A prospective study of anal symptoms and continence among obese patients before and after bariatric surgery.

BACKGROUND: The effects of bariatric surgery on anal continence are not known. Data about proctologic lesions are very rare and do not include clinical data. The aim of this prospective study was to evaluate anal continence and anal lesions before and after sleeve gastrectomy (SG). METHODS: We prospectively included all patients presenting for bariatric surgery consultation at Bichat-Claude Bernard University Hospital, Paris, France, between 20 April 2015 and 16 December 2017. The patients were evaluated with questionnaires, anorectal manometry and clinical examination before SG (at enrollment) and between 12 and 24 months after (SG). Anal incontinence was defined as a Vaizey score above 4. RESULTS: Of 118 enrolled patients, 98 had SG. The patients were mostly women (n = 99, 84.6%). Median patient age was 45 years (IQR 34-54 years). The median follow-up period after surgery among the 86 patients who completed follow-up was 15 months (IQR 12.5-17.3 months). There was no significant change in the prevalence of anal incontinence after SG (12.8% preoperatively vs 24.4% postoperatively, p = 0.06). The median Vaizey score was 4 (IQR 4-4) both before and after SG (p = 0.1). No patient had de novo anal incontinence but worsening of anal incontinence was noted in 10 patients. Manometry revealed significantly lower median resting pressure (29 mmHg [IQR 22-68 mmHg] vs 22 mmHg [IQR 15-30 mmHg], p = 0.0015) and maximal squeeze pressure (IQR 29-74 mmHg vs IQR 30-60 mmHg, p = 0.0008) after SG. Anismus was more frequent after SG and was associated with constipation and Bristol type 1-2 stool consistency. Quality of life was unchanged. Proctologic lesions were rare and were present in 11 patients (12%) at enrollment and in 2 (2.4%) at follow-up. CONCLUSIONS: SG affected clinical anal continence but not significantly, and manometric measurements for anal pressures were lower postoperatively. Proctologic lesions were rare in this study population.

Long-Term Results After Laparoscopic Adjustable Gastric Banding for Morbid Obesity: 18-Year Follow-Up in a Single University Unit.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) remains one of the most performed bariatric procedures worldwide, but a few long-term studies have been reported often with limited data at time of longest follow-up. We review our 18-year LAGB experience with special regard to weight loss failure and long-term complications leading to band removal. METHODS: We performed 897 LAGB procedures from April 1996 to December 2007: 376 using the perigastric dissection and 521 using the pars flaccida dissection. We performed a retrospective analysis of the data of this consecutive series. Failure was defined as band removal with or without conversion to another procedure or excess weight loss (EWL%) <25 %. RESULTS: There were 120 men and 770 women. Mean age was 39.5 years, and mean BMI was 45.6 kg/m2. Mean follow-up was 14.6 years (range 101-228 months) with 90 % follow-up beyond 10 years. Ten (1.1 %) had early complications and 504 (56 %) late complications. Overall, 374 (41.6 %) bands were explanted for complications, weight regain, or intolerance. Mean 15-year EWL% in patients with band in place was 41.73 %. Over time, band failure rate increases from 18.4 % at 2 years to 43 % at 10 years and more than 70 % beyond 15 years. CONCLUSIONS: Despite good initial results, late complications, weight regain, and intolerance lead to band removal in nearly half of the patients over time. However, given that there is no good information on alternative procedures in the long term and considering its reversibility and safety still has a place in the treatment of morbid obesity for informed and motivated patients.

[Phytosterols and atherosclerosis]. / Phytostérols et athérosclérose.

Phytosterols/stanols (PS) enriched food products have been shown to consistently lower plasma cholesterol levels. The intake of 2g/d of PS decreases LDL-cholesterol by about 10%. With respect to the association of LDL-cholesterol lowering with reduction in the cardiovascular (CV) risk, it is likely that supplementation in PS reduces the incidence of CV disease. In addition, the vast majority of animal studies have shown that oral administration of PS reduces the progression atherosclerosis. However, it has been recently suggested that an increase in PS plasma concentrations may increase CV risk. Evidence to support this hypothesis come mainly from observations in sitosterolemic patients who hyperabsorb PS and cholesterol and display very high levels of PS, which may be associated with a premature atherosclerosis. Some epidemiological studies in non-sitosterolemic subjects have shown a positive correlation between PS plasma levels and coronary heart disease. However, these are observational studies and some of them present major methodological bias. In addition, recent studies with a larger number of subjects have indicated, either an absence or a negative relationship between PS and the incidence of CV disease. The guidelines of several French and international institutions recommend the use of PS enriched food in association with other classical recommendations in hypercholesterolemic subjects. However, further studies are highly encouraged to examine the CV benefit of PS enriched food.

