title: Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Results of our Learning Curve in 100 Consecutive Patients Prediction of coronary heart disease using risk factor categories. The UKPDS risk engine: a model for the risk of coronary heart disease in Type II diabetes (UKPDS 56). Predictive accuracy of the Framingham coronary risk score in British men:prospective cohort study Are the Framingham and PROCAM coronary heart disease risk functions applicable to different European populations? The PRIME Study. Cardiovascular risk estimates and risk factors in renal transplant recipients. Is the Framingham risk function valid for northern European populations? A comparison of methods for estimating absolute coronary risk in high risk men Effects of bariatric surgery on mortality in Swedish obese subjects. Methods for assessing difference between groups in change when initial measurements is subject to intra-individual variation. Short-term effects of weight loss on the cardiovascular risk factors in morbidly obese patients. Gastric bypass surgery for severe obesity: what can be achieved? Validation of cardiovascular risk scores in a liver transplant population.
abstract: Background : Morbid obesity requires life-long treatment , and bariatric surgery provides the best results . Among the bariatric procedures , laparoscopic Roux-en-Y gastric bypass ( LRYGBP ) has been considered to be superior . However , it requires advanced laparoscopic skills and a learning curve . We analyzed our results in an initial series of 100 patients . Methods : Data of 100 consecutive patients who underwent LRYGBP for morbid obesity in a 2.5-year period were prospect ively collected and analyzed with emphasis on results and complications . Results : Mean age was 31±5 years . There were 63 woman and 37 men . Preoperative BMI was 50±9 kg/m2 . 33 patients were considered super-obese ( BMI > 50 )  . Mean operative time was 3.8 ± 0.7 hours . Two patients required conversion to open surgery . Mean hospital stay was 6 days . Complications occurred in 10 patients . Mortality rate was 2 % . Excess body weight loss was as follows : 33 ± 8 % at 3 months ( n=92 ) , 47 ± 2 % at 6 months ( n=82 ) , 62 ± 4 % at 1 year ( n= 70 ) , 66 ± 5 % at 18 months ( n= 63 ) and 67 ± 8 % at 2 years ( n= 35 ) . There was significant improvement in several co-morbid conditions , such as diabetes and hypertension . Conclusion : LRYGBP is a reproducible technique . It requires the combination of bariatric and laparoscopic expertise BACKGROUND The objective of this study was to examine the association of Joint National Committee ( JNC-V ) blood pressure and National Cholesterol Education Program ( NCEP ) cholesterol categories with coronary heart disease ( CHD ) risk , to incorporate them into coronary prediction algorithms , and to compare the discrimination properties of this approach with other noncategorical prediction functions . METHODS AND RESULTS This work was design ed as a prospect i ve , single-center study in the setting of a community-based cohort . The patients were 2489 men and 2856 women 30 to 74 years old at baseline with 12 years of follow-up . During the 12 years of follow-up , a total of 383 men and 227 women developed  CHD , which was significantly associated with categories of blood pressure , total cholesterol , LDL cholesterol , and HDL cholesterol ( all P<.001 ) . Sex-specific prediction equations were formulated to predict CHD risk according to age , diabetes , smoking , JNC-V blood pressure categories , and NCEP total cholesterol and LDL cholesterol categories . The accuracy of this categorical approach was found to be comparable to CHD prediction when the continuous variables themselves were used . After adjustment for other factors , approximately 28 % of CHD events in men and 29 % in women were attributable to blood pressure levels that exceeded high normal ( > or = 130/85 ) . The corresponding multivariable-adjusted attributable risk percent associated with elevated total cholesterol ( > or = 200 mg/dL ) was 27 % in men and 34 % in women . CONCLUSIONS Recommended guidelines of blood pressure , total cholesterol , and LDL cholesterol effectively predict CHD risk in a middle-aged white population sample . A simple coronary disease prediction algorithm was developed using categorical variables , which allows physicians to predict multivariate CHD risk in patients without overt CHD A definitive model for predicting absolute risk of coronary heart disease ( CHD ) in male and female people with Type II diabetes is not yet available . This paper provides an equation for estimating the risk of new CHD events in people with Type II diabetes , based on data from 4540 U.K. Prospect i ve Diabetes Study male and female patients . Unlike previously published risk equations , the model is diabetes-specific and incorporates  glycaemia , systolic blood pressure and lipid levels  as risk factors , in addition to age , sex , ethnic group , smoking status and time since diagnosis of diabetes . All variables included in the final model were statistically significant ( P<0.001 , except smoking for which P=0.0013 ) in likelihood ratio testing . This model provides the