[Surgical procedures for severely obese patients: impact and long-term results]. / Chirurgische Verfahren bei krankhafter Adipositas. Stellenwert und Langzeitergebnisse.

Obesity is a multifactorial, genetically-determined, neuroendocrine, and chronic condition. Conservative treatment of patients with class II and III obesity (BMI >35 kg/m(2)) has only modest long-term success. Surgical procedures have been used since 1954, and the methods used are continually being updated and improved. With experienced surgeons, patients can achieve a weight reduction from around 50% with purely restrictive procedures, increasing to 75% with combined restrictive-malabsorptive methods. All weight-loss methods offer a considerable improvement or elimination of obesity-related co-morbidities and substantially improvement of quality of life. Well-documented, long-term studies reveal a perioperative mortality of 0.2-1.0%, dependent on the surgeon's experience, and a maximum perioperative morbidity of 20%. Bariatric surgery is accepted as evidence based, safe and effective treatment of obesity.

Conservative management of intragastric migration of Swedish adjustable gastric band by endoscopic retrieval.

BACKGROUND: Intragastric migration is a known complication of gastric banding for morbid obesity. METHODS: Instead of immediate reoperation, complete migration of the Swedish Adjustable Gastric Band (SAGB) into the gastric lumen was awaited in 4 patients who were asymptomatic. RESULTS: After completed migration, the episternally placed access port was removed with the patient under local anesthesia, and the disconnected adjustable band was retrieved endoscopically. All 4 patients underwent rebanding with SAGB within 3 months after extraction. CONCLUSIONS: With this procedure, patients who are asymptomatic can be spared laparotomy and possibly gastrostomy.

[Effect of controlled reconditioning training on performance and mood in patients after aortocoronary bypass operation]. / Einfluss eines kontrollierten Rekonditionstrainings auf Leistungsentwicklung und Psyche bei Patienten nach aortokoronarer Bypassoperation.

The cardiovascular rehabilitation after coronary artery bypass surgery (CABS) is carried out in different intensities and intervals after the intervention in an inpatient or outpatient manner. Studies, which prospectively evaluate the influence of such programs concerning the physical and the psychological status are missing. The following questions were therefore pursued in the present prospective study (66 patients with recently performed myocardial revascularisation): 1. Is it possible by a controlled, regular physical training to normalize the functional capacity in patients after CABS in comparison with a healthy, not specially trained control collective? 2. Do psychological factors and/or age, sex and postoperative anaemia influence the recovery of the reduced functional capacity after the intervention? To answer these questions 66 patients were enrolled 16 +/- 1 days after CABS in a controlled, inpatient average three week-rehabilitation program. During this program the functional capacity of the patients doubled, however without reaching the values of the normal collective. Furthermore, physical and psychological wellbeing and disability as well as the initially mentioned feelings of despondency normalized in men and women. The improvement of fitness during the rehabilitation program was mainly dependent on the improvement of the social integration in women, whereas it correlated with the increase of the physical and psychological well-being in men. Moreover, only in the male patient group the correction of anaemia was an important factor. Age, sex and the preoperative left ventricular function didn't have any effect on the rapidity of recovery after the operation. In summary patients (aged between 30 and 75) of both sexes can already be enrolled in a regular training program two weeks after CABS, leading to a good recovery of their physical and psychological capacity.

Treatment of morbid obesity with the Swedish adjustable gastric band (SAGB): complication rate during a 12-month follow-up period.

