M. Fysekidis

Insulin- and glucagon-like peptide-1-induced changes in heart rate and vagosympathetic activity: why they matter

Heart rate (HR) predicts cardiovascular morbidity and mortality in individuals either with or without diabetes. In type 2 diabetic patients, cardiac autonomic neuropathy is a risk marker for cardiac morbidity and mortality. A major pathogenic potential may be attributed to vagal depression and sympathetic predominance. In this issue of Diabetologia, Berkelaar et al (DOI: 10.1007/s00125-013-2848-6) examined the effects of euglycaemic, and hyperglycaemic clamp with the addition of glucagon-like-peptide-1 (GLP-1) and arginine, on cardiac vagal control in a large number of healthy subjects. After adjustments for age, BMI and insulin sensitivity, insulin associations with HR remained partially intact while those with vagal control disappeared. This suggested that BMI and insulin sensitivity, but not insulin levels, were the main drivers of cardiac vagal control. GLP-1 infusion during hyperglycaemia increased HR and BP and produced a statistically non-significant decrease in measures of cardiac vagal control compared with values before any manipulation of insulin levels. This commentary summarises how, and to what extent, insulin and GLP-1 affect autonomic nervous system activity, HR and BP. More information is needed on the mechanisms through which acute administration of, and long-term treatment with, GLP-1 may affect haemodynamics and autonomic activity in diabetic and obese patients, since this may influence cardiovascular outcomes.

Sleeve Gastrectomy Is a Safe and Efficient Procedure in HIV Patients with Morbid Obesity: a Case Series with Results in Weight Loss, Comorbidity Evolution, CD4 Count, and Viral Load

BackgroundThe efficacy and safety of bariatric surgery have been poorly studied in patients affected with HIV. Although sleeve gastrectomy (SG) is the most widely used procedure in many countries, most of the published literature reported results with the gastric bypass (GBP) procedure on morbidly obese HIV patients.MethodsWe have evaluated retrospectively, in eight consecutive patients who underwent a SG, its effect in weight loss and its impact on the treatment and on the markers of HIV infection.ResultsSeven out of eight patients were females. The mean age was 46xa0years, with a median preoperative BMI of 42xa0kg/m2. The mean duration of HIV infection and CD4 cell count were 13.4xa0years and 457xa0cells/mm3, respectively. The mean weight loss was 37xa0kg in 20xa0months, the excess BMI loss was 80.8u2009±u200930.9xa0%, and the excess weight loss is 81.5u2009±u200928.9xa0% with one minor complication. CD4 counts were unchanged. Three patients had therapy modifications that were unrelated to bariatric surgery. Two patients had a therapeutic drug monitoring before and after the intervention. Plasma concentrations remained in therapeutic levels after the SG. Most comorbidities disappeared postoperatively, decreasing the cardiovascular risk.ConclusionsThe sleeve gastrectomy was safe and effective with no consequences on CD4 counts and viral load in HIV-affected obese patients. It should be considered as a part of the treatment in morbidly obese HIV patients.

Body mass index association with functional gastrointestinal disorders: differences between genders. Results from a study in a tertiary center

BackgroundObesity is considered as a risk factor for many functional gastrointestinal disorders. The aim of the study was to evaluate if functional digestive disorders are associated with specific body mass index groups and gender.MethodsA total of 1074 patients (50.3xa0±xa016.5xa0years, 67xa0% females) filled out a standard Rome III questionnaire (79xa0% acceptance rate). The patients were assigned to five groups according to their body mass index: underweight (6xa0%), normal (49xa0%), overweight (28xa0%), obese (12xa0%), and morbidly obese (5xa0%). Data analysis was performed using multinomial logistic regression; subjects with the normal weight were the reference group.ResultsPatients presented specific demographic and clinical characteristics according to the weight groups. Underweight patients were younger (pxa0<xa00.001), and presented a female predominance (pxa0=xa00.006), dysphagia (pxa0=xa00.013) and soiling (pxa0=xa00.021).Overweight patients were older (pxa0=xa00.001), and reported more frequently globus (pxa0=xa00.001), regurgitation (pxa0=xa00.004), postprandial distress syndrome (pxa0=xa00.009).Obese patients reported more frequently regurgitation (pxa0<xa00.001).Morbid obese patients reported dyspepsia (pxa0=xa00.046).In patients, the odds of regurgitation increased with body mass index from underweight to obesity, but not when compared to morbid obesity. The probability of globus and regurgitation increased with body mass index and presented a steeper increase in females.ConclusionsIn patients with functional gastrointestinal disorders, globus and regurgitation are associated with body mass index, mainly in female patients.