estimates of CHD risk required by current guidelines for the primary prevention of CHD in Type II diabetes Abstract Objective To establish the predictive accuracy of the Framingham risk score for coronary heart disease in a representative British population . Design Prospect i ve cohort study . Setting 24 towns in the United Kingdom . Participants 6643 British men aged 40 - 59 years and free from cardiovascular disease at entry into the British regional heart study . Main outcome measures Comparison of observed 10 year coronary heart disease mortality and event rates with predicted rates for each individual , using the relevant Framingham risk equation . Results Of 6643 men , 2.8 % ( 95 % confidence interval 2.4 % to 3.2 % ) died from coronary heart disease compared with 4.1 % predicted ( relative overestimation 47 % , P < 0.0001 ) . A fatal or non-fatal coronary heart disease event occurred in 10.2 % ( 9.5 % to 10.9 % ) of the men compared with 16.0 % predicted ( relative overestimation 57 % , P < 0.0001 ) . These relative degrees of overestimation were similar at all levels of coronary heart disease risk , so that overestimation of absolute risk was greatest for those at highest risk . A simple adjustment provided an improved level of accuracy . In a “ high risk score ” approach , most cases occur in the low risk group . In this case , 84 % of the deaths from coronary heart disease and non-fatal events occurred in the 93 % of men classified at low risk ( < 30 % in 10 years ) by the Framingham score . Conclusion Guidelines for the primary prevention of coronary heart disease advocate offering preventive measures to individuals at high risk . Currently recommended risk scoring methods derived from the Framingham study significantly overestimate the absolute coronary risk assigned to individuals in the United Kingdom AIMS To assess whether the Framingham and PROCAM risk functions were applicable to men in Belfast and France . METHODS AND RESULTS We performed an external validation study within the PRIME ( Prospect i ve Epidemiological Study of Myocardial Infa rct ion ) cohort study . It comprised men recruited in Belfast ( 2399 ) and France ( 7359 ) who were aged 50 to 59 years , free of CHD at baseline ( 1991 to 1993 ) and followed over 5 years for CHD events ( coronary death , myocardial infa rct ion , angina pectoris ) . We compared the relative risks of CHD associated with the classic risk factors in PRIME with those in Framingham and PROCAM cohorts . We then compared the number of predicted and observed 5-year CHD events ( calibration ) . Finally , we estimated the ability of the risk functions to separate high risk from low risk subjects ( discrimination ) . The relative risk of CHD calculated for the various factors in the PRIME population were not statistically different from those published in the Framingham and PROCAM risk functions . The number of CHD events predicted by these risk functions however clearly overestimated those observed in Belfast and France . The two risk functions had a similar ability to separate high risk from low risk subjects in Belfast and France ( c-statistic range : 0.61 - 0.68 ) . CONCLUSION The Framingham and PROCAM risk functions should not be used to estimate the absolute CHD risk of middle-aged men in Belfast and France without any CHD history because of a clear overestimation . Specific population risk functions are needed Cardiovascular morbidity , including coronary artery disease and left ventricular hypertrophy , and mortality are high in patients following renal transplantation . Cardiovascular disease is thought to be due to traditional ( hypertension , hyperlipidemia , diabetes mellitus and smoking ) as well as nontraditional cardiovascular risk factors ( microinflammation ) . Furthermore , immunosuppressive drugs , namely , calcineurin inhibitors , sirolimus , and steroids , have been reported to adversely affect cardiovascular risk factors ( e.g. , hypertension , hyperlipidemia , hyperglycemia ) . Evidence from comparative trials and from conversion studies suggest that blood pressure , hyperlipidemia , and hyperglycemia after renal transplantation may be differentially affected by the calcineurin inhibitors cyclosporine and tacrolimus . In the European Tacrolimus versus  Cyclosporin A Microemulsion Renal Transplantation Study , 557 patients were r and omly allocated to therapy with tacrolimus  ( n = 286 ) versus cyclosporine ( n = 271 ) . In addition , to blood pressure , serum cholesterol , HDL cholesterol , triglycerides , and blood glucose , we estimated the 10-year risk of coronary heart disease ( Framingham risk score ) . Tacrolimus result ed in a significantly lower time-weighted average of serum cholesterol ( P < .001 ) , and mean arterial blood pressure ( P < .05 ) , but a higher time-weighted average of blood glucose ( P < .01 ) than cyclosporine .  