[Follow-up of patients after an acute coronary event: the Apulia PONTE-SCA program]. / Follow-up del paziente dopo sindrome coronarica acuta: il progetto PONTE-SCA Puglia.

BACKGROUND: Patients who suffered from acute coronary syndrome (ACS) need a tight follow-up in order to optimize therapy and prevent adverse events. The aim of the PONTE-SCA Puglia program was to evaluate the impact of an integrated management of patients between hospital and local territorial outpatient facilities on adherence and outcome of patients discharged after ACS event. METHODS: This was a prospective, longitudinal, cohort study which enrolled patients who suffered ACS and/or coronary revascularization in a Hub hospital of ASL Bari. Patients underwent clinical and laboratory evaluation at 30 days, 3 months, 6 months, and 1 year after the index event. The following endpoints were considered: all-cause mortality, ACS recurrence/cardiac ischemia/angina, restenosis/intrastent thrombosis, stroke/transient ischemic attack, heart failure, all-cause bleeding. We evaluated persistence on therapies and the percentage of patients who attained therapeutic goals. RESULTS: A total of 2476 patients (mean age 67.2 ± 12.0 years, 77.4% male) were enrolled. At 1-year follow-up, 99.5% of patients (p<0.05) were on statin therapy, 16.1% (p<0.01) on ezetimibe, and 9.9% (p<0.01) on proprotein convertase subtilisin/kexin type 9 inhibitors. All-cause mortality was 3.1% at 1-year follow-up, whereas recurrence of ACS/cardiac ischemia/angina and restenosis/stent thrombosis were 3% and 1.3%, respectively. The prevalence of all bleeding complications was 2.2%. CONCLUSIONS: The PONTE-SCA Puglia program allowed to implement a dedicated taking in charge of patients after an ACS/coronary revascularization event, to manage a dedicated follow-up route for them, to ameliorate persistence on recommended therapies, and to keep lower the incidence of major adverse cardiovascular events and bleedings.

Fat mass, fat-free mass, and resting metabolic rate in weight-stable sleeve gastrectomy patients compared with weight-stable nonoperated patients.

BACKGROUND: There is evidence that body composition and resting metabolic rate (RMR) in weight-stable patients after Roux-en-Y gastric bypass and duodenal switch is similar to that of nonoperated individuals within the same body mass index (BMI) interval. Currently, data concerning fat mass (FM), fat-free mass (FFM), and RMR on weight-stable patients after sleeve gastrectomy (SG) are lacking. OBJECTIVES: To assess FM, FFM, and RMR, in a selected and homogenous population of weight-stable SG patients (WSSG) and compare them with those obtained from healthy normal weight-stable nonoperated (WSNO) volunteers controls of similar sex, age, and BMI. SETTING: University hospital, Italy. METHODS: We assessed total weight, FM, and FFM by bioelectrical impedance assay, and RMR by indirect calorimetry, in 70 WSSG patients (47 females, 23 males) at a mean follow-up of 3.2 ± 2.1 years after SG and compared them with 70 healthy WSNO volunteers, as controls (47 females, 23 males). RESULTS: There was no significant difference between WSSG and WSNO groups concerning total weight (males, 72 ± 2.66 versus 72.8 ± 1.99 kg, P = .0254; females 65.1 ± 2.53 versus 63.7 ± 2.87 kg, P = .0139), FM (males, 17.7 ± 1.53 versus 16.7 ± 1.57 kg, P = .0341; females 19.6 ± 0.50 versus 18.5 ± 2.85 kg, P = .0104), FFM (males, 54.3 ± 3.07 versus 56.1 ± 3.30 kg; P = .049; females 45.5 ± 2.29 versus 45.1 ± 1.13 kg, P = .287), and RMR (males, 1541 ± 121.3 versus 1463 ± 74.4 kcal/d; P = .0118; females 1214 ± 54.9 versus 1250 ± 90.1 kcal/d, P = .0215). CONCLUSION: At a mean follow-up of 3.2 ± 2.1 years after SG, WSSG patients of both sexes have a FM, FFM, and RMR comparable to that of healthy WSNO individuals within the same age and BMI interval. These findings further support bariatric surgery-induced weight loss as a physiologic process and indicate that young patients, in the setting of an adequate preoperative and postoperative specific diet and moderate physical activity, do not suffer from excessive FFM depletion after SG in the mid-term.

A Comparative Study Examining the Impact of a Protein-Enriched Vs Normal Protein Postoperative Diet on Body Composition and Resting Metabolic Rate in Obese Patients after Sleeve Gastrectomy.