BACKGROUND: The Swedish adjustable gastric band (SAGB) is used to treat morbid obesity. However, no quantitative data are available describing the follow-up of these patients with respect to the frequency and the complication rate of inflating and deflating the adjustable system. METHODS: We prospectively investigated 207 morbidly obese patients. All patients completed 12 months of follow-up and were seen in intervals of 1 to 3 months on an outpatient basis. RESULTS: A total of 207 patients had 1692 consultations (8.3 +/- 2.4 consultations per patient per year [mean +/- SD]), 920 port-a-cath punctions (4.6 +/- 2.0), 820 inflations (4.1 +/- 1.6), and 100 deflations (1.4 +/- 0.6). Complications related to the port-a-cath (n = 6, 2.9% of all patients) were 1 leakage of the tube (0.5%), 2 disconnections of the connecting tube (1.0%), and 3 reimplantations of the port-a-cath as a result of discomfort (1.4%). Complications related to the SAGB (n = 10, 4.8%) were 6 leakages of the band (2.9%), 2 penetrations (1.0%), 1 intraoperative perforation of the esophagus (0.5%), and 1 dystopically implanted SAGB (0.5%). Additionally, 9 minor early postoperative wound infections (4.3%) were recorded. CONCLUSIONS: Follow-up can be safely performed on an outpatient basis after implantation of a SAGB without infectious and other minor complications directly linked to the filling procedure.

Is bariatric surgery worth its costs?

Formal economic evaluations of obesity surgery have not been reported in the medical literature to date. In this article, we briefly review the most important types of health economic evaluations, namely cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Bariatric surgery has the potential to substantially impact quality of life, morbidity, and mortality costs in patients with morbid obesity. Health economic studies that include these effects are needed.

Effects of deflazacort versus prednisone on bone mass, body composition, and lipid profile: a randomized, double blind study in kidney transplant patients.

To compare the effects of deflazacort (DEFLA) vs. prednisone (PRED) on bone mineral density (BMD), body composition, and lipids, 24 patients with end-stage renal disease were randomized in a double blind design and followed 78 weeks after kidney transplantation. BMD and body composition were assessed using dual energy x-ray absorptiometry. Seventeen patients completed the study. Glucocorticosteroid doses, cyclosporine levels, rejection episodes, and drop-out rates were similar in both groups. Lumbar BMD decreased more in PRED than in DEFLA (P < 0.05), the difference being particularly marked after 24 weeks (9.1 +/- 1.8% vs. 3.0 +/- 2.4%, respectively). Hip BMD decreased from baseline in both groups (P < 0.01), without intergroup differences. Whole body BMD decreased from baseline in PRED (P < 0.001), but not in DEFLA. Lean body mass decreased by approximately 2.5 kg in both groups after 6-12 weeks (P < 0.001), then remained stable. Fat mass increased more (P < 0.01) in PRED than in DEFLA (7.1 +/- 1.8 vs. 3.5 +/- 1.4 kg). Larger increases in total cholesterol (P < 0.03), low density lipoprotein cholesterol (P < 0.01), lipoprotein B2 (P < 0.03), and triglycerides (P = 0.054) were observed in PRED than in DEFLA. In conclusion, using DEFLA instead of PRED in kidney transplant patients is associated with decreased loss of total skeleton and lumbar spine BMD, but does not alter bone loss at the upper femur. DEFLA also helps to prevent fat accumulation and worsening of the lipid profile.

Differential impact of conventional oral or transdermal hormone replacement therapy or tibolone on body composition in postmenopausal women.

OBJECTIVE: To compare the effects on body composition and body weight of tibolone vs two different sequential oral or transdermal oestrogen-progestogen hormone replacement therapies versus no therapy. PATIENTS AND METHODS: One hundred postmenopausal women were assigned to a control group (n = 26), or randomized to 1) tibolone (TIB) 2.5 mg/day (n = 28), 2) oral oestradiol 2 mg/day (PO) plus sequential dydrogesterone 10 mg/day for 14 of 28 days per cycle (n = 26), or 3) transdermal oestradiol patch (TTS) releasing 50 micrograms/day plus oral sequential dydrogesterone 10 mg/day for 14 of 28 days per cycle (n = 20). Body composition was measured at the base-line and every 6 months for 2 years by DXA (Hologic QDR 1000 W). RESULTS: Total body fat mass increased (P < 0.05) in controls (+3.6 +/- 1.5%) and in TTS treated (+4.7 +/- 2.2%), but not in PO (-1.2 +/- 2.4%) and TIB (-1.6 +/- 2.2%) treated subjects. This increase in total fat mass in controls and TTS treated women was mostly due to an increase in fat mass of the trunk (P < 0.05), but not legs. As a result, a redistribution of body fat to the trunk occurred in controls, TTS and TIB, but not in PO treated women (P < 0.05). Total lean body mass decreased (P < 0.02) in controls (-1.7 +/- 0.7%) and PO (-1.4 +/- 0.6%) but not in TTS (+0.3 +/- 0.8%) and TIB (+0.4 +/- 0.5%) treated subjects. CONCLUSIONS: The menopause is associated with an increase in total body fat and a decline in lean body mass. Oral oestradiol/dydrogesterone and tibolone prevent total body fat changes, whereas transdermal oestradiol/oral dydrogesterone and tibolone prevent the lean mass changes. Furthermore, oral oestradiol/dydrogesterone prevents the shift to a central, android fat distribution.

