Abstract Morbid obesity is the most rapidly increasing health threat of developed countries, and the costs caused by it are already higher than those of smoking. In an increasing number of developing countries both starvation and morbid obesity are increasing simultaneously. Obesity in children and adolescents is also increasing rapidly. Conservative treatment almost invariably fails when treating morbid obesity. Results of pharmacotherapy have been disappointing after great expectations. Laparoscopic gastric banding has been used in the treatment of morbid obesity since 1993. The method was first used mostly in Europe. In the USA either an open or laparoscopic gastric bypass have been the most common methods of surgery. The aim of this study was to investigate the operation results of 280 patients operated in Vaasa Central Hospital during the 11 years after March 1996. Of these patients, 123 have been followed at least 5 years. The results have been analyzed with BAROS that measures the quality of life. Quality of life was measured prospectively 1 year after surgery with the 15D questionnaire that is validated in the Finnish population. The effect of gastric banding in esophageal motility and reflux was studied prospectively in 31 patients. Late results were analyzed in 123 patients 11 years after the first operation. Mean excess weight loss (EWL) was 56% in patients who had their band in place 7 years after surgery, and 46% in all patients. There was no mortality related to the operation, and there was only one serious complication. Disease-specific quality of life improved in 78.8% of the patients in 28 months of follow-up. Health-related quality of life was significantly improved 12 months after surgery, but improvement was not connected to the amount of weight loss. The band inhibited reflux 19 months after surgery. Complications, failures, and reoperations increase with longer follow-up. Weight loss is moderate 9 years after a gastric banding operation, and in carefully selected patients this operation is still a good option in the treatment of morbid obesity.

Objectives: to determine the effectiveness of bariatric surgery to reduce the risk of cardiovascular events such as coronary heart disease, stroke, cardiovascular mortality, and total mortality in morbidly obese patients, compared with a non-surgical treatment and no intervention control group. Methods: a systematic review was carried out with cohort-type studies that evaluated, with a minimum follow-up of one year, morbidly obese adults who had undergone bariatric surgery compared to a control group of non-surgical treatment and without intervention in relation to the cardiovascular events such as coronary heart disease, stroke, cardiovascular mortality, and total mortality in morbidly obese patients. Results: 14 studies were selected that met our inclusion criteria. 44,912 patients who underwent bariatric surgery and 208,347 non-surgical controls were included. The high heterogeneity of the included studies did not allow the meta-analysis to be carried out. However, most of the individual results show decreased risk of the outcomes studied. A subgroup analysis was performed, where Bariatric Roux-en-Y surgery reduces the risk of coronary artery disease by approximately 60%. In morbidly obese diabetic patients, our calculations showed a risk reduction of 80% for cardiovascular mortality and 70% for total mortality. Finally, our calculations show a 58% decrease in cardiovascular mortality in studies with a follow-up of 2 or more years. Conclusions: Our study suggests that bariatric surgery is beneficial for morbidly obese adult patients at risk of presenting cardiovascular events. / Objetivos: determinar la efectividad de la cirugía bariátrica para disminuir el riesgo de eventos cardiovasculares como enfermedad coronaria, accidente cerebrovascular, mortalidad cardiovascular y mortalidad total en pacientes obesos mórbidos, comparado con un grupo control de tratamiento no quirúrgico y sin intervención. Métodos: se realizó una revisión sistemática con estudios de tipo cohortes que evalúen, con seguimiento mínimo de un año, a adultos obesos mórbidos que se hayan sometido a cirugía bariátrica en comparación a un grupo control de tratamiento no quirúrgico y sin intervención en relación con los eventos cardiovasculares como enfermedad coronaria, accidente cerebrovascular, mortalidad cardiovascular y mortalidad total en pacientes obesos mórbidos. Resultados: se seleccionaron 14 estudios que cumplieron nuestros criterios de inclusión. Se incluyeron 44 912 pacientes que se sometieron a cirugía bariátrica y 208 347 controles no quirúrgicos. La alta heterogeneidad de los estudios incluidos no permitió realizar el metaanálisis. Sin embargo, la mayoría de los resultados individuales muestran disminución del riesgo de los desenlaces estudiados. Se realizó un análisis por subgrupos, en donde la cirugía bariátrica en Y de Roux disminuye el riesgo de enfermedad coronaria en aproximadamente 60%. En pacientes obesos mórbidos diabéticos nuestros cálculos mostraron reducción del riesgo en 80% de mortalidad cardiovascular y 70% de mortalidad total. Por último, nuestros cálculos demuestran disminución del 58% de la mortalidad cardiovascular en los estudios con un seguimiento de 2 a más años. Conclusiones: Nuestro estudio sugiere que la cirugía bariátrica es beneficiosa para los pacientes adultos obesos mórbidos en riesgo de presentar eventos cardiovasculares / Tesis

No description available.

