Effects of Pharmacotherapy for the Treatment of Obesity in an Urban, Safety-Net Population

OBJECTIVE

To evaluate the effect of common weight loss pharmacotherapies among low-income, racially diverse adult patients at an urban safety-net weight management clinic.

METHODS

Our retrospective review from 2015 to 2019 examined patients who took either GLP-1 analog (GL) or phentermine/topiramate (PT) for ≥90 days and patients who exclusively pursued non-pharmacologic treatment for comparison. Changes in weight, blood pressure, and hemoglobin A1c at 1-year follow-up were reported.

RESULTS

We analyzed 22 GL and 26 PT patients and included 40 patients who pursued only lifestyle modifications (LM). All three groups achieved significant weight loss at one year: GL -3.69 (interquartile range (IQR): -11.0, -1.77) kg (p=0.0004), PT -7.01 (IQR: -13.4, -1.45) kg (p<0.001), and LM -3.01 (IQR: -6.81, 1.13) kg (p=0.005). There was no significant difference in the median weight loss (p=0.11) between the three groups. We observed no significant changes in systolic blood pressure but saw a significant change of -0.75 in hemoglobin A1c (IQR: -1.35, -0.25) (p=0.01) among patients with diabetes in the GL group.

CONCLUSIONS

Our real-world applications of GLP-1 and phentermine/topiramate suggest that both are effective weight loss medication regimens in low-socioeconomic status patients.

Autoantibodies to Perilipin-1 Define a Subset of Acquired Generalized Lipodystrophy

Acquired lipodystrophy is often characterized as an idiopathic subtype of lipodystrophy. Despite suspicion of an immune-mediated pathology, biomarkers such as autoantibodies are generally lacking. Here, we used an unbiased proteome-wide screening approach to identify autoantibodies to the adipocyte-specific lipid droplet protein perilipin 1 (PLIN1) in a murine model of autoimmune polyendocrine syndrome type 1 (APS1). We then tested for PLIN1 autoantibodies in human subjects with acquired lipodystrophy with two independent severe breaks in immune tolerance (including APS1) along with control subjects using a specific radioligand binding assay and indirect immunofluorescence on fat tissue. We identified autoantibodies to PLIN1 in these two cases, including the first reported case of APS1 with acquired lipodystrophy and a second patient who acquired lipodystrophy as an immune-related adverse event following cancer immunotherapy. Lastly, we also found PLIN1 autoantibodies to be specifically enriched in a subset of patients with acquired generalized lipodystrophy (17 of 46 [37%]), particularly those with panniculitis and other features of autoimmunity. These data lend additional support to new literature that suggests that PLIN1 autoantibodies represent a marker of acquired autoimmune lipodystrophies and further link them to a break in immune tolerance.

Doença de Van Neck-Odelberg — Entidade rara ou subdiagnosticada?

A doença de Van Neck-Odelberg (VNO) é uma osteocondrose rara, que acomete a sincondrose isquiopúbica (SIP). Esta entidade deve ser incluída no diagnóstico diferencial de crianças com claudicação na marcha, dor inguinal e limitação funcional do quadril. Imagiologicamente é caracterizada por hipertrofia assimétrica da SIP. Apresentamos o caso clínico de uma criança de 4 anos, previamente saudável, atendida no serviço de emergência devido a dor inguinal no lado esquerdo e claudicação na marcha com início no mesmo dia. Não havia história prévia de trauma ou alteração dos parâmetros inflamatórios. Foi realizada uma radiografia da bacia e ressonância magnética nuclear (RMN) que evidenciou imagem radiopaca de contornos bem definidos no ramo isquiopúbico esquerdo e edema na SIP. Com diagnóstico provável de doença de VNO, o paciente foi medicado sintomaticamente, com resolução completa ao fim de 10 dias. A claudicação na marcha é um motivo frequente de avaliação médica na população pediátrica. Até os 5 anos de idade, as causas mais comuns são sinovite transitória do quadril, artrite séptica e Doença de Legg-Calvé-Perthes. Na ausência de história de trauma ou clínica sugestiva de infeção deverá ser equacionada a hipótese de doença de VNO. Para o seu diagnóstico, é fundamental a realização de radiografia da bacia, cujo achado mais comum é uma opacificação fusiforme unilateral, no nível do ísquion, podendo ser necessária a realização de RMN. O tratamento recomendado é conservador, com recuperação sintomática em 2 semanas. O conhecimento e o diagnóstico desta entidade permitem uma abordagem direcionada e sem a carga emocional para o paciente e seus familiares que outras patologias poderiam transmitir.

