [21.9-26.4] vs. 27.5 [23.2-30.9], p=0.14, OR 0.88 [0.75-1.04]). CONCLUSIONS: Obesity may negatively influence the response to IFX in RA. These data could help physicians to choose biologic agents for obese RA patients.

Do hip OA patients referred to orthopedic surgeons by general practitioners and rheumatologists differ?

There is no consensus regarding indications for total hip arthroplasty (THA) in hip osteoarthritis (OA). Patients can be referred to surgeons either by a general practitioner (GP) or a rheumatologist. The aim of this study was to determine whether patients referred to orthopedic surgeons by GP and rheumatologists differed. GPs and rheumatologists were asked to include one patient suffering from hip OA for whom a consultation with a surgeon was planned to determine if THA was indicated. Surgeons' decisions were obtained by follow-up questionnaires. Univariate and then multivariate statistical analysis evaluated differences between patients referred by GPs and those referred by rheumatologists. A total of 558 patients were included. THA was prescribed in 71.6 % of patients referred by rheumatologists vs. 57.6 % of patients referred by GPs (p = 0.008). Patients referred by rheumatologists were younger (66.3 vs. 69.3 years; p = 0.006), less frequently retired (72.9 vs. 84.2 %; p = 0.007), and presented with a higher New Zealand score (54.3 vs. 48.1; p = 0.0009). On multivariate analysis, the variables related to patients referred by rheumatologists were the SF-12 mental score, the New Zealand score, and the surgeon's decision. Patients consulting a surgeon to discuss THA were more likely to be operated on when referred by a rheumatologist, which might be due to differences in the rheumatologists' and GPs' opinions on the right time to perform surgery or due to differences in the populations followed by rheumatologists and GPs, those followed by rheumatologists being younger, more active, more urban, with a greater willingness to undergo surgery.

Surgical management of patients with Marfan syndrome: evolution throughout the years.

AIM: To evaluate the evolution of surgical management in a large population of patients with Marfan syndrome. METHODS: This is a retrospective study of patients fulfilling the Ghent criteria for Marfan syndrome, who visited the Centre de référence national pour le syndrome de Marfan et apparentés and underwent a surgical event before or during follow-up in the centre. RESULTS: One thousand and ninety-seven patients with Marfan syndrome, according to international criteria, came to the clinic between 1996 and 2010. Aortic surgery was performed in 249 patients (22.7%; 20 children and 229 adults), including the Bentall procedure in 140 patients (56%) and valve-sparing surgery in 88 patients (35%); a supracoronary graft was performed in 19 patients (7.6%), usually for aortic dissection. During the past 20 years, the predominant reason for aortic surgery has switched from aortic dissection to aortic dilatation, while age at surgery has tended to increase (from 32.4 ± 11.9 years to 35.2 ± 12.4 years; P=0.075). Mitral valve surgery was performed in 61 patients (5.6%; six children and 55 adults), including 37 valvuloplasties (60.6%) and 18 mitral valve replacements (29.5%). No significant difference was observed when comparing mitral valve surgery before and after 2000. CONCLUSION: Surgery performed in patients with Marfan syndrome has switched from emergency surgery for aortic dissection to elective surgery for aortic dilatation; this is associated with surgery performed at an older age despite the indication for surgery having decreased from 60mm to 50mm. No significant evolution was observed for mitral valve surgery.

Aortic event rate in the Marfan population: a cohort study.

BACKGROUND: Optimal management, including timing of surgery, remains debated in Marfan syndrome because of a lack of data on aortic risk associated with this disease. METHODS AND RESULTS: We used our database to evaluate aortic risk associated with standardized care. Patients who fulfilled the international criteria, had not had previous aortic surgery or dissection, and came to our center at least twice were included. Aortic measurements were made with echocardiography (every 2 years); patients were given systematic ß-blockade and advice about sports activities. Prophylactic aortic surgery was proposed when the maximal aortic diameter reached 50 mm. Seven hundred thirty-two patients with Marfan syndrome were followed up for a mean of 6.6 years. Five deaths and 2 dissections of the ascending aorta occurred during follow-up. Event rate (death/aortic dissection) was 0.17%/y. Risk rose with increasing aortic diameter measured within 2 years of the event: from 0.09%/y per year (95% confidence interval, 0.00-0.20) when the aortic diameter was <40 mm to 0.3% (95% confidence interval, 0.00-0.71) with diameters of 45 to 49 mm and 1.33% (95% confidence interval, 0.00-3.93) with diameters of 50 to 54 mm. The risk increased 4 times at diameters ≥50 mm. The annual risk dropped below 0.05% when the aortic diameter was <50 mm after exclusion of a neonatal patient, a woman who became pregnant against our recommendation, and a 72-year-old woman with previous myocardial infarction. CONCLUSIONS: Risk of sudden death or aortic dissection remains low in patients with Marfan syndrome and aortic diameter between 45 and 49 mm. Aortic diameter of 50 mm appears to be a reasonable threshold for prophylactic surgery.

