What is the role of bariatric surgery in the management of obesity?

Diet, exercise, cognitive behavioral therapy and pharmacotherapy are some of the means of assisting patients to lose weight, with bariatric surgery being the most effective. Over the last two decades, the increased awareness of the systemic benefits of bariatric surgery, as well as the improved safety and the wider use of the laparoscopic approach, has made bariatric surgery flourish. In the United Kingdom, the adjustable gastric band (10%), vertical sleeve gastrectomy (37%) and Roux-en-Y gastric bypass (45%) are the three most common procedures. Obesity-associated mortality and co-morbidities such as type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, renal dysfunction and depression improve significantly with bariatric surgery. The mechanisms of weight loss extend beyond restriction and malabsorption and include changes in hunger and satiety, food preferences, and possibly energy expenditure. Despite its safety and efficacy, bariatric surgery is underutilized as less than 1% of adults with obesity receive it. In view of the evolution of obesity into a global threat, access to bariatric surgery should be increased, whilst developing safer and less invasive weight loss treatments.

[Suicide among the French National Police forces: Implication of life events and life trajectories]. / Suicide dans la Police nationale française : trajectoires de vie et facteurs associés.

OBJECTIVES: Research indicates that suicide rates are high among members of law enforcement. Our objectives were: (1) to determine life events implicated in suicide mortality among French law enforcement; and (2) to describe the different life trajectories of police officers who deceased by suicide. METHODS: All suicides of police officers which occurred during 2008 (n=49) were explored using the psychological autopsy method. Key informants were: a supervisor, a colleague and a member of the family or a close friend. Each of them were interviewed by trained psychologists using standardized questionnaires exploring: sociodemographic characteristics, life events, social integration and support, health service use, mental health with the Composite International Diagnostic Interview short form (CIDI-SF), occupational stress with the Spielberger Inventory, impulsiveness with the Barratt Impulsiveness Scale and aggressiveness with the Brown-Goodwin Lifetime Aggression Scale. Information was then summarized in a timetable life trajectory of all life areas. All cases were finally appraised by at least two experts in order to identify the determinants of the suicide and to determine psychiatric diagnoses. For each period of time, a burdensomeness score was determined, from 6 (no adversity) to 1 (adversities in each sphere of life). RESULTS: Of the 49 cases of suicide, two were excluded and 39 were investigated and appraised (response rate: 39/47=83%). Eighty-two percent of the suicide cases were men and the mean age at death was 35years. In more than half of the cases, police officers used their service weapon to commit suicide. All deceased police officers were suffering from mental health symptoms (primarily depression). Of them, two thirds had used healthcare for this distress. The main other cause of suicide was problems in the married life (70% of the cases). Four distinct types of life trajectories of adversities could be identified by a qualitative analysis. DISCUSSION: It is the first time such a study was performed in France, and results are concordant with those of the literature. This study showed that all deceased police officers were suffering from mental disorders and that there was not one single profile of life trajectory: screening and support of police officers in distress need to be prioritized. Moreover, results suggested that the availability of the service weapon during off-duty periods should be reconsidered. This study helped the Home ministry to elaborate and improve strategies to prevent suicide among police officers.

Can medical therapy mimic the clinical efficacy or physiological effects of bariatric surgery?

The number of bariatric surgical procedures performed has increased dramatically. This review discusses the clinical and physiological changes, and in particular, the mechanisms behind weight loss and glycaemic improvements, observed following the gastric bypass, sleeve gastrectomy and gastric banding bariatric procedures. The review then examines how close we are to mimicking the clinical or physiological effects of surgery through less invasive and safer modern interventions that are currently available for clinical use. These include dietary interventions, orlistat, lorcaserin, phentermine/topiramate, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, pramlintide, dapagliflozin, the duodenal-jejunal bypass liner, gastric pacemakers and gastric balloons. We conclude that, based on the most recent trials, we cannot fully mimic the clinical or physiological effects of surgery; however, we are getting closer. A 'medical bypass' may not be as far in the future as we previously thought, as the physician's armamentarium against obesity and type 2 diabetes has recently got stronger through the use of specific dietary modifications, novel medical devices and pharmacotherapy. Novel therapeutic targets include not only appetite but also taste/food preferences, energy expenditure, gut microbiota, bile acid signalling, inflammation, preservation of ß-cell function and hepatic glucose output, among others. Although there are no magic bullets, an integrated multimodal approach may yield success. Non-surgical interventions that mimic the metabolic benefits of bariatric surgery, with a reduced morbidity and mortality burden, remain tenable alternatives for patients and health-care professionals.