BACKGROUND: Current guidelines give class I recommendations for uninterrupted use of dabigatran rivaroxaban as an alternative to vitamin K antagonist (VKA) in patients of atrial fibrillation (AF) who are undergoing catheter ablation. The recent randomized controlled trials have shown similar efficacy of novel oral anticoagulants when compared to VKA in these patients. We sought to perform a meta-analysis with a focus on subgroup analysis of novel oral anticoagulants. METHODS: We searched PubMed, Clinical trials registry and the Cochrane Center Register of Controlled Trials were searched through August 2020. Six RCTs studies (n = 2260) comparing the use of NOACs versus VKA in patients with AF undergoing catheter ablation were included. The odds ratio (OR) with 95% confidence interval was computed and P < 0.05 was considered as a level of significance. Major adverse cardiac events (MACE) were considered as a primary endpoint. RESULTS: Our results showed a significant difference in MACE between NOACs and VKA [OR 0.57 (0.37-0.88); P = 0.01] and in major bleeding events [OR 0.55 (0.35-0.86); P = 0.009], which is mainly derived from the use of dabigatran. No significant difference in MACE or major bleeding events was found on the subgroup analysis of rivaroxaban and apixaban over VKA therapy. CONCLUSION: Uninterrupted use of NOACs is safe and effective alternative for the prevention of cerebral thromboembolism and reducing the risk of major bleeding in patients undergoing catheter ablation of AF. However, the individual subgroup analysis showed that only dabigatran is superior to VKA in terms of reducing MACE through a reduction in major bleeding. The rivaroxaban, apixaban and edoxaban are non-inferior to VKA therapy based on these results. Further studies are needed to generalize these recommendations in morbidly obese patients.

This study aimed at exploring the impact of early traumatic experiences on bariatric patients with the intent to give "voice" to their experiences. The impact of morbid obesity and the lack of quality of life among those suffering from this form of chronic illness can be devastating. Meaningful support systems and bariatric surgery are therefore considered as forced behavioural interventions to remediate the impact of childhood trauma and subsequent development of morbid obesity among this group of bariatric patients. Through a process of social constructivism and dialogue between the researcher and the five participants, the co-construction according to themes was supported by a qualitative research approach and the case study method. For the analysis of the themes according to the participants' "voices", the thematic content analysis method was used to analyse the data and was finally linked to supportive literature. It is hoped that the results from this study will contribute to the development of a unique assessment and support programme to those who have to endure the burden of morbid obesity associated with early childhood trauma; and that the process prior to and post bariatric surgery will be an important contribution to finding quality of life and giving new meaning to patients after suffering through their bodies and traumatised minds. / Psychology / D.Litt. et. Phil (Psychology)

INTRODUÇÃO: A secreção do hormônio de crescimento (GH) está diminuída em obesos. Existem controvérsias se esta diminuição é conseqüência ou um dos fatores causais da obesidade. Perda de peso leva a alguma recuperação da secreção de GH. Não há estudos publicados sobre o efeito da derivação gástrica (gastrojejunal) com anastomose em Y-de-Roux (BPG) sobre o perfil de secreção de 24 h de GH. Por outro lado, a ghrelina é um peptídeo secretagogo de GH produzido no estômago, orexigênico, lipogênico e adipogênico, cujos níveis oscilam ao longo do dia e estão diminuídos na obesidade. As variações circadianas de ghrelina têm papel no controle da homeostase energética e secreção de GH. O nível de ghrelina eleva-se com perda de peso induzida por dieta, mas os dados são controversos sobre mudanças desses níveis após cirurgias bariátricas. Este estudo tem por objetivo caracterizar os perfis de secreção de GH e ghrelina em mulheres com obesidade grau III antes e após BPG e suas correlações com variáveis metabólicas. MÉTODOS: Coletas de sangue a cada 20 minutos por 24 horas foram realizadas em obesas mórbidas não diabéticas na pré-menopausa antes e seis meses após BPG. O procedimento foi realizado em balanço calórico neutro por quatro dias. Foram dosados glicose e insulina; GH em todas as amostras e ghrelina às 08:00h, 10:00h, 12:00h, 19:00h e 02:00h. A taxa metabólica de repouso (TMR) foi avaliada por calorimetria indireta e as massas adiposa (MA) e magra (MM) foram medidas por DEXA. RESULTADOS: Houve uma redução de 27% do peso corporal e IMC (de 55,9 ± 6,2 kg/m2 para 40,7 ± 5,8 kg/m2, p<0,001) com elevação de vários parâmetros de secreção de GH (GH basal, GH médio, p<0,05; área, amplitude e número de picos, p<0,001); redução de glicemia (p = 0,03), insulinemia de jejum (p = 0,005) e HOMA (p = 0,004). Não houve diferença nos níveis de ghrelina basal, pós-prandial e médio. O GH médio apresentou correlação negativa com as mudanças no peso (p = 0,003; r = -0,631), IMC (p <0,001; r = -0,731), MA (p = 0,003; r = -0,635), MM (p = 0,02; r = -0,507), circunferência abdominal (p = 0,01; r = -0,555), TMR (p = 0,01; p = -0,539), insulina de jejum (p = 0,014, r = -0,538) e HOMA (p = 0,01; r = -0,560), mas não com a glicemia de jejum (p = 0,13; r = -0,354) e a ghrelina (p = 0,6; r = 0,118). O melhor determinante da secreção de GH foi o IMC sendo responsável por 54% da variação do GH médio (r2 = 0,54). CONCLUSÕES: Há uma recuperação parcial da secreção de GH, reduzida no pré-operatório em obesas mórbidas, após perda de peso induzida seis meses após a cirurgia, indicando que a secreção reduzida não é um fator primário ou causal da obesidade, mas sim uma conseqüência da obesidade e essa recuperação é independente do perfil de secreção de ghrelina / INTRODUCTION: Growth hormone (GH) concentration is decreased in obesity. It is not clear if reduced GH secretion is consequence or cause of the obese state. GH secretion is partially restored by weight loss. There are no published studies about the effect of Roux-en-Y gastric bypass (RYGBP) on GH secretory profile. Ghrelin is a GH releasing peptide produced by stomach, with orexigenic, lipogenic and adipogenic actions. Ghrelin levels oscillate throughout the day and are low in obesity. Circadian changes in ghrelin levels have a role both in energy homeostasis control and GH secretion. Ghrelin levels rise after diet-induced weight loss, but results are controverse in relation to changes in ghrelin levels after bariatric surgeries. In this study, we analyzed GH and ghrelin concentrations in morbidly obese women before and after RYGBP and its relationships with metabolic parameters. METHODS: Blood was sampled at 20-minute intervals during 24 hours in non diabetic pre-menopausal morbid obese women before and six months after RYGBP. The study was done after four days in neutral caloric balance. Fasting glucose and insulin were determined in basal samples. GH concentrations were measured in all samples and ghrelin in serum collected at 08:00h, 10:00h, 12:00h, 19:00h e 02:00h. Resting metabolic rate (RMR) was evaluated by indirect calorimetry and fat mass (FM) and free-fat mass (FFM) were measured by DEXA. RESULTS: A 27% drop in body weight and BMI (55.9 ± 6.2 kg/m2 to 40.7 ± 5.8 kg/m2, p<0.001), augmentation of spontaneous GH secretory episodes (basal and mean levels, p <0.05; area, amplitude and peak frequency, p <0.001); and reduction of fasting glucose (p = 0.03), insulinemia (p = 0.005) and HOMA (p = 0.004) were observed. Neither basal, post-prandial or mean ghrelin were changed. A negative correlation was found between mean GH levels and weight changes (p = 0.003, r = -0.631), BMI (p <0.001, r = -0.731), FM (p = 0.003, r = -0.635), FFM (p = 0.02, r = -0.507), waist (p = 0.01, r = -0.555), RMR (p = 0.01, p = -0.539), fasting insulin (p = 0.014, r = -0.538), as well as HOMA (p = 0.01, r = -0.560), but not between mean GH levels and glucose (p = 0.13, r = -0.354) or ghrelin (p = 0.6, r = 0.118). BMI accounted for 54% of the mean GH variation (r2 = 0.54). CONCLUSIONS: There is a partial recovery of GH secretion after weight loss induced by RYGBP, suggesting that a blunted secretion is not a primary or causal factor of obesity, but a consequence of the obese state. This recovery is independent of ghrelin secretory profile

This study aimed at exploring the impact of early traumatic experiences on bariatric patients with the intent to give "voice" to their experiences. The impact of morbid obesity and the lack of quality of life among those suffering from this form of chronic illness can be devastating. Meaningful support systems and bariatric surgery are therefore considered as forced behavioural interventions to remediate the impact of childhood trauma and subsequent development of morbid obesity among this group of bariatric patients. Through a process of social constructivism and dialogue between the researcher and the five participants, the co-construction according to themes was supported by a qualitative research approach and the case study method. For the analysis of the themes according to the participants' "voices", the thematic content analysis method was used to analyse the data and was finally linked to supportive literature. It is hoped that the results from this study will contribute to the development of a unique assessment and support programme to those who have to endure the burden of morbid obesity associated with early childhood trauma; and that the process prior to and post bariatric surgery will be an important contribution to finding quality of life and giving new meaning to patients after suffering through their bodies and traumatised minds. / Psychology / D.Litt. et. Phil (Psychology)

INTRODUÇÃO: A secreção do hormônio de crescimento (GH) está diminuída em obesos. Existem controvérsias se esta diminuição é conseqüência ou um dos fatores causais da obesidade. Perda de peso leva a alguma recuperação da secreção de GH. Não há estudos publicados sobre o efeito da derivação gástrica (gastrojejunal) com anastomose em Y-de-Roux (BPG) sobre o perfil de secreção de 24 h de GH. Por outro lado, a ghrelina é um peptídeo secretagogo de GH produzido no estômago, orexigênico, lipogênico e adipogênico, cujos níveis oscilam ao longo do dia e estão diminuídos na obesidade. As variações circadianas de ghrelina têm papel no controle da homeostase energética e secreção de GH. O nível de ghrelina eleva-se com perda de peso induzida por dieta, mas os dados são controversos sobre mudanças desses níveis após cirurgias bariátricas. Este estudo tem por objetivo caracterizar os perfis de secreção de GH e ghrelina em mulheres com obesidade grau III antes e após BPG e suas correlações com variáveis metabólicas. MÉTODOS: Coletas de sangue a cada 20 minutos por 24 horas foram realizadas em obesas mórbidas não diabéticas na pré-menopausa antes e seis meses após BPG. O procedimento foi realizado em balanço calórico neutro por quatro dias. Foram dosados glicose e insulina; GH em todas as amostras e ghrelina às 08:00h, 10:00h, 12:00h, 19:00h e 02:00h. A taxa metabólica de repouso (TMR) foi avaliada por calorimetria indireta e as massas adiposa (MA) e magra (MM) foram medidas por DEXA. RESULTADOS: Houve uma redução de 27% do peso corporal e IMC (de 55,9 ± 6,2 kg/m2 para 40,7 ± 5,8 kg/m2, p<0,001) com elevação de vários parâmetros de secreção de GH (GH basal, GH médio, p<0,05; área, amplitude e número de picos, p<0,001); redução de glicemia (p = 0,03), insulinemia de jejum (p = 0,005) e HOMA (p = 0,004). Não houve diferença nos níveis de ghrelina basal, pós-prandial e médio. O GH médio apresentou correlação negativa com as mudanças no peso (p = 0,003; r = -0,631), IMC (p <0,001; r = -0,731), MA (p = 0,003; r = -0,635), MM (p = 0,02; r = -0,507), circunferência abdominal (p = 0,01; r = -0,555), TMR (p = 0,01; p = -0,539), insulina de jejum (p = 0,014, r = -0,538) e HOMA (p = 0,01; r = -0,560), mas não com a glicemia de jejum (p = 0,13; r = -0,354) e a ghrelina (p = 0,6; r = 0,118). O melhor determinante da secreção de GH foi o IMC sendo responsável por 54% da variação do GH médio (r2 = 0,54). CONCLUSÕES: Há uma recuperação parcial da secreção de GH, reduzida no pré-operatório em obesas mórbidas, após perda de peso induzida seis meses após a cirurgia, indicando que a secreção reduzida não é um fator primário ou causal da obesidade, mas sim uma conseqüência da obesidade e essa recuperação é independente do perfil de secreção de ghrelina / INTRODUCTION: Growth hormone (GH) concentration is decreased in obesity. It is not clear if reduced GH secretion is consequence or cause of the obese state. GH secretion is partially restored by weight loss. There are no published studies about the effect of Roux-en-Y gastric bypass (RYGBP) on GH secretory profile. Ghrelin is a GH releasing peptide produced by stomach, with orexigenic, lipogenic and adipogenic actions. Ghrelin levels oscillate throughout the day and are low in obesity. Circadian changes in ghrelin levels have a role both in energy homeostasis control and GH secretion. Ghrelin levels rise after diet-induced weight loss, but results are controverse in relation to changes in ghrelin levels after bariatric surgeries. In this study, we analyzed GH and ghrelin concentrations in morbidly obese women before and after RYGBP and its relationships with metabolic parameters. METHODS: Blood was sampled at 20-minute intervals during 24 hours in non diabetic pre-menopausal morbid obese women before and six months after RYGBP. The study was done after four days in neutral caloric balance. Fasting glucose and insulin were determined in basal samples. GH concentrations were measured in all samples and ghrelin in serum collected at 08:00h, 10:00h, 12:00h, 19:00h e 02:00h. Resting metabolic rate (RMR) was evaluated by indirect calorimetry and fat mass (FM) and free-fat mass (FFM) were measured by DEXA. RESULTS: A 27% drop in body weight and BMI (55.9 ± 6.2 kg/m2 to 40.7 ± 5.8 kg/m2, p<0.001), augmentation of spontaneous GH secretory episodes (basal and mean levels, p <0.05; area, amplitude and peak frequency, p <0.001); and reduction of fasting glucose (p = 0.03), insulinemia (p = 0.005) and HOMA (p = 0.004) were observed. Neither basal, post-prandial or mean ghrelin were changed. A negative correlation was found between mean GH levels and weight changes (p = 0.003, r = -0.631), BMI (p <0.001, r = -0.731), FM (p = 0.003, r = -0.635), FFM (p = 0.02, r = -0.507), waist (p = 0.01, r = -0.555), RMR (p = 0.01, p = -0.539), fasting insulin (p = 0.014, r = -0.538), as well as HOMA (p = 0.01, r = -0.560), but not between mean GH levels and glucose (p = 0.13, r = -0.354) or ghrelin (p = 0.6, r = 0.118). BMI accounted for 54% of the mean GH variation (r2 = 0.54). CONCLUSIONS: There is a partial recovery of GH secretion after weight loss induced by RYGBP, suggesting that a blunted secretion is not a primary or causal factor of obesity, but a consequence of the obese state. This recovery is independent of ghrelin secretory profile

Made available in DSpace on 2017-06-01T18:08:52Z (GMT). No. of bitstreams: 1 gabriela_nunes_catarino.pdf: 507365 bytes, checksum: 4fc758346d9198724d8fa4fbf606c4d3 (MD5) Previous issue date: 2014-03-25 / This dissertation aimed, in general, analyze the action of the clinical psychologist in the preparation and psychological care of people undergoing bariatric surgery process. Specifically seeks to identify the elements that can interfere positively and / or negatively, in relation therapist - patient, analyze the resonances that therapeutic monitoring exercises on patients undergoing bariatric surgery. Sought to