obese patients

Exploring the benefits of non-invasive MR Elastography in obese patients.

Posted by

0


Omar Darwish, PhD student at King’s College London, is researching new approaches to 3D MRE sequences for measuring liver fibrosis and inflammation simultaneously in obese patients.

Three-dimensional MR elastography (MRE) scans have demonstrated the potential to assess both liver fibrosis and inflammation simultaneously. However, researchers face challenges in that current 3D MRE approaches typically require multiple sequences, each with its own breath-hold by the patient, which reduces the precision of geometric alignment of the liver and hampers clinical acceptance. This is further complicated in obese patients where the challenge of a high body mass index (BMI) can preclude adequate penetration of the mechanical waves.

Non-alcoholic fatty live disease is a health crisis across the globe and evaluating patients in a time efficient fashion is becoming of high importance in medicineOmar Darwish

In his paper published in the journal Investigative Radiology, Omar Darwish has tested the viability of an approach that uses one single breath-hold rather than the more usual four to six consecutive breath-holds that can be easily tolerated and reproduced by obese patients. 

His technical development study demonstrates how a single 17 second breath-hold was successfully used to reduce the total MRE sequence acquisition time including multiple slices, wave offsets and motion encodings. 

He says: “Non-alcoholic fatty live disease is a health crisis across the globe and evaluating patients in a time efficient fashion is becoming of high importance in medicine. Liver biopsy is invasive, costly, and accompanied with complications. These could be mitigated by a successful proof of concept in 3D MRE sequencing and warrants a larger clinical study to further evaluate diagnostic accuracy and performance.” 

Gastric bypass a potential BP control strategy in obese patients

Posted by

0


Gastric bypass may be an effective method of reducing blood pressure (BP) levels in obese patients with hypertension, according to findings of the GATEWAY* trial presented at the AHA** 2017 Scientific Sessions.

Nonadherence to medications presents a major problem in the management of hypertension, particularly in patients receiving multiple antihypertensive drugs, said lead author Dr Carlos Schiavon from the Heart Hospital in São Paulo, Brazil, who presented the results.

“These results have implications in minimizing nonadherence to therapy and its related consequences,” he said.

In this single-centre trial, 100 patients with BMI 30–39.9 kg/m2 and on ≥2 maximum dose or >2 moderate dose hypertension medications (mean age 43.8 years, 70 percent female, mean BMI 36.9 kg/m2) were randomized 1:1 to undergo Roux-en-Y gastric bypass in addition to medication or medication alone (control group).

Patients whose BP was at target (<140/90 mm Hg) were maintained on current medication, while for those above target, the primary medications were ACE inhibitors or ARBs plus calcium channel blockers, with thiazide diuretics, spironolactone, or clonidine prescribed as needed.

Compared with those on medication only, more patients who underwent gastric bypass met the primary endpoint of a ≥30 percent reduction in total number of antihypertensive medications while maintaining BP at <140/90 mm Hg at 12 months (83.7 percent vs 12.8 percent; rate ratio [RR], 6.6, 95 percent confidence interval [CI], 3.1–14.0; p<0.001). [AHA 2017, session LBS.03; Circulation2017;doi:10.1161/CIRCULATIONAHA.117.032130]

At 12 months, 51 percent of patients who underwent gastric bypass demonstrated remission of hypertension (office BP <140/90 mm Hg without medication), while no patients in the control group were free of medication at the end of follow-up.

When using the SPRINT*** target as a guide (systolic BP <120 mm Hg), 22.4 percent of patients who underwent gastric bypass achieved hypertension remission compared with zero in the control group at 12 months (RR, 3.8, 95 percent CI, 1.4–10.6; p=0.005).

Twelve months post-treatment, patients who underwent gastric bypass also demonstrated better improvement than those on medication only in terms of BMI (26.8 vs 36.3 kg/m2) and waist circumference (86.9 vs 109.8 cm), as well as fasting plasma glucose (84.0 vs 98.4 mg/dL), LDL-C (86.9 vs 116.5 mg/dL), and triglyceride levels (85.7 vs 130.0 mg/dL; all p<0.001).

“Taken together with the improved metabolic and inflammatory profile, such effects have, in theory, the potential to reduce major cardiovascular events,” said Schiavon.

More patients in the gastric bypass group required rehospitalization compared with the control group (12 percent vs 0 percent; p=0.03), while incidence of hypertensive crisis requiring emergency department visit and anaemia was comparable between groups.

According to discussant Professor Paul Poirier from the Quebec Heart and Lung Institute, Quebec, Canada, there are several potential mechanisms behind these findings including insulin resistance which could influence renal sodium reabsorption, inflammation which could modulate arterial stiffness, and gut hormones such as glucagon-like peptide 1 and peptide YY which could influence electrolyte transport in the renal tubular cells as well as cause diuresis.

The researchers hope that the 4-year follow-up will help determine the long-term outcomes of bariatric surgery in this population.

Dr Carlos Schiavon (photo courtesy of AHA)

Dr Carlos Schiavon (photo courtesy of AHA)

*GATEWAY: GAstric bypass to Treat obEse patients With steAdy hYpertension

**AHA: American Heart Association

***SPRINT: Systolic Blood Pressure Intervention Trial

Balloon in Gut as Primary Weight-Loss Treatment?

Posted by

0


Obese patients who underwent placement of an intragastric balloon and participated in a behavioral management program lost significantly more weight than patients in a behavioral management program alone, researchers reported here.

The Orbera Intragastic Balloon System met thresholds of an endoscopic bariatric therapy as a primary obesity intervention set by the American Society for Gastrointestinal Endoscopy (ASGE), said Barham Abu Dayyeh, MD, a bariatric endoscopist at the Mayo Clinic in Rochester, Minn., and colleagues at the Digestive Disease Week annual meeting.

Patients shed pounds and had fewer comorbidities with minimally invasive procedure..
It was also a safe and effective adjunct to lifestyle intervention for mild to moderately obese patients, Abu Dayyeh said. It can serve as an intermediate, minimally invasive option between lifestyle changes and bariatric surgery, he added.

Patients who underwent the treatment saw improvements in diabetes, hypertension, lipid levels, depression, and quality of life.

“I think this is very exciting data,” said John Vargo II, MD, MPH, chair of the department of gastroenterology and hepatology at the Cleveland Clinic in Ohio, at a press conference. Obesity is “a tsunami of an epidemic” in the U.S., he added.

The year-long, multicenter, randomized, prospective trial included 273 patients, ages 18 to 65, with a body mass index (BMI) of 30-40 kg/m2.

Exclusion criteria were previous gastrointestinal surgery or obstruction, a hiatal hernia >3 cm, a motility disorder, inflammatory bowel disease, and a positive Helicobacter pyloriscreening test.

After a run-in period with the device implanted in 35 patients, the 273 subjects were randomized to undergoing balloon implantation and behavioral management and undergoing behavioral management alone.

The balloon was filled with 500-600 cc of saline and formed a “bezoar” so that patients felt a feeling of satiety. It was removed after 6 months.

Patients in both the control and intervention groups received behavioral management treatment for 12 months.

Primary endpoints were based on recommendations set out by the ASGE for primary obesity intervention in patients with a BMI of greater than 35 kg/m2:

  • Subjects should achieve a mean minimum threshold of 25% excess weight loss (EWL) at 12 months.
  • The mean percent EWL difference between intervention and control groups should be at least 15% and statistically significant.

Three months after removal of the balloon (9 months into the study), patients in the intervention group had a mean EWL of 26.5% (95% CI 22.9-30.1%). They maintained an EWL of greater than 25% at 1 year.

Also at 3 months’ post-balloon removal, more than 30% of patients in the intervention group differed by at least 15% EWL from the control group. The 15% EWL difference was maintained at the year-mark (P<0.001 at 9 months and 12 months).

At 1 year, intervention participants had a mean percent total body weight loss of 7.7% compared with 3.9% of those in the control group (P<0.001).

The intervention group had lower rates of diabetes mellitus (0.98% versus 4.1%), hypertension (5.7% versus 15.2%), and dyslipidemia (3.4% versus 9.0%) at 1 year.

Device-related serious adverse events affected 9.6% of patients and included “intolerance,” gastric outlet obstruction, laryngospasm during placement, severe abdominal cramping, and severe dehydration. No deaths were reported.

Common adverse events included nausea and vomiting (32.8%), abdominal pain (12.6%), reflux (5.4%), eructation (4.8%), dyspepsia (4.4%), and constipation (4.4%).

A total of 22% (28) of patients removed the device early, though only 15 of those were for symptoms.

The authors concluded that “this represents a minimally-invasive and effective approach to manage obesity and associated comorbidities.”

Sustained weight loss reduces AF burden in obese patients

Posted by

1


Sustained weight loss in obese patients with atrial fibrillation (AF) reduces AF burden and symptom severity, the 5-year LEGACY* trial has shown. The benefits appeared to be dose dependent.

