Search

Most men older than 60 years experience some degree of erectile dysfunction (ED). The physiology of erections is complex, with contributions from hormonal, vascular, psychological, neurologic, and cellular components. ED is strongly associated with cardiovascular risk factors, and this fact plays a major role in the prevention and treatment of ED. In this article, we review the evaluation of ED in terms of history, physical examination, and common laboratory studies. Additionally, we review major considerations when prescribing phosphodiesterase type 5 inhibitors and other medical treatments, including intraurethral alprostadil, penile injection therapy, and testosterone replacement. [ABSTRACT FROM AUTHOR]

Background and Aims: Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings., Methods: We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020., Intervention: We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation., Results: The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old [IQR, 39-58]). The median follow-up time was 9.1 months [IQR, 4.2-14.1] with a median number of 3 visits [IQR, 2-4]. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects., Conclusions: AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Patients from various countries may have unique patterns of using complementary and alternative medicine (CAM) and unique reasons for using it., Objective: Our objective was to assess the use of CAM among patients from the Gulf region attending the Executive and International Health Program of the Department of General Internal Medicine at Mayo Clinic in Rochester, Minnesota., Methods: This cross-sectional survey was administered to all patients who were from the Gulf region and were undergoing outpatient evaluation in the Executive and International Health Program. After their initial medical evaluation by a physician, the patients were invited to anonymously complete the modified International Complementary and Alternative Medicine Questionnaire., Results: The survey was completed by 69 patients (41 women, 27 men; mean age, 45.4 years). The most frequently seen providers for CAM treatments were physicians (71.0% of patients), spiritual healers (29.0%), and chiropractors (20.3%). CAM treatments most frequently received from a physician were massage therapy (51.0%), hijama (38.8%), spiritual healing (24.5%), and acupuncture or herbs (16.3%). The most frequently used dietary supplements were ginger (42.0%), bee products (30.4%), and garlic (27.5%). The most common self-help therapies were prayers for health (68.1%), meditation (15.9%), and relaxation techniques (11.6%). CAM therapy, including visits to CAM providers, was used by 92.8% of patients. CAM was mainly used to improve well-being and long-term health conditions rather than for acute illnesses., Conclusion: The use of CAM was high among our patients from the Gulf region, and the CAM therapies used by this population differed from the ones used by US patients. Physicians providing care to patients from the Gulf region should be aware of how the use of CAM may affect the care needs of these patients., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Purpose: The purpose of the present study was to investigate body mass index, multi-morbidity, and COVID-19 Risk Score as predictors of severe COVID-19 outcomes., Patients: Patients from this study are from a well-characterized patient cohort collected at Mayo Clinic between January 1, 2020 and May 23, 2020; with confirmed COVID-19 diagnosis defined as a positive result on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays from nasopharyngeal swab specimens., Measures: Demographic and clinical data were extracted from the electronic medical record. The data included: date of birth, gender, ethnicity, race, marital status, medications (active COVID-19 agents), weight and height (from which the Body Mass Index (BMI) was calculated, history of smoking, and comorbid conditions to calculate the Charlson Comorbidity Index (CCI) and the U.S Department of Health and Human Services (DHHS) multi-morbidity score. An additional COVID-19 Risk Score was also included. Outcomes included hospital admission, ICU admission, and death., Results: Cox proportional hazards models were used to determine the impact on mortality or hospital admission. Age, sex, and race (white/Latino, white/non-Latino, other, did not disclose) were adjusted for in the model. Patients with higher COVID-19 Risk Scores had a significantly higher likelihood of being at least admitted to the hospital (HR = 1.80; 95% CI = 1.30, 2.50; P  < .001), or experiencing death or inpatient admission (includes ICU admissions) (HR = 1.20; 95% CI = 1.02, 1.42; P  = .028). Age was the only statistically significant demographic predictor, but obesity was not a significant predictor of any of the outcomes., Conclusion: Age and COVID-19 Risk Scores were significant predictors of severe COVID-19 outcomes. Further work should examine the properties of the COVID-19 Risk Factors Scale.

