Weight Loss Directly Influences Intermediate-Term Remission of Diabetes Mellitus After Bariatric Surgery: A Retrospective Case-Control Study

PURPOSE

Roux en Y gastric bypass surgery (RYGB) is an effective therapy for patients with severe obesity. It induces both significant weight loss and rapid improvements of metabolic complications. This study was undertaken to better define the direct role of weight loss in the metabolic improvements.

METHODS

A retrospective, case-control study of a cohort of 649 patients with obesity who underwent RYGB, comparing higher and lower responders at 2 years after surgery (n = 100 pairs). Pairs of patients were matched for age, gender, and initial BMI. The rates of remission of diabetes, hypertension, dyslipidemia, and hyperuricemia were compared using a mixed effects logistic regression analysis.

RESULTS

Diabetes before surgery was present in 12/100 lower responders and 17/100 higher responders. Remission at 2 years was observed in 4/12 (33%) of lower responders, compared to 15/17 (88%) of higher responders. Thus, the odds of diabetes remission was significantly smaller in lower responders (OR = 0.067, 95% CI 0.01-0.447). A mixed model regression analysis of all the parameters for each patient showed that the odds of achieving remission of any comorbidity was significantly lower in lower responders (OR = 0.62, 95% CI = 0.39-0.97).

CONCLUSION

We could demonstrate that weight loss is a significant determinant of the remission of diabetes 2 years after RYGB. These data underline the importance of weight loss in the benefits of this procedure.

A vital region for human glycoprotein hormone trafficking revealed by an LHB mutation

Glycoprotein hormones are complex hormonally active macromolecules. Luteinizing hormone (LH) is essential for the postnatal development and maturation of the male gonad. Inactivating Luteinizing hormone beta (LHB) gene mutations are exceptionally rare and lead to hypogonadism that is particularly severe in males. We describe a family with selective LH deficiency and hypogonadism in two brothers. DNA sequencing of LHB was performed and the effects of genetic variants on hormone function and secretion were characterized by mutagenesis studies, confocal microscopy and functional assays. A 20-year-old male from a consanguineous family had pubertal delay, hypogonadism and undetectable LH. A homozygous c.118_120del (p.Lys40del) mutation was identified in the patient and his brother, who subsequently had the same phenotype. Treatment with hCG led to pubertal development, increased circulating testosterone and spermatogenesis. Experiments in HeLa cells revealed that the mutant LH is retained intracellularly and showed diffuse cytoplasmic distribution. The mutated LHB heterodimerizes with the common alpha-subunit and can activate its receptor. Deletion of flanking glutamic acid residues at positions 39 and 41 impair LH to a similar extent as deletion of Lys40. This region is functionally important across all heterodimeric glycoprotein hormones, because deletion of the corresponding residues in hCG, follicle-stimulating hormone and thyroid-stimulating hormone beta-subunits also led to intracellular hormone retention. This novel LHB mutation results in hypogonadism due to intracellular sequestration of the hormone and reveals a discrete region in the protein that is crucial for normal secretion of all human glycoprotein hormones.

[DXA imaging: the multifunction Swiss army knife?]

The significant progress on the quality and resolution of the images obtained by "Dual X-ray Absorptiometry" or DXA has permitted on one hand to improve some existing features and on the other to develop new ones, significantly refining the care of our patients in various pathologies. For example, by improving the prediction of fracture risk by indirect analysis of micro- and macro-architecture of the bone, by looking for markers of associated bone diseases (research vertebral fractures or atypical femoral fractures), or by assessing the metabolic status by the measurement of body composition. With the best performing DXA devices we will soon be able, in clinical routine, to determine bone age, to estimate cardiovascular risk (by measuring the calcification of the abdominal aorta) or to predict the progression of joint osteoarthritis and its evolution after surgical management.