Patients who lost >10 percent of their body weight and kept it off for 4 years were six times more likely to achieve long-term freedom from arrhythmia without the help of medication or ablation compared with patients who lost less weight (p<0.001). Conversely, significant weight fluctuation over 4 years attenuated the positive impact of weight loss. Weight fluctuation of >5 percent was associated with a two-fold increased risk of arrhythmia recurrence (95% CI, 1.0-4.3; p=0.02). [J Am Coll Cardiol  2015;doi:10.1016/j.jacc.2015.03.002]

“LEGACY demonstrated that sustained weight loss is associated with dose dependent reduction in AF burden and maintenance of sinus rhythm,” said study author Dr. Rajeev Pathak, a cardiologist and electrophysiologist at the University of Adelaide in Adelaide, Australia. “Weight loss and avoidance of weight fluctuation are important strategies for reducing AF burden.”

The study enrolled 355 obese adults (body mass index ≥27 kg/m2) with AF, participating in a weight management program. Yearly weight trend and fluctuation were recorded.

After a median of 4 years, 135 patients lost >10 percent of their body weight, 103 patients lost 3-9 percent, and 117 lost ❤ percent. Arrhythmia-free survival rates were 86.2 percent, 66 percent and 40 percent, respectively.

“Weight loss also led to favourable changes in cardiovascular risk factors such as high blood pressure, obstructive sleep apnoea, and diabetes, along with improvements in the structure and function of the heart,” said Pathak.

Obesity and AF often co-exist. Weight loss in the short term reduces AF burden, but until this research, it is not known whether this benefit can be sustained in the long term, the authors said. LEGACY also addresses the impact of weight fluctuation and the role of weight loss clinics on arrhythmia control.

“A dedicated [weight loss] clinic improves patient engagement and promotes treatment adherence, thus preventing weight regain and fluctuation in AF patients.”

Obese Women Have Unique Surgical Risks

Posted by

0


Gynecologic surgeons should be familiar with the specific risks that obese women face, such as surgical site infection, venous thromboembolism, and wound complications, so as to counsel them about their individual risks before surgery, according to a committee opinion by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice.

The opinion, published in the January 2015 issue of Obstetrics & Gynecology, also indicates that for obese women, as for women of normal weight, better outcomes and fewer complications are associated with vaginal hysterectomy compared with laparoscopic or abdominal hysterectomy.

According to the Centers for Disease Control and Prevention, 34.9% of US adults, or 78.6 million people, are obese. The opinion authors define three classes of obesity, with class 1 obesity applying to people whose body mass index (BMI) falls between 30 to less than 35 kg/m2. People whose BMI is from 35 to less than 40 kg/m2 fall under the class 2 obesity definition; class 3 obesity is defined as a BMI higher than 40 kg/m2.

“Adverse effects after gynecologic surgery such as surgical site infection (with a BMI greater than 35), venous thromboembolism (with a BMI equal to or greater than 35), and wound complications (10 times more likely with a BMI of 40–49 compared with normal-weight patients) are more prevalent in obese women than in normal-weight women,” the authors write.

Although obese people are at higher risk of dying and suffering from such chronic ailments as hypertension, diabetes, and obstructive sleep apnea, paradoxically, morbidity and mortality among obese patients who do not have metabolic complications are lower than for normal weight patients, the authors write. Obese patients with hypertension and diabetes, however, are at heightened risk for perioperative morbidity and mortality when compared with patients who are not overweight, defined as having a BMI of 8.5 to 24.9 kg/m2.

Vaginal hysterectomy, in general, is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy, the authors write. For obese women who are not good candidates for vaginal hysterectomy, laparoscopic hysterectomy can be more complicated but may result in less blood loss and a shorter hospital stay; the procedure also is associated with higher quality of life 4 years after surgery compared with laparotomy.

“Every effort should be made to offer all patients, regardless of BMI, the least invasive procedure in order to decrease complications, length of hospital stay, and postoperative recovery time,” the authors note.

In addition, the authors suggest considering a presurgical consultation with an anesthesiologist for obese patients suspected of having obstructive sleep apnea, which can be associated with postsurgical complications, such as pneumonia or hypoxemia, or for patients who are at risk for coronary artery disease.

Additional precautions need to be taken for certain obese patients undergoing surgery lasting more than 45 minutes, such as prescribing low-molecular-weight heparin, because of moderate risk for venous thromboembolism. Because obese patients have more subcutaneous tissue, abdominal hysterectomies may take longer to perform and more than one skin preparation kit may be needed. In addition, two operating tables may need to be joined to accommodate the patient’s weight and girth, with sufficient belts and gel pads to limit the patient’s movement.
After surgery, hypoxemia, which occurs more often in obese patients, can be managed through aggressive incentive spirometry or continuous positive airway pressure. Wound complications and surgical site infections, however, are the most common postsurgical complication for obese patients who have undergone abdominal hysterectomy; subcutaneous placement of sutures, talc application, and wound vacuums have been associated with reduced complications. Preoperative or intraoperative nonsteroidal anti-inflammatories appear to work better than acetaminophen to reduce nausea and vomiting and decrease postoperative opiod use.