Relationship between alcohol intake, health and social status and cardiovascular risk factors in the Urban Paris-Ile-de-France Cohort: is the cardioprotective action of alcohol a myth?

BACKGROUND/OBJECTIVES: Observational studies document the inverse relationship between cardiovascular disease (CVD) and moderate alcohol intake. However, the causal role for alcohol in cardioprotection remains uncertain as such protection may be caused by confounders and misclassification. The aim of our study was to evaluate potential confounders, which may contribute to putative cardioprotection by alcohol. SUBJECTS/METHODS: We evaluated clinical and biological characteristics, including cardiovascular (CV) risk factors and health status, of 149,773 subjects undergoing examination at our Center for CVD Prevention (The Urban Paris-Ile-de-France Cohort). The subjects were divided into four groups according to alcohol consumption: never, low (30 g/day); former drinkers were analyzed as a separate group. RESULTS: After adjustment for age, moderate male drinkers were more likely to display clinical and biological characteristics associated with lower CV risk, including low body mass index, heart rate, pulse pressure, fasting triglycerides, fasting glucose, stress and depression scores together with superior subjective health status, respiratory function, social status and physical activity. Moderate female drinkers equally displayed low waist circumference, blood pressure and fasting triglycerides and low-density lipoprotein-cholesterol. Alcohol intake was strongly associated with plasma high-density lipoprotein-cholesterol in both sexes. Multivariate analysis confirmed that moderate and low drinkers displayed better health status than did never drinkers. Importantly, few factors were causally related to alcohol intake. CONCLUSIONS: Moderate alcohol drinkers display a more favorable clinical and biological profile, consistent with lower CV risk as compared with nondrinkers and heavy drinkers. Therefore, moderate alcohol consumption may represent a marker of higher social level, superior health status and lower CV risk.

[Lipid profile and cardiovascular risk in patients with rheumatoid arthritis: Effect of the disease and of drug therapy]. / Profil lipidique et risque cardiovasculaire chez les patients atteints de polyarthrite rhumatoïde : influence de la maladie et de la thérapeutique médicamenteuse.

The increased mortality in patients with rheumathoid arthritis (RA) is mainly due to high incidence of cardiovascular (CV) disease. CV morbidity and mortality in RA can be explained by several mechanisms: (1) chronic inflammation, (2) enhanced prevalence of traditional CV risk factors including atherogenic dyslipoproteinemia, (3) a lower use of evidence-based therapy such as statins and (4) chronic treatment for RA such as glucocorticoids. It is difficult to distinguish between the role of pharmacological treatment per se and the severity or duration of the disease since these two parameters are closely interrelated. RA likely influences lipoprotein metabolism leading to quantitative and qualitative alteration of low-density lipoproteins (LDL) and of high-density lipoproteins. Glucocorticoids alter carbohydrate and lipid metabolism. However, by reducing the inflammation level, the net effect on lipid parameters and on the CV risk may be favorable. Data from open follow-up studies would suggest that methotrexate use is associated with a beneficial effect on lipid parameters and with a reduction in the incidence of CV disease. Anti-TNF agents increase LDL-cholesterol in some but not all studies; however the use of anti-TNF agents likely reduce CV risk in patients with RA. The influence of recently developed compounds, anti-CD20, CTLA-4 Ig or anti-IL6 is not well documented. Anti-IL6 seem to increase total and LDL-cholesterol; however these changes are associated with an improvement in the TC/HDL-C ratio.

[Prevalence of sleep apnea in men with metabolic syndrome and controlled hypertension]. / Prévalence et déterminants du syndrome d'apnée du sommeil chez des hommes ayant un syndrome métabolique et une hypertension artérielle contrôlée.