Severe and prolonged hypophosphatemia after intravenous iron administration in a malnourished patient

Malnutrition may result in a phosphate-deficient state owing to a chronically insufficient phosphate intake. Concomitant iron deficiency is common and often supplemented by the intravenous route. It is not widely recognized that some parenteral iron formulations can induce hypophosphatemia. Herein we report a case of a severe and symptomatic hypophosphatemia (0.18 mM, normal range 0.8-1.4 mM) associated with an inappropriately reduced tubular reabsorption of phosphate (33%, norm >95%) in a malnourished patient with anorexia/bulimia who received 2 × 500 mg iron carboxymaltose (FCM) intravenously. Despite intravenous and oral phosphate supplements, it required 2 months to achieve a normal serum phosphate level. Our case demonstrates that in a chronically malnourished and phosphate-deficient state intravenous FCM could potentially be dangerous. If this form of iron application cannot be avoided, phosphate supplementation before and after iron infusion as well as close monitoring of phosphate levels are needed.

Profiling of steroid metabolites after transdermal and oral administration of testosterone by ultra-high pressure liquid chromatography coupled to quadrupole time-of-flight mass spectrometry

The screening of testosterone (T) misuse for doping control is based on the urinary steroid profile, including T, its precursors and metabolites. Modifications of individual levels and ratio between those metabolites are indicators of T misuse. In the context of screening analysis, the most discriminant criterion known to date is based on the T glucuronide (TG) to epitestosterone glucuronide (EG) ratio (TG/EG). Following the World Anti-Doping Agency (WADA) recommendations, there is suspicion of T misuse when the ratio reaches 4 or beyond. While this marker remains very sensitive and specific, it suffers from large inter-individual variability, with important influence of enzyme polymorphisms. Moreover, use of low dose or topical administration forms makes the screening of endogenous steroids difficult while the detection window no longer suits the doping habit. As reference limits are estimated on the basis of population studies, which encompass inter-individual and inter-ethnic variability, new strategies including individual threshold monitoring and alternative biomarkers were proposed to detect T misuse. The purpose of this study was to evaluate the potential of ultra-high pressure liquid chromatography (UHPLC) coupled with a new generation high resolution quadrupole time-of-flight mass spectrometer (QTOF-MS) to investigate the steroid metabolism after transdermal and oral T administration. An approach was developed to quantify 12 targeted urinary steroids as direct glucuro- and sulfo-conjugated metabolites, allowing the conservation of the phase II metabolism information, reflecting genetic and environmental influences. The UHPLC-QTOF-MS(E) platform was applied to clinical study samples from 19 healthy male volunteers, having different genotypes for the UGT2B17 enzyme responsible for the glucuroconjugation of T. Based on reference population ranges, none of the traditional markers of T misuse could detect doping after topical administration of T, while the detection window was short after oral TU ingestion. The detection ability of the 12 targeted steroids was thus evaluated by using individual thresholds following both transdermal and oral administration. Other relevant biomarkers and minor metabolites were studied for complementary information to the steroid profile, including sulfoconjugated analytes and hydroxy forms of glucuroconjugated metabolites. While sulfoconjugated steroids may provide helpful screening information for individuals with homozygotous UGT2B17 deletion, hydroxy-glucuroconjugated analytes could enhance the detection window of oral T undecanoate (TU) doping.

[Recent advances in the treatment of adrenocortical carcinomas]

Adrenocortical carcinomas are rare and aggressive malignant tumors, with an incidence of 1 to 2 cases per million inhabitants. Their diagnosis is made in three clinical situations: during the work up of a syndrome of hormonal hypersecretion, during the work up of locoregional symptoms, or incidentally during an unrelated radiological procedure. Surgery is usually indicated except in situations of advanced metastatic disease. Adjuvant chemotherapy with mitotane is associated with a significant increase in disease-free survival when the drug is administered at adequate therapeutic dosage. Novel anti-mitotic therapies have recently been described for treating recurrent adrenocortical carcinoma under mitotane treatment, but their overall efficacy remains unsatisfactory.