A gene-diet interaction controlling relative intake of dietary carbohydrates and fats

OBJECTIVE

Preference for dietary fat vs. carbohydrate varies markedly across free-living individuals. It is recognized that food choice is under genetic and physiological regulation, and that the central melanocortin system is involved. However, how genetic and dietary factors interact to regulate relative macronutrient intake is not well understood.

METHODS

We investigated how the choice for food rich in carbohydrate vs. fat is influenced by dietary cholesterol availability and agouti-related protein (AGRP), the orexigenic component of the central melanocortin system. We assessed how macronutrient intake and different metabolic parameters correlate with plasma AGRP in a cohort of obese humans. We also examined how both dietary cholesterol levels and inhibiting de novo cholesterol synthesis affect carbohydrate and fat intake in mice, and how dietary cholesterol deficiency during the postnatal period impacts macronutrient intake patterns in adulthood.

RESULTS

In obese human subjects, plasma levels of AGRP correlated inversely with consumption of carbohydrates over fats. Moreover, AgRP-deficient mice preferred to consume more calories from carbohydrates than fats, more so when each diet lacked cholesterol. Intriguingly, inhibiting cholesterol biosynthesis (simvastatin) promoted carbohydrate intake at the expense of fat without altering total caloric consumption, an effect that was remarkably absent in AgRP-deficient mice. Finally, feeding lactating C57BL/6 dams and pups a cholesterol-free diet prior to weaning led the offspring to prefer fats over carbohydrates as adults, indicating that altered cholesterol metabolism early in life programs adaptive changes to macronutrient intake.

CONCLUSIONS

Together, our study illustrates a specific gene-diet interaction in modulating food choice.

Elastase 3B mutation links to familial pancreatitis with diabetes and pancreatic adenocarcinoma

While improvements in genetic analysis have greatly enhanced our understanding of the mechanisms behind pancreatitis, it continues to afflict many families for whom the hereditary factors remain unknown. Recent evaluation of a patient with a strong family history of pancreatitis sparked us to reexamine a large kindred originally reported over 50 years ago with an autosomal dominant inheritance pattern of chronic pancreatitis, diabetes and pancreatic adenocarcinoma. Whole exome sequencing analysis identified a rare missense mutation in the gene encoding pancreas-specific protease Elastase 3B (CELA3B) that cosegregates with disease. Studies of the mutant protein in vitro, in cell lines and in CRISPR-Cas9 engineered mice indicate that this mutation causes translational upregulation of CELA3B, which upon secretion and activation by trypsin leads to uncontrolled proteolysis and recurrent pancreatitis. Although lesions in several other pancreatitic proteases have been previously linked to hereditary pancreatitis, this is the first known instance of a mutation in CELA3B and a defect in translational control contributing to this disease.

