The Role of Lifestyle Modification with Second-Generation Anti-obesity Medications: Comparisons, Questions, and Clinical Opportunities

PURPOSE OF REVIEW

This review examines lifestyle modification for obesity management with the goal of identifying treatment components that could support the use of a new generation of anti-obesity medications (AOMs).

RECENT FINDINGS

Semaglutide reliably reduces baseline body weight by approximately 15% at 68 weeks, in contrast to 5-10% for lifestyle modification. Tirzepatide induces mean losses as great as 20.9%. Both medications reduce energy intake by markedly enhancing satiation and decreasing hunger, and they appear to lessen the need for traditional cognitive and behavioral strategies (e.g., monitoring food intake) to achieve calorie restriction. Little, however, is known about whether patients who lose weight with these AOMs adopt healthy diet and activity patterns needed to optimize body composition, cardiometabolic health, and quality of life. When used with the new AOMs, the focus of lifestyle modification is likely to change from inducing weight loss (through calorie restriction) to facilitating patients' adoption of dietary and activity patterns that will promote optimal changes in body composition and overall health.

Semaglutide for the treatment of obesity

Semaglutide is a glucagon-like peptide-1 receptor agonist that was recently approved by the US Food and Drug Administration for chronic weight management. This paper reviews data on the mechanism of action, weight-loss and cardiometabolic efficacy, and safety of semaglutide 2.4 mg/week for obesity. Semaglutide has demonstrated the largest weight loss of any obesity medication to date with reductions of approximately 15% of initial weight at 68 weeks, accompanied by improvements in cardiovascular risks factors and physical functioning. The approval of this medication provides patients with greater options for weight management.

Clinical Insight on Semaglutide for Chronic Weight Management in Adults: Patient Selection and Special Considerations

Losses of 5-10% or more of initial body weight are associated with improvements in obesity-related comorbidities. However, attaining and sustaining this level of weight loss is challenging. The novel anti-obesity medication semaglutide 2.4 mg injected subcutaneously once weekly as an adjunct to a reduced-calorie diet and physical activity helps patients achieve average losses of 9.6-17.4% of initial body weight at week 68, as well as improvements in cardiometabolic and psychosocial indices. Despite these average benefits, prescribers should carefully assess the suitability of patients for this medication. In this paper, we discuss considerations for the selection of individuals who are candidates for semaglutide and special considerations related to the use of this medication. These include its efficacy and safety, as well as its contraindications, potential adverse effects, management of comorbidities and drug interactions, insurance coverage and cost, and patient preferences.

Case presentation of 8-year follow up of recurrent malignant duodenal Insulinoma and lymph node metastases and literature review of malignant Insulinoma management

BACKGROUND

Insulinoma is an uncommon insulin-secreting neuroendocrine tumor that presents with severe recurrent hypoglycemia. Although cases of extrapancreatic insulinomas have been reported, the majority of insulinomas occur in the pancreas. The number of reported cases of ectopic insulinomas with follow-up assessments is limited and they do not report disease recurrence. The current report presents the first documented case of recurrent extrapancreatic insulinoma with 8 years of follow-up, provides relevant literature review, and proposes surveillance and treatment strategies.

CASE PRESENTATION

We describe an insulinoma localized in the duodenal wall of a 36-year-old female who presented in 2013 with weight gain and Whipple's triad and was successfully managed with duodenotomy and enucleation. She presented again in 2017 with recurrent Whipple's triad and was found to have metastatic disease localized exclusively to peripancreatic lymph nodes. Primary pancreatic insulinoma was not evident and her hypoglycemia resolved following lymph node dissection. Eight years after initial presentation continuous glucose monitoring (CGM) showed a trend for euglycemia, and PET-CT Gallium 68 DOTATATE scan evaluation indicated absence of recurrent disease.

CONCLUSION

Insulinomas are rare clinical entities and extrapancreatic insulinomas are particularly uncommon. Follow-up evaluation and treatment strategies for ectopic insulinoma recurrence presents a significant clinical challenge as the condition has hitherto remained undescribed in the literature. Available evidence in the literature indicates that lymph node metastases of intrapancreatic insulinomas likely do not change prognosis. Given the absence of long-term data informing the management and monitoring of patients with extrapancreatic insulinoma, we suggest patient education for hypoglycemic symptoms, monitoring for hypoglycemia with CGM, annual imaging, and a discussion with patients regarding treatment with octreotide or alternative somatostatin receptor analog therapies.

Managed care considerations of weight management interventions for obesity

The growing prevalence of obesity in the United States has presented an opportunity to increase knowledge about optimal treatment approaches based on a better understanding of patient and provider biases, health care coverage and practices, and social determinants of health. Guideline-recommended obesity treatment begins with lifestyle intervention, and weight management may be enhanced by metabolic and bariatric surgery or anti-obesity medication (AOM) use. However, patient and provider perceptions surrounding obesity and different treatment modalities may present barriers to discussion and uptake of these interventions. Furthermore, it is uncommon for all effective obesity treatments (particularly AOMs) to be covered by insurance. Limited patient access to these treatments carries the potential for negative health consequences and higher health care costs. For these reasons, managed care decision makers are encouraged to improve access to effective obesity treatments, including coverage of AOMs such as semaglutide 2.4 mg.

Patient well-being and the clinical and economic burdens associated with obesity in the United States

Obesity is a serious, progressive, chronic disease that is associated with a spectrum of complications and poor outcomes (eg, premature death, diminished quality of life) and is a risk factor for several other diseases. Obesity increases the risk of developing type 2 diabetes, cardiovascular disease, and certain cancers. More recently, obesity was recognized as a risk factor for poor outcomes in patients with COVID-19. When experienced concurrently with a serious disease, obesity may increase the risk of negative health outcomes. Furthermore, individuals with obesity are more likely to experience social stigma and discrimination at work and in educational and health care settings; these may impact mental and physical health and contribute to increased adiposity. In the United States, the economic burden of obesity is immense-according to estimates, hundreds of billions of dollars are spent annually on direct medical needs and lost productivity associated with obesity. More severe classes of obesity greatly impact both the health of individuals and health care expenditures. As obesity becomes more prevalent, policy makers, health care professionals, and payers must consider its clinical, social, and economic implications.

