Orientador: Elinton Adami Chaim / Dissertação (mestrado) - Universidade Estaduasl de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T20:05:58Z (GMT). No. of bitstreams: 1 Gobato_RenataCristina_M.pdf: 664324 bytes, checksum: f4cb1996e3e4b9708c687287f2012cdb (MD5) Previous issue date: 2013 / Resumo: A cirurgia bariátrica é considerada um método efetivo de perda e manutenção de peso, mas pode causar várias complicações nutricionais. O objetivo deste estudo foi avaliar o estado nutricional do zinco e cobre em pacientes obesos no momento em que entram no grupo de obesidade e no pós-operatório de seis meses da gastroplastia redutora em Y de Roux. A população de estudo, composta por 36 pacientes, foi avaliada prospectivamente antes e após seis meses da gastroplastia redutora em Y de Roux. Em cada fase, o peso, altura, índice de massa corpórea (IMC), circunferência abdominal (CA), níveis séricos de proteína total, albumina, préalbumina, zinco e cobre foram mensurados. A média da porcentagem de perda de peso desde o início até seis meses após a cirurgia foi 35.34±4.82%. Dentre os micronutrientes mensurados, 31 pacientes apresentaram algum tipo de deficiência, houve grande porcentagem de deficiência de zinco tanto no pré (55.55%) quanto no pós-operatório (61.11%), no pós-operatório 8,33% dos pacientes apresentaram deficiência de cobre e 33.33% apresentaram deficiência de pré-albumina. A ingestão protéica após seis meses de cirurgia estava abaixo do recomendado (<70g/dia) em 88,88% dos pacientes. Houve diminuição na média quando se comparou as análises laboratoriais no pré e pós-operatório para proteína total (p<0,05) e pré-albumina (p<0,05). A deficiência de Zn foi frequente e apresentou alta prevalência antes e após seis meses da gastroplastia redutora em Y de Roux e, suplementos protéicos são necessários para a adequação da ingestão protéica até os 6 meses de pós-operatório / Abstract: Background Bariatric surgery is considered as an effective method for sustained weight loss, but may cause various nutritional complications. The aim of this study was to evaluate the nutritional status of zinc and copper in obese patients before and after 6 months of Roux-en-Y gastric bypass surgery (RYGBP). Methods 36 patients who underwent RYGBP were prospectively evaluated before and 6 months after surgery. At each phase their weight, height, body mass index (BMI), waist circumference, serum levels of total protein, albumin, prealbumin, zinc and copper were assessed. Results The mean weight loss from baseline to 6 months after surgery was 35.34±4.82%. Among the micronutrients measured 31 patients had some kind of deficiency, there was a high percentage of zinc deficiency both in pre (55.55%) and post-operative (61.11%) and after surgery 8,33% of the patients were deficient in copper and 33.33% in pre-albumin. The protein intake after 6 months of surgery was below the recommendations (<70g/day) for 88,88% of the patients. There was a decrease between the laboratory analysis pre and post-surgery on average for total protein (p<0,05) and pre-albumin (p<0,05). Conclusions Hypozincaemia was frequent and had high prevalence after 6 months of RYGBP and protein supplements are needed to maintain an adequate protein intake up to 6 months after surgery / Mestrado / Fisiopatologia Cirúrgica / Mestra em Ciências da Cirurgia

