Laurence Salomon

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.

Microparticle increase in severe obesity: Not related to metabolic syndrome and unchanged after massive weight loss

To clarify the relationships between circulating microparticles (MPs), leukocyte–platelet aggregates (LPAs), obesity, and metabolic abnormalities and evaluate the effect of losing weight on these parameters.

Central or Peripheral Catheters for Initial Venous Access of ICU Patients: A Randomized Controlled Trial

Objectives:The vast majority of ICU patients require some form of venous access. There are no evidenced-based guidelines concerning the use of either central or peripheral venous catheters, despite very different complications. It remains unknown which to insert in ICU patients. We investigated the rate of catheter-related insertion or maintenance complications in two strategies: one favoring the central venous catheters and the other peripheral venous catheters. Design:Multicenter, controlled, parallel-group, open-label randomized trial. Setting:Three French ICUs. Patients:Adult ICU patients with equal central or peripheral venous access requirement. Intervention:Patients were randomized to receive central venous catheters or peripheral venous catheters as initial venous access. Measurements and Results:The primary endpoint was the rate of major catheter-related complications within 28 days. Secondary endpoints were the rate of minor catheter-related complications and a composite score-assessing staff utilization and time spent to manage catheter insertions. Analysis was intention to treat. We randomly assigned 135 patients to receive a central venous catheter and 128 patients to receive a peripheral venous catheter. Major catheter-related complications were greater in the peripheral venous catheter than in the central venous catheter group (133 vs 87, respectively, p = 0.02) although none of those was life threatening. Minor catheter-related complications were 201 with central venous catheters and 248 with peripheral venous catheters (p = 0.06). 46% (60/128) patients were managed throughout their ICU stay with peripheral venous catheters only. There were significantly more peripheral venous catheter-related complications per patient in patients managed solely with peripheral venous catheter than in patients that received peripheral venous catheter and at least one central venous catheter: 1.92 (121/63) versus 1.13 (226/200), p < 0.005. There was no difference in central venous catheter-related complications per patient between patients initially randomized to peripheral venous catheters but subsequently crossed-over to central venous catheter and patients randomized to the central venous catheter group. Kaplan–Meier estimates of survival probability did not differ between the two groups. Conclusion:In ICU patients with equal central or peripheral venous access requirement, central venous catheters should preferably be inserted: a strategy associated with less major complications.

The Suburethral Sling for Female Stress Urinary Incontinence: A Retropubic or Obturator Approach?

STUDY OBJECTIVE To evaluate the feasibility and safety of the obturator approach for placement of a vaginal suburethral sling indicated for women with stress urinary incontinence. DESIGN Retrospective cohort analysis (Canadian Task Force classification IV). SETTING University teaching hospital. PATIENTS Forty-nine women suffering from stress incontinence. INTERVENTION Analysis of the suburethral sling according to surgical approach during two consecutive periods: retropubic from January 1, 2001 through September 30, 2001, and obturator from October 1, 2001 through January 31, 2002. MEASUREMENTS AND MAIN RESULTS During the study period, 25 patients underwent surgery with the retropubic approach and 24 with the obturator approach. The patient characteristics did not differ between the two groups. The obturator approach was feasible in all attempted procedures. The mean operative time was 46 minutes (range 20-90) for the retropubic approach compared with 32 minutes (range 15-50) for the obturator approach (p = .03). Two bladder injuries occurred with the former, none with the latter (although cystoscopy was not routinely performed) (p = .49). Similarly, significantly more patients in the retropubic approach group had difficulty with postoperative voiding compared with those in the obturator approach group (10 [40%] vs 2 [8%], p = .01). Only two patients, both in the retropubic group, had voiding difficulties for longer than 1 week. One month after surgery, continence results did not differ significantly between the two groups (p = .30). In the retropubic approach group, 20 (80%) of the women were cured, and substantial improvement was experienced by 5 (20%). In the obturator approach group, these figures were 20 (83%) and 3 (12.5%), respectively, with one surgical failure (4%). Those initial results were unchanged at last follow-up (mean follow-up was 13.7 +/- 3 months for the retropubic approach group and 7.2 +/- 2 months for the obturator approach group). CONCLUSION The obturator approach for suburethral slings is feasible and safe and may limit both preoperative and postoperative complications. Our short-term continence results compare well with those achieved with the retropubic approach. A randomized study is now needed to compare these two approaches.