Comparison of clinical presentations and outcomes between patients with TGFBR2 and FBN1 mutations in Marfan syndrome and related disorders.

BACKGROUND: TGFBR2 mutations were recognized recently among patients with a Marfan-like phenotype. The associated clinical and prognostic spectra remain unclear. METHODS AND RESULTS: Clinical features and outcomes of 71 patients with a TGFBR2 mutation (TGFBR2 group) were compared with 50 age- and sex-matched unaffected family members (control subjects) and 243 patients harboring FBN1 mutations (FBN1 group). Aortic dilatation was present in a similar proportion of patients in both the TGFBR2 and FBN1 groups (78% versus 79%, respectively) but was highly variable. The incidence and average age for thoracic aortic surgery (31% versus 27% and 35+/-16 versus 39+/-13 years, respectively) and aortic dissection (14% versus 10% and 38+/-12 versus 39+/-9 years) were also similar in the 2 groups. Mitral valve involvement (myxomatous, prolapse, mitral regurgitation) was less frequent in the TGFBR2 than in the FBN1 group (all P<0.05). Aortic dilatation, dissection, or sudden death was the index event leading to genetic diagnosis in 65% of families with TGFBR2 mutations, versus 32% with FBN1 mutations (P=0.002). The rate of death was greater in TGFBR2 families before diagnosis but similar once the disease had been recognized. Most pregnancies were uneventful (without death or aortic dissection) in both TGFBR2 and FBN1 families (38 of 39 versus 213 of 217; P=1). Seven patients (10%) with a TGFBR2 mutation fulfilled international criteria for Marfan syndrome, 3 of whom presented with features specific for Loeys-Dietz syndrome. CONCLUSIONS: Clinical outcomes appear similar between treated patients with TGFBR2 mutations and individuals with FBN1 mutations. Prognosis depends on clinical disease expression and treatment rather than simply the presence of a TGFBR2 gene mutation.

Effect of response format for clinical vignettes on reporting quality of physician practice.

BACKGROUND: Clinical vignettes have been used widely to compare quality of clinical care and to assess variation in practice, but the effect of different response formats has not been extensively evaluated. Our objective was to compare three clinical vignette-based survey response formats - open-ended questionnaire (A), closed-ended (multiple-choice) questionnaire with deceptive response items mixed with correct items (B), and closed-ended questionnaire with only correct items (C) - in rheumatologists' pre-treatment assessment for tumor-necrosis-factor (TNF) blocker therapy. STUDY DESIGN: Prospective randomized study. SETTING: Rheumatologists attending the 2004 French Society of Rheumatology meeting. Physicians were given a vignette describing the history of a fictitious woman with active rheumatoid arthritis, who was a candidate for therapy with TNF blocking agents, and then were randomized to receive questionnaire A, B, or C, each containing the same four questions but with different response formats, that asked about their pretreatment assessment. MEASUREMENTS: Long (recommended items) and short (mandatory items) checklists were developed for pretreatment assessment for TNF-blocker therapy, and scores were expressed on the basis of responses to questionnaires A, B, and C as the percentage of respondents correctly choosing explicit items on these checklists. STATISTICAL ANALYSIS: Comparison of the selected items using pairwise Chi-square tests with Bonferonni correction for variables with statistically significant differences. RESULTS: Data for all surveys distributed (114 As, 118 Bs, and 118 Cs) were complete and available for analysis. The percentage of questionnaire A, B, and C respondents for whom data was correctly complete for the short checklist was 50.4%, 84.0% and 95.0%, respectively, and was 0%, 5.0% and 5.9%, respectively, for the long version. As an example, 65.8%, 85.7% and 95.8% of the respondents of A, B, and C questionnaires, respectively, correctly identified the need for tuberculin skin test (p < 0.0001). CONCLUSION: In evaluating clinical practice with use of a clinical vignette, a multiple-choice format rather than an open-ended format overestimates physician performance. The insertion of deceptive response items mixed with correct items in closed-ended (multiple-choice) questionnaire failed to avoid this overestimation.