BACKGROUND: We recently showed that an 8-week preoperative protein-enriched diet (PED) is associated with significant reductions in body weight and fat mass (FM) without significant loss of fat-free mass (FFM) in morbidly obese patients scheduled for laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: The objective of this study is to evaluate the impact of PED vs a normal protein diet (NPD) on total weight loss (TWL), FM, FFM, and resting metabolic rate (RMR) in patients after LSG. METHODS: Before LSG and at 3, 6, and 12 months after, we prospectively measured and compared total body weight (TBW), FM, FFM, and RMR in 60 male patients who received either a NPD (n = 30) with protein intake 1.0 g/kg of ideal body weight, or a PED (n = 30) with protein intake 2.0 g/kg of ideal body weight. Compliance in following the prescribed diet was determined with food frequency questionnaires in all patients. The impact of NPD and PED on renal function was also evaluated. RESULTS: Despite non-significant variation in total body weight (TBW), FM decreased more significantly (p < 0.01) with the PED compared to the NPD. In addition, the PED group showed a significantly (p < 0.01) lower decrease in FFM and RMR when compared with the NPD group. Both groups showed high compliance in following the prescribed diets, without negative impact on renal function. CONCLUSION: PED is more effective than NPD in determining FM loss and is associated with a lower decrease in FFM and RMR, without interfering with renal function in male patients after LSG.

Sleeve gastrectomy to treat concomitant polycystyc ovary syndrome, insulin and leptin resistance in a 27-years morbidly obese woman unresponsive to insulin-sensitizing drugs: A 3-year follow-up.

INTRODUCTION: Insulin resistance (IR), leptin resistance (LR), and polycystic ovary syndrome (PCOS) commonly coexists with obesity. IR and PCOS are often successfully treated with the use of insulin-sensitizing drugs (ISDs). However, some women are poorly responsive or intolerant to them. If we additionally consider that currently no medical treatment for LR exists, it is crucial for the physician to find different therapeutic ways to treat patients with such multifactorial endocrinopathy. PRESENTATION OF CASE: We present a case where sleeve gastrectomy (SG) was applied to a 27-year-old obese woman affected by concomitant IR, LR and PCOS, and unresponsive to ISDs. At three years from surgery the patient is now 71.6kg. More importantly, her levels of insulin and leptin started to improve at postoperative month 6 and became normal at postoperative month 24. Patient's ovaries that at baseline had characteristic aspects related to PCOS, at postoperative month 36 were normal. DISCUSSION: SG is one of the most commonly performed bariatric procedures. The literature has moved away from labeling SG as a purely restrictive procedure, as its interactions with several hormones (ghrelin, leptin, insulin, etc.) are now recognized. CONCLUSION: In the present report, SG was applied to resolve an intricate endocrinological framework confirming its therapeutic value not only in determining weight loss but also as endocrine/metabolic surgery able to treat multifactorial endocrinopathy. The underlying molecular mechanisms contributing to these benefits remain largely undetermined, despite offering tremendous potential to reveal new targets for therapeutic intervention, mostly in those patients unresponsive to classical pharmacotherapy.

Nonsurgical management of multiple splenic abscesses in an obese patient that underwent laparoscopic sleeve gastrectomy: case report and review of literature.

Sleeve gastrectomy (SG) is a surgical weight-loss procedure. Splenic abscess is a rare complication of SG. Four cases of splenic abscess after SG have been reported, all managed by surgical intervention. We report the first documented case of multiple splenic abscesses following SG managed conservatively by an integrated medical treatment.

Clinical impact of Mediterranean-enriched-protein diet on liver size, visceral fat, fat mass, and fat-free mass in patients undergoing sleeve gastrectomy.

BACKGROUND: Weight loss before laparoscopic sleeve gastrectomy (LSG) is desirable because it can reduce visceral fat and liver size thereby facilitating the surgical procedure. Preoperative very-low-energy diets have been demonstrated to decrease weight, visceral fat, and liver size. However, no studies have been conducted using the Mediterranean-protein-enriched diet (MPED) or on the amount of preoperative weight loss attributed to the loss of fat-free mass (FFM). OBJECTIVES: To evaluate the effect of the MPED on weight, visceral fat, liver size, fat mass (FM), and FFM in obese patients undergoing LSG. SETTING: University Hospital, Italy. MATERIALS AND METHODS: Obese male patients (n = 37) with a mean body mass index (BMI) of 45.2 kg/m(2) scheduled for LSG underwent an 8-week preoperative MPED. Their weight, visceral fat, body composition, liver size, and biochemical and metabolic patterns were measured before and after the diet. Patient compliance was assessed by the presence of ketonuria and weight loss. Qualitative methods (5-point Likert questionnaire) were used to measure diet acceptability and side effects. RESULTS: We observed highly significant decreases in weight, liver size, visceral fat, and FM; however, there was no significant reduction in FFM. All tested patients showed a high frequency of acceptability and compliance in following the diet, and no secondary effects were observed. CONCLUSION: Based on our findings, we were able to support the hypothesis that MPED might be associated with significant reductions in weight loss, FM, and liver size without a significant loss of FFM.

