Skin manifestations after bariatric surgery

Several studies have reported that morbid obesity is associated with increased thyroid-stimulating hormone (TSH) levels. However, it is not clear what is the impact of bariatric surgery on postoperative thyroid function.The aim of this study was to evaluate the effect of weight loss after bariatric surgery on TSH levels in euthyroid patients with morbid obesity. We performed a retrospective observational study of 949 euthyroid patients (86.1% female; age 42.0±10.3years, BMI 44.3±5.7kg/m2) with morbid obesity submitted to bariatric surgery (laparoscopic adjustable gastric band, Roux-en-Y gastric bypass, or sleeve gastrectomy). Patients were subdivided in two groups: normal TSH group (TSH <2.5mU/L) and high-normal TSH group (TSH ≥2.5mU/L). The impact of anthropometric parameters, comorbidities, TSH, free thyroxine (FT4), free triiodothyronine (FT3), type of surgery, and excessive body weight loss (EBWL) on TSH variation 12months after surgery was evaluated. The high-normal TSH group (24.3% of patients) included more women, presented a higher BMI, higher systolic blood pressure, and higher FT3 levels. There was a significant decrease of TSH 12months after surgery that was more marked in the high-normal TSH group (normal TSH group: 1.57±0.49to1.53±0.69mIU/L, p=0.063; high-normal TSH group: 3.23±0.59to2.38±0.86mIU/L, p<0.001). In a multivariate analysis, after adjusting for relevant covariates, EBWL, baseline BMI, and baseline FT3 were significantly associated with TSH decrease 12months after bariatric surgery. Bariatric surgery promotes a decrease of TSH that is significantly greater in patients with high-normal TSH and is independently associated with EBWL after surgery.

Baseline factors affecting the efficacy of troglitazone on plasma glucose in Japanese patients with non-insulin-dependent diabetes mellitus

Low socioeconomic status (SES) correlates with higher obesity rates and challenges in accessing treatments like bariatric surgery (BS). This study aims to assess SES's influence on medium-term BS outcomes in a setting of universal healthcare, ensuring equitable treatment access. We conducted a retrospective analysis of 193 BS patients (1997-2018) at a tertiary care hospital. Weight loss was expressed as change in % total weight loss (%TWL) and excess body weight (EBW) loss. Successful BS was defined as > 50% EBW loss. SES was gauged using quartiles of the Spanish Deprivation Index. A multivariable Cox regression model evaluated SES impact on BS success over follow-up. The mean follow-up was 6.9 ± 4.6years; patients averaged 43.9 ± 11.8years, with 29.7% men. Preoperative BMI was 48.2 ± 8.2kg/m2. At follow-up, BMI was 33.9 ± 6.6kg/m2, with 29.3 ± 12.02% of %TWL. No SES quartile differences in BS success were noted at follow-up (log rank p = 0.960). Cox regression revealed no SES disparities in BS outcomes post-adjustment. However, female sex (HR 1.903; p = 0.009) and diabetes mellitus (HR = 0.504; p = 0.010) correlated with weight-related outcomes. In a universal healthcare system with equitable treatment access, medium-term BS outcomes remain consistent irrespective of patients' socioeconomic status.

BackgroundEpidemiological studies have identified obesity as a major risk factor for cancer in humans, and trials have demonstrated a significant reduction in the incidence of cancer after bariatric surgery. The rapidity of weight loss after bariatric surgery provides an opportunity to identify the molecular changes associated with effective obesity treatment. Indirectly, this may provide some insights into the mechanisms that drive the association between obesity and cancer. We sought to measure circulating cancer-associated proteins before and after laparoscopic sleeve gastrectomy (LSG).MethodsWe prospectively enrolled 15 patients undergoing LSG. Thirty-four plasma protein biomarkers thought to be associated with cancer processes were analyzed at baseline and following successful weight loss at 12 weeks using a multiplex bead-based assay.ResultsMean excess body weight loss was 44 % at 12-week follow-up. After LSG, a significant reduction in circulating plasma levels was observed for half (17/34) of the proteins assessed: VEGF-A, VEGF-C, VEGF-D, endoglin, PLGF, sFASL, IGFBP-1, IL-18, prolactin, EGF, TGFα, sCD40L, IL-18, TNFα, IL-6, HB-EGF, and PAI-1. Nonsignificant decreases were found for the remaining proteins.ConclusionsCirculating cancer-related biomarker levels were reduced by surgical weight loss, and this benefit was achieved as early as 3 months after operation. The observed reduction in cancer biomarkers may be related to the reported decrease in cancer incidence following bariatric surgery.