Antibody studies in a patient with acute thrombocytopenia following infusion of plasma containing anti-PI(A1).

Immune thrombocytopenia due to passive transfer of anti-PI(A1) alloantibody has been noted as a rare but potentially dangerous complication of plasma transfusions. We report a patient with a preoperative platelet count of 241 x 10(9)/l who developed severe thrombocytopenia within 2 hr following transfusion of 2 U of fresh frozen plasma. The plasma donor was found to be a PI(A1)-negative woman. The platelet count of the PI(A1)-positive patient recovered within 7 days to normal values. In the frozen plasma, excessive antibody binding to GPIIb-IIIa on the recipient's platelets was detected. The antibody was shown to have anti-PI(A1)-specificity. Only 40 min after transfusion of the frozen plasma, no antibody was detected in the plasma of the recipient. This case suggests that passively administered anti-PI(A1) alloantibody is immediately adsorbed onto the recipient's platelets and thus removed from circulation.

Effect of sex and age on bone mass, body composition and fuel metabolism in humans.

The mechanism(s) governing the gain of upper-body fat and its relationship to the decrease in bone mass with age is still unclear. Therefore, four groups of subjects matched for weight, height, and body mass index (n = 119; 60 women, 59 men), but differing in age (above and below 50 y) and sex were investigated using dual energy x-ray absorptiometry (DXA) to assess body composition (bone, lean, and fat mass as well as its distribution) and indirect calorimetry to determine resting fuel metabolism. Fat mass of trunk and arms (P < 0.01), but not legs, increased with advancing age in males, resulting in a continuous increase in the ratio of upper- to lower-body fat (r = 0.45, P < 0.001). In contrast, total fat mass remained stable in women, irrespective of menopause, but a redistribution of fat occurred with advancing age (r = 0.43, P < 0.001), resulting in a higher upper- to lower-body fat ratio (P < 0.05) in older than in younger women. Total lean soft-tissue mass of all segments of the body was greater in men than in women irrespective of age (P < 0.001), and lower in the older groups than in the younger ones irrespective of sex. In males, but not females, lean soft-tissue mass in arms and legs decreased (r = 0.57, P < 0.001), whereas the ratio of total fat to lean soft-tissue mass increased (r = 0.53, P < 0.001) with age. Bone mineral content correlated with total body fat in both groups of women and in young males (r > 0.5, P < 0.001), but not in older males. With advancing age, the proportion of lean soft-tissue mass occupied by total skeleton declined in women (n = 59, P < 0.001), but remained stable in males. Resting energy expenditure decreased with age in both sexes. Protein and carbohydrate oxidation were similar in all four groups of subjects. Total fat oxidation and fat oxidation per kilogram of lean soft-tissue mass decreased with age (r > 0.36, P < 0.01) in males, but not in females, whereas it increased with increasing fat mass in females (r > 0.32, P < 0.03), but not in males. In contrast, fat oxidation per kilogram of fat mass decreased with fat mass in males (r = 0.61, P < 0.001), but not in females. Our results suggest that aging affects body composition and fuel metabolism differently in each gender, leading to reduced fat oxidation and accumulation of upper-body fat with loss of striated muscle in men, and to an increased ratio of upper- to lower-body fat and bone loss in women, the latter depending on fat mass.

