Disease activity in women with ankylosing spondylitis remains higher under Tumour Necrosis Factor inhibitor treatment than in men: a five-year observational study.

OBJECTIVE: To assess sex differences in response, level of disease activity, and drug survival in tumour necrosis factor inhibitor (TNFi)-naïve ankylosing spondylitis (AS) patients. METHOD: Consecutive AS patients, fulfilling the modified New York criteria, were included in a prospective cohort study at initiation of the first TNFi and followed until this medication was stopped (drug survival). Disease activity scores [AS Disease Activity Score using C-reactive protein (ASDAS-CRP), Bath AS Disease Activity Index (BASDAI), and CRP] were measured at 3, 6, and 12 months, and every subsequent year, up to 5 years. The response was defined by the ASDAS-CRP response criteria (clinically important improvement: ASDAS-CRP decrease ≥ 1.1). Analyses included regression methods for repeated measurements and survival analyses. RESULTS: Overall, 356 patients were included (34% women, mean ± sd age 46 ± 12 years), with a median disease duration of 12 (interquartile range 6;20) years. Women were less likely than men to achieve a clinically important response after 6 months of TNFi treatment (47% vs 64%; relative risk 1.4, 95% confidence interval (CI) 1.1;1.9, p = 0.02], despite a lack of sex differences in mean ASDAS-CRP levels over 5 year follow-up. Adjusted models for BASDAI over 5 years showed that women had a 0.6 point higher BASDAI score than men (ß = 0.6 0.1;1.1 <0.02). Numerically, more women than men discontinued treatment over a period of 5 years (hazard ratio = 1.5, 95% CI 0.9;2.5, p = 0.15). CONCLUSION: Female AS patients show a lower response to TNFi and a higher disease activity compared to men.

Deceleration and Trapping of SrF Molecules.

We report on the electrostatic trapping of neutral SrF molecules. The molecules are captured from a cryogenic buffer-gas beam source into the moving traps of a 4.5-m-long traveling-wave Stark decelerator. The SrF molecules in X^{2}Σ^{+}(v=0,N=1) state are brought to rest as the velocity of the moving traps is gradually reduced from 190 m/s to zero. The molecules are held for up to 50 ms in multiple electric traps of the decelerator. The trapped packets have a volume (FWHM) of 1 mm^{3} and a velocity spread of 5(1) m/s, which corresponds to a temperature of 60(20) mK. Our result demonstrates a factor 3 increase in the molecular mass that has been Stark decelerated and trapped. Heavy molecules (mass>100 amu) offer a highly increased sensitivity to probe physics beyond the standard model. This work significantly extends the species of neutral molecules of which slow beams can be created for collision studies, precision measurement, and trapping experiments.

Local cooling during hot water immersion improves perceptions without inhibiting the acute interleukin-6 response.

PURPOSE: Passive elevation of body temperature can induce an acute inflammatory response that has been proposed to be beneficial; however, it can be perceived as uncomfortable. Here, we investigate whether local cooling of the upper body during hot water immersion can improve perception without inhibiting the interleukin-6 (IL-6) response. METHODS: Nine healthy male participants (age: 22 ± 1 years, body mass: 83.4 ± 9.4 kg) were immersed up to the waist for three 60-min water immersion conditions: 42 °C hot water immersion (HWI), 42 °C HWI with simultaneous upper-body cooling using a fan (FAN), and 36 °C thermoneutral water immersion (CON). Blood samples to determine IL-6 plasma concentration were collected pre- and post-water immersion; basic affect and thermal comfort were assessed throughout the intervention. RESULTS: Plasma IL-6 concentration was higher for HWI and FAN when compared with CON (P < 0.01) and did not differ between HWI and FAN (P = 0.22; pre to post, HWI: 1.0 ± 0.6 to 1.5 ± 0.7 pg·ml-1, FAN: 0.7 ± 0.5 to 1.1 ± 0.5 pg·ml-1, CON: 0.5 ± 0.2 to 0.5 ± 0.2 pg·ml-1). At the end of immersion, basic affect was lowest for HWI (HWI: - 1.8 ± 2.0, FAN: 0.2 ± 1.6, CON 1.0 ± 2.1, P < 0.02); thermal comfort for HWI was in the uncomfortable range (3.0 ± 1.0, P < 0.01 when compared with FAN and CON), whereas FAN (0.7 ± 0.7) and CON (-0.2 ± 0.7) were in the comfortable range. CONCLUSION: Local cooling of the upper body during hot water immersion improves basic affect and thermal comfort without inhibiting the acute IL-6 response.

