No description available.

<p>Background: The objective of this thesis was to examine the role of psychosocial factors in weight loss success after bariatric surgery. It was proposed that a higher pre-operative body mass index (BMI), greater weight, depression, low self-esteem, and a childhood history of sexual abuse (CSA) would predict poor outcomes one year after Roux-en-y gastric bypass as evidenced by a BMI > 35 kg/m²and a lower percent total weight loss (%TWL). Methods: We administered a battery of psychological screening tools, including the Beck Depression Inventory-II, the Rosenberg Self-Esteem Scale and a self-report measure assessing CSA, to 262 patients seeking bariatric surgery at St. Joseph's Healthcare Hamilton. Patients completed the questionnaires prior to surgery and again one year post-surgery. Results: On average patients (n = 79) achieved good weight loss outcomes (BMI = 32.8 kg/m²) at one-year follow-up. Through multiple regression analysis we found that pre-operative BMI accounted for a significant proportion of variance in postoperative BMI [<em>R²</em> = .60, <em>F</em>(1, 77) = 114.4, <em>p</em> < .001]. Weight before surgery, however, did not predict %TWL after surgery. None of the psychosocial variables significantly predicted post-operative BMI or weight loss. These results are preliminary and are limited by the fact that participants did not present with clinically significant symptomatology and those with active psychopathology were excluded as suitable surgical candidates. Conclusion: These findings indicate that pre-operative BMI is a significant predictor of BMI one year after bariatric surgery, suggesting that more attention should be directed toward managing pre-operative BMI for heavier patients.</p> / Master of Science (MSc)

Introduction: Obesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial. Material and Methods: Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed. Results: Twenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child–Pugh score, while three could be removed from the waiting list for a liver transplantation. Conclusion: BS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

Ce mémoire évalue l'influence des perturbations naturelles et anthropiques sur l'utilisation de l'habitat par deux espèces animales. Nous avons comparé l'intensité d'utilisation de l'habitat par le lièvre d'Amérique (Lepus americanus) et par l'écureuil roux (Tamiasciurus hudsonicus) le long de deux chronoséquences de succession, l'une après feu (20-200 ans) et l'autre après coupe (20-80 ans), dans la forêt boréale du Nord-Est québécois. Nous avons également caractérisé les changements temporels de la végétation le long des chronoséquences. Nos résultats révèlent que le lièvre d'Amérique utilise préférentiellement les coupes et que le maximum d'utilisation de l'habitat par l'écureuil roux a lieu environ 20 ans plus tôt après coupe qu'après feu. Le développement plus rapide de la régénération du sapin baumier (Abies balsamea) après coupe qu'après feu pourrait partiellement expliquer ces différences. Ces résultats indiquent que la coupe à blanc ne reproduit pas parfaitement les effets du feu.

