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BACKGROUND: Bariatric surgery has grown from an obscure experimental procedure to one of the most popular operations in the world. Such accelerated progress left many gaps, notably concerning subsequent rehabilitation needs of this population. AIM: In the present study, a brief description of both the patients and the interventions is provided, along with potentially disabling features especially concerning the locomotor system, which has received comparatively little attention . DESIGN: Based on reported protocols and actual experience, major issues are addressed. SETTING: Bariatric patients are initially managed in the hospital, however long-term and even lifetime needs may be recognized, requiring major lifestyle and physical activity changes. These have to be focused in all settings, inside and outside the healthcare institutions. POPULATION: Initially only adults were considered bariatric candidates, however currently also adolescents and the elderly are admitted in many centers. RESULTS: Bariatric weight loss is certainly successful for remission or prevention of metabolic, cardiovascular and cancer comorbidities. Yet benefits for bones, joints and muscles, along with general physical performance are still incompletely established. This should be no reason for denying continued care to such individuals, within the context of well-designed protocols, as available evidence points toward favorable rehabilitation in the realms of physical, social and workplace activities. CONCLUSION: The importance of a physiatric curriculum in medical schools has been emphasized. Even more crucial is the presence of such a specialists in obesity and bariatric teams, a requirement recognized in a few countries but not in others. CLINICAL REHABILITATION IMPACT: The relevance of obesity as a disabling condition is reviewed, along with the positive changes induced by surgical weight loss. Although obesity alleviation is a legitimate end-point it is not a sufficient one. The shortcomings of such result from the point of view of physical normalization are outlined, and recommendations are suggested.

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BACKGROUND: Short bowel syndrome is a disabling disease requiring long-term nutritional support and ancillary drugs. Aiming to analyze the most commonly prescribed drugs, a retrospective analysis was conducted is an outpatient cohort. PATIENTS AND METHODS: Stable patients (N= 37, 59.5% males, age 51.1 ± 20.1 years, body mass index 20.1 ± 7.9 kg/m2) with three or more appointments in the Outpatient Service during the last 18 months were retrospectively analyzed. regarding oral pharmacologic prescriptions. Medications were classified as on label or off label. RESULTS: A total of 257 oral prescriptions were retrieved from computer files, encompassing 17 different preparations. The majority was employed on label however 28.8% (74/257) were classified as off label and scrutinized with regard to indications. The main categories were pharmacologic modulators of gastrointestinal secretions and motility, along with antibiotics. Virtually all patients required one or more of such drugs, without differences regarding demographic or clinical variables. Adverse effects or premature drug discontinuation were not observed. CONCLUSIONS: This is the first study to our knowledge highlighting the importance of adjuvant drugs, particularly with unconventional indications, in the management of short bowel syndrome. Antidiarrheic agents, pancrelipase micropellets, antacids and antibiotics represented the most relevant off label prescriptions for this population.

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Introduction: Ascitis and undernutrition are frequent complications of cirrhosis, however ascitis volume and anthropometric assessment are not routinely documented or considered in prognostic evaluation. In a homogeneous cohort followed during two years these variables were scrutinized, aiming to ascertain relevance for longterm outcome. Methods: Population (N = 25, all males with alcoholic cirrhosis) was recruited among patients hospitalized for uncomplicated ascitis. Exclusion criteria were refractory or tense ascitis, cancer, spontaneous bacterial peritonitis, bleeding varices and critical illness. Measurements included ultrasonographically estimated ascitis volume, dry body mass index/BMI , upper arm anthropometrics, hematologic counts and liver function tests. Results: Population (age 48.3 ± 11.3 years, BMI 21.1± 3.5 kg/m2, serum albumin 2.5 ± 0.8 g/dL) was mostly in the Child-Pugh C category (77.8%) but clinically stable. During the follow-up period of 22.6 ±3.8 months, additional hospitalizations numbered 1.7 ± 1.0 and more than one quarter succumbed. Admission ascitis volume corresponded to 7.1 ± 3.6 L and dry BMI to 18.3 ± 3.5 kg/m2. Child Pugh index was relevant for both mortality and rehospitalization. Nevertheless, similar matches for mortality were documented with ascitis volume and dry BMI, and arm circumference below the 5th percentile was highly significantly associated with rehospitalization. Conclusions: A greater association than hitherto acknowledged, between ascitis volume and anthropometric measurements from one side, and long-term rehospitalization and mortality from the other, was demonstrated in male stable alcoholic cirrhotics. Further studies with alcoholic and other modalities of cirrhosis including women are recommended (AU)