The Clinical Spectrum of RET proto-oncogene mutations in codon 790

OBJECTIVEnDue to a strong genotype-phenotype correlation, the timing of prophylactic thyroidectomy in rearranged during transfection (RET) gene mutation carriers is usually dictated by genetic analysis.nnnSUBJECTS AND METHODSnWe report a nationwide retrospective study of the clinical data of 77 French patients from 19 families with a mutation in codon 790 of the RET proto-oncogene.nnnRESULTSnThe average age at diagnosis was 35.6 years ± 20.5. Thirty-nine patients were women. Fifty-five patients underwent operations for the treatment of medullary thyroid carcinoma (MTC) at the mean age of 38 years (4-82 years). The mean follow-up duration was 89 months. TNM staging was as follows: T0NxMx in 19, TxNxMx in 1, T1NxMx in 22, T1N1Mx in 8, T2N1Mx in 1 and T3N1Mx in four patients. In the T1/x-Nx group, 96% were considered cured after surgery. In the N1 group (n=13), six patients had multifocal disease and five patients were cured. Age and gender were not significant predictors of remission. Twenty-two patients did not undergo an operation (age 1.5-78 years); among them, 11 patients had a mean basal calcitonin (CT) level of 9.8 pg/ml (2-24) after 53 months of follow-up. One patient had been operated on for phaeochromocytoma (PHEO), and their CT level remained normal for 262 months.nnnCONCLUSIONSnThis study confirms that RET 790 mutation is associated with a non-aggressive form of multiple endocrine neoplasia type 2, as 28% of the patients were followed up without thyroidectomy, 25% had been thyroidectomised with no tumour being detected and even patients with MTC had slow-evolving disease. Moreover, only one patient had PHEO, and no-one had primary hyperparathyroidism.

Socioeconomic deprivation remains a significant barrier in the choice of bariatric surgery even when full medical expense coverage is present

BACKGROUNDnThe prevalence of obesity is increasing in the socioeconomically deprived sector of the French population.nnnOBJECTIVESnOur objective was to assess whether the presence of a socioeconomic gradient could affect access to bariatric surgery in a publicly funded healthcare system with full medical expense coverage.nnnSETTINGnThe study was conducted at a general hospital and a health examination center.nnnMETHODSnWe prospectively included 100 patients who were admitted to the hospital for a preoperative bariatric surgery evaluation. As a reference group, we included 578 patients from the same area with body mass index (BMI) values≥35 kg/m² who visited the health center for regular medical, cardiovascular checkups. The patients were required to complete the Evaluation of Precariousness and Health Inequalities in Health Examination Centers (EPICES) questionnaire to investigate deprivation (deprivation cutoff≥30.17).nnnRESULTSnA total of 94 patients had complete data, with a mean EPICES score of 37.7±19.1 (P<.001). Patients were younger (mean age 39.2±12.7 years, P<.001), had a stronger female predominance (87%, P = .030), and higher mean BMI (43.3±6.9 kg/m², P<.001) than the reference group and were less socioeconomically deprived (64% versus 82% in the reference group, P<.001). No significant correlations existed among BMI, participant age, and deprivation score. In a subsequent age- and BMI-matched analysis, bariatric surgery candidates exhibited lower levels of deprivation.nnnCONCLUSIONSnThe presence not only of material (e.g., coverage for medical expenses) but also social support is an important step toward the acceptance of bariatric surgery by morbidly obese patients.

Change of appetite in patients with Functional digestive Disorder. Association with psychological disorders: a cross-sectional study.

Changes in appetite are a frequent complaint in patients with functional gastrointestinal disorders (FGIDs). The aims of this study are to evaluate whether the changes in appetite are associated with specific FGIDs and to explore associations of these changes with symptoms of anxiety or depression.

Ketosis prone diabetes presenting as fulminant type 1 diabetes

Patients with ketosis prone diabetes have been reported primarily in Africans and African Americans. At presentation, both insulin secretion and insulin action are impaired in ketosis prone diabetes patients. Fulminant diabetes is a subtype of type 1 diabetes reported mainly in the Asian populations characterized by diabetic ketosis or ketoacidosis occurring soon after the onset of hyperglycemic symptoms with inappropriately low HbA1c (< 8.5%). We report here the first case of a ketosis prone diabetes presenting as fulminant diabetes.

Long-term Effects of Nutrition Education in Bariatric Surgery Patients

Dear editor, Taube-Schiff et al. have provided significant data for an important topic in morbid obesity that is the evaluation of nutrition knowledge after bariatric surgery [1]. Patients eligible for bariatric surgery completed a questionnaire in order to assess their nutrition knowledge before and 1 month after bariatric surgery. The authors demonstrated that patients who scored significantly higher in terms of nutrition knowledge presented gender differences and lower scores of anxiety and depression. They also found that nutrition knowledge decreased as time increased between nutrition education class and surgery. We think that the 1 month period is a very short term for a nutrition knowledge evaluation after a traumatic and stressful event such as bariatric surgery and can induce a significant bias in the results. The impact would be more important in patients with high levels of anxiety and depression. We think that at least a 3-month evaluation period would be more appropriate. The role of nutritional education is well established in weight loss after bariatric surgery [2, 3], and the effectiveness of bariatric surgery is known to be superior than medical interventions [4]. In France, a national program of nutrition and health was developed (Programme National Nutrition Santé: PNNS) in order to provide simple and adequate nutritional advice to a large part of the population. Patients eligible for bariatric surgery in our department participate in individual and group education sessions with a registered dietitian. The auto questionnaire for the assessment of the achievement of national nutritional goals (NAQAPNNS) was used [5]. In a group of patients with a mean follow-up of 854 days postoperatively (range 143– 1538) [6], the analysis of 144 NAQAPNNS (7 patients with gastric banding, 9 with gastric bypass, and 128 with sleeve gastrectomy) demonstrated positive results after bariatric surgery. Forty-five percent of patients had a mean daily physical activity more than 30 min. All patients had a balanced diet in dairy products, protein, and grain products as recommended. Half of the patients met the recommendations for fruits and vegetables (5 portions a day) while the estimated fat and water consumption was quite lower than the recommendations. The percentage of the mean excess BMI loss was 69.7±26.8 %. In conclusion, the work reported by Dr. Taube-Schiff and colleagues established that dietary knowledge in a very short term after surgery depends on the time that it was received and on psychological factors. Although standardized measures are needed to be developed for evaluating nutritional education, we have showed that this effect can persist on the late postoperative period. This approach can certainly help to improve excess body weight loss, comorbidities, and the quality of life of these patients.