To evaluate the efficacy and safety of four doses of pioglitazone monotherapy in the treatment of patients with type 2 diabetes. There were 408 patients randomized in this multicenter double-blind placebo-controlled clinical trial. Patients who had HbA1c > or = 7.0%, fasting plasma glucose (FPG) > or = 140 mg/dl, and C-peptide > 1 ng/ml were randomized to receive placebo or 7.5, 15, 30, or 45 mg pioglitazone administered once a day for 26 weeks. Patients treated with 15, 30, or 45 mg pioglitazone had significant mean decreases in HbA1c (range -1.00 to -1.60% difference from placebo) and FPG (-39.1 to -65.3 mg/dl difference from placebo). The decreases in FPG were observed as early as the second week of therapy; maximal decreases occurred after 10-14 weeks and were maintained until the end of therapy (week 26). In the 15-, 30-, or 45-mg pioglitazone groups, there were significant mean percent decreases in triglycerides, significant mean percent increases in HDL cholesterol, and only small percent changes in total cholesterol and LDL. The subset of patients naive to therapy had greater improvements in HbA1c and FPG (difference from placebo of -2.55% and -79.9 mg/dl for the 45-mg group) compared with previously treated patients. The overall adverse event profile of pioglitazone was similar to that of placebo. There was no evidence of drug-induced hepatotoxicity or drug-induced elevations of alanine aminotransferase levels in this study Pioglitazone monotherapy significantly improves HbA1c and FPG while producing beneficial effects on serum lipids in patients with type 2 diabetes with no evidence of drug-induced hepatotoxicity.

BACKGROUNDLaparoscopic sleeve gastrectomy (LSG) has been established as an effective means of weight loss. Multiple studies report LSG as a cost-effective procedure with few perioperative complications.OBJECTIVESReport long-term weight changes after LSG in a single center in Kuwait.DESIGNRetrospective analysis of data collected 5–8 years after surgery.SETTINGA single medical center.PATIENTS AND METHODSAll patients that had undergone LSG between December 2008 and December 2011.MAIN OUTCOME MEASURESWeight changes, short-term complications following surgery (within one month).SAMPLE SIZE187.RESULTSThe mean age at the time of the surgery was 36.5 (10.3) years. Females composed 71.6% of this study population. Two patients (1.1%) presented with a leak within 30 days of the surgery. Twenty-one (11.2%) patients underwent revisional bariatric surgery after LSG. Mean (SD) BMI decreased from 47.1 (8.3) kg/m2 before surgery to 34.3 (7) kg/m2 5–8 years after surgery. Mean (SD) body weight decreased from 126.3 (25.3) kg to 91.6 (19.9) kg 5–8 years following LSG. The mean excess body weight loss was 58.8% (29.2%).CONCLUSIONLSG is a bariatric procedure with low complications and mortality in relation to other forms of bariatric surgery. It is associated with a significant improvement in weight loss in the long term.LIMITATIONSRecall bias due to the nature of collecting the data, small sample size.

To assess the effect of massive weight loss in relation to insulin resistance and its correlation to changes in glycemic homeostasis and lipid profile in severely obese patients. A prospective clinical intervention study was carried out with 31 morbidly obese women (body mass index: 54.2 +/- 8.8 kg/m(2)) divided into three groups according to their glucose tolerance test: 14 normal, 8 impaired glucose tolerance, and 9 type 2 diabetes. All subjects underwent an insulin tolerance test with intravenous bolus of 0.1 U insulin/kg body weight before silastic ring vertical gastroplasty Roux-en-Y gastric bypass surgery, and again at 2, 4, 6, and 12 months postoperatively. Fasting plasma glucose, hemoglobin A1c, and lipid profile were also evaluated. A reduction of 68 +/- 15% in initial excess body weight was evident within 1 year. Along with weight loss, the following statistically significant changes were found: an increase in the insulin-sensitivity index (Kitt) and a decrease in fasting plasma glucose and hemoglobin A1c, most notably in the type 2 diabetes group. An overall improvement in lipid profile was observed in all three groups. Bariatric surgery was an effective therapeutic approach for these obese patients because it reduced both weight and insulin resistance, along with improving metabolic parameters. Significant correlations were found between insulin resistance and metabolic improvements. Weight loss after bariatric surgery induced an improvement in metabolic fitness, related to the reduction in insulin resistance over a range of glucose tolerance statuses from normal to diabetic.

