John A. Papadakis

Sleeve gastrectomy-a "food limiting" operation.

BackgroundSleeve gastrectomy (SG), which, thus far, is showing good resolution of comorbidities and good weight loss, shows increasing popularity among bariatric surgeons. The aim of this study was to evaluate clinical outcome and the gastric emptying of solid foods, 24xa0months after SG.MethodsFourteen morbidly obese patients, four males and ten females, median age 41xa0years (range 29–65), median body mass index (BMI) 49.46xa0kg/m2 (range 41.14–55.63), who underwent SG for weight loss, were studied prospectively. Nine patients underwent gastric emptying studies, using radioisotopic technique before, 6xa0months and 24xa0months after the operation. The remaining five patients underwent gastric emptying studies, 6xa0months and 24xa0months after the operation.ResultsA significant reduction in patients’ weight and BMI was evident at 6, 12 and 24xa0months postoperatively. In the nine patients who underwent gastric emptying studies pre-, 6 and 24xa0months postoperatively, the T-lag phase duration significantly decreased, following the SG, from 17.30 (range 15.50–20.90)xa0min, to 12.50 (range 9.20–18.00)xa0min at 6xa0months and 12.16 (range 10.90–20.00)xa0min at 24xa0months postoperatively (Pu2009<u20090.05). The gastric emptying half time (T1/2) accelerated significantly postoperatively from 86.50 (range 77.50–104.60)xa0min, to 62.50 (range 46.30–80.00)xa0min at 6xa0months and 60.80 (range 54.80–100.00)xa0min at 24xa0months after SG (Pu2009<u20090.05). The percentage of gastric emptying (%GE) increased significantly postoperatively, from 52 (range 43–58) % to 72 (range 57–97) % at 6xa0months and 74 (range 45–82) % at 24xa0months, following SG (Pu2009<u20090.05). No differences in gastric emptying were observed, when values at 24xa0months were compared to those at 6xa0months postoperatively. When the whole group of 14 patients was studied, there were also no significant changes in T-lag, T1/2 and %GE between 6 and 24xa0months postoperatively.ConclusionsOur study indicates the constant effect of SG in the acceleration of gastric emptying of solids, which occurs faster, not only in short but also in long-term postoperatively. Such effects on gastric motility, in combination with the reported alterations in gut hormones, may explain how this ‘food limiting’ operation results in weight loss.

Metabolic syndrome is common among middle-to-older aged Mediterranean patients with rheumatoid arthritis and correlates with disease activity: a retrospective, cross-sectional, controlled, study

Objectives: Patients with rheumatoid arthritis have an increased risk for cardiovascular disease (CVD). The prevalence of metabolic syndrome (MetS)—a major contributor to CVD—in a cohort of patients with rheumatoid arthritis and its relationship with rheumatoid arthritis related factors is investigated here. Methods: 200 outpatients with rheumatoid arthritis (147 women and 53 men), with a mean (standard deviation (SD)) age of 63 (11) years, and 400 age and sex-matched controls were studied. MetS was assessed according to the adult treatment panel III criteria and rheumatoid arthritis disease activity by the disease activity score of 28 joints (DAS28). A standard clinical evaluation was carried out, and a health and lifestyle questionnaire was completed. Results: The overall prevalence of MetS was 44% in patients with rheumatoid arthritis and 41% in controls (pu200a=u200a0.5). Patients with rheumatoid arthritis were more likely to have low high-density lipoprotein cholesterol compared with controls (pu200a=u200a0.02), whereas controls were more likely to have increased waist circumference or raised blood pressure (pu200a=u200a0.001 and 0.003, respectively). In multivariate logistic regression analysis adjusting for demographics and rheumatoid arthritis treatment modalities, the risk of having moderate-to-high disease activity (DAS28>3.2) was significantly higher in patients with MetS compared with those with no MetS components (OR 9.24, 95% CI 1.49 to 57.2, pu200a=u200a0.016). Conclusion: A high, albeit comparable to the control population, prevalence of MetS was found in middle-to-older aged patients with rheumatoid arthritis. The correlation of rheumatoid arthritis disease activity with MetS suggests that the increased prevalence of coronary heart disease in patients with rheumatoid arthritis may, at least in part, be attributed to the inflammatory burden of the disease.