Introdução: A incidência de obesidade é crescente e alarmante, principalmente no mundo ocidental. De acordo com o National Center for Health Statistics, cerca de 61% da população adulta nos Estados Unidos está acima do peso e 30% é obesa, sendo que 5 a 6% está classificada na faixa de obesidade Grau III. No Brasil, o Ministério da Saúde aponta que 32,9% dos brasileiros estão fora da faixa de peso ideal, e 4,8% dos homens e 11,7% das mulheres encaixam-se na faixa de obesidade Grau III. Devido a alta prevalência da Doença Hepática Gordurosa Não Alcoólica (DHGNA) em pacientes portadores de obesidade grave e os escassos conhecimentos acerca de sua evolução para doença crônica do fígado após cirurgias bariátricas, foram objetivos deste estudo avaliar os efeitos da cirurgia gastrorredutora com derivação intestinal em Y de Roux Cirurgia de Fobi-Capella) sobre DHGNA após 24 meses. Métodos: Dentre 40 pacientes com IMC > 40 kg/m2 submetidos à cirurgia bariátrica (cirurgia de Fobi-Capella) no período de 2001 a 2003, 18 pacientes foram seguidos por aproximadamente 24 meses (700 ± 42 dias) e incluídos no estudo, realizando-se exames laboratoriais, tais como enzimas hepáticas, perfil lipídico e glicêmico; e a biopsia hepática no perioperatório e 24 meses após a cirurgia. O diagnóstico histológico de DHGNA e Esteatohepatite Não Alcoólica (ENA) foi determinado segundo a classificação padronizada por meio da revisão pelo Pathology Committee of the NASH Clinical Research Network Americano, que designou e validou as características histológicas e um sistema de escore de atividade para DHGNA para estudos clínicos. esultados: O IMC médio inicial dos 18 pacientes foi de 51,7 ± 7 kg/m2 e na segunda biopsia, após 24 meses de seguimento foi de 32,3 ± 6 kg/m2, com excesso do índice de massa corpórea perdida de 72,56%. DHGNA foi constatada no exame histológico inicial em 100% dos pacientes, sendo steatohepatite em 67% (10 pacientes com escore de atividade da DHGNA maior ou igual a 5 e dois pacientes com escore 4 com algum grau de fibrose) e 33% com esteatose isolada. Dos pacientes com ENA, 8,3% apresentavam cirrose. Após cerca de 24 meses houve desaparecimento da esteatose em 89% e manutenção da esteatose Grau I em 11% (p < 0,001). Em relação à fibrose, observada inicialmente em 10 (55%) dos pacientes, somente 4 (22,22%) dos pacientes mantiveram algum grau de fibrose (p = 0,020). No que se refere ao infiltrado inflamatório, 78% mantiveram discreto infiltrado lobular (Grau I) não relacionado à degeneração gordurosa. A balonização hepatocelular desapareceu em 50% dos pacientes e manteve-se discreta (Grau I) em 50% (p < 0,001). Não houve diferença estatística no que se refere às aminotranferases no pré e pós-operatório tardio. Houve redução significativa dos lípides e glicemia em quase a totalidade dos pacientes. Conclusão: A correção da síndrome metabólica obtida pela acentuada perda de peso após cirurgia de Fobi-Capella promoveu melhora da esteatose, fibrose, e os escores de atividade da DHGNA menores que 5, respectivamente em 89%, 75% e 100%dos pacientes previamente portadores de DHGNA, não se observando efeito deletério na histologia hepática nesta série. / Background: The incidence of obesity is increasing in western countries at an alarming rate. The National Center for Health Statistics of United Stated estimated in adult population 61% the prevalence of overweight or obesity, and 30% has obesity, and 5 to 6% were classified in severe obesity. In Brazil, the Ministry of Health reported 32.9% the prevalence of overweight or obese in adult brazilian population, and severe obesity 4.8% were men and 11.7% were women. Although nonalcoholic fatty liver disease (NAFLD) has been proved very frequent among morbidly obese patients and the effect of weight loss after bariatric surgery in inflammation and fibrosis related NAFLD is still a matter of debate. The aim of this study was to evaluate the impact of Fobi-Capella surgery in NAFLD in a follow up of 24 months. Methods: Forty patients with body mass index (BMI) IMC > 40 kg/m2 were submitted to Roux-en-Y gastric bypass with intraoperatory liver biopsies between 2001 a 2003, and 18 patients were followed and selected to underwent a liver biopsies after 24 months (700 ± 42 days). Blood biochemical tests and liver histology were compared before and after weight loss. The histological diagnosis of Nonalcoholic fatty liver disease (NAFLD) and Nonalcoholic steatohepatitis (NASH) was analyzed using the classification proposed by Pathology Committee of the NASH Clinical Research Network, which designed and validated a histological feature scoring system that address the characteristics of NASH lesions and a NAFLD activity score (NAS) for use in clinical trials. Eighteen patients with body mass index >40 kg/m2 submitted to Roux-n-Y gastric bypass were enrolled, and wedge liver biopsy was obtained at the operation. After 24 months, patients agreed to be submitted to a percutaneous liver biopsy. Results: The initial average BMI of 18 patientes were 51.7 ± 7 kg/m2. After following 24 months, average BMI was 32.3 ± 6 kg/m2. The average of percent excess body mass index loss was 72.56%. NAFLD was present in all 18 patients at the initial biopsy, NASH in 67% (10 patient had score of NAS ? 5 and two patients with score 4 had some degree of fibrosis) and 33% with steatosis only; 8.3% of patients with NASH has cirrhosis. After 24 months steatosis disappeared in 89% (p < 0,001) and fibrosis disappeared in 60% of the patients (p = 0.020). Hepatocellular ballooning disappeared in 50% (p < 0.001). A slight lobular inflammatory infiltrate remained in 78%, apparently unrelated to fatty degeneration. Since liver biochemical variables AST and ALT had been found within normal limits in 88% and 89%, respectively of patients at initial biopsy, no difference was found 24 months later (p = 1.000). Lipid profile and blood sugar plasma concentration were closer to normal in all patients after 24 months of follow up (p < 0.05). Conclusions: The improvement of metabolic syndrome related a severe obesity after sustained weight loss surgery promoted significant improvement in liver histology. The steatosis, fibrosis and NAS ? 5 were decreased in 89%, 75% and 100% of patients, respectively. None patient had progression of hepatic fibrosis in this series.