BackgroundType 2 diabetes mellitus has become one of the most important public health concerns worldwide. Due to its high prevalence and morbidity, there is an avid necessity to find new therapies that slow the progression and promote the regression of the disease. Imatinib mesylate is a tyrosine kinase inhibitor that binds to the Abelson tyrosine kinase and related proteins. It enhances β-cell survival in response to toxins and pro-inflammatory cytokine. The aim of this study is to evaluate the effect of imatinib on fasting plasma glucose in subjects with normal fasting glucose, subjects with impaired fasting glucose and in subjects with type 2 diabetes mellitus.MethodsWe identified 284 subjects diagnosed with chronic myeloid leukemia or gastrointestinal stromal tumors from the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran database. 106/284 subjects were treated with imatinib. We compared the effect of imatinib on fasting plasma glucose after 1 and 6 months of treatment. We used ANOVA test of repeated samples to determine statistical significance in fasting plasma glucose before imatinib treatment and the follow-up. Statistical analysis was performed with Statistical Package for the Social Sciences v22.ResultsWe included a total of 106 subjects: 76 with fasting plasma glucose concentrations < 100 mg/dL (normal FG), 19 subjects with fasting plasma glucose concentrations ≥100 mg/dL (impaired fasting glucose), and 11 subjects with ≥126 mg/dL (type 2 diabetes mellitus). We found a significant increase in fasting plasma glucose concentration in the normal fasting glucose group (p = 0.048), and a significant decrease in fasting plasma glucose concentration in the type 2 diabetes mellitus group (p = 0.042). In the impaired fasting glucose group, we also found a tendency towards a decrease in fasting plasma glucose (p = 0.076). We identified 11 subjects with type 2 diabetes mellitus, of whom, 7 (64%) had a reduction in their fasting plasma glucose concentrations after 6 months. A significant glycosylated hemoglobin reduction (p = 0.04) was observed.ConclusionSubjects with chronic myeloid leukemia or gastrointestinal stromal tumor with type 2 diabetes mellitus had a significant reduction in fasting plasma glucose and glycosylated hemoglobin at 1 and 6 months while using imatinib.

To examine the impact of increased hepatic glucose production (HGP) on the decrease in plasma glucose concentration caused by empagliflozin in individuals living with diabetes and in nondiabetic individuals. A total of 36 individuals living with diabetes and 34 nondiabetic individuals were randomized to receive, in double-blind fashion, empagliflozin or matching placebo in a 2:1 treatment ratio. Following an overnight fast, HGP was measured with 3-3 H-glucose infusion before, at the start of, and 3 months after therapy with empagliflozin. On Day 1 of empagliflozin administration, the increase in urinary glucose excretion (UGE) in individuals with normal glucose tolerance was smaller than in those with impaired glucose tolerance and those living with diabetes, and was accompanied by an increase in HGP in all three groups. The amount of glucose returned to the systemic circulation as a result of the increase in HGP was smaller than that excreted by the kidney during the first 3 h after empagliflozin administration, resulting in a decrease in fasting plasma glucose (FPG) concentration. After 3 h, the increase in HGP was in excess of UGE, leading to a small increase in plasma glucose concentration, which reached a new steady state. After 12 weeks, the amount of glucose returned to the circulation due to the empagliflozin-induced increase in HGP was comparable with that excreted by the kidney in all three groups. The balance between UGE and increase in HGP immediately after sodium-glucose cotransporter-2 (SGLT2) inhibition determined the magnitude of decrease in FPG and the new steady state which was achieved. After 12 weeks, the increase in HGP caused by empagliflozin closely matched the amount of glucose excreted by the kidneys; thus, FPG level remained stable despite the continuous urinary excretion of glucose caused by SGLT2 inhibition.