[Gastrointestinal neuroendocrine tumors: pleomorphic and often ignored]

Although generally considered as rare, incidence of gastrointestinal neuroendocrine tumors (GI-NETs) is increasing. The general practitioner has thus to be familiar with the vast array of clinical presentations and the growing family of diagnostic tools that can be used. Symptoms can be related to their hormonal production, their local extent or a bleeding complication. The prognosis depends on the grade of tumor, its local extent at diagnosis and its localization. The diagnosis relies on radiologic, endoscopic and nuclear medicine strategies. In case of typical symptoms, a hormonal secretion should be sought. Treatment options are extensive and should be discussed in an interdisciplinary manner.

[Testosterone and prostate]

Age related testosterone deficiency syndrome may occur with other diseases of the elderly men, as prostate diseases. The relationship between testosterone and prostate has been widely studied the last 10 years, with the increased use of testosterone replacement therapy. The traditional belief that testosterone administration causes prostate cancer growth has been challenged by recent studies. To date, nothing has been found to support the evidence that restoring testosterone levels within physiological range increases the incidence of prostate cancer in hypogonadic patients. In these patients, testosterone replacement therapy does not seem to worsen lower urinary tract symptoms.

[Gender identity disorder: challenges and specificity in the treatment of requests for sexual reassignment]

Gender identity disorder is defined as a permanent desire to relieve one's own sexual features to acquire the sexual features and line to life of the opposite sex. The diagnosis is based on the psychiatric evaluation and treatment on an interdisciplinary approach by endocrinologists, surgeons and psychiatrists, and can be conceptualized into distinct phases: diagnostic evaluation, real life experience, hormonal treatment and surgery. Multiples challenges have to be faced, especially by the psychiatrist who follows the patient during the whole process.

[The impact of obesity on fertility]

There are many negative impacts of obesity on fertility. Obese couples present decreased sperm count, decreased ovulation and conception rates, increased erectile dysfunction and spontaneous abortion rate as well as increased maternal and foetal complications of pregnancy. Moreover, obesity tends to decrease response to fertility treatments. Fortunately, intensive lifestyle modifications can restore fertility while decreasing pregnancy complications risk. With the increasing trend of obesity to affect young populations, taking care of these infertile couples rapidly is capital to restore fertility and decrease its related pregnancy complications.

[Adrenal function after induction of cardiac surgery patients with an etomidate bolus: a retrospective study]

OBJECTIVE

A single bolus dose of etomidate decreases cortisol synthesis by inhibiting the 11-beta hydroxylase, a mitochondrial enzyme in the final step of cortisol synthesis. In our institution, all the patients undergoing cardiac surgery receive etomidate at anesthesia induction. The purpose of this study was to assess the incidence of adrenocortical dysfunction after a single dose of etomidate in selected patients undergoing major cardiac surgery and requiring high-dose norepinephrine postoperatively.

STUDY DESIGN

Retrospective descriptive study in the surgical ICU of a university hospital.

PATIENTS AND METHODS

Sixty-three patients presented acute circulatory failure requiring norepinephrine (>0,2 microg/kg/min) during the 48 hours following cardiac surgery. Absolute adrenal insufficiency was defined as a basal cortisol below 414 nmo/l (15 microg/dl) and relative adrenal insufficiency as a basal plasma cortisol between 414 nmo/l (15 microg/dl) and 938 nmo/l (34 microg/dl) with an incremental response after 250 microg of synthetic corticotropin (measured at 60 minutes) below 250 nmol/l (9 microg/dl).

RESULTS

Fourteen patients (22%) had normal corticotropin test results, 10 (16%) had absolute and 39 (62%) relative adrenal insufficiency. All patients received a low-dose steroid substitution after the corticotropin test. Substituted patients had similar clinical outcomes compared to patients with normal adrenal function.

CONCLUSION

A high incidence of relative adrenal failure was observed in selected cardiac surgery patients with acute postoperative circulatory failure.