BACKGROUND: Abdominal obesity and high blood pressure (HBP) are known to be associated with sleep apnea syndrome (SAS). Resistant hypertension commonly leads physicians to prescribe a sleep record because the prevalence of SAS is high in patients with resistant hypertension. Data on the prevalence of SAS in patients with treated and controlled hypertension are lacking. Moreover, while the metabolic syndrome (MS) and insulin resistance frequently occur in association with SAS, few studies have evaluated the prevalence of SAS in patients with MS. Epworth sleepiness scale (ESS) is often proposed to identify patients at high risk for sleep disorders and for which a sleep record should be prescribed. The reliability of this test to identify SAS has not been studied in patients with MS. OBJECTIVES: (i) To assess the prevalence of SAS in men with MS, (ii) to study the relationship between controlled hypertension and SAS in patients with MS, (iii) to assess the reliability of the ESS to diagnose SAS in patients with MS. METHODS: Among 135 men hospitalized for MS, the 125 who had no history of SAS were systematically evaluated by a nocturnal polygraphy was systematically performed in the 125 men without known SAS at the admission. An excessive daytime sleepiness was assessed by the ESS. Results of analyses in patients with controlled HBP (<130/85 mmHg with antihypertensive drug(s), n=41) were compared with those in patients with normotension (<130/85 mmHg without treatment, n=32). RESULTS: The prevalence of SAS (apnea-hypopnea index (AHI) >or=15/h) in men with MS was 44% in the whole population, 28.1% in the subgroup of patients with normotension and 61.0% in patients with treated and controlled HBP. A severe SAS (AHI >or=30/h) was respectively present in 6.3% and 34.1% of patients with normotension and controlled HTA (p<0.01). Compared with patients without SAS, those with SAS displayed higher blood pressure and BMI. Logistic regression analysis showed that controlled HTA was a determinant of SAS which persisted after adjustment for BMI. As suggested by the ROC curve, the ESS is not a good tool to identify patients with SAS. With a threshold of 11/24 the positive and negative values of this scale were of 0.20 and 0.47. CONCLUSION: The prevalence of SAS is high in men with MS. The ESS does not identify patients who should undergo a nocturnal record. Because a severe SAS is found in nearly one third of patients with MS and controlled HBP, we suggest that a nocturnal record should be systematically proposed to these patients irrespective of the degree of daytime sleepiness assessed by questionnaires.

HDL-c is a powerful lipid predictor of cardiovascular diseases.

RELATIONSHIP BETWEEN HDL-C AND CARDIOVASCULAR DISEASES: Beyond the role of low-density lipoprotein cholesterol (LDL-c) in the development of atherosclerosis, growing evidence suggest that high-density lipoprotein cholesterol (HDL-c) is a powerful predictor of cardiovascular disease. Indeed, epidemiological, mechanistic and intervention studies suggest that low HDL-c is a major cardiovascular risk factor and that increasing HDL-c plasma levels may be beneficial, particularly in patients with low HDL-c levels. The inverse association between HDL-c concentrations and cardiovascular risk is continuous without threshold value. Thus, any categorical definition of low HDL-c is arbitrary. PROTECTIVE EFFECTS OF HDL: HDL particles are highly heterogeneous in structure and intravascular metabolism. Antiatherogenic properties of HDL include its role in the reverse cholesterol transfer, besides its antioxidant, anti-inflammatory and antiapoptotic activities. WHAT SHOULD CLINICIANS DO?: From a practical point of view, HDL-c should be systematically measured to assess the cardiovascular risk in patients. The first step to consider in subjects with low HDL-c is to look for specific causes and give advice to change inappropriate lifestyle components associated with low HDL-c, such as smoking, lack of physical exercise and overweight. Patients with very low HDL-c need a thorough evaluation by specialist physicians. Statins are associated with a modest increase of HDL-c (5%) while fibrates and nicotinic acid increase HDL-c by 10% and 20% respectively.

[Diabetes prevention in hypertensive patients]. / Prevention du diabète chez l'hypertendu.