Obesity and Fat Metabolism in Human Immunodeficiency Virus-Infected Individuals: Immunopathogenic Mechanisms and Clinical Implications

Metabolic complications relating to complex effects of viral and immune-mediated mechanisms are now a focus of clinical care among persons living with human immunodeficiency virus (PLHIV), and obesity is emerging as a critical problem. To address knowledge gaps, the US National Institutes of Health sponsored a symposium in May 2018 entitled "Obesity and Fat Metabolism in HIV-infected Individuals." Mechanisms relating to adipose dysfunction and fibrosis, immune function, inflammation, and gastrointestinal integrity were highlighted as contributors to obesity among PLHIV. Fibrotic subcutaneous adipose tissue is metabolically dysfunctional and loses its capacity to expand, leading to fat redistribution, including visceral obesity and ectopic fat accumulation, promoting insulin resistance. Viral proteins, including viral protein R and negative regulatory factor, have effects on adipogenic pathways and cellular metabolism in resident macrophages and T cells. HIV also affects immune cell trafficking into the adipose compartments, with effects on adipogenesis, lipolysis, and ectopic fat accumulation. Key cellular metabolic functions are likely to be affected in PLHIV by gut-derived cytokines and altered microbiota. There are limited strategies to reduce obesity specifically in PLHIV. Enhancing our understanding of critical pathogenic mechanisms will enable the development of novel therapeutics that may normalize adipose tissue function and distribution, reduce inflammation, and improve insulin sensitivity in PLHIV.

Sweet cognition: The differential effects of glucose consumption on attentional food bias in individuals of lean and obese status

In general, glucose consumption improves cognitive performance; however, it is unknown whether glucose specifically alters attentional food bias, and how this process may vary by BMI status. We hypothesized that glucose consumption would increase attentional food bias among individuals of obese BMI status more so than among individuals of lean BMI status. Participants (N = 35) completed the n-back, a working memory task modified to assess attentional food bias (ATT-Food), under fasting and glucose challenge conditions. We computed pre-post changes in ATT-Food, blood glucose and insulin (∆BG & ∆BI), and perceived task-stress (∆stress). After the second cognitive test and blood draw, participants ate lunch and completed a "taste test" of highly palatable foods, and we recorded food consumption. Pre-post changes in ATT-Food were greater among participants of obese (relative to lean) BMI status (F(1,33) = 5.108, p = .031). Greater ∆ATT-Food was significantly associated with greater ∆BG (r = .462, p = .007) and reduced ∆stress (r =-.422, p = .011), and marginally associated with greater taste-test eating (r =.325, p = .057), but was not associated with ∆BI. Our findings suggest that individuals of obese BMI status may exhibit "sweet cognition," as indexed by greater attentional food bias following glucose ingestion, relative to individuals of lean BMI status. Among individuals of obese BMI status, sweet cognition may arise from difficulty broadening attention toward non-food cues after consuming a high glucose load, thereby potentially perpetuating sugar consumption. If confirmed by further research, measures of sweet cognition may help identify individuals with a phenotype of risk for obesity and greater sugar consumption, who may benefit from tailored interventions.

Developmental staging of male murine embryonic gonad by SAGE analysis

Despite the identification of key genes such as Sry integral to embryonic gonadal development, the genomic classification and identification of chromosomal activation of this process is still poorly understood. To better understand the genetic regulation of gonadal development, we performed Serial Analysis of Gene Expression (SAGE) to profile the genes and novel transcripts, and an average of 152,000 tags from male embryonic gonads at E10.5 (embryonic day 10.5), E11.5, E12.5, E13.5, E15.5 and E17.5 were analyzed. A total of 275,583 non-singleton tags that do not map to any annotated sequence were identified in the six gonad libraries, and 47,255 tags were mapped to 24,975 annotated sequences, among which 987 sequences were uncharacterized. Utilizing an unsupervised pattern identification technique, we established molecular staging of male gonadal development. Rather than providing a static descriptive analysis, we developed algorithms to cluster the SAGE data and assign SAGE tags to a corresponding chromosomal position; these data are displayed in chromosome graphic format. A prominent increase in global genomic activity from E10.5 to E17.5 was observed. Important chromosomal regions related to the developmental processes were identified and validated based on established mouse models with developmental disorders. These regions may represent markers for early diagnosis for disorders of male gonad development as well as potential treatment targets.