Mean 10-year coronary artery disease risk estimate was significantly lower in men treated with tacrolimus , ( 10.0 % versus 13.2 % ; P < .01 ) but was unchanged in women ( 4.7 % versus 7.0 % ) . Tacrolimus and cyclosporine microemulsion have compound-specific effects on cardiovascular risk factors that differentially affect the predicted rate of coronary artery disease Objective To examine the validity of estimates of coronary heart disease ( CHD ) risk by the Framingham risk function , for European population s. Design Comparison of CHD risk estimates for individuals derived from the  Framingham , prospect i ve cardiovascular Münster ( PROCAM ) , Dundee , and British regional heart ( BRHS ) risk functions . Setting Sheffield Hypertension Clinic . Patients —206 consecutive hypertensive men aged 35–75 years without preexisting vascular disease . Results There was close agreement among the Framingham , PROCAM , and Dundee risk functions for average CHD risk . For individuals the best correlation was between Framingham and PROCAM , both of which use high density lipoprotein ( HDL ) cholesterol . When Framingham was used to target a CHD event rate > 3 % per year , it identified men with mean CHD risk by PROCAM of 4.6 % per year and all had CHD event risks > 1.5 % per year . Men at lower risk by Framingham had a mean CHD risk by PROCAM of 1.5 % per year , with 16 % having a CHD event risk > 3.0 % per year . BRHS risk function estimates of CHD risk were fourfold lower than those for the other three risk functions , but with moderate correlations , suggesting an important systematic error . Conclusion There is close agreement between the Framingham , PROCAM , and Dundee risk functions as regards average CHD risk , and moderate agreement for estimates within individuals . Taking PROCAM as the external st and ard , the Framingham function separates high and low CHD risk groups and is acceptably accurate for northern European population s , at least in men BACKGROUND Obesity is associated with increased mortality . Weight loss improves cardiovascular risk factors , but no prospect i ve interventional studies have reported whether weight loss decreases overall mortality . In fact , many observational studies suggest that weight reduction is associated with increased mortality . METHODS The prospect i ve , controlled Swedish Obese Subjects study involved 4047 obese subjects . Of these subjects , 2010 underwent bariatric surgery ( surgery group ) and 2037 received conventional treatment ( matched control group ) .  We report on overall mortality during an average of 10.9 years of follow-up . At the time of the analysis ( November 1 , 2005 ) , vital status was known for all but three subjects ( follow-up rate , 99.9 % ) . RESULTS The average weight change in control subjects was less than + /-2 % during the period of up to 15 years during which weights were recorded . Maximum weight losses in the surgical subgroups were observed after 1 to 2 years : gastric bypass , 32 % ; vertical-b and ed gastroplasty , 25 % ; and b and ing , 20 % . After 10 years , the weight losses from baseline were stabilized at 25 % , 16 % , and 14 % , respectively . There were 129 deaths in the control group and 101 deaths in the surgery group . The unadjusted overall hazard ratio was 0.76 in the surgery group ( P=0.04 ) , as compared with the control group , and the hazard ratio adjusted for sex , age , and risk factors was 0.71 ( P=0.01 ) . The most common causes of death were myocardial infa rct ion ( control group , 25 subjects ; surgery group , 13 subjects ) and cancer ( control group , 47 ; surgery group , 29 ) . CONCLUSIONS Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality Statistical analysis of difference between groups in change for some variable , adjusting for initial value , is complicated by the presence of intra-individual variation in that variable . We estimate here the asymptotic bias that results from calculating the adjusted between-group difference by ordinary least squares ( OLS ) from observed data . We also present explicit formulae that use the OLS estimates , the difference between treatment groups in mean initial values , and a measure of the intra-individual variation to compute a corrected estimator and its variance . Alternatively , we can use OLS on transformed data to obtain unbiased estimates , in which we replace initial observed values by conditional Stein estimates of true values . We illustrate the results with data from an observational study and a clinical trial OBJECTIVE To analyze the short-term effects of weight loss on the cardiovascular risk factors in morbidly obese patients . RESEARCH METHODS AND PROCEDURES Five metabolic cardiovascular risk factors ( blood glucose , blood pressure , total cholesterol , high-density lipoprotein (HDL)-cholesterol , and triglycerides ) were determined before and 15.3 + /- 2.1 months after  laparoscopic gastric b and ing in 650 morbidly obese patients .  