Hypertension and type-2 diabetes are frequently observed concomitantly in a same patient. There are possibilities to delay the onset of type-2 diabetes, especially in patients already managed for hypertension. Trials on renin-angiotensin blockers show that compared to other drug therapies, there is a lower incidence of diabetes in patients treated by an ACE-inhibitor or an Angiotensin 11 antagonist and the benefit can be estimated at 22% (relative risk at 0.78 with a confidence interval from 0.74 to 0.83). A higher risk of occurrence of type-2 diabetes is particularly noted in those under beta-blocking therapy combined to diuretics. In ALLHAT, the comparison of a thiazide diuretic, an ACE-inhibitor and a calcium antagonist showed that the incidence of new cases of diabetes was the highest in the diuretic group and the lowest in the ACE-inhibitor group. Hypertensive patients under calcium antagonists presented an incidence in between the two other groups. According to a recent hypothesis, the insulin-resistance decrease as a consequence of renin-angiotensin system blocking is related to the recruitment of pre-adipocytes. The NAVIGATOR and ONTARGET trials will probably confirm the preliminary results obtained in this topic. Their results are expected within the 2 next years.

[New insights and perspectives in the management of dyslipidemia]. / Avancées récentes et perspectives dans le traitement des dyslipidémies athérogènes.

PURPOSE: Recent end point trials of lipid-lowering drugs have shown that patients at very high-risk for coronary disease benefit from treatments that lowers low density lipoprotein cholesterol (LDL cholesterol) plasma levels< or =70 mg/dl and that patients with at least 2 risk factors benefit from LDL cholesterol levels< or =100 mg/dl. Epidemiologic studies have shown that the concentration of high density lipoprotein cholesterol (HDL cholesterol) is a strong, independent, inverse predictor of coronary disease risk. Innovative pharmacological approaches to raise low HDL cholesterol levels are currently of considerable interest, especially for patients with type 2 diabetes or metabolic syndrome. RESULTS: Rosuvastatin has shown superior efficacy in lowering LDL cholesterol, although evidence of clinical benefit is actually lacking. Ezetimibe is a lipid-lowering drug that inhibits absorption of dietary and biliary cholesterol. Its co-administration with statin has given very interesting results. Niacin is the most effective of currently available options for raising HDL cholesterol, although tolerability can be an issue, with serious side effects such as loss of glucose control and liver toxicity. Flushing may occur in 80% of treated patients. Two CETP inhibitors have shown therapeutical efficacy to raise HDL cholesterol, but clinical benefit remains uncertain.

Defective antioxidative activity of small dense HDL3 particles in type 2 diabetes: relationship to elevated oxidative stress and hyperglycaemia.

AIMS/HYPOTHESIS: Elevated oxidative stress, hyperglycaemia, and dyslipidaemia involving low levels of HDL particles are key proatherogenic factors in type 2 diabetes mellitus. We examined the relationship of oxidative stress, and the degree of glycaemia and triglyceridaemia, to antioxidative function of HDL particle subspecies in type 2 diabetes. SUBJECTS AND METHODS: Five HDL subfractions (2b, 2a, 3a, 3b, 3c) were isolated by density gradient ultracentrifugation from well-controlled type 2 diabetic subjects (n=20) and normolipidaemic, non-diabetic controls (n=10). Specific antioxidative activity (capacity to protect LDL from oxidation on a unit particle mass or on a particle number basis), chemical composition and enzymatic activities were measured in each subfraction. Systemic oxidative stress was assessed as plasma levels of 8-isoprostanes. RESULTS: Specific antioxidative activity of small dense HDL3b and 3c particles in diabetic patients was significantly diminished (up to -47%, on a particle mass or particle number basis) as compared with controls. Plasma 8-isoprostanes were markedly elevated (2.9-fold) in diabetic patients, were negatively correlated with both specific antioxidative activity of HDL3 subfractions and plasma HDL cholesterol (HDL-C) levels, and were positively correlated with glycaemia and triglyceridaemia. Paraoxonase 1 activity was consistently lower in diabetic HDL subfractions and was positively correlated with HDL3 antioxidative activity. The altered chemical composition of diabetic HDL3 subfractions (core cholesteryl ester depletion, triglyceride enrichment) was equally correlated with diminished antioxidative activity. CONCLUSIONS/INTERPRETATION: Antioxidative activity of small dense HDL is deficient in type 2 diabetes, is intimately linked to oxidative stress, glycaemia and hypertriglyceridaemia and primarily reflects abnormal intrinsic physicochemical properties of HDL particles.