Cardiometabolic risk factors efficacy of semaglutide in the STEP program

People with overweight or obesity often suffer from associated cardiometabolic diseases and comorbidities. Current therapies for obesity include lifestyle intervention, bariatric surgery, and pharmacotherapy. The magnitude of weight loss achieved with these therapies can determine the level of improvement in various comorbidities. Once-weekly subcutaneous semaglutide 2.4 mg is a glucagon-like peptide-1 receptor agonist recently approved by the US Food and Drug Administration for the treatment of obesity. This article reviews data from the global phase 3 Semaglutide Treatment Effect in People with obesity (STEP) program, comparing the efficacy of once-weekly subcutaneous semaglutide 2.4 mg versus placebo for weight loss and improvements in cardiometabolic parameters across the STEP 1 to 5 trials. In STEP 1 to 3 and STEP 5, semaglutide led to greater reductions from baseline versus placebo in body weight, waist circumference, body mass index, systolic blood pressure (SBP), and diastolic blood pressure, as well as positive changes in glycated hemoglobin (HbA_1c), C-reactive protein, and lipid levels. In STEP 4, all participants had a 20-week run-in period on semaglutide before either continuing on semaglutide or switching to placebo at week 20 in a 2:1 ratio for 48 weeks. At week 68, continued semaglutide led to further reductions from week 20 in HbA_1c, improvements in lipid profile, and stabilization of SBP. Overall, across the STEP trials, treatment with semaglutide 2.4 mg versus placebo improved cardiometabolic risk factors associated with obesity, illustrating an effective treatment option for people with overweight (and associated comorbidities) or obesity.

Efficacy and safety of semaglutide for weight management: evidence from the STEP program

Obesity is a global health challenge. It is a multifactorial, complex, and progressive disease associated with various health complications and increased mortality. Lifestyle modifications are central to weight management but may be insufficient to maintain clinically meaningful weight loss. Pharmacotherapies are recommended as an adjunct to lifestyle interventions to induce and sustain clinically meaningful weight loss and reduce the risk of comorbidities in appropriate patients. Glucagon-like peptide-1 is an incretin metabolic hormone responsible for a range of physiological effects, including glucose and appetite regulation. Several glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been approved for the treatment of type 2 diabetes since 2005 including exenatide (short- and extended-release), lixisenatide, liraglutide, dulaglutide, albiglutide, and semaglutide. Of these, semaglutide (subcutaneous) and liraglutide are currently US Food and Drug Administration (FDA)-approved for chronic weight management in patients with or without diabetes. The phase 3 Semaglutide Treatment Effect in People with obesity (STEP) program was designed to investigate the effect of semaglutide versus placebo on weight loss, safety, and tolerability in adults with overweight or obesity. Following the submission of the results of the STEP 1-4 trials, the FDA approved once-weekly subcutaneous semaglutide 2.4 mg for chronic weight management in people with overweight or obesity in April 2021. Data from the program demonstrated that semaglutide (2.4 mg once weekly) achieved significant and sustained weight loss, together with improvements in cardiometabolic risk factors compared with placebo, and was generally well tolerated, with a safety profile consistent with other GLP-1RAs. The most common adverse events reported in STEP 1-5 were gastrointestinal events, which were transient, mild-to-moderate in severity, and typically resolved without permanent treatment discontinuation. This article reviews the data from STEP 1-5 and highlights clinically relevant findings for primary care providers.

Feasibility, tolerability, and safety of hysterosalpingo-foam sonography (hyfosy). multicenter, prospective Spanish study

OBJECTIVE

To determine the feasibility,tolerability, and safety of the ultrasound assessment of tubal patency using foam as contrast.

METHODS

This was a prospective multicenter study of 915 infertile nulliparous women scheduled for sonohysterosalpingography with foam instillation (HYFOSY) for tubal patency testing as a part of the fertility workup. Clinical and sonographic data were recorded into a web-shared database. Tubal patency, cervical catheterization, pain during the procedure and post-procedural complications were collected. Patients reported discomfort or pain experienced during the procedure with a visual analogue scale (VAS) score.

RESULTS

Nine hundred fifteen women were included in the final analysis. Median age was 34 (range, 21-45) years and median body mass index was 23 (range, 16-41) kg/m2. Of 839 women, only 8(0.95 %) cases were abandoned due to impossibility of introducing the intracervical catheter. Most of the cervical os were easily cannulated with either paediatric nasogastric probes or special catheter for intrauterine insemination / sonohysterosalpingography 688/914(75.3 %). With a median instillation of 4 mL (range 1-16) of foam, both tubes were identified in 649/875 (70.9 %) patients, while unilateral patency was observed in 190/875 (20.8 %). Only 36/875 (3.9 %) of the women had bilateral tubal obstruction. The median VAS score for perception of pain during HyFoSy examination was 2 (range 0-10), and only 17 (1.9 %) of women reported severe pain (VAS ≥ 7). Pain was unrelated to tubal patency or tubal blockage. Unexpectedly, difficult cervical catheterizations that needed tenaculum, were more likely associated with mild pain during procedure [nasogastric probe group 176/289 (70.9 %) vs. insemination catheter group 166/399 (41.6 %) vs. tenaculum group 190/218(87.2 %) p < 0.001]. Finally, among 915 patients, we only noticed 3 (0.32 %) complications of the technique: two vasovagal episodes and a mild urinary infection.

CONCLUSION

HYFOSY is a feasible, well-tolerated and safe technique for the evaluation of tubal patency in infertile women.

