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    ABSTRACT: Background Obesity is a risk factor for the development of gout. An increased incidence of early gouty attacks after bariatric surgery has been reported, but the data is sparse. The effect of weight-loss surgery on the behavior of gout beyond the immediate postoperative phase remains unclear. Objectives To evaluate the pre- and post-operative frequency and features of gouty attacks in bariatric surgery patients Setting Academic Institution, United States. Methods Charts were reviewed to identify patients who had gout prior to bariatric surgery. Demographic and gout-related parameters were recorded. The comparison group consisted of obese individuals with gout who underwent non-bariatric upper abdominal procedures. Results Ninety-nine morbidly obese patients who underwent bariatric surgery had gout. The comparison group consisted of 56 patients. The incidence of early gouty attack in the first month following surgery was significantly higher in the bariatric group than the non-bariatric group (17.5% versus 1.8%, p=0.003). In the bariatric group, 23.8% of patients had at least one gouty attack during the 12-month period before surgery, which dropped to 8.0% during postoperative months 1 to 13 (p=0.005). There was no significant difference in the number of gouty attacks in the comparison group before and after surgery (18.2% versus 11.1%, p=0.33). There was a significant reduction in uric acid levels 13-months after bariatric surgery when compared to baseline values (9.1±2.0 versus 5.6±2.5 mg/dL, p=0.007). Conclusion The frequency of early postoperative gout attacks after bariatric surgery is significantly higher than that of patients undergoing other procedures. However, the incidence decreases significantly after the first postoperative month up to 1 year.
    Surgery for Obesity and Related Diseases 01/2014;
  • Surgery for Obesity and Related Diseases 01/2014;
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    ABSTRACT: Introduction The number of times an article has been cited reflects its influence in a specific field. Objective The aim of this study was to identify and characterize the most highly cited articles published on bariatric and metabolic surgery. Materials and Methods The 50 most frequently cited articles in bariatric and metabolic surgery were identified from the Scopus database in December 2013. Results The median number of citations was 383.5 (range 275-2482). Most of the articles were published between 2000-2012 (n=35), followed by 1990-1999 (n=12), then before 1990 (n=3). These citation classics came from eight countries, with the majority originating from the United States (n=34), followed by Sweden (n=4) and Australia (n=4). The 50 articles were published in 20 journals, led by New England Journal of Medicine (n=9) and Annals of Surgery (n=9). Only 10 of the articles were published in obesity specific journals. The level of evidence of the 49 clinical publications and one animal study consisted of level I (n=5), II (n=11), III (n=9), IV (n=19), and V (n=6). Meta-analyses were 16% of the total citations. Metabolic (n=12) and survival (n=6) impacts of surgery were among the most common fields of study. Conclusion Extending from the early 1950’s through the voluminous growth period of the early 2000s, the field of bariatric and metabolic surgery led to the emergence of many top-cited scientific articles. These articles have provided the scientific basis for the only currently effective treatment for severe obesity. Articles published in high-impact journals, innovative observational studies, meta-analyses, survival analyses, and research on postoperative metabolic changes are most likely to be cited in the field of bariatric surgery.
    Surgery for Obesity and Related Diseases 01/2014;
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    ABSTRACT: OBJECTIVE To evaluate the effects of two bariatric procedures versus intensive medical therapy (IMT) on β-cell function and body composition.RESEARCH DESIGN AND METHODSA prospective, randomized, controlled trial of 60 subjects with uncontrolled type 2 diabetes (HbA(1c) 9.7 ± 1%) and moderate obesity (BMI 36 ± 2 kg/m(2)) randomized to IMT alone, IMT plus Roux-en-Y gastric bypass, or IMT plus sleeve gastrectomy. Assessment of β-cell function (mixed meal tolerance testing) and body composition were performed at baseline and 12 and 24 months.RESULTSGlycemic control improved in all three groups at 24 months (N = 54), with a mean HbA(1c) of 6.7 ± 1.2% for gastric bypass, 7.1 ± 0.8% for sleeve gastrectomy, and 8.4 ± 2.3% for IMT (P < 0.05 for each surgical group versus IMT). Reduction in body fat was similar for both surgery groups, with greater absolute reduction in truncal fat in gastric bypass versus sleeve gastrectomy (-16 vs. -10%; P = 0.04). Insulin sensitivity increased significantly from baseline in gastric bypass (2.7-fold; P = 0.004) and did not change in sleeve gastrectomy or IMT. β-cell function (oral disposition index) increased 5.8-fold in gastric bypass from baseline, was markedly greater than IMT (P = 0.001), and was not different between sleeve gastrectomy versus IMT (P = 0.30). At 24 months, β-cell function inversely correlated with truncal fat and prandial free fatty acid levels.CONCLUSIONS Bariatric surgery provides durable glycemic control compared with intensive medical therapy at 2 years. Despite similar weight loss as sleeve gastrectomy, gastric bypass uniquely restores pancreatic β-cell function and reduces truncal fat, thus reversing the core defects in diabetes.
