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

BACKGROUND

The 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.

METHODS

We 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.

RESULTS

Seven out of eight patients were females. The mean age was 46 years, with a median preoperative BMI of 42 kg/m(2). The mean duration of HIV infection and CD4 cell count were 13.4 years and 457 cells/mm(3), respectively. The mean weight loss was 37 kg in 20 months, the excess BMI loss was 80.8 ± 30.9 %, and the excess weight loss is 81.5 ± 28.9 % 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.

CONCLUSIONS

The 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.

Plasma lipids and fatty acid synthase activity are regulated by short-chain fructo-oligosaccharides in sucrose-fed insulin-resistant rats

The aim of this study was to evaluate the chronic effects of a short-chain fructo-oligosaccharide (FOS)-containing diet on plasma lipids and the activity of fatty acid synthase (FAS) in insulin-resistant rats. Normal male Sprague-Dawley rats, 5 wk old, were randomly assigned to two groups and fed either a sucrose-rich diet (S, 575 g sucrose /kg diet and 140 g lipids/kg diet) or a sucrose-rich diet supplemented with 10 g/100 g short-chain fructo-oligosaccharides (S/FOS). A third reference group (R) was fed a standard nonpurified diet (g/kg, 575 g starch, 50 g fat). After 3 wk the sucrose-fed rats (compared with the R group) were characterized by the following: 1) higher insulin responses after a glucose challenge (P < 0.05); 2) heavier liver (P < 0.001) and retroperitoneal adipose tissue (P < 0.01); 3) hypertriglyceridemia (P < 0.0001) and higher plasma free fatty acids (P < 0.0001); and 4) higher fatty acid synthase activity in the liver but a low activity in the adipose tissue (P < 0.001). The addition of FOS to the diet resulted in 11% lower liver weight than in the S group (P < 0.05) and tended to result in lower adipose tissue weight (P < 0.11). Plasma triglycerides and plasma free fatty acids were lower in S/FOS- than in S-fed rats (P < 0.05). Chylomicrons + VLDL, and intermediate density lipoprotein (IDL) concentrations did not differ between groups, nor was plasma cholesterol influenced by diet. Hepatic FAS activity was lower in S/FOS-fed rats than in the S-fed rats (P < 0.05). In adipose tissue, however, this activity tended to be greater in rats fed S/FOS than in rats fed the S diet (P < 0.07). In conclusion, in a rat model of diet-induced (57.5% sucrose and 14% lipids) insulin resistance, the addition of short-chain FOS prevented some lipid disorders, lowered fatty acid synthase activity in the liver and tended to raise this activity in the adipose tissue. Short-chain FOS, in addition to being a nondigestible sweetener with good bulking capacity, might be useful in the treatment of insulin resistance and hyperlipidemia.

Moderate intake of n-3 fatty acids for 2 months has no detrimental effect on glucose metabolism and could ameliorate the lipid profile in type 2 diabetic men. Results of a controlled study

OBJECTIVE

To evaluate the effect of a moderate dose of fish oil on glycemic control and in vivo insulin action in type 2 diabetic men with elevated plasma triacylglycerols and to determine the effect of the same treatment on gene expression of GLUT4, lipoprotein lipase (LPL), and hormone-sensitive lipase (HSL) in the abdominal adipose tissue.

RESEARCH DESIGN AND METHODS

A total of 12 type 2 diabetic men were randomly allocated to 2 months of 6 g daily of either fish oil or sunflower oil, separated by a 2-month washout interval, in a double-blind crossover design.

RESULTS

For glucose metabolism, 2 months of fish oil supplementation compared with sunflower oil led to similar fasting plasma insulin, glucose, and HbA1c. Basal hepatic glucose production did not increase after fish oil. There was no difference in insulin suppression of hepatic glucose production nor in insulin stimulation of whole-body glucose disposal measured by the euglycemic-hyperinsulinemic clamp. Fish oil did not ameliorate the low mRNA level of GLUT4 in adipose tissue of these patients. For lipid profile, fish oil lowered plasma triacylglycerol more than sunflower oil (P < 0.05) and tended to increase the amount of mRNA of both LPL and HSL in adipose tissue.

CONCLUSIONS

A moderate dose of fish oil did not lead to deleterious effects on glycemic control or whole-body insulin sensitivity in type 2 diabetic men, with preserved triacylglycerol-lowering capacities.

Hyperlactatemia during acute severe asthma

OBJECTIVE

To evaluate arterial lactate levels during treatment of acute severe asthma (ASA) and the prognostic value of arterial hyperlactatemia in ASA.

DESIGN

Prospective study.

SETTING

A respiratory intensive care unit (ICU) of a university hospital.

PATIENTS

29 consecutive patients admitted to the ICU for ASA not intubated on admission and with a peak expiratory flow (PEF) < 150 l/min or an arterial carbondioxide tension (PaCO2) > 40 mm Hg. All patients received standardized treatment during the first 24 h including i.v. and nebulized salbutamol, i.v. theophylline, and dexamethasone.

MEASUREMENTS AND RESULTS

Arterial lactate levels were serially measured by an enzymatic method during the first 24 h following admission. On admission, the mean arterial lactate level was 3.1 +/- 0.38 mmol/l (range 1.1-10.4); 17 patients (59%) had arterial hyperlactatemia with a lactate level > 2 mmol/l. No difference was found in lactate levels between patients with progressively worsening asthma and those with an acute onset of severe asthma. No correlation was found between arterial lactate levels on admission, on the one hand, and respiratory rate (RR), heart rate, PEF, pH, PaCO2, arterial oxygen tension, potassium, phosphorus, creatine kinase, or transaminase values on admission, on the other hand. All patients developed an important but transient increase in arterial lactate levels during treatment, with a peak at 7.72 +/- 0.46 mmol/l and a mean elevation of 4.62 +/- 0.45 mmol/l (range 0.4-12.1), from the initial admission value contrasting with a significant clinical improvement assessed by RR, PEF, and arterial blood gas parameters.

CONCLUSION

This study suggests that, in ASA, arterial hyperlactatemia is frequently present on admission to the ICU. Delayed hyperlactatemia is a constant finding during treatment of ASA. Initial or delayed hyperlactatemia seems of no prognostic value because none of the patients required mechanical ventilation. The effects of therapy for acute asthma on lactate metabolism still need to be studied.

Lack of effect of an acute ileal perfusion of short-chain fatty acids on glucose metabolism in healthy men

Dietary fiber intake is associated with several beneficial effects on carbohydrate metabolism. Some authors have speculated that this improvement may be due to short-chain fatty acids (SCFA) produced by the colonic fermentation of dietary fibers. To test this hypothesis, six healthy men aged 26 +/- 2 (SE) yr with a body mass index of 20.9 +/- 0.7 received on three occasions an 18-h ileal perfusion infused at a flow rate of 3.3 ml/min, containing either 90 mmol/l of SCFA (60% acetate, 25% propionate, and 15% butyrate) (A), SCFA during the first 12 h and then a saline solution (A/S), or a saline solution (S). Basal hepatic glucose production (BHGP), insulin sensitivity (3-step euglycemic-hyperinsulinic clamp), and erythrocyte insulin binding (EIB) were studied 12 h after the beginning of the ileal perfusion. There was no change in BHGP or insulin sensitivity. However, maximal EIB was significantly different: 7.1 +/- 0.1 (A), 6.8 +/- 0.1 (A/S), vs. 6.5 +/- 0.1% (S) (P = 0.03). We conclude that acute administration of SCFA does not significantly alter glucose metabolism in healthy subjects.

Chronic consumption of short-chain fructooligosaccharides by healthy subjects decreased basal hepatic glucose production but had no effect on insulin-stimulated glucose metabolism

We aimed to study the effects of chronic ingestion of short-chain fructooligosaccharides (FOS), an indigestible carbohydrate, on hepatic glucose production, insulin-mediated glucose metabolism, erythrocyte insulin binding, and blood lipids in healthy subjects. Twelve healthy volunteers received either 20 g FOS/d or sucrose for 4 wk in a double-blind crossover design. FOS did not modify fasting plasma glucose and insulin concentrations. Mean (+/- SEM) basal hepatic glucose production was lower after FOS than after sucrose consumption (2.18 +/- 0.10 compared with 2.32 +/- 0.09 mg.kg-1, min-1, respectively; P < 0.02, paired Student's t test). However, neither insulin suppression of hepatic glucose production nor insulin stimulation of glucose uptake measured by hyperinsulinemic clamp was significantly different between the two dietary periods. Erythrocyte insulin binding was also comparable. Serum triacylglycerols, total and high-density- lipoprotein cholesterol, apolipoproteins A-I and B, and lipoprotein(a) were not modified by FOS. To try to understand why FOS did not increase serum lipids, the in vitro production of short-chain fatty acids from FOS was evaluated by using human fecal inoculum and compared with that from lactulose, which was found to increase serum lipids. FOS produced an acetate-propionate ratio two times lower than that of lactulose. We conclude that 4 wk of 20 g FOS/d decreased basal hepatic glucose production but had no detectable effect on insulin-stimulated glucose metabolism in healthy subjects. The colonic fermentation pattern of undigestible carbohydrates may be relevant to predicting their metabolic effects.

Urine benzodiazepines screening of involuntarily drugged and robbed or raped patients

OBJECTIVE

This study involved 35 patients who claimed to have been drugged before being robbed or raped, despite urine negative toxicologic screening by immunoenzymatic methods. The urines were frozen for further investigations, including enzymatic hydrolysis of urinary conjugates, liquid-solid extraction and, finally, immunoenzymatic screening of concentrated urine extract.

METHODS

Urine benzodiazepines were analyzed by immunoenzymatic assay before and after enzymatic hydrolysis combined with extraction.

RESULTS

On direct immunoenzymatic screening, 17 of the 35 urine samples were benzodiazepine positive. Enrichment of preserved specimens improved the detection threshold from 200 ng/mL to 50 ng/mL and 10 of the 18 negative urines became positive.

CONCLUSION

This method allowed us to demonstrate the benzodiazepines in half of previously negative urine samples. Benzodiazepine screening is particularly problematic because of low dosage, rapid elimination, failure to detect conjugated metabolites by immunoenzymatic reagents and high threshold of sensitivity for certain substances.