Impact of a nurse-led limited risk factor modification program on arrhythmia outcomes in patients with atrial fibrillation undergoing catheter ablation

BACKGROUND

We have previously demonstrated the feasibility of a nurse-led risk factor modification (RFM) program for improving weight loss and obstructive sleep apnea (OSA) care among patients with atrial fibrillation (AF).

OBJECTIVE

We now report its impact on arrhythmia outcomes in a subgroup of patients undergoing catheter ablation.

METHODS

Participating patients with obesity and/or need for OSA management (high risk per Berlin Questionnaire or untreated OSA) underwent in-person consultation and monthly telephone calls with the nurse for up to 1 year. Arrhythmias were assessed by office ECGs and ≥2 wearable monitors. Outcomes, defined as Arrhythmia control (0-6 self-terminating recurrences, with ≤1 cardioversion for nonparoxysmal AF) and Freedom from arrhythmias (no recurrences on or off antiarrhythmic drugs), were compared at 1 year between patients undergoing catheter ablation who enrolled and declined RFM.

RESULTS

Between 1 November 2016 and 1 April 2018, 195 patients enrolled and 196 declined RFM (body mass index, 35.1 ± 6.7 vs 34.3 ± 6.3 kg/m² ; 50% vs 50% paroxysmal AF; P = NS). At 1 year, enrolled patients demonstrated significant weight loss (4.7% ± 5.3% vs 0.3% ± 4.4% in declined patients; P < .0001) and improved OSA care (78% [n = 43] of patients diagnosed with OSA began treatment). However, outcomes were similar between enrolled and declined patients undergoing ablation (arrhythmia control in 80% [n = 48] vs 79% [n = 38]; freedom from arrhythmia in 58% [n = 35] vs 71% [n = 34]; P = NS).

CONCLUSION

Despite improving weight loss and OSA care, our nurse-led RFM program did not impact 1-year arrhythmia outcomes in patients with AF undergoing catheter ablation.

A Nurse-Led Limited Risk Factor Modification Program to Address Obesity and Obstructive Sleep Apnea in Atrial Fibrillation Patients

Background

Obesity and obstructive sleep apnea (OSA) are associated with atrial fibrillation (AF), yet these conditions remain inadequately treated. We report on the feasibility and efficacy of a nurse‐led risk factor modification program utilizing a pragmatic approach to address obesity and OSA in AF patients.

Methods and Results

AF patients with obesity (body mass index ≥30 kg/m²) and/or the need for OSA management (high risk per Berlin Questionnaire or untreated OSA) were voluntarily enrolled for risk factor modification, which comprised patient education, lifestyle modification, coordination with specialists, and longitudinal management. Weight loss and OSA treatment were monitored by monthly follow‐up calls and/or continuous positive airway pressure (CPAP) unit downloads. Quality of life and arrhythmia symptoms were assessed with the SF‐36 and AF Severity Scale at baseline and at 6 months. From November 1, 2016 to October 31, 2017, 252 patients (age 63±11 years; 71% male; 57% paroxysmal AF) were enrolled, 189 for obesity and 93 for OSA. Obese patients who enrolled lost significantly greater percent body weight than those who declined (3% versus 0.3%; P<0.05). Among 93 patients enrolled for OSA, 70 completed sleep studies, OSA was confirmed in 50, and the majority (76%) started CPAP therapy. All components of quality of life and arrhythmia symptoms improved significantly from baseline to 6 months among enrolled patients.

Conclusions

A nurse‐led risk factor modification program is a potentially sustainable and generalizable model that can improve weight loss and OSA in AF patients, translating into improved quality of life and arrhythmia symptoms.

SUN-310 Duodenal Wall Insulinoma with Recurrence as Lymph Node Metastases

Background: The overwhelming majority of insulinomas are intrapancreatic, but rare cases have been described outside the pancreas. The course of extrapancreatic insulinoma is unclear as there are no reported cases with follow-up beyond 3 months. We present a case of extrapancreatic insulinoma with recurrence as metastatic disease at 5-year follow-up. Clinical Case: In June 2013 a 36-year-old woman presented with Whipple’s triad and 40-pound weight gain. Her serum glucose was 49 mg/dL (normal range 70-99 mg/dL) with insulin level 8.1 uIU/mL (2.6 - 24.9 uIU/mL) and C-peptide 2.2 ng/mL (1.1 - 4.4 ng/mL) prior to receiving dextrose. 72-hour fast confirmed hyperinsulinemic hypoglycemia at 26 hours. Abdominal CT with IV contrast showed a 1.1 x 1.6 x 2 cm hypervascular mass in the second portion of the duodenum and a normal pancreas. OctreoScan did not show uptake in the area of the mass. Esophagogastroduodenoscopy found a mass in the duodenal sweep and endoscopic ultrasound (EUS) showed a 1.6 x 1.6 cm duodenal mass and 3 hypoechoic well-defined lymph nodes up to 1 cm in length distal to the mass. She underwent exploratory laparotomy with duodenotomy and neuroendocrine tumor (NET) enucleation in August 2013. Pathology showed a well-differentiated intermediate grade 1.5 cm NET with Ki-67 index 3-4%. 4/4 lymph nodes were negative for disease. After surgery, she had 30-pound weight loss and resolution of hypoglycemia at her 6-month follow-up. In September 2015 she had mild hypoglycemia (60-70 mg/dL) during exercise. 7-day continuous glucose monitoring (CGM) showed no glucose values <60 mg/dL, and abdominal CT with IV contrast did not show evidence of disease. Due to more frequent hypoglycemia symptoms, she had another 7-day CGM placed in July 2017 which showed 29% of glucose values <60 mg/dL and a pattern of hypoglycemia overnight. Abdominal CT was negative, but PET-CT with Ga68-DOTATATE showed a 1.5 x 1.3 cm soft tissue nodule adjacent to the inferior pancreatic head and wall of the 2nd portion of the duodenum with max SUV of 41. A 72-hour fast was not repeated. EUS showed normal duodenum and pancreas but found peripancreatic lymphadenopathy. Lymph node fine needle aspiration confirmed NET. Repeat surgery found metastatic well-differentiated NET to 5/12 lymph nodes with Ki-67 index 3.8%. Her hypoglycemia resolved after surgery. Follow-up Ga68-DOTATATE scan in January 2018 did not show evidence of disease. Conclusions: Extrapancreatic insulinoma is rare, and while few cases have been described there has not been long-term follow-up reported. This is the first known case of extrapancreatic insulinoma recurrence. Current evidence shows lymph node metastases of intrapancreatic insulinoma do not change prognosis (Krampitz, et al. Arch Surg 2012). It is unclear if this applies to extrapancreatic insulinoma. More long-term outcome data are needed to help determine how these patients should be monitored and managed.