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

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

Introdução: A incidência de obesidade é crescente e alarmante, principalmente no mundo ocidental. De acordo com o National Center for Health Statistics, cerca de 61% da população adulta nos Estados Unidos está acima do peso e 30% é obesa, sendo que 5 a 6% está classificada na faixa de obesidade Grau III. No Brasil, o Ministério da Saúde aponta que 32,9% dos brasileiros estão fora da faixa de peso ideal, e 4,8% dos homens e 11,7% das mulheres encaixam-se na faixa de obesidade Grau III. Devido a alta prevalência da Doença Hepática Gordurosa Não Alcoólica (DHGNA) em pacientes portadores de obesidade grave e os escassos conhecimentos acerca de sua evolução para doença crônica do fígado após cirurgias bariátricas, foram objetivos deste estudo avaliar os efeitos da cirurgia gastrorredutora com derivação intestinal em Y de Roux Cirurgia de Fobi-Capella) sobre DHGNA após 24 meses. Métodos: Dentre 40 pacientes com IMC > 40 kg/m2 submetidos à cirurgia bariátrica (cirurgia de Fobi-Capella) no período de 2001 a 2003, 18 pacientes foram seguidos por aproximadamente 24 meses (700 ± 42 dias) e incluídos no estudo, realizando-se exames laboratoriais, tais como enzimas hepáticas, perfil lipídico e glicêmico; e a biopsia hepática no perioperatório e 24 meses após a cirurgia. O diagnóstico histológico de DHGNA e Esteatohepatite Não Alcoólica (ENA) foi determinado segundo a classificação padronizada por meio da revisão pelo Pathology Committee of the NASH Clinical Research Network Americano, que designou e validou as características histológicas e um sistema de escore de atividade para DHGNA para estudos clínicos. esultados: O IMC médio inicial dos 18 pacientes foi de 51,7 ± 7 kg/m2 e na segunda biopsia, após 24 meses de seguimento foi de 32,3 ± 6 kg/m2, com excesso do índice de massa corpórea perdida de 72,56%. DHGNA foi constatada no exame histológico inicial em 100% dos pacientes, sendo steatohepatite em 67% (10 pacientes com escore de atividade da DHGNA maior ou igual a 5 e dois pacientes com escore 4 com algum grau de fibrose) e 33% com esteatose isolada. Dos pacientes com ENA, 8,3% apresentavam cirrose. Após cerca de 24 meses houve desaparecimento da esteatose em 89% e manutenção da esteatose Grau I em 11% (p < 0,001). Em relação à fibrose, observada inicialmente em 10 (55%) dos pacientes, somente 4 (22,22%) dos pacientes mantiveram algum grau de fibrose (p = 0,020). No que se refere ao infiltrado inflamatório, 78% mantiveram discreto infiltrado lobular (Grau I) não relacionado à degeneração gordurosa. A balonização hepatocelular desapareceu em 50% dos pacientes e manteve-se discreta (Grau I) em 50% (p < 0,001). Não houve diferença estatística no que se refere às aminotranferases no pré e pós-operatório tardio. Houve redução significativa dos lípides e glicemia em quase a totalidade dos pacientes. Conclusão: A correção da síndrome metabólica obtida pela acentuada perda de peso após cirurgia de Fobi-Capella promoveu melhora da esteatose, fibrose, e os escores de atividade da DHGNA menores que 5, respectivamente em 89%, 75% e 100%dos pacientes previamente portadores de DHGNA, não se observando efeito deletério na histologia hepática nesta série. / Background: The incidence of obesity is increasing in western countries at an alarming rate. The National Center for Health Statistics of United Stated estimated in adult population 61% the prevalence of overweight or obesity, and 30% has obesity, and 5 to 6% were classified in severe obesity. In Brazil, the Ministry of Health reported 32.9% the prevalence of overweight or obese in adult brazilian population, and severe obesity 4.8% were men and 11.7% were women. Although nonalcoholic fatty liver disease (NAFLD) has been proved very frequent among morbidly obese patients and the effect of weight loss after bariatric surgery in inflammation and fibrosis related NAFLD is still a matter of debate. The aim of this study was to evaluate the impact of Fobi-Capella surgery in NAFLD in a follow up of 24 months. Methods: Forty patients with body mass index (BMI) IMC > 40 kg/m2 were submitted to Roux-en-Y gastric bypass with intraoperatory liver biopsies between 2001 a 2003, and 18 patients were followed and selected to underwent a liver biopsies after 24 months (700 ± 42 days). Blood biochemical tests and liver histology were compared before and after weight loss. The histological diagnosis of Nonalcoholic fatty liver disease (NAFLD) and Nonalcoholic steatohepatitis (NASH) was analyzed using the classification proposed by Pathology Committee of the NASH Clinical Research Network, which designed and validated a histological feature scoring system that address the characteristics of NASH lesions and a NAFLD activity score (NAS) for use in clinical trials. Eighteen patients with body mass index >40 kg/m2 submitted to Roux-n-Y gastric bypass were enrolled, and wedge liver biopsy was obtained at the operation. After 24 months, patients agreed to be submitted to a percutaneous liver biopsy. Results: The initial average BMI of 18 patientes were 51.7 ± 7 kg/m2. After following 24 months, average BMI was 32.3 ± 6 kg/m2. The average of percent excess body mass index loss was 72.56%. NAFLD was present in all 18 patients at the initial biopsy, NASH in 67% (10 patient had score of NAS ? 5 and two patients with score 4 had some degree of fibrosis) and 33% with steatosis only; 8.3% of patients with NASH has cirrhosis. After 24 months steatosis disappeared in 89% (p < 0,001) and fibrosis disappeared in 60% of the patients (p = 0.020). Hepatocellular ballooning disappeared in 50% (p < 0.001). A slight lobular inflammatory infiltrate remained in 78%, apparently unrelated to fatty degeneration. Since liver biochemical variables AST and ALT had been found within normal limits in 88% and 89%, respectively of patients at initial biopsy, no difference was found 24 months later (p = 1.000). Lipid profile and blood sugar plasma concentration were closer to normal in all patients after 24 months of follow up (p < 0.05). Conclusions: The improvement of metabolic syndrome related a severe obesity after sustained weight loss surgery promoted significant improvement in liver histology. The steatosis, fibrosis and NAS ? 5 were decreased in 89%, 75% and 100% of patients, respectively. None patient had progression of hepatic fibrosis in this series.