Application of the International Diabetes Federation and American Diabetes Association criteria in the assessment of metabolic control after bariatric surgery.

The International Diabetes Federation (IDF) and the American Diabetes Association (ADA) have introduced specific criteria to define the 'optimization' of the metabolic state and glycaemic 'remission' of type 2 diabetes mellitus (T2DM) after bariatric surgery, respectively. Our objective was to assess the percentage of patients achieving these criteria. Data were collected for body mass index, glycaemic markers, lipids, blood pressure, hypoglycaemia and medication usage from 396 morbidly obese T2DM patients who underwent bariatric surgery in two centres and followed up for 2 years. At year 1, 14% of patients achieved the IDF criteria and 38% the ADA criteria, whereas at 2 years 8 and 9% satisfied these criteria, respectively. A relatively low proportion of patients achieved optimization of the metabolic state and T2DM remission. These patients may potentially benefit from the combination of bariatric surgery and adjuvant medical therapy to achieve optimal metabolic outcomes.

A holistic assessment of bariatric surgical outcomes in a Northern Irish cohort.

The King's Obesity Staging system was developed to evaluate the effect of obesity treatments in multiple physical, psychological and functional domains. In this prospective cohort study, a Northern Irish cohort was scored using the King's Obesity Staging system before and 1 year after bariatric surgery. 71 individuals underwent surgery and 31 (44%) had type 2 diabetes. Bariatric surgery improved each health domain (p < 0.05). A subgroup with type 2 diabetes showed a significantly greater improvement in gonadal disease (polycystic ovarian syndrome and sub-fertility) (p = 0.02), and a trend towards greater improvement in cardiovascular disease (p = 0.07) compared with the non-diabetic subgroup. Half of those with pre-diabetes were normoglycaemic postoperatively (p < 0.05). The King's Obesity Staging system can be used to holistically evaluate the outcomes of bariatric surgery. Patients benefit from bariatric surgery in many ways, but those with diabetes may benefit more.

A step forward in sustainable pesticide production from Amphidinium carterae biomass via photobioreactor cultivation with urea as a nitrogen source.

This study addresses the problem of replacing nitrate and ammonium with urea as a greener nitrogen source in the mass cultivation of the microalga Amphidinium carterae for the development of amphidinol-based phytosanitary products. To solve this problem, a nuclear magnetic resonance assisted investigation evaluated the effect of nitrogen sources on growth and metabolic profiles in photobioreactors. Urea-fed cultures exhibited growth kinetics comparable to nitrate-fed cultures (µmax = 0.30 day-1, Pbmax = 43 mgL-1day-1). Urea-fed cultures had protein, lipid, and carbohydrate contents of 39.5%, 14.5%, and 42.4%, respectively, while nitrate-fed cultures had 27.9 %, 17.5% and 48.1%, respectively. Metabolomics revealed nitrogen source-dependent metabotypes and a correlation between amphidinols and polyunsaturated fatty acids. The amphidinol-to-nitrogen yield coefficient in urea-fed cultures (135 mg/g) was approximately 2.5 times higher than in nitrate-fed cultures. The potent antiphytopathogenic activity exhibited by extracts from urea-fed cultures underscores the potential of urea as a sustainable nitrogen source in microalgae-based biorefineries.

Alternatives to classic solvents for the isolation of bioactive compounds from Chrysochromulina rotalis.

This paper demonstrates a sequential partitioning method for isolating bioactive compounds from Chrysochromulina rotalis using a polarity gradient, replacing classic and hazardous solvents with greener alternatives. Seventeen solvents were evaluated based on their Hansen solubility parameters and for having a similar polarity to the solvents they would replace, four of which were selected as substitutes in the classic fractionation process. Considering the fatty acid and carotenoid recovery yields obtained for each of the solvents, it has been proposed to replace hexane (HEX), toluene (TOL), dichloromethane (DCM) and n-butanol (BUT) with cyclohexane, chlorobenzene, isobutyl acetate and isoamyl alcohol, respectively. In addition, cytotoxic activity was observed when the TOL and DCM solvent extracts were tested against tumour cell lines, demonstrating the antiproliferative potential of compounds containing, for example, fucoxanthin, fatty acids, peptides, isoflavonoids or terpenes, among others.

Assessment of the marine microalga Chrysochromulina rotalis as bioactive feedstock cultured in an easy-to-deploy light-emitting-diode-based tubular photobioreactor.

