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The effect of carbohydrate (CHO), or CHO supplemented with either sodium caseinate protein (CHO–C) or a sodium caseinate protein hydrolysate (CHO–H) on the recovery of skeletal muscle glycogen and anabolic signaling following prolonged aerobic exercise was determined in trained male cyclists [n = 11, mean ± SEM age 28.8 ± 2.3 years; body mass (BM) 75.0 ± 2.3 kg; VO2peak 61.3 ± 1.6 ml kg−1 min−1]. On three separate occasions, participants cycled for 2 h at ~ 70% VO2peak followed by a 4-h recovery period. Isoenergetic drinks were consumed at + 0 and + 2 h of recovery containing either (1) CHO (1.2 g kg −1 BM), (2) CHO–C, or (3) CHO–H (1.04 and 0.16 g kg−1 BM, respectively) in a randomized, double-blind, cross-over design. Muscle biopsies from the vastus lateralis were taken prior to commencement of each trial, and at + 0 and + 4 h of recovery for determination of skeletal muscle glycogen, and intracellular signaling associated with protein synthesis. Despite an augmented insulin response following CHO–H ingestion, there was no significant difference in skeletal muscle glycogen resynthesis following recovery between trials. CHO–C and CHO–H co-ingestion significantly increased phospho-mTOR Ser2448 and 4EBP1 Thr37/46 versus CHO, with CHO–H displaying the greatest change in phospho-4EBP1 Thr37/46. Protein co-ingestion, compared to CHO alone, during recovery did not augment glycogen resynthesis. Supplementing CHO with intact sodium caseinate or an insulinotropic hydrolysate derivative augmented intracellular signaling associated with skeletal muscle protein synthesis following prolonged aerobic exercise.

Objective Transgender and non-binary individuals frequently engage with healthcare services to obtain gender-affirming care. Little data exist on the experiences of young people accessing gender care. This systematic review and meta-ethnography aimed to identify and synthesise data on youths’ experiences accessing gender-affirming healthcare. Method A systematic review and meta-ethnography focusing on qualitative research on the experiences of transgender and non-binary youth accessing gender care was completed between April-December 2020. The following databases were used: PsychINFO, MEDLINE, EMBASE, and CINAHL. The protocol was registered on PROSPERO, international prospective register of Systematic Reviews (CRD42020139908). Results Ten studies were included in the final review. The sample included participants with diverse gender identities and included the perspective of parents/caregivers. Five dimensions (third-order constructs) were identified and contextualized into the following themes: 1.) Disclosure of gender identity. 2.) The pursuit of care. 3.) The cost of care. 4.) Complex family/caregiver dynamics. 5.) Patient-provider relationships. Each dimension details a complicated set of factors that can impact healthcare navigation and are explained through a new conceptual model titled “The Rainbow Brick Road”. Conclusion This synthesis expands understanding into the experience of transgender and non-binary youth accessing gender-affirming healthcare. Ryvicker’s behavioural-ecological model of healthcare navigation is discussed in relation to the findings and compared to the authors’ conceptual model. This detailed analysis reveals unique insights on healthcare navigation challenges and the traits, resources, and infrastructure needed to overcome these. Importantly, this paper reveals the critical need for more research with non-binary youth and research which includes the population in the design.

Obesity is associated with chronic inflammation and metabolic disease. Bariatric surgery offers a treatment that can effectively reduce weight and improve the metabolic function. However, the effect of bariatric surgery on chronic inflammation in obesity is under-investigated. In this expert review, the authors outline the effect of Roux-en-Y gastric bypass, the most commonly performed bariatric surgery in current practice, on the markers of inflammation. They include a discussion of the relationship between inflammation and weight loss after surgery, the interaction between these markers and metabolic disease, and the effect on adipose tissue inflammation. They also briefly explore the role of glucagon-like-peptide 1 in remediating inflammation and the changes in gut microbiota after Roux-en-Y gastric bypass, and how they may be important in inflammation.

