Orientador: Bruno Geloneze Neto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T01:31:55Z (GMT). No. of bitstreams: 1 Hirsch_FernandaMariaPossidonioFilgueira_M.pdf: 2513385 bytes, checksum: 670868cb2865c16ec53810e4f4acc3e4 (MD5) Previous issue date: 2012 / Resumo: O principal objetivo deste estudo foi avaliar os mecanismos fisiopatológicos subjacentes às diferentes evoluções quanto à remissão do diabetes mellitus tipo 2 (DM2) após a gastroplastia com reconstrução em Y-de-Roux (RYGB). Métodos: Um grupo de pacientes com não-remissão do DM2 (NR) foi formado (n=13) baseado na revisão de prontuários de pacientes obesos mórbidos diagnosticados com DM2 submetidos ao RYGB. Um grupo remissão (R) foi composto por pacientes que tiveram normalização da glicemia e da A1c, sem drogas antidiabéticas e pareados para as mesmas características (i.e., duração da doença, IMC prévio e final, distribuição de gordura, e idade; n=15). Um grupo controle foi formado por pacientes magros (n=41). Resultados: O grupo NR apresentou maiores níveis de ácido úrico (5.1 vs. 3.9 mg/dL), número de leucócitos (6866.9 vs. 5423.6), PCR-us (0.27 vs. 0.12 mg/dL), MCP-1 (118.4 vs. 64.4 ng/mL), HOMA-IR e AUCglicose, mas níveis menores de adiponectina (9.4 vs. 15.4 ng/mL), leptina (12.7 vs. 20.7 ng/mL) e AUCGLP-1 em comparação com o grupo R; o grupo NR também teve menor leptina e maior adiponectina, HOMA-IR, AUCglicose, AUCpeptídeo-C, AUCglucagon e AUCGLP-1 que o grupo controle. O grupo R apresentou menor nível de MCP-1 e maior de adiponectina em relação ao grupo controle. A sensibilidade à insulina foi significantemente menor no grupo NR que nos grupos R e controle. Os índices de secreção de insulina foram menores no grupo NR que nos grupos R e controle. Conclusão: Este estudo demonstrou que pacientes sem remissão do DM2 após RYGB apresentam maior resistência à insulina, menor secreção de insulina, adiposopatia e inflamação subclínica crônica persistentes apesar de perda de peso semelhante. Mecanismos fisiopatológicos persistentemente alterados podem explicar a não remissão do DM2 após RYGB / Abstract: Objective: The aim of this study was to evaluate the pathophysiological mechanisms underlying the remission of type 2 diabetes in Roux-en-Y gastric bypass (RYGB) patients. Research Design and Methods: A group of patients not in remission (NR) was formed (n=13). A remission group (R) was composed of patients who had undergone normalization of fasting glycemia and A1c, without anti-diabetic drugs and matched for selected baseline characteristics (i.e., duration of disease, previous BMI, final BMI, fat distribution, and age; n=15). A control group of lean subjects (n=41) was formed. Results: The NR group had higher uric acid (5.1 vs. 3.9 mg/dL), number of leukocytes (6866.9 vs. 5423.6), hs-CRP (0.27 vs. 0.12 mg/dL), MCP-1 (118.4 vs. 64.4 ng/mL), HOMA-IR and AUCglucose but lower adiponectin (9.4 vs. 15.4 ng/mL), leptin (12.7 vs. 20.7 ng/mL) and AUCGLP-1 in comparison to R group; NR group also had lower leptin and higher adiponectin, HOMA-IR, AUCglucose, AUCC-peptide, AUCglucagon and AUCGLP-1 than controls. The R group had lower MCP-1 and higher adiponectin compared to controls. Insulin sensitivity was significantly lower in the NR group than in the R and control groups.The insulin secretion index values were lower in the NR group than in the R and control groups. Conclusions: This study found greater insulin resistance, lower insulin secretion, persistent adiposopathy and chronic subclinical inflammation and less robust incretin response in NR group despite a similar level of weight loss. Persistently altered pathophysiological mechanisms can be related to the lack of remission of type 2 diabetes after RYGB / Mestrado / Clinica Medica / Mestre em Clinica Medica

orionpizango@gmail.com / Case report: A 43-year-old female presented with decreased visual acuity in the right eye.“Snowball-like” retinal lesions were found in both eyes on examination. Due to a lackof improvement with intravitreal antifungal empirical treatment, vitreous culture wasperformed and Candida glabrata was isolated. The patient then received intravitreal ampho-tericin B, as well as systemic treatment with caspofungin and amphotericin B lipid complex.Discussion: Endogenous fungal endophthalmitis is a sight-threatening condition. There arefew reports of C. glabrata endogenous endophthalmitis. Treatment regimens for Candidaendophthalmitis include combinations of systemic and/or intravitreal antifungals, as wellas vitrectomy.

