Acute Exudative Tonsillitis

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Should Physicians Measure High-sensitivity C-reactive Protein Levels to Assess Coronary Heart Disease Risk?

When I was a medical student, atherosclerosis was seen as a process resembling the deposition of calcium deposits in pipes in an old house with gradual accumulation of precipitated minerals on the inner walls of these pipes. Basic science and clinical research over the last 40 years have made it clear that the process that actually leads to atherosclerosis involves inflammatory changes within the arterial wall that begin after some form of injury to the vascular endothelium that lines the arteries.

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-- Joseph S. Alpert, MD

This article was originally published in the May 2009 issue of The American Journal of Medicine.

Body Weight, Insulin Resistance, and Serum Adipokine Levels 2 Years after 2 Types of Bariatric Surgery

Clinically severe obesity is associated with premature death and disability from heart disease and cancer. Gastric bypass surgery is an effective tool to induce sustained weight loss and normalization of metabolic parameters.

Abstract
Objective
Bariatric surgery reverses obesity-related comorbidities, including type 2 diabetes mellitus. Several studies have already described differences in anthropometrics and body composition in patients undergoing Roux-en-Y gastric bypass compared with laparoscopic adjustable gastric banding, but the role of adipokines in the outcomes after the different types of surgery is not known. Differences in weight loss and reversal of insulin resistance exist between the 2 groups and correlate with changes in adipokines.

Methods
Fifteen severely obese women (mean body mass index [BMI]: 46.7 kg/m2) underwent 2 types of laparoscopic weight loss surgery (Roux-en-Y gastric bypass = 10, adjustable gastric banding = 5). Weight, waist and hip circumference, body composition, plasma metabolic markers, and lipids were measured at set intervals during a 24-month period after surgery.

Results
At 24 months, patients who underwent Roux-en-Y were overweight (BMI 29.7 kg/m2), whereas patients who underwent gastric banding remained obese (BMI 36.3 kg/m2). Patients who underwent Roux-en-Y lost significantly more fat mass than patients who underwent gastric banding (mean difference 16.8 kg, P < .05). Likewise, leptin levels were lower in the patients who underwent Roux-en-Y (P = .003), and levels correlated with weight loss, loss of fat mass, insulin levels, and Homeostasis Model of Assessment 2. Adiponectin correlated with insulin levels and Homeostasis Model of Assessment 2 (r = −0.653, P = .04 and r = −0.674, P = .032, respectively) in the patients who underwent Roux-en-Y at 24 months.

Conclusion
After 2 years, weight loss and normalization of metabolic parameters were less pronounced in patients who underwent gastric banding compared with patients who underwent Roux-en-Y gastric bypass. Our findings require confirmation in a prospective randomized trial.

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-- Michael A. Trakhtenbroit, BA, Joshua G. Leichman, MD, Mohamed F. Algahim, BS, Charles C. Miller III, PhD, Frank G. Moody, MD,Thomas R. Lux, MD, Heinrich Taegtmeyer, MD, DPhil

This article was originally published in the May 2009 issue of The American Journal of Medicine.

Prediction of Incident Hypertension Risk in Women with Currently Normal Blood Pressure

Hypertension risk prediction calculated from a few readily available clinical factors—age, blood pressure, ethnicity, and body mass index—offers better calibration than more complicated models and improved risk stratification over blood pressure alone.

Abstract
Background
We examined whether a hypertension risk prediction model based on clinical characteristics and blood biomarkers might improve on risk prediction based on current blood pressure alone.

Methods
A prospective cohort of 14,822 normotensive women aged 45 years and older were followed over 8 years beginning in 1992 for the development of hypertension. Among a randomly selected two-thirds sample (N = 9427), hypertension prediction models were developed using 52 potential predictors and compared with a model based on blood pressure alone. Each prediction model was validated in the remaining one third (N = 5395).

Results
In the development cohort, the best prediction model for incident hypertension included age, blood pressure, ethnicity, body mass index, total grain intake, apolipoprotein B, lipoprotein(a), and C-reactive protein (Bayes Information Criteria [BIC] = 8788). Although this model was superior to a model based on blood pressure alone (BIC = 8957), it was only marginally better than a simplified model including age, blood pressure, ethnicity, and body mass index (BIC = 8820). In the validation cohort, the simplified model demonstrated adequate calibration, a c-index similar to that of the best model (0.703 vs 0.705), and when compared with the model based on blood pressure alone, reclassified 1499 participants to hypertension risk categories that proved to be closer to observed risk in all but one instance.

Conclusion
In this prospective cohort of initially normotensive women, a model based on readily available clinical information predicted incident hypertension better than a model based on blood pressure alone.

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-- Nina P. Paynter, PhD, Nancy R. Cook, ScD, Brendan M. Everett, MD, Howard D. Sesso, ScD, MPH, Julie E. Buring, ScD, Paul M. Ridker, MD, MPH

This article was originally published in the May 2009 issue of The American Journal of Medicine.