Abstract 146: Efficacy of a Nurse-Led Risk Factor Modification Program in Achieving Weight Loss in Obese Atrial Fibrillation Patients

Objective: Weight loss (WL) can improve arrhythmia outcomes in obese patients (pts) with atrial fibrillation (AF). Although WL in this population has been achieved by strict dietary and lifestyle modification in physician-led research protocols, these resource intensive strategies have limited real-life applicability. We report the efficacy of a pragmatic outpatient based nurse-led risk factor modification (RFM) program that utilizes a high-touch, single point of care approach for achieving WL in AF pts at a tertiary care arrhythmia program.

Methods: All new AF pts with obesity (defined as body mass index (BMI) ≥30kg/m 2 ) were offered enrollment. The pragmatic approach to WL focused on patient engagement and education, motivational interviewing, development of individualized lifestyle modification goals to improve dietary and exercise habits, and longitudinal telephonic care management to reinforce these changes. WL and compliance with established goals were assessed during ongoing biweekly (initial 2 months) then monthly follow-up support calls for up to 12 months. Continuing participation in RFM program was on a voluntary basis. Pts unable to achieve ≥3% WL by 3 months were referred for escalated care to a WL physician specialist. Pts who declined participation served as controls. Student t-test and chi-square tests were used to compare continuous and dichotomous variables.

Results: Between 11/1/16 to 10/31/17, 189 pts (BMI 36.3±6) enrolled in RFM program, and 115 pts (BMI 35.5±5.4; P=NS) declined participation. The majority of enrolled pts (72%, n=136 of 189) had failed ≥1 previous WL attempts. Follow-up WL data (5.5±4.1 months for enrolled; 5.2±2.9 months for declined; P=NS) was available and compared in 162 enrolled (86%, n=162 of 189) and 59 declined (51%, n=59 of 115) pts. Pts enrolled in RFM program achieved significantly greater WL than declined pts (2.7±3.8% vs. 0.3±3.5%, respectively; p<0.05). See table for details.

Conclusions: A pragmatic nurse-led risk factor modification strategy focusing on lifestyle changes reinforced by frequent patient follow-up can be effective in achieving weight loss in obese atrial fibrillation patients. This single point of care approach is a potentially sustainable model for maintaining weight loss in this population.

Cardiometabolic Effects of Anti-obesity Pharmacotherapy

PURPOSE OF REVIEW

We review recent studies discussing the impact of pharmacologic agents for weight loss on clinical cardiovascular events, as well as cardiometabolic risk factors.

RECENT FINDINGS

Pharmacotherapy with current FDA-approved medications for weight loss can significantly improve known risk factors for the development of cardiovascular disease such as hypertension, hyperlipidemia, insulin resistance, inflammatory biomarkers, and the quantity of visceral fat, as well as non-alcoholic fatty liver disease. However, data regarding the actual reduction in clinical cardiovascular events with the use of weight loss medications is scarce. Pharmacotherapy for weight loss may have additional benefit in optimizing patient's cardiometabolic comorbidities and improving their clinical cardiovascular outcomes, but each drug should be carefully selected based upon individual patient characteristics.

Exogenous hormonal regulation in breast cancer cells by phytoestrogens and endocrine disruptors

Observations on the role of ovarian hormones in breast cancer growth, as well as interest in contraception, stimulated research into the biology of estrogens. The identification of the classical receptors ERα and ERβ and the transmembrane receptor GPER and the resolution of the structure of the ligand bound to its receptor established the principal molecular mechanisms of estrogen action. The presence of estrogen-like compounds in many plants used in traditional medicine or ingested as food ingredients, phytoestrogens, as well as the estrogenic activities of many industrial pollutants and pesticides, xenoestrogens, have prompted investigations into their role in human health. Phyto- and xenoestrogens bind to the estrogen receptors with a lower affinity than the endogenous estrogens and can compete or substitute the hormone. Xenoestrogens, which accumulate in the body throughout life, are believed to increase breast cancer risk, especially in cases of prenatal and prepuberal exposure whereas the role of phytoestrogens is still a matter of debate. At present, the application of phytoestrogens appears to be limited to the treatment of post-menopausal symptoms in women where the production of endogenous estrogens has ceased. In this review we discuss chemistry, structure and classification, estrogen signaling and the consequences of the interactions of estrogens, phytoestrogens and xenoestrogens with their receptors, the complex interactions of endogenous and exogenous ligands, the evaluation of the health risks related to xenoestrogens, and the perspectives toward the synthesis of potent third generation selective estrogen receptor modulators (SERMs).

