Large body mass index does not predict short-term survival in peritoneal dialysis patients.

OBJECTIVE: Higher than normal body mass index (BMI) is associated with an increased risk of death in the general population. We examined the effect of higher than normal BMI on patient and technique survival in peritoneal dialysis patients (PD), controlling for comorbidity, initial albumin, dialysate-to-plasma ratio of creatinine (D/P(Cr)), and initial urea clearance (Kt/V). DESIGN: Registry database. SETTINGS: Four dialysis centers. PATIENTS: Incident PD patients. METHODS: All data were collected prospectively. Demographics, BMI, serum albumin, D/P(Cr), and comorbidity using the Charlson Comorbidity Index (CCI) were determined at the start of PD. 104 patients with a high BMI (> 27) were matched to a control group of 104 patients with normal BMI (20-27) for age, gender, presence of diabetes, and CCI. Patient and technique survival were compared using Cox proportional hazards model. MAIN OUTCOME MEASURES: Patient and technique survival. RESULTS: The groups were of similar age (56.1 vs 56.7 years), sex (60% males in both groups), race (Caucasian 80% vs 86%), presence of diabetes (40% vs 37%), CCI score (5.4 in both groups), initial albumin (3.6 vs 3.5 g/dL), and D/P(Cr) (0.65 in both groups). Kaplan-Meier survival analysis showed similar 2-year patient survival between large BMI (> 27) and control (20-27) groups (76.6% vs 76.1%). Two-year technique survival was also similar between the two groups (59.7% vs 66.8%). With Cox proportional hazards analysis, BMI was not a predictor of patient mortality or technique survival when controlling for initial albumin, D/P(Cr), and initial Kt/V. CONCLUSIONS: We conclude that a BMI above normal is not associated with any increased or decreased risk of death in patients on PD for 2 years.     

Reduced body mass index is associated with increased angiotensin II in young women with postural tachycardia syndrome

Altered peripheral haemodynamics, decreased cardiac output, decreased blood volume and increased AngII (angiotensin II) have been reported in POTS (postural tachycardia syndrome). Recent findings indicate that BMI (body mass index) may be reduced. In the present study, we investigated the hypothesis that reduced BMI is associated with haemodynamic abnormalities in POTS and that this is related to AngII. We studied 52 patients with POTS, aged 14-29 years, compared with 36 control subjects, aged 14-27 years. BMI was not significantly reduced on average in the POTS patients, but was reduced in patients with decreased peripheral blood flow. POTS patients were then subdivided on the basis of BMI, and supine haemodynamics were measured. There was no difference in blood volume or cardiac output once BMI or body mass were accounted for. When POTS patients with BMI <50th percentile were compared with controls, calf blood flow [1.63+/-0.31 compared with 3.58+/-0.67 ml(-1).min(-1).(100 ml of tissue)(-1)] and maximum venous capacity (3.87+/-0.32 compared with 4.98+/-0.36 ml/100 ml of tissue) were decreased, whereas arterial resistance [56+/-0.5 compared with 30+/-4 mmHg.ml(-1).min(-1).(100 ml of tissue)(-1)] and venous resistance [1.23+/-0.17 compared with 0.79+/-0.11 mmHg.ml(-1).min(-1).(100 ml of tissue)(-1)] were increased. Similar findings were also observed when POTS patients with BMI <50th percentile were compared with POTS patients with BMI >50th percentile. There was no relationship between blood flow, resistance or maximum venous capacity with BMI in control subjects. BMI was inversely related to plasma AngII concentrations in those POTS patients with decreased peripheral blood flow, consistent with cachectic properties of the octapeptide. Patients with low-flow POTS had decreased body mass, but decreased body mass alone cannot account for findings of peripheral vasoconstriction. In conclusion, the findings suggest that reduced body mass relates to increased plasma AngII.     

Nutritional depletion in relation to mortality in patients with chronic respiratory insufficiency treated with long-term oxygen therapy