Objective: To describe the process and outcome of creating a patient cohort in the early stages of the COVID-19 pandemic in order to better understand the process of and predict the outcomes of COVID-19., Patients and Methods: A total of 1169 adults aged 18 years of age or older who tested positive in Mayo Clinic Rochester or the Mayo Clinic Midwest Health System between January 1 and May 23 of 2020., Results: Patients were on average 43.9 years of age and 50.7% were female. Most patients were white (69.0%), and Blacks (23.4%) and Asians (5.8%) were also represented in larger numbers. Hispanics represented 16.3% of the sample. Just under half of patients were married (48.4%). Common comorbid conditions included: cardiovascular diseases (25.1%), dyslipidemia (16.0%), diabetes mellitus (11.2%), chronic obstructive pulmonary disease (6.6%), asthma (7.5%), and cancer (5.1%). All other comorbid conditions were less the 5% in prevalence. Data on 3 comorbidity indices are also available including the: DHHS multi-morbidity score, Charlson Comorbidity Index, and Mayo Clinic COVID-19 Risk Factor Score., Conclusion: In addition to managing the ever raging pandemic and growing death rates, it is equally important that we develop adequate resources for the investigation and understanding of COVID-19-related predictors and outcomes.

Appropriate patient identification is a critical component of safe health care delivery. With increasing reliance on electronic medical records (EMRs), errors of test ordering and documentation have become commonplace. Incorporating patients' photograph in the EMR has considerably decreased error frequency and improved health care delivery by making it easier for physicians to identify a patient. We conducted a survey of all 35 physicians working in the Executive Health Program to determine the importance of having patient photographs in the EMR. Of the 35 physicians who received the survey, 26 (74.3%) responded, 24 (92.3%) of whom agreed that it was important to improve patient identification, care, and safety. Based on these data, we implemented a quality improvement project to increase the percentage of new patients having a photograph included in the EMR. Our goal was to increase photograph inclusion by more than 20% from baseline within 6 months without any unintended consequences (ie, not slowing down any of the workflow during the intake process). The intervention took place between June 1, 2015, and February 8, 2016. Using Define-Measure-Analyze-Improve-Control models, the baseline rate of photographs in the EMR was 49.5% (302 of 607). We initiated 3 Plan-Do-Study-Act cycles targeting awareness and data sharing campaigns. After the Plan-Do-Study-Act cycles, the weekly rate of patient photographs incorporated into the EMR was at 71.4%, which was significantly improved compared with baseline (F test, P <.001). No unintended consequences were identified. Increased inclusion of patient photographs in the EMR aided in patient identification and improved staff satisfaction with minimal interruption to workflow., (© 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc.)

Background and Aims: Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature., Methods: Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used., Results: 130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4  kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5-10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported., Conclusion: When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