Nutritional management of type 2 diabetes mellitus and obesity and pharmacologic therapies to facilitate weight loss

Diet plays an integral role in the treatment of type 2 diabetes mellitus (T2DM). Unfortunately, many patients with T2DM do not have access to a registered dietitian or certified diabetes educator, and rates of physician counseling about diet remain low. This article provides an overview of the current recommendations for the nutritional management of T2DM, which are endorsed by the American Diabetes Association (ADA). Medical nutrition therapy, which provides a flexible and individualized approach to diet, emphasizes the total number (rather than the type) of carbohydrate consumed. Because fat intake also affects glycemia and cardiovascular risk, a reduction in daily mono- and polyunsaturated fat intake is recommended for most patients with T2DM. Weight loss plays an important adjunct role in treating patients with T2DM, because the majority of individuals with T2DM are overweight or obese. Patient lifestyle modification, which encompasses diet, physical activity, and behavioral therapy, can be used to facilitate weight loss in conjunction with several different dietary approaches. These include low-carbohydrate, low-fat, low-glycemic index, and Mediterranean diets. Studies have demonstrated that modest weight loss (5%-10% of body weight) is associated with significant improvements in patient measures of glycemic control, lipids, blood pressure, and other cardiovascular risk factors. Furthermore, a modest weight loss of as little as 4.5 kg can result in reducing the glycated hemoglobin level by approximately 0.5%. Pharmacologic agents, when combined with these approaches, may further augment weight loss. Familiarity with these principles can help physicians provide dietary counseling to their patients with T2DM and obesity.

Gold nanoprobe assay for the identification of mycobacteria of the Mycobacterium tuberculosis complex

Members of the Mycobacterium tuberculosis complex (MTC) are causative agents of human and animal tuberculosis. This complex encompasses several phylogenetically related species, including M. tuberculosis, the main aetiological agent of human tuberculosis, and Mycobacterium bovis, the causative agent of bovine tuberculosis, a relevant worldwide zoonosis. Clear epidemiological evaluation of appropriate and effective treatment requires unambiguous differentiation between MTC members. Routine diagnosis has been increasingly relying on the molecular identification of MTC members. In the present study, we report the use of a gold nanoparticle-based approach for the sensitive, specific and fast identification of MTC and for the differentiation of M. bovis and M. tuberculosis using the gyrB locus as target. This gold nanoprobe strategy relies on the colorimetric differentiation of specific DNA sequences based on differential aggregation profiles in the presence or absence of specific target hybridization. Three nanoprobes were designed and successfully used for the specific identification of members of MTC, M. bovis and M. tuberculosis.

Dissociation between intrahepatic triglyceride content and insulin resistance in familial hypobetalipoproteinemia

BACKGROUND & AIMS

Hepatic steatosis is associated with insulin resistance, but it is not clear whether increased intrahepatic triglyceride (IHTG) content causes the resistance or is a marker. Subjects with familial hypobetalipoproteinemia (FHBL) have high levels of IHTG because of a genetic defect in hepatic export of triglycerides, and provide a unique cohort to study the relationship between steatosis and insulin sensitivity.

METHODS

One group of lean subjects with normal IHTG content (2.2% +/- 0.6% of liver volume) (n = 6), and 3 groups of overweight and obese subjects matched for body mass index, were studied: (1) normal IHTG content (3.3% +/- 0.5%; n = 6), (2) high IHTG content (21.4% +/- 2.6%) due to nonalcoholic fatty liver disease (NAFLD; n = 6), and (3) high IHTG content (18.1% +/- 2.2%) due to FHBL (n = 3). A hyperinsulinemic-euglycemic clamp procedure, in conjunction with glucose tracer infusion, was used to determine multiorgan insulin sensitivity.

RESULTS

Hepatic insulin sensitivity (reciprocal of glucose rate of appearance [micromol x kg fat-free mass(-1) x min(-1)] x insulin [mU/L]) was greatest in the Lean group (2.0 +/- 0.4); it was the same among subjects with FHBL (0.8 +/- 0.1) and the group with normal IHTG content, matched for body mass index (0.7 +/- 0.1), but greater than the NAFLD group (0.3 +/- 0.1) (P < .01). Muscle insulin sensitivity (percent increase in glucose uptake during insulin infusion) was greatest in the Lean group (576% +/- 70%). Muscle insulin sensitivity was similar in subjects with FHBL and those with normal IHTG (319% +/- 77%, 326% +/- 27%, respectively), but greater than the NAFLD group (145% +/- 18%) (P < .01).

CONCLUSIONS

Steatosis is dissociated from insulin resistance in FHBL, which suggests that increased IHTG content is a marker, not a cause, of metabolic dysfunction.

Blood COX-2 and PGES gene transcription during the peripartum period of dairy cows with normal puerperium or with uterine infection

In the dairy cow, puerperal uterine intra-luminal concentrations of PGE(2) are related to the establishment and severity of uterine infections. Here we evaluated whether the blood concentrations of PGE(2) and the gene transcription profiles of enzymes involved in its synthesis (cyclooxygenase-2 and prostaglandin E synthase) could be used as markers of predisposition and/or presence of puerperal uterine infections. We also studied the relationship between the endocrine status and the leukocyte profiles around parturition and the transcription patterns of the genes. Finally, we have characterized the in vitro gene transcription and expression response to a challenge of LPS. Gene transcription profiles, quantified by real-time PCR, were similar in normal puerperium and metritis/endometritis cows, indicating that they are not suitable markers of predisposition to/presence of puerperal uterine infections. Transcription decreased from 2 weeks before parturition until parturition, when a minimum was attained, and then increased during the first week postpartum. The lowest gene transcription, at parturition, was coincidental with the highest total leukocytes, polymorphonuclear neutrophils and CD14 positive cell numbers. It is suggested that by this mechanism, a large number of PMN can be recruited into the uterus after parturition, avoiding an excessive acute inflammatory response. The lowest gene transcription was also coincidental with the surge in cortisol concentrations, indicating that this hormone plays a main immunomodulatory role around parturition. Gene transcription was significantly greater after stimulation with LPS than in non-stimulated blood. We suggest that this PGE(2) producing cells might arrive to the uterine lumen, contributing to the local PGE(2) concentrations and mediating the inflammatory response.