The Intragastric Balloon – Smoothing the Path to Bariatric Surgery

Background: Intragastric balloon placement in association with diet for weight reduction is steadily gaining popularity. However, long-term follow-up studies on the effect of this method in maintaining weight loss are lacking. This study evaluated the long-term outcome following balloon removal in morbidly obese patients who had selected this method for weight loss. Methods: 140 morbidly obese patients who refused bariatric surgery because of fear of complications and mortality, underwent intragastric balloon placement and were followed over a 6- to 30-month period (mean 18.3 months) after balloon extraction. The 34 males and 106 females, with median age 38 years (range 16-62), median weight 122 kg (range 85-203), median BMI 42.3 kg/m2 (range 35-61.3) and median excess weight (EW) 59 kg (range 29-132), received a Bioenterics Intragastric Balloon (BIB). Excess weight loss (EWL) ≥25% when the BIB was removed was considered a success. Weight fluctuations and any further interventional therapy requested by the patients after balloon removal were recorded. Results: 100 patients (71.4%) lost ≥25% of their EW on balloon extraction and were categorized as successes, while 40 patients (28.6%) did not achieve that weight loss and were categorized as failures of the method. During the follow-up period, 44 of the originally successful patients (31.4%) regained weight and were categorized as recurrences, while the remaining 56 patients (40%) maintained their EWL of ≥25% and were considered long-term successes. During follow-up, 45 patients (32.1%) requested and underwent bariatric surgery for their morbid obesity (21 Adjustable Gastric Band, 11 Laparoscopic Sleeve Gastrectomy, 13 Laparoscopic Gastric Bypass). Of these, 13 (32.5%) were from the group of 40 patients categorized as failures on BIB removal, 28 (63.6%) were from the group of 44 patients whose obesity recurred, and 4 (7.1%) were from the 56 patents who although they maintained successful weight loss requested further weight reduction. Conclusions: The BIB served as a first step and a smooth introduction to bariatric surgery for morbidly obese patients who initially refused surgical intervention. The incidence of surgical intervention was double in patients who initially experienced the benefits of weight loss and then had obesity recurrence, compared with patients in whom the method failed. Indeed, a significant number of patients were assisted in their efforts to lose and maintain an acceptable weight loss over a 6- to 30-month follow-up period.

Alterations in gut hormones after laparoscopic sleeve gastrectomy: a prospective clinical and laboratory investigational study.

Objective:To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on fasting and meal-stimulated release of the gut hormones ghrelin, pancreatic polypeptide (PP), peptide-YY (PYY), glucagon-like peptide-1 (GLP-1), and amylin and of the adipocytokine leptin. Background:Mounting evidence suggests that the mechanisms of weight loss and the improvement in glucose metabolism seen after LSG are related not only to gastric restriction but also to neurohormonal changes. Methods:Fasting and postprandial levels at 60 and 120 minutes after a standard test meal of the above peptides and glucose metabolism indices were evaluated in 15 consecutive morbidly obese (MO) subjects before and 6 and 12 months after LSG. As study controls, 15 lean subjects matched for age and sex were also assessed. Results:Body mass index values notably decreased at 6 and 12 months (P < 0.01), postoperatively. In addition, an overall improvement of the glycemic profile of MO patients was noted. After LSG, markedly decreased fasting and postprandial levels of ghrelin, amylin, and leptin were observed. A significant postprandial increase of PYY and GLP-1 levels was also noted postoperatively. Interestingly, significantly increased levels of PP were noted only at 60 minutes postprandially after LSG. Conclusions:LSG markedly improved glucose homeostasis and generated significant changes in ghrelin, PP, PYY, GLP-1, amylin, and leptin levels. These multiple hormonal actions may have several beneficial effects on the underlying mechanism of weight loss, demonstrating that LSG could be more than just a restrictive bariatric operation.

Plasma antioxidant capacity in morbidly obese patients before and after weight loss.

