Evidence for the Necessity to Systematically Assess Micronutrient Status Prior to Bariatric Surgery

Background: Bariatric surgery has been proven the most effective treatment of morbid obesity, but micronutrient deficiency following bariatric surgery is a major concern. Increasing evidence points to a generally poor micronutrient status in obese subjects. Methods: We assessed micronutrient status in 232 morbidly obese subjects (BMI ≥ 35kg/m2) prior to bariatric surgery. Serum albumin, calcium, phosphate, magnesium, ferritin, hemoglobin, zinc, folate, vitamin B12, 25-OH vitamin D3, and intact parathormone (iPTH) were determined. In a sub-sample of 89 subjects, we additionally assessed copper, selenium, vitamin B1, B3, B6, A, and E levels. Results: Deficiencies were found in 12.5% of the subjects for albumin, 8.0% for phosphate, 4.7% for magnesium, 6.9% for ferritin, 6.9% for hemoglobin, 24.6% for zinc, 3.4% for folate, and 18.1% for vitamin B12. In addition, 25.4% showed a severe 25-OH vitamin D3 deficiency, which was accompanied by a secondary hyperparathyroidism in 36.6% cases. Prevalence of albumin deficiency (p < 0.007) and of anemia (p < 0.003; in women only) significantly increased with BMI. Of note, 48.7% of the subjects showed at least one of the most prevalent deficiencies, i.e., vitamin B12, zinc and severe 25-OH vitamin D3 deficiency. In the sub-sample, 32.6% showed a selenium, 5.6% a vitamin B3, 2.2% a vitamin B6, and 2.2% a vitamin E deficiency. Copper, vitamin B1, and vitamin A deficiency was found in none of the subjects. Conclusion: Data indicate a high prevalence of micronutrient deficiencies in morbidly obese subjects. Based on these results, we strongly recommend a systematic assessment of the micronutrient status in all candidates for bariatric surger

A Novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) as a Primary Bariatric Procedure—Complication Rates, Weight Loss, and Nutritional/Metabolic Changes in the First 355 Patients

Proximal Roux-en Y gastric bypass (RYGB) representing the most frequently performed bariatric procedure yields a weight loss failure rate of around 20%. In order to reduce failure rates, we established a novel distal RYGB variant characterized by a very long alimentary (Roux) limb and a short common channel. Up to 5years, follow-up data (complication rates, weight loss, nutritional/metabolic changes) of the first 355 patients (mean ± SD preoperative age, 41.4 ± 10.8years; BMI, 48.5 ± 11.5kg/m2) who underwent the novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) were analysed. Overall follow-up rate was 98.9%, mean follow-up time 1.6 ± 1.4years. Limb lengths were as follows: common channel 76 ± 7cm, biliopancreatic limb 79 ± 14cm, and alimentary (Roux) limb 604 ± 99cm. The operation was performed laparoscopically in 95.2% of the cases. Thirty-day mortality was zero; major and minor complication rate was 4.5% and 10.4%, respectively. Average excess weight loss (EWL) was >74% 3, 4, and 5years after the operation and failure rate defined by an EWL < 50% remained < 6%. Annually blood measurements revealed a relatively low incidence rate of severe nutritional deficiencies, but mild anaemia and hypoproteinemia were frequently observed. Laparoscopic revision with a proximalization of the lower anastomosis was required in 4 (1.1%) patients. Data indicate that our DVLRYGB leads to excellent weight loss results. Furthermore, within the setting of a structured multidisciplinary follow-up program, the incidence of severe malnutrition states was relatively lo

Differential Changes in Dietary Habits after Gastric Bypass Versus Gastric Banding Operations

Background: Reduction of food intake is an important mechanism by which bariatric procedures reduce body weight. However, only few studies have systematically assessed what patients actually eat after different types of bariatric operations. Methods: Dietary habits were assessed by a food frequency questionnaire in 121 bariatric patients (48 gastric bypass patients, 73 gastric banding patients) during follow-up visits in our interdisciplinary obesity center as well as in 45 severely obese (body mass index (BMI) > 35kg/m2) and 45 nonobese (BMI < 27kg/m2) control subjects. Results: As compared with nonobese control subjects, obese control subjects consumed more meat, white bread, and diet soft drinks. Gastric bypass patients showed an enhanced consumption of foods rich in protein such as poultry, fish, and eggs as well as of cooked vegetables, while the consumption of fatty sweets like chocolate, cake, biscuits, and cookies was found to be distinctly reduced in this patient group. In contrast, gastric banding patients reported on a reduced intake of pasta, white bread, and fresh fruits and, just like gastric bypass patients, also on an enhanced intake of poultry and fish. Direct comparison of dietary habits between the two bariatric patient groups revealed that gastric bypass patients consumed more frequently fresh fruits, eggs, and diet soft drinks but strikingly less chocolate than gastric banding patients. Conclusion: Collectively, data clearly point to distinct changes in dietary habits after bariatric operations which markedly differ between gastric bypass and gastric banding patients. Overall, it is tempting to conclude that gastric bypass operations lead to a healthier and a more balanced diet than gastric band implantation

QT interval shortening after bariatric surgery depends on the applied heart rate correction equation

A shortening of electrocardiographic QT interval has been observed in obese subjects after weight loss, but previous results may have been biased by inappropriate heart rate (HR) correction.Methods Electrocardiography (ECG) recordings of 49 (35 females) severely obese patients before and 12 months after Roux-en-Y gastric bypass (RYGB) surgery were analysed. QT interval (QTc) was calculated by using four different equations, i.e. Bazett, Fridericia, Framingham and Hodges.Results Irrespectively of the used correction formula, QTc interval length was reduced after the surgery (QTcBazett −31 ± 18 ms; QTcFridericia −12 ± 15 ms; QTcFramingham −14 ± 15 ms; QTcHodges −9 ± 15 ms; all Ps Bazett reduction was significantly greater than the reduction in QTc calculated upon the other three equations (all Ps Bazett (P Fridericia, QTcFramingham and QTcHodges (all Ps > 0.05) were significantly correlated with concurrent changes in HR. Multivariate regression analyses revealed a significant independent association of serum insulin levels with QTcFridericia, QTcFramingham and QTcHodges values (all Ps < 0.05) preoperatively, whilst changes in QTc interval length after the surgery were not consistently associated to concurrent changes in metabolic traits.Conclusions Our data show that the extent of weight loss-associated QTc interval shortening largely depends on the applied HR correction equation and appears to be overestimated when the most popular Bazett’s equation is used

Seasonal Variation in the Deficiency of 25-Hydroxyvitamin D3 in Mildly to Extremely Obese Subjects

Background: Vitamin D deficiency is a common finding in obese subjects even before any bariatric operation. However, most previous studies reporting on high rates of vitamin D deficiency in obese subjects have not systematically controlled for seasonal variations. Furthermore, the existence of seasonal variation in serum 25-hydroxyvitamin D3 levels has not been well documented in obese subjects so far. Methods: Serum 25-hydroxyvitamin D3 levels were measured in 248 obese subjects (body mass index: range, 30.1-68.9kg/m2). Fat mass was determined using standard bioelectrical impedance analysis. Results: Serum 25-hydroxyvitamin D3 levels decreased with the increasing body mass index and fat mass (both P < 0.001) and showed a marked variation across the seasons of the year (P < 0.001), which was not affected by the degree of obesity. According to the variation in absolute levels, the prevalence of vitamin D deficiency (<50nmol/l) was 3.8-fold higher during winter than during summer (91.2% vs. 24.3%; P < 0.001). Conclusion: Data show a marked seasonal variation in absolute serum 25-hydroxyvitamin D3 concentrations and prevalence of vitamin D deficiency in subjects with mild to extreme obesity. Considering the increasing number of studies reporting on vitamin D deficiency in obesity, the present finding points to season as a crucial factor that should not be neglected when assessing serum levels of this vitamin in obese subject

Erratum to: Differential Changes in Exercise Performance After Massive Weight Loss Induced by Bariatric Surgery