Background: No study has compared patients' self-reported heights and weights (and resultant self-reported body mass indexes [BMIs]) with their actual heights, weights, and BMIs; their self-perceived BMI categories; and their desired weights and BMIs and determined rates of clinicians' documented diagnoses of overweight and obesity in affected patients in a single patient group. The objectives of this study were to make these comparisons, determine patient factors associated with accurate self-perceived BMI categorization, and determine the frequency of clinicians' documented diagnoses of overweight and obesity in affected patients., Results: A total of 508 consecutive adult general internal medicine outpatients (257 women, 251 men; mean age, 62.9 ± 14.9 years) seen at Mayo Clinic in Rochester, Minnesota, between November 9 and 20, 2009, completed a questionnaire in which they reported their heights, weights, self-perceived BMI categories ("underweight," "about right," "overweight," or "obese"), and desired weights. These self-reported data were compared to actual heights, actual weights, and actual BMI categories (measured after the questionnaire was completed). Overall, 70% of the patients were overweight or obese. The average self-reported weight was significantly lower than the average actual weight (80.3 ± 20.1 kg vs 81.9 ± 21.1 kg; P < .001). The average self-reported BMI was significantly lower than the average actual BMI (27.6 ± 5.7 kg/m(2) vs 28.3 ± 6.1 kg/m(2); P < .001). Overall, 32% of patients had obesity; however, only 6% perceived they were obese. Accuracy of self-perceived BMI category decreased with higher actual BMI category (P < .001 for trend). Female sex, higher education level, smoking status, and lower BMI were associated with higher accuracy of self-perceived BMI category. Desired weight loss increased with higher self-perceived and actual BMI categories (P < .001 for trends). Of the 165 patients who actually were obese, only 40 (24%) had obesity documented as a diagnosis in their medical records by their clinicians. Statistical tests used were the paired t test, the Pearson χ2 test, the Cochrane-Armitage trend test, the Wald test of marginal homogeneity, analysis of variance, and univariate and multivariate logistic regression., Conclusions: Many obese patients inaccurately perceive their BMI categories; accuracy decreases with increasing BMI. Clinicians should inform patients of their BMIs and prescribe treatment plans for those with overweight and obesity.

Context: The association between acute pancreatitis and primary hyperparathyroidism (PHPT) is controversial., Objective: The aim of the study was to address the incidence and disease characteristics of acute pancreatitis in PHPT from a large inception cohort of community residents., Design and Setting: Patients with acute pancreatitis were identified in an Olmsted County, Minnesota, cohort of PHPT subjects diagnosed from 1965-2001 and compared to matched control subjects., Main Outcome Measures: The estimated rate of developing acute pancreatitis was calculated by person-years method. Cox models assessed the effect of PHPT disease status on the development of acute pancreatitis., Results: Of 684 patients with PHPT, 10 patients (1.5%) developed acute pancreatitis, compared to 32 of 1364 control patients (2.3%). The estimated rate of development of acute pancreatitis in PHPT was 114 per 100,000 person-years, compared to 140 per 100,000 person-years in control subjects (P = 0.56). The estimated hazard ratio of acute pancreatitis for PHPT relative to the control subjects was 0.84 (P = 0.89). The majority of subjects with PHPT and acute pancreatitis were women (n = 7), and the mean age was 70.6 yr at the time of acute pancreatitis. PHPT was present an average of 137 months before the development of acute pancreatitis, and contributing causes for acute pancreatitis were in identified in four patients. Maximal serum calcium levels in PHPT were not significantly associated with the development of acute pancreatitis., Conclusions: Acute pancreatitis was not increased in community patients with PHPT, and therefore, there does not appear to be a causal relationship between PHPT and acute pancreatitis.

Objective: To describe an unusual case of pathologically confirmed primary hyperparathyroidism in a patient presenting with severe hypercalcemia and an undetectable parathyroid hormone (PTH) level., Methods: We present a detailed case report and outline the serial laboratory findings. In addition, the possible causes of low serum PTH levels in the setting of primary hyperparathyroidism are discussed., Results: A 16-year-old female patient presented with severe epigastric pain, found to be attributable to acute pancreatitis. At hospital admission, her serum calcium concentration was high (14.0 mg/dL); the patient also had a normal serum phosphorus level of 3.6 mg/dL and an undetectable PTH level (<0.2 pmol/L). An evaluation for non-PTH-mediated causes of hypercalcemia revealed a partially suppressed thyroid-stimulating hormone concentration and a below normal 1,25-dihydroxyvitamin D level, consistent with her suppressed PTH. One week after the patient was dismissed from the hospital, repeated laboratory studies showed a serum calcium value of 11.1 mg/dL, a serum phosphorus level of 2.8 mg/dL, and an elevated PTH concentration of 11.0 pmol/L, consistent with primary hyperparathyroidism. A repeated 1,25-dihydroxyvitamin D measurement was elevated. A parathyroid scan showed a parathyroid adenoma in the left lower neck area, and she subsequently underwent successful surgical resection of a pathologically confirmed parathyroid adenoma., Conclusion: This case demonstrates that the serum PTH level can be suppressed in patients with primary hyperparathyroidism. Moreover, it emphasizes the need for careful evaluation of the clinical context in which the PTH measurement is determined. Consideration should be given to repeating measurement of PTH and serum calcium levels when the initial laboratory evaluation of hypercalcemia is unclear because dynamic changes in calcium metabolism may occur in the presence of secondary contributing factors.