Distribution and genesis of the RFRP-producing neurons in the rat brain: comparison with melanin-concentrating hormone- and hypocretin-containing neurons

Prepro-RFRP-containing neurons have recently been described in the mammalian brain. These neurons are only found in the tuberal hypothalamus. In this work, we have provided a detailed analysis of the distribution of cells expressing the RFRP mRNA, and found them in seven anatomical structures of the tuberal hypothalamus. No co-expression with melanin-concentrating hormone (MCH) or hypocretin (Hcrt), that are also described in neurons of the tuberal hypothalamus, was observed. Using the BrdU method, we found that all RFRP cell bodies are generated between E13 and E14. Thus, RFRP neurons form a specific cell population with a complex distribution pattern in the tuberal hypothalamus. However, they are generated in one peak. These observations are discussed with data concerning the distribution and genesis of the MCH and Hcrt cell populations that are also distributed in the tuberal hypothalamus.

AMP-activated protein kinase mediates glucocorticoid-induced metabolic changes: a novel mechanism in Cushing's syndrome

Chronic exposure to glucocorticoid hormones, resulting from either drug treatment or Cushing's syndrome, results in insulin resistance, central obesity, and symptoms similar to the metabolic syndrome. We hypothesized that the major metabolic effects of corticosteroids are mediated by changes in the key metabolic enzyme adenosine monophosphate-activated protein kinase (AMPK) activity. Activation of AMPK is known to stimulate appetite in the hypothalamus and stimulate catabolic processes in the periphery. We assessed AMPK activity and the expression of several metabolic enzymes in the hypothalamus, liver, adipose tissue, and heart of a rat glucocorticoid-excess model as well as in in vitro studies using primary human adipose and primary rat hypothalamic cell cultures, and a human hepatoma cell line treated with dexamethasone and metformin. Glucocorticoid treatment inhibited AMPK activity in rat adipose tissue and heart, while stimulating it in the liver and hypothalamus. Similar data were observed in vitro in the primary adipose and hypothalamic cells and in the liver cell line. Metformin, a known AMPK regulator, prevented the corticosteroid-induced effects on AMPK in human adipocytes and rat hypothalamic neurons. Our data suggest that glucocorticoid-induced changes in AMPK constitute a novel mechanism that could explain the increase in appetite, the deposition of lipids in visceral adipose and hepatic tissue, as well as the cardiac changes that are all characteristic of glucocorticoid excess. Our data suggest that metformin treatment could be effective in preventing the metabolic complications of chronic glucocorticoid excess.

Expression of peroxisome proliferator-activated receptor-gamma1 and peroxisome proliferator-activated receptor-gamma2 in visceral and subcutaneous adipose tissue of obese women

Data regarding the expression of peroxisome proliferator-activated receptor (PPAR)-gamma(1) and PPAR-gamma(2) in human visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) are conflicting. To clarify this issue, we studied 50 women who had a BMI >35 kg/m(2) were undergoing gastric reduction surgery. Phenotyping included recording of anthropometric parameters and of a biological profile. Quantification of the expression of PPAR-gamma(1) and PPAR-gamma(2) in samples of VAT and SAT was performed by real-time RT-PCR. In both SAT and VAT, the level of expression of PPAR-gamma(2) were >20-fold that of PPAR-gamma(1) (P < 0.001 for both). However, only PPAR-gamma(1) was differentially expressed, its levels in SAT being 216 +/- 34% those in VAT (P < 0.001). In a stepwise, multivariate regression analysis, the levels of PPAR-gamma(1) in both SAT and VAT were the major determinants of waist circumference (R(2) = 21% for both; P < 0.01). Finally, leptin but not PPARs appeared as the single parameter explaining the largest part of the variability of BMI in our cohort of patients (R(2) = 22%, P < 0.001). These results are consistent with the putative roles of PPAR-gamma(1) and PPAR-gamma(2) in carbohydrate metabolism and energy homeostasis, respectively. As such, they constitute an important step toward the identification of potential targets for novel therapeutic strategies in the fields of obesity.

Neuropeptide Y: the universal soldier

The peptidic neuropeptide Y (NPY) has received great attention because it has been implicated in the regulation of several organ systems. In particular, NPY is involved in the regulatory loops that control food intake in the hypothalamus and appears also to be important for regulating the activity of neuroendocrine axes under poor metabolic conditions. Furthermore, NPY exerts vasoconstrictive action on the vasculature and potentiates the actions of many other vasoconstrictors. In addition, it was demonstrated to have trophic properties and could therefore contribute to cardiovascular remodeling. These various effects plus a number of others make NPY an attractive target for the potential treatment of human diseases, such as obesity, metabolic disorders, hypertension and heart failure.