Six-month overnight administration of intraperitoneal amino acids does not improve lean mass.

UNLABELLED: Intraperitoneal administration of 1% amino acid dialysis solution in patients on continuous peritoneal dialysis (CAPD) is associated with improvement in plasma amino acid concentrations and inconsistent results with respect to nitrogen balance. Whether alteration(s) in lean mass and body fat distribution also occur remains controversial. Therefore 18 patients (P), on CAPD for at least 6 months, were assigned in a prospective and controlled fashion to receive overnight either a 1% amino acid (AA-P) or a 1.36% glucose (Glu-P) containing dialysis solution. Body composition was investigated using whole body dual energy X-ray absorptiometry (Hologic QDR 1000/W). In P receiving glucose (n = 9), total body fat mass increased (+1.0 +/- 0.4 kg, mean +/- SEM, p < 0.03), whereas in patients on amino acids (n = 9), it decreased (-0.6 +/- 0.3, p < 0.02). This decrease in fat mass in AA-P was attributable to a decrease in upper body fat (-0.6 +/- 0.2, p < 0.02), whereas in Glu-P, it increased (+0.9 +/- 0.03, p < 0.03). No change in lower body fat was observed in either group. Total body lean mass remained similar in both groups during the six months of study (AA-P: 46.6 +/- 2.9 kg vs 47.0 +/- 3.0 kg, Glu-P 50.8 +/- 3.2 vs 50.1 +/- 2.2 kg baseline vs 6 months, respectively). In AA-P plasma urea concentrations increased from 25 +/- 2 to 34 +/- 3 mmol/l (p < 0.05), whereas plasma bicarbonate concentrations were similar before and after 6 months of therapy in either group. Plasma albumin and transferrin concentrations did not change in either group. Protein catabolic rate increased in AA-P (p < 0.01), whereas K x t/V did not change as a consequence of either therapy. CONCLUSION: Reduction in the amount of glucose in the peritoneal dialysate and the addition of amino acids decreases, whereas continuous dialysis with overnight glucose increases upper body fat over a 6-month period. However, no changes in protein stores were observed with the addition of amino acids. Therefore overnight peritoneal dialysis with amino acids offers minor advantages to protein-malnourished patients on CAPD, but may be of benefit in overweight CAPD patients.

Effect of regular physical training on age-associated alteration of body composition in men.

