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SOARD Category 1 CME Credit Featured Articles, Volume 10, January–February 2014
SOARD Category 1 CME Credit Featured Articles, Volume 10, January–February 2014 Relevance of beta-cell function for improved glycemic control after gastric bypass surgery. Jesús Blanco, Amanda Jiménez, Roser Casamitjana, Lílliam Flores, Antonio Lacy, Ignacio Conget, Josep Vidal. Surg Obes Relat Dis 2014;10;9-13.
Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: A decision analysis. Rashikh A. Choudhury, Kenric M. Murayama, Peter L. Abt, Henry A. Glick, Ali Naji, Noel N. Williams, Kristoffel R. Dumon. Surg Obes Relat Dis 2014;10;79-87.
Objectives: After reading the featured articles published in this issue of Surgery for Obesity and Related Diseases (SOARD) participants in the SOARD CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with three to five response choices, and a critique discussing the objective. Disclosure Statement. It is the policy of the American Society for Metabolic and Bariatric Surgery that speakers and/or anyone in control of content of a CME Category 1 event must disclose any financial or other relationship with (1) any manufacturer(s) of commercial products that may be discussed in the speaker’s presentation and/or (2) commercial supporters of the event. All disclosures are included under the list of author names. There was no commercial support received for this activity. Accreditation Statement: The American Society for Metabolic and Bariatric Surgery (ASMBS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Society for Metabolic
and Bariatric Surgery (ASMBS) designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. SOARD CME Online provides two articles from each issue for 2 credits per month; 1 credit per article. The articles this month on SOARD CME Online are: Relevance of beta-cell function for improved glycemic control after gastric bypass surgery Jesús Blanco, Amanda Jiménez, Roser Casamitjana, Lílliam Flores, Antonio Lacy, Ignacio Conget, Josep Vidal. Surg Obes Relat Dis 2014;10;9-13. Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: A decision analysis Rashikh A. Choudhury, Kenric M. Murayama, Peter L. Abt, Henry A. Glick, Ali Naji, Noel N. Williams, Kristoffel R. Dumon. Surg Obes Relat Dis 2014;10;79-87.
1550-7289/14/$ – see front matter r 2014 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery. http://dx.doi.org/10.1016/j.soard.2014.01.001
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 10 (2014) 188–190
VOLUME 10
189
NUMBER 1 JANUARY/FEBRUARY 2014
Relevance of beta-cell function for improved glycemic control after gastric bypass surgery Jesús Blanco, Amanda Jiménez, Roser Casamitjana, Lílliam Flores, Antonio Lacy, Ignacio Conget, Josep Vidal. Surg Obes Relat Dis 2014;10;9-13. Learning Objectives The background of this study is based on two premises:
Diabetes mellitus (DM) is the result of an imbalance of the hyperbolic relationship between pancreatic beta-cell function and insulin action. Thus, it could be predicted that in the absence of residual pancreatic beta-cell function improved insulin action would not result in restoration of glucose tolerance. Because of its weight-loss independent effects, Roux-enY gastric bypass (RYGB) is increasingly being considered as a therapeutic tool for patients with DM, regardless of their clinical characteristics. In this context, the key findings of our study suggest:
RYGB surgery results in marginal or no benefit in glycemic control at 2-years after surgery in the absence of residual pancreatic beta-cell function. An enlarged GLP-1 secretion as observed following RYGB surgery is not sufficient to improve glycemic control in the absence of residual pancreatic beta-cell function. A marked and sustained weight loss as observed at 2 years after RYGB is not sufficient to result in remission of DM in the absence of residual pancreatic beta-cell function. Although RYGB could be considered for morbidly obese patients with type 1 DM as a means to improve weightrelated comorbidities, it should be emphasized that this type of surgery resulted in negligible benefit on glycemic control at 2 years in this subgroup of patients.
Question 1 In morbidly obese patients with type 1 DM, RYGB surgery results in: A. marked and sustained weight loss, and marked and sustained improvement in glycemic (HbA1c) control. B. marked and sustained weight loss, but no change in glycemic (HbA1c) control. C. marked and sustained weight loss, and a transitory but not sustained improvement in glycemic (HbA1c) control. D. no major change in weight loss and no improvement in glycemic (HbA1c) control. Question 2 Concerning the GLP-1 response to meal intake following RYGB surgery, which of the following statements is correct? A. RYGB results in a marked hormonal response regardless of the type of DM. B. The enlargement of the hormonal response is an early phenomenon that is restricted to the first months after surgery, and thus it is not observed at 2 years after the surgical procedure. C. The hormonal response is blunted in subjects with type 1 DM as compared with patients with type 2 DM. D. An elevated HbA1c results in blunting of the hormonal response. Question 3 Which of the following is sufficient for the effect of RYGB on glucose tolerance in humans with DM? A. An enlarged GLP-1 B. The bypass of the duodenum and proximal jejunum C. A reduction of the hyperglucagonemia characteristic of hyperglycemia D. None of the above
190
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 10 (2014) 188–190
Question 4 Based on the data presented in this article, which of the following conclusions can be drawn? A. RYGB should be considered in subjects with type 1 DM regardless of their BMI prior to surgery. B. RYGB could be of potential benefit for weight-related comorbidities other than DM in morbidly obese subjects with type 1 DM. C. The mismatch between oral carbohydrate absorption and subcutaneous insulin kinetics could result in deterioration of glycemic control after RYGB in subjects with type 1 DM. D. RYGB results in comparable rates of remission of DM in subjects with type 2 DM regardless of pancreatic betacell function.