OBJECTIVE: An association between malnutrition, weight loss and mortality has been demonstrated in patients with chronic obstructive pulmonary disease (COPD), but the prognostic influence of low body-mass index (BMI) and plasma concentrations of albumin and cholesterol is less clear in patients with chronic respiratory insufficiency treated with domiciliary long-term oxygen therapy (LTOT). We therefore analysed the prognostic value of BMI, plasma albumin and cholesterol concentrations in patients receiving LTOT. PATIENTS AND METHODS: From 1996 to 2001, LTOT was initiated in 255 patients. Analysis of the impact of nutritional status on survival was confined to a study group of 108 patients in whom the main outcomes, i.e. BMI, plasma cholesterol and albumin, were measured. Standard laboratory methods were used in the biochemical analyses. Pulmonary function was assessed with bodyplethysmography. RESULTS: 63 patients (58.3%) survived for two years post-initiation of LTOT and 45 patients (41.7%) did not. There were no differences between these two groups in pulmonary function tests and arterial blood gases at the start of LTOT. Overall, 10.2% of the study population were underweight, defined as BMI <20 kg/m2. Compared with patients who survived two years of LTOT, those who did not survive were older (69.3+/-0.9 versus 64.7+/-1.2 years, p<0.01), had significantly lower BMI (24.5+/-0.7 versus 26.5+/-0.7 kg/m2, p < 0.05), lower plasma cholesterol (4.61+/-0.19 versus 5.22+/-0.13 mmol/l, p<0.01) and lower plasma albumin concentrations (41.4+/-0.4 versus 42.8+/-0.4 g/l, p <0.05). Logistic regression analysis revealed that, in addition to age (p < 0.01), both BMI (p < 0.05) and cholesterol (p < 0.05) significantly affected the 2-year survival. CONCLUSION: This study suggests that nutritional status is closely linked with prognosis in patients with chronic respiratory insufficiency treated with domiciliary LTOT: low BMI, low plasma cholesterol and low albumin are related to worse 2-year survival in such patients.     

Obesity and treatment of diabetes with glyburide may both be risk factors for acute pancreatitis

OBJECTIVE: To evaluate risk factors, notably drugs, for acute pancreatitis. RESEARCH DESIGN AND METHODS: A population-based case-control study was conducted of 1.4 million inhabitants, aged 20-85 years, of four regions in Sweden between 1 January 1995 and 31 May 1998. A total of 462 case subjects were hospitalized in surgery departments for their first episode of acute pancreatitis without previous gallbladder disease. A total of 1,781 control subjects were randomly selected from a population register. Information was obtained from case records and through telephone interviews. RESULTS: A total of 27 case subjects (6%) and 55 control subjects (3%) had prevalent diabetes. A total of 53 case subjects (11%) and 130 control subjects (7%) had a BMI >30 kg/m(2). Use of glyburide had a crude odds ratio (OR) of 3.2 (95% CI 1.5-5.9), and in a multivariate logistic regression adjusted for covariates, the OR for use of glyburide was 2.5 (1.1-5.9). BMI had a continuous OR of 1.2 (1.1-1.4) per 5 units of BMI. The relative risk for hospitalization longer than 14 days or treatment in an intensive care unit was 2.4 (1.1-5.4) among patients with a BMI >30 kg/m(2) when compared with patients with a BMI between 20 and 25 kg/m(2). CONCLUSIONS: Use of glyburide and obesity may both be risk factors for acute pancreatitis. Obesity is associated with an extended hospitalization time in subjects with acute pancreatitis.     

Waist-to-hip ratio correlates with homocysteine levels in male patients with coronary artery disease

BACKGROUND: Obesity and homocysteine are important risk factors for cardiovascular disease. The relation between pattern of obesity and homocysteine is unclear. The objective of this study was to investigate the relation between pattern of obesity and plasma total homocysteine (tHcy) level in male patients with coronary artery disease (CAD). METHODS: A total of 63 male patients (mean age 66.2 years) with angiographically documented CAD were enrolled. Overnight fasting blood samples were measured for plasma tHcy, serum folic acid and serum vitamin B12 levels. Anthropometric measurements included waist-to-hip ratio (WHR) and body mass index (BMI). RESULTS: The mean WHR was 0.90+/-0.05, mean BMI 24.6+/-3.3 kg/m2 and the mean plasma tHcy level 11.6+/-3.2 micromol/L. In univariate analysis, plasma tHcy level correlated significantly with serum vitamin B12 level, serum folic acid level, WHR, estimated creatinine clearance, aspirin use and fibrate use. There was no significant association between plasma tHcy level and BMI. In multivariate analysis, only WHR (beta-value 22.263, p<0.001), serum level of vitamin B12 (beta-value -0.004, p=0.003), estimated creatinine clearance (beta-value -4.154, p=0.003) and use of fibrates (beta-value 2.307, p=0.031) were independent predictors of plasma tHcy level. CONCLUSIONS: WHR, but not BMI, is a strong independent predictor of plasma tHcy level in male patients with CAD.     

