Bone mineral density and expression of vitamin D receptor-dependent calcium uptake mechanisms in the proximal small intestine after bariatric surgery.

BACKGROUND: Roux-en-Y gastric bypass may lead to impaired calcium uptake. Therefore, operation-specific effects of gastric bypass and vertical banded gastroplasty on bone mineral density (BMD) were examined in a randomized clinical trial. Bone resorption markers and mechanisms of decreased calcium uptake after gastric bypass were investigated using blood and endoscopic samples from two additional patient cohorts. METHODS: Total BMD and non-weight-bearing skull BMD were measured by dual-energy X-ray absorptiometry at baseline, and 1 and 6 years after gastric bypass or vertical banded gastroplasty in patients who were not receiving calcium supplements. Bone resorption markers in serum and calcium uptake mechanisms in jejunal mucosa biopsies were analysed after gastric bypass by proteomics including radioimmunoassay, gel electrophoresis and mass spectrometry. RESULTS: One year after surgery, weight loss was similar after gastric bypass and vertical banded gastroplasty. There was a moderate decrease in skull BMD after gastric bypass, but not after vertical banded gastroplasty (P < 0·001). Between 1 and 6 years after gastric bypass, skull BMD and total BMD continued to decrease (P = 0·001). C-terminal telopeptide levels in serum had increased twofold by 18 months after gastric bypass. Proteomic analysis of the jejunal mucosa revealed decreased levels of heat-shock protein 90ß, a co-activator of the vitamin D receptor, after gastric bypass. Despite increased vitamin D receptor levels, expression of the vitamin D receptor-regulated calcium transporter protein TRPV6 decreased. CONCLUSION: BMD decreases independently of weight after gastric bypass. Bone loss might be attributed to impaired calcium absorption caused by decreased activation of vitamin D-dependent calcium absorption mechanisms mediated by heat-shock protein 90ß and TRPV6.

Long-term results of a randomized clinical trial comparing Roux-en-Y gastric bypass with vertical banded gastroplasty.

BACKGROUND: The long-term results of Roux-en-$\hbox{Y}$ gastric bypass (gastric bypass) and vertical banded gastroplasty (VBG) from randomized studies have not been described in detail. METHODS: Patients were randomized to gastric bypass or VBG. Body mass index (BMI), body composition, eating habits and gastrointestinal hormones were reviewed after 6 years. The frequency of reoperation was assessed up to 10 years after surgery. RESULTS: Sixty-six (80 per cent) of the 82 subjects randomized were assessed for weight and BMI 6 years after surgery, 30 (81 per cent) in the gastric bypass group and 36 (80 per cent) in the VBG group. Intention-to-treat analysis demonstrated greater weight loss after gastric bypass compared with VBG, 6 years after surgery: BMI reduced from 41·8 (95 per cent confidence interval 41·3 to 42·3) to 30·3 (28·6 to 32·0) kg/m(2) for gastric bypass and from 42·3 (42·8 to 44·8) to 32·9 (31·3 to 34·5) kg/m(2) for VBG (P = 0·036). Gastric bypass caused a larger loss of fat mass (P = 0·026) and better preservation of lean tissue (P = 0·009). Patients having a gastric bypass had greater postprandial responses to the satiety hormones glucagon-like peptide 1 and peptide YY (P = 0·003 and P = 0·004 respectively). Ghrelin levels did not differ between the groups. Patients with a gastric bypass maintained a lower intake of fat compared with those having VBG (P = 0·013). Some 89 per cent of patients who initially had VBG had undergone, or were scheduled for, conversion to gastric bypass at latest follow-up. CONCLUSION: Gastric bypass was superior to VBG regarding weight loss, body composition, dietary composition and postprandial satiety hormone responses.

Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS).

