Early continuous glucose monitoring for predicting remission of type 2 diabetes 1 year after bariatric surgery.

BACKGROUND: Bariatric surgery in obese subjects can result in remission of type 2 diabetes (T2D) at a distant time post-surgery. The aim of our observational prospective single-centre study was to examine glycaemic patterns in adult T2D candidates for bariatric surgery using a continuous glucose monitoring (CGM) sensor for 14 days after surgery to search for indicators predictive of T2D remission 1 year later. METHODS: Patients underwent CGM preoperatively and for 14 days postoperatively. Thereafter, body weight and glycated haemoglobin (HbA1c) levels were monitored at 3, 6 and 12 months after surgery. RESULTS: A total of 31 patients (mean age 47±2 years) were analyzed. After surgery, mean interstitial glucose levels fell rapidly from 157±31mg/dL preoperatively to 109±35mg/dL postoperatively (P<0.001), reaching nadir levels from day 3 after surgery. Successful bariatric surgery (loss of excess weight ≥50%) was observed in 28 (90%) patients, and diabetes remission (HbA1c≤6% with no antidiabetic treatment) 1 year after surgery was noted in 21 (68%) patients. CGM for 14 days post-surgery allowed prediction of diabetes remission 1 year after surgery: time spent above range <14% and standard deviation (SD) of glucose levels <33mg/dL were both strong predictors of T2D remission. Indeed, the association of these two criteria predicted diabetes remission with a 100% positive predictive value, 81% sensitivity and 100% specificity and, when combined with the advanced Diabetes Remission (Ad-DiaRem) score, further increased predictive accuracy. CONCLUSION: The use of 14-day postoperative CGM recordings together with presurgical clinical scores can help to predict diabetes remission 1 year after bariatric surgery.

Effect of intra-operative intravenous lidocaine on opioid consumption after bariatric surgery: a prospective, randomised, blinded, placebo-controlled study.

Peri-operative lidocaine infusion warrants investigation in bariatric surgery because obese patients present different physiological and pharmacological risks. This single-centre, prospective, randomised double-blind placebo-controlled study enrolled obese patients scheduled for laparoscopic bariatric surgery using an enhanced recovery protocol. Patients received either lidocaine (bolus of 1.5 mg.kg-1 , then a continuous infusion of 2 mg.kg-1 .h-1 until the end of the surgery, then 1 mg.kg-1 .h-1 for 1 h in the recovery area) or identical volumes and rates of 0.9% saline. The primary outcome was the consumption of the equivalent of oxycodone consumption over the first 3 postoperative days. Secondary outcomes were: postoperative pain; incidence of nausea and vomiting; bowel function recovery; and lengths of stay in the recovery area and in hospital. Plasma concentrations of lidocaine were measured. On the 178 patients recruited, data were analysed from 176. The median (IQR [range]) equivalent intravenous oxycodone consumption was 3.3 mg (0.0-6.0 [0.0-14.5]) and 5.0 mg (3.3-7.0 [3.3-20.0]) in the lidocaine and saline groups, respectively (difference between medians (95%CI): 1.7 (0.6-3.4) mg; p = 0.004). Length of stay in the recovery area, postoperative pain, nausea and vomiting, day of recovery of bowel function, and length of stay in hospital were not different between groups. Mean (SD) lidocaine plasma concentrations were 2.44 (0.70) µg.ml-1 and 1.77 (0.51) µg.ml-1 at the end of surgery and 1 hour after the end of infusion, respectively. Lidocaine infusion during bariatric surgery resulted in a clinically non-relevant difference in postoperative oxycodone consumption.

Bariatric revisional surgery: What are the challenges for the patient and the practitioner?

Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.

Guiding the non-bariatric surgeon through complications of bariatric surgery.

Complications in bariatric surgery are varied; they are severe at times but infrequent. They may be surgical or non-surgical, and may occur early or late. The goal of this systematic review is to inform and help the attending physician, the emergency physician and the non-bariatric surgeon who may be called upon to manage surgical complications that arise after adjustable gastric band (AGB), sleeve gastrectomy (SG), or gastric bypass (GBP). Data from evidence-based medicine were extracted from the literature by a review of the Medline database and also of the most recent recommendations of the learned societies implicated. The main complications were classified for each intervention, and a distinction was made between early and late complications. Early complications after AGB include prosthetic slippage or perforation; SG can be complicated early by staple line leak or fistula, and BPG by fistula, stenosis and postoperative hemorrhage. Delayed complications of AGB include intragastric migration of the prosthesis, late prosthetic slippage and infection, while SG can be complicated by gastro-esophageal reflux, and BPG by anastomotic ulcer and internal hernia. The analysis of available data allowed us to develop decisional algorithms for the management of each of these complications.