Impact of overweight on chronic microvascular complications in type 1 diabetic patients

OBJECTIVE: To investigate a possible association of BMI with retinopathy and neuropathy in type 1 diabetes. Retinopathy and neuropathy may not only be related to glycemic control and diabetes duration but also to blood pressure and BMI. RESEARCH DESIGN AND METHODS: A total of 592 type 1 diabetic patients without nephropathy were studied (M/F: 324/268; age: 41 +/- 12 years; duration: 19 +/- 11 years; HbA(1c) [A1C]: 7.9 +/- 1.1%). Patients were subdivided according to BMI: 168 men and 146 women with BMI <25 kg/m(2), and 156 men and 122 women with BMI > or =25 kg/m(2). Retinopathy was examined by fundoscopy and neuropathy by electromyography. RESULTS: Hypertension (>130/85 mmHg) was present in 40%, retinopathy in 53%, and neuropathy in 43% of patients. Overweight subjects had more retinopathy (63 vs. 45%, P < 0.0001, odds ratio [OR] = 2.1) and neuropathy (49 vs. 38%, P = 0.008, OR = 1.6) than normal-weight patients. Patients with retinopathy were older (45 +/- 12 vs. 37 +/- 11 years, P < 0.0001) and had a longer diabetes duration (25 +/- 10 vs. 12 +/- 8 years, P < 0.0001), a higher A1C (8.0 +/- 1.1 vs. 7.7 +/- 1.1%, P = 0.001), and a higher BMI (25.8 +/- 4.1 vs. 24.7 +/- 4.2 kg/m(2), P = 0.001) than individuals without retinopathy. The same results are found in neuropathy. Logistic regression analysis showed that diabetes duration (beta = 0.15, P < 0.0001), blood pressure (beta = 0.22, P = 0.0047), and A1C (beta = 0.24, P = 0.01), but not BMI, lipid levels, sex, or age, were independent risk factors for retinopathy. Likewise, duration (beta = 0.05, P < 0.0001), age (beta = 0.04, P = 0.0001), A1C (beta = 0.35, P < 0.0001), and sex (beta = 0.74, P = 0.0001) but not BMI, lipid levels, or hypertension were independently associated with neuropathy. Men had more neuropathy than women (50 vs. 34%, P < 0.0001, OR = 1.9). Leptin and adiponectin levels did not differ between individuals with or without microvascular complications. CONCLUSIONS: Retinopathy and neuropathy are more prevalent in overweight (BMI > or =25 kg/m(2)) type 1 diabetic subjects. However, logistic regression analysis showed that diabetes duration and A1C remain the main determinants for retinopathy and neuropathy.     

青年腰椎间盘突出症发病原因与物理治疗效果分析

目的：探讨青年腰椎间盘突出症（LDH）的发病原因及物理治疗的临床效果。方法：选取20—30岁青年初发LDH患者18例。应用腰椎牵引、脉冲短波、脉冲磁疗及低频调制中频电疗对患者进行综合物理治疗。治疗前后采用JOA下腰痛评估表评价患者的腰椎功能状况,并计算改善率。结果：9例患者有明确外伤史;9例患者有久坐生活方式史;5例患者站立位工作时间超过8h/d,4例患者体重超过正常。男性与女性患者的年龄、BMI及JOA评分无显著差异（P>0.05）。治疗后患者JOA评分明显高于治疗前,差异有显著性意义（P<0.05）。物理治疗的显效率为72.22%。结论：外伤、久坐、久站、体重超重或肥胖是青年LDH的主要危险因素。物理治疗对青年初发LDH有显著疗效。     

Obesity, weight change, and risk of adenoma recurrence: a prospective trial

Background and study aims: Obesity is a risk factor for colorectal neoplasia. Lifestyle modifications, including weight loss, have been advocated to reduce the risk. However, no prospective study has evaluated whether weight loss actually affects adenoma recurrence. The aim of this study was to examine whether weight change (loss or gain) over 4 years is associated with adenoma recurrence.Patients and methods: A total of 1826 patients with colorectal adenoma in the Polyp Prevention Trial had their height and weight measured at baseline. Adenoma recurrence was determined by end of trial colonoscopy 4 years after study entry when patients' weights were re-measured. Poisson regression models were used to evaluate body mass index (BMI), weight change over 4 years, and the risk of any adenoma and advanced adenoma recurrence. Results: Adenoma recurrence was observed in 723 patients (39.6 %), 118 (6.5 %) of whom had advanced adenoma recurrence. Among those with baseline BMI < 25 kg/m2 (n = 466), BMI 25 - 29 kg/m2 (n = 868), and BMI ≥ 30 kg/m2 (n = 492), the recurrence rate was 34.5 %, 41.0 %, and 41.9 %, respectively. Obesity was associated with an increased risk of adenoma recurrence (RR = 1.19; 95 %CI 1.01 - 1.39) and advanced adenoma recurrence (RR = 1.62; 95 %CI 1.01 - 2.57). However, when compared with those with relatively stable weight (weight change < 5 lb) over the 4-year trial, weight gain or loss was not associated with adenoma recurrence. This was consistent, regardless of the baseline BMI.Conclusions: Weight loss or gain over 4 years does not affect adenoma recurrence. This study does not support weight loss alone as an effective intervention for reducing adenoma recurrence.     