    Diabetes care 02/2013;
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    ABSTRACT: Objective: Peri-operative glycemic control in critically-ill cardio-thoracic surgery patients may improve post-surgical outcomes. The objective of the study was to compare outcomes before and after the implementation of a protocol using subcutaneous (SC) glargine at transition from IVII.Methods: In August 2006, the authors' institution started using glargine and supplemental rapid-acting insulin (SSI) at transition from IVII (intravenous insulin infusion) (glargine-SSI group). Before that month, only supplemental insulin was used (SSI group). The Primary outcome was first glucose (BG1) after discontinuation (DC) of IVII. Secondary outcomes were absolute difference between last glucose before DC of IVII (BG0) and BG1; mean glucose in first 24 hours after DC of IVII (BG-24); need for SSI; hypoglycemia as well as other outcomesResults: Mean BG0, mean BG1, Mean BG24, the difference between BG1 and BG0 and the difference between BG-24 and BG0 were not statistically different between the 2 groups. Among DM patients, those who had received glargine had lower mean difference between BG1 and BG0, and lower mean BG24 than those who had not received glargine (14.6 vs. 33.1 mg/dL, p=0.20 and 163.8 vs. 177.9 mg/dL, p=0.29 respectively). A higher proportion of patients with DM needed SSI compared to those without DM (82% vs. 36%, p<0.001).Conclusion: Glargine administered at the cessation of IVII enabled less SSI coverage in diabetic patients subsequent to transition from IVII. However, BG control did not show statistically significant difference between the glargine-SSI vs SSI groups. Prospective studies with larger number of patients will be needed to show possible clinically significant benefits of this intervention.
    Endocrine Practice 02/2013;
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    ABSTRACT: Objective: To report a rare case of hypophosphatemic rickets (HR) leading to extensive cardiac complications.Methods: We present the clinical course and autopsy findings of a patient with HR, treated with chronic phosphate-only therapy as a child, who subsequently developed tertiary hyperparathyroidism leading to extensive cardiac calcifications and complications. We also review the literature on the pathophysiology of calcifications from HR.Results: A 34-year-old man was diagnosed with HR at 4 years of age after presenting with growth delay and leg bowing. Family history was negative for the disease. He was initiated on high-dose phosphate therapy (2-6 grams of elemental phosphorus/day) with sporadic calcitriol use between 4-18 years old. For 6 years total, he received phosphate-only therapy. Subsequently, he developed nephrocalcinosis, heart valve calcifications, severe calcific coronary artery disease, heart block, and congestive heart failure. At a young age, he required an aortic valve replacement and a biventricular pacemaker that was subsequently upgraded to an implantable cardioverter defibrillator. Autopsy showed extensive endocardial, myocardial, and coronary artery calcifications.Conclusions: Cardiac calcification is a known sequela of tertiary hyperparathyroidism when it occurs in patients with renal failure, but it is rarely seen in HR due to high phosphate therapy. Phosphate alone should never be used to treat HR; high doses, even with calcitriol, should be avoided. It is important to be cognizant of high-dose phosphate effects and to consider parathyroidectomy for autonomous function, if needed. This case emphasizes the importance of appropriate therapy, monitoring and management of patients with HR.Abbreviations: FGF, fibroblast growth factor; HR, hypophosphatemic rickets.
    Endocrine Practice 11/2012;
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    ABSTRACT: Cushing's syndrome (CS) results from prolonged exposure to elevated endogenous cortisol. Majority of cases are caused by ACTH, pituitary, or ectopic origin. Primary adrenal hypersecretion is 15-20% caused by adenomas, carcinomas (ACC), and rarely by nodular adrenocortical disease. CS presents with all typical features. Commonly recommended initial testing are urinary free cortisol, late-night salivary cortisol, and 1-mg overnight dexamethasone suppression test (DST). Imaging is the key to diagnosis. CS continues to pose diagnostic and therapeutic challenges; life-long follow-up is mandatory. J. Surg. Oncol. 2012; 106:565-571. © 2012 Wiley Periodicals, Inc.