Double resonant absorption measurement of acetylene symmetric vibrational states probed with cavity ring down spectroscopy.

A novel mid-infrared/near-infrared double resonant absorption setup for studying infrared-inactive vibrational states is presented. A strong vibrational transition in the mid-infrared region is excited using an idler beam from a singly resonant continuous-wave optical parametric oscillator, to populate an intermediate vibrational state. High output power of the optical parametric oscillator and the strength of the mid-infrared transition result in efficient population transfer to the intermediate state, which allows measuring secondary transitions from this state with a high signal-to-noise ratio. A secondary, near-infrared transition from the intermediate state is probed using cavity ring-down spectroscopy, which provides high sensitivity in this wavelength region. Due to the narrow linewidths of the excitation sources, the rovibrational lines of the secondary transition are measured with sub-Doppler resolution. The setup is used to access a previously unreported symmetric vibrational state of acetylene, ν1+ν2+ν3+ν4 (1)+ν5 (-1) in the normal mode notation. Single-photon transitions to this state from the vibrational ground state are forbidden. Ten lines of the newly measured state are observed and fitted with the linear least-squares method to extract the band parameters. The vibrational term value was measured to be at 9775.0018(45) cm(-1), the rotational parameter B was 1.162 222(37) cm(-1), and the quartic centrifugal distortion parameter D was 3.998(62) × 10(-6) cm(-1), where the numbers in the parenthesis are one-standard errors in the least significant digits.

Near edge X-ray absorption mass spectrometry on coronene.

We have investigated the photoionization and photodissociation of free coronene cations C24H12 (+) upon soft X-ray photoabsorption in the carbon K-edge region by means of a time-of-flight mass spectrometry approach. Core excitation into an unoccupied molecular orbital (below threshold) and core ionization into the continuum both leave a C 1s vacancy, that is subsequently filled in an Auger-type process. The resulting coronene dications and trications are internally excited and cool down predominantly by means of hydrogen emission. Density functional theory was employed to determine the dissociation energies for subsequent neutral hydrogen loss. A statistical cascade model incorporating these dissociation energies agrees well with the experimentally observed dehydrogenation. For double ionization, i.e., formation of intermediate C24H12 (3+⋆)trications, the experimental data hint at loss of H(+) ions. This asymmetric fission channel is associated with hot intermediates, whereas colder intermediates predominantly decay via neutral H loss.

Deexcitation dynamics of superhydrogenated polycyclic aromatic hydrocarbon cations after soft-x-ray absorption.

We have investigated the response of superhydrogenated gas-phase coronene cations upon soft x-ray absorption. Carbon (1s)⟶π^{⋆} transitions were resonantly excited at hν=285 eV. The resulting core hole is then filled in an Auger decay process, with the excess energy being released in the form of an Auger electron. Predominantly highly excited dications are thus formed, which cool down by hydrogen emission. In superhydrogenated systems, the additional H atoms act as a buffer, quenching loss of native H atoms and molecular fragmentation. Dissociation and transition state energies for several H loss channels were computed by means of density functional theory. Using these energies as input into an Arrhenius-type cascade model, very good agreement with the experimental data is found. The results have important implications for the survival of polyaromatic hydrocarbons in the interstellar medium and reflect key aspects of graphene hydrogenation.

Ischaemic preconditioning improves upper-body endurance performance without altering V̇O2 kinetics.