Marine microalgae have potential to be low-cost raw materials. This depends on the exploitation of different biomass fractions for high-value products, including unique compounds. Chrysochromulina rotalis, an under-explored haptophyte with promising properties, was the focus of this study. For the first time, C. rotalis was successfully cultivated in an 80 L tubular photobioreactor, illuminated by an easy-to-use light-emitting-diode-based system. C. rotalis grew without certain trace elements and showed adaptability to different phosphorus sources, allowing a significant reduction in the N:P ratio without compromising biomass yield and productivity. The design features of the photobioreactor provided a protective environment that ensured consistent biomass production from this shear-sensitive microalgae. Carotenoid analysis showed fucoxanthin and its derivatives as major components, with essential fatty acids making up a significant proportion of the total. The study emphasizes the tubular photobioreactor's role in sustainable biomass production for biorefineries, with C. rotalis as a valuable bioactive feedstock.

Exogenous peptide YY3-36 and Exendin-4 further decrease food intake, whereas octreotide increases food intake in rats after Roux-en-Y gastric bypass.

BACKGROUND: Patients show an elevated postprandial satiety gut hormone release after Roux-en-Y Gastric bypass (gastric bypass). The altered gut hormone response appears to have a prominent role in the reduction of appetite and body weight (BW) after gastric bypass. Patients with insufficient BW loss after gastric bypass have an attenuated postprandial gut hormone response in comparison with patients who lost an adequate amount of BW. The effects of additional gut hormone administration after gastric bypass are unknown. METHODS: The effects of peripheral administration of peptide YY3-36 (PYY3-36; 300 nmol kg(-1)), glucagon-like peptide-1 (GLP-1) analogue Exendin-4 (20 nmol kg(-1)) and somatostatin analogue octreotide (10 µg kg(-1)) on feeding and BW were evaluated in rats after gastric bypass. RESULTS: Gastric bypass rats weighed (P<0.01) and ate less on postoperative day 5 (P<0.001) and thereafter, whereas postprandial plasma PYY and GLP-1 levels were higher compared with sham-operated controls (P<0.001). Administration of both PYY3-36 and Exendin-4 led to a further decrease in food intake in bypass rats compared with saline treatment (P=0.02 and P<0.0001, respectively). Similar reduction in food intake was observed in sham rats (P=0.02 and P<0.001, respectively). Exendin-4 treatment resulted in a significant BW loss in bypass (P=0.03) and sham rats (P=0.04). Subsequent treatment with octreotide led to an increase in food intake in bypass (P=0.007), but not in sham rats (P=0.87). CONCLUSION: Peripheral administration of PYY3-36 and Exendin-4 reduces short-term food intake, whereas octreotide increases short-term food intake in rats after gastric bypass. The endogenous gut hormone response after gastric bypass can thus potentially be further enhanced by additional exogenous therapy with pharmacological doses of gut hormones in patients with insufficient weight loss or weight regain after surgery.

Treatment of secondary urban wastewater with a low ammonium-tolerant marine microalga using zeolite-based adsorption.

The low tolerance of marine microalgae to ammonium and hyposalinity limits their use in urban wastewater (UWW) treatments. In this study, using the marine microalga Amphidinium carterae, it is demonstrated for the first time that this obstacle can be overcome by introducing a zeolite-based adsorption step to obtain a tolerable UWW stream. The maximum ammonium adsorption capacities measured in the natural zeolite used are among the highest reported. The microalga grows satisfactorily in mixtures of zeolite-treated UWW and seawater at a wide range of proportions, both with and without adjusting the salinity, as long as the ammonium concentration is below the threshold tolerated by the microalgae (6.3 mg L-1). A proof of concept performed in 10-L bubble column photobioreactors with different culture strategies, including medium recycling, showed an enhanced biomass yield relative to a control with no UWW. No noticeable effect was observed on the production of specialty metabolites.

An integrated approach for the efficient separation of specialty compounds from biomass of the marine microalgae Amphidinium carterae.