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

A) Bariatric surgery for the treatment of obesity has shown much promise. The Roux-en-Y gastric bypass is a procedure that combines both restrictive and malabsorptive elements. Post-operative weight loss and co-morbidity improvements previously achieved are over and above those which are seen during life style modification and drug therapy. 330 patients (2005-2007) with a mean BMI of 45.87 ± 0.63 were characterised pre-operatively with regard to clinical, anthropometric and DEXA scan measurements. 130 were matched for the same parameters post-operatively over a 9-12 month observation period. The data was analysed statistically using paired t-tests and regression analyses. Significant post-operative improvements were observed with regard to patients’ weight loss and co-morbidity improvement. Positive and significant correlations of anthropometric measures to biochemical parameters ensued. Risk factor scoring methodology produced an average total score of 17 points / 36. Average post-op weight loss at 9-12 months follow-up was 20% of initial pre-op weight. Co-morbid diseases and anthropometric measurements illustrated significant changes following surgery. Risk factor scoring is a valuable pre-op tool for assessing eligibility for medical aid re-imbursement for surgery. B) Obesity is a global epidemic and is increasing the worlds’ mortality rate. Genetic predisposition to obesity is recognized as being significant. Polymorphisms within the Melanocortin 4 Receptor (MC4R) gene, which encodes a G-protein coupled receptor responsible for post-prandial satiety signalling, have been associated with monogenic obesity. Obesity prevalence in South Africa is drastically increasing, however there has been no causative investigation done. Thus we sought to perform an initial assessment of the prevalence of MC4R polymorphisms within a South African representative group. Blood was drawn from a mixed Body Mass Index (BMI) cohort of 259 adult individuals and their DNA was extracted. The MC4R gene was PCR amplified from the DNA, the amplicon sequenced and the sequence data was analyzed for polymorphisms. A polymorphism prevalence of 13.51% was found within the patients across a BMI range that spanned from underweight (19.6) to super-obese (126.0). In addition to MC4R polymorphisms that had been identified previously, two new polymorphisms namely R7H and S36T were observed. Four haplotypes were also identified. MC4R mutation frequency was observed to be ethnically dependant; however the hypothesis of differing ethnic backgrounds illustrating varying mutational penetrance was not confirmed. The expected trend regarding MC4R polymorphism functional effect and associated pathogenicity was not followed in light of our results. The question of whether or not MC4R polymorphisms contribute to the development of obesity is indisputable; however the current accepted trend regarding their precise role may be incorrect and must be challenged. / Dissertation (MSc)--University of Pretoria, 2009. / Immunology / unrestricted

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.

Bakgrund: Enligt World Health Organization [WHO] är övervikt och fetma ett växande hälsoproblem med global påverkan. Livsstilsförändringar som kostomläggning, beteendeterapi och ökad fysisk aktivitet är viktiga verktyg för att hjälpa patienterna att uppnå en viktnedgång men idag är viktoperationer den mest effektiva metoden mot fetma.  Syfte: Belysa patienters erfarenheter i det dagliga livet efter genomgången viktoperation. Metod: Nio steg av Polit och Beck (2016) har använts för att göra forskningsprocessen tydlig och överskådlig. Använda databaser i sökningen: CINAHL och PubMED. I resultat ingår åtta artiklar. Resultat: Viktoperation påverkar och förändrar patientens liv och erbjuder dessa ett nytt matsmältningssystem som kan upplevas både positivt och negativt. Tre kategorier framkom i studie: Fysiska och fysiologiska förändringar, psykiska processen och sociala ändringar. Från dessa kategorier tillkom underkategorierna: Kroppsförändringar och dess effekt på hälsan och intimitet, förändrad relation till mat postoperativt, motion och kondition, känslomässiga reaktioner och självkänslan, samhällets influenser och familjestöd efter viktoperation. Slutsats: Patienterna förmedlade både positiva och negativa erfarenheter av en viktoperation som påverkade deras nya sätt att leva och gav dem en ny framtid.

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.

Purpose: The authors' aim in this study was to gain insight on the psychological risk factors related to weight loss following bariatric surgery. Method: The authors used archival data of 137 participants who underwent both a psychological pre-assessment and bariatric surgery and attended a post-operative appointment at least six months following surgery. The factors examined at the psychological pre-assessment included alcohol abuse, smoking, exercise, binge eating, depression, stress, social support, dieting history, and history of sexual abuse. These factors were examined in relation to weight loss success defined as 50% loss of excess weight at follow-up. Main Findings: No significant relationships were found between weight loss success and the predictor variables. Conclusions: The researchers evaluated the present study results in relation to previous literature on bariatric surgery. Several limitations were evaluated, including examiner bias, participant population, and the assessment tool used. Areas of future research included examining alcohol consumption, exercise behavior, and binging and purging after surgery.

No description available.