[A new program of therapeutic education for obese patients]. / Un nouveau programme d'éducation thérapeutique pour les patients obèses.

Obesity is a chronic disease which is increasing over the past thirty years. This disease is complex and its treatment is difficult and generally frustrating for the patients and the medical team because of a high risk of relapse. Indeed, a dietetic approach alone is most of the time not good enough to obtain a long-lasting weight loss; the few drugs on the market should also be prescribed as a part of a more global approach. A multidisciplinary approach with a long-standing follow-up including a cognitive-behavioral therapy coupled to a diet and physical activity is mandatory to avoid any weight regain. We propose a new multidisciplinary program of two years with in hospital-stay and ambulatory follow-up which is showing some promising results (90% of success at one year).

Impact of body fat mass extent on cardiac autonomic alterations in women.

BACKGROUND: Obesity has been associated with significant abnormalities of the cardiac autonomic regulation. However, the precise impact of increasing body weight on cardiac autonomic function and the metabolic and hormonal contributors to these changes are presently unclear. The aim of our study was to explore in subjects with increasing values of body mass index (BMI) the alterations of cardiac autonomic function and to establish the potential role of various metabolic and hormonal contributors to these alterations. MATERIALS AND METHODS: We investigated time and frequency domain heart rate variability (HRV) parameters taken from 24-h Holter recordings, and several anthropometric, metabolic and hormonal parameters (plasma glucose, insulin, triglycerides, free fatty acids, leptin and adiponectin) in 68 normoglycaemic and normotensive women (mean age of 40 +/- 3 years), subdivided according to their BMI into 15 normal body weight (controls), 15 overweight, 18 obese and 20 morbidly obese. RESULTS: Heart rate was increased and HRV was decreased in the morbidly obese group as compared with controls. In overall population, a negative association linked body fat mass (FM) to HRV indices. None of the metabolic and hormonal parameters were significantly related to the HRV indices, after they were adjusted for the body FM. CONCLUSIONS: Morbidly obese, normoglycaemic and normotensive young women have increased HR and low HRV, indicating an abnormal cardiac autonomic function and representing a risk factor for adverse cardiovascular events. A decrease of HRV parameters is associated with a progressive increase of body FM. Other metabolic and hormonal factors, characterising obesity, do not show an independent influence on these HRV alterations.

[Therapeutic education in the field of infection diseases: the example of HIV infection]. / Education thérapeutique en maladie infectieuse: l'exemple de l'infection à VIH.

The advent of antiretroviral therapies represent a major therapeutic progress which dramatically modifies HIV seropositive people's life during the past fifteen years. After the violence of a formerly rapidly fatal disease comes nowadays the heaviness of a chronic disease. If some problems are new for the patients, it also represents new challenges for the caregivers. Due to the lack of access to medications in certain context or because of nonadherence to treatment, the full potential of these therapies is difficult to reach. We present here the experience of a therapeutic patient educational program for HIV seropositive persons. This program aimed not only to develop patient's skills to elicit them to find a balance between their life and their disease, but also to improve the skills of the caregivers to face the problem of chronicity.

Upregulation of peroxisome proliferator-activated receptor gamma coactivator gene (PGC1A) during weight loss is related to insulin sensitivity but not to energy expenditure.

AIMS/HYPOTHESIS: We investigated whether skeletal muscle peroxisome proliferator-activated receptor gamma coactivator-1 (PGC1A; also known as PPARGC1A) and its target mitofusin-2 (MFN2), as well as carnitine palmitoyltransferase-1 (CPT1; also known as carnitine palmitoyltransferase 1A [liver] [CPT1A]) and uncoupling protein (UCP)3, are involved in the improvement of insulin resistance and/or in the modification of energy expenditure during surgically induced massive weight loss. MATERIALS AND METHODS: Seventeen morbidly obese women (mean BMI: 45.9 +/- 4 kg/m(2)) were investigated before, and 3 and 12 months after, Roux-en-Y gastric bypass (RYGB). We evaluated insulin sensitivity by the euglycaemic-hyperinsulinaemic clamp, energy expenditure and substrate oxidation by indirect calorimetry, and muscle mRNA expression by PCR. RESULTS: Post-operatively, PGC1A was enhanced at 3 (p = 0.02) and 12 months (p = 0.03) as was MFN2 (p = 0.008 and p = 0.03 at 3 and 12 months respectively), whereas UCP3 was reduced (p = 0.03) at 12 months. CPT1 did not change. The expression of PGC1A and MFN2 were strongly (p < 0.0001) related. Insulin sensitivity, which increased after surgery (p = 0.002 at 3, p = 0.003 at 12 months), was significantly related to PGC1A and MFN2, but only MFN2 showed an independent influence in a multiple regression analysis. Energy expenditure was reduced at 3 months post-operatively (p = 0.001 vs before RYGB), remaining unchanged thereafter until 12 months. CPT1 and UCP3 were not significantly related to the modifications of energy expenditure or of lipid oxidation rate. CONCLUSIONS/INTERPRETATION: Weight loss upregulates PGC1A, which in turn stimulates MFN2 expression. MFN2 expression significantly and independently contributes to the improvement of insulin sensitivity. UCP3 and CPT1 do not seem to influence energy expenditure after RYGB.

[Supportive care in oncology: a concept of rehabilitation]. / Soins de support en oncologie: un concept de réhabilitation.

The prevalence and prognosis of cancer are changing. The number of diagnosed cancers is rising in Western countries. These diseases often become chronic illnesses and necessitate major efforts of adjustment and coping for patients and families, but also for health professionals. This paper focuses on the question of the follow-up of cancer patients and highlights some of the difficulties faced by professionals and institutions when attempting to improve the quality of care in this field. We describe how the divisions of general medical rehabilitation and of oncology of the Geneva university hospitals promote the implementation of supportive oncological care practice in a rehabilitation centre.

The effect of insulin on cardiac autonomic balance predicts weight reduction after gastric bypass.

AIMS/HYPOTHESIS: The aim of this study was to assess the predictive role of autonomic reactivity in body weight loss induced by gastric bypass. METHODS: A group of 22 morbidly obese subjects, who were due to undergo a gastric bypass, were submitted, before surgery, to a euglycaemic-hyperinsulinaemic clamp, during which a continuous recording of the ECG was performed. The effect of insulin on cardiac autonomic balance was evaluated by performing power spectral analysis of heart rate variability. The low-to-high frequency ratio was calculated before and during the clamp and its modifications were expressed as % delta low-to-high frequency ratio (%Delta L: H). RESULTS: Preoperative %Delta L: H showed a significant (p=0.0009, r2=0.43), positive relationship to the reduction of body weight, measured 1 year after surgery and expressed as % excess weight loss (% EWL). Preoperative BMI was also significantly (p=0.0009, r2=0.43) negatively related to the 12-month % EWL. In a multiple regression analysis, %Delta L: H remained a significant (p=0.003), independent predictor of body weight loss, even when preoperative BMI or age, % fat mass, insulinaemia and glucose disposal were taken into account. CONCLUSIONS/INTERPRETATION: The best correction of excess body weight was achieved by those obese subjects who had a preserved capacity to shift their cardiac autonomic balance towards a sympathetic prevalence in response to an euglycaemic-hyperinsulinaemic clamp. Further studies are needed to elucidate the mechanisms through which the autonomic nervous system influences weight reduction.