Introducción: Ascitis y desnutrición son complicaciones frecuentes de la cirrosis, pero el volumen ascítico y la evaluación antropométrica no son como rutina documentadas o consideradas para la evaluación del pronóstico. En un coorte homogéneo de pacientes acompañados por dos años estas variables fueron escrutinadas, con el objetivo de determinar su releváncia para los resultados clínicos de largo plazo. Métodos: La población (N = 25, todos hombres con cirrosis alcohólica) fue recrutada entre pacientes hospitalizados por ascitis no complicada. Los critérios de exclusión fueron ascitis tensa o refractária, peritonitis bacteriana espontánea, varices sangrantes y enfermedad crítica. Los métodos involucraron volumen ascítico estimado ultrasonograficamente, el índice seco de masa corporal/IMC seco, antropometria del brazo, recuentos hematológicos y pruebas de función hepática. Resultados: La población (edad 48,3 ± 11,3 años, IMC 21,1 ± 3,5 kg/m2, albumina sérica 2,5 ± 0,8 g/dL) encontrabase predominantemente en la categoria Child-Pugh C (77,8%) , pero clinicamente estable. En el período de seguimiente de 22,6 ± 3,8 meses hubo 1,7 ± 1,0 hospitalizaciones adicionales por paciente, y mas de una cuarta parte sucumbió. El volumen ascítico de admisión fue de 7,1 ± 3,6 L y el IMC seco de 18,3 ± 3,5 kg/m2. El indice de Child-Pugh fue relevante tanto para mortalidad como para rehospitalización. Asociaciones similares para mortalidad fueron demonstradas para volumen ascítico y para IMC seco, y la circunferencia del brazo abajo del 5o percentil fue un indicador muy significativo para rehospitalización. Conclusiones: Una asociación mas importante que lo hasta ahora publicado ocurrió entre volumen ascítico y antropometria de una parte, y mortalidad asimismo rehospitalización de otra parte, en pacientes masculinos cirróticos alcohólicos estables. Estúdios adicionales con cirrosis alcohólica y de otras modalidades incluyendo mujeres son recomendados (AU)

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INTRODUCTION: Ascitis and undernutrition are frequent complications of cirrhosis, however ascitis volume and anthropometric assessment are not routinely documented or considered in prognostic evaluation. In a homogeneous cohort followed during two years these variables were scrutinized, aiming to ascertain relevance for longterm outcome. METHODS: Population (N = 25, all males with alcoholic cirrhosis) was recruited among patients hospitalized for uncomplicated ascitis. Exclusion criteria were refractory or tense ascitis, cancer, spontaneous bacterial peritonitis, bleeding varices and critical illness. Measurements included ultrasonographically estimated ascitis volume, dry body mass index/BMI , upper arm anthropometrics, hematologic counts and liver function tests. RESULTS: Population (age 48.3 ± 11.3 years, BMI 21.1 ± 3.5 kg/m², serum albumin 2.5 ± 0.8 g/dL) was mostly in the Child-Pugh C category (77.8%) but clinically stable. During the follow-up period of 22.6 ± 3.8 months, additional hospitalizations numbered 1.7 ± 1.0 and more than one quarter succumbed. Admission ascitis volume corresponded to 7.1 ± 3.6 L and dry BMI to 18.3 ± 3.5 kg/m². Child Pugh index was relevant for both mortality and rehospitalization. Nevertheless, similar matches for mortality were documented with ascitis volume and dry BMI, and arm circumference below the 5th percentile was highly significantly associated with rehospitalization. CONCLUSIONS: A greater association than hitherto acknowledged, between ascitis volume and anthropometric measurements from one side, and long-term rehospitalization and mortality from the other, was demonstrated in male stable alcoholic cirrhotics. Further studies with alcoholic and other modalities of cirrhosis including women are recommended.