After RYGB and renal transplantation, there may be decreased intestinal absorption, thereby requiring increased doses of immune suppressant medication.
Question 1 Which of the following statements is correct regarding a 45year-old male patient with end-stage renal disease and an initial body mass index (BMI) of 45 kg/m2? A. This patient is expected to gain an additional 5.4 years with a diet and weight loss strategy for 1 year. B. This patient is expected to gain an additional 5.4 years with a diet and weight loss strategy for 2 years. C. This patient is expected to gain an additional 5.4 years, 1 year after RYGB.
ARTICLE 2 Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: A decision analysis.
Question 2
Rashikh A. Choudhury, Kenric M. Murayama, Peter L. Abt, Henry A. Glick, Ali Naji, Noel N. Williams, Kristoffel R. Dumon.
A. a greater number of patients becoming eligible for transplants. B. more accelerated eligibility for transplantation, when compared with diet and exercise only strategies. C. resolution or improvement of comorbidities, thereby reducing mortality risk. D. decreased dropout rate of diet and exercise patients when compared with surgical patients.
Surg Obes Relat Dis 2014;10;79-87. Learning Objectives
Obesity has been defined as an independent risk factor for kidney disease, which may result in end-stage renal disease, particularly when combined with chronic hypertension and diabetes. Obesity is associated with poor graft and patient survival, and therefore many centers refuse to offer renal transplantation to morbidly obese patients. Roux-en-Y gastric bypass (RYGB) offers a survival advantage by allowing a greater number of patients to be eligible for renal transplantation and by allowing patients to receive transplants more quickly.
RYGB offers a survival advantage to end-stage renal patients due to all of the following, except:
Question 3 Decision analytic Markov state transition models are useful in evaluating the effect of a variety of interventions in the treatment of: A. acute self-limiting diseases. B. chronic diseases. C. communicable diseases.
Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: A decision analysis. Rashikh A. Choudhury, Kenric M. Murayama, Peter L. Abt, Henry A. Glick, Ali Naji, Noel N. Williams, Kristoffel R. Dumon. Surg Obes Relat Dis 2014;10;79-87.
Objectives: After reading the featured articles published in this issue of Surgery for Obesity and Related Diseases (SOARD) participants in the SOARD CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with three to five response choices, and a critique discussing the objective. Disclosure Statement. It is the policy of the American Society for Metabolic and Bariatric Surgery that speakers and/or anyone in control of content of a CME Category 1 event must disclose any financial or other relationship with (1) any manufacturer(s) of commercial products that may be discussed in the speaker’s presentation and/or (2) commercial supporters of the event. All disclosures are included under the list of author names. There was no commercial support received for this activity. Accreditation Statement: The American Society for Metabolic and Bariatric Surgery (ASMBS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Society for Metabolic
and Bariatric Surgery (ASMBS) designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. SOARD CME Online provides two articles from each issue for 2 credits per month; 1 credit per article. The articles this month on SOARD CME Online are: Relevance of beta-cell function for improved glycemic control after gastric bypass surgery Jesús Blanco, Amanda Jiménez, Roser Casamitjana, Lílliam Flores, Antonio Lacy, Ignacio Conget, Josep Vidal. Surg Obes Relat Dis 2014;10;9-13. Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: A decision analysis Rashikh A. Choudhury, Kenric M. Murayama, Peter L. Abt, Henry A. Glick, Ali Naji, Noel N. Williams, Kristoffel R. Dumon. Surg Obes Relat Dis 2014;10;79-87.