PURPOSE: Whilst pre-exercise ischaemic preconditioning (IPC) can improve lower-body exercise performance, its impact on upper-limb performance has received little attention. This study examines the influence of IPC on upper-body exercise performance and oxygen uptake (V̇O2) kinetics. METHODS: Eleven recreationally-active males (24 ± 2 years) completed an arm-crank graded exercise test to exhaustion to determine the power outputs at the ventilatory thresholds (VT1 and VT2) and V̇O2peak (40.0 ± 7.4 ml·kg-1·min-1). Four main trials were conducted, two following IPC (4 × 5-min, 220 mmHg contralateral upper-limb occlusion), the other two following SHAM (4 × 5-min, 20 mmHg). The first two trials consisted of a 15-minute constant work rate and the last two time-to-exhaustion (TTE) arm-crank tests at the power equivalents of 95% VT1 (LOW) and VT2 (HIGH), respectively. Pulmonary V̇O2 kinetics, heart rate, blood-lactate concentration, and rating of perceived exertion were recorded throughout exercise. RESULTS: TTE during HIGH was longer following IPC than SHAM (459 ± 115 vs 395 ± 102 s, p = .004). Mean response time and change in V̇O2 between 2-min and end exercise (ΔV̇O2) were not different between IPC and SHAM for arm-cranking at both LOW (80.3 ± 19.0 vs 90.3 ± 23.5 s [p = .06], 457 ± 184 vs 443 ± 245 ml [p = .83]) and HIGH (96.6 ± 31.2 vs 92.1 ± 24.4 s [p = .65], 617 ± 321 vs 649 ± 230 ml [p = .74]). Heart rate, blood-lactate concentration, and rating of perceived exertion did not differ between conditions (all p ≥ .05). CONCLUSION: TTE was longer following IPC during upper-body exercise despite unchanged V̇O2 kinetics.HighlightsWhilst pre-exercise ischaemic preconditioning can improve lower-body exercise performance and alter V̇O2 kinetics, its impact on upper-limb performance has received little attention.An acute bout of ischaemic preconditioning prior to arm-crank ergometry exercise significantly improved time to exhaustion compared to a sham control condition.V̇O2 kinetics in response to ischaemic preconditioning remained unchanged, suggesting alternative mechanisms may explain performance improvements.

A supersonic laser ablation beam source with narrow velocity spreads.

A supersonic beam source for SrF and BaF molecules is constructed by combining the expansion of carrier gas (a mixture of 2% SF6 and 98% argon) from an Even-Lavie valve with laser ablation of a barium/strontium metal target at a repetition rate of 10 Hz. Molecular beams with a narrow translational velocity spread are produced at relative values of Δv/v = 0.053(11) and 0.054(9) for SrF and BaF, respectively. The relative velocity spread of the beams produced in our source is lower in comparison with the results from other metal fluoride beams produced in supersonic laser ablation sources. The rotational temperature of BaF is measured to be 3.5 K. The source produces 6 × 108 and 107 molecules per steradian per pulse in the X2Σ+ (ν = 0, N = 1) state of BaF and SrF molecules, respectively, a state amenable to Stark deceleration and laser cooling.

Acute and chronic effects of hot water immersion on inflammation and metabolism in sedentary, overweight adults.

Regular exercise-induced acute inflammatory responses are suggested to improve the inflammatory profile and insulin sensitivity. As body temperature elevations partly mediate this response, passive heating might be a viable tool to improve the inflammatory profile. This study investigated the acute and chronic effects of hot water immersion on inflammatory and metabolic markers. Ten sedentary, overweight men [body mass index (BMI): 31.0 ± 4.2 kg/m2, mean ± SD] were immersed in water set at 39°C for 1 h (HWI) or rested for 1 h at ambient temperature (AMB). Venous blood was obtained before the session, immediately postsession, and 2 h postsession for assessment of monocyte intracellular heat shock protein-72 (iHsp72) and plasma concentrations of extracellular Hsp72 (eHsp72), interleukin-6 (IL-6), fasting glucose, insulin, and nitrite. Thereafter, participants underwent a 2-wk intervention period, consisting of 10 hot water immersion sessions (INT). Eight BMI-matched participants (BMI: 30.0 ± 2.5 kg/m2) were included as control (CON). Plasma IL-6 and nitrite concentrations were higher immediately following HWI compared with AMB (IL-6 P < 0.001, HWI: 1.37 ± 0.94 to 2.51 ± 1.49 pg/ml; nitrite P = 0.04, HWI: 271 ± 52 to 391 ± 72 nM), whereas iHsp72 expression was unchanged ( P = 0.57). In contrast to resting iHsp72 expression ( P = 0.59), fasting glucose ( P = 0.04; INT: 4.44 ± 0.93 to 3.98 ± 0.98 mmol/l), insulin ( P = 0.04; INT: 68.1 ± 44.6 to 55.0 ± 29.9 pmol/l), and eHsp72 ( P = 0.03; INT: 17 ± 41% reduction) concentrations were lowered after INT compared with CON. HWI induced an acute inflammatory response and increased nitric oxide bioavailability. The reductions in fasting glucose and insulin concentrations following the chronic intervention suggest that hot water immersion may serve as a tool to improve glucose metabolism. NEW & NOTEWORTHY A single hot water immersion (HWI) session induces an acute increase in plasma interleukin-6 and nitrite concentrations but does not acutely elevate heat shock protein-72 expression in monocytes [intracellular Hsp72 (iHsp72)]. A chronic HWI intervention reduces fasting glucose and insulin concentrations in the absence of changes in resting iHsp72. Therefore, HWI shows potential as a strategy to combat chronic low-grade inflammation and improve glucose metabolism in individuals without the physical capacity to do so using exercise.

