Daniel Antonio de Luis

Micronutrient status in morbidly obese women before bariatric surgery

BACKGROUND A high prevalence of micronutrient deficiencies in obese subjects has been reported. Bariatric surgery is the most effective long-term treatment of morbid obesity, but this treatment can result in secondary micronutrient deficiencies. The aim of our work was to describe the micronutrient status in obese women before surgery at a university hospital. METHODS We analyzed a consecutive series of 115 women who were referred to our unit for evaluation for bariatric surgery. Their weight, height, body mass index, and waist circumference were measured. The basal hemoglobin, albumin, prealbumin, ferritin, copper, zinc, calcium, phosphorus, parathyroid hormone, and vitamin (A, D, E, K, B12, and folic) blood levels were also determined. RESULTS Deficiencies were found in 6.1% of the subjects for albumin, 21.7% for prealbumin, 2.6% for hemoglobin, and 5.2% for ferritin. In the vitamin analysis, no deficiencies were found in the patients for vitamins A, E, or K, but 71.3% had a moderate deficiency of vitamin D and 26.1% a severe deficiency of vitamin D (<15 ng/mL). In concorndance with the high prevalence of 25-OH vitamin D deficiency, 22.6% of the patients had secondary hyperparathyroidism with intact parathyroid hormone levels >72 pg/mL. Deficiencies were found in 9.5% for vitamin B12, 25.2% for folic acid, 67.8% for copper, and 73.9% for zinc. CONCLUSION Our study has demonstrated a high prevalence of micronutrient deficiencies in morbidly obese women seeking obesity surgery.

Nutritional Assessment: Predictive Variables at Hospital Admission Related with Length of Stay

Background: Studies indicate that 40–50% of hospitalized patients show malnutrition, a variable that is associated with length of stay and morbidity. The aim of our study was to detect nutritional parameters, which could have an influence on length of stay in hospitalized patients. Material and Methods: All patients with a nutritional evaluation at hospital admission were elegible for inclusion. A total of 1,088 patients were studied from January 1999 to December 2003. Length of stay (LOS) data was obtained from the patient hospital record after the patient was discharged. All patients received instruction in 24-hour written food record keeping. Albumin, prealbumin, transferrin, glucose levels and total lymphocytes, were measured in all patients. Weight, body mass index, tricipital skinfold, midarm muscle circumference and midarm muscle area were assessed in a standard way. Weight loss in the previous 3 months was recorded. Results: A total of 1,088 patients were enrolled, mean age 61.8 ± 17 years, weight 64.2 ± 15 kg and BMI 23.9 ± 4.6, with a weight loss 4.15 ± 9.6 kg. The sex distribution of patients was 65.2% male and 34.8% females. Distribution of diagnosis showed leukemia and lymphoma (11.5%), solid cancer (37.4%), infections (3.5%), neurological disease (13.6%), respiratory tract disease (8.8%), and miscellaneous group (25.3%). Length of stay was 29.45 ± 25.13 days. In whole group, the correlation analysis among length of stay (days) and predictive parameters showed a positive association between albumin and length of stay (r = –0.2; p < 0.05). In the multivariant analysis with a dependent variable (length of stay (days)) and independent variables with an association in univariant analysis adjusted by age and sex, only albumin remained as an independent predictor in the model (F = 8.8; p < 0.05), with an increase of 6.2 days (95% CI: 3.5–8.9) with each decrease of 1 g/dl of albumin. Conclusion: The serum albumin levels are a good marker of LOS, a decrease in admission levels produces an increase in LOS.