Background: Oxidative stress may play a critical role in the pathogenesis and development of obesity-associated co-morbidities. Reactive oxygen and nitrogen species are produced as a consequence of normal aerobic metabolism and removed and/or inactivated in vivo by both endogenous (uric acid, bilirubin, thiols) and diet-derived (exogenous) antioxidants. The purpose of this study is to measure the total plasma antioxidant capacity (TAC), as well as the corrected TAC (cTAC, an index of exogenous provided antioxidants) in morbidly obese patients before and after surgical weight reduction. Methods: 16 morbidly obese (5 male and 11 female) candidates for surgical intervention, median age 34 (range 22-56) years, median weight 128 (range 96-186) kg, median excess weight 62 (range 28-115) kg and median BMI 44.4 (range 33.7-60.1) kg/m2 were evaluated before and 6 months after implantation of an intragastric balloon. 15 healthy blood donors (4 male and 11 female) on a normal diet, median age 35 (range 21-52) years, median weight 64.3 (range 46-78) kg and median BMI 24.2 (range 23.7-25.2) kg/m2 were also evaluated. Blood samples for routine clinical chemistry, TAC and cTAC determination were drawn, and weight and BMI calculation were performed once in the control group, and in the morbidly obese patients (MO) before and 6 months after the balloon implantation. Results: 6 months after balloon placement, weight and BMI of the MO patients were statistically significantly reduced from the preoperative values (P<0.001). Plasma TAC and cTAC values in the MO group were significantly lower preoperatively, compared to the control group (P<0.05 and P<0.001 respectively). cTAC values in the MO patients increased significantly following weight loss (P<0.001) and were restored to normal. However, the postoperative TAC values in the MO group did not change significantly and remained lower than in the normal controls. A significant decrease (P<0.001) in uric acid values was also noticed in the MO group after weight loss. Conclusion: Plasma TAC and cTAC values are impaired in morbidly obese patients. Weight loss from an intragastric balloon is associated with significant increase in plasma cTAC values. Plasma TAC values, after the weight loss remain unchanged, possibly due to a decrease in uric acid, an important endogenous antioxidant.

Gram-negative bacteremia in non-neutropenic patients: A 3-year review

SummaryThe causative organisms, clinical manifestations, factors influencing prognosis, and other epidemiological characteristics of 81 episodes of bacteremia due to gram-negative organisms, in non-neutropenic patients, were studied retrospectively during a 3-year period (1992–1994) at the Department of Internal Medicine of the University Hospital of Heraklion, Crete, Greece. The gram-negative bacteremia incidence was 2% and the overall mortality 12%. All 81 patients had fever;Escherichia coli was the most frequent organism isolated (from 47 patients −58%) and was associated with shock (9/47), disseminated intravascular coagulation (DIC) (8/47), anuria (5/47), adult respiratory distress syndrome (ARDS) (3/47), and pneumonia (1/47). Other less frequent gram-negative microorganisms wereKlebsiella spp. (ten patients; 12%),Pseudomonas spp. (7; 7%),Salmonella spp. (5; 6%),Enterobacter spp. (5; 6%),Proteus spp. (3; 3.4%),Stenotrophomonas spp. (3; 3.4%), andAcinetobacter spp. (1; 1.2%). ARDS, shock, DIC, anuria, presence of central venous catheter, urinary catheter, unknown origin of infection and inappropriate treatment were significantly associated with a higher death rate. Early initiation of appropriate therapy was the most important intervention that favorably affected the outcome of gram-negative bacteremias in this patient population.

Effect of diabetes mellitus on the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis.

OBJECTIVES: To study potential differences in the clinical and microbiological features of hospitalized elderly patients with acute pyelonephritis with and without diabetes mellitus.