Background: Some investigators have postulated that a history of being the victim of childhood sexual abuse may impact outcome of bariatric surgery., Methods: In this retrospective chart review, we examined the electronic medical records of 152 adults with morbid obesity who underwent Roux-en-Y gastric bypass and who had a weight recorded in their medical record or reported in a follow-up surgery at 2 years after the RYGBP. The purpose of this retrospective chart review was to examine the relationship between psychosocial factors assessed preoperatively and the percent of excess weight lost (%EWL) at 2 years after bariatric surgery., Results: We found a high prevalence of being the victim of childhood sexual abuse (27%), adult sexual trauma (9%), and/or physical abuse (19%) at the initial evaluation. There was no association between these factors and %EWL at 2 years. However, when we examined participants' medical records for post-operative psychiatric hospitalizations at our medical center, 8 of 11 hospitalized patients reported a history of childhood sexual abuse (73%)., Conclusions: History of being the victim of childhood sexual abuse is reported frequently by patients seeking bariatric surgery. Our finding that having been the victim of childhood sexual abuse may be associated with increased risk of psychiatric hospitalization after RYGBP has several clinical implications. First, we recommend that clinicians assess carefully for a history of sexual or physical abuse, and secondly, abuse survivors may need to be told that there is an increased risk of psychiatric morbidity after bariatric surgery. Finally, perhaps close monitoring of these patients may prevent psychiatric difficulties after surgery. Further research to verify these preliminary findings is clearly needed.

Context: Abnormal homocysteine metabolism may contribute to increased cardiovascular death in type 1 diabetes (T1DM). Amino acid metabolism is altered in T1DM. In vitro, insulin reduces hepatic catabolism of homocysteine by inhibiting liver transsulfuration. It remains to be determined whether methionine-homocysteine metabolism is altered in T1DM., Objective: We sought to determine whether insulin deficiency during insulin deprivation or high plasma insulin concentration after insulin treatment alters homocysteine metabolism in T1DM., Design: This was an acute interventional study with paired and comparative controls., Setting: The study was conducted at a general clinical research center., Patients and Intervention: We used stable isotope tracers to measure methionine-homocysteine kinetics in six patients with T1DM during insulin deprivation (I-) and also during insulin treatment (I+) and compared them with nondiabetic controls (n = 6)., Main Outcome Measures: Homocysteine kinetics (transmethylation, transsulfuration, and remethylation) were from plasma isotopic enrichment of methionine and homocysteine and (13)CO(2)., Results: T1DM (I-) had lower rates of homocysteine-methionine remethylation (P < 0.05 vs. control and I+). In contrast, transsulfuration rates were higher in I- than controls and I+ (P < 0.05). Insulin treatment normalized transsulfuration and remethylation (P < 0.05 vs. I- and P > 0.8 vs. control). Plasma homocysteine concentrations were lower in T1DM (P < 0.05 vs. control during both I- and I+), which may be explained by increased homocysteine transsulfuration. Thus, significant alterations of methionine-homocysteine metabolism occur during insulin deprivation in humans with T1DM., Conclusions: Insulin plays a key role in the regulation of methionine-homocysteine metabolism in humans, and altered homocysteine may occur during insulin deficiency in type 1 diabetic patients.