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.

Search for an association between V249I and T280M CX3CR1 genetic polymorphisms, endothelial injury and preeclampsia: the ECLAXIR study.

Background Preeclampsia and coronary-artery disease share risk factors, suggesting common pathophysiological mechanisms. CX3CR1/CX3CL1 mediates leukocyte migration and adhesion and has been implicated in the pathophysiology of several inflammatory diseases. M280/I249 variants of CX3CR1 are associated with an atheroprotective effect and reduced endothelial dysfunction. The aim of this study was to search for an association between V249I and T280M polymorphisms of CX3CR1, preeclampsia and endothelial dysfunction. Methodology/Principal Findings We explored these polymorphisms with real-time polymerase chain reaction in a case-control study (184 white women with preeclampsia and 184 matched normotensive pregnant women). Endothelial dysfunction biomarkers including von Willebrand factor, VCAM-1 and thrombomodulin, as well as the soluble form of CX3CL1 were measured by enzyme-linked immunosorbent assays (ELISA). The I249 and M280 alleles were associated neither with preeclampsia, nor with its more severe form or with endothelial injury. In contrast, we found a trend toward increased CX3CL1 levels in preeclampsia patients, especially in early-onset- preeclampsia as compared to its level in later-onset- preeclampsia. Conclusions/Significance This is the first study to characterize the CX3CR1 gene polymorphisms in patients with preeclampsia. We found no differences in genotype or haplotype frequencies between patients with PE and normal pregnancies, suggesting that maternal CX3CR1 V249I and T280M polymorphisms do not increase susceptibility to preeclampsia. Further studies should be performed to directly evaluate the pathophysiological role of CX3CL1, a molecule abundantly expressed in endometrium, which has been shown to stimulate human trophoblast migration.

Risk of invasive breast cancer after lobular intra-epithelial neoplasia: Review of the literature

OBJECTIVE Lobular intra-epithelial neoplasia (LIN) is a rare breast disease that has been regarded alternately as a risk factor for invasive breast cancer in both breasts or a true breast cancer precursor. The controversy is largely dependent on the estimation of the IBC (Invasive Breast Cancer) risk after LIN; however a systematic review of the published data has not been previously performed. We aimed to review the IBC after LIN and the characteristics of those cancers. METHODS A PubMed search was performed to identify the published articles in English addressing the breast cancer risk after LIN. RESULTS There was a wide range in the figures estimating the risk of the breast cancer among the 22 studies that form the basis of this review. The cumulative average risk of invasive breast cancer (IBC) was 8.7% (range 0-33). It was 4.7% (range 0-25) for the ipsilateral and 4.2% (range 0-16) for the contralateral breast. 52% of the breast cancers occurred more than 10 years after the initial LIN. A lobular histotype was present in 30% (range 0-67%) of all IBC. CONCLUSIONS LIN should be considered both as a risk factor (low and similar level of IBC risk for both breasts, long delay between LIN and IBC) and a precursor for IBC (over-representation of lobular histotype).

MRI urethrovesical junction mobility is associated with global pelvic floor laxity in female stress incontinence