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Background: Risk-factors for mortality in hip fractures encompass nutritional status, nominally body mass index, but not body composition. Given the difficulty of anthropometric assessment in bedridden patients a prospective study with bioimpe dance analysis was designed. Methods: Elderly patients with hip fracture were consecutively recruited. Biochemical tests, primitive bioimpe dance measurements (resistance, reactance and phase angle) and follow-up till one year were targeted. Results: Patients (N = 69, 81.2 ± 8.1 years old, 72.5%females) stayed in the hospital for 15.5 ± 17.1 days, and18.8%(13/69) required further hospitalization during the ensuing months. Mortality was 11.6% within 30 days, coinciding with hospital mortality, and an additional11.6% till one year, thus reaching 23.2%. Anemia, hypoalbuminemia and low transferrin, along with elevated glucose and urea were frequent, suggesting undernutrition with metabolic derangements. Reactance, urea and creatinine were different in patients suffering both early and late demise. Resistance, white blood cell count and osteoporosis were risk factors for early mortality only , and anemia exclusively for late mortality .Conclusions: Primitive bioimpe dance measurements, which had not been hitherto investigated , were prognostically related to early and late mortality. These markers of disease-related malnutrition and especially reactance should be further studied in patients unfit for anthropometric evaluation due to fracture and immobility (AU)

Antecedentes: Los factores de riesgo para mortalidad en las fracturas de cadera involucran estado nutricional, nominalmente índice de masa corporal, pero no composición corporal. Considerándose la dificultad de evaluación antropométrica de pacientes acamados, un estúdio prospectivo con bioimpedáncia fue programado. Métodos: Pacientes de mayor edad con fractura de cadera fueron consecutivamente recrutados. Testes bioquímicos, medidas primitivas de bioimpedáncia (resisténcia, reactáncia, ángulo de fase) e seguimiento hasta un año fueron valorizados. Resultados: Los pacientes (N = 69, 81,2 ± 8,1 años,72,5% mujeres) quedaronse en el hospital por 15,5 ± 17,1 días, y el 18,8% (13/69) necesitaron de hospitalización adicional en los meses siguientes. La mortalidad de 30 días fue 11,6%, coincidiendo con la mortalidad hospitalária, con 11,6% adicionales hasta un año, alcanzando un total de 23,2%. Anemia, hipoalbuminemia e baja de transferrina, asimismo glucosa y urea elevadas, se observaron con frecuencia, compatibles con desnutrición e trastornos metabólicos. La reactáncia, urea y creatinina eran diferentes en pacientes con mortalidad precoz y tardía. La resistencia, recuento de leucocitos y presencia de osteoporosis indicaron mortalidad e precoz solamente, y anemia solo la mortalidad de un año. Conclusiones: Las medidas primitivas de bioimpedáncia, que no habían sido hasta el momento investigadas en ese contexto, mostraronse pronosticamente relacionadas como mortalidad precoz y tardía. Estos marcadores y en especial la reactancia merecen ser más estudiados en pacientes donde la antropometría es difícil o imposible por razones de fractura y inmovilidad (AU)

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UNLABELLED: No nutritional protocol for poorly controlled diabetic patients receiving well-managed drug treatment is currently available. OBJECTIVE: Aims were to compare dietary consumption of calcium and fibers with lipid profile and glycosilated hemoglobin HbA1c. METHODOLOGY: This was a prospective observational study. Patients with poorly controlled diabetes were consecutively recruited. A food-frequency questionnaire and tests for lipid profile, HbA1c, and C reactive protein were collected, along with clinical and anthropometric assessment. RESULTS: Patients (N = 114, age 65.7 ± 6.5 years, 75.4% females, BMI 29.0 ± 5.3 kg/m²) were often insulin-dependent (32.5%) and with systemic inflammation (C-reactive protein 4.2 ± 3.9 mg/L). Diet was energy restricted (1,365 ± 565 kcal/day) and mostly adequate but with suboptimal fiber (15.4 ± 8.6 g/day) and very low calcium (592.4 ± 204.4 mg/day). Calcium and fiber in the diet correlated with serum lipids, whereas fiber alone displayed a protective association regarding diabetes (HBA1c, insulin use) and arterial hypertension. CONCLUSIONS: Calcium and fiber ingestion exhibited correlations with important markers of metabolic status and cardiovascular risk. Future studies should address enhancement of these ingredients by means of dietary changes and supplements.

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BACKGROUND: Botanical omega-3 fatty acid (alphalinolenic acid/ALA) has been shown to alleviate the prothrombotic and proinflammatory profile of metabolic syndrome, however clinical protocols are still scarce. Aiming to focus an obese population, a pilot study was designed. METHODS: Morbidly obese candidates for bariatric surgery (n = 29, age 46.3 ± 5.2 years), 82.8% females (24/29), BMI 44.9 ± 5.2 kg/m², with C-reactive protein/CRP > 5 mg/L were recruited. Twenty were randomized and after exclusions, 16 were available for analysis. Flaxseed powder (60 g/day, 10 g ALA) and isocaloric roasted cassava powder (60 g/day, fat-free) were administered in a double-blind routine for 12 weeks. RESULTS: During flaxseed consumption neutrophil count decreased and fibrinogen, complement C4, prothrombin time and carotid diameter remained stable, whereas placebo (cassava powder) was associated with further elevation of those measurements. CONCLUSIONS: Inflammatory and coagulatory markers tended to exhibit a better outlook in the flaxseed group. Also large-artery diameter stabilized whereas further increase was noticed in controls. These findings raise the hypothesis of a less deleterious cardiovascular course in seriously obese subjects receiving a flaxseed supplement.

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No nutritional protocol for poorly controlled diabetic patients receiving well-managed drug treatment is currently available. Objective: Aims were to compare dietary consumption of calcium and fibers with lipid profile and glycosilated hemoglobin HbA1c. Methodology: This was a prospective observational study. Patients with poorly controlled diabetes were consecutively recruited. A food-frequency questionnaire and tests for lipid profile, HbA1c, and C reactive protein were collected, along with clinical and anthropometric assessment. Results: Patients (N = 114, age 65.7 ± 6.5 years, 75.4%females, BMI 29.0 ± 5.3 kg/m2) were often insulin-dependent (32.5%) and with systemic inflammation (C-reactive protein 4.2 ± 3.9 mg/L). Diet was energy restricted (1,365± 565 kcal/day) and mostly adequate but with suboptimal fiber (15.4 ± 8.6 g/day) and very low calcium (592.4 ±204.4 mg/day). Calcium and fiber in the diet correlated with serum lipids, where as fiber alone displayed a protective association regarding diabetes (HBA1c, insulin use) and arterial hypertension. Conclusions: Calcium and fiber ingestion exhibited correlations with important markers of metabolic status and cardiovascular risk. Future studies should address enhancement of these ingredients by means of dietary changes and supplements (AU)

Ningún protocolo nutricional es presentemente disponible para pacientes diabéticos mal controlados recibiendo terapia farmacológica bien estructurada. Objetivo: Una comparación entre consumo dietético de calcio y fibras, y concentraciones de lípidos y hemoglobina glicosilada HbA1c fue efectuada.Metodología: Este fue un estudio prospectivo observacional. Pacientes con diabetes mal controlada fueron consecutivamente recrutados. Las variables fueron cuestionario de frecuencia alimentaria, evaluación clínica y antropométrica, y valores séricos de lípidos, HbA1c, proteína C reactiva (PCR).Resultados: Los pacientes (N = 114, edad 65,7 ± 6,5años, 75,4% mujeres, IMC 29,0 ± 5,3 kg/m2) eran con moderada frecuencia insulino-dependientes (32,5%) y también sistémicamente inflamados (PCR 4,2 ± 3,9mg/L). La dieta era pobre en calorías (1,365 ± 565 kcal/d) pero globalmente acceptable, aún que baja en fibras (15,4± 8,6 g/d) y muy baja en calcio (592,4 ± 204,4 mg/d). El calcio e la fibra de la dieta se correlacionaran con valores lipídicos, pero solo la fibra estuvo asociada a mejor panorama de diabetes (HbA1c, uso de insulina) y de hipertensión arterial. Conclusiones: La ingestión de calcio y fibra estuvieron correlacionadas con importantes marcadores de estado metabólico y riesgo cardiovascular. Estudios futuros son recomendados con empleo de mayores proporciones de estos ingredientes en forma de dieta o suplementos (AU)

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Background: Botanical omega-3 fatty acid (alphalinolenic acid/ALA) has been shown to alleviate the prothrombotic and proinflammatory profile of metabolic syndrome, however clinical protocols are still scarce. Aiming to focus an obese population, a pilot study was designed. Methods: Morbidly obese candidates for bariatric surgery (n = 29, age 46.3 ± 5.2 years), 82.8% females (24/29), BMI 44.9 ± 5.2 kg/m2, with C-reactive protein/CRP > 5 mg/L were recruited. Twenty were randomized and after exclusions, 16 were available for analysis. Flaxseed powder (60 g/day, 10 g ALA) and isocaloric roasted cassava powder (60 g/day, fat-free) were administered in a double-blind routine for 12 weeks. Results: During flaxseed consumption neutrophil count decreased and fibrinogen, complement C4, prothrombin time and carotid diameter remained stable, whereas placebo (cassava powder) was associated with further elevation of those measurements. Conclusions: Inflammatory and coagulatory markers tended to exhibit a better outlook in the flaxseed group. Also large-artery diameter stabilized whereas further increase was noticed in controls. These findings raise the hypothesis of a less deleterious cardiovascular course in seriously obese subjects receiving a flaxseed supplement (AU)