Non-insulin-dependent diabetes, bone mineral density, and cardiovascular risk factors

People with Type 2 diabetes have bone mass alterations and may have a higher risk of hip fractures. Moreover, they have increased cardiovascular risk factors. The objective of this paper is to investigate the association among non-insulin-dependent diabetes, bone mineral density (BMD), and cardiovascular risk factors. Ninety-two patients (36 males and 56 females) were studied and cardiovascular risk factors were measured: total cholesterol, triglycerides, lipoprotein(a), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), glucose, HbA1c, and microalbuminuria. The densitometric studies were carried out in the calcaneal region using a DEXA densitometer. The diabetic women had a higher BMD than the control group (0.502 +/- 0.127 vs. 0.408 +/- 0.102, P = .027). The women showed a positive relationship between BMD and triglycerides (r =. 478, P = .0001) and a negative relationship with HDL-C (r = -.322, P = .016). The men had a BMD similar to that of the control group, and there was no relationship with the cardiovascular risk factors. When a multivariate logistic regression analysis was performed with the presence of osteoporosis as a dependent variable and each lipid level, age, sex, and BMI as independent variables, only age and BMI were found to be associated with the presence of osteopososis. The diabetic women had a higher BMD than the controls, and there was no relationship between osteoporosis and cardiovascular risk factors in diabetics.

Odanacatib, a New Drug for the Treatment of Osteoporosis: Review of the Results in Postmenopausal Women

Osteoclasts are specialized cells that initiate the process of bone resorption, which has two phases, dissolution of the mineral component and degradation of the organic matrix, in which cathepsin K plays a key role. Cathepsin K inhibitors, which block the activity of cathepsin on bone resorption lacunae, may be a new therapeutic option in osteoporosis. Odanacatib is a nonpeptidic biaryl inhibitor of cathepsin K. Two studies have evaluated the efficacy and safety of odanacatib, a phase I study to determine the dose and a phase II study of safety and efficacy. Due to the long half-life of odanacatib and the similar effects of different doses on bone remodeling markers, a weekly dosage was chosen for the phase II trail, with the best results being obtained with a dose of 50 mg. At 36 months, increases in bone mineral density similar to those produced by other powerful antiresorptive drugs (zoledronate and denosumab) were observed but there were differences in the behaviour of bone remodeling markers. Data on fractures from the phase III trial currently in development are required to confirm these possible advantages.

The effect of liver transplantation on circulating levels of estradiol and progesterone in male patients: Parallelism with hepatopulmonary syndrome and systemic hyperdynamic circulation improvement

The correction of hepatopulmonary syndrome (HPS) after liver transplantation (LT) remains controversial. The aims of our study were to: 1) analyze whether LT reverses HPS; 2) note any relationship between HPS and the systemic hemodynamic disturbance; and 3) note changes in circulating sex hormones and the possible association with pulmonary and systemic hemodynamic changes. Systemic hemodynamic parameters, cardiac output and systemic vascular resistance (SVR), sex hormones, and intrapulmonary vasodilatation assessed by contrast transesophageal echocardiography, and gas exchange abnormalities were investigated in 19 patients with advanced cirrhosis prior to and 6 months (176.8±30 days) after LT. LT was followed by a marked reduction in cardiac output (6.6±1.7 vs 3.5±0.5 l/min; plt0.001) and SVR (1039±460 vs 1978±294 dyn⊙sec⊙cm−5; plt0.005). Before LT, circulating estradiol and progesterone levels were invariably elevated (66±22 pg/ml and 1.8±1.1 ng/ml, respectively, normal values lt31 pg/ml and 0.35 ng/ml, respectively), and dropped after LT (28±12 pg/ml plt0.001 and 0.38±0.2 ng/ml; plt0.001, respectively). Seventeen of 19 patients had intrapulmonary vasodilatation and increased alveolar-arterial oxygen difference, thereby fulfilling diagnostic criteria for HPS. Patients with HPS presented higher cardiac output (plt0.05), lower SVR (plt0.01), and higher progesterone and estradiol levels than patients without HPS (plt0.05). LT produced normalization of intrapulmonary vasodilatation in all patients. LT normalized hyperdynamic circulation and is a useful therapeutic option in patients with HPS. Normalization of sex hormone levels after LT suggests that they could play a pathogenic role in the development of HPS.