Objective: To review one institution's experience with parathyroid lipoadenomas and to report the associated clinical characteristics., Methods: We present a case series of parathyroid lipoadenomas. A parathyroid lipoadenoma was defined as a single adenoma with more than 50% fat on histologic examination in conjunction with primary hyperparathyroidism and resolution of hypercalcemia postoperatively. Patients who fulfilled the diagnostic criteria were identified from the surgical pathology files of the Mayo Clinic., Results: Five cases of parathyroid lipoadenomas, including 1 oxyphil lipoadenoma, were identified during the period from 1971 to 2001. The clinical picture of the study subjects resembled that of a typical patient with primary hyperparathyroidism. Parathyroid lipoadenomas were identified in 3 women (60%) and 2 men (40%), and only 1 patient presented with possible hypercalcemia-related symptoms of nephrolithiasis and hip fracture, leading to diagnosis. The mean serum calcium concentration was 11.1 mg/dL. Preoperatively, all study subjects had elevation of serum parathyroid hormone levels. Two of 3 patients (67%) had the tumor identified preoperatively by neck ultrasonography., Conclusion: A parathyroid lipoadenoma is a rare cause of primary hyperparathyroidism. The clinical features of this pathologic entity are similar to those of the more common pathologic variants of parathyroid disease associated with primary hyperparathyroidism.

Background: How psychosocial factors may impact on weight loss after bariatric surgery is not well understood. This lack of knowledge is problematic, because there is a high prevalence of psychosocial distress in patients seeking treatment for obesity in hospital-based programs. The purpose of this study was to examine the relationship between preoperative psychosocial factors and eventual weight loss., Method: Between 1987 and 1998, all individuals undergoing Roux-en-Y gastric bypass for weight loss in our institution had psychologic preoperative evaluations. Patients who were followed prospectively were studied. The relation of having received mental health treatment to percentage of excess weight loss at 2 years is examined using t-tests., Results: 62 women and 18 men completed a 2-year follow-up. Patients who had received treatment for either substance abuse (n=10) or psychiatric co-morbidity (n=39) lost more weight compared with those without such histories (P<0.05, P <0.001 respectively)., Conclusion: Given these results, it is plausible that a history of having received either psychiatric treatment for a disorder or counseling for substance abuse should not be a contraindication to bariatric surgery, and, in fact, may be prognostic of favorable outcome. Further research examining psychosocial factors and outcome from bariatric surgery is clearly warranted.

Objective: To determine whether patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) had evidence of increased homocysteine levels compared with non-CADASIL patients with ischemic stroke or transient ischemic attack., Patients and Methods: We compared fasting plasma homocysteine levels and levels 6 hours after oral loading with methionine, 100 mg/kg, in non-CADASIL patients with ischemic stroke or transient ischemic attack and in patients with CADASIL. Prechallenge, postchallenge, and change in homocysteine levels between the 2 groups were compared with use of the Wilcoxon rank sum test., Results: CADASIL and non-CADASIL groups were similar in age (mean, 48.8 vs. 46.5 years, respectively; 2-tailed t test, P=.56) and sex (men, 86% vs 59%; Fisher exact test, P=.12). The 59 patients in the CADASIL group had higher median plasma homocysteine levels compared with the 14 patients in the non-CADASIL group, both in the fasting state (12.0 vs 9.0 micromol/L; P=.03) and after methionine challenge (51.0 vs 34.0 micromol/L; P=.007). Median difference between homocysteine levels before and after methionine challenge was greater in the CADASIL group than in the non-CADASIL group (34.5 vs. 24.0 micromol/ L; P = .02)., Conclusion: Our findings raise the possibility that increased homocysteine levels or abnormalities of homocysteine metabolism may have a role in the pathogenesis of CADASIL.