Comparison of three DNA extraction methods for Mycobacterium bovis, Mycobacterium tuberculosis and Mycobacterium avium subsp. avium

AIMS

To compare three methods for DNA extraction from Mycobacterium bovis, Mycobacterium tuberculosis and Mycobacterium avium subsp. avium.

METHODS AND RESULTS

The DNA was extracted from mycobacterial cultures using enzymatic extraction, combined bead beating and enzymatic extraction and cetyltrimethylammonium bromide (CTAB) extraction. The yield and quality of DNA were compared by spectrophotometry, agarose gel electrophoresis, restriction endonuclease analysis and PCR. The combined bead beating and enzymatic extraction method yielded more DNA. However, that method produced some sheared DNA, visible either by agarose gel electrophoresis or by restriction endonuclease analysis. All methods were appropriate for PCR amplification of a 123 bp fragment of IS6110 in M. bovis and M. tuberculosis, and of a 1700 bp fragment of FR300 region in M. avium avium.

CONCLUSIONS

Combined bead beating and enzymatic extraction method was the most efficient and easy method for extracting DNA from bacteria of the M. tuberculosis complex.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results reveal important differences among the DNA extraction methods for mycobacteria, which are relevant for the success of further downstream molecular analysis.

Gluteus medius muscle atrophy is related to contralateral and ipsilateral hip joint osteoarthritis

In order to understand the role of the GLUTEUS MEDIUS muscle (GM) in hip joint osteoarthritis, the objective of this study was to analyze the correlation between morphometric data of GM samples with osteoarthritis scores of ipsilateral and contralateral hips in 41 patients. GM samples obtained during unilateral hip replacement surgery were used to evaluate muscle fibers in the cross-sectional area (CSA) and other features indicative for muscle aging. Clinical symptoms were assessed by the Lequesne pain score. Hip osteoarthritis was graded by the Kellgren score and by measuring the sum joint space width (sumJSW) at three different articular locations and minimal JSW in a. p. radiographs. Varying degrees of GM muscle atrophy correlated with the pain score; pain score also correlated with radiographic signs of osteoarthritis. GM CSA was significantly correlated with all radiographic signs of the contralateral hip, but only with the sumJSW in the ipsilateral hip. It can be concluded that a weak GM may be the result of ipsilateral osteoarthitis, but may especially predispose the contralateral hip to develop osteoarthritis. This can be associated with an impaired GM capacity to avoid the shock impact in the load transfer during gait. Muscle strengthening is therefore recommended.

Characteristics of the gluteus medius muscle in an asymptomatic patient with radiographic signs of coxarthrosis

This case study describes the micromorphology and some biochemical features of gluteus medius muscle in a 79-year-old woman with radiographic signs of coxarthrosis but with no clinical symptoms who initially was admitted in the orthopaedic emergency service with a non-displaced subcapital fracture of the femoral neck due to a domestic accident (fall). The X-ray of the hip showed some characteristic features of coxarthrosis, classified grade 2 of the Kellgren criteria. After informed consent, it was decided to carry out the functional evaluation according to the indexes of Lequesne and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) and to take a biopsy of the gluteus medius muscle for microscopical examination and myosin heavy chain isoform identification during hip replacement surgery. For the Lequesne Index (score 0-24), the total score was 0, and for the WOMAC (score 0-96), the total score was also 0, both speaking in favour of full joint and muscle function. All the structural features observed in muscle were considered not to have any pathological relevance. The composition of the myosin heavy chains in the gluteus medius muscle was 48% MHC I, 41% MHC IIa, and 11% MHC IIx. The muscle characteristics do not support earlier concepts about muscle weakness as a predisposing factor for osteoarthritis. It is moreover concluded that the diagnosis should rather consider clinical symptoms than radiographic signs of osteoarthritis.

Screening of obstructive sleep apnoea: heart rate spectral analysis of nocturnal pulse oximetric recording

Using heart rate spectral analysis of nocturnal pulse oximetry, we prospectively evaluated the utility of this methodology in patients clinically suspected of having obstructive sleep apnoea (OSA). A hundred and ninety-seven outpatients referred with symptoms compatible with the diagnosis of OSA were studied. All participants had nocturnal pulse oximetry performed simultaneously with conventional polysomnography. Power density of heart rate obtained by nocturnal pulse oximetry was analysed using fast Fourier transformation of a Hamming-windowed signal. Recording test results were classified as abnormal (suspicion of OSA) in the presence of a peak in the periodogram between period boundaries 30-70 sec. A normal test result was defined as the absence of the 30-70 sec peak in the periodogram. The total area of the periodogram (S(TOT)), the area enclosed in the periodogram between the period boundaries 30-70 sec (S(30-70)), the area enclosed in the period boundaries 30-70 sec with respect to the total area of the periodogram (S) and the peak amplitude 30-70 sec (PA) were measured. The presence of a peak in the periodogram has a sensitivity of 81.3%, a specificity of 91.5% a positive predictive value of 89.1% and a negative predictive value of 85.1% for OSA diagnosis. The OSA patients were found to have higher values of S(TOT), S(30-70), S and PA than the non OSA patients. Receiver operating characteristics (ROC) curve was constructed at different thresholds of S(TOT), S(30-70) S and PA. For a PA threshold of 10(%)2, heart rate spectra analysis sensitivity for OSA was 58% and specificity was 92%. Furthermore, the positive and negative predictive values for diagnosis of OSA were 87 and 72% respectively. Apnoea hypopnea index (AHI) correlated significantly with S(TOT) (r=0.44; P<0.001), S(30-70) (r=0.59: P<0.001), S (r=0.58; P<0.001) and PA (r=0.58; P<0.001). According to our results, heart rate spectral analys s obtained by nocturnal pulse oximetry and identification of peak in the periodogram between period boundaries 30-70 sec could be useful as a diagnostic technique for OSA patients.