Suppressive effect of inflammation and other forms of stress on the binding of prolactin by rat liver.

We have found that in female rats a variety of stressful stimuli, including sc inflammation, skin incision, endotoxin injection, and cold exposure, cause a significant decrease (30-86%) in the capacity of the hepatic cell membranes to specifically bind [125I]ovine PRL. Stress-induced decrease in food intake was not a factor in these studies, as nourishment was given only by tube feeding. Neither sc inflammation nor cold exposure affected hepatic binding of [125I]insulin. Further, the induction of inflammation in lactating rats and rats bearing 7,12-dimethylbenz[a]anthracene-induced mammary carcinomas did not affect the binding of PRL by the lactating or malignant mammary tissue. The suppressive effect of inflammation on hepatic binding of PRL was demonstrable in adrenalectomized-ovariectomized rats, in hypophysectomized rats receiving hormone replacement, and in adrenalectomized rats that had undergone partial chemical sympathectomy. We conclude that sc inflammation, as well as other forms of stress, decreases hepatic binding of PRL, but does not affect hepatic binding of insulin or mammary binding of PRL. The decrease in hepatic PRL binding is not mediated by a hormone secreted by the adrenals, ovaries, or pituitary, or by catecholamines, but could be mediated by another plasma factor or by peripheral dopaminergic neurons. Stress-induced decrease in hepatic PRL binding, or a related decrease in the binding of other polypeptide hormones, could play a role in the physiological response to stress.

Effects of prolactin and growth hormone on tissue and serum carnitine in the rat.

Previous experimental observations have suggested to us that PRL and GH may be involved in regulating the metabolism of carnitine, a factor that plays a critically important role in fatty acid oxidation and ketogenesis. In the present study we administered bovine PRL (bPRL) or bovine GH (bGH) at a physiologic rate to hypophysectomized female rats for 2-3 days, and observed that bPRL caused a small (16%) increase (P less than 0.01), and bGH a 36% increase (P less than 0.01), in hepatic carnitine, bPRL decreased serum carnitine by 24% (P less than 0.05), and bPRL and bGH each increased the liver/serum carnitine ratio by 58% (P less than 0.01), suggesting that these hormones enhance the active uptake of carnitine from plasma. bPRL and bGH, alone or in combination, did not affect the carnitine content of cardiac or skeletal muscle, but in combination they increased the heart/serum and muscle/serum carnitine ratios by 45-76% (P less than 0.01), thus allowing maintenance of normal cardiac and skeletal muscle carnitine despite a decreased plasma level. In hypophysectomized male rats, bPRL did not affect liver or epididymal carnitine. We hypothesize that PRL and GH may play a role in the regulation of the carnitine concentration of female liver by enhancing hepatic uptake of carnitine from plasma, and through this mechanism may affect hepatic fatty acid oxidation and ketogenesis. The effect of lactogenic and somatogenic hormones on hepatic carnitine and ketogenesis could be of particular physiological importance in late pregnancy and during lactation.

Effect of combination treatment with zanoterone (WIN 49596), a steroidal androgen receptor antagonist, and finasteride (MK-906), a steroidal 5 alpha-reductase inhibitor, on the prostate and testes of beagle dogs.