An amphidinol-prioritized fractioning approach was for the first time developed to isolate multiple specialty metabolites such as amphidinols, carotenoids and fatty acids using the biomass of the marine microalgae Amphidinium carterae. The biomass was produced in a raceway photobioreactor and the exhausted culture media were reused, thus fulfilling sustainability criteria employing a circular economy concept. The integrated bioactive compounds-targeted approach presented here consisted of four steps with which recovery percentages of carotenoids, fatty acids and amphidinols of 97%, 82% and 99 %, respectively, were achieved. The proposed process was proved to be a better extraction system for this microalga than another based on a sequential gradient partition with water and four water-immiscible organic solvents (hexane, carbon tetrachloride, dichloromethane and n-butanol). The proposed process could be scaled-up as a commercial solid-phase extraction technology well-established for industrial bioprocesses.

Improved extraction of bioactive compounds from biomass of the marine dinoflagellate microalga Amphidinium carterae.

The extraction of three families of compounds (carotenoids, fatty acids and amphidinols) from the biomass of two strains of Amphidinium carterae (ACRN03 and Dn241EHU) was improved by tuning cell disruption and solvent extraction operations. The extraction of carotenoids was evaluated using alkaline saponification (0%-60% KOH d.w.) at different temperatures (25-80 °C). High levels of carotenoids were obtained at 60 °C using freeze-dried biomass, not subjected to cell disruption methods. The ACRN03 strain required 20% KOH whereas the Dn241EHU strain did not require saponification since carotenoid degradation was observed. The extraction efficiencies were determined with a wide range of pure solvents and mixtures thereof. Two empirical non-linear equations were used to correlate extraction percentages for each family of compounds with the Hildebrand solubility parameter (δT) and the polarity index of the solvents (PI). Thresholds of δT and PI of around 20 MPa1/2 and 6, respectively, were determined for the extraction of amphidinols, consistent with antiproliferative activity measurements.

DIAGNOSIS OF ENDOCRINE DISEASE: Drug-induced endocrinopathies and diabetes: a combo-endocrinology overview.

In the currently overwhelming era of polypharmacy, the balance of the dynamic and delicate endocrine system can easily be disturbed by interfering pharmaceutical agents like medications. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the feedback axis, on hormonal transport, binding and signaling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can interfere with the hormonal assays, leading to erroneous laboratory results that disorientate clinicians from the right diagnosis. The purpose of this review is to cover a contemporary topic, the drug-induced endocrinopathies, which was presented in the monothematic annual Combo Endo Course 2018. This challenging part of endocrinology is constantly expanding particularly during the last decade, with the new oncological therapeutic agents, targeting novel molecular pathways in the process of malignancies. In this new context of drug-induced endocrine disease, clinicians should be aware that drugs can cause endocrine abnormalities via different mechanisms and mimic a variety of clinical scenarios. Therefore, it is extremely important for clinicians not only to promptly recognize drug-induced hormonal and metabolic abnormalities, but also to address the therapeutic issues for timely intervention.

Assessment of multi-step processes for an integral use of the biomass of the marine microalga Amphidinium carterae.

Sustainable dinoflagellate microalgae-based bioprocess designed to produce secondary metabolites (SMs) with interesting bioactivities are attracting increasing attention. However, dinoflagellates also produce other valuable bioproducts (e.g polyunsaturated fatty acids, carotenoids, etc.) that could be recovered and should therefore be taken into account in the bioprocess. In this study, biomass of the marine dinoflagellate microalga Amphidinium carterae was used to assess and optimise three different methods in order to obtain three families of high-value biochemical compounds present in the biomass. The existing processes encompassed a multi-step extraction process for carotenoids, fatty acids and APDs individually and are optimized for the integral valorization of raw A. carterae biomass, with SMs being the primary target compounds. Total process recovery yields were 97% for carotenoids, 80% for total fatty acids and 100% for an extract rich in APDs (not purified).

Data on the Amphidinium carterae Dn241EHU isolation and morphological and molecular characterization.

We present the data corresponding to the isolation and morphological and molecular characterization of a strain of Amphidinium carterae, isolated in Mallorca Island waters and now deposited in the microalgae culture collection of the Plant Biology and Ecology Department of the University of the Basque Country under the reference Dn241Ehu. The morphological characterization was made using two different techniques of microscopy and the molecular characterization by using the 28S rDNA sequences of D1 and D2 domains. This strain has been used for a culture study in an indoor LED-lighted pilot-scale raceway to determine its production of carotenoids and fatty acids, "Long-term culture of the marine dinoflagellate microalga Amphidinium carterae in an indoor LED-lighted raceway photobioreactor: Production of carotenoids and fatty acids." (Molina-Miras et al., 2018) [1].

Long-term culture of the marine dinoflagellate microalga Amphidinium carterae in an indoor LED-lighted raceway photobioreactor: Production of carotenoids and fatty acids.