Two-hour insulin determination improves the ability of abdominal fat measurement to identify risk for the metabolic syndrome

OBJECTIVE: Visceral obesity is shown to be a predictor of morbidity and mortality. We evaluated the association of measurements of generalized adiposity and visceral fat area (VFA), with abnormalities of metabolic syndrome (MS). RESEARCH DESIGN AND METHODS: Seventy-six women (47.9 +/- 9.2 years) with BMI of 38.7 +/- 5.4 kg/m(2) underwent anthropometric measurements, laboratory procedures, bioeletrical impedance, and abdominal computed tomography (CT) scan. Diagnosis of MS was based on the presence of abdominal obesity and at least two of the following components: hypertension, dyslipidemia, and glucose intolerance and/or hyperinsulinemia. RESULTS: BMI was correlated with both components of adipose tissue--subcutaneous (r = 0.66, P < 0.01) and VFA (r = 0.33, P < 0.02)--and leptin levels (r = 0.38, P < 0.01). In contrast, VFA was correlated with 2-h glucose and insulin levels (r = 0.32 and 0.35, P < 0.05, respectively), triglyceride, HDL cholesterol, and uric acid (r = 0.33, -0.34 and 0.24, P < 0.05, respectively). Subjects with high VFA, matched for BMI, showed greater plasma glucose area under the curve (621 +/- 127 vs. 558 +/- 129 mg x h(-1) x dl(-1), P < 0.05), 2-h insulin (804 +/- 599 vs. 579 +/- 347 pmol/l, P < 0.05), and uric acid levels (0.33 +/- 0.07 vs. 0.26 +/- 0.06 mmol/l, P < 0.05) than subjects with low VFA. In logistic regression analysis, waist circumference, VFA, and 2-h insulin were identified as independent predictors of MS. Receiver operating characteristic curve analysis pointed out the values of 104 cm for waist circumference (58.1% specificity, 84.1% sensitivity), 158.5 cm(2) for VFA (78.1% specificity, 52.3% sensitivity), and 559.8 pmol/l for 2-h insulin (71.9% specificity, 69.8% sensitivity); the presence of at least two of the three variables resulted in a degree of concordance of 76%. CONCLUSIONS: While BMI was unable to differentiate between obese people and those at higher risk for MS, abdominal fat was shown to be associated with its metabolic abnormalities. The usefulness of abdominal fat in the identification of high-risk subjects may be improved when combined with 2-h insulin determination.     

Glycaemic control in type 2 diabetes: the impact of body weight, beta-cell function and patient education

We examined the determinants of glycaemic control in a consecutive cohort of 562 newly-referred Chinese type 2 diabetic patients (57% women) during a 12-month period. All patients underwent a structured assessment with documentation of clinical and biochemical characteristics. Pancreatic beta-cell function was assessed by fasting plasma C-peptide concentration. Insulin deficiency was defined as fasting plasma C-peptide <0.2 pmol/ml. Insulin resistance (IR) was calculated using the homeostasis model assessment (HOMA) based on a product of fasting plasma glucose and insulin concentrations. Treatment was considered appropriate when insulin-deficient patients were treated with insulin and non-insulin-deficient patients were treated with oral agents or diet. Mean (+/-SD) age was 54.3+/-13.8 years (range 17-87 years) and disease duration was 5.0+/-5.9 years. At the time of referral, 70.5% (n=396) were on drug therapy (9% on insulin and 62.8% on oral agents), 20.6% (n=116) were on diet and 9% (n=50) had not received any form of treatment. The mean HbA(lc) was 8.4+/-2.3%. The geometric mean (x// antilog SD) of IR was 4.62x//2.51 (range 0. 63-162.7) and correlated only with waist : hip ratio (WHR, p=0.008). The geometric mean of plasma C peptide was 0.47x//2.89 nmol/l and correlated with BMI (p<0.001). Glycated haemoglobin was correlated positively with age (p=0.013), disease duration (p<0.001), IR (p<0. 001) and negatively with BMI (p<0.001). Glycated haemoglobin was lower in patients who had seen a dietitian (7.9% vs. 8.7%, p<0.001) or diabetes nurse (7.8% vs. 8.7%, p<0.001) or who performed self blood glucose monitoring (7.9% vs. 8.6%, p=0.001) and higher among smokers (8.9% vs. 8.2%, p=0.003). Compared to insulin-deficient patients (n=118), non-insulin-deficient patients (n=413) had features resembling that of the Metabolic Syndrome with increased WHR (p=0.005), blood pressure (p<0.001), BMI (p=0.001) and were older (p=0.04). Amongst the insulin-deficient patients, 27% were treated with oral agents or diet. Patients receiving appropriate therapy (n=362) had a lower HbA(lc) than those treated inappropriately (n=173) (8.2% vs. 8.7%, p=0.02). On multivariate analysis, short disease duration (p<0.001), low IR (p<0.001), high BMI (p=0.001), diabetes education (p<0.001), lack of smoking (p=0. 014) and choice of appropriate treatment (p=0.009) were the independent determinants of good glycaemic control.     