The effects of the steroidal androgen receptor antagonist zanoterone (WIN 49596) and the steroidal 5 alpha-reductase inhibitor finasteride (MK-906) either alone or in combination on prostatic size, histomorphology, and biochemistry were determined in the intact male dog. Additionally, the effects of treatment with zanoterone and/or finasteride on testicular size, serum testosterone and LH levels, and spermatogenesis were determined in the same dogs. Daily oral treatment for 16 weeks with either zanoterone alone at 10 mg/kg.day or finasteride alone at 1.0 mg/kg.day reduced (P < 0.05) the size of the prostate, resulted in mild to moderate diffuse glandular atrophy of the prostate, and decreased prostatic DNA and prostatic arginine esterase (the primary canine prostatic protein) levels compared to those in intact controls. These changes occurred with no effect on testicular weight, testicular histomorphology, daily sperm production, or serum LH levels. Serum testosterone concentrations were increased (P < 0.05) approximately 3-fold in the 10 mg/kg.day zanoterone treatment group compared to those in intact controls. Combination treatment of male dogs for 16 weeks with zanoterone (10 mg/kg.day) plus finasteride (1.0 mg/kg.day) orally also reduced (P < 0.05) prostate size, resulted in moderate to marked diffuse prostatic glandular atrophy, and decreased prostatic DNA and arginine esterase levels more than either drug alone, without affecting testicular size, testicular histomorphology, serum LH concentrations, or serum testosterone concentrations compared to those in intact controls. The effects of combination treatment with zanoterone and finasteride on prostatic size; histomorphology; and DNA, arginine esterase protein, and arginine esterase mRNA levels were similar to those observed in castrate controls. In addition, in situ estimates of prostatic size using transrectal ultrasonography indicated that the median time to 70% prostatic regression in dogs administered combination zanoterone plus finasteride was similar to that in castrate controls (9.6 and 9.3 weeks, respectively), indicating that the combination was more effective in causing prostatic regression than either drug alone. Finally, at the dosages used, no adverse effects of combination treatment with zanoterone plus finasteride on testicular or other major body organ weights were observed. Based on these results, combination therapy using zanoterone and finasteride for the treatment of human androgen-dependent disorders such as benign prostatic hyperplasia and prostate cancer has potential utility.

Suppressive effect of glucose administration on the binding of prolactin by rat liver.

In an attempt to elucidate the physiologic role of the hepatic receptors for prolactin (PRL), we studied the effect of changes in diet on the specific binding of 125I-ovine prolactin (oPRL) by membranes from female rat liver. Specific binding of PRL (SBP) was decreased by over 50% in rats fed 15% glucose ad lib for 2 days, as compared with fasted rats (P less than .01), while serum PRL was similar in both groups. Feeding 20% glucose by tube decreased SBP significantly, but tube-feeding equicaloric amounts of fat or protein-amino acid solution did not. Glucose feeding did not decrease the specific binding of 125I-bovine growth hormone (bGH) to liver, or decrease SBP to membranes of nitrosomethylurea (NMU)-induced mammary carcinomas, indicating that the effect of glucose on hepatic SBP is selective. Administration of glucose decreased SBP significantly in adrenalectomized-ovariectomized rats, in adrenalectomized-chemically sympathectomized rats, and in hypophysectomized rats receiving replacement therapy, including bovine prolactin (bPRL), bGH, hydrocortisone, estrogen, and thyroid hormones. Thus, the effect of glucose is not mediated by a factor from the adrenals, ovaries, or pituitary, and probably not by catecholamines. Administration of insulin to fasted diabetic rats did not alter SBP. Infusion of glucagon for 1 day, at a rate that did not alter serum glucose, increased hepatic SBP 29% (P less than .01). Since glucose administration decreases plasma glucagon, we hypothesize that glucagon may contribute to the maintenance of the hepatic PRL receptors, and that the suppressive effect of glucose on hepatic SBP may be mediated at least in part by suppression of plasma glucagon.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving outcome from extremity shotgun injury.

The charts of 124 consecutive patients with extremity shotgun injuries managed over an 8-year period were reviewed to assess the results of a uniform protocol. This consisted of liberal use of arteriography, prompt exploration, wide debridement or fasciotomy, and frequent operating room dressing changes for large wounds. Thirty-three patients had arterial injuries and 16 had major venous injuries. Twenty patients had major soft tissue wounds and there were 15 significant long bone injuries. Results overall were excellent with over 95 per cent of patients retaining an intact and functional limb. Of the six limb amputations, three were done primarily and three were performed for late septic complications. Two of these late amputations were done following inadequate initial revascularization at referring hospitals. Early wound closure, liberal use of arteriography and fasciotomy, early fracture stabilization, and repair of all significant vascular injuries contribute to a successful outcome in patients with extremity shotgun wounds.

A coherent approach to health informatics education: results of the Dutch curriculum project.