Objective: To assess the importance of classic and nonclassic risk factors in the development of coronary artery disease (CAD) or cerebrovascular disease (CVD) in patients with type 2 diabetes mellitus (DM)., Patients and Methods: In this community-based, prospective cohort study, quantitative measurements for cholesterol, triglycerides (TGs), glucose, and lipoprotein(a) detected as a sinking pre-beta-lipoprotein band on electrophoresis were obtained from 1968 through 1982 from 449 patients who were free of CAD and CVD but had type 2 DM. Demographic data and covariables obtained were age, body mass index, duration of diabetes, sex, smoking, and hypertension. The relationship of individual continuous factors to the development of CAD and CVD as well as multivariate models were evaluated with use of the Cox proportional hazards model. The primary outcome was to determine which risk factors are associated with development of CAD or CVD in patients with type 2 DM., Results: After a mean follow-up of 13 years, 216 CAD and 115 CVD events had developed. The hazard ratio estimates with 95% confidence intervals (CIs) for CAD after multivariate analysis were significant for age, 1.45 (95% CI, 1.27-1.67); fasting glucose levels at enrollment, 1.63 (95% CI, 1.17-2.25); smoking, 1.45 (95% CI, 1.10-1.91); and TGs, 1.49 (95% CI, 1.15-1.92). The hazard ratio estimates for CVD were significant for age, 1.95 (95% CI, 1.59-2.38); hypertension, 1.89 (95% CI, 1.30-2.74); fasting glucose levels at enrollment, 1.69 (95% CI, 1.06-2.70); and smoking, 1.57 (95% CI, 1.07-2.30)., Conclusion: In diabetic patients, age, fasting glucose levels, smoking, and TG levels are independent risk factors for development of CAD events. Age, hypertension, glucose, and smoking predicted development of CVD events.

Objective: To determine prospectively the results of Roux-en-Y gastric bypass (RYGB) used as the primary weight-reducing operation in patients with medically complicated ("morbid") obesity. The RYGB procedure combines the advantages of a restrictive physiology (pouch of 10 mL) and a "dumping physiology" for high-energy liquids without requiring an externally reinforced (banded) stoma., Patients and Methods: Between April 1987 and December 1998, a total of 191 consecutive patients with morbid obesity (median weight, 138 kg [range, 91-240 kg]; median body mass index, 49 kg/m2 [range, 36-74 kg/m2]), all of whom had directly weight-related morbidity, underwent RYGB and prospective follow-up., Results: Hospital mortality was 0.5% (1/191), and hospital morbidity occurred in 10.5% (20/191). Good long-term weight loss was achieved, and patients adapted well to the required new eating habits. The mean +/- SD weight loss at 1 year after operation (113 patients) was 52 +/- 1 kg or 68% +/- 2% of initial excess body weight. By 3 years postoperatively (74 patients), weight loss was still 66% +/- 2% of excess body weight. Overall, 53 (72%) of 74 patients had achieved and maintained a weight loss of 50% or more of their preoperative excess body weight 3 years after the operation. In addition, only 1 (1%) of 98 patients had persistent postoperative vomiting 1 or more times per week., Conclusion: We believe that RYGB is a safe, effective procedure for most patients with morbid obesity and thus may be the current procedure of choice in patients requiring bariatrics++ surgery for morbid obesity.

Background: Elevated lipoprotein(a) [Lp(a)] levels have been associated with the presence of atherosclerotic disease. However, the results of prospective studies of Lp(a) and cardiovascular disease have been contradictory., Methods and Results: From 1968 through 1982, lipoprotein analysis was performed in 11,335 Olmsted County residents. Quantitative cholesterol and triglycerides were obtained along with semiquantitative Lp(a) levels based on electrophoretic pattern. Lp(a) bands were scored from 0 (absent) to 3 (increased). A cohort of 4967 men and 4968 women with no prior history of atherosclerotic disease who had baseline Lp(a) determinations were followed up for 14 years for development of coronary artery disease (CAD) and cerebrovascular disease (CVD). During 131,330 person-years of follow-up, there were 1848 CAD events and 841 CVD events. Age, diabetes, hypertension, cholesterol, and triglycerides were significantly and independently associated with an increased risk of CAD and CVD in men and women. There was a significant increase in the adjusted hazards ratio for CAD with increasing Lp(a) levels for men and women. For Lp(a) level 3, the hazard ratio was 1.9 (range, 1.3 to 2.9) in women and 1.6 (range, 1.0 to 2.5) in men. The adjusted hazard ratio for CVD showed an irregular association with Lp(a) levels in men and no association in women., Conclusions: In this cohort of 9936 men and women initially free of cardiovascular disease who were followed up for 14 years, Lp(a) was a significant predictor of risk of future CAD. Lp(a) was a weak risk factor for CVD in men and was not a significant predictor of CVD risk in women.