Traumatic brain injuries after mass-casualty incidents: lessons from the 11 September 2001 World Trade Center attacks

INTRODUCTION: The 11 September 2001 terrorist attacks on the World Trade Center (WTC) resulted in thousands of deaths and injuries. Research on previous bombings and explosions has shown that head injuries, including traumatic brain injuries (TBIs), are among the most common injuries. OBJECTIVE: The objective of this study was to identify diagnosed and undiagnosed (undetected) TBIs among persons hospitalized in New York City following the 11 September 2001 WTC attacks. METHODS: The medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the WTC attacks were abstracted for signs and symptoms of TBIs. Diagnosed TBIs were identified using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons with an undiagnosed TBI were contacted and informed of the diagnosis of potential undetected injury. RESULTS: A total of 282 records were abstracted. Fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the abstracted records). The leading cause of TBI was being hit by falling debris (22 cases). One-third of the TBIs (13 cases) occurred among rescue workers. More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they currently were experiencing symptoms consistent with a TBI. CONCLUSIONS: Not all of the TBIs among hospitalized survivors of the WTC attacks were diagnosed at the time of acute injury care. Some persons with undiagnosed TBIs reported problems that may have resulted from these TBIs three years after the event. For hospitalized survivors of mass-casualty incidents, additional in-hospital, clinical surveys could help improve pre-discharge TBI diagnosis and provide the opportunity to link patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers deserves re-evaluation.     

Association between body mass index and functional independence measure in patients with deconditioning

OBJECTIVE: To assess the association of body mass index (BMI) with functional independence measure (FIM) score in patients with deconditioning. We also examined whether the association was different for motor and cognitive subscales of the FIM instrument. DESIGN: A retrospective study of 1077 inpatients admitted to the general medicine service for deconditioning at an acute rehabilitation hospital. Patients were classified into underweight (BMI < 18.5), normal range (BMI = 18.5-24.9), overweight (BMI = 25.0-29.9), obese class I (BMI = 30.0-34.9), obese class II (BMI = 35.0-39.9), and obese class III (BMI > or = 40). RESULTS: Median gain in FIM scores from admission to discharge was highest in obese class I patients (27 points), followed by obese class II patients (26 points). The most gain in FIM scores was accounted for by the motor subscale. Adjusting for age, gender, and length of in-hospital stay, obese class I patients had a 5.8-point (95% confidence limits = 1.2, 7.0) higher gain in FIM score compared with patients with BMI in the normal range. CONCLUSIONS: In an acute rehabilitation setting, obese patients had higher gains in FIM scores as compared with normal-range-BMI patients. Most of the improvements in FIM scores were accounted for by the motor subscale, with little or no improvement on the cognitive scale.     

Vascular symptoms of Behcet's disease

AIM: To characterize vascular symptoms of Behcet's disease (BD) in patients treated for the last 10 years in the Institute of Rheumatology. MATERIAL AND METHODS: Vascular symptoms of BD were studied in 151 patients with BD (mean age 33.5 +/- 9.5 years, duration of the disease 14.0 +/- 10.1 years, 104 males and 47 females, 67.4% carried HLA B51(5) antigen). Duplex vascular scanning was made to detect venous thrombosis. RESULTS: Thrombotic complications were found in 37 of 151 (24.5%) patients with BD (30 males and 7 females, mean age 37.1 +/- 9.1 years, mean duration of the disease 7.3 +/- 9.7 years). Venous thromboses prevailed (36 patients). Four males (2.6%) had arterial lesions: aneurysms of the iliac arteries (n = 1), thrombosis of the iliac artery (n = 1), pulmonary infarction and thrombosis of the pulmonary arteries (n = 2). Combination of venous and arterial manifestations occurred in 3 patients. One patient had thrombosis of the venous sinus, occlusion of the retinal vessels was diagnosed in 7 patients. CONCLUSION: Incidence of vascular disorders was observed in 1/4 of the patients. This corresponds to those observed worldwide and concerns venous thrombosis and other thromboses. Among the examinees, vascular disorders were associated with a young age, earlier development of thrombotic complications in males than in females.     

