Vol 49, No 5 (2021)

The causes of postprandial hyperinsulinemic hypoglycemia (PHH) in patients who have under-gone an upper gastrointestinal tract surgery are still a matter of debate in the scientific community. Low postoperative body mass index, high postprandial beta-cell activity before the surgery, and younger age are all have been associated with higher PHH risk. It is hypothesized that the insulin-like growth factor-1 increases the tissue sensitivity to insulin and indirectly promotes the development of hypoglycemia. An increase in postprandial secretion of enteropancreatic hormones is still considered to be the main reason for PHH manifestation; however, a particular contribution has been ascribed to glycentin, which could be used as a marker of PHH risk in the future. At present, there are no clinical guidelines for the diagnosis of PHH. Undoubtedly, the first step in this direction should be the collection of the disease history. The provocative tests have been proposed for the detection of PHH. Today, the 72-hour fast test is still the gold standard in the diagnosis of hypoglycemia. However, most post-bariatric patients do not have fasting hypoglycemia, and insulinoma is extremely rare in this patient category. The use of a prolonged oral glucose tolerance test as the main method is associated with a risk of a false diagnosis, because about 12% of healthy individuals may have their glycemic levels at below 2.8 mmol/l. The mixed meal test has not been validated yet. The best results in the assessment of glucose variability have been obtained with “real time” continuous glucose monitoring the interstitial fluid for several days. The goal of PHH treatment is to reduce the stimulated insulin secretion. First of all, patients are advised to eat small meals consisting of carbohydrates with a low glycemic index in combination with proteins and lipids, with high fiber content. Should the nutritional modification be ineffective, it is possible to prescribe medical treatment, such as acarbose or somatostatin analogs. Diazoxide and slow calcium channel blockers can be used as the third line of therapy. A recent study has suggested that exogenous agonists of glucagon-like peptide-1 (GLP-1) receptors by stronger bonds with receptors, compared to those with endogenous GLP-1, could enhance glucagon response to hypoglycemia, thereby stabilizing glucose levels. In severe refractory PHH, reconstructive surgery and gastric banding are to be considered. If the expected decrease in insulin hypersecretion by reconstructive surgery is not achieved, partial or complete pancreatectomy remains the only possible approach to prevent hypoglycemia. However, due to the small number and short duration of the studies, effectiveness and safety of these techniques for PHH treatment have not yet been proven.

Rationale: The contribution of the adiponectin gene polymorphisms (ADIPOQ, located at 3q27) in the residents of Nigeria and China to the risk of overweight and its association with the risk of arterial hypertension in the European population have been demonstrated.

Aim: To identify associations between rs266729 and rs16861194 polymorphisms of the ADIPOQ gene with overweight and obesity in the Moscow region residents.

Materials and methods: Identification of rs266729 and rs16861194 polymorphisms of the ADIPOQ gene was carried out in 222 people (140 women and 82 men, aged 25 to 65 years) living in the Moscow region. Genotyping was performed using allele-specific amplification with real-time detection of the results on the CFX96 Real-Time System amplifier (Bio-Rad, USA) and using TaqMan probes complementary to polymorphic DNA regions. To assess an association between these genetic polymorphisms and overweight/obesity, we performed a case control study, with the cases being subjects with body mass index (BMI) of ≥ 30 kg/m², and the controls those with BMI of < 30 kg/m².

Results: The mean frequency of the minor allele G rs266729 polymorphism of the ADIPOQ gene in the subjects from the Moscow region was 26.8% and similar in men and women. Comparison of the CC and GG genotypes carriers of the rs266729 polymorphism of the ADIPOQ gene in men showed a statistically significant association of the GG genotype to the BMI value (p = 0.04). There were no statistically significant differences between anthropometric indicators (BMI, body fat mass) in the carriers of different rs16861194 polymorphism genotypes of the ADIPOQ. No association between the studied polymorphisms and blood glucose levels and lipid spectrum could be found.

Conclusion: The frequency of the minor allele G of the rs266729 polymorphism of the ADIPOQ gene in the subjects from the Moscow region was similar to their rates in the Russian Federation and European countries. In Moscow residents, the rs266729 polymorphism of the ADIPOQ gene (G allele) contributes to the risk of obesity in homozygous carriers (genotype GG). No association of the rs16861194 polymorphism of the ADIPOQ gene with the BMI was found; therefore, this polymorphism cannot be considered as a genetic marker of the obesity risk.

Rationale: According to the published data, bariatric procedure of left gastric artery embolization (LGAE) as one of the minimally invasive and innovative methods for obesity treatment promotes reductions in bodyweight and ghrelin levels.

Aim: To evaluate the effect of LGAE on the parameters of fat and carbohydrate metabolism in obese patients.

Materials and methods: Twenty three (23) patients (10 male and 13 female, mean age 40.2 ± 10.6 years) with morbid obesity (body mass index [BMI] > 40 kg/m²) and obesity grade 2 (BMI > 35 kg/m²) underwent a minimally invasive procedure in the form of bariatric embolization of the left gastric artery with polyvinyl alcohol particles of 500 to 700 mcm in diameter. We compared anthropometric parameters (height in cm, body-weight in kg, BMI in kg/m², waist circumference in cm) at baseline and at 6 months after LGAE. Laboratory examinations included measurements of plasma adiponectin, ghrelin, leptin, fasting glucose, HbA1c, insulin, and HOMA-IR (insulin resistance index).