Thesis (MA (Afrikaans and Dutch))--University of Stellenbosch, 2003. / AFRIKAANSE OPSOMMING: Die doelstelling met hierdie studie is om die verskyning en ontvangs van Afrikaanse dig-debuutbundels teen die millenniumwending met behulp van die polisisteemteorie te bestudeer. Dié teorie behels dat die literatuur as 'n sisteem tussen ander sisteme in die samelewing beskryf word. In hierdie geval word die sisteemgrens tot die Afrikaanse poësie beperk. Die resepsies van die ses debuutbundels wat in 1999–2000 verskyn het en wat vir die Ingrid Jonker-prys in aanmerking geneem is, word ondersoek. Binne die polisisteemverband word 'n studie onderneem na die marginalisering van die Afrikaanse poësie; dít terwyl die poësie as sodanig reeds 'n gemarginaliseerde genre is. Dié marginalisering is grootliks die gevolg van ekonomiese oorwegings – hoofstroomuitgewers dink twee maal daaroor voordat hulle 'n digbundel uitgee, veral 'n debuutdigbundel. Terwyl die poësie in die orale vorm toenemend gewild blyk te wees, is daar nie veel publikasie-moontlikhede vir debuutdigters nie. Hierdie toestand gaan veral die opkomende digters nadelig tref. In hoofstuk 1 word 'n uiteensetting van die studie gegee. Die stand van sake in die Afrikaan-se poësiesisteem teen die millenniumwending word voorlopig beskryf. Die doel van die navorsing, die afbakening van die studie-objek en die hoofstukindeling van die tesis word uiteengesit. Hoofstuk 2 bied 'n uiteensetting van die polisisteemteorie, wat gegrond is op die werk van die Russiese Formaliste. Verder word aandag bestee aan 'n omskrywing van die poli-sisteem, die struktuur van die polisisteem en die toepassingsmoontlikhede van die teorie. 'n Teoretiese oorsig van kanonisering in die literatuur word in hoofstuk 3 onderneem. In dié hoofstuk word die verskillende definisies van die konsep kanon gegee, die verskillende soorte kanons en die proses van kanonvorming word bespreek. Laastens word die invloede van kanonisering vermeld. Die Afrikaanse literêre veld is die fokuspunt in hoofstuk 4, waar die poësie as gemargina-liseerde genre, die voorkoms van die Afrikaanse poësieveld, die Ingrid Jonker-prys en die rol van die uitgewer bespreek word. Die vraag na die afwesigheid van die "nuwe stemme" in die letterkunde word ook ondersoek. Die toekoms van die Afrikaanse poësie word verder onder die soeklig geplaas. In hoofstuk 5 word 'n studie onderneem van die resepsies van die ses debuutbundels van 1999–2000. Die resensent as kritikus en die taak van resensente word eerstens ondersoek. Kwalitatiewe en kwantitatiewe ondersoeke word onderneem ten einde na te gaan welke van die debutante moontlik die kanondrempel kan oorsteek. In die slothoofstuk, hoofstuk 6, word die bevindinge van die ondersoek saamgevat ten einde die gesprek oor die Afrikaanse poësie verder te voer. Verdere moontlike navorsingsterreine word uitgestippel. / ENGLISH ABSTRACT: The aim of this study is to examine the publication and reception of first volumes of poetry at the end of the twentieth century by means of the polysystem theory. This theory maintains that literature should be considered as a system within other systems in society. In this case the systemic boundary is limited to Afrikaans poetry. The reception of six first volumes of poetry that appeared between 1999 and 2000 and were taken into account for the Ingrid Jonker Prize is investigated. A study is made of the reception of Afrikaans poetry within the polysystemic context and in the light of the fact that poetry is already a marginalised genre. This marginalisation is largely the result of economic pressures – mainstream publishers think twice before publishing a volume of poetry, especially a first volume. While poetry, particularly oral poetry, seems to be increasingly popular, there are few publishing opportunities for new poets. This situation is going to affect especially upcoming poets negatively. Chapter 1 gives an outline of the study. The state of affairs in the Afrikaans poetry system at the end of the twentieth century is described briefly. The aim of the research, the delimitation of the field of study, and the organisation of the chapters of the thesis are set out. Chapter 2 offers an explanation of polysystems theory, which has its foundations in Russian Formalism. The chapter also describes the structure of a polysystem and discusses the possible applications of the theory. Chapter 3 presents a theoretical overview of the process of canonisation in literature. Different definitions of the concept of the canon are given and the process and effects of canonisation are considered. Chapter 4 focuses on Afrikaans literature, including discussion of poetry as a marginalised genre, the future of Afrikaans poetry, the Ingrid Jonker Prize, and the role of the publisher. The issue of the absence of "new voices" in literature is also investigated, as well as the future of Afrikaans poetry. Chapter 5 examines the reception of six first volumes of poetry between 1999 and 2000. The reviewer as literary critic and the function of reviewing are considered first. Qualitative and quantitative studies are undertaken in order to determine which of the first volumes might be incorporated into the canon. Chapter 6 draws together the findings of the investigation in order to extend the discussion on Afrikaans poetry. Possible areas of research are suggested.