Is obesity a favorable prognostic factor in peritoneal dialysis patients?

OBJECTIVE: To determine the influence of an elevated body mass index (BMI) on cardiovascular outcomes and survival in peritoneal dialysis (PD) patients. DESIGN: Prospective, observational study of a prevalent PD cohort at a single center. SETTING: Tertiary care institutional dialysis center. PATIENTS: The study included all patients with a BMI of at least 20 who had been receiving PD for at least 1 month as of 31 January 1996 (n = 43). Patients were classified as overweight [BMI > 27.5; mean +/- standard error of mean (SEM): 32.1 +/- 1.1; n = 14] or normal weight (BMI 20-27.5; mean +/- SEM: 23.8 +/- 0.4; n = 29). OUTCOME MEASURES: Patient survival and adverse cardiovascular events (myocardial infarction, congestive cardiac failure, cerebrovascular accident, and symptomatic peripheral vascular disease) were recorded over a 3-year period. RESULTS: At baseline, no significant differences were seen between the groups in clinical, biochemical, nutritional, or echocardiographic parameters, except for a lower dietary protein intake (0.97 +/- 0.10 g/kg/day vs 1.44 +/- 0.10 g/kg/day, p = 0.004) and a higher proportion of well-nourished patients by subjective global assessment (100% vs 72%, p < 0.05) in the overweight group. After 3 years of follow-up, 29% of overweight patients and 69% of normal-weight patients had died (p < 0.05). Using a Cox proportional hazards model, a BMI greater than 27.5 was shown to be an independent positive predictor of patient survival, with an adjusted hazard ratio (HR) of 0.09 [95% confidence interval (CI): 0.01-0.85; p < 0.05]. However, being overweight did not significantly influence myocardial infarction-free survival (adjusted HR: 0.33; 95% CI: 0.07-1.48; p = 0.15) or combined adverse cardiovascular event-free survival (adjusted HR: 0.67; 95% CI: 0.23-1.93; p = 0.46). CONCLUSIONS: Obesity conferred a significant survival advantage in our PD population. Obese patients should therefore not be discouraged from receiving PD purely on the basis of BMI. Moreover, maintaining a higher-than-average BMI to preserve "nutritional reserve" may help to reduce the mortality and morbidity rates associated with PD.     

Metabolic alterations in middle-aged and elderly obese patients with type 2 diabetes.

OBJECTIVE: We conducted this study to assess the metabolic alterations in middle-aged and elderly obese patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Healthy control subjects (9 middle-aged, aged 42 +/- 2 years, BMI 33 +/- 1 kg/m2; 10 elderly, aged 71 +/- 1 years, BMI 29 +/- 1 kg/m2) and patients with type 2 diabetes (11 middle-aged, aged 43 +/- 2 years, BMI 34 +/- 2 kg/m2; 23 elderly, aged 73 +/- 1 years; BMI 30 +/- 1 kg/m2) underwent a 3-h oral glucose tolerance test (OGTT), a 2-h hyperglycemic glucose clamp, and a 3-h euglycemic glucose clamp study with tritiated glucose methodology to measure hepatic glucose production and peripheral disposal rates. RESULTS: Middle-aged and elderly control subjects and patients with diabetes were similar in percentage of body fat. Waist-to-hip ratio was greater in elderly patients with diabetes than in elderly control subjects (P < 0.01), but was similar in both middle-aged groups. VO2max was less in control subjects than in both middle-aged and elderly patients with diabetes (P < 0.05). Insulin responses during the OGTT were similar in elderly control subjects and patients with diabetes, but were less in middle-aged patients with diabetes than in control subjects (305 +/- 49 vs. 690 +/- 136 pmol/l, P < 0.01). Patients with type 2 diabetes had absent first-phase insulin responses during the hyperglycemic clamp. Second-phase (80-120 min) insulin values were similar in elderly patients and control subjects, but were reduced in middle-aged patients with diabetes compared with control subjects (285 +/- 35 vs. 894 +/- 143 pmol/l, P < 0.0001). During the euglycemic clamp, basal and steady-state (150-180 min) hepatic glucose output values were less in middle-aged control subjects than in patients with diabetes (basal, 3.03 +/- 0.10 vs. 3.69 +/- 0.09 mg.kg-1 lean body mass.min-1, P < 0.0001; steady-state, 0.72 +/- 0.10 vs. 1.84 +/- 0.20 mg.kg-1 lean body mass.min-1, P < 0.0001). Basal and steady-state hepatic glucose output values were similar in elderly patients and control subjects. Finally, steady-state (150-180 min) glucose disposal rates were higher in control subjects than in patients with diabetes in both the middle-aged (7.51 +/- 0.85 vs. 4.62 +/- 0.24 mg.kg-1 lean body mass.min-1, P < 0.01) and elderly (9.91 +/- 0.61 vs. 6.78 +/- 0.60 mg.kg-1 lean body mass.min-1, P < 0.01) groups. CONCLUSIONS: We conclude that type 2 diabetes in obese middle-aged subjects is characterized by impaired glucose-induced insulin release, altered regulation of hepatic glucose output, and resistance to insulin-mediated glucose disposal. In contrast, the primary defect in elderly obese patients with type 2 diabetes is resistance to insulin-mediated glucose disposal. Our findings may have important therapeutic implications for these patient populations.     