Impact of Intragastric Balloon Before Laparoscopic Gastric Bypass on Patients with Super Obesity: a Randomized Multicenter Study.

BACKGROUND: Super obese patients are recommended to lose weight before bariatric surgery. The effect of intragastric balloon (IGB)-induced weight loss before laparoscopic gastric bypass (LGBP) has not been reported. The aim of this prospective randomized multicenter study was to compare the impact of preoperative 6-month IGB with standard medical care (SMC) in LGBP patients. METHODS: Patients with BMI >45 kg/m2 selected for LGBP were included and randomized to receive either SMC or IGB. After 6 months (M6), the IGB was removed and LGBP was performed in both groups. Postoperative follow-up period was 6 months (M12). The primary endpoint was the proportion of patients requiring ICU stay >24 h; secondary criteria were weight changes, operative time, hospitalization stay, and perioperative complications. RESULTS: Only 115 patients were included (BMI 54.3 ± 8.7 kg/m2), of which 55 underwent IGB insertion. The proportion of patients who stayed in ICU >24 h was similar in both groups (P = 0.87). At M6, weight loss was significantly greater in the IGB group than in the SMC group (P < 0.0001). Three severe complications occurred during IGB removal. Mean operative time for LGBP was similar in both groups (P = 0.49). Five patients had 1 or more surgical complications, all in the IGB group (P = 0.02). Both groups had similar hospitalization stay (P = 0.59) and weight loss at M12 (P = 0.31). CONCLUSION: IGB insertion before LGBP induced weight loss but did not improve the perioperative outcomes or affect postoperative weight loss.

Stenosis without stricture after sleeve gastrectomy.

Sleeve gastrectomy (SG) is an increasingly popular restrictive bariatric procedure as attested by the 5,302 procedures performed in 2009, increasing worldwide to 13,557 in 2011 and to 24,190 in 2013. Among the early complications, gastric stricture is well described with a prevalence between 0.7 and 4.0% (Dhahri et al., 2010). The patient reported here had functional stenosis without any underlying anatomic stricture. This complication is rare and is the consequence of spiral stapling resulting in a gastric tube that is twisted from the start (Iannelli et al., 2014). Twisted sleeve gastrectomy resulting from spiral stapling exposes the patient to the risk of recurrent dysphagia, which has the appearance of stenosis on upper GI series but not on fibroscopy. Conversion to RY-GBP is one solution. At six months follow-up after conversion, our patient is symptom-free, with quality of life was rated excellent (a score greater than 9 on the BAROS questionnaire).

Short communication: Effect of subclinical mastitis on proteolysis in ovine milk.

The aim of this work was to evaluate the effect of intramammary infection (IMI) on the endogenous proteolysis of milk. Four control checks were carried out in the half-udder milk of 10 ewes that acquired unilateral subclinical mastitis. Two of these checks were conducted before the infection was established and 2 after. Ten healthy ewes were tested as a control group. The presence of a subclinical IMI involved an increase of the products of casein hydrolysis, the proteose-peptone (p-p) fraction and minor (m) caseins, and a decrease of ß-casein. As a result, a significant increase in the proteolysis index (PI), calculated as the ratio of m-casein to the sum of caseins (α + ß + κ), took place. α-Casein and κ-casein were not significantly affected by IMI. Correlations confirmed the scenario: log(10) of somatic cell count (SCC) was positively correlated with p-p content and negatively with ß-casein, whereas log(10) SCC was not correlated with α-casein or κ-casein. On the other hand, p-p content was positively correlated with m-casein and PI and negatively with ß-casein, but no correlation was detected between p-p content and α- or κ-casein. Furthermore, between casein fractions, m-casein was only significantly correlated with ß-casein. These results suggest that use of indices of proteolysis of caseins such as p-p, m-casein, and PI, could be applied together with SCC to evaluate the cheese-making quality of milk.

First evidence of the presence of genomic islands in Escherichia coli P4, a mammary pathogen frequently used to induce experimental mastitis.