Thesis (MA (VA)(Visual Arts))--Stellenbosch University, 2008. / The purpose of this study was to develop an academic approach towards my own work. The main objective was to determine my position as the subject in the art-making process and, in doing so, to find a way in which to discuss my own work more readily. My underlying assumption was that identity is formed through a visual rather than a verbal process. I realised however that language played an important role, especially since the metonymic and metaphoric characteristics of my art flow from language. The study therefore focuses on the forming of identity, on the road to self-identity, but takes this factor into consideration. Lacan’s theory on the mirror phase offered me the opportunity to investigate the inseparable relationship between subjectivity and visuality. His work on the intrinsic interaction between image and language, the conscious and the unconscious, being human as a “lack of being” and the endeavour towards completion in a broken world, culminates in the construction that language originates from the moment at which the conscious makes an appearance at the end of the mirror phase and that the unconscious is structured like a language. For Lacan the subject is not mono-dimensional, but occupies two positions, one in the imaginary, known as the moi, and the other in the symbolic, known as the je. Based on this view, Lacan demonstrates that the symbols artists use should not only be understood as icons, but should be seen as signifiers in which the subject comes to the fore. What I have drawn from the theoretical part of my research is the fact that the composition of factors that determine the meeting of subjects in the viewing process are extremely complex. The core of the gaze is however that the gazing subject always experiences something of itself in the gaze. This insight not only helped me to describe some of the work of my favourite artists better, but to identify myself in my work. The experience of unravelling and restructuring my thoughts in the writing process was most liberating.