As obesity becomes a growing concern in the United States, bariatric surgery is also growing in popularity, leading patients to regain control of their health and resolve many chronic conditions associated with morbid obesity, such as Type II diabetes mellitus (DM II), heart disease, and hypertension (HTN)[1–7]. On average, bariatric surgery patients lose 50% excess weight within the first two years following a Roux-en-Y gastric bypass, sleeve gastrectomy, or laparoscopic gastric banding[4–6,8–11], leading to problematic excess skin, most commonly located at the abdomen, but also found on the arms, thighs, buttocks, groin, and other areas of the body[12]. While survey-based studies have found approximately 90% of bariatric surgery patients develop excess skin[13], other studies have shown only 11-12% of patients undergo excess skin removal following bariatric surgery[14,15]. This study conducted a retrospective review of patients undergoing massive weight loss (MWL) (defined as at least 50% excess weight loss or 100 lb weight loss) at one year follow up after bariatric surgery at one large academic medical center in Massachusetts. The goal was to identify which step in the pursuit of excess skin removal created the largest barrier to entry and whether patient demographics (age, sex, type of bariatric surgery, payor, weight loss at one year, and highest level of education) played a role in creating a healthcare disparity in the patients undergoing excess skin removal. Patients were identified through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Through chart review, patients were followed from bariatric surgery to first complaint of excess skin to plastic surgery consultation for excess skin removal to undergoing excess skin removal. Of 370 patients who experienced a MWL within the first year after bariatric surgery, 36.2% (134) of patients complained of excess skin at bariatric surgery follow up and were referred to a plastic surgeon at the same academic institution for a plastic surgery consultation. Of patients who complained of excess skin, 37.3% (50) attended a plastic surgery consultation. Finally, 48% (24) of patients who attended a plastic surgery consultation underwent excess skin removal at the same academic institution. Of patients who complained of excess skin, 17.9% of patients underwent excess skin removal. Demographics of patients were tracked to determine whether certain demographics had a higher barrier to entry in pursuing excess skin removal. No healthcare disparity based on: patient age at time of bariatric surgery, race, highest level of education, type of bariatric surgery, or payor was found. It is important to note that this study was performed at a single Massachusetts academic institution, and the final number of patients undergoing excess skin removal was relatively small (n=24). A higher-powered study with a larger group of patients from multiple bariatric surgery programs could be more telling in identifying whether a healthcare disparity exists. Regardless of patient demographic, 82.1% of patients who complained of excess skin did not undergo excess skin removal, so there may be a societal or insurance-driven gap in understanding the importance and need for these procedures in bariatric surgery patients that should be studied further.

BACKGROUND: One of the most common long-term problems after bariatric surgery is weight regain, occurring between 18 and 24 months after surgery in 30% of patients.1 Weight regain after bariatric surgery supports the concept that obesity is a chronic, progressive disease that needs constant follow-up.2 To ensure long-term post-operative success, patients are recommended to adopt comprehensive lifestyle changes, which include adhering to a diet of at least 60-120 g/day of protein and engaging in mild exercise 20 min/day 3-4 days/week.3–7 Based on the current literature there is growing evidence that patients' health behaviors, including physical activity and protein intake, may play a significant role in weight loss and other postoperative outcomes.8–11 However, there is little long-term evidence for behaviors important for sustained weight loss following bariatric surgery. OBJECTIVE: The purpose of our research initiative was to determine whether protein intake and physical activity have an effect on maintaining weight loss in patients who underwent bariatric surgery 1-2 years earlier. METHODS: Our study included 368 patients who underwent bariatric surgery at Boston Medical Center from 06/01/2016-05/31/2017. We extracted baseline clinical data from electronic medical records (EMR), including gender, self-identified race, weight, height, date of birth, date of enrollment in the bariatric surgery program, and surgery date. We also collected self-reported physical activity (calculated as active metabolic equivalent [MET]-hours) and 24-hour dietary recall information from patients who had this data available in their EMR at least 1-year post surgery (n=121, 80.2% female), and assessed weight status through 06/01/2019. We conducted a retrospective analysis to observe the association of lifestyle factors with weight maintenance post-bariatric surgery. Prevalence and odds ratio (OR) were calculated for % weight regain (<2% vs. ≥2%) by active MET-hours & percent protein in diet, with adjustment for age, gender, race, and time to nadir weight. We ran additional analysis to test the combined effect of physical activity and high protein diet by comparing percent weight regain in those consuming a low protein diet (with any activity level) to those consuming moderate-high protein & lower active METS-hour vs. moderate-high protein & higher active METS-hour. RESULTS: Our study implemented two novel ways to examine physical activity and dietary recalls in the context of bariatric surgery patients, and how they influenced percent weight regain of nadir weight. Our results show that patients had an average of 84.4 pounds of weight loss at 1-year post operation, the average nadir weight was 179.0 pounds. However, many participants experienced weight regain after achieving their nadir weight. In fact, the average weight regain was 5.8 pounds. Patients who had active MET-hours <1.5 (n=78) had an average of 5.77 pounds regained after reaching nadir weight, compared to patients who had an active MET-hour ≥1.5 (n=43) who had an average of 5.89 pounds regained. But after adjusting for age, gender, and race, those who were less active (active MET-hours <1.5) did not have significantly higher odds of gaining more that 2% of their nadir weight back during out follow-up period (OR = 0.71 [CI 0.32-1.60]). Protein intake was defined as either a low protein intake (<26.7% protein of total diet) or moderate-high protein intake (≥26.7% protein of total diet). A patient consuming a low protein diet had 2.71 (CI 1.16 – 5.29) times the odds gaining ≥ 2% of their weight back from nadir compared to patients who consumed a moderate-high protein diet, after adjusting for age, sex, and race (p-value <0.05). After adjustments, those with moderate-high protein and low activity had 1.84 (CI 0.69-4.94) times the odds of ≥2% weight regain of nadir weight compared to patients who were moderate-high protein and higher activity, which, although not statistically significant, may be an important relationship to explore further. CONCLUSION: The findings indicate that consuming a moderate-high protein diet while engaging in physical activity tend to gain less weight after bariatric surgery in comparison to consuming less protein. There is also some evidence that those achieving moderate-high protein levels see an added benefit on weight maintenance if they are physically active. Future prospective longitudinal studies and strategies are needed to investigate implications further and define the magnitude of the association between protein intake, physical activity and bariatric surgery, as well as targeting various demographic subpopulations who might stand to benefit more from certain lifestyle interventions post-bariatric surgery.

