Bariatric surgery in individuals with human immunodeficiency virus and type 2 diabetes: a case series.

BACKGROUND: The efficacy and safety of bariatric surgery have not been fully elucidated in patients affected with human immunodeficiency virus. Although adjustable gastric banding and sleeve gastrectomy are starting to be used in patients with human immunodeficiency virus, there are limited descriptions of the outcomes of type 2 diabetes mellitus in individuals who are human immunodeficiency virus positive and undergoing these procedures. CASE PRESENTATION: We have evaluated retrospectively three patients who underwent adjustable gastric banding or sleeve gastrectomy, the effect in weight reduction and glycemic control as well as its impact on human immunodeficiency virus management. Case 1 (adjustable gastric banding), a 58-year-old Caucasian male, achieved 19% total weight loss, Case 2, a 33-year-old Caucasian male (sleeve gastrectomy) lost 25%, and Case 3, a 48-year-old Caucasian female (sleeve gastrectomy), lost 14% postoperation. In terms of type 2 diabetes mellitus, Case 2 achieved complete remission according to American Diabetes Association criteria, while Case 1 would also have achieved remission were it not for the continuation of metformin postoperatively. Insulin requirements and pill burden were markedly reduced in Case 3 after sleeve gastrectomy, although lack of remission was predictable given the longevity of type 2 diabetes mellitus and preoperative insulin dosage. In all three cases, human immunodeficiency virus status did not appear to be affected by the bariatric surgery which was supported by the postoperative stable CD4 count and undetectable viral load. CONCLUSIONS: Bariatric surgery is a safe and effective treatment modality in patients who are human immunodeficiency virus positive with obesity and type 2 diabetes mellitus.

Intragastric balloon outcomes in super-obesity: a 16-year city center hospital series.

BACKGROUND: Intragastric balloons represent an endoscopic therapy aimed at achieving weight loss by mechanical induction of satiety. Their exact role within the bariatric armamentarium remains uncertain. OBJECTIVE: Our study aimed to evaluate the use of intragastric balloon therapy alone and before definitive bariatric surgery over a 16-year period. SETTING: A large city academic bariatric center for super-obese patients. METHODS: Between January 2000 and February 2016, 207 patients underwent ORBERA intragastric balloon placement at esophagogastroduodenoscopy. Four surgeons performed the procedures, and data were entered prospectively into a dedicated bariatric database. Patients' weight loss data were measured through body mass index (BMI) and excess weight loss and recorded at each clinic review for up to 5 years (60 mo). Treatment arms included intragastric balloon alone with lifestyle therapy or intragastric balloon and definitive bariatric surgery: gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass. An additional treatment arm of analysis included the overall results from intragastric balloon followed by stapled procedure. RESULTS: One hundred twenty-nine female and 78 male patients had a mean age of 44.5 (±11.3) years and a mean BMI of 57.3 (±9.7) kg/m2. Fifty-eight percent of patients suffered from type 2 diabetes. Time from initial or first balloon insertion to definitive surgical therapy ranged between 9 and 13 months. Seventy-six patients had intragastric balloon alone, and 131 had intragastric balloon followed by definitive procedure. At 60 months postoperatively the intragastric balloon alone with lifestyle changes demonstrated an excess weight loss of 9.04% and BMI drop of 3.8; intragastric balloon with gastric banding demonstrated an excess weight loss of 32.9% and BMI drop of 8.9. Intragastric balloon and definitive stapled procedure demonstrated a BMI drop of 17.6 and an excess weight loss of 52.8%. Overall, there were 3 deaths (1.4%), 2 within 10 days due to acute gastric perforation secondary to vomiting and 1 cardiac arrest at 4 weeks postoperatively. CONCLUSION: Intragastric balloons can offer effective weight loss in selected super-obese patients within a dedicated bariatric center offering multidisciplinary support. Balloon insertion alone offers only short-term weight loss; however, when combined with definitive bariatric surgical approaches, durable weight loss outcomes can be achieved. A strategy of early and continual vigilance for side effects and a low threshold for removal should be implemented. Surgeon and unit experience with intragastric balloons can contribute to "kick starting" successful weight loss as a bridge to definitive therapy in an established bariatric surgical pathway.