Micronutrient Deficiencies in Patients Candidate for Bariatric Surgery: A Prospective, Preoperative Trial of Screening, Diagnosis, and Treatment.

Bariatric surgery candidates often show preoperative micronutrient deficiency. Although it is documented that a comprehensive micronutrient assessment should be conducted preoperatively to correct the deficiencies before surgery, no previous studies have been effective in correcting deficiencies in sufficient time prior to surgery. Our aim was to identify micronutrient deficiencies preoperatively and correct them before surgery.

Effect of ciguatoxin 3C on voltage-gated Na+ and K+ currents in mouse taste cells.

The marine dinoflagellate Gambierdiscus toxicus produces highly lipophilic, polycyclic ether toxins that cause a seafood poisoning called ciguatera. Ciguatoxins (CTXs) and gambierol represent the two major causative agents of ciguatera intoxication, which include taste alterations (dysgeusiae). However, information on the mode of action of ciguatera toxins in taste cells is scarce. Here, we have studied the effect of synthetic CTX3C (a CTX congener) on mouse taste cells. By using the patch-clamp technique to monitor membrane ion currents, we found that CTX3C markedly affected the operation of voltage-gated Na(+) channels but was ineffective on voltage-gated K(+) channels. This result was the exact opposite of what we obtained earlier with gambierol, which inhibits K(+) channels but not Na(+) channels. Thus, CTXs and gambierol affect with high potency the operation of separate classes of voltage-gated ion channels in taste cells. Our data suggest that taste disturbances reported in ciguatera poisoning might be due to the ability of ciguatera toxins to interfere with ion channels in taste buds.

Inhibition of voltage-gated potassium currents by gambierol in mouse taste cells.

Ciguatera is a food poisoning caused by toxins of Gambierdiscus toxicus, a marine dinoflagellate. The neurological features of this intoxication include sensory abnormalities, such as paraesthesia, heightened nociperception, and also taste alterations. Here, we have evaluated the effect of gambierol, one of the possible ciguatera toxins, on the voltage-gated ion currents in taste cells. Taste cells are excitable cells endowed with voltage-gated Na+, K+, and Cl- currents (I(Na), I(K), and I(Cl), respectively). By applying the patch-clamp technique to single cells in isolated taste buds obtained from the mouse vallate papilla, we have recorded such currents and determined the effect of bath-applied gambierol. We found that this toxin markedly inhibited I(K) in the nanomolar range (IC50 of 1.8 nM), whereas it showed no significant effect on I(Na) or I(Cl) even at high concentration (1 microM). The block of I(K) was irreversible even after a 50-min wash. In addition to affecting the current amplitude, we found that gambierol significantly altered both the activation and inactivation processes of I(K). In conclusion, unlike other toxins involved in ciguatera, such as ciguatoxins, which affect the functioning of voltage-gated sodium channels, the preferred molecular target of gambierol is the voltage-gated potassium channel, at least in taste cells. Voltage-gated potassium currents play an important role in the generation of the firing pattern during chemotransduction. Thus, gambierol may alter action potential discharge in taste cells and this could be associated with the taste alterations reported in the clinical literature.

Role of gustatory thalamus in anticipation and comparison of rewards over time in rats.

Rats reduce intake of a palatable saccharin solution when it is followed by access to a preferred sucrose solution. This phenomenon, referred to as an anticipatory contrast effect (ACE), is thought to occur because the value of the saccharin conditioned stimulus pales in comparison to the highly rewarding sucrose unconditioned stimulus expected in the near future. Although relatively little is known about the underlying neural substrates, lesions of the gustatory thalamus fully disrupt the phenomenon (Reilly S, Bornovalova M, and Trifunovic R. Behav Neurosci 118: 365-376, 2004; Reilly S and Pritchard TC. Behav Neurosci 110: 746-759, 1996). The present set of experiments revisited this issue to determine the nature of this deficit. Rats with bilateral ibotenic acid lesions of the gustatory thalamus were given 3-min access to 0.15% saccharin and, after a 0-s or 5-min interval, were given 3-min access to either the same saccharin solution or a highly preferred 1.0 M sucrose solution. In experiment 1, ACE testing began with the 5-min interstimulus interval (ISI) and then switched to the 0-s ISI. For experiment 2, the order of ISI testing was reversed. The results show that axon-sparing, neurotoxic lesions of the gustatory thalamus prevent ACEs with a 0-s ISI and lead to a reversal (i.e., a reinforcement effect) with a 5-min ISI. Together, the results suggest that the lesion leads to a specific reward comparison deficit, whereby the rats fail to compare the value of an available reward with the memory of a preferred reward that is anticipated in the near future.