[Adrenal insufficiency caused by treatment with levothyroxine]

Primary adrenal insufficiency is a rare disease. Its diagnosis remains a clinical challenge since the signs and symptoms of the disease are insidious in onset and non specific in nature. A case report of Addison's crisis induced by levothyroxine substitution therapy is described. This clinical case is discussed in details with a special emphasis to the published literature regarding the strategy of diagnosis and the specific therapy of primary adrenal insufficiency.

PAC1 null females display decreased fertility

We report here that PAC1 KO females display decreased fertility, whereas male fertility was normal. ICC on pituitary section showed that FSH, LH, and prolactin synthesis were not affected in KO mice. Moreover, the pituitary-gonadal axis responded properly to an acute fasting test in KO mice. Hence, the phenotype of PAC1 null mice provides clear evidence for the role of PAC1 receptor in reproduction process.

Sexual dimorphism in the mouse hypothalamic-pituitary-adrenal axis function after endotoxin and insulin stresses during development

Bidirectional communication between the immune and the endocrine systems is now widely accepted as essential for the survival of the organism. Since a classical nonresponsive period of the hypothalamic-pituitary-adrenal (HPA) axis takes place shortly after birth and because endogenous sex hormones modulate immune function, the aim of the present work was to determine whether sex steroids regulate the PHA axis response to immune (bacterial, lipopolysaccharide, LPS) and nonimmune (insulin, INS) stressors in mice during development. For this purpose 7-, 15-, 30-, 45- and 60-day-old mice of both sexes were intraperitoneally injected with either vehicle alone (basal) or containing LPS (2 mg/kg body weight) or INS (12 IU/kg body weight). The animals were then killed by decapitation, 2 h or 45 min after LPS or INS, respectively. Plasma samples were assayed to measure corticosterone concentrations. The results indicated that: (a) there was a transient increase in basal plasma corticosterone levels during development, with a peak value at the juvenile age, regardless of sex; (b) a higher basal plasma corticosterone concentration in females than in males characterized the adult age; (c) the infantile age is a period of the HPA axis function nonresponsive to purely neuroendocrine but not to inflammatory stimuli; (d) during the juvenile age, females showed a hyporesponsive HPA axis to neurendocrine and immune stress, whereas male mice were fully unresponsive to both challenges; (e) animals of both sexes showed a maximal HPA axis response to purely neuroendocrine stress at the prepubertal age; this response to the immune stimulus was also maximal in 30-day-old males, while it was found in females after puberty (45-day-old mice); (f) sexual dimorphism in the HPA axis response to a purely neuroendocrine stimulus was found at 30 days of age or later, while this characteristic of the response to endotoxin was not present until puberty. These data clearly suggest that these are gender-dependent characteristics of the ontogeny of the HPA and HP-gonadal axes that are responsible for the sexual dimorphism of HPA axis function in mice.

Dexamethasone treatment increases neuropeptide Y levels in rat hypothalamic neurones

Immunoreactive glucocorticoid receptors (GR) have previously been demonstrated in neuropeptide Y (NPY) neurones of the rat hypothalamus. To determine whether NPY synthesis is influenced by glucocorticoids, the effect of dexamethasone (DEX) on the levels of immunoreactive NPY in rat hypothalamic neurones was investigated in vivo and in vitro. Daily injections of DEX (0.1 mg/day) for 5 days increased the NPY content of the mediobasal hypothalamus in female rats by 117% (p less than 0.002). Primary cultures of hypothalamic neurones were also sensitive to the effect of glucocorticoids. Intracellular NPY levels were significantly increased (p less than 0.001) compared to control values by 151%, 222% and 268% when cultures were maintained in a defined serum free medium containing DEX 10(-9), 10(-8) and 10(-7) M respectively.