Objective. To assess in a population of stress incontinent patients without genital prolapse whether urethrovesical junction mobility is associated with global pelvic floor laxity. Methods. Dynamic MRI of 40 patients referred prior to surgery for urinary stress incontinence were reviewed retrospectively. The orientation of the urethrovesical junction was evaluated at rest and at straining in reference to the pubococcygeal line, and defined as the bladder neck pubococcygeal angle. The urethrovesical junction mobility was calculated as the difference between the bladder neck pubococcygeal angles at rest and at straining. Urethrovesical junction mobility and bladder neck pubococcygeal angles at rest and at straining were tested for correlations with the resting and straining position of different pelvic organs, urogenital hiatus size, levator plate angle, and anterior rectal bulging when straining. Results. Urethrovesical junction mobility was correlated with the position of the bladder neck (p<0.0001), bladder base (p<0.0001) and uterine cervix (p<0.0001) at straining, as well as the hiatus length (p = 0.0012) and width (p = 0.0002), and levator plate angle (p<0.0001). The bladder neck pubococcygeal angle at rest was correlated with the resting position of the bladder neck (p<0.0001), bladder base (p<0.0001), uterine cervix (p = 0.02), and the hiatus length (p = 0.0004) and width (p = 0.045) at rest, whereas the bladder neck pubococcygeal angle at straining was correlated with the straining position of the bladder neck (p<0.0001), bladder base (p<0.0001), uterine cervix (p<0.0001), and hiatus length (p = 0.0005) and width (p = 0.0004), and levator plate angle (p<0.0001) at straining. Conclusion. In a population of stress incontinent patients, the urethrovesical junction mobility was correlated with global pelvic floor laxity.

End of life in the intensive care unit: should French law be adapted?

BackgroundLongstanding concerns regarding end of life in the ICU led in France to the publication of guidelines, updated in 2009, that take into account the insights provided by a recent law (Leonetti’s law) regarding patients’ rights. After the French President asked a specific expert to review end of life issues, the French Intensive Care Society (SRLF) surveyed their members (doctors and paramedics) about various aspects of end of life in the ICU.MethodsSRLF members were invited to respond to a questionnaire, sent by Email, designed to assess their knowledge of Leonetti’s law and to determine how many caregivers would agree with the authorization of lethal drug administration in selected end of life situations.ResultsQuestionnaires returned by 616 (23%) of 2,700 members were analyzed. Most members (82.5%) reported that they had a good knowledge of Leonetti’s law, which most (88%) said they have often applied. One third of respondents had received ‘assisted death’ requests from patients and more than 50% from patients’ relatives. One quarter of respondents had experienced the wish to give lethal drugs to end of life patients. Assuming that palliative care in the ICU is well-managed, 25.7% of the respondents would approve a law authorizing euthanasia, while 26.5% would not. Answers were influenced by the fear of a possible risk of abuse. Doctors and nurses answered differently.ConclusionICU caregivers appear to be well acquainted with Leonetti’s law. Nevertheless, in selected clinical situations with suitable palliative care, one quarter of respondents were in favor of a law authorizing administration of lethal drugs to patients.

MRI anatomical study of the outside-in transobturator suburethral tape procedure

Background. This study aims to clarify the relationship between the outside‐in transobturator suburethral tape and the anatomical structures at the blind passage of the obturator foramen, and to detail the tape position, shape, and the factors on which they are dependent. Methods. MRI scans were performed on 30 patients operated on with a dermal porcine collagen suburethral tape, indicated for urodynamically proven stress incontinence. Results. The lateral bladder wall was the closest structure to the tape at the passage of the obturator foramen, whereas vascular injuries appeared to be minimal using the outside‐in technique. The distance from tape to bladder neck was correlated with the distance from tape to pubococcygeal line (PCL) (p = 0.001), and with urethral length (p = 0.049). From the obturator foramen to its passage under the urethra, the tape was U‐shaped with a cranio‐caudal and antero‐posterior orientation. The cranio‐caudal tape shape was correlated with the distance between the tape and the PCL (p = 0.002), and to the patients anatomical characteristics: distance between the bladder neck and the pubis (p = 0.01), and the urethral length (p = 0.01). The antero‐posterior shape was correlated with the urethral length (p = 0.02). Conclusion. The lateral bladder wall is the structure most at risk during the outside‐in transobturator suburethral tape procedure. The distance from tape to bladder neck is dependent on the vertical position of the tape. The tape shape is dependent on both tape position under the urethra and the patients anatomical characteristics.