Mastitis pathogens belonging to Escherichia coli species are often considered as environmental opportunistic pathogens that invade the udder and are rapidly killed by the immune system of cows. However, several studies have reported that some of these strains are able to persist in the udder for prolonged periods or to adhere and invade mammary epithelial cells, suggesting that they might possess some specific properties or genes that could be involved in their capacity to provoke mastitis. The aim of this work was to search for such specific genes in the E. coli strain P4, which was isolated from a case of severe mastitis and is often used to induce experimental mastitis. We established that this strain belongs to phylogenetic group A of the E. coli species, and that its core genome is very similar to that of the commensal nonpathogenic strain E. coli K-12 MG1655. Seventeen transfer RNA loci, known to be frequently associated with genomic islands, were screened and an altered structure was detected for 7 of them. The partial characterization of 5 of these loci (asnT, leuX, pheV, serU, and thrW) and the complete characterization of 1 (argW) revealed the presence of genomic islands that differ from those already described in pathogenic or nonpathogenic E. coli strains.

Short communication: can the mammopathogenic Escherichia coli P4 strain have a direct role on the caseinolysis of milk observed during bovine mastitis?

During bacterial bovine mastitis, the quality of milk is altered because of caseinolysis. Endogenous potential actors in milk responsible for this caseinolysis have been well studied, unlike the exogenous bacterial ones. The aim of this study was to evaluate the direct role in caseinolysis of a mammopathogenic strain, Escherichia coli P4. Secretion of at least 4 extracellular bacterial caseinolytic enzymes was highlighted by zymography, in 3 different growth media, and at each bacterial growth state, suggesting that their expression was constitutive. Different experimental conditions to evaluate caseinolytic potential did not show any significant caseinolytic activity of E. coli P4 and of the 4 extracellular proteases detected, suggesting that the high caseinolysis observed during E. coli bovine mastitis does result from endogenous milk actors.

[Omental infarct after a gastric by-pass]. / Infarctus épiploïque après by-pass gastrique.

The authors describe the case of a 56 year old woman 25 days status post laparoscopic gastric bypass who presented with an acute onset of severe epigastric pain with signs of inflammation and localized peritoneal irritation. Although her findings suggested a late anastomotic leak, an abdominal CT scan revealed only necrosis of the greater omentum beneath the left hepatic lobe. This finding permitted a non-surgical approach; after observation over several days, the patient's symptoms resolved completely.

[Using administrative data to assess the impact of length of stay on readmissions: study of two procedures in surgery and obstetrics]. / Lien entre durée de séjour et réadmissions en chirurgie et en obstétrique: étude de deux procédures à partir des données du PMSI.

BACKGROUND: The prospective payment system for the French short-stay hospitals creates a financial incentive to reduce length of stay. The potential impact of the resulting decrease in length of stay on the quality of healthcare is unknown. Readmission rates are valid outcome indicators for some clinical procedures. METHODS: Retrospective study of the association between length of stay and unplanned readmissions related to the initial stay, for two procedures: cholecystectomy and vaginal delivery. DATA: Administrative diagnosis-related groups database of "Assistance publique-Hôpitaux de Paris", a large teaching hospital, for years 2002 to 2005. RESULTS: The risk of readmission according to length of stay, taking age, sex, comorbidity, hospital and year of admission into account, followed a J-shaped curve for both procedures. The probability of readmission was higher for very short stays, with odds ratios and 95% confidence intervals of 6.03 [2.67-13.59] for cholecystectomies (1- versus 3-night stays), and of 1.74 [1.05-2.91] for vaginal deliveries (2- versus 3-night stays). CONCLUSION: For both procedures, the shortest lengths of stay are associated with a higher readmission probability. Suitable indicators derived from administrative databases would enable monitoring of the association between length of stay and readmissions.

Drinking behavior of lactating dairy cows and prediction of their water intake.