Introducción: Los ácidos grasos botánicos omega-3 (ácido alfa-linolénico/ALA) se muestran convenientes para atenuar las características protrombóticas y proinflamatórias del síndrome metabólico, pero protocolos clínicos todavía son escasos. Con el objetivo de enfocar una población obesa, un estudio clínico fue dibujado. Métodos: Candidatos a cirugía bariátrica morbidamente obesos (n = 29, edad 46,3 ± 5,2 años), 82,8% mujeres (24/29), IMC 44,9 ± 5,2 kg/m2, con proteína C reactiva/CRP > 5 mg/L fueron recrutados. Veinte fueron randomizados y após exclusiones, 16 se puderon analisar. Harina de linaza (60 g/día, 10 g ALA) y harina de casava tostada isocalórica (60 g/día, sin grasas) fueron suministradas em uma rutina doble-ciega por 12 semanas. Resultados: Mientras se recibió linaza los neutrófilos bajaron y fibrinógeno, complemento C4, tiempo de protrombina y diámetro de la carótida permanecieron estables. El uso de casava se asoció con elevación de todas estas variables. Conclusiones: Los marcadores inflamatórios y coagulatórios tuvieron un curso mas favorable con la linaza. Asimismo el diámetro arterial se quedó estable, en cambio hubo peor a en el segundo grupo. La hipótesis de una evolución cardiovascular menos deletérea en obesos graves recibiendo casava se plantea en estas circunstancias (AU)

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BACKGROUND: Risk-factors for mortality in hip fractures encompass nutritional status, nominally body mass index, but not body composition. Given the difficulty of anthropometric assessment in bedridden patients a prospective study with bioimpedance analysis was designed. METHODS: Elderly patients with hip fracture were consecutively recruited. Biochemical tests, primitive bioimpedance measurements (resistance, reactance and phase angle) and follow-up till one year were targeted. RESULTS: Patients (N = 69, 81.2 ± 8.1 years old, 72.5% females) stayed in the hospital for 15.5 ± 17.1 days, and 18.8% (13/69) required further hospitalization during the ensuing months. Mortality was 11.6% within 30 days, coinciding with hospital mortality, and an additional 11.6% till one year, thus reaching 23.2%. Anemia, hypoalbuminemia and low transferrin, along with elevated glucose and urea were frequent, suggesting undernutrition with metabolic derangements. Reactance, urea and creatinine were different in patients suffering both early and late demise. Resistance, white blood cell count and osteoporosis were risk factors for early mortality only , and anemia exclusively for late mortality. CONCLUSIONS: Primitive bioimpedance measurements, which had not been hitherto investigated , were prognostically related to early and late mortality. These markers of disease-related malnutrition and especially reactance should be further studied in patients unfit for anthropometric evaluation due to fracture and immobility.

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Low-grade inflammation adversely influences metabolism and cardiovascular prognosis, nevertheless increased in take of fruits and vegetables has rarely been studied in this context. Objective: In a prospective controlled study, the effect on C-reactive protein (CRP) levels was assessed. Methodology: Sixty consecutive women undergoing cosmetic abdominal surgery were instructed to consume six servings each of fruits and vegetables during the first postoperative month. Detailed 24h interviewer-administered dietary recall was conducted at baseline and at the end of the study, with weekly returns to monitor unscheduled dietary changes and compliance with the protocol. Variance (ANOVA)and covariance (ANCOVA) were evaluated to confirm significance and minimize confounding variables. Results: No differences concerning age (42.2 ± 5.3 vs 41.1± 6.0 years) or BMI (25.5± 3.1 vs 25.0± 3.0 kg/m2) occurred. Ingestion of fruits increased to approximately 5.2 vs 3.9 and of vegetables 5.9 vs 3.4 servings/ day, respectively. CRP decreased more conspicuously in the treated group (P=0.028),and correlation between vitamin C in put and CRP in supplemented participants was demonstrated ( P=0.014).Conclusions: Higher intake of antioxidant foods was feasible, and an antiinflammaotory effect occurred. Further studies with longer administration and follow up period are recommended (AU)