[Wiktor coronary stent for elective placement with an antiaggregation regimen. WINE study. WINE Group Study]

INTRODUCTION AND OBJECTIVES

The main problems associated with coronary stent implantation are subacute thrombosis and vascular and hemorrhagic complications due to the intensive anticoagulant regime. We studied the complications and the six-month restenosis rate after the elective implantation of a Wiktor stent in patients treated only with antiplatelet drugs.

PATIENTS AND METHODS

The WINE study is an open, observational, multicenter study that included 368 patients (380 lesions) from 11 Spanish hospitals. All patients were treated with aspirin (125-325 mg/day) and ticlopidine (250 mg/12 h for 4 weeks). After hospitalization, a clinical control and clinical and angiographic controls were performed at one and six months respectively.

RESULTS

27 patients were excluded after the procedure because of failed delivery of the stent (5 cases), suboptimal angiographic result (15 cases) or lack of adherence to the antithrombotic regime (7 cases). Among the 341 patients with an adequate result most lesions (76.2%) were type B, including 39.1% type B2 and 8.5% type C. Subacute stent occlusion occurred in two patients (0.6%). Seven patients (2.1%) had vascular complications related to the arterial puncture. No major hemorrhagic complications needing transfusion were found. At six months 64 patients (19.8%) showed angiographic restenosis.

CONCLUSIONS

When the angiographic result after Wiktor stent placement is adequate, the therapy with aspirin and ticlopidine is associated with a very low stent thrombosis rate as well as with a low rate of vascular complications and 6 month angiographic restenosis.

Effect of maternal delta 9-tetrahydrocannabinol on developing serotonergic system

In this study we investigated the effects of maternal delta 9-tetrahydrocannabinol on the developing serotonergic system. A daily dose of delta 9-tetrahydrocannabinol (5 mg/kg body weight) was administered p.o. to pregnant rats from gestational day 5 to postnatal day 1. Levels of indolamines were measured in four brain areas of the offspring on the day before or after birth. Levels of indolamines depended on the cerebral area, sex and pre- or postnatal age. Maternal exposure to delta 9-tetrahydrocannabinol decreased diencephalic levels of 5-hydroxytryptamine (5-HT), males being more susceptible than females. These perinatal changes could be responsible for the long-term neurophysiological alterations produced by cannabinoids.

Plasma leukocyte elastase concentration in angiographically diagnosed coronary artery disease

OBJECTIVE

To evaluate the clinical usefulness of leukocyte elastase determination in the diagnosis of coronary artery disease (CAD).

BACKGROUND

Recent research has shown the important role of elastase, a proteolytic enzyme released by neutrophils, in the pathogenesis of CAD.

METHODS

141 patients underwent coronary angiography during investigation of chest pain and/or heart valve disease. Ninety-six had coronary lesions and 45 non-stenotic coronaries. The patients were characterized as regards presence or absence of angina (stable or unstable), family history of CAD, smoking, diabetes mellitus, hypertension, leukocyte counts, and plasma lipid and elastase concentrations. Among CAD-group patients, those with simple atheromatous plaques were distinguished from those with complex plaques.

RESULTS

Elastase concentrations were greater in the CAD group than in the non-CAD group (49.7 +/- 2.8 micrograms.l-1; as against 29.5 +/- 2.2 micrograms.l-1; P < 0.001), and greater among complex-plaque CAD patients than among simple-plaque CAD patients (65.2 +/- 5.3 micrograms.l-1 as against 38.6 +/- 1.9 micrograms.l-1; P < 0.001). Logistic regression analysis showed (a) that the risk of CAD varied with elastase concentration, angina status, age and sex, increasing by 11% for every 1 microgram.l-1 increase in elastase concentration; and (b) that among CAD patients the risk of complex plaques was greatest for those with unstable angina and high elastase concentration, increasing by 6% for every 1 microgram.l-1 increase in elastase concentration.

CONCLUSIONS

Peripheral blood leukocyte elastase concentration is a sensitive diagnostic marker of CAD. High values suggest the presence of complex atheromatous plaques.

Activity of leucocyte elastase in women with coronary artery disease documented using angiography

BACKGROUND

Recent studies suggest that leucocyte elastase is involved in the pathogenesis of atherosclerosis. The objective of this study was to characterize the role of leucocyte elastase in arterial disease in women.

METHODS

Forty-two women underwent coronary angiography because of chest pain or valvulopathy. Twenty-three showed no signs of lesions (group 1) and 19 had coronary stenosis (group 2). Their age, weight and height were recorded, together with the presence of angina, arterial hypertension, diabetes mellitus, any family history of coronary disease and levels of tobacco consumption. Leucocyte counts, lipid levels and neutrophil elastase concentrations were determined from peripheral blood samples.

RESULTS

Levels of elastase were found to be significantly higher in group 2 than in group 1 (mean +/- SD 53.3 +/- 15.9 compared with 28.6 +/- 16.8 micrograms/l, P < 0.01). Patients from group 2, who had a greater mean age (69 +/- 7 compared with 58 +/- 9 years for group 1, p < 0.001), were more often diabetic (26% compared with 0%, p < 0.05) and were more likely to have family histories of ischaemic cardiomyopathy (59% compared with 18%, P < 0.05). However, multivariate analysis indicated that age and elastase levels were of independent value as predictors of coronary artery disease.

CONCLUSION

The concentration of elastase in peripheral blood is higher in women who have stenosis on coronary angiography.