CA-037: Chez l'obèse, l'intolérance au glucose s'accompagne d'une hyperkinésie cardiaque. Rôle de l'hyperactivité sympathique

Objectif Chez lobese le debit cardiaque (DC) est augmente et les alterations autonomes cardio-vasculaires sont frequentes. Le but etait dexaminer linfluence du controle autonome sur DC et la frequence cardiaque (FC) et les intervalles de temps systoliques chez des obeses normotolerants ou intolerants au glucose (NGT ou IGT). Patients et Methodes Nous avons inclus 66 patients obeses normotendus ou hypertendus controles, sans antecedent cardio-vasculaire, separes selon lepreuve de charge orale en glucose en NGT ( n =38) et IGT ( n =28), apparies selon sexe, âge et IMC (38,4±4,1 et 37,4±4,3kg/m 2 ). La pression arterielle peripherique et centrale et la duree dejection ventriculaire gauche (DEVG) ont ete mesurees par tonometrie daplanation (SphygmoCor®), lactivite vagale sympathique et la balance sympatho-vagale cardiaque (HF-FC, LF-FC et LF/ HF-FC) par analyse spectrale des variations de FC (Task Force Monitor®), DC et le volume dejection ventriculaire gauche (VE) et les intervalles de temps systoliques par impedance thoracique. La compliance arterielle totale (TAC=VE/ pression pulsee) a ete calculee. Resultats La pression arterielle etait identique chez NGT et IGT. Sur la population totale, les glycemies a jeun et 2 h apres glucose etaient correlees a LF/HF-FC ( p p p mediane etaient plus jeunes, avaient FC inferieure et LF-FC superieur ( p mediane, les IGT avaient une FC voisine mais DC indexe, VE, TAC et PPE plus eleves ( p Conclusions Les obeses avec une bonne activite vagale ont egalement une bonne activite sympathique. Lintolerance au glucose saccompagne dune hyperkinesie cardiaque, principalement chez les patients avec une bonne activite vagale, probablement favorisee par une plus forte activite sympathique concomitante.

CA-189: Influence de l'activité vago-sympathique sur la fréquence cardiaque et la réponse insulinique à la charge orale en glucose chez les obèses métaboliquement sains

Introduction Nous avons montre que lactivite parasympathique cardiaque est souvent alteree chez les patients obeses non diabetiques et de la meme facon chez les obeses metaboliquement sains. Cette etude avait pour but dexaminer linfluence de lactivite vago-sympathique sur la frequence cardiaque (FC) et la reponse insulinique a lhyperglycemie provoquee orale (HGPO) chez les patients obeses metaboliquement sains. Patients et Methodes Nous avons inclus 24 patients, âges de 34±13 ans, IMC 42,2±6,9kg/m 2 , nayant aucun ou un seul critere du syndrome metabolique en plus dun large tour de taille. Lactivite parasympathique cardiaque (HF-FC) a ete evaluee par analyse spectrale des variations de frequence cardiaque en respiration controlee (Finapress®). Une HGPO (75 g de glucose) a ete realisee. Des index dinsulinosecretion, lindex insulinogenique (IGI = Δinsulinemie (T0-T30)/Δglycemie (T0-T30)) et lindex de disposition orale (DIO = IGI/insuline-mie) ont ete calcules. Les taux seriques dadrenaline et de noradrenaline ont ete mesures. Resultats Les patients ont ete separes en deux groupes selon leur activite para-sympathique a jeun. Les patients ayant une forte activite parasympathique a jeun (HF-FC superieure a la mediane) maintenaient une plus forte activite parasympathique durant lHGPO ( p p =0,002), mais etait plus faible a jeun et durant lHGPO de 10 battements/minute en moyenne chez les patients ayant une forte activite parasympathique ( p =0,03). Les patients avec forte activite parasympathique avaient un DIO plus eleve ( p =0,035). Conclusions Parmi les patients obeses metaboliquement sains, ceux dont lactivite parasympathique est plus forte a jeun conservent cette activite plus elevee apres lingestion de glucose. Ce profil rend compte dune plus faible frequence cardiaque a jeun et apres HGPO et semble contribuer a une meilleure reponse insulinique.