Transcriptome analyses of male germ cells with serial analysis of gene expression (SAGE)

Serial analysis of gene expression (SAGE) provides an alternative with additional advantages to microarrays for studying gene expression during spermatogenesis. The digitized transcriptome provided by SAGE of purified mouse germ cells identified 27,504 species of transcripts expressed in type A spermatogonia, pachytene spermatocytes, and round spermatids. Over 2700 of these transcripts were novel. Computational analyses allowed the identification of clusters of co-regulated genes, cell-specific promoter modules, cell-specific biological processes, as well as "preferential" biological networks in different cell types. These analyses provided potential drug targets for interference of specific pathways at different stages of spermatogenesis. Analyses of the transcriptomes revealed the prominent role of cytochrome c oxidase in germ cells and suggest a novel role for this enzyme in cytochrome c-mediated apoptosis in spermatogonia. A number of genes were shown to undergo differential splicing during spermatogenesis giving rise to cell-specific splice variants.

Application of transcriptional and biological network analyses in mouse germ-cell transcriptomes

Serial analysis of gene expression (SAGE) provides a global analysis platform for profiling mRNA populations present in cells of interest without the constraint of gene selection and the ambiguous nature of data obtained. However, most of the reports on SAGE and germ cell development are limited to descriptive analyses. Here, we report a series of bioinformatic analyses using recently published SAGE data on the transcriptome of mouse type A spermatogonia (Spga), pachytene spermatocytes (Spcy), and round spermatids (Sptd). Tags with a total count of > or =20 in three SAGE libraries were examined. Our aim was to identify and discover potential transcriptional regulators and pathways involved at different stages of spermatogenesis. Unsupervised hierarchical clustering based on tag expression and Gene Ontology analysis were applied to identify genes and biological processes overrepresented at a particular stage of development. The 5' cis-regulatory elements were examined for common regulators in different functional clusters. Potential biological networks were also constructed to reveal the link between the gene candidates. Biological pathways related to the three germ cell stages were constructed. A number of known transcription regulators in spermatogenesis, including NF-kappaB, SP1, AP-1, and EGR, were identified. Novel promoter elements such as the E box in Spga-specific genes, GATA in Spcy-specific genes, and GKLF in Sptd-specific genes were also observed. Taken together, our approach is reliable and provides a foundation for the generation of novel biological hypotheses for studying spermatogenesis.

Relationship of basal and postprandial intraduodenal bile acid concentrations and plasma cholecystokinin levels with abdominal pain in patients with chronic pancreatitis

Abdominal pain in patients with chronic pancreatitis has been related to an increase in plasma cholecystokinin (CCK) levels. The aim of the study was to disclose the relation of the altered response with the low intraduodenal bile acids levels found in these patients. Twenty patients with chronic pancreatitis were classified into groups I (n = 11) and II (n = 9) according to the presence or absence of pain. Intraduodenal trypsin and bile acids concentrations and plasma CCK levels were measured before and 30, 60, and 90 min after a test meal. Comparisons between values in both groups were carried out. Correlation of intraduodenal trypsin and bile acids with plasma CCK was analyzed. Patients with pain exhibited significantly lower intraduodenal trypsin levels at 30 and 90 min and lower basal and postprandial intraduodenal bile acids levels than patients without pain. In patients with pain, basal and postprandial plasma CCK levels were significantly higher than in patients without pain. A negative correlation was demonstrated between intraduodenal bile acids and plasma CCK. In patients with chronic pancreatitis and pain, a reduction in intraduodenal postprandial trypsin and basal and postprandial bile acids concentrations, as well as an increase in basal and postprandial plasma CCK levels, was encountered. A negative correlation between intraduodenal bile acids and plasma CCK concentrations was detected that may be implicated in the pathogenesis of pain.