Beneficial effects of liraglutide on adipocytokines, insulin sensitivity parameters and cardiovascular risk biomarkers in patients with Type 2 diabetes: A prospective study

AIMS To evaluate the effects of liraglutide after 14 weeks of treatment on serum adipokines, insulin resistance index and cardiovascular risk biomarkers in overweight or obese T2DM patients unable to achieve glycemic control with metformin alone or in association with a sulfonylurea in daily clinical practice. METHODS Prospective study in 59 consecutive overweight or obese (BMI≥25kg/m(2)) T2DM patients unable to achieve glycemic control (HbA1c>7%, 53mmol/mol) with metformin alone or in association with sulfonylurea that require initiation of liraglutide in progressive dose increase up to 1.8mg/day subcutaneously. Weight, body composition, blood pressure, glucose, HbA1c, C-peptide, insulin, plasma lipids, adipokines (leptin, adiponectin, resistin and visfatin) as well as cardiovascular biomarkers (IL-6 and TNF-a) levels were measured fasting at baseline and 14 weeks after liraglutide initiation. RESULTS 14 weeks of liraglutide treatment significantly reduced HbA1c, BMI and total body fat mass by 0.9%, 1.4kg/m(2) and 0.5% respectively. Statistically significant lower insulin resistance and higher insulin secretion was found by HOMA-IR 8.4 (1.6) vs 4.6 (0.9)molmIU/L(2) and HOMA-B 48.2 (9.0) vs 87.6 (16.3)μIU/mmol. Statistically significantly higher levels of visfatin 6.3 (2.1) vs 6.8 (2.1)ng/ml and resistin 3.6 (2.0) vs 4.3 (2.3)ng/ml were also observed after treatment. Baseline visfatin was negatively correlated with basal fasting plasma glucose r=-0.360 (p<0.05). CONCLUSIONS Liraglutide treatment for 14 weeks in daily clinical practice led to reduction of BMI and improvement of glucose control and insulin sensitivity and resistance parameters. Additionally, circulating levels of adipokines and pro-inflammatory factors could play an important role in GLP-1 treatment response.

Surgical infection and malnutrition.

BACKGROUND Malnutrition in surgical patients is associated with delayed recovery, higher rates of morbidity and mortality, prolonged hospital stay, increased healthcare costs and a higher early re-admission rate. METHODS Data synthesis after review of pertinent literature. RESULTS The aetiology of malnutrition is multifactorial. In cancer patients, there is an abnormal peripheral glucose disposal, gluconeogenesis, and whole-body glucose turnover. Malnourished cancer patients undergoing major operations are at significant risk from perioperative complications such as infectious complications. Surgical aggression generates an inflammatory response which worsens intermediary metabolism. CONCLUSIONS Nutritional evaluation and nutritional support must be performed in all surgical patients, in order to minimize infectious complications. Enteral nutrition early in the postoperative period is effective and well tolerated reducing infectious complications, improving wound healing and reducing length of hospital stay. Pharmaconutrition is indicated in those patients, who benefit from enteral administration of arginine, omega 3 and RNA, as well as parenteral glutamine supplementation. When proximal sutures are used, tubes allowing early jejunal feeding should be used.

Circulating visfatin in obese non-diabetic patients in relation to cardiovascular risk factors, insulin resistance, and adipocytokines: a contradictory piece of the puzzle.