Results: At 6 month after LGAE, the patients' bodyweight decreased from 138.1 ± 33.2 kg to 113 ± 26 kg (p < 0.01) (by 18.2%), BMI from 47.4 ± 9.3 kg/m² to 38.1 ± 7.4 kg/m² (p < 0.01) (by 19.6%), waist circumference from 130.4 ± 9.7 cm to 115 ± 10.3 cm (p < 0.01) (by 11.8%). Mean adiponectin levels increased significantly from 22.5 ± 8.1 μg/ml before LGAE to 42.4 ± 11 μg/ml at 6 months (p < 0.001) (by 88.4%). Baseline ghrelin levels of 20.23 ± 4.8 femtomol/μL decreased to 2.09 ± 0.6 femtomol/μL at 6 months (p < 0.001) (by 89.6%). Mean leptin levels were 23.3 ± 4.9 ng/ml and 10.5 ± 3.7 ng/ml at baseline and at 6 months, respectively (p < 0.001) (by 54.9%). At 6 months after LGAE, there was a positive and significant trends in the parameters of carbohydrate metabolism: fasting glucose decreased from 6.9 ± 1.5 mmol/L to 5.1 ± 0.9 mmol/L (p < 0.001) (by 26%), HbA1c from 6.2 ± 1% to 5.3 ± 0.6% (p < 0.01) (by 14.5%), insulin from 15.6 ± 7.7 μU/ml to 8.1 ± 0.7 μU/ml (p < 0.001) (by 48%), and the HOMA-IR index from 4.5 ± 1.2 to 1.9 ± 0.32 (p < 0.001) (by 57.7%).

Conclusion: At 6 months after LGAE, the patients with obesity grades 2 and 3 have demonstrated a reduction in bodyweight of 18–19%, with a decrease in the levels of leptin (the obesity hormone), ghrelin (hunger inducing hormone), and an increase in adiponectin levels, which is a marker of metabolic health. The patients also achieved their individual glycemic goals with a decrease in fasting glucose, insulin, glycated hemoglobin, and demonstrated an improvement in HOMA-IR.

The prevalence of primary hyperaldosteronism (PHA) among individuals with essential arterial hypertension is about 5 to 10%. We present a clinical case of a 32 year old male patient, who despite the full clinical picture of PHA, was managed in primary care setting with the diagnosis of myalgia and treatment-resistant arterial hypertension. The article discusses clinical and laboratory parameters of the patient with the diagnosis of unilateral aldosteroma and the efficacy of its treatment. The generally accepted algorithm of PHA diagnosis with unilateral aldosterone-producing adenoma in young patients does not involve comparative selective blood sampling from adrenal veins. This accelerates the differential diagnosis and facilitates the decision to undertake surgery. This simplified diagnostic algorithm was successfully applied in the patient. Reasonable surgical intervention has led to the recovery of the patient. Awareness of various medical specialties of the up-to-date information on PHA and wide implementation of its screening into clinical practice, first of all, assessment of aldosterone-renin ratio, would allow for detection of the disease as early as possible and prevention of the development of life-threatening cardiovascular complications.

Relevance: Surgical treatment for congenital heart disease (CHD) with borderline left ventricle (LV) dimensions is one of the most challenging issues in current pediatric cardiac surgery. Despite the prevailing general trend to the expansion of indications for biventricular repair of an unbalanced atrioventricular septal defect (AVSD) with a dominant right ventricle (RV), the diagnostic criteria for imbalance, feasibility of radical repair and its functional results are intensively discussed in the literature.

Aim: To present quantitative criteria for the assessment of the LV size which could serve as an indication for biventricular repair of the right dominant unbalanced AVSD.

Materials and methods: We present a  series of 4  patients with AVSD and dominant RV, who underwent radical repair of the defect. The mean age of the patients was 2.4 years, and 3 of 4 had concomitant CHD: tetralogy of Fallot, double outlet right ventricle with pulmonary artery stenosis, and moderate hypoplasia of the aortic arch with subaortic stenosis. Three of 4 patients had previously undergone palliative interventions: two of them – pulmonary bending, one, the first stage of univentricular repair (atrioseptostomy, cavopulmonary anastomosis). Two children had been diagnosed with Down syndrome. The mean left ventricular end diastolic diameter (LVEDD) at baseline was 17.9 mm, corresponding to Z score of -5.4.

Results: All four patients underwent biventricular repair of the defect with a  two-patch technique. In one case, it was supplemented with placement of the pulmonary trunk homograft prosthesis, in the other with pulmonary valve commissurotomy and cavopulmonary anastomosis due to moderate tricuspid valve stenosis and in the third case the mitral valve was replaced. In 3 patients pacemaker implantation was performed. The criterion for feasibility of complete septation was the ratio of the longitudinal dimensions of the left and right ventricles (LAR > 0.7), confirmed by computed tomography performed before the surgery. The mean LVEDD after surgery was 28.3 mm, corresponding to Z score of -0.8. At the time of the hospital discharge, the left and right atrioventricular valves insufficiency did not exceed 2 and 1 degrees, respectively.

Conclusion: Computed tomography allows for accurate measurement and comparison of the longitudinal dimensions of the heart ventricles with LAR index as a tool for assessment of the LV size before the biventricular repair. An additional prospective study is required to objectify the data obtained and identify predictors of an unfavorable outcome of radical repair in patients with right dominant unbalanced AVSD.

.