Doppler echocardiographic comparison of small (19 mm) bileaflet and pericardial heart valve prostheses in aortic position

The resting haemodynamics of five types of small (19 mm) aortic valve prosthesis (2 bileaflet, 3 pericardial) were evaluated with Doppler echocardiography in 43 patients. Two received St Jude Medical and six CarboMedics bileaflet valves and 35 were given bioprostheses--16 Ionescu-Shiley, four Mitroflow and 15 Labcor-Santiago. No significant differences in peak or mean transvalvular pressure drop or in effective valve area were found between the bileaflet and the pericardial valves or among the three types of bioprosthesis. All but one of the bileaflet prostheses showed a characteristic regurgitation pattern, with two lateral and one central jet, and 16 (46%) of the bioprostheses showed central regurgitation, but in no case were these jets haemodynamically significant. Thus the 19 mm bileaflet and the studied pericardial prostheses all have satisfactory resting haemodynamics, and all are suitable for implanting in small aortic roots.

[Aortic pseudoaneurysm and acute myocardial infarct secondary to thoracic trauma]

Three cases of traumatic cardiovascular disease following chest trauma in males with no previous ischemic heart episodes are presented. One of them coursed with a combination of myocardial infarction and aortic pseudoaneurysm in an unusual location. The others coursed with and acute myocardial infarction and an aortic pseudoaneurysm, respectively. It is also underlined the utility of transthoracic and transesophageal echocardiography as well as a routine hemodynamic evaluation in this kind of patients.

Echocardiographic features of the normofunctional Labcor-Santiago pericardial bioprosthesis

Echocardiography was performed in 94 patients with a total of 99 normally functioning Labcor-Santiago bioprostheses, 62 in the aortic and 37 in the mitral position. The following variables were measured: peak and mean transvalvular velocities, peak and mean instantaneous pressure gradients as calculated from the modified Bernoulli equation, pressure half-time, cardiac index, stroke volume and effective orifice area (using continuity and Hatle equations). Regurgitation patterns were sought by transthoracic echocardiography (all valves) and, for selected mitral bioprostheses, by transesophageal echocardiography. Calculated mean aortic pressure gradient ranged from six to 10 mmHg and calculated effective aortic orifice area increased with ring diameter, with means of 1.27 cm2 for the 19 mm valve and 2.58 cm2 for the 27 mm valve. For mitral bioprostheses, mean pressure gradient ranged from 3.0 to 4.5 mmHg and calculated effective orifice area from 2.27 to 2.73 cm2. Only central regurgitation was observed. The Labcor-Santiago pericardial bioprostheses created little resistance to forward flow. In the small aortic root their hemodynamic performance was as good or better than that of other currently available devices. It is hoped that this new design will contribute increased in vivo mechanical durability.

[Myocardial ischemia secondary to a bilateral coronary fistula with drainage into the pulmonary artery trunk]

A case of bilateral coronary artery fistula into main pulmonary artery which courses with crisis of angina and subepicardial ischaemic changes in anterolateral leads is presented. The interest of the case reported is based on the peculiar anatomy of the fistula; there is only an unique collector to the pulmonary artery for both fistula and they present a completely different way of emerging: an unique vessel from the right coronary artery and several vessels from the anterior descending coronary artery. Ligation of the fistula was performed successfully and postoperative course was uneventful.

Leukocyte count as a predictor of the severity ischaemic heart disease as evaluated by coronary angiography

Increased white blood cell count has been reported associated with increase risk of coronary heart disease. We studied the relationship of white blood cell count to the 5 year incidence of coronary heart disease mortality in 152 men, without myocardial infarction or infection in the 6 months prior to the study. The coronary heart disease was determined by coronary arteriography study in all patients. None was treated by revascularization procedures (surgical or percutaneous transluminal coronary angioplasty). The severity of coronary heart disease was assessed by Gensini's Score and number of main coronary arteries with significant stenosis. The white blood cell count showed a positive correlation with Gensini's Score (r = 0.45, p < 0.01), and was significantly higher in the patients with three vessels disease (one vessel = 7084 +/- 1679 leukocytes/mm3; two vessels = 7768 +/- 1860 leukocytes/mm3; three vessels = 8174 +/- 2016 leukocytes/mm3; p < 0.05). The patients who died differed significantly from the survivors as regards total leukocyte count (8309 +/- 2271 against 7548 +/- 1702 cells/mm3; p < 0.05). Multivariate analysis, using a stepwise logistic regression, identified the white blood cell count as the more strong independent predictive variable for Gensini's Score (r = 0.42, p < 0.001). We conclude that, in our experience, increased white blood cell count may contribute to the initiation and progression of the coronary heart disease, and was associated with a shorter subsequent survival time.

Treatment of massive pulmonary thromboembolism with low intrapulmonary dosages of urokinase. Short-term angiographic and hemodynamic evolution

Sixteen patients who had massive pulmonary thromboembolism and shock had no history of cardiopulmonary disease. We present an evaluation of the short-term effects of fibrinolytic treatment consisting of intrapulmonary administration of a bolus of 500,000 IU of urokinase followed by infusion of 1 x 10(6) IU into the right auricle over 12 h and subsequent intravenous infusion of heparin. For each patient, the effectiveness of treatment was evaluated by comparing pretreatment angiographic and hemodynamic parameters with those measured 48 h after the start of treatment. The Miller index fell from 22.9 +/- 5.9 to 9.8 +/- 3.3 (p less than 0.001), with a mean improvement of 57.2 percent. All the hemodynamic parameters studied (cardiac output and index, total pulmonary vascular resistance, and systolic, diastolic, and mean pulmonary vascular pressure) also exhibited statistically significant differences between pretreatment and posttreatment values (p less than 0.001 for each parameter), with a mean improvement of over 30 percent in each case. All the patients survived, and in no case did treatment fail; only one patient (6.2 percent) suffered severe hemorrhage. We conclude that this form of administration of urokinase is useful for patients with critical massive pulmonary thromboembolism.

[Aortic dissection with rupture into the pulmonary artery trunk]

We report a case of a hypertensive male with dissection of the ascending aorta involving the left carotid and subclavian arteries, with rupture into the pulmonary artery trunk, a vascular complication which has not been reported.