[Vertical infraclavicular technique of brachial plexus block]. / Vertikale infraklavikuläre Technik zur Plexus-brachialis-Blockade. Eine Methode zur weiteren Optimierung des Blockadeerfolges.

In comparison to preceding infraclavicular methods, vertical infraclavicular blockade of the brachial plexus (VIP), as described by Kilka et al. in 1995, has quickly established itself because of the high success rates and comparatively low risks. Users define the blockade success achieved at around 85 %. However, this figure includes a more or less large number of patients who require supplementary analgesia/sedation and/or sleep induction in addition to pre-medication. Such a combined procedure, VIP plus analgesia/sedation is sometimes problematic e. g. in geriatric patients with a number of additional diseases. This patient group in particular could possibly profit from VIP without additional medication. Based initially on purely clinical observations, the following study reports on a method to improve the success rate of VIP blockade (operability) without additional analgesia and/or sedation. Altogether 499 patients were included in a retrospective study. In 88 patients (Group 1), the method of Kilka et al. was strictly applied. In a second Group (99 patients) the determined puncture site was moved 1 cm laterally. In Group 3 (312 patients), elicitation of a response to stimulation of the fasciculi of the brachial plexus was examined. This was performed by multiple punction, as a rule lateral to the puncture site of Kilka et al. In this group, the total dose of anesthetic (identical in all groups) was divided into 2 - 3 single doses. The pre-operative data of the patients in all groups were comparable. In the course of the VIP (Group 1), the method was changed in 13 patients (14.8 %) with incomplete blockade and after initial modification (Group 2), this was necessary in 12 patients (12.1 %). By means of targeted stimulation of individual sections of the brachial plexus (Group 3), the rate of incomplete blockade could be reduced to 8.3 %. The clearly improved blockade success was achieved without an increase in complications. In contrast to other authors, we came to the conclusion that the success rate was considerably higher when the anaesthetist had several years of experience. In the case of the authors of this study (longest experience), only 3.7 % of the plexus blocks were incomplete. For the use of VIP in practice it can be concluded that the optimal puncture site is often somewhat lateral to that defined by Kilka et al. By means of multiple stimulation with the aim of locating the individual fasciculi of the brachial plexus, the success of blockade, in terms of operability with unchanged low complication rates, can be considerably improved without the need for additional analgesics and/or sedation.

[Perioperative local instillation of ropivacaine for postoperative pain relief after surgery on extremities]. / Perioperative lokale Instillation von Ropivacain zur postoperativen Schmerzreduktion in der Extremitätenchirurgie. Eine prospektiv randomisierte Doppelblindstudie.

INTRODUCTION: The relief of postoperative pain remains one of the most important goals for adequate surgical patient care. METHODS: Prospective, randomised, double-blinded study, including 118 patients (67 M;/ 51 F; median age 43 years, min. 18, max. 74). Two groups were formed. In the verum group a wound instillation with ropivacaine was performed, in the control group not. Intensity of pain, demand for analgesics and satisfaction of the patient were evaluated postoperatively. In 10 patients ropivacaine plasma levels were measured. RESULTS: Significant postoperative pain relief and a decrease in analgesic consumption were found on instillation of ropivacaine. Compared to the control group, patients receiving ropivacaine were significantly more satisfied with the postoperative pain management. Potential toxic plasma levels were not found. CONCLUSION: By the presented method, the surgeon actively contributes to a significant reduction in postoperative pain and analgesic consumption. Furthermore, the patient's benefit is reflected by higher satisfaction with the pain management. Complications due to toxic plasma levels are not seen.

Insufflation. Complications and recommendations.

This article focuses on complications in colonoscopy related to colonic insufflation. Causes of colonic insufflation complications are examined and methods that may be used to minimize complications are proposed. Testing of state-of-the-art video colonoscope systems is the basis of this analysis of insufflation complications and the resulting recommendations.

Expression of factor V on human umbilical vein endothelial cells is modulated by cell injury.