Changes in Metabolic Profile and Adipoinsular Axis in Morbidly Obese Premenopausal Females Treated with Restrictive Bariatric Surgery

BackgroundThe aim of the present study was to evaluate the effects of surgically induced weight loss on the metabolic profile and adipocytokine levels in premenopausal morbidly obese females.MethodsTwenty premenopausal morbidly obese (MO) women with a median age of 34xa0years (range: 24–48xa0years) and a median body mass index (BMI) of 41.47xa0kg/m2 (range: 38.0–56.73xa0kg/m2) were studied (13 women underwent gastric banding and 7 women underwent sleeve gastrectomy). In addition, 20 lean premenopausal women with a median age of 32xa0years (range: 22–44xa0years) and a median BMI of 20.0xa0kg/m2 (range: 18.5–24.7xa0kg/m2) were also studied. Anthropometric measurements and metabolic parameters were analyzed in each patient, along with changes in leptin, adiponectin, resistin, and interleukin-6 (IL-6) before surgery, 6xa0months after surgery, and 12xa0months after surgery. Comparisons with the reference normal-weight subjects were also performed.ResultsBoth weight and BMI were found to be significantly decreased postoperatively. A 54.5% loss of excess BMI was observed 12xa0months after surgery, and was associated with significant improvement in all anthropometric and metabolic parameters. Twelve months after surgery we also observed decreased levels of serum leptin, resistin, and IL-6; increased levels of serum adiponectin; and a remarkable improvement in metabolic syndrome markers. Furthermore, postoperative serum resistin and IL-6 levels were found to reach those of normal-weight volunteers.ConclusionsThe results of this study suggest that weight loss through restrictive bariatric surgery results in a significant reduction in leptin, resistin, and IL-6 levels, and an increase in adiponectin levels, in addition to improving insulin sensitivity and glucose and lipid homeostasis in young morbidly obese female patients. These changes were significantly correlated with the magnitude of weight loss.

Bacteremic community-acquired pneumonia due to Pasteurella multocida

An 87-year-old man was admitted to hospital because of fever, productive cough, dyspnea and altered consciousness. His medical history was significant for chronic obstructive pulmonary disease. He owned several pets. Physical examination and a chest radiograph revealed right upper lobe pneumonia. Blood cultures taken on admission yielded Pasteurella multocida and antimicrobial susceptibility testing showed susceptibility to beta-lactams. The fever subsided four days after treatment with intravenous ceftriaxone and the patient was discharged in a very good clinical condition after two weeks of treatment. Although no history of bites or scratches was documented, it is likely that our patient was exposed to the secretions of his many pets through inhalation of contaminated aerosols. This resulted in tracheobronchial tree colonization by P. multocida, which later developed into pneumonia. Close animal contact should be avoided by frail, elderly patients with chronic pulmonary diseases, as it is a risk factor for pneumonia due to Pasteurella spp.

Nosocomial lower respiratory tract infections: prevalence and risk factors in 14 Greek hospitals

Nosocomial lower respiratory tract infections (NLRTIs) are associated with significant morbidity and mortality. The aim of this study was to investigate the epidemiological features of NLRTIs in Greece, where knowledge about these infections is limited. Two point-prevalence studies of hospital-acquired infections were carried out in 14 Greek hospitals located throughout the country, one in 1999 and one in 2000. NLRTIs were diagnosed in accordance with the Centers for Disease Control and Prevention (CDC) definitions. Among the 7,120 hospitalized patients registered during the two studies, 610 (8.6%) cases of hospital-acquired infections were identified, of which 200 (32.8%) were NLRTIs. Sixty-nine (34.5%) patients had pneumonia, and the remaining 131 (65.5%) patients had bronchitis. The greatest prevalence of NLRTI was found in the adult ICUs (30.4%). Male gender, age >65 years, mechanical ventilation, tracheostomy, an intravenous central line, and an indwelling urethral catheter were the main risk factors. There was no significant difference in the incidence of NLRTI among hospital-acquired infections between the 1999 study and the 2000 study. The causative microorganism was identified in 78 of 200 (39%) cases, and 103 strains were isolated. The majority of strains (67%) were gram-negative bacteria. The most frequently isolated microorganisms were Pseudomonas aeruginosa (22.3%), Acinetobacter spp. (19.4%), Klebsiella pneumoniae (12.6%), and Staphylococcus aureus (10.7%). There was no difference between the two prevalence studies in the frequency of isolation of the microorganisms. NLRTI was the leading cause of morbidity and mortality among hospitalized patients with hospital-acquired infections in Greek hospitals. Gram-negative microorganisms were the most frequently isolated pathogens.