[Viridans streptococci isolated from cerebrospinal fluid. Clinical significance of 9 cases]

Viridans streptococci (VS) are often isolated from cerebrospinal fluid (CSF). However, the significance of such isolates is poorly understood. In the present study we carry out a retrospective analysis of 9 patients in whom VS were isolated from CSF during a 1-year period at La Paz Hospital. Two patients (22.2%) had meningitis diagnosed through clinical, laboratory and bacteriologic findings. Both patients had predisposition diseases (previous difficult spinal tap, ventriculo-peritoneal shunt). The other isolations were considered as contaminants. Three patients (33.3%) with no VS meningitis had other different serious disease (sepsis without bacteriologic confirmation). VS are isolated with relative frequency from CSF, although they cause meningitis in less than one-quarter of the cases (those who have a predisposition disease). In the other cases, VS are isolated as contaminants of CSF and other disease should be search as cause of patient symptoms.

Thoracic pain and abnormal chest radiograph

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[Isolated laryngeal candidiasis. Description of 2 cases and review of the literature]

Infection of the larynx by Candida is rare and usually accompanies lung or disseminated candidiasis. The incidence of isolated laryngeal candidiasis (ILC) is low, although it may be underestimated. We describe 2 patients with ILC confirmed during autopsy: a 45-years-old male with pulmonary fibrosis and a 4-years-old girl with acute myeloblastic leukemia. Hoarseness and dysphagia are the most common symptoms of ILC. The most effective diagnostic technique is laryngoscopy with specimen culture and/or histopathology. Specimens usually show whitish plaques on the larynx. Most ILC patients have some associated disease and/or predisposing factors, with frequent antibiotic treatment prior to the advent of candidiasis. Intravenous amphotericin B provides the most effective therapy, although other antimycotics are also useful. Early diagnosis and initiation of therapy curtail the disease and can prevent systemic dissemination.

[Invasive pulmonary aspergillosis associated with influenza virus]

Invasive pulmonary aspergillosis can occur after viral influenza infection. It is described a previously healthy 58-year-old man with influenza virus infection who later suffered pulmonary aspergillosis. His response to amphotericin B was successful. The seven similar cases reported in the literature are revised and some common features established. Early antifungal therapy should be administered to any patient with previous flu illness presenting bilateral pulmonary infiltrates without response to antibiotics, if Aspergillus is isolated from the respiratory secretions.

[Neurologic manifestations of Whipple disease]

Pure neurologic Whipple's disease (WD) may be suspected by same clinical data (dementia-ophthalmoplegia-myoclonus triad, oculomasticatory myorhythmia) with support of MRI. Diagnosis is confirmed by intestinal and/or brain biopsy. Early recognition is critical in a disease that can lead to irreversible neurologic sequelae and that can potentially be cured. Despite therapy, relapses in patients with WD are common, being neurologic recurrence the most frequent and serious. Antibiotics that do not cross the blood-brain barrier are not adequate initial therapy for WD, because they predispose to neurologic relapse. Patients with WD should be treated for one year with antibiotics that cross the blood-brain barrier (such as parenteral penicillin+streptomycin, followed by oral trimethoprim-sulfamethoxazole). CNS relapse is usually resistant to therapy.

[Sero-ascitic gradient of albumin: usefulness and diagnostic limitations]

The serum-ascites albumin (SAA) gradient has been defined as the serum albumin concentration minus the ascitic fluid albumin concentration. The SAA gradient is superior to the exudate-transudate concept to classify ascites, being a exact portal hypertension (PH) marker. An elevated SAA gradient (1.1 g/L or greater) correlates with PH, whereas a low gradient indicates no PH. The SAA gradient correlates well with PH in cirrhotic patients. It is also of particular utility to differentiate between congestive heart failure and malignant ascites without liver metastases (both of them with elevated ascites fluid proteins -AFP-). However, a low SAA gradient do not differentiate between tuberculous and malignant ascites. Consequently, there are still need for tests a cytology, culture for mycobacteria or ascites fluid polymorphonuclear cell count in some cases. The level of AFP, apart from the exudate-transudate concept, has some value for certain cases (a low level of AFP implicates a high risk of spontaneous bacterial peritonitis). The SAA gradient should replace the AFP concentration as the initial test to classify ascites.