Background: Exercise performance and pulmonary function are often impaired in severely obese subjects. Bariatric surgery represents the most effective therapy for severe obesity, but data on changes in exercise performance after massive weight loss induced by bariatric surgery have rarely been assessed so far. Methods: Exercise performance was obtained by bicycle spiroergometry in 18 severely obese patients before and at least 1year after bariatric surgery. Additionally, pulmonary function was assessed by spirometry. Results: BMI was reduced from 46.3 ± 1.6 to 33.5 ± 1.4kg/m2 after surgery. Pulmonary function (forced expiratory volume within 1s; inspiratory vital capacity) improved after weight loss (both p ≤ 0.01). At peak exercise, heart rate (HR) peak, absolute oxygen uptake (VO2) peak, and load peak did not differ between both assessments (all p > 0.25). However, relative (related to actual body weight) VO2 peak and workload peak were higher after than before surgery (both p ≤ 0.005), while gross efficiency peak and ventilatory equivalent peak remained unchanged (both p > 0.30). At anaerobic threshold (AT), patients showed lower HR AT and absolute VO2 AT after than before surgery (both p < 0.05), while absolute workload AT did not differ (p = 0.58). In turn, relative VO2 AT did not change (p = 0.30), whereas relative workload AT was higher after surgery (p = 0.04). Also, ventilatory efficiency AT and gross efficiency AT tended to be improved (both p = 0.08). Before surgery, the patients performed 27.0% of VO2 peak above their AT, while this fraction increased to 35.3% (p = 0.006). Conclusions: Results indicated differential changes in exercise performance, with the relative but not the absolute peak performance being improved after massive weight loss. Interestingly, anaerobic exercise tolerance was markedly improved after surger

C-Reactive Protein 2 Days After Laparoscopic Gastric Bypass Surgery Reliably Indicates Leaks and Moderately Predicts Morbidity

Background: The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods: The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. Results: Forty-nine of 410 patients (12.0%; 95% confidence intervals [95% CI], 9.2-15.5%) developed surgery-related complications. Leaks occurred in 17 patients (4.1%; 95% CI, 2.6-6.5%) at a median of 5days after surgery. CRP levels 2days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95% CI, 0.60-0.89). Sensitivity was 0.53 (95% CI, 0.31-0.74) and specificity was 0.91 (95% CI, 0.79-0.96) on day 2 (cutoff level, 229mg/l). The sensitivity for intestinal leaks was 1.00 (95% CI, 0.51-1.00). Conclusion: CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229mg/

Are Predictors for Overall Mortality in COPD Patients Robust over Time?

(1) Background: Mortality is a major outcome in research on chronic obstructive pulmonary disease (COPD) with various predictors described. However, the dynamic courses of important predictors over time are disregarded. This study evaluates if longitudinal assessment of predictors provides additional information on the mortality risk in COPD when compared with a cross-sectional analysis.; (2) In a longitudinal, prospective, non-interventional cohort study including mild to very severe COPD patients, mortality and its various possible predictors were annually assessed up to seven years.; (3) Results: 297 patients were analysed. Mean (SD) age was 62.5 (7.6) years and 66% males. Mean (SD) FEV1 was 48.8 (21.4)%. A total of 105 events (35.4%) happened with a median (95% CI) survival time of 8.2 (7.2/NA) years. No evidence for a difference between the raw variable and the variable history on the predictive value for all tested variables over each visit was found. There was no evidence for changing effect estimates (coefficients) across the study visits due to the longitudinal assessment; (4) Conclusions: We found no evidence that predictors of mortality in COPD are time dependent. This implies that cross-sectional measured predictors show robust effect estimates over time and multiple assessments seem not to change the predictive value of the measure

Adherence to sofosbuvir and velpatasvir among people with chronic HCV infection and recent injection drug use:The SIMPLIFY study