Body composition changes with increasing age in men, in that lean body mass decreases whereas fat mass increases. Whether this altered body composition is related to decreasing physical activity or to the known age-associated decrease in growth hormone secretion is uncertain. To address this question, three groups of healthy men (n = 14 in each group), matched for weight, height and body mass index, were investigated using dual-energy X-ray absorptiometry, indirect calorimetry and estimate of daily growth hormone secretion [i.e. plasma insulin-like growth factor I (IGF-I-) levels]. Group 1 comprised young untrained subjects aged 31.0 +/- 2.1 years (mean +/- SEM) taking no regular physical exercise; group 2 consisted of old untrained men aged 68.6 +/- 1.2 years; and group 3 consisted of healthy old men aged 67.4 +/- 1.2 years undergoing regular physical training for more than 10 years with a training distance of at least 30 km per week. Subjects in group 3 had for the past three years taken part in the 'Grand Prix of Berne', a 16.5-km race run at a speed of 4.7 +/- 0.6 min km-1 (most recent race). Fat mass was more than 4 kg higher in old untrained men (P < 0.01, ANOVA) than in the other groups (young untrained men, 12.0 +/- 0.9 kg; old untrained men, 16.1 +/- 1.0 kg; old trained men, 11.0 +/- 0.8 kg), whereas body fat distribution (i.e. the ratio of upper to lower body fat mass) was similar between the three groups. The lean mass of old untrained men was more than 3.5 kg lower (P < 0.02, ANOVA) than in the other two groups (young untrained men, 56.4 +/- 1.0 kg; old untrained men, 52.4 +/- 1.0 kg; old trained men, 56.0 +/- 1.0 kg), mostly because of a loss of skeletal muscle mass in the arms and legs (young untrained men, 24.0 +/- 0.5 kg; old untrained men 20.8 +/- 0.5 kg; old trained men, 23.6 +/- 0.7 kg; P < 0.01, ANOVA). Resting metabolic rate per kilogram lean mass decreased with increasing age independently of physical activity (r = -0.42, P < 0.005). Fuel metabolism was determined by indirect calorimetry at rest. Protein oxidation was similar in the three groups. Old untrained men had higher (P < 0.001) carbohydrate oxidation (young untrained men, 13.2 +/- 1.0 kcal kg-1 lean mass; old untrained men, 15.2 +/- 1.3 kcal Kg-1; old trained men, 7.8 +/- 0.8 kcal kg-1), but lower (P < 0.05, ANOVA) fat oxidation (young untrained men, 10.1 +/- 1.2 kcal kg-1 lean mass; old untrained men, 6.5 +/- 1.0 kcal kg-1; old trained men, 13.7 +/- 1.0 kcal kg-1) than the other two groups. Mean plasma IGF-I level in old trained men was higher than in old untrained men (P < 0.05), but was still lower than that observed in young untrained men (P < 0.005) (young untrained men, 236 +/- 24 ng mL-1; old untrained men, 119 +/- 13 ng mL-1; old trained men, 166 +/- 14 ng mL-1). In summary, regular physical training in older men seems to prevent the changes in body composition and fuel metabolism normally associated with ageing. Whether regular physical training in formerly untrained old subjects would result in similar changes awaits further study.

Evidence for preservation of cortical bone mineral density in patients on continuous ambulatory peritoneal dialysis.

It is still unclear whether dialysis modality, i.e., continuous ambulatory peritoneal dialysis (CAPD) versus hemodialysis (HD) specifically affects bone mineral density (BMD). To answer this question, 34 patients on HD and 25 on CAPD were matched for age, sex, height, and body weight with 125 normal subjects. BMD was measured using dual-energy X-ray absorptiometry (DXA; Hologic QDR 1000/W) at the lumbar spine (trabecular bone), the femoral neck (mixed cortical and trabecular bone), the distal tibial diaphysis (cortical bone), and the epiphysis (trabecular bone) in all subjects. No significant difference for blood hemoglobin, albumin, total and ionized calcium, intact parathyroid hormone (PTH) or phosphorus concentrations, as well as for alkaline phosphatase activity, failed renal allograft, prior steroid therapy, prior parathyroidectomy, duration of uremia, or of dialysis was found between patients on HD and those on CAPD. However, the residual daily urine volume and renal function at the time of the absorptiometry were higher in CAPD than in HD patients (p < 0.05) as well as the mean dialysate calcium concentration during dialysis, the blood bicarbonate concentration, and the residual renal function at the initiation of dialysis (p < 0.01, p < 0.05, and p < 0.005, respectively). In contrast, the total dose of calcium carbonate was lower in CAPD than in HD patients (p < 0.01). Results of BMD were expressed as Z scores (the number of standard deviations from the appropriate mean of BMD of 623 healthy subjects adjusted for age and sex). At the lumbar spine, no significant difference with respect to BMD was observed between the three groups. At the femoral neck and tibial epiphysis, HD patients had lower BMD (p < 0.001) than normal controls, whereas no difference was observed between HD and CAPD patients. At tibial diaphysis, patients on HD had lower BMD (p < 0.001) than patients on CAPD and than normal controls, with the values being similar in patients on CAPD and in normal controls. The results remained identical after exact matching of HD (n = 25) and CAPD (n = 25) patients for dialysis duration (1.9 +/- 0.3 and 1.7 +/- 0.3 years, respectively). Multiple regression analysis revealed significant negative correlations between Z scores at the lumbar spine (p < 0.05), femoral neck (p < 0.02), tibial diaphysis (p < 0.005), and tibial epiphysis (p < 0.05) on the one hand and plasma alkaline phosphatase activity on the other. The Z score at tibial diaphysis was also correlated with residual renal function at the initiation of dialysis (p < 0.05). In conclusion, this study provides evidence for the preservation of cortical bone with CAPD as opposed to HD. The higher residual renal function observed in the former treatment modality might account, at least in part, for this finding.