Inflamación subclínica influencia adversamiente el metabolismo y el pronóstico cardiovascular, pero ingestión elevada de vegetales y frutas há sido pocas veces investigada en este contexto. Objetivo: En un estúdio prospectivo y controlado, el impacto sobre la proteina C-reactiva fue determinado.Metodología: Sesenta pacientes consecutivas sometidas a cirugía cosmética abdominal fueron instruídas a consumir seis porciones diárias de frutas y mais seis de vegetales, en el primero més de postoperatório. Un recordatório alimentar detallado registrado por dietista fue conducido inicialmiente y al cabo del estúdio, con retornos semanales para monitorar aderéncia y cámbios eventuales de la dieta. Análisis de variancia (ANOVA) y covariáncia (ANCOVA) fueron realizadas para evaluar resultados y minimizar variables de confusión. Conclusiones: Un consumo mas alto de alimientos antioxidantes fue posible, y una respuesta antiinflamatória fue documentada. Estúdios adicionales com suministración y seguimiento mas prolongados son recomendados (AU)

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UNLABELLED: Low-grade inflammation adversely influences metabolism and cardiovascular prognosis, nevertheless increased intake of fruits and vegetables has rarely been studied in this context. OBJECTIVE: In a prospective controlled study, the effect on C-reactive protein (CRP) levels was assessed. METHODOLOGY: Sixty consecutive women undergoing cosmetic abdominal surgery were instructed to consume six servings each of fruits and vegetables during the first postoperative month. Detailed 24 h interviewer-administered dietary recall was conducted at baseline and at the end of the study, with weekly returns to monitor unscheduled dietary changes and compliance with the protocol. Variance (ANOVA) and covariance (ANCOVA) were evaluated to confirm significance and minimize confounding variables. RESULTS: No differences concerning age (42.2±5.3 vs 41.1±6.0 years) or BMI (25.5±3.1 vs 25.0±3.0 kg/m²) occurred. Ingestion of fruits increased to approximately 5.2 vs 3.9 and of vegetables 5.9 vs 3.4 servings/ day, respectively. CRP decreased more conspicuously in the treated group (P=0.028), and correlation between vitamin C input and CRP in supplemented participants was demonstrated (P=0.014). CONCLUSIONS: Higher intake of antioxidant foods was feasible, and an antiinflammatory effect occurred. Further studies with longer administration and follow-up period are recommended.

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UNLABELLED: Weight loss and resolution of comorbidities is well established after modern bariatric procedures, however chronology of glyco-lipidic biochemical response is still debated. OBJECTIVE: Aiming to analyze this variable as well as its correlation with food amount and composition, a prospective study was designed. METHODOLOGY: Eighty consecutive patients undergoing Roux-en-Y gastric bypass were investigated every three months until one year after surgery. Females only were accepted and variables included general and nutritional course as well as glucose and lipid measurements. Energy intake was documented including percentage of macronutrients in the diet. RESULTS: Surgery was successful with about 71% excess body weight loss at the end of the first year. Mean energy intake on the 4 postoperative quarters was respectively 519.6 +/- 306.6, 836.0 +/- 407.9, 702.1 +/- 313.1 and 868.8 +/- 342.8 kcal/day (mean +/- SD). Fat intake was initially low but reached 34.1 +/- 7.9% of total calories at final measurement. Blood glucose and lipid fractions tended to be borderline or abnormal preoperatively, and favorably changed by 12 months. Consumption of glucose-and lipid-lowering medication significantly diminished, but each of these was still necessary in 6.3% of the group. Correlation between body mass index and also calorie intake versus glucose and lipid measurements was highly significant (P = 0.000). CONCLUSIONS: 1) Energy intake after operation was very low; 2) Weight loss proceeded rapidly and correlated with meal pattern; 3) Improvement of glucose and lipid tests was adequate but took several quarters to normalize; 4) Decreased requirements for glucose- and lipid-lowering medication was significant but not absolute; 4) Fat percentage of total calories exceeded 30% at the end of the observation period, despite recommendations to the contrary.