BACKGROUND:This study investigated treatment adherence among people with recent injecting drug use in a study of sofosbuvir/velpatasvir therapy for HCV infection. METHODS:SIMPLIFY is an international open-label, single-arm multicentre study that recruited participants with recent injecting drug use (previous six months) and chronic HCV genotype (G) 1-6 infection between March and October 2016 in seven countries (19 sites). Participants received sofosbuvir/velpatasvir once-daily for 12 weeks administered in a one-week electronic blister pack (records the time and date of each dose) for 12 weeks. We evaluated non-adherence (<90% adherent) as measured by electronic blister-pack assessed using logistic regression and generalised estimating equations (continuous) with detailed analyses of dosing dynamics. RESULTS:Among 103 participants, 97% (n = 100) completed treatment. Median adherence to therapy was 94%. Overall, 32% (n = 33) were considered non-adherent (<90% adherence). Adherence significantly decreased over the course of therapy. Recent stimulant injecting (cocaine and/or amphetamines) at treatment initiation and during treatment was independently associated with non-adherence. Inconsistent dose timing (standard deviation of daily dose timing of ≥240 min) was also independently associated with non-adherence to therapy. Factors associated with inconsistent dose timing included lower levels of education and recent stimulant injecting. SVR was similar among adherent and non-adherent populations (94% vs. 94%, P = 0.944). CONCLUSION:This study demonstrated high adherence to once-daily sofosbuvir/velpatasvir therapy among a population of people with recent injecting drug use. Recent stimulant injecting prior to and during DAA therapy and inconsistent dose-timing during treatment was associated with non-adherence. However, there was no impact of non-adherence on response to therapy, suggesting that adherence is not a significant barrier to successful DAA therapy in people with recent injecting drug use.Evan B.Cunningham, Janaki Amin, Jordan J.Feld, Julie Bruneau, Olav Dalgard, Jeff Powis ... et al

CD4/CD8 Ratio and the Risk of Kaposi Sarcoma or Non-Hodgkin Lymphoma in the Context of Efficiently Treated Human Immunodeficiency Virus (HIV) Infection: A Collaborative Analysis of 20 European Cohort Studies

BACKGROUND: A persistently low CD4/CD8 ratio has been reported to inversely correlate with the risk of non-AIDS defining cancer in people living with human immunodeficiency virus (HIV; PLWH) efficiently treated by combination antiretroviral therapy (cART). We evaluated the impact of the CD4/CD8 ratio on the risk of Kaposi sarcoma (KS) or non-Hodgkin lymphoma (NHL), still among the most frequent cancers in treated PLWH. METHODS: PLWH from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) were included if they achieved virological control (viral load ≤ 500 copies/mL) within 9 months following cART and without previous KS/LNH diagnosis. Cox models were used to identify factors associated with KS or NHL risk, in all participants and those with CD4 ≥ 500/mm3 at virological control. We analyzed the CD4/CD8 ratio, CD4 count and CD8 count as time-dependent variables, using spline transformations. RESULTS: We included 56 708 PLWH, enrolled between 2000 and 2014. At virological control, the median (interquartile range [IQR]) CD4 count, CD8 count, and CD4/CD8 ratio were 414 (296-552)/mm3, 936 (670-1304)/mm3, and 0.43 (0.28-0.65), respectively. Overall, 221 KS and 187 NHL were diagnosed 9 (2-37) and 18 (7-42) months after virological control. Low CD4/CD8 ratios were associated with KS risk (hazard ratio [HR] = 2.02 [95% confidence interval {CI } = 1.23-3.31]) when comparing CD4/CD8 = 0.3 to CD4/CD8 = 1) but not with NHL risk. High CD8 counts were associated with higher NHL risk (HR = 3.14 [95% CI = 1.58-6.22]) when comparing CD8 = 3000/mm3 to CD8 = 1000/mm3). Similar results with increased associations were found in PLWH with CD4 ≥ 500/mm3 at virological control (HR = 3.27 [95% CI = 1.60-6.56] for KS; HR = 5.28 [95% CI = 2.17-12.83] for NHL). CONCLUSIONS: Low CD4/CD8 ratios and high CD8 counts despite effective cART were associated with increased KS/NHL risks respectively, especially when CD4 ≥ 500/mm3