CONTEXT: The prevalence of obesity among adolescents has increased and we lack effective treatments. OBJECTIVE: To determine if gastric bypass is safe and effective for an unselected cohort of adolescents with morbid obesity in specialized health care. DESIGN, SETTING AND PATIENTS: Intervention study for 81 adolescents (13-18 years) with a body mass index (BMI) range 36-69 kg m(-2) undergoing laparoscopic gastric bypass surgery in a university hospital setting in Sweden between April 2006 and May 2009. For weight change comparisons, we identified an adult group undergoing gastric bypass surgery (n=81) and an adolescent group (n=81) receiving conventional care. MAIN OUTCOME MEASUREMENTS: Two-year outcome regarding BMI in all groups, and metabolic risk factors and quality of life in the adolescent surgery group. RESULTS: Two-year follow-up rate was 100% in both surgery groups and 73% in the adolescent comparison group. In adolescents undergoing surgery, BMI was 45.5 ± 6.1 (mean ± s.d.) at baseline and 30.2 (confidence interval 29.1-31.3) after 2 years (P<0.001) corresponding to a 32% weight loss and a 76% loss of excess BMI. The 2-year weight loss was 31% in adult surgery patients, whereas 3% weight gain was seen in conventionally treated adolescents. At baseline, hyperinsulinemia (>20 mU l(-1)) was present in 70% of the adolescent surgery patients, which was reduced to 0% at 1 year and 3% at 2 years. Other cardiovascular risk factors were also improved. Two-thirds of adolescents undergoing surgery had a history of psychopathology. Nevertheless, the treatment was generally well tolerated and, overall, quality of life increased significantly. Adverse events were seen in 33% of patients. CONCLUSIONS: Adolescents with severe obesity demonstrated similar weight loss as adults following gastric bypass surgery yet demonstrating high prevalence of psychopathology at baseline. There were associated benefits for health and quality of life. Surgical and psychological challenges during follow-up require careful attention.

Treatment and outcome in post-resuscitation care after out-of-hospital cardiac arrest when a modern therapeutic approach was introduced.

BACKGROUND: The outcome among patients who are hospitalised alive after out-of-hospital cardiac arrest is still relatively poor. At present, there are no clear guidelines specifying how they should be treated. The aim of this survey was to describe the outcome for initial survivors of out-of-hospital cardiac arrest when a more aggressive approach was applied. PATIENTS: All patients hospitalised alive after out-of-hospital cardiac arrest in the Municipality of Göteborg, Sweden, during a period of 20 months. RESULTS: Of all the patients in the municipality suffering an out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted (n=375), 85 patients (23%) were hospitalised alive and admitted to a hospital ward. Of them, 65% had a cardiac aetiology and 50% were found in ventricular fibrillation. In 32% of the patients, hypothermia was attempted, 28% underwent a coronary angiography and 21% had a mechanical revascularisation. In overall terms, 27 of the 85 patients who were brought alive to a hospital ward (32%) survived to 30 days after cardiac arrest. Survival was only moderately higher among patients treated with hypothermia versus not (37% versus 29%; NS), and it was markedly higher among those who had early coronary angiography versus not (67% versus 18%; p<0.0001). CONCLUSION: In an era in which a more aggressive attitude was applied in post-resuscitation care, we found that the survival (32%) was similar to that in previous surveys. However, early coronary angiography was associated with a marked increase in survival and might be of benefit to many of these patients. Larger registries are important to further confirm the value of hypothermia in representative patient populations.

[Strategies against the stigmatisation of mentally ill subjects and their practical realisation in the example of Irrsinnig Menschlich e. V]. / Strategien gegen die Stigmatisierung psychisch kranker Menschen und ihre praktische Umsetzung am Beispiel des Irrsinnig Menschlich e. V.

In our society people with mental illness are still stigmatised and exposed to various forms of discrimination. Individual and structural discrimination and discrimination due to self-stigmatisation can be distinguished. The association "Irrsinnig Menschlich" ("Madly human") in Leipzig will serve as a model to present approaches to reduce these different kinds of discrimination of mentally ill people. The school project "Crazy? So what!" and the film festival "Ausnahmezustand" ("state of emergency"), carried out all over Germany in 2006, will be described in more detail. The first evaluation of both projects showed a reduction of stigmatisation to be possible. Students participating in the project tended to decrease their social distance to the mentally ill. These developments were not present with the control groups. Although the majority of the audience at the film festival either knew somebody who is mentally ill or were themselves suffering from a mental illness, the results showed that watching these documentaries can result in a reduction of social distance towards mentally ill people. Only long-term efforts can make anti-stigma campaigns successful and effective. Irrsinnig Menschlich has established the framework for this.

The effect of enzyme predigestion on the nutritional quality of prepressed turkey feather meal.