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Weight loss and resolution of comorbidities is well established after modern bariatric procedures, however chronology of glyco-lipidic biochemical response is still debated. Objective: Aiming to analyze this variable as well as its correlation with food amount and composition, a prospective study was designed. Methodology: Eighty consecutive patients undergoing Roux-en-Y gastric bypass were investigated every three months until one year after surgery. Females only were accepted and variables included general and nutritional course as well as glucose and lipid measurements. Energy intake was documented including percentage of macronutrients in the diet. Results: Surgery was successful with about 71% excess body weight loss at the end of the first year. Mean energy intake on the 4 postoperative quarters was respectively 519.6 ± 306.6, 836.0 ± 407.9, 702.1 ± 313.1 and 868.8 ± 342.8 kcal/day (mean ± SD). Fat intake was initially low but reached 34.1 ± 7.9% of total calories at final measurement. Blood glucose and lipid fractions tended to be borderline or abnormal preoperatively, and favorably changed by 12 months. Consumption of glucose-and lipid-lowering medication significantly diminished, but each of these was still necessary in 6.3% of the group. Correlation between body mass index and also calorie intake versus glucose and lipid measurements was highly significant (P = 0.000). Conclusions: 1) Energy intake after operation was very low; 2) Weight loss proceeded rapidly and correlated with meal pattern; 3) Improvement of glucose and lipid tests was adequate but took several quarters to normalize; 4) Decreased requirements for glucose- and lipid-lowering medication was significant but not absolute; 4) Fat percentage of total calories exceeded 30% at the end of the observation period, despite recommendations to the contrary (AU)

Pérdida de peso y resolución de las comorbidades estan bien establecidas luego de los modernos procedimientos bariátricos, pero la cronología de la respuesta bioquímica glico-lipídica es aun debatida. Objetivo: Con el interés de analizar esta variable y sus correlaciones con la cantidad y composición de la dieta, un estudio prospectivo fue preparado. Metodología: Ochenta pacientes consecutivas sometidas a bypass gástrico en Y de Roux fueron investigadas a cada tres meses hasta el fin del primero año. Acceptaronse solamente mujeres y las variables involucraban evolución general y nutricional asimismo medidas de glucemia y lípidos. La ingestión energética fue documentada con su porcentual de macronutrientes. Resultados: La operación fue exitosa con pérdida de un promedio de 71% de exceso de peso al término de un año. Los ingresos calóricos en los 4 trimestres fueron respectivamente 519,6 ± 306,6, 836,0 ± 407,9, 702,1 ± 313,1 y 868,8 ± 342,8 kcal/día. El consumo inicial de grasas fue bajo pero alcanzó progresivamente el 34,1 ± 7,9% del total calórico. La glucemia y fracciones lipídicas quedabanse en el límite superior del normal en el preoperatório , con mejora significativa a los 12 meses. La utilización de medicación hipoglucemiante y hipolipemiante disminuyó, pero al término era aún necesária para 6,3% de la población. Las correlaciones entre índice de masa corporal y también ingestión calórica versus valores lipídicos y glucídicos fueron muy significativas (P= 0,000). Conclusiones: 1) La ingestión calórica postoperatória fue muy baja; 2) La pérdida de peso avanzó rápidamente y fue proporcional a los parámetros dietéticos; 3) La respuesta de la glucemia y hiperlipidemia fue adecuada pero solo se completó al cabo de varios trimestres; 4) El porcentaje final de grasas en la dieta fue superior al 30% pese a recomendaciones contrarias (AU)

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BACKGROUND AND STUDY AIMS: Endoscopic evaluation of the excluded stomach after Roux-en-Y gastric bypass surgery for morbid obesity is a challenge, and the pathological changes that take place in the bypassed stomach are unclear. A new double-balloon method of evaluating the bypassed stomach after Roux-en-Y gastric bypass surgery for morbid obesity is described here. PATIENTS AND METHODS: This new enteroscope uses two balloons, one attached to the tip of the endoscope and the other to the distal end of the soft overtube. The procedures were carried out in six patients using the retrograde route, through the end-to-side jejunal anastomosis via the duodenobiliopancreatic limb up to the bypassed stomach. RESULTS: The bypassed stomach was reached in five of six patients (83.3 %). An endoscopic appearance of atrophic gastritis was found in three patients, mild in two cases and severe in one case with intestinal metaplasia. Erosive and hemorrhagic gastritis was found in two patients. CONCLUSIONS: Endoscopic evaluation of the bypassed stomach via the retrograde route after Roux-en-Y gastric bypass for morbid obesity is feasible using the double-balloon enteroscope.