    Journal of Surgical Oncology 06/2012; 106(5):565-71.
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    ABSTRACT: BACKGROUND: Microparticles bud from cellular elements during inflammation and are associated with the vascular dysfunction related to type 2 diabetes mellitus. Although weight loss is known to reduce inflammation, the metabolic effects of bariatric surgery on microparticle concentration and composition are not known. Our objectives were to determine the effect of bariatric surgery on the microparticle concentration and to correlate these changes with clinical parameters in a multispecialty group practice. METHODS: We studied 14 obese subjects with type 2 diabetes mellitus 2 weeks before and 1 and 12 months after bariatric surgery. Of the 14 patients, 9 underwent Roux-en-Y gastric bypass and 5 gastric restrictive surgery. RESULTS: At 1 month after surgery, the body mass index had decreased by ∼10%, glycemic control had improved dramatically (P < .01), and a >60% reduction in endothelial and platelet microparticles and C-reactive protein levels (P < .05) had occurred. The tissue factor microparticles had decreased by 40% (P = .1). At 12 months after surgery, the body mass index had decreased by ∼20%, glycemic control was maintained (P < .01), and a >50% reduction in monocyte microparticles compared with before surgery was found. The reduction in monocyte microparticles 1 month after surgery was strongly associated with the reduction in hemoglobin A1c (P < .05). The reduction in monocyte microparticles 12 months after surgery correlated strongly with the reduction in body mass index (P < .05). CONCLUSION: The reduction in microparticles after bariatric surgery in patients with type 2 diabetes mellitus reflects an attenuation of inflammation, and this mechanism might contribute to normalization of glycemic control.
    Surgery for Obesity and Related Diseases 10/2011;
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    ABSTRACT: Although individuals with obesity and type 2 diabetes are insulin resistant, pancreatic beta cell failure is the core defect that distinguishes individuals who eventually develop diabetes. This process is known to occur well before the onset of hyperglycemia. Although clinical trial data support the effectiveness of intensive lifestyle modification in delaying the onset of diabetes in obese subjects, less is known about the effects of and mechanisms underlying bariatric surgery, particularly gastric bypass surgery, on diabetes. The paper under evaluation clarifies the role of both lifestyle intervention and gastric bypass surgery on pancreatic beta cell function and raises questions regarding the role of weight loss versus incretin related mechanisms on recovery of beta cell failure.
    Expert Review of Endocrinology &amp Metabolism 07/2011; 6(4):557-561.
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    ABSTRACT: Altered cytokine secretion from dysfunctional adipose tissue or "adiposopathy" is implicated in obesity related inflammation and may mediate reduced cardiovascular disease (CVD) risk in response to weight loss after bariatric surgery. We hypothesized that bariatric surgery reduces CVD risk by favorably altering the pro-inflammatory profile of adipose tissue as a result of weight loss. In this observational study with repeated measures, 142 patients underwent bariatric surgery of which 45 returned for follow-up at ∼6 months. At both time-points, lipid profiles and levels of plasma adiponectin, leptin, and TNF-α were obtained. Ratios of various adipokine parameters were related to pre- and post- surgical (gastric bypass vs. other restrictive bariatric procedures) lipid ratios. Prior to surgery, circulating adiponectin and the adiponectin/TNF-α ratio was strongly associated with CVD risk characterized by levels of triglycerides, HDL, and the TC/HDL, LDL/HDL, and TG/HDL ratios (all P < 0.05). Following bariatric surgery, BMI was decreased by 22%, adiponectin was increased by 93%, and leptin decreased by 50% as compared to baseline (all P < 0.01). TNF-α levels increased by 120% (P < 0.01) following surgery. Post-surgical changes in adiponectin and the leptin/adiponectin ratio were strongly associated with incremental improvements in triglycerides, HDL, and TC/HDL, LDL/HDL and TG/HDL ratios (all P < 0.05). Roux-en-y gastric bypass surgery (RYGB) as compared to other bariatric procedures was associated with more robust improvements in BMI, HDL, and leptin/adiponectin ratio than other gastric restrictive procedures (P < 0.05). Thus, bariatric surgery, especially RYGB, ameliorates CVD risk through a partial recovery from "adiposopathy", distinctively characterized by improved adiponectin and the leptin/adiponectin ratio.
    Obesity Surgery 05/2011; 21(12):1928-36.
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