both the theoretical contributions about the body in Merleau Ponty and psychoanalysis Winnicott. Mainly addressed the relationship therapist - patient by Winnicott's approach and within the context of psychologists working with the theme of obesity. This is a qualitative study, whose participants seven clinical psychologists who develop activities in the field of bariatric surgery, both in the private and public sectors and two included patients aged 33 to 56 years, who underwent surgery and continue in psychological counseling. Semistructured interview used to psychologists and for both patients through a different starter question. The analysis of the narrative was taken from the thematic analysis, which identified themes related to the issue of professional practice and theoretical concepts used by psychologists, especially axes as the nature of the bond established relationship therapist and patient, the importance of family participation in the process and especially body image experienced by the patient before, during and after surgery. O care that the psychologist should have to take into account in its therapeutic relationship , the promotion of self-knowledge and understanding about a body experienced by the patient and therefore a body guy, not objectified ; constituted themselves as elements of fundamental importance , reminding us that policies accompanying attitudes are necessary but not sufficient for successful treatment. For these reasons, we point out that intrapsychic issues and the internal resources of the patient are sufficiently worked out, thus avoiding that the same replace the symptom of obesity by another symptom of compulsion. / Esta dissertação objetivou, de forma geral, analisar a ação do psicólogo clínico no processo de preparação e acompanhamento psicológico das pessoas que se submetem à cirurgia bariátrica. De forma específica pretendeu-se identificar os elementos que podem interferir positivamente e/ou negativamente, na relação terapeuta - paciente; analisar as ressonâncias que o acompanhamento terapêutico exerce sobre os pacientes que se submetem à cirurgia bariátrica. Para tanto buscou as contribuições teóricas a respeito do corpo na filosofia de Merleau Ponty e na psicanálise de Winnicott. Sobretudo, abordou o relacionamento terapeuta paciente pela abordagem winnicottiana e dentro do contexto dos psicólogos que trabalham com o tema da obesidade. Trata-se de uma pesquisa qualitativa, que tem como participantes sete psicólogas clínicas que desenvolvem atividades na área de cirurgia bariátrica, tanto no setor privado como público e duas pacientes compreendidas na faixa etária de 33 e 56 anos, que se submeteram à cirurgia e continuam em acompanhamento psicológico. Utilizamos a entrevista semidirigida tanto para as psicólogas como para as pacientes, através de uma questão disparadora diferenciada. A análise das narrativas foi feita a partir da análise temática, que permitiu identificar eixos temáticos ligados à questão da prática profissional e às concepções teóricas utilizadas pelas psicólogas, destacando-se eixos como a natureza do vinculo estabelecido na relação terapeuta e paciente, a importância da família na participação do processo e, sobretudo, a imagem corporal vivida pelo paciente antes, durante e depois do procedimento cirúrgico. O cuidado que o psicólogo deve ter para levar em consideração no seu relacionamento terapêutico, a promoção do autoconhecimento e a compreensão a respeito de um corpo vivido pelo paciente e, portanto, um corpo sujeito, não coisificado; constituíram-se como elementos de fundamental importância, lembrando-nos que, atitudes explicativas diretivas são necessárias, mas não suficientes para o sucesso do tratamento. Por essas razões, apontamos que questões intrapsíquicas e os recursos internos do paciente sejam suficientemente trabalhados, evitando, assim, que o mesmo substitua o sintoma da obesidade por outro sintoma de compulsão.

No description available.