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UNLABELLED: The hospital pharmacy in large and advanced institutions has evolved from a simple storage and distribution unit into a highly specialized manipulation and dispensation center, responsible for the handling of hundreds of clinical requests, many of them unique and not obtainable from commercial companies. It was therefore quite natural that in many environments, a manufacturing service was gradually established, to cater to both conventional and extraordinary demands of the medical staff. That was the case of Hospital das Clínicas, where multiple categories of drugs are routinely produced inside the pharmacy. However, cost-containment imperatives dictate that such activities be reassessed in the light of their efficiency and essentiality. METHODS: In a prospective study, the output of the Manufacturing Service of the Central Pharmacy during a 12-month period was documented and classified into three types. Group I comprised drugs similar to commercially distributed products, Group II included exclusive formulations for routine consumption, and Group III dealt with special demands related to clinical investigations. RESULTS: Findings for the three categories indicated that these groups represented 34.4%, 45.3%, and 20.3% of total manufacture orders, respectively. Costs of production were assessed and compared with market prices for Group 1 preparations, indicating savings of 63.5%. When applied to the other groups, for which direct equivalent in market value did not exist, these results would suggest total yearly savings of over 5 100 000 US dollars. Even considering that these calculations leave out many components of cost, notably those concerning marketing and distribution, it might still be concluded that at least part of the savings achieved were real. CONCLUSIONS: The observed savings, allied with the convenience and reliability with which the Central Pharmacy performed its obligations, support the contention that internal manufacture of pharmaceutical formulations was a cost-effective alternative in the described setting.

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Refeeding syndrome encompasses fluid and electrolyte imbalances and metabolic, intestinal, and cardiorespiratory derangements associated with appreciable morbidity and mortality. Although refeeding syndrome has been well documented in concentration-camp subjects, and more recently during parenteral therapy of critically ill patients, little is known about the importance of refeeding syndrome during recovery from a hunger strike. Thus, we studied the response to a four-step dietary replenishment routine in eight hunger strikers who refused food for 43 d. In this retrospective, observational study, we assessed the safety and efficacy of the refeeding procedure and analyzed the clinical and nutritional course of the cohort during both starvation and refeeding, mainly on the basis of clinical as well as a few biochemical determinations. During starvation, average weight loss was about 18% and, with the exception of occasional oral vitamins and electrolytes, the subjects consumed only water. Available body-composition and biochemical profiles showed no clinically significant changes during starvation, but one-half of the group displayed spontaneous diarrhea at some time before refeeding. Stepwise nutritional replenishment lasted for 9 d, after which all patients tolerated a full, unrestricted diet. Only one episode of diarrhea occurred during this phase, and both clinical and biochemical indexes confirmed a favorable clinical course, without any manifestation of refeeding syndrome. In conclusion, we observed the following: 1) Hypophosphatemia and other micronutrient imbalances did not occur, nor was macronutrient intolerance detected. 2) Despite some episodes of diarrhea, nutritional replenishment was not associated with significant enteral dysfunction. 3) There was some fluid retention, but this was mild. 4) Acute-phase markers were abnormally elevated during the refeeding phase, without associated sepsis or inflammation.

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UNLABELLED: Prolonged total food deprivation in non-obese adults is rare, and few studies have documented body composition changes in this setting. In a group of eight hunger strikers who refused alimentation for 43 days, water and energy compartments were estimated, aiming to assess the impact of progressive starvation. Measurements included body mass index (BMI), triceps skinfold (TSF), arm muscle circumference (AMC), and bioimpedance (BIA) determinations of water, fat, lean body mass (LBM), and total resistance. Indirect calorimetry was also performed in one occasion. The age of the group was 43.3+/-6.2 years (seven males, one female). Only water, intermittent vitamins and electrolytes were ingested, and average weight loss reached 17.9%. On the last two days of the fast (43rd-44th day) rapid intravenous fluid, electrolyte, and vitamin replenishment were provided before proceeding with realimentation. Body fat decreased approximately 60% (BIA and TSF), whereas BMI reduced only 18%. Initial fat was estimated by BIA as 52.2+/-5.4% of body weight, and even on the 43rd day it was still measured as 19.7+/-3.8% of weight. TSF findings were much lower and commensurate with other anthropometric results. Water was comparatively low with high total resistance, and these findings rapidly reversed upon the intravenous rapid hydration. At the end of the starvation period, BMI (21.5+/-2.6 kg/m2) and most anthropometric determinations were still acceptable, suggesting efficient energy and muscle conservation. CONCLUSIONS: 1) All compartments diminished during fasting, but body fat was by far the most affected; 2) Total water was low and total body resistance comparatively elevated, but these findings rapidly reversed upon rehydration; 3) Exaggerated fat percentage estimates from BIA tests and simultaneous increase in lean body mass estimates suggested that this method was inappropriate for assessing energy compartments in the studied population; 4) Patients were not morphologically malnourished after 43 days of fasting; however, the prognostic impact of other impairments was not considered in this analysis.

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