[Meningitis due to streptococcus viridans]

Viridans Streptococci (VS) may cause meningitis although, in most cases, they are isolated as contaminants in CSF. However VS should not be systematically underestimated as contaminants in CSF without a suitable clinical and analytical evaluation. Meningitis as a result of VS is being diagnosed with increasing frequency, especially in new born babies. Classic predisposition factors and illnesses (traumatism, surgery and infection) have increased, one frequent pathogenic mechanism being rupture of the mucous membrane with subsequent meningitis. VS are normally sensitive to penicillin G. However VS may be resistant to penicillin (low affinity of PBP to penicillin) and cause serious infections, including meningitis. For this reason it is convenient to perform sensitivity tests on VS in vitro in isolation to determine the appropriate therapy.

[Invasive pulmonary aspergillosis. Necropsy series]

Invasive pulmonary aspergillosis (IPA) is a severe infection which is usually diagnosed at postmortem examination. This infection occurs mainly in immunosuppressed patients, although it has also been reported in immunocompetent patients. Clinical records from patients diagnosed with IPA in our institution from 1983 to 1992 were retrospectively studied to analyse clinical and therapeutical characteristics of IPA. Sixteen episodes of IPA were recorded, all of them but one from necrotic specimens. A total of 18.7% of patients were immunocompetent, one patient had the acquired immunodeficiency syndrome (AIDS), and the remaining patients had a classical immunosuppression. Fever and dyspnea were noted in all patients; hemoptysis was recorded in 12.5% of patients. The predominant radiological pattern was a bilateral alveolar infiltrate (75%). Diagnosis was made at postmortem examination in 15 cases (93.7%), and a clinical premortem suspicion was obtained only in 25% of patients. IPA can occur in immunocompetent patients more frequently than considered until now. The suspicion index for IPA is low, even in immunosuppressed patients.

[Extrahepatic portal vein aneurysm and recurrent cholestasis]

Aneurysm of the portal vein is quite infrequent and its clinical manifestations is variable. The association between aneurysm of the extrahepatic portal vein and recurring obstructive jaundice has only been described on one occasion, one where there was also portal hypertension. One case of aneurysm of extrahepatic portal vein associated with recurring cholestasis is described. The diagnosis was performed via echography and abdominal TAC and confirmed by portal venography. There was no evidence of hepatopathy or portal hypertension. Possibly, the displacement of the biliary tract the portal vein is a contributing factor to recurring cholestasis in the present case.

Tracheoesophageal fistula as the presenting manifestation of Hodgkin's lymphoma

We present a patient with tracheoesophageal fistula as the initial manifestation of Hodgkin's disease with oesophageal involvement. To our knowledge, this has not been previously reported. The diagnosis of Hodgkin's lymphoma was made at autopsy.

[Pleuroperitoneal shunt in the treatment of pleural effusion associated with cirrhosis]

Some patients with unbalanced hepatic cirrhosis may develop a recidivant pleural leakage resulting in relevant gas interchange disorders. In the treatment of recidivant pleural leakage, evacuative thoracocentesis and pleurodesis may be used. If these procedures fail, pleurectomy or surgery may be used, although with relevant morbidity and mortality rates. Another option, used mainly for malignant leakages, is the placement of a pleuroperitoneal shunt. We present the case of a patient with recidivant pleural leakage associated to hepatic cirrhosis, in which after the failure of paracentesis and pleurodesis, a pleuroperitoneal shunt was successfully inserted. The pleuroperitoneal shunt may be a therapeutical alternative in the recidivant pleural leakage associated to cirrhosis.