Body composition and fuel metabolism after kidney grafting.

Kidney transplant patients display decreased muscle mass and increased fat mass. Whether this altered body composition is due to glucocorticoid induced altered fuel metabolism is unclear. To answer this question, 16 kidney transplant patients were examined immediately after kidney transplantation (12 +/- 4 days, mean +/- SEM) and then during months 2, 5, 11 and 16, respectively, by whole body dual energy X-ray absorptiometry (Hologic QDR 1000W) and indirect calorimetry. Results were compared with those of 16 age, sex and body mass index matched healthy volunteers examined only once. All patients received dietary counselling with a step 1 diet of the American Heart Association and were advised to restrict their caloric intake to the resting energy expenditure plus 30%. Immediately after transplantation, lean mass of the trunk was higher by 7 +/- 1% (P < 0.05) and that of the limbs was lower by more than 10% (P < 0.01) in patients than in controls. In contrast, no difference in fat mass and resting energy expenditure could be detected between patients and controls. During the 16 months of observation, total fat mass increased in male (+4.9 +/- 1.5 kg), but not in female patients (0.1 +/- 0.8 kg). The change in fat mass observed in men was due to an increase in all subregions of the body analysed (trunk, arms+legs as well as head+neck), whereas in women only an increase in head+neck by 9 +/- 2% (P = 0.05) was detected. Body fat distribution remained unchanged in both sexes over the 16 months of observation. Lean mass of the trunk mainly decreased between days 11 and 42 (P < 0.01) and remained stable thereafter. After day 42, lean mass of arms and legs (mostly striated muscle) and head+neck progressively increased over the 14 months of observation by 1.6 +/- 0.6 kg (P < 0.05) and 0.4 +/- 0.1 kg (P < 0.01), respectively. Resting energy expenditure was similar in controls and patients at 42 days (30.0 +/- 0.7 vs. 31.0 +/- 0.9 kcal kg-1 lean mass) and did not change during the following 15 months of observation. However, composition of fuel used to sustain resting energy expenditure in the fasting state was altered in patients when compared with normal subjects, i.e. glucose oxidation was higher by more than 45% in patients (P < 0.01) during the second month after grafting, but gradually declined (P < 0.01) over the following 15 months to values similar to those observed in controls. Protein oxidation was elevated in renal transplant patients on prednisone at first measurement, a difference which tended to decline over the study period. In contrast to glucose and protein oxidation, fat oxidation was lower in patients 42 days after grafting (P < 0.01), but increased by more than 100% reaching values similar to those observed in controls after 16 months of study. Mean daily dose of prednisone per kg body weight correlated with the three components of fuel oxidation (r > 0.93, P < 0.01), i.e. protein, glucose and fat oxidation. These results indicate that in prednisone treated renal transplant patients fuel metabolism is regulated in a dose-dependent manner. Moreover, dietary measures, such as caloric and fat intake restriction as well as increase of protein intake, can prevent muscle wasting as well as part of the usually observed fat accumulation. Furthermore, the concept of preferential upper body fat accumulation as consequence of prednisone therapy in renal transplant patients has to be revised.

Impact of chronic cigarette smoking on body composition and fuel metabolism.