Since human endothelial cells synthesize Factor V but do not secrete it into the medium, we studied the effects of cell injury on the availability of Factor V at the surface of these cells. Human umbilical vein endothelial cells (HUVEC), grown to confluency and incubated with human 125I Factor Va, specifically bound 5000 to 7000 molecules per cell. In the absence of added Va, no antigen was detected on adherent HUVEC with either labeled anti-V(Va) monoclonal or polyclonal IgG. However, exogenous Va, not V, prebound to these cells allows binding of labeled 125I anti-V(Va). Immunodectectibility of bovine Factor V contributed by fetal calf serum in the concentration used in cultures is less than 0.1% of that detected in human plasma. HUVEC, suspended by scraping from dishes, specifically bound 4000 molecules/cell of 125/I monoclonal IgG against V(Va). Although undisturbed cells excluded trypan blue, dye uptake by many of the suspended HUVEC indicated cell injury. Quantitation of injury by 51Cr release after scraping followed by multiple passages through an 18 g needle showed that 51Cr release increased with number of manipulations up to 60% and was observed almost immediately after manipulation. We suggest that little Factor V(Va) is present on the surface of intact adherent HUVEC. However, mechanical injury to HUVEC released or exposed endogenous Factor V(Va), resulting in expression of V that might mediate Factor Xa binding as well as activation of protein C by thrombin. Thus, injured, but not intact, HUVEC could participate in both promoting and limiting blood coagulation.

Preliminary studies of the histopathological responses to Ti-13% Cu casting alloys.

A preliminary study of some of the biological properties of a new dental casting alloy (Ti-13% Cu) was undertaken by employing the skeletal muscle implantation test in rabbits. Routine histopathological and chemical analysis techniques were utilized to study in vivo tissue reactions of skeletal muscle to this alloy. A moderately thick, somewhat cellular fibrous connective tissue capsule surrounded the implants after 2 wk. Remodelling of the fibrous tissue into a thin acellular tissue capsule occurred at 52 wk after implantation. Chemical analyses failed to detect deposition of either Ti or Cu corrosion products at the implant sites or within major organs.

Regulation of enzymes by fatty acyl coenzyme A. Interactions of short and long chain spin-labeled acyl-CoA with the acetyl-CoA site on pig heart citrate synthase.

The binding of two similar spin-labeled fatty acyl-CoA analogues, one short chain, 6-doxyloctanoyl-CoA (S-(2-(5-carboxybutyl)-2-ethyl-4, 4-dimethyl-3-oxazolidinyl-N-oxyl)-CoA) and one long chain, 6-doxylstearoyl-CoA (S-(2-(5-carboxybutyl)-2-dodecyl-4, 4-dimethyl-3-oxazolidinyl-N-oxyl)-CoA) to pig heart citrate synthase (citrate oxaloacetate-lyase (pro-3S-CH2COO- leads to acetyl-CoA) EC 4.1.3.7) has been compared. The binding of the short chain analogue could be satisfactorily fit by a classical treatment (independent, noninteracting sites) with well defined stoichiometry: 2 mol of spin label bound per mol of dimeric enzyme. Binding of the long chain analogue was complex and in excess of 2 mol/dimer. Competitive binding experiments using either analogue in the presence of various nucleotides and substrates revealed differences in the binding of the long and short chain analogues. These additional studies, together with kinetic measurements, implied isosteric binding of acyl-CoA, ATP, NADPH, NADH, NADP+, acetyl-CoA, and partial isosteric binding of the long chain acyl-CoA. Binding of NADPH and NADP+ to the same form of the enzyme, perhaps through overlapping sites, was kinetically verified even though these nucleotides had differing effects on the binding of the spin-labeled analogues. Oxalacetate was shown to decrease the binding of the long chain analogue but to have no effect on the binding of the short chain. This result was supported by kinetic measurements. The competitive binding experiments with the long chain analogue suggested that its complex isotherm resulted from binding in two classes of sites, i.e. two cooperative nucleotide sites and other sites. An empirical mathematical model employing this rationale provided a satisfactory fit for the binding of fatty acyl-CoA to citrate synthase. A spin-labeled fatty acid which was not bound by the native enzyme was appreciably bound in the presence of additional palmitoyl-CoA. This binding might be identified with one of the two sets of binding sites proposed in the model. These and previous results on acyl-CoA binding were correlated with the properties of the CoA binding site defined crystallographically (Remington, S., Wiegand, G., and Huber, R. (1982) J. Mol. Biol. 158, 111-152).