Acid taste thresholds assessed by conditioned taste aversion and two-bottle preference in rats.

The conditioned taste aversion (CTA) threshold for either citric acid (CA) or HCl solutions and the two-bottle taste preference (TBP) threshold were determined in rats that are familiarized to the odor of conditioning solutions or that are naive. The CTA method appeared to be more sensitive than the TBP test, particularly when rats were not familiarized to the odor of the conditioning solution. The CTA threshold for HCl-conditioned rats and familiarized to the odor of conditioning solution lies between 1.00 and 2.00 mmol; in unconditioned rats, it lies between 4.00 and 5.00 mmol. In CA-conditioned and odor-familiarized rats, the threshold lies between 0.09 and 0.20 mmol; in unconditioned rats, it lies between 7.00 and 10.00 mmol. In rats not familiarized to the odor of the conditioning solution, the threshold for HCl-conditioned rats lies between 0.90 and 1.00 mmol; in unconditioned rats, it lies between 2.00 and 3.00 mmol. In CA-conditioned rats, the CTA threshold lies between 0.03 and 0.05 mmol; in unconditioned rats, it lies between 4.00 and 7.00 mmol. The two-bottle test is less sensitive than the CTA method. The TBP threshold lies between HCl 4.00 and 5.00 mmol, and between CA 4.00 and 7.00 mmol. The odor of a solution may potentiate the ability of rats to detect the concentration of CA and HCl solutions.

Peptides that regulate food intake: somatostatin alters intake of amino acid-imbalanced diets and taste buds of tongue in rats.

The present studies were designed to evaluate a potential dose-dependent effect of somatostatin (SRIF) administered peripherally on intake of either a low-protein basal diet or threonine-imbalanced diet (THR-IMB), on body weight gain (DeltaBW), gut motility, and on the histology of taste buds in rats. SRIF administration had a dual effect related to its concentration, increasing the intake of THR-IMB diet at low concentration and decreasing THR-IMB diet at high concentration. During the light phase, SRIF treatment increased the intake of THR-IMB diet, suggesting that the usual anorectic effect induced by intake of THR-IMB diet was attenuated. High-dosage SRIF decreases gastrointestinal motility, which, in turn, can decrease food intake and DeltaBW. The combination of THR-IMB diet regimen and SRIF treatment also induced significant modifications on the taste buds of the tongue. The feeding response to an amino acid-imbalanced diet includes a learned aversion to the diet, and animals may use taste in establishing that aversion. Modifications of taste buds of SRIF-treated rats eating THR-IMB diet might explain the increase of imbalanced diet intake if treated rats perceive this food as less aversive.

Effects of conditioned food aversions on nutritional behavior in humans.

Conditioned food aversion (CFA) and taste aversion (CTA) are widely occurring phenomena mediating rejection of solids or liquids, the ingestion of which has induced the onset of post-ingestional malaise. It is a powerful and durable imprint learning that may influence food choice and intake in all animals, including humans. For ethical reasons, CTA has been extensively investigated in a wide variety of laboratory animal's species but only incidentally in humans. Nevertheless, convincing evidence has been provided that CFA and CTA learning are possible in a wide range of human subjects. The results in humans may have some limitations in accuracy since data are sparse, sometimes indirect, and poorly controlled. There is only limited information on the extent of CFA in the elderly since most studies have employed questionnaire and/or interview methods on young people (i.e. college students). The present review evaluates the literature derived both from laboratory animals and humans. In the first instance, the salient features of food and taste aversion learning and the neural mechanisms involved in this learning behavior will be examined. Then, the problems encountered when trying to assess the role of learned food and taste aversions in the nutritional status of healthy as well as sick young or elderly people will be considered. In particular, the importance of CFA on the nutritional status of cancer patients and treatment of alcoholism will be examined. It is concluded that the data are compelling enough to warrant further research and, some indications and recommendations are suggested.