Ablation with low-dose radioiodine and thyrotropin alfa in thyroid cancer.

BACKGROUND: It is not known whether low-dose radioiodine (1.1 GBq [30 mCi]) is as effective as high-dose radioiodine (3.7 GBq [100 mCi]) for treating patients with differentiated thyroid cancer or whether the effects of radioiodine (especially at a low dose) are influenced by using either recombinant human thyrotropin (thyrotropin alfa) or thyroid hormone withdrawal. METHODS: At 29 centers in the United Kingdom, we conducted a randomized noninferiority trial comparing low-dose and high-dose radioiodine, each in combination with either thyrotropin alfa or thyroid hormone withdrawal before ablation. Patients (age range, 16 to 80 years) had tumor stage T1 to T3, with possible spread to nearby lymph nodes but without metastasis. End points were the rate of success of ablation at 6 to 9 months, adverse events, quality of life, and length of hospital stay. RESULTS: A total of 438 patients underwent randomization; data could be analyzed for 421. Ablation success rates were 85.0% in the group receiving low-dose radioiodine versus 88.9% in the group receiving the high dose and 87.1% in the thyrotropin alfa group versus 86.7% in the group undergoing thyroid hormone withdrawal. All 95% confidence intervals for the differences were within ±10 percentage points, indicating noninferiority. Similar results were found for low-dose radioiodine plus thyrotropin alfa (84.3%) versus high-dose radioiodine plus thyroid hormone withdrawal (87.6%) or high-dose radioiodine plus thyrotropin alfa (90.2%). More patients in the high-dose group than in the low-dose group were hospitalized for at least 3 days (36.3% vs. 13.0%, P<0.001). The proportions of patients with adverse events were 21% in the low-dose group versus 33% in the high-dose group (P=0.007) and 23% in the thyrotropin alfa group versus 30% in the group undergoing thyroid hormone withdrawal (P=0.11). CONCLUSIONS: Low-dose radioiodine plus thyrotropin alfa was as effective as high-dose radioiodine, with a lower rate of adverse events. (Funded by Cancer Research UK; ClinicalTrials.gov number, NCT00415233.).

Familial nonmedullary thyroid cancer: a review of the genetics.

OBJECTIVE: Thyroid cancer, the commonest of endocrine malignancies, continues to increase in incidence with over 19,000 new cases diagnosed in the European Union per year. Although nonmedullary thyroid cancer (NMTC) is mostly sporadic, evidence for a familial form, which is not associated with other Mendelian cancer syndromes (e.g., familial adenomatous polyposis and Cowden's syndrome), is well documented and thought to cause more aggressive disease. Just over a decade ago, the search for a genetic susceptibility locus for familial NMTC (FNMTC) began. This review details the genetic studies conducted thus far in the search for potential genes for FNMTC. DESIGN: An electronic PubMed search was performed from the English literature for genetics of FNMTC and genetics of familial papillary thyroid carcinoma (subdivision of FNMTC). The references from the selected papers were reviewed to identify further studies not found in the original search criteria. MAIN OUTCOME: Six potential regions for harboring an FNMTC gene have been identified: MNG1 (14q32), TCO (19p13.2), fPTC/PRN (1q21), NMTC1 (2q21), FTEN (8p23.1-p22), and the telomere-telomerase complex. Important genes reported to have been excluded are RET, TRK, MET, APC, PTEN, and TSHR. CONCLUSION: The genetics of FNMTC is an exciting field in medical research that has the potential to permit individualized management of thyroid cancer. Studies thus far have been on small family groups using varying criteria for the diagnosis of FNMTC. Results have been contradictory and further large-scale genetic studies utilizing emerging molecular screening tests are warranted to elucidate the underlying genetic basis of FNMTC.