Despite the evidence for benefits beyond weight loss following bariatric surgery, assessments of surgical outcomes are often limited to changes in weight and remission of type 2 diabetes mellitus. To address this shortfall in assessment, the King's Obesity Staging System was developed. This system evaluates the individual in severity stages of physical, psychological, socio-economic and functional disease. These are categorised into disease domains arranged so as to allow an alphabetic mnemonic as Airways, Body Mass Index (BMI), Cardiovascular, Diabetes, Economic, Functional, Gonadal, Health Status (perceived) and (body) Image.In this cohort study, patients were assessed before and 12 months after surgery using the modified King's Obesity Staging Score. We studied 217 consecutive patients undergoing Roux-en-Y gastric bypass (RYGB; N = 148) and laparoscopic adjustable gastric band (LAGB; N = 69) using the modified King's Obesity Staging System to determine health benefits after bariatric surgery.Preoperatively, the groups had similar BMI, but the RYGB group had worse Airways, Cardiovascular, and Diabetes scores (p 0.05). After surgery, RYGB and LAGB produced improvements in all scores. In a subgroup paired analysis matched for preoperative Airways, BMI, Cardiovascular, and Diabetes scores, both procedures showed similar improvements in all scores, except for BMI where RYGB had a greater reduction than LAGB (p 0.05).Both RYGB and LAGB deliver multiple benefits to patients as evaluated by the modified King's Obesity Staging System beyond BMI and glycaemic markers. A validated staging score such as the modified King's Obesity Staging System can be used to quantify these benefits.

To construct a clinical management matrix using serial fetal abdominal circumference measurements (ACMs) that will predict normal birth weight in pregnancies complicated by gestational diabetes (GDM) and reduce unnecessary ultrasound examination in women with GDM.Retrospective cohort study of 144 women with GDM in a specialist obstetric-diabetes clinic. Women with GDM who delivered singleton infants were identified from a clinical register. Regression analysis was used to identify associations between serial ACMs, maternal parameters and normal birth weight (birth weight between the 10th and 90th percentiles). Predictive clinical models were designed with the aim of identifying normal birth weight infants with the lowest number of fetal ultrasound scans.Compared to mothers of large-for-gestational-age (LGA) infants, mothers of normal weight infants had lower fasting glucose measurements at diagnosis (5.9 mmol/l±1.0 vs. 6.6 mmol/l±0.7, p0.05), lower maternal weight at delivery (90 kg±17 vs. 96 kg±17, p0.05), and a lower rate of prior LGA infants (31% vs. 60%, p0.05). Maternal weight and a history of prior LGA delivery were identified as useful predictors of fetal birth weight in predictive models. Serial ACMs below the 50th, 75th and 90th percentiles could predict normal birth weight with 100%, 97% and 96% positive predictive value respectively when used in these risk factor based models. Two measurements sufficed in low-risk pregnancies.Serial ACMs can predict normal birth weight in GDM.

Obesity is associated with metabolic dysfunction, including a positive energy balance, increased insulin resistance, dyslipidemia, hypertension and inflammation. Bariatric surgery is an effective treatment of many of the metabolic defects associated with obesity. In this review, we outline the effect of bariatric surgery on energy balance, glucose homeostasis, blood pressure control and lipid metabolism. We also examine the effect of bariatric surgery on inflammation, and in particular renal inflammation, and detail the evidence for the mechanisms underlying these effects.

Incretins and related gastrointestinal peptides are key regulators of the appetite and of glucose homeostasis. In the last decade, they have come to prominence as they have been utilized in the treatment of diabetes. Ongoing research is identifying relationships between these peptides and the pathogenesis of diabetes and obesity that could open up new avenues of treatment. With the growing recognition of the importance of diabetes and obesity prevention, this article examines the potential for these peptides to yield treatment options for the prevention of these conditions in the years ahead. In this review, the effects of the available therapies that modulate the incretin system are evaluated and the other related gastrointestinal peptides are briefly reviewed. The focus of the article is the use of therapies such as GLP-1, DPP4 inhibitors and bariatric surgery in preventing diabetes and obesