Circulating free testosterone in obese men after bariatric surgery increases in parallel with insulin sensitivity

BACKGROUND AND AIM

Male hypogonadism has been linked to obesity and diabetes. We aimed to study the association of changes in insulin sensitivity and testosterone levels in severe obese patients submitted to bariatric surgery.

SUBJECTS AND METHODS

Prospective intervention study with twenty consecutive patients who underwent bariatric surgery studied before and after significant weight loss. Serum testosterone, SHBG, fasting glucose, and insulin were measured among others. Free testosterone was calculated with the Vermeulen formula and insulin sensitivity with the homeostatic model assessment (HOMA).

RESULTS

At baseline, thirteen patients had low total testosterone levels, whereas eight of these patients also had free testosterone levels below the reference range obtained from the control group. After bariatric surgery total testosterone, SHBG, and free testosterone significantly increased and achieved normal values in all evaluated patients. Insulin sensitivity improved in all of them. Multivariate linear regression showed that changes in fasting glucose (β=-1.868, p=0.001), insulin (β=-3.782, p=0.001), weight (β=-0.622, p=0.002), and SHBG (β=-0.635, p=0.022) were associated with changes in free testosterone (adjusted R2=0.936, F=26.613, p=0.001). When insulin resistance calculated by HOMA was in the model instead of insulin and glucose, it also was associated (β=-3.488, p=0.008) with free testosterone (adjusted R2=0.821, F=11.111, p=0.005).

CONCLUSIONS

Circulating tes tos terone in obese men increases after bariatric surgery in parallel with an improvement in insulin sensitivity.

Clinical characterisation of pneumonia caused by atypical pathogens combining classic and novel predictors

The aim of this study was to characterise community-acquired pneumonia (CAP) caused by atypical pathogens by combining distinctive clinical and epidemiological features and novel biological markers. A population-based prospective study of consecutive patients with CAP included investigation of biomarkers of bacterial infection, e.g., procalcitonin, C-reactive protein and lipopolysaccharide-binding protein (LBP) levels. Clinical, radiological and laboratory data for patients with CAP caused by atypical pathogens were compared by univariate and multivariate analysis with data for patients with typical pathogens and patients from whom no organisms were identified. Two predictive scoring models were developed with the most discriminatory variables from multivariate analysis. Of 493 patients, 94 had CAP caused by atypical pathogens. According to multivariate analysis, patients with atypical pneumonia were more likely to have normal white blood cell counts, have repetitive air-conditioning exposure, be aged <65 years, have elevated aspartate aminotransferase levels, have been exposed to birds, and have lower serum levels of LBP. Two different scoring systems were developed that predicted atypical pathogens with sensitivities of 35.2% and 48.8%, and specificities of 93% and 91%, respectively. The combination of selected patient characteristics and laboratory data identified up to half of the cases of atypical pneumonia with high specificity, which should help clinicians to optimise initial empirical therapy for CAP.

Community-acquired pneumonia of mixed etiology: prevalence, clinical characteristics, and outcome

Community-acquired pneumonia (CAP) of mixed etiology has increasingly been appreciated in the literature, but its clinical significance remains unknown. The aim of this analysis was to describe the prevalence, clinical characteristics, and outcome of CAP of mixed etiology. Data were obtained from a 2-year prospective study of consecutive patients with CAP in whom an extensive microbiological workup was performed. Predefined strict criteria were used to establish the etiology. A total of 493 patients were included. A single pathogen was detected in 222 (45%) cases and two or more pathogens in 28 (5.7%) cases. Mixed infections were seen across all age groups and in patients treated both in hospital and as outpatients. The most frequent combinations of pathogens were those of a bacterium plus an "atypical" organism (28.6%) and of two bacterial organisms (28.6%). Compared with patients with monomicrobial pneumonia, patients with mixed pneumonia were more likely to have underlying conditions (64% vs. 45%, p=0.04) and dementia (25% vs. 10%, p=0.02). The incidence of a defined series of complications was higher in patients with mixed pneumonia (39.3% vs. 18.6%; OR=2.84; p=0.02). Community-acquired pneumonia of mixed etiology is uncommon. Patients with mixed pneumonia are more likely to have underlying medical conditions, and they may have a more severe course of disease.

Rosiglitazone up-regulates lipoprotein lipase, hormone-sensitive lipase and uncoupling protein-1, and down-regulates insulin-induced fatty acid synthase gene expression in brown adipocytes of Wistar rats

AIMS/HYPOTHESIS

Although thiazolidinediones are now widely used to treat type 2 diabetes, their mechanism of action remains largely unknown. They are agonists for the transcription factor PPARgamma, and in addition to their insulin-sensitising effects, they can promote adipogenesis and control gene expression in adipose tissues. We have explored the effect of rosiglitazone on insulin-mediated induction of pivotal genes involved in lipid metabolism and thermogenesis in brown fat. The genes studied were: (1) lipoprotein lipase (lpl), which is involved in lipid uptake; (2) hormone-sensitive lipase (hsl), which mobilises fatty acids from stored triglycerides; (3) fatty acid synthase (fas), which regulates de novo lipogenesis; and (4) the uncoupling proteins (ucp) 1 and 3, which control thermogenesis.

METHODS

We used fetal rat primary brown adipocytes cultured with insulin, rosiglitazone or both combined. Then, we studied gene expression by northern and western blotting, as well as 'run-on' and gel-shift assays to identify binding of potential transcription factors to the fas promoter.

RESULTS

Exposure to rosiglitazone for 24 h induced ucp-1, lpl and hsl gene expression and when rosiglitazone was combined with insulin a synergistic effect on lpl and ucp-3 mRNA expression was produced. These effects were consistent with increased LPL and HSL activities as well as respiration rates, mainly in response to exogenous palmitate. In contrast, treatment with rosiglitazone did not alter FAS mRNA basal levels but prevented the induction elicited by insulin in a time- and dose-dependent manner. Correspondingly diminished FAS protein levels and activity, as well as cellular lipid content, were observed, indicating an antilipogenic action of rosiglitazone in brown adipocytes. Furthermore, rosiglitazone impaired insulin increase in the FAS transcription rate by antagonising insulin-induced binding of upstream stimulatory factors to the E-box consensus sequence in the FAS promoter and insulin-induced binding of activating protein-1.

CONCLUSIONS/INTERPRETATION

Rosiglitazone prevents insulin-induced up-regulation of the main lipogenic enzyme but increases the expression of those enzymes involved in lipid uptake and mobilisation, favouring fatty acid utilisation through uncoupled respiration.

Corynebacterium pseudodiphtheriticum: an easily missed respiratory pathogen in HIV-infected patients

Despite being a well-known respiratory pathogen for immunocompromised patients, Corynebacterium pseudodiphtheriticum has uncommonly been reported to occur in persons with infection attributable to HIV virus. We report three cases of respiratory tract infection attributable to C. pseudodiphtheriticum in HIV-infected patients and review the four previous cases from the medical literature. All of them were male with a median CD4 lymphocyte count of 110 cells/mm3 (range, 18-198/mm3); five of the seven cases occurred in persons for whom AIDS was diagnosed previously. The onset of symptomatology was usually acute and the most common radiographic appearance was alveolar infiltrate (six patients) with cavitation (two patients) and pleural effusion (two patients). In five of the seven cases, C. pseudodiphtheriticum was isolated from bronchoscopic samples and in the remaining two cases was recovered from lung biopsy (one patient) and sputum (one patient). In the three patients reported herein and in one previous case from the medical literature, quantitative culturing of bronchoscopic samples obtained through either bronchoalveolar lavage or protected brush catheter procedures yielded more than 10(3) CFU/mL. All the strains tested were susceptible to penicillin and vancomycin. Resistance to macrolides was common. Recovery was observed in six of the seven patients. C. pseudodiphtheriticum should be regarded as a potential respiratory pathogen in HIV-infected patients. This infection presents late in the course of HIV disease and it seems to respond well to appropriate antibiotic treatment in most of the cases. This easily overlooked pathogen should be added to the list of organisms implicated in respiratory tract infections in this population.

Effect of diabetes on protein synthesis rate and eukaryotic initiation factor activities in the liver of virgin and pregnant rats

To study the effect of prolonged diabetes on protein synthesis and on the activities of initiation factors eIF-2 and eIF-2B in the liver, female rats were treated with streptozotocin. Some animals were mated and studied on day 20 of pregnancy, whereas others were kept virgin and studied in parallel. The protein synthesis rate was measured with an "in vitro' cellfree system, and was lower in diabetic pregnant and virgin animals than in pregnant and virgin controls (30-60%). The fetuses of diabetic rats had a lower protein synthesis rate than those from controls, although they always showed a higher protein synthesis rate than their mothers or virgin rats. Protein synthesis rate, RNA concentration, and initiation factor 2 activity were higher in pregnant than in virgin rats. Both activity and level of eIF-2 factor changed in parallel to the protein synthesis rate, although no differences could be detected between control and diabetic animals. The eIF-2B activity in tissue extracts from diabetic virgin rats and fetuses was lower than in extracts from their controls, whereas no differences could be detected between pregnant and virgin control rats nor between pregnant control and pregnant diabetic animals. The percentage of the phosphorylated form of eIF-2 factor, eIF-2(alpha P), was slightly lower in virgin than in pregnant rats but was unaffected by the diabetic condition, while in diabetic fetuses this parameter was lower than in their corresponding controls. The cyclic adenosine monophosphate dependent protein kinase level was lower in diabetic rats than in controls, whereas no changes in the activity of casein kinase II were found. The isoelectric forms of the beta subunit of eIF-2 factor, eIF-2 beta, were different in the diabetic and the control animals, indicating that insulin deficiency modifies the phosphorylation of specific substrates. Since no differences were detected in RNA or eIF-2 content between control and diabetic rats, translation may, at least partly, be inhibited in the liver by an impairment of peptide chain initiation caused by the decreased eIF-2B activity which nevertheless is independent of eIF-2 alpha phosphorylation.

Lipoprotein lipase and hormone-sensitive lipase activity and mRNA in rat adipose tissue during pregnancy

To investigate the factors controlling maternal depot fat accumulation during early pregnancy and net decrease during late pregnancy, the activity and mRNA expression of adipose tissue lipoprotein lipase (LPL) and hormone-sensitive lipase (HSL) were related to several other lipid metabolic parameters. Virgin control rats, pregnant rats (at days 12, 15, 19, and 21), and lactating rats (at days 5 and 10 postpartum) were studied. In adipose lumbar tissue of late pregnant rats, LPL activity decreased to about one-third that of the virgin control animals, with < 10% of initial LPL mRNA expressed as determined by Northern blots. HSL activity increased maximally 1.5-fold with a fourfold increase of HSL expression at days 12-15 of pregnancy and decreased to control levels after parturition. The HSL-to-LPL mRNA and activity ratios were enhanced from days 15 and 19 of pregnancy, respectively, and remained so even during lactation, mainly because of the marked lowering of the LPL values. This enhancement coincided with increments in plasma free fatty acids and glycerol levels indicating an increased depot fat breakdown. These results give no indication of an involvement of LPL and HSL gene expression changes in the accumulation of maternal depot during early pregnancy. In contrast, such changes could be responsible for the net breakdown of this fat depot during late gestation. Thus, during this physiological state, long-term (e.g., transcriptional) regulation of LPL and HSL gene expression could be an important mechanism for the control of adipose tissue mass breakdown during late gestation.