Reduced skeletal muscle oxygen uptake and reduced beta-cell function: two early abnormalities in normal glucose-tolerant offspring of patients with type 2 diabetes

OBJECTIVE: Studies on insulin sensitivity and insulin secretion in subjects with a familial predisposition for type 2 diabetes mellitus (T2DM) traditionally produce inconsistent results. This may be due to small sample size, subject selection, matching procedures, and perhaps lack of a measure of physical fitness. RESEARCH DESIGN AND METHODS: In the present study, we specifically tested the hypothesis that a family history of T2DM is associated with reduced VO(2max), measured by incremental bicycle ergometry, independent of insulin sensitivity estimated from an oral glucose tolerance test (OGTT; n = 424) and measured by a euglycemic-hyperinsulinemic clamp (n = 185). Subjects included in the study were young (34 +/- 10 years), healthy, and normal glucose tolerant with either a first-degree relative (FDR) with T2DM (n = 183), a second-degree relative with T2DM (n = 94), or no family history of T2DM (control subjects, n = 147). BMI, percent body fat, waist-to-hip ratio (WHR), and habitual physical activity (HPA; standard questionnaire) were comparable among groups. FDRs had significantly lower VO(2max) than control subjects: 40.5 +/- 0.6 vs. 45.2 +/- 0.9 ml O(2)/kg lean body mass, P = 0.01 after adjusting for sex, age, BMI, HPA, and insulin sensitivity (euglycemic-hyperinsulinemic clamp). RESULTS: BMI, percent body fat, waist-to-hip ratio (WHR), and habitual physical activity (HPA; standard questionnaire) were comparable among groups. FDRs had significantly lower VO(2max) than control subjects: 40.5 +/- 0.6 vs. 45.2 +/- 0.9 ml O(2)/kg lean body mass, P = 0.01 after adjusting for sex, age, BMI, HPA, and insulin sensitivity (euglycemic-hyperinsulinemic clamp). Insulin sensitivity per se was not affected by family history of T2DM after adjusting for age, sex, BMI, and percent body fat (P = 0.76). The appropriateness of beta-cell function for the individual insulin sensitivity (disposition index: product of a validated secretion parameter [OGTT] and sensitivity [clamp]) was significantly lower in FDRs (87 +/- 4 units) versus control subjects (104 +/- 6 units, P = 0.02 after adjusting for sex, age, and BMI). Analyses of the larger OGTT group produced essentially the same results. CONCLUSIONS: In conclusion, these data are compatible with the hypothesis that familial predisposition for T2DM impairs maximal oxygen consumption in skeletal muscle. Because habitual physical activity was not different, genetic factors may be involved. Conceivably, reduced VO(2max) precedes skeletal muscle insulin resistance, providing a partial explanation for discrepancies in the literature.     