Outcome and serum ion determination up to 11 years after implantation of a cemented metal-on-metal hip prosthesis.

BACKGROUND AND PURPOSE: Little is known about the long-term outcome of cemented metal-on-metal hip arthroplasties. We evaluated a consecutive series of metal-on-metal polyethylene-backed cemented hip arthroplasties implanted in patients under 60 years of age. METHODS: 109 patients (134 joint replacements) were followed prospectively for mean 9 (7-11) years. The evaluation included clinical score, radiographic assessment, and blood sampling for ion level determination. RESULTS: At the final review, 12 hips had been revised, mainly because of aseptic loosening of the socket. Using revision for aseptic loosening as the endpoint, the survival rate at 9 years was 91% for the cup and 99% for the stem. In addition, 35 hips showed radiolucent lines at the bone-cement interface of the acetabulum and some were associated with osteolysis. The median serum cobalt and chromium levels were relatively constant over time, and were much higher than the detection level throughout the study period. The cobalt level was 1.5 microg/L 1 year after implantation, and 1.44 microg/L 9 years after implantation. INTERPRETATION: Revisions for aseptic loosening and radiographic findings in the sockets led us to halt metal-on-metal-backed polyethylene cemented hip arthroplasty procedures. If the rigidity of the cemented socket is a reason for loosening, excessive release of metal ions and particles may be involved. Further investigations are required to confirm this hypothesis and to determine whether subluxation, microseparation, and hypersensitivity also play a role.

Neglected external validity in reports of randomized trials: the example of hip and knee osteoarthritis.

OBJECTIVE: To evaluate data reporting related to external validity from randomized controlled trials (RCTs) assessing pharmacologic and nonpharmacologic treatment for hip and knee osteoarthritis (OA). METHODS: All RCTs assessing pharmacologic treatments and nonpharmacologic treatments for hip and knee OA indexed between January 2002 and December 2006 were selected. A sample of 120 articles were randomly selected: 30 each assessing pharmacologic treatments, surgery or technical interventions, rehabilitation, and nonimplantable devices. RESULTS: The country was clearly reported in 25 (21%) reports, the setting described in 40 (33%) reports, and the number of centers in 54 (45%). Details about the centers (volume of care) were given in 24 (20%) reports. Rates were lower for surgical trials for the country (3%), the setting (3%), the number of centers (13%), and details about the centers (7%). The intervention was adequately described in all pharmacologic reports and in >80% of rehabilitation reports. The technical procedure was given in all surgical intervention trial reports, but the type of anesthesia was reported in 4 (13%), preoperative care in 2 (7%), and postoperative care in 15 (50%). The device was described in 93% of device trial reports, but the manufacturer was reported in only 33%. CONCLUSION: There is low reporting of data related to external validity in reports of RCTs assessing pharmacologic and nonpharmacologic treatments for hip and knee OA.

Comparison of in vitro-specific blood tests with tuberculin skin test for diagnosis of latent tuberculosis before anti-TNF therapy.

INTRODUCTION: Latent tuberculosis infection (LTBI) is detected with the tuberculin skin test (TST) before anti-TNF therapy. We aimed to investigate in vitro blood assays with TB-specific antigens (CFP-10, ESAT-6), in immune-mediated inflammatory diseases (IMID) for LTBI screening. PATIENTS AND METHODS: Sixty-eight IMID patients with (n = 35) or without (n = 33) LTBI according to clinico-radiographic findings or TST results (10 mm cutoff value) underwent cell proliferation assessed by thymidine incorporation and PKH-26 dilution assays, and IFNgamma-release enzyme-linked immunosorbent spot (ELISPOT) assays with TB-specific antigens. RESULTS: In vitro blood assays gave higher positive results in patients with LTBI than without (p<0.05), with some variations between tests. Among the 13 patients with LTBI diagnosed independently of TST results, 5 had a negative TST (38.5%) and only 2 a negative blood assays result (15.4%). The 5 LTBI patients with negative TST results all had positive blood assays results. Ten patients without LTBI but with intermediate TST results (6-10 mm) had no different result than patients with TST result 0.3) and lower results than those with LTBI (p<0.05) on CFP-10+ESAT-6 ELISPOT and CFP-10 proliferation assays. CONCLUSION: Anti-TB blood assays are beneficial for LTBI diagnosis in IMID. Compared with TST, they show a better sensitivity, as seen by positive results in 5 patients with certain LTBI and negative TST, and better specificity, as seen by negative results in most patients with intermediate TST as the only criteria of LTBI. In the absence of clinico-radiographic findings for LTBI, blood assays could replace TST for antibiotherapy decision before anti-TNF.