From the beginning a coherent approach to health informatics education has been aimed for in our project to develop learning materials. The features are the thematic approach of the contents, the interrelationship of the modules and the didactical approach embedded in the learning materials. Following results have been achieved. Learning materials have been developed for the following themes: healthcare policy and management, delivery of professional care (specific for nursing and allied health), more generic themes such as electronic patient record, clinical decision making, classification and coding of healthcare data and knowledge based systems. Software made available by private companies has been selected for use in the learning modules. In specific cases the available software products did not match the criteria to support the learning materials. In these cases model applications have been developed that can be considered as forerunners for systems in practical use. Already some companies have expressed interest to adapt our home grown products for use in clinical practice. The modules are based on a model curriculum that has been developed by Aarts et al in 1995. New developments in healthcare have prompted modification of the contents of a few modules. For example, a module has been redefined to cover the important issue of logistics in healthcare. The module on patient education has been adapted to take into account the resources available on the Internet. Also, new insights in the effectiveness of computer-based patient education have been taken into account. The module on informatics for disabled persons has been focussed on computer-based aids and is being linked to the EU-project "Impact" aimed at increasing knowledge about assistive technology. However, the model curriculum has proved to be reasonable robust as a base for our project to develop learning materials for health informatics.

Exploring factors required for successful implementation of healthcare informatics.

This paper examines factors that are essential for a successful implementation of healthcare informatics in professional curricula. These factors are related to the design framework of the learning materials that have been developed as a part of a Dutch model curriculum of healthcare informatics. Next some ideas and suggestions for a successful implementation are presented.

The management of large soft-tissue defects following close-range shotgun injury.

Large soft-tissue defects following close-range shotgun blasts remain a major technical challenge to trauma surgeons. During the period 1980 through 1988, 43 patients who survived greater than 48 hours following this injury were managed in our center. The locations of their soft-tissue defects were: extremity, 22; abdomen/chest, 18; and head/neck, three. All patients underwent immediate surgical exploration and wide debridement of all devitalized tissue along with repair of associated injuries. Management included mandatory frequent dressing changes, debridement, irrigation in the operating room, and the perioperative administration of broad-spectrum antibiotics. Four patients whose abdominal wall defects could not be initially closed had temporary placement of rayon cloth to prevent evisceration. Overall, four patients underwent delayed primary closure, eight were covered with split-thickness skin grafts, nine had closure with myocutaneous flaps, and 19 closed by secondary intent. Two patients, who were transferred to us following initial management, developed wound sepsis due to inadequate debridement and both eventually required amputation as did one patient who developed early myonecrosis following lengthy arterial repair. Frequent operative dressing changes, adequate debridement, and irrigation minimize sepsis following close-range shotgun blasts and should be the treatment of choice for this devastating injury. Techniques of wound closure need to be individualized to the particular situation.

A comparison of the gastric bypass and the gastric wrap for morbid obesity.

The standard for surgical treatment of morbid obesity is gastric reservoir reduction (GRR). The two popular techniques for GRR are the gastric bypass (GBP) and vertical banded gastroplasty. In 1981, a new approach to GRR, namely, the gastric wrap (GW) was introduced. The GW envelops the stomach in a customized Teflon (polytetrafluoroethylene) mesh. The current study compares, for the first time, the long term efficacy of GW and GBP. One hundred and five morbidly obese patients were studied. Fifty-two patients had GBP and 53 had GW. Preoperative and ideal weights averaged 301 and 129 pounds in the GW patients versus 278 and 123 pounds in the GBP patients. The two groups had similar age, height and co-morbid conditions. All patients survived the operation. After discharge, the patients had follow-up examinations at two weeks, two months, six months and then yearly. The GW was significantly more effective than the GBP in attaining and maintaining weight loss. The increased percent excess weight loss (percent EWL) was statistically significant at 12 months when the GW patients achieved 67 percent EWL compared with 57 percent EWL in the GBP patients. After the third year, the percent of EWL declined in the GBP patients, averaging 48 percent at four years and 47 percent at five years. In contrast, the GW patients maintained a 72 percent EWL at four years and a 66 percent EWL at five years. This weight loss was accomplished without nutritional embarrassment in both groups. The superiority of the GW in achieving and maintaining weight loss is reflected by the opinions of the patients regarding the attainment of preoperative objectives and their willingness to recommend GW to others. The downside of the GW is the higher incidence of reversal and the increased technical difficulties with reversal or revision compared with the GBP.