Three experiments were conducted to determine the protein efficiency ratio (PER), pepsin digestibility, TMEn, and true amino acid availability (TAAA) of prepressed turkey feather meal (PFM), enzyme-digested PFM (EPFM), and commercial feather meal (CFM). Turkey feathers from a commercial processing plant were mechanically pressed alone or mechanically pressed, followed by treatment with a mixture of protease, lipase, and amylase prior to autoclaving. In the first study, feather meal diets containing 16,20, or 24% CP from PFM, EPFM, or CFM were fed to starter poults for 10 d. All diets resulted in negative or negligible growth. In a second study, PFM, EPFM, and CFM were again the primary sources of CP, but dietary protein levels were increased to 20, 24, and 28% CP, and all diets contained 20% corn and 10% soybean meal (PFMCS, EPFMCS, CFMCS), respectively, to allow for a basal level of growth. Performance and PER of the poults fed the diets with PFMCS, EPFMCS, and CFMCS were similar. The efficiency of use of the PFMCS diet was numerically lower (P < or = 0.1) when compared with the EPFMCS and CFMCS diets. Similarly, pepsin digestibilities of EPFM and CFM were higher than PFM. The TAAA of PFM (82.1%) and EPFM (80.6%) were not significantly higher than that of CFM (71.4%); however, the availabilities of lysine, threonine, aspartate, glutamate, proline, and histidine were significantly higher. Digestion of pressed turkey feathers with an enzyme mixture prior to autoclaving could have a positive impact on its protein and amino acid nutritional values.

Protein quality and calcium availability from extruded and autoclaved turkey hatchery residue.

The protein quality of an extruded mixture of hatchery by-product meal and soybean meal (EHSM) and the calcium availability of autoclaved hatchery by-product meal (AHBM) were determined. In Experiments 1 and 2, EHSM or soybean meal (SBM) were the only protein sources in diets formulated to contain 16, 20, or 24% CP. In both experiments, there were five or six replicate pens randomly allotted to each level of dietary protein and each pen contained five poults. In Experiment 1, there was a significant increase in the Protein Efficiency Ratio (PER; P < or = 0.005) in poults from a fast-growing line compared with poults from a slow-growing line selected for egg production but no significant differences between EHSM and SBM. In Experiment 2, PER was increased in poults fed EHSM (P < or = 0.002). In both studies, there was a large decline in PER in those poults fed the 16% SBM diet, and this resulted in a significant source by level interaction. There were no significant source or level of protein effects on the Net Protein Ratio (NPR) or Net Protein Utilization (NPU) in Experiment 2. In Experiment 3, AHBM, steamed bone meal and limestone were the primary sources of calcium in diets containing 0.6, 0.8, 1.0, and 1.2% calcium. There were four replicate pens per level and source of calcium. The length and width of the femur and tibia were measured along with fat-extracted bone weight and ash. Poults fed diets containing AHBM and limestone had improved feed efficiency (P < or = 0.008) compared with those fed bone meal. There were no significant diet effects on any bone measurements.

The effect of enzyme predigestion on the quality of poultry by-product meal from whole turkey mortality.

Enzyme predigested poultry by-product meal made from onfarm, whole turkey mortality (E-TBM) was compared with soybean meal (SBM) and commercial poultry by-product meal (CPBM) in each of three experiments. In Experiment 1, young poults were fed diets containing 16, 20, or 24% CP with either SBM or E-TBM as protein sources. A separate group of poults was fed a nitrogen-free diet. The E-TBM was higher than SBM in protein, fat, lysine, methionine, and total sulfur amino acids. Diets containing E-TBM resulted in increased BW, feed consumption, and a higher protein efficiency ratio (PER) and net protein ratio (NPR) compared with diets containing SBM. In Experiment 2, feeding nonenzyme-treated turkey by-product (TBM) or E-TBM resulted in significantly improved BW and feed efficiency compared with CPBM but this may have been due to decreased protein in diets containing CPBM. Protein source did not affect feed intake, PER, NPR, or net protein utilization (NPU). In Experiment 3, the TMEn content of CPBM was lower than both TBM and E-TBM but lysine and methionine digestibilities were greater.