BACKGROUND: The polymorphism rs1801282 (Pro12Ala) may be one of the reasons for the heterogeneous response of patients with carbohydrate metabolism disorders to thiazolidinedione therapy. Studies of this polymorphism in patients with metabolic syndrome (MS) will help identify a group of patients in whom the use of thiazolidinedione is advisable.&#x0D; AIMS: To assess the clinical effect of thiazolidinediones in patients with metabolic syndrome, depending on the presence of polymorphism rs1801282.&#x0D; MATERIALS AND METHODS: All patients with newly diagnosed MS with impaired carbohydrate metabolism were included in the open cohort study. All patients were recommended a diet, expansion of physical activity and pioglitazone at a dose of 30 mg per day. After the appointment of the therapy, the patients come to the center back at 12 weeks.&#x0D; The main outcome in the study assessed in patients with impaired glucose tolerance (IGT) was fasting glycemia and 2 hours after glucose tolerance test, in patients with type 2 diabetes HbA1c.&#x0D; RESULTS: 109 patients were included in the study. Of these, 14 were carriers of rs1801282, the other 95 had a typical PPAR genotype. After the appointment of therapy in the groups of IGT and type 2 diabetes, improvement of glycemic control was observed. The degree of decrease in fasting plasma glucose and after glucose tolerance test was more pronounced with IGT in patients with polymorphism rs1801282 compared with the rest (plasma fasting plasma glucose level was -0.7 [-0.9, -0.7] vs. -0, 4 [-0.5, -0.3] mmol/L, p=0.001; plasma glucose level 2 hours after glucose tolerance test was -1.1 [-1.8, -0.3] vs. -0.5 [-0.7, -0.1] mmol/L, p=0.031). In patients with type 2 diabetes, no data were obtained for the statistically significant effect of rs1801282 polymorphism on the results of pioglitazone, but there was a tendency for a greater decrease in fasting plasma glucose in the case of carrying the polymorphic gene (-1.9 [-2.2, -1.8] against -1,5 [-1,7, -1,2] mmol/l, p=0,073).&#x0D; CONCLUSIONS: The study shows the effect of polymorphism rs1801282 on the results of pioglitazone in patients with MS, both in IGT and in type 2 diabetes. Carrying polymorphism leads to a significant decrease in fasting glycemia and after glucose tolerance test in patients with IGT. The tendency to improve the parameters of carbohydrate metabolism (fasting glycemia, HbA1c) was noted in a subgroup of patients with type 2 diabetes.

This study examined relationships between excess body weight (EBW) loss and current gait and functional status in women 5 years after Roux-en-Y gastric bypass surgery. Gait data were analyzed in nine female bariatric patients for relationships with longitudinal changes in weight, body composition, and physical function assessed by the Short Musculoskeletal Functional Assessment (SMFA) questionnaire and the timed "get-up-and-go" (TGUG) test. Gait characteristics in the bariatric sample were also compared to an age- and BMI-matched nonsurgical reference sample from the Fels Longitudinal Study. Bariatric patients lost an average of 36.4 kg (61.1%) of EBW between preoperative and 5-year follow-up visits (P < 0.01); SMFA function index scores and TGUG times also decreased (both P < 0.01). Degree of EBW loss was correlated with less time spent in initial double support and more time in single support (both P = 0.02), and for all gait variables, the bariatric sample fell within the 95% confidence intervals of gait/EBW relationships in the reference sample. Gait and function 5 years after bariatric surgery were characteristic of current weight, not preoperative obesity, suggesting that substantial, sustained recovery of physical function is possible with rapid surgical weight loss.