Cigarette smoking has been associated with increased upper body fat deposition, as estimated by the waist to hip ratio, which has been shown to be associated with glucose intolerance and dyslipidemia in nonsmoking subjects. Whether smoking is at the origin of central adiposity and its related metabolic disturbances is unclear. Moreover, it is controversial whether smoking influences fuel metabolism. Therefore, young healthy male volunteers smoking more than 10 cigarettes/day for more than 5 yr (n = 14) were compared with nonsmokers (n = 13) matched for age, sex, body mass index, alcohol consumption, physical activity, as well as family history for hypertension, diabetes, obesity, and coronary heart disease. After an overnight fast, blood was drawn for chemistry, body composition was assessed by dual energy x-ray absorptiometry, and fuel metabolism was determined by indirect calorimetry. Nicotine uptake was estimated by 24-h urinary excretion of cotinine. Lean and fat body mass as well as their respective segmental distribution (i.e. arms, trunk, legs, and head), total bone mineral content, resting energy expenditure, and fat, carbohydrate, and protein oxidation were similar between smokers and nonsmokers. In contrast, 24-h urinary cotinine excretion (72.0 +/- 11.4 vs. 0.8 +/- 0.2 mumol/L.24 h; P < 0.001), plasma glucose (4.62 +/- 0.09 vs. 4.25 +/- 0.1 mmol/L; P < 0.01), total cholesterol (4.87 +/- 0.15 vs. 4.27 +/- 0.16 mmol/L; P < 0.02), low density lipoprotein cholesterol (3.05 +/- 0.19 vs. 2.43 +/- 0.16 mmol/L; P < 0.02), and apolipoprotein B concentrations (1.09 +/- 0.11 vs. 0.83 +/- 0.03 mmol/L; P < 0.03) were all higher in smokers than in nonsmokers. In smokers, 24-h urinary cotinine excretion positively correlated with the waist to hip ratio (r = 0.58; P = 0.03) and negatively with hip circumference (r = 0.87; P < 0.001). Moreover, 24-h cotinine excretion positively correlated with fat oxidation (r = 0.57; P = 0.03), but was independent of the other metabolic parameters studied. These results suggest that the dyslipidemia and glucose intolerance observed in smokers are not related to either central obesity or the amount of nicotine inhaled, but, rather, are due to some other component in cigarette smoke. In contrast, in smokers, fat oxidation increases with increasing nicotine uptake, a fact that might account for the often observed weight gain after cessation of smoking, thus suggesting different mechanisms of action of tobacco consumption on cholesterol and glucose metabolism on one side and fat oxidation on the other.

Altered parathyroid gland function in severely immunocompromised patients infected with human immunodeficiency virus.

Several endocrine functions have been found disturbed in patients with acquired immunodeficiency syndrome (AIDS). However, no information is available on parathyroid function in these patients. Six patients with AIDS and 10 healthy volunteers underwent an EDTA infusion to induce hypocalcemia and stimulate PTH secretion. A group of 6 severely ill patients with malignancies was studied at baseline and served as additional controls for the effect of a severe disease per se. Baseline values showed that mean serum intact PTH concentration was lower in patients infected with the human immunodeficiency virus than in healthy volunteers (P < 0.04) as well as in patients with malignancies (P = 0.004). Whole blood calcium also tended to be lower in patients with the human immunodeficiency virus than in both control groups, the difference reaching the limit of statistical significance for the healthy controls only (P < 0.04). Mean serum magnesium, 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D concentrations were similar in both groups. Throughout the entire EDTA stimulation procedure, i.e. at any blood calcium concentration, serum intact PTH concentration remained lower in patients with AIDS than in healthy control subjects (P < 0.04, analysis of variance for repeated measurements). Basal and maximal secretion of PTH is reduced in patients with AIDS. The mechanisms underlying this finding remain speculative.

Altered body composition and fuel metabolism in stable kidney transplant patients on immuno-suppressive monotherapy with cyclosporine A.