The feasibility of the long-term (>170 days) culture of a dinoflagellate microalga in a raceway photobioreactor is demonstrated for the first time. Amphidinium carterae was chosen for this study as it is producer of interesting high-value compounds. Repeated semicontinuous culture provided to be a robust operational mode. Different concentration levels of the f/2 medium nutrients (i.e. f/2×1-3) were assayed. The composition f/2×3 (N:P = 5), combined with a sinusoidal irradiance pattern (L/D = 24:0) with a 570 µE m-2 s-1 daily mean irradiance, maximized the biomass productivity (2.5 g m-2 day-1) and production rate of the valuable carotenoid peridinin (19.4 ±â€¯1.35 mg m-2 L-1 with nearly 1% of the biomass d.w.). Several carotenoids and polyunsaturated fatty acids were also present in significant percentages in the harvested biomass (EPA, 1.69 ±â€¯0.31% d.w.; DHA, 3.47 ±â€¯0.24% d.w.), which had an average P-molar formulate of C40.7O21.2H73.9N3.9S0.3P1.

Proximal jejunal stoma as ultima ratio in case of traumatic distal duodenal perforation facilitating successful EndoVAC® treatment: A case report.

INTRODUCTION: During damage control surgery for blunt abdominal traumata simultaneous duodenal perforations can be missed making secondary sufficient surgical treatment challenging. Endoluminal vacuum (EndoVAC™) therapy has been shown to be a revolutionary option but has anatomical and technical limits. PRESENTATION OF THE CASE: A 59-year old man with hemorrhagic shock due to rupture of the mesenteric root after blunt abdominal trauma received damage control treatment. Within a scheduled second-look, perforation of the posterior duodenal wall was identified. Due to local and systemic conditions, further surgical treatment was limited. Decision for endoscopic treatment was made but proved to be difficult due to the distal location. Finally, double-barreled jejunal stoma was created for transstomal EndoVAC™ treatment. Complete leakage healing was achieved and jejunostomy reversal followed subsequently. DISCUSSION: During damage control surgery simultaneous bowel injuries can be missed leading to life-threatening complications with limited surgical options. EndoVAC™ treatment is an option for gastrointestinal perforations but has anatomical limitations that can be sufficiently shifted by a transstomal approach for intestinal leakage. CONCLUSION: In trauma related laparotomy complete mobilization of the duodenum is crucial. As ultima ratio, transstomal EndoVAC™ is a safe and feasible option and can be considered for similar cases.

Using kisspeptin to assess GnRH function in an unusual case of primary amenorrhoea.

SUMMARY: Primary amenorrhoea is defined as the failure to commence menstruation by the age of 15 years, in the presence of normal secondary sexual development. The potential causes of primary amenorrhoea extend from structural to chromosomal abnormalities. Polycystic ovarian syndrome (PCOS) is a common cause of secondary amenorrhoea but an uncommon cause of primary amenorrhoea. An early and prompt diagnosis of PCOS is important, as up to 30% of these women are predisposed to glucose intolerance and obesity, with the subgroup of women presenting with primary amenorrhoea and PCOS displaying a higher incidence of metabolic dysfunction. We describe a case of an 18-year-old female presenting with primary amenorrhoea of unknown aetiology. Although initial investigations did not demonstrate clinical or biochemical hyperandrogenism or any radiological evidence of polycystic ovaries, a raised luteinising hormone (LH) suggested a diagnosis of PCOS. If PCOS was the correct diagnosis, then one would expect intact hypothalamic GnRH and pituitary gonadotropin release. We used the novel hormone kisspeptin to confirm intact hypothalamic GnRH release and a GnRH stimulation test to confirm intact pituitary gonadotroph function. This case highlights that kisspeptin is a potential unique tool to test GnRH function in patients presenting with reproductive disorders. LEARNING POINTS: Polycystic ovarian syndrome (PCOS) can present with primary amenorrhoea, and therefore, should be considered in the differential diagnosis.PCOS is a heterogeneous condition that may present in lean women with few or absent signs of hyperandrogenism.GnRH stimulation tests are useful in evaluating pituitary function; however, to date, we do not have a viable test of GnRH function. Kisspeptin has the potential to form a novel diagnostic tool for assessing hypothalamic GnRH function by monitoring gonadotropin response as a surrogate marker of GnRH release.Confirmation of intact GnRH function helps consolidate a diagnosis in primary amenorrhoea and gives an indication of future fertility.