The reporting of randomized clinical trials using a surgical intervention is in need of immediate improvement: a systematic review.

OBJECTIVE: To assess the reporting of surgical interventions, care providers, and number of centers in randomized clinical trials. METHODS: Systematic review was performed to assess reports of randomized controlled trials assessing surgical procedure published in 2004. A standardized abstraction form was used to extract data. RESULTS: A total of 158 articles were included. Details on the intervention intended, such as the surgical procedure, were reported in 138 (87.3%) articles, anesthetic management in 56 (35.4%), preoperative care in 34 (15.2%), and postoperative care in 78 (49.4%). How the experimental surgical intervention was carried out was reported in 64 articles (40.5%). Most trials were conducted in single centers (n = 109, 69.0%). The setting was reported in only 11 articles, and the volume of interventions performed was only reported in 5. Selection criteria were reported for care providers in 64 articles (40.5%). The number of care providers performing the intervention was reported in 51 articles (32.2%). The quality of reporting was low as assessed by CLEAR NPT (a 10-items checklist specifically developed to assess the reporting quality of RCTs assessing nonpharmacologic treatment). CONCLUSIONS: Inadequate reporting on the management of the surgical procedure, care providers, and surgery center may introduce bias in RCTs of surgical interventions, making their results questionable. We recommend extending the CONSORT Statement to surgical interventions.

Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is more efficient than adjustable gastric banding (AGB) in weight loss and relieving co-morbidities, but nutritional complications of each surgical procedure have been poorly evaluated. METHODS: A cross-sectional study was performed to compare nutritional parameters in 201 consecutive obese patients, who had been treated either by conventional behavioral and dietary therapy (CT, n=110) or by bariatric surgery, including 51 AGB and 40 RYGBP. RESULTS: BMI was similar after AGB (36.6 +/- 5.3 kg/m2) and RYGBP (35.4 +/- 6.3 kg/m2), but patients in the RYGBP group had lost more weight and had less metabolic disturbances than those in the AGB group. On the other hand, the prevalence of nutritional deficits was significantly higher in the RYGBP group than in the 2 other groups (P<0.01), whereas the AGB group did not differ from CT. Particularly, the RYGBP group presented an unexpected high frequency of deficiencies in fat-soluble vitamins. Moreover, vitamin B12, hemoglobin, plasma prealbumin and creatinine concentrations were low in the RYGBP group. CONCLUSION: RYGBP is more efficient than AGB in correcting obesity, but this operation is associated with a higher frequency of nutritional deficits that should be carefully monitored.

Static and dynamic MRI features of the levator ani and correlation with severity of genital prolapse.

BACKGROUND: To describe the static and dynamic MRI features of the levator ani, and evaluate whether they are associated with the MRI evaluation of the severity of genital prolapse. METHODS: Static and dynamic MRI of 40 patients, referred for evaluation prior to genital prolapse surgery, were reviewed retrospectively. Prolapse severity was evaluated on MRI at maximal straining by descent of the bladder neck under the pubococcygeal line for the anterior compartment, by descent of the uterine cervix under the pubococcygeal line for the middle compartment, and by anterior bulging of the rectum for the posterior compartment. For evaluation of the levator ani, the following parameters were recorded: (1) at rest: thinning or defects in both puborectalis and iliococcygeus muscles, (2) at rest and at straining: urogenital hiatus length and width, M line, iliococcygeal and levator plate angles. The levator ani features were tested for potential associations with the MRI evaluation of prolapse severity. RESULTS: Bladder neck descent at straining was correlated with the levator plate angle at rest (p=0.001), and with the hiatus length at rest (p=0.02), and at straining (p=0.008). Uterine cervix descent at straining was correlated with the hiatus length (p=0.0005), and width (p=0.014) at straining, M line (p=0.002) and levator plate angle (p=0.007) at straining, whereas anterior rectal bulging at straining was paradoxically inversely correlated with the hiatus width at rest (p = 0.04). CONCLUSION: In a population of women with genital prolapse, MRI evaluation of the levator ani was associated with MRI evaluation of the severity of genital prolapse.