OBJECTIVE Obesity and insulin resistance are associated with cardiovascular risk factors. The aim of the present study was to explore the relation of circulating visfatin to insulin resistance, cardiovascular risk factors, anthropometry, and adipocytokines in obese patients without diabetes mellitus. METHODS A population of 228 obese non-diabetic outpatients was analyzed in a prospective way. All patients with a 2-wk weight-stabilization period before recruitment were enrolled. Biochemical analysis and nutritional evaluation were performed. RESULTS Subjects were 62 men (27.2%) and 166 women (62.8%) with a mean age of 41.1 ± 16.4 y and a mean body mass index of 35.8 ± 3.6 kg/m(2). Patients were divided in two groups by median visfatin value (22.8 ng/mL), i.e., those with low values (group I) and those with high values (group II). Patients in group I had greater weight, body mass index, fat mass, fat-free mass, insulin, homeostasis model of assessment, triacylglycerol, leptin, and adiponectin than patients in group II. Patients in group II had higher total cholesterol, low-density lipoprotein cholesterol, resistin, and tumor necrosis factor-α levels than patients in group I. In a multivariate analysis with age- and sex-adjusted basal visfatin concentration as a dependent variable, only weight and leptin remained as an independent predictor in the model (F = 6.5, P < 0.05), with an inverse correlation. CONCLUSION Total cholesterol, low-density lipoprotein cholesterol, tumor necrosis factor-α, and resistin levels are elevated in patients with visfatin levels above the median value. Homeostasis model of assessment, insulin, weight, fat mass, fat-free mass, triacylglycerols, leptin, and adiponectin are decreased in these patients.

Vitamin D Levels and Lipid Response to Atorvastatin

Adequate vitamin D levels are necessary for good vascular health. 1,25-dihydroxycholecalciferol activates CYP3A4, an enzyme of the cytochrome P450 system, which metabolizes atorvastatin to its main metabolites. The objective of this study was to evaluate the response of cholesterol and triglycerides to atorvastatin according to vitamin D levels. Sixty-three patients with acute myocardial infarction treated with low and high doses of atorvastatin were included. Levels of total cholesterol, triglycerides, HDL cholesterol, and LDL cholesterol were measured at baseline and at 12 months of follow-up. Baseline levels of 25-hydroxyvitamin D (25-OHD) were classified as deficient (<30 nmol/L), insufficient (30–50 nmol/L), and normal (>50 nmol/L). In patients with 25-OHD <30 nmol/L, there were no significant changes in levels of total cholesterol (173 ± 47 mg/dL versus 164 ± 51 mg/dL), triglycerides (151 ± 49 mg/dL versus 177 ± 94 mg/dL), and LDL cholesterol (111 ± 48 mg/dL versus 92 45 ± mg/dL); whereas patients with insufficient (30–50 nmol/L) and normal vitamin D (>50 nmol/L) had a good response to atorvastatin. We suggest that vitamin D concentrations >30 nmol/L may be required for atorvastatin to reduce lipid levels in patients with acute myocardial infarction.

Influence of Ala54Thr polymorphism of fatty acid–binding protein-2 on clinical results of biliopancreatic diversion

OBJECTIVE Bariatric surgery is the most effective long-term treatment for morbid obesity, reducing obesity-associated comorbidities. The purpose of the present study was to evaluate the fatty acid-binding protein-2 Ala54Thr polymorphism outcomes 1 y after biliopancreatic diversion in morbidly obese patients. METHODS A sample of 41 morbidly obese patients (body mass index >40 kg/m(2)) were operated upon from December 2004 to December 2006. Weight, fat mass, blood pressure, basal glucose, triacylglycerides, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were measured at the basal visit and at each visit. The frequency of patients with diabetes mellitus, hypertension, and hyperlipidemia was recorded at each visit. RESULTS Twenty-three patients (56.1%) had genotype Ala54/Ala54 (wild group) and 18 patients had genotype Ala54/Thr54 (15 patients, 36.5%) or Thr54/Thr54 (3 patients, 7.4%; mutant group). In the wild group, body mass index, weight, fat mass, systolic blood pressure, glucose, total cholesterol, low-density lipoprotein cholesterol, and triacylglycerol concentrations decreased. Diastolic blood pressure remained unchanged. In the mutant group, the same parameters improved, without statistical differences from the wild group. Initial excess weight percent loss at 1 y of follow-up was similar in both genotype groups (61.8% versus 61.9%, NS). CONCLUSION Polymorphism Ala54Thr of fatty acid-binding protein did not have an effect on weight loss or clinical outcomes after bariatric surgery.