The influence of diabetes on the relationship between N-terminal pro-B-type natriuretic peptide and body mass index

This study evaluated the influence of diabetes on the relationship between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and body mass index (BMI). Simultaneous NT-proBNP and echocardiographic Doppler examinations were performed in 1117 patients with dyspnoea undergoing cardiac catheterization. Patients were divided into BMI > or =25 kg/m2 (obese), 23-25 kg/m2 (overweight) and <23 kg/m2 (non-obese) groups. In the 803 non-diabetic patients, mean plasma NT-proBNP levels in non-obese, overweight and obese patients showed a significant negative correlation with BMI (862.3 +/- 228.8 pg/ml, 611.5 +/- 149.7 pg/ml, 278.3 +/- 172.5 pg/ml, respectively). In the 314 patients with diabetes, there was no correlation between BMI and NT-proBNP. This study demonstrated that obese patients had reduced concentrations of NT-proBNP compared with non-obese patients, despite having higher left ventricular filling pressures. NT-proBNP was not reduced in obese patients with diabetes. These results suggest that factors other than cardiac status impact on NT-proBNP concentration.     

Endoscopic balloon dilation of gastroenteric anastomotic stricture after laparoscopic gastric bypass

BACKGROUND AND STUDY AIMS: Laparoscopic gastric bypass is a recently introduced treatment option for morbid obesity, with promising initial results. Stenosis of the gastroenterostomy is a recognized complication. The efficacy and safety of endoscopic balloon dilation for the management of this type of anastomotic stenosis has not been studied. PATIENTS AND METHODS: 450 patients who underwent laparoscopic gastric bypass at our institution were followed prospectively. All patients had a 15 ml gastric pouch and either a 75 cm or 150 cm jejunal Roux limb depending on whether obesity was morbid (body mass index (BMI) < 50 kg/m 2) or super-morbid (BMI > 50 kg/m 2). Patients who developed symptoms compatible with stenosis of the gastrojejunostomy were referred for upper gastrointestinal endoscopy. RESULTS: 14 patients, 11 women and three men, underwent a total of 27 endoscopies, with 23 balloon dilations. Their average age was 46 years (range 33 - 59 years), average preoperative BMI was 47 kg/m 2, and they presented an average of 2.7 months after surgery (range 0.3 - 15.7 months). Of the 14 patients, 13 had a stricture of the gastrojejunostomy and one patient had edema. For initial dilation, a 15 mm hydrostatic balloon was used in 12 patients and an 18 mm balloon in two patients. There was response to treatment with the 15 mm balloon in seven of the 12 patients (58 %), and they required no further dilation; in one there was a response to a further 15 mm balloon dilation; in three patients a response to subsequent 18 mm balloon dilation; and one patient required 18 mm and 25 mm balloon dilations. The two patients treated with an initial 18 mm balloon dilation required no further dilations. The average length of follow-up after successful dilation was 18 months (range 7 - 30 months). There were no complications with any of the 23 dilations performed. CONCLUSION: Stenosis of the gastroenterostomy after laparoscopic gastric bypass occurred in 3.1 % of the patients in this series. It can be successfully and safely treated with endoscopic balloon dilation with good long-term follow-up.     

The incidence of retinopathy 10 years after diagnosis in young adult people with diabetes: results from the nationwide population-based Diabetes Incidence Study in Sweden (DISS)

OBJECTIVE: To estimate the prevalence and severity of diabetic retinopathy (DR) 10 years after diagnosis in a nationwide population-based cohort study of young adult diabetic patients in Sweden. RESEARCH DESIGN AND METHODS: The Diabetes Incidence Study in Sweden (DISS) aims to register all incident cases of diabetes aged 15-34 years in Sweden. In 1987-1988, 806 cases were reported, and 627 (78%) of them were followed up with regard to retinopathy 8-10 years later. The assessment was based on retinal photographs in most cases (86%). RESULTS: Ten years after diagnosis, retinopathy was found in 247 patients (39%). The retinopathy was mild in 206 (33%), whereas 30 (4.8%) patients had moderate nonproliferative DR (NPDR) and 11 (1.8%) had proliferative DR (PDR). Patients with retinopathy had worse glycemic control during the years than patients without (HbA(1c) 8.1 +/- 1.5% and 6.8 +/- 1.2%, respectively; P < 0.001). In a Cox regression analysis, time to retinopathy was related to high HbA(1c) (P < 0.001) and high BMI (P = 0.001). Patients with type 2 diabetes had an increased prevalence of severe retinopathy (NPDR or PDR) compared with those with type 1 diabetes (14 of 93 [15%] versus no or mild 24 of 471 [5%], respectively; P < 0.001). CONCLUSIONS: Despite modern diabetes management, 39% of young adult diabetic patients developed retinopathy within the first 10 years of the disease. Nevertheless, compared with the prevalence of retinopathy (63%), after a similar duration of diabetes before the Diabetes Control and Complications Trial, this prevalence was clearly lower. Current treatment aimed to achieve strict glycemic control has reduced the risk for developing retinopathy.