1550-7289/14/$ – see front matter r 2014 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery. http://dx.doi.org/10.1016/j.soard.2014.01.001
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 10 (2014) 188–190
VOLUME 10
189
NUMBER 1 JANUARY/FEBRUARY 2014
Relevance of beta-cell function for improved glycemic control after gastric bypass surgery Jesús Blanco, Amanda Jiménez, Roser Casamitjana, Lílliam Flores, Antonio Lacy, Ignacio Conget, Josep Vidal. Surg Obes Relat Dis 2014;10;9-13. Learning Objectives The background of this study is based on two premises:
Diabetes mellitus (DM) is the result of an imbalance of the hyperbolic relationship between pancreatic beta-cell function and insulin action. Thus, it could be predicted that in the absence of residual pancreatic beta-cell function improved insulin action would not result in restoration of glucose tolerance. Because of its weight-loss independent effects, Roux-enY gastric bypass (RYGB) is increasingly being considered as a therapeutic tool for patients with DM, regardless of their clinical characteristics. In this context, the key findings of our study suggest:
RYGB surgery results in marginal or no benefit in glycemic control at 2-years after surgery in the absence of residual pancreatic beta-cell function. An enlarged GLP-1 secretion as observed following RYGB surgery is not sufficient to improve glycemic control in the absence of residual pancreatic beta-cell function. A marked and sustained weight loss as observed at 2 years after RYGB is not sufficient to result in remission of DM in the absence of residual pancreatic beta-cell function. Although RYGB could be considered for morbidly obese patients with type 1 DM as a means to improve weightrelated comorbidities, it should be emphasized that this type of surgery resulted in negligible benefit on glycemic control at 2 years in this subgroup of patients.
Question 1 In morbidly obese patients with type 1 DM, RYGB surgery results in: A. marked and sustained weight loss, and marked and sustained improvement in glycemic (HbA1c) control. B. marked and sustained weight loss, but no change in glycemic (HbA1c) control. C. marked and sustained weight loss, and a transitory but not sustained improvement in glycemic (HbA1c) control. D. no major change in weight loss and no improvement in glycemic (HbA1c) control. Question 2 Concerning the GLP-1 response to meal intake following RYGB surgery, which of the following statements is correct? A. RYGB results in a marked hormonal response regardless of the type of DM. B. The enlargement of the hormonal response is an early phenomenon that is restricted to the first months after surgery, and thus it is not observed at 2 years after the surgical procedure. C. The hormonal response is blunted in subjects with type 1 DM as compared with patients with type 2 DM. D. An elevated HbA1c results in blunting of the hormonal response. Question 3 Which of the following is sufficient for the effect of RYGB on glucose tolerance in humans with DM? A. An enlarged GLP-1 B. The bypass of the duodenum and proximal jejunum C. A reduction of the hyperglucagonemia characteristic of hyperglycemia D. None of the above
190
Continuing Medical Education Program / Surgery for Obesity and Related Diseases 10 (2014) 188–190
Question 4 Based on the data presented in this article, which of the following conclusions can be drawn? A. RYGB should be considered in subjects with type 1 DM regardless of their BMI prior to surgery. B. RYGB could be of potential benefit for weight-related comorbidities other than DM in morbidly obese subjects with type 1 DM. C. The mismatch between oral carbohydrate absorption and subcutaneous insulin kinetics could result in deterioration of glycemic control after RYGB in subjects with type 1 DM. D. RYGB results in comparable rates of remission of DM in subjects with type 2 DM regardless of pancreatic betacell function.
After RYGB and renal transplantation, there may be decreased intestinal absorption, thereby requiring increased doses of immune suppressant medication.
Question 1 Which of the following statements is correct regarding a 45year-old male patient with end-stage renal disease and an initial body mass index (BMI) of 45 kg/m2? A. This patient is expected to gain an additional 5.4 years with a diet and weight loss strategy for 1 year. B. This patient is expected to gain an additional 5.4 years with a diet and weight loss strategy for 2 years. C. This patient is expected to gain an additional 5.4 years, 1 year after RYGB.
ARTICLE 2 Roux-en-Y gastric bypass compared with aggressive diet and exercise therapy for morbidly obese patients awaiting renal transplant: A decision analysis.
Question 2
Rashikh A. Choudhury, Kenric M. Murayama, Peter L. Abt, Henry A. Glick, Ali Naji, Noel N. Williams, Kristoffel R. Dumon.
A. a greater number of patients becoming eligible for transplants. B. more accelerated eligibility for transplantation, when compared with diet and exercise only strategies. C. resolution or improvement of comorbidities, thereby reducing mortality risk. D. decreased dropout rate of diet and exercise patients when compared with surgical patients.
Surg Obes Relat Dis 2014;10;79-87. Learning Objectives
Obesity has been defined as an independent risk factor for kidney disease, which may result in end-stage renal disease, particularly when combined with chronic hypertension and diabetes. Obesity is associated with poor graft and patient survival, and therefore many centers refuse to offer renal transplantation to morbidly obese patients. Roux-en-Y gastric bypass (RYGB) offers a survival advantage by allowing a greater number of patients to be eligible for renal transplantation and by allowing patients to receive transplants more quickly.
RYGB offers a survival advantage to end-stage renal patients due to all of the following, except:
Question 3 Decision analytic Markov state transition models are useful in evaluating the effect of a variety of interventions in the treatment of: A. acute self-limiting diseases. B. chronic diseases. C. communicable diseases.