[A mental health education program: the school project "Crazy? So What!" initiated by "Irrsinnig Menschlich (Madly Human) e.V. Leipzig"]. / "Verrückt? Na und!" Ein Schulprojekt sensibilisiert Jugendliche für psychische Probleme.

The school project "Crazy? So What!" aims to educate young people about mental disorders and to raise their tolerance of the mentally sick. Personal encounters between the students and the mental ill is a major aspect of the scheme. To date, 820 students from 27 schools in Saxony, Thuringia and Saxony-Anhalt have participated in the program. The evaluation of the project within the framework of a case-control study revealed that negative stereotypes and the reserve shown towards the mentally handicapped actually can be reduced. The long-term goal is to integrate mental health/illness into the school curriculum.

Cryoconservation of Oocytes in a Patient with Breast Cancer and Intrauterine Early Pregnancy.

Case Report: A 38-year-old patient newly diagnosed with invasive ductal breast cancer wished to cryoconserve her unfertilised oocytes. Stimulation was started on the 26th day of her menstrual cycle with daily administration of 300 IE hMG s. c. and a GnRH antagonist (cetrorelix 0.25 mg s. c.). The patient additionally received an aromatase inhibitor during the first 5 days of stimulation (letrozole 5 mg p. o.). Induction of ovulation occurred on the 11th day of stimulation with hCG (10 000 IE s. c.) and a GnRH agonist (triptorelin 0.2 mg s. c.). Seventeen oocytes were retrieved during follicle puncture and 11 were cryopreserved. Despite the administration of cetrotide (a GnRH antagonist) no luteolysis occurred during stimulation. A pregnancy test was therefore done on the 11th day of stimulation and the result was positive (ß-HCG 3493 mIU/ml). Sonography showed an intrauterine pregnancy. The patient was in gestational week 5 + 0. The aspirated oocytes mostly showed a normal morphology (metaphase II) despite high progesterone levels during stimulation. The patient decided to terminate the pregnancy before starting adjuvant chemotherapy. Conclusion: We describe the case of a patient who underwent stimulation for cryopreservation of oocytes during a spontaneous pregnancy conceived in the same cycle just before starting stimulation. Stimulation was done over a short period using a combination of a GnRH antagonist and an aromatase inhibitor to ensure the lowest possible estradiol levels. The quality of the oocytes does not appear to have been negatively affected by the high progesterone levels of early pregnancy.

Beneficial impact of epidural anesthesia on recovery after outpatient arthroscopy.

The ideal outpatient anesthetic provides analgesia, is readily reversible, has minimal complications, and allows for a prompt hospital discharge. Iatrogenic side effects, such as nausea/vomiting and pain, however, may hamper patient recovery and delay discharge. The influence of anesthesia [general (G) versus epidural (E)] was assessed in 260 patients (G = 181, E = 79) undergoing ambulatory knee arthroscopic surgery. Patients were studied before discharge and on follow-up (24 h) to evaluate the effect of the anesthetic technique. Discharge times were shorter in the E group (159 +/- 6 min SEM E, compared with 208 +/- 8 min SEM G), as was the incidence of pain (24.1% versus 49.7%), and nausea/vomiting (8.9% versus 32%) before discharge. Patient satisfaction was equal in the two groups. Our study shows that in select patients, epidural anesthesia is a viable alternative to general anesthesia for knee arthroscopy, offering the advantages of fewer side effects and earlier discharge times.

Crazy? So what! Effects of a school project on students' attitudes towards people with schizophrenia.

OBJECTIVE: Aiming at promoting young people's mental health and reducing stigma towards people with schizophrenia, project weeks were carried out with secondary school students aged 14-18 years (n=90). Key to the project week is meeting a (young) person with schizophrenia. METHOD: Students' attitudes and behavioural intentions towards people with schizophrenia were assessed before and after the project. Parallelly, a control group of students were questioned (n=60). Assessment was repeated after 1 month. RESULTS: Despite expected ceiling effects, the project led to a significant reduction of negative stereotypes. For social distance, a positive trend could be observed. These developments were not present with the controls. Attitude changes were still evident at the 1-month follow-up. CONCLUSION: Results support the hypothesis that young people's attitudes about schizophrenia are susceptible to change. Antistigma projects at school level could thus be a promising approach to improving public attitudes and to preventing stereotypes from becoming reinforced.