Several studies have confirmed the increased incidence of vitamin B12 deficiency in patients with type 2 diabetes mellitus. Metformin is currently the most commonly used anti-diabetic drug, metformin being prescribed as first-line therapy for patients with type 2 diabetes mellitus (T2DM) worldwide. Other disorders including insulin resistance, such as polycystic ovary syndrome (PCOS), can also be treated with metformin. Metformin has positive effects on metabolism, weight loss, and vascular defence of carbohydrates, but it also has significant side effects. Patients on long-term treatment with metformin, for example, have been shown to be at risk of anemia. This may be because of a decrease in metformin-related vitamin B12. It is estimated that 30 percent of patients undergoing long-term metformin treatment have experienced vitamin B12 malabsorption, with a 14 percent to 30 percent reduction in serum vitamin B12 concentration. A critical nutrient for wellbeing is vitamin B12. It plays a significant role in the functioning and the production of red blood cells in the brain and nervous system. In addition to anemia, a deficiency of vitamin B12 may increase the severity of peripheral neuropathy in T2DM patients. In addition, since vitamin B12 is involved in the most critical homocysteine (Hcy) metabolism pathway, a decrease in vitamin B12 will increase plasma concentrations of Hcy, which in patients with T2DM and PCOS is closely linked to cardiovascular disease. Evaluating serum vitamin B12 levels will also provide an early diagnosis of the status of the deficiency. This will offer an incentive for harm caused by routine screening and early detection to be reversed. KEY WORDS Vitamin B12, Metformin, Diabetes Mellitus, Glycated Hb

UK prospective diabetes study 7: Response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients

Purpose: Bariatric surgery is an effective treatment for obesity, however it does not lead to equal results in every patient. Although the prevalence of obesity in women in the US parallels the increase in men, little data exists on differences in predictors of bariatric surgery outcome between men and women. The aim of this study was to identify gender differences in predictors of weight loss success in the first year after bariatric surgery. Methods: The charts of all patients who underwent laparoscopic adjustable gastric banding (LAGB) or Roux-en Y gastric bypass (RYGB) between 10/1/2000 and 10/31/2005 were reviewed. Demographic data, social history, past psychiatric history, personal and family history of obesity, self and professionally assessed eating behavior, as well as post-op data on excess body weight loss at 1, 3, 6 and 12 months follow-up were collected for each patient. Post-op weight loss success was defined as >50% of excess weight loss (EWL) at 12 months. Results: A total of 1,722 patients were evaluated and 635 without follow-up data at 12 months were excluded. Among the 1,087 analyzed individuals, 994 (88%) had the LAGB and 136 (12%) had RYGB. Women made up 73% and 83% of patients in the LAGB and RYGB groups respectively. The mean age was 41 ± 12 y and 44 ± 12 y for women and men respectively. The racial distribution was similar in both groups. The initial mean BMI was 44.8 kg/m2 and 47.7 kg/m2 for women and men. 70% of men were married, compared to only 48% of women (P < 0.001). Women had a higher number of negative pre-op social psychiatric factors compared to men (7.4 ± 3 vs. 6.3 ± 3, P < 0.001), but were more likely to achieve successful EWL compared to their male counterparts (53% vs. 38%, P < 0.001). Factors that were predictive of successful EWL among women included late night eating (P= 0.018), not eating carbohydrates (P= 0.020), being socially avoidant (P= 0.029), and having a marriage that was impacted by obesity (P= 0.016). None of these factors were predictive of post-op weight loss success in men. Conclusion: In this cohort we identified significant gender differences in bariatric surgery outcome as well as in the predictors of successful post-op weight loss. Further evaluation is warranted to better understand the impact of these factors on long-term weight loss outcome.

Modest, preoperative weight loss will improve perioperative outcomes among high-risk, morbidly obese patients undergoing Roux-en-Y gastric bypass. A prospective, longitudinal assessment of characteristics and outcomes of gastric bypass patients. All patients undergoing open or laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity or its comorbid medical problems at Geisinger Medical Center in Danville, Pennsylvania, during a 3-year period from May 31, 2002, to February 24, 2006, were included in this analysis. Patients were required to participate in a standardized multidisciplinary preoperative program that encompasses medical, psychological, nutritional, and surgical interventions and education. In addition, patients were encouraged to achieve a 10% loss of excess body weight prior to surgical intervention. Of the 884 subjects, 425 (48%) lost more than 10% of their excess body weight prior to the operation. After surgery (mean follow-up, 12 months), this group was more likely to achieve 70% loss of excess body weight (P < .001). Those who lost more than 5% of excess body weight prior to surgery were statistically less likely to have a length of stay of greater than 4 days (P = .03). This study shows that high-risk morbidly obese candidates for bariatric surgery who are able to achieve a loss of 5% to 10% excess body weight prior to surgery have a higher probability of a shorter length of hospital stay and more rapid postoperative weight loss.