Glucocorticoid associated altered body fat distribution and muscle wasting are well known following kidney grafting. Whether an immunosuppressive regimen after glucocorticoid withdrawal (i.e. monotherapy with cyclosporine A (CsA)) is associated with normalization of altered body fat distribution and muscle mass remains to be determined. Therefore 18 renal transplant patients (nine males and nine females, 64 +/- 5 (mean +/- SEM) months since transplantation; CsA-monotherapy: 38 +/- 7 months) and 18 age, sex and body mass index matched healthy volunteers were investigated using indirect calorimetry and dual energy X-ray absorptiometry. Lean body mass (LBM) was decreased in patients mostly due to loss of striated muscle in the legs (P < 0.01). Compared to healthy controls, fat mass was increased in head and trunk (P < 0.01) and similar in extremities. Resting energy expenditure expressed per kg LBM was increased by more than 10% (P < 0.05) in patients vs. controls. Plasma insulin and glucose concentrations, total serum cholesterol (C), triglyceride levels and the ratio of LDL-C to HDL-C were all elevated (P < 0.01) in patients as compared with controls. In summary, renal transplant patients on immunosuppressive monotherapy with CsA demonstrate decreased muscle mass despite discontinuation of prednisone therapy. The increased upper body fat might account, at least in part, for peripheral hyperinsulinaemia and dyslipidaemia observed in kidney transplant patients even years after successful transplantation.

Changes in bone mass early after kidney transplantation.

Renal transplant patients exhibit increased rates of trabecular bone fractures, probably due to glucocorticoid-induced osteopenia, which is known to occur within 6 months after kidney grafting. This mineral loss at a mostly trabecular site (lumbar spine) contrasts with a gain at the radius, which consists mainly of cortical bone. However, the early effects of kidney transplantation on the other parts of the human skeleton and the time course of these changes during the first 5 months after transplantation remain unknown. Therefore, 34 kidney transplant recipients were prospectively followed immediately after kidney grafting (12 +/- 1 days, mean +/- SEM, and then on a monthly basis up to 152 +/- 3 days) and compared with 34 normal healthy volunteers matched for age, sex, and body mass index. Bone mineral measurements of whole body (n = 34), lumbar spine (n = 32), and upper femur (n = 23) were performed using dual-energy x-ray absorptiometry (Hologic QDR 1000W). At time of transplantation, lumbar bone mineral density (BMD) and BMD of the upper femur were lower (p < 0.01) in female but not male patients compared with controls. Lumbar BMD decreased by 1.6 +/- 0.2% per month in both sexes (p < 0.01), whereas BMD of upper femur further decreased in males (p < 0.01) but only tended to decrease in females. At time of transplantation, whole-body bone area (BA), bone mineral content (BMC), and BMD were decreased by about 8, 15, and 9%, respectively, in patients compared with controls (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[The accuracy of intravenous digital subtraction angiography regarding kidney arteries in hypertensive patients. A contribution to cost control in diagnostic medicine]. / Zur Treffsicherheit der intravenösen digitalen Subtraktionsangiographie bezüglich Nierenarterien bei Hypertonikern. Ein Beitrag zur Kostensenkung in der diagnostischen Medizin.

In a retrospective study the results of intravenous digital subtraction angiography (DSA) of renal arteries from 149 hypertensive outpatients investigated 1984 to 1989 at the University of Berne were evaluated. 118 i.v. DSA's (79%) were normal, 10 (7%) were inconclusive and 21 (14%) revealed stenosis. In 16 patients the course of the vessel and the degree of stenosis were verified by intraarterial DSA. In nine patients (6%) a significant stenosis was confirmed and subsequently treated by percutaneous transluminal angioplasty. Renal size was not a predictive parameter for stenosis in this population. Accessory renal arteries were found in 44% of patients with stenosis and only in 18% of those without. The late phase images of i.v. DSA revealed many morphologic abnormalities. The indication for i.v. DSA was assessed according to internationally accepted criteria: 1. severe hypertension, 2. hypertension refractory to treatment, 3. hypertension of sudden onset or aggravation, 4. onset of hypertension in patients younger than 20 or older than 50 years. In the group without stenosis (n = 118) 52 patients (44%) did not fulfill a single one of these criteria, whereas the patients with stenosis (n = 9) had at least one criterion fulfilled. Hypertensive patients should, therefore, only be studied by i.v. DSA if at least one criterion applies. 22,000 SFr. could thus have been saved without loss of medical quality and the treatment options.