Global cardiovascular risk was calculated according to the Prospect i ve Cardiovascular Münster ( PROCAM ) scoring system . RESULTS Mean weight loss was 22.7 + /- 20.4 kg . Normalization of the metabolic alteration was observed in 67.3 % of patients with diabetes , 38.3 % of patients with hypercholesterolemia , 72.5 % of patients with low HDL-cholesterol , 72.3 % of patients with hypertriglyceridemia , and 46.7 % of patients with hypertension . PROCAM score fell from 31.4 + /- 11.6 to 28.0 + /- 12.0 points ( p < 0.001 ) . The modifications of total cholesterol and blood pressure were unrelated to percentage weight loss . Percentage weight loss was significantly related to the reductions of fasting blood glucose , triglyceride level , and the PROCAM score and to the increase of HDL-cholesterol concentrations observed after surgery . However , the strength of these four relationships was generally low . The variations of HDL-cholesterol concentrations and blood pressure levels were more influenced by actual energy balance than by the extent of weight loss . DISCUSSION Weight loss observed in the first 12 to 18 months after gastric b and ing was associated with a significant improvement of single cardiovascular risk factors and global risk . On the other h and , the extent of weight loss was poorly related to the magnitude of improvement in cardiovascular risk BACKGROUND As severe obesity becomes an increasing problem , it is important that the role of surgery in the management of the condition becomes better understood and recognised . This study reports the outcome of a large series of gastric bypass operations performed for severe obesity by a single surgeon . METHODS AND RESULTS Between 1990 - 2002 , 310 patients underwent gastric bypass surgery with all data being collected prospect ively and recorded on a computerised data base .  Mean preoperative weight and percentage excess weight were 132 kg and 119 % , respectively . There was no 30-day mortality and only one life threatening complication . Re-operations were required in 43 patients , most of which were related to ring removal or staple line disruption seen in the earlier form of gastric bypass . These problems are largely overcome with the currently performed technique . Percentage excess weight loss at 1 , 2 , 3 , 4 and 5 years was 73 % , 73 % , 66 % , 64 % , and 59 % respectively . Forty-nine of the 52 patients with type 2 diabetes were cured following surgery and 87 % of those with hypertension resolved or improved their condition . Dyslipidaemia resolved or improved in 87 % and asthma was cured or improved in 89 % of those affected . 61 patients had symptoms of obstructive sleep apnoea prior to surgery and in 51 of these symptoms resolved following surgery . CONCLUSION This study confirms that gastric bypass is a very effective treatment for severe obesity  and can be performed with a high level of safety . Gastric transection is an important component of the operation . The majority of important comorbidities seen before surgery either resolve or improve following surgery . Bariatric surgery is establishing itself as a very important and satisfying branch of upper gastrointestinal ( GI ) surgery Increased prevalence of cardiovascular risk factors has been acknowledged in liver transplant recipients , and an increased incidence of cardiovascular events has been suspected . Individual risk determination , however , has not yet been established . Outpatient charts of 438 primary liver transplants have been review ed , and suspected cardiovascular risk factors were correlated with cardiovascular events observed during a follow-up period of 10 yr . Receiver operation characteristics curve ( ROC ) analysis was performed to vali date established cardiovascular risk scores . For calibration , the Hosmer-Lemeshow test was performed . A total of 303 of 438 patients were available for risk factor analysis at 6 months and demonstrated complete follow-up data ( 175 male , 128 female ) . A total of 40 of those 303 patients experienced fatal or nonfatal cardiovascular events ( 13.2 % ) . In univariate analysis , age ( P < 0.001 ) , gender ( P = 0.002 ) , body mass index ( P = 0.018 ) , cholesterol ( P = 0.044 ) , creatinine ( P = 0.006 ) , diabetes mellitus ( P = 0.017 ) , glucose ( 0.006 ) , and systolic blood pressure ( P = 0.043 ) , but not cyclosporine A ( P = 0.743 ) , tacrolimus ( P = 0.870 ) , or steroid medication ( P = 0.991 ) , were significantly associated with cardiovascular events . Multivariate analysis , however , identified only age , gender , and cholesterol as independent predictors . In ROC analysis , corresponding areas under the curve for Systematic Coronary Risk Evaluation Project ( SCORE ) , Prospect i ve Cardiovascular Münster Study ( PROCAM ) , and Framingham risk scores ( FRSs ) were calculated with 0.800 , 0.778 , and 0.707 , respectively . Calibration demonstrated an improved goodness of fit for PROCAM compared to SCORE risk calculations . In conclusion , SCORE and PROCAM proved to be valuable in discriminating our liver transplant recipients for their individual risk of cardiovascular events . Furthermore , calibrated PROCAM risk estimates are required to calculate the number of patients needed to treat in the setup of prospect i ve intervention trials
target: Using mean data from the validation study , the trend and directionality in risk was similar in the Roux-en-Y group .
  In conclusion , bariatric surgery predicts long-term decreases in CV risk in obese patients
background: Obese patients have an increased prevalence of  cardiovascular ( CV ) risk factors , which improve with bariatric surgery , but whether bariatric surgery reduces long-term CV events remains ill defined .