Objective: To determine the types of mutations and the clinical significance of a specific genotype in familial medullary thyroid carcinoma (MTC) syndromes., Design: We retrospectively and prospectively studied patients with MTC at a tertiary referral center., Material and Methods: The study cohort consisted of 348 affected patients and at-risk family members of MTC kindreds, including 33 multiple endocrine neoplasia type IIA (MEN IIA) kindreds with 165 members, 13 familial MTC alone (FMTC) kindreds (at least 4 affected members with MTC per kindred, without evidence of pheochromocytoma and hyperparathyroidism) with 108 members, 15 "other hereditary MTC" kindreds (2 or 3 affected members) with 42 members, and 33 individuals with sporadic MTC. An additional 53 subjects from the aforementioned MEN IIA kindreds who were clinically affected but not genetically tested were also included in an analysis of the relationship between genotype and phenotype. The presence of germline mutations in the RET proto-oncogene was studied by DNA sequence analysis of exons 10, 11, and 13., Results: Germline RET mutations in exons 10 and 11 were identified in 32 of 33 MEN IIA kindreds (97%), 10 of 13 FMTC kindreds (77%), and 10 of 15 "other hereditary MTC" kindreds (67%). No mutations were identified in exon 13. No patient with sporadic MTC had a germline mutation. In MEN IIA, codon 634 was affected in 73% of the kindreds, whereas in FMTC, the main affected codon was codon 618 (54%). In MEN IIA, patients with codon 634 mutations had a higher risk of having C-cell disease, pheochromocytoma, and hyperparathyroidism than did those with other mutations (P < 0.05, P < 0.001, and P < 0.01, respectively)., Conclusion: RET analysis is a reliable, practical, and cost-effective test in the screening of at-risk family members of MEN IIA and FMTC kindreds. In addition, RET analysis may be helpful in the follow-up of gene carriers and for the early detection of pheochromocytoma and hyperparathyroidism in patients with codon 634 mutations.

Insulin deficiency is a protein catabolic state. In vivo studies have shown that insulin enhances short-side-chain amino acid intracellular uptake, stimulates transcription and translation of RNA, increases the gene expression of albumin and other proteins and inhibits liver protein breakdown enzymes. In IDDM patients most of the whole-body protein turnover studies have shown that insulin deficiency increases protein breakdown and increases amino acid oxidation and that these effects are reversed by insulin treatment. Recent studies have demonstrated that a substantial increase in leucine transamination during insulin deprivation contributes to leucine catabolism in IDDM patients. Protein synthesis in the insulin-deprived state is also increased although to a lesser extent than protein breakdown, and this increased whole-body protein synthesis is reduced with an insulin infusion; thus the effects of insulin are largely mediated through its effects on protein breakdown. The metabolic derangements in diabetes frequently involve disturbances in substrates and hormones other than insulin. The observed effects of insulin deficiency in diabetic patients vary in different body compartments; most of the effects of insulin on protein synthesis appear to occur in non-muscular tissues especially in the splanchnic area. In addition, insulin has a differential effect on hepatic protein synthesis, i.e. inhibits fibrinogen synthesis and promotes albumin synthesis. Insulin's anticatabolic effect in IDDM patients is largely due to its inhibition of protein breakdown. The net protein anabolism due to insulin occurs largely in skeletal muscle. In patients with NIDDM these effects are not noted, presumably because of residual endogenous insulin secretion. In fact, treatments that result in improvement of glucose metabolism in obese NIDDM patients do not affect protein metabolism.