INTRODUCTION: Unplanned hospital visits have emerged as a quality metric encompassing many aspects of postoperative morbidity and deficiencies in the transition from inpatient to outpatient care. This study aims to identify patient, encounter, and organizational factors that may influence Emergency Department (ED) visits and readmissions following bariatric surgery. METHODS: A modified version of a framework initially proposed by Vest et al. in their systematic review of the determinants of preventable readmissions was used as a conceptual framework for this study. The Michigan Bariatric Surgery Collaborative (MBSC) database was used to identify patients undergoing all primary bariatric procedures at 40 centers with >100 patients in the database from 2006–2015. Multivariate logistic regression modeling was used to identify factors associated with unplanned hospital visits. Using an indirect standardization process, each sites’ observed to expected ratio for 30-day readmission was calculated. The association between each site’s adjusted readmission rate with their rate of ED visits, Emergency Department-Sourced readmissions (EDSR), major complications, and compliance with best practices were calculated with Pearson’s correlation coefficients. RESULTS: Younger age, greater comorbidities, increased length of stay, procedure type, and Medicaid/Medicare insurance were significantly associated with readmissions in a multivariate logistic regression model. There was significant variation among sites’ adjusted rates of readmission, EDSR, best practice compliance, and major complications. There was a moderately strong association between each sites’ adjusted readmission rate with their rate of EDSR (r=0.53), major complications (r=0.53), and ED visits (r=0.55). However, the association between bariatric centers’ compliance with best practices to reduce unplanned hospital visits and their readmission rates was fairly weak (r= -0.14). CONCLUSION: Several individual, encounter, and organization-level characteristics are associated with an increased risk of unplanned visits after bariatric surgery. Bariatric centers are more likely to have higher readmission rates if their site has higher rates of major complications and if their ED is less likely to treat and then discharge bariatric patients. Further examination of organizational characteristics of bariatric programs that affect postoperative readmissions, including ED practices, is needed to better guide future initiatives aimed at improving this quality metric.

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Obesity is a worldwide public health epidemic with no sign of yet abating. Although previous studies have examined the impact of obesity on walking, little is known about the effects of practice on walking patterns in individuals with obesity. The purpose of this current study was to evaluate whether an obstacle-crossing task may detect walking deficits in a group of adults electing to undergo bariatric surgery. With a cross-sectional design, we collected walking parameters as 24 adults (M age= 46.19, SD= 12.90) with obese body mass index (BMI) scores (M BMI= 41.68, SD= 5.80) and 26 adults (M age= 21.88, SD= 3.48) with normal BMI scores (M BMI= 23.09, SD= 4.47) walked in 5 conditions for 5 trials each: on flat ground, crossing over low, medium, and high obstacles, and again on flat ground. The timing and distance of participants' steps were collected with a mechanized gait carpet (GAITRite, Inc.). We conducted 5 (condition) repeated measures (RM) ANOVAs on our main dependent variables, which measured how fast (velocity) and long (step length) participants' steps were and how much time they spent with one (single limb support time) versus two (double limb support time) feet on the ground. The results showed within session improvements in participants' walking patterns. Comparisons of the first and last trials on flat ground showed that participants took longer, faster steps by increasing step length and velocity (ps<.01). They also spent more time with one versus two feet on the ground via increased single limb support time and decreased double limb support time (ps<.001). Our findings suggest that an obstacle-crossing task may help spur improvements in walking patterns even before adults elect to undergo bariatric surgery.

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