The water intake of 41 lactating dairy cows managed according to current dairy farm practices was individually and continuously monitored to 1) investigate drinking behavior and 2) determine factors affecting water intake. The cows were housed in a free-stall barn and fed once daily with a corn silage and concentrate-based total mixed ration (48% dry matter content; 20.6 +/- 3.3 kg/d of dry matter intake). Cows were milked twice daily, with a yield of 26.5 +/- 5.9 kg/d. The daily free water intake (FWI) was 83.6 +/- 17.1 L, achieved during 7.3 +/- 2.8 drinking bouts. The drinking bout water intake was 12.9 +/- 5.0 L. Almost three-fourths of the FWI occurred during working hours (0600 to 1900 h). Consumption peaks corresponded to feeding and milking times. More than one quarter of the daily FWI was met during the 2 h after each milking. About 75% of the present cows visited the watering point at least once during the 2 h after the evening milking. It is probable that drinking behavior evolved with lactation, but further studies are required to identify the relationship between lactation stage and drinking behavior. The most relevant factors affecting the daily FWI of lactating cows were best combined according to the following predictive equation: (R(2) = 0.45; n = 41 cows, n = 1,837): FWI, L/d = 1.53 x dry matter intake (kg/d) + 1.33 x milk yield (kg/d) + 0.89 x dry matter content (%) + 0.57 x minimum temperature ( degrees C) - 0.30 x rainfall (mm/d) - 25.65. The results obtained using these equations were in agreement with the equations developed by other researchers.

[Evolution of functional autonomy in geriatric medium-term care units: a reliable performance indicator?]. / Evolution de l'autonomie fonctionnelle en soins de suite gériatriques: un indicateur de performance?

The objective of this study was to compare the evolution of the level of functional dependence of patients between the time of their hospital admission and release following treatment received in the geriatric medium-term care units, in order to propose this variable as a clinical performance indicator for this type of service. The differential score of physical dependence observed was determined for each hospital stay, and the adjusted significant functional improvement rate (SFI) was calculated for every unit. This adjusted SFI rate was then compared to the overall rate of all of the units combined. The overall SFI rates were 23% in 2004. Seven of the 49 units studied present an adjusted rate significantly inferior to the average rate of the total number of units combined. This study constitutes one of the first performance analyses in the medium-term sector, and the adjusted SFI rate seems to be a pertinent and reliable indicator within this framework.

Study of mammary epithelial role in polycyclic aromatic hydrocarbons transfer to milk.

Food would appear to be one of the main routes for animal and human contamination with polycyclic aromatic hydrocarbons (PAH). Many studies have shown the presence of PAH in milk and dairy products, suggesting that these foods can represent a part of this contamination. Our work aimed at defining, in vitro, the mammary barrier role in PAH transfer to milk. MAC T cells were cultivated on permeable filters to measure transepithelial permeability of 14C labeled benzo[a]pyrene (BaP), pyrene (Pyr), and phenanthrene (Phen), which differed in their physicochemical properties. The results showed that only 2 molecules, Phen and Pyr, were able to cross mammary cell layers. Phenanthrene radioactivity appeared more quickly in apical media, and its level after a 6-h exposure was 1.3 times higher than for Pyr and 7.7 times higher than for BaP. These findings suggested that mammary epithelium could play a key role in the selective transfer of PAH from food to milk.

Isolation and characterization of copolymers of beta-lactoglobulin, alpha-lactalbumin, kappa-casein, and alphas1-casein generated by pressurization and thermal treatment of raw milk.

Raw skim milk was submitted to high pressure (300 to 600 MPa) and temperature (4 to 70 degrees C) treatments for 2 or 5 min. The combined effects of pressure and temperature on milk proteins induced structural changes and polymer and copolymer formation characterized by anion-exchange and size-exclusion fast protein liquid chromatography and electrophoretic techniques. Approximately half of the beta-lactoglobulin formed polymers, and the other half formed large copolymers, mainly with kappa-casein, alpha-lactalbumin via intermolecular disulfide bond exchange, and alpha(s1)-casein via physicochemical interactions, in proportions of 1.0:0.7:0.3:0.1, respectively. Minor whey proteins (serum albumin, immunoglobulins, and lactoferrin) also participated in the formation of the copolymers but to a lesser extent. Two populations of the copolymers were found with apparent molecular masses ranging from 440 to 2000 kDa for the first and more than 2000 kDa for the second. On the contrary, for heated milks the aggregation kinetics obtained by combination of high pressure and thermal treatment were very fast, as no intermediates such as dimers and small size oligomers were observed after pressurization, whatever the temperature studied. Lactosylation of proteins as well as proteolysis were very limited. A beta-casein amino-terminal peptide of 22 kDa was specifically recovered in milk samples treated under the more drastic conditions (500 MPa/55 degrees C per 5 min and 600 MPa/70 degrees C per 5 min) and might have been generated by neutral proteases such as elastase released from somatic cells present in milk. No casein was released from the micelle whatever the combination of high pressure and temperature studied.

Proteolysis in milk during experimental Escherichia coli mastitis.

This work consisted of the intramammary infections (IMI) of 8 heifers by high doses of Escherichia coli to study both the proteolytic activity in milk and the resulting peptides. Therefore, a milking kinetic has been followed, and several parameters have been studied, such as proteose peptones (PP) fraction (quantitative and qualitative changes), plasmin activity (PA), milk somatic cell count (SCC), and bacterial count. A qualitative study of milk proteins and PP was performed by sodium dodecyl sulfate-PAGE, and the peptides recovered in PP during the acute phase of inflammation were amino-terminal micro-sequenced. A BSA increase in milk over time supported the hypothesis of an increase in the permeability of the epithelial barrier. A significant increase in PP content, considered to be an indicator of proteolysis, was observed from postinfusion hours (PIH) 12 to 48. Both the E. coli bacterial count and the SCC increased from PIH 3 to 216. Plasmin activity was increased noticeably from PIH 15 to 24. The respective increases in SCC, bacterial count, and PA suggest their involvement in a global mechanism responsible for the increase in proteolysis in milk after E. coli challenge. Somatic cell count and E. coli may be involved from PIH 3 to 216, and PA involvement might be highlighted during the maximum proteolysis, from PIH 15 to 24. A qualitative study of PP fraction by electrophoresis revealed the apparition of 5 peptide bands: P1 and P2 previously recovered during the lipopolysaccharide challenge, and E1 (27.0 kDa), E2 (15.5 kDa), and E3 (9.0 kDa) were specific to E. coli challenge; E1, E2, and E3 contained casein fragments. The roles played by leukocytes and E. coli are discussed.

Thoracoscopic plication of the diaphragm for postoperative phrenic paralysis: a report of two cases.

Unilateral phrenic nerve paralysis after cardiothoracic surgery is not uncommon. When symptomatic, it can require surgical treatment. Plication of the diaphragm through a thoracotomy is known to provide excellent long-term results. Plication is now being performed via video-assisted thoracoscopic surgery (VATS). We report the cases of two patients with postoperative left phrenic nerve paralysis who underwent plication of the diaphragm using VATS and achieved total relief of all symptoms.

Characterization and proteolytic origins of specific peptides appearing during lipopolysaccharide experimental mastitis.

Based on the compositional change of the proteose peptone fraction, proteolysis was studied over time following lipopolysaccharide-induced experimental mastitis. Electrophoresis of the proteose peptone fraction revealed many degradation products. Five peptides were identified by amino-terminal sequencing as internal fragments of beta-, kappa-, alpha(s1)-, and alpha(s2)-casein that were generated by somatic cell proteases. Although kappa-casein is considered particularly resistant to endogenous proteolysis, a kappa-casein peptide was electrophoretically isolated in association with a beta-casein fragment. The in vitro kinetic studies of caseinate hydrolysis by elastase, one of the main polymorphonuclear neutrophil (PMN) proteases, suggested that the beta-casein peptide might be generated by elastase. In addition, elastase activity in milk PMN was higher during the inflammation of the mammary gland than prior to infusion.

Contamination of pastures by polycyclic aromatic hydrocarbons (PAHs) in the vicinity of a highway.

To assess PAH contamination pastures, grass and soil samples have been collected from 10 m (d1), 50 m (d2), and 150 m (d3) perpendicular to a French highway (70,000 vehicles per day) and at a control site in a rural area away from nearby contaminating sources. Total PAH concentration ranges from 767 ng/g dry weight to 3989 ng/g dry weight, according to the matrix and the distance from the highway. Distance is not a significant factor for PAH deposition on grass, while in soil it has an effect between d1 and d2 or d3. The total PAH concentration in highway samples is 8 times higher than in control site samples for grass and 7 to 4 times higher for soil. Fluoranthene, pyrene, and phenanthrene are the major PAHs in grass samples at the control site and the highway, but the concentrations are about 5 times higher near the highway. In soil samples collected near the highway, the values of concentrations between all compounds are not statistically different. PAH deposition on grass is linked to the physicochemical properties of the compounds, which lead to a specific distribution of each molecule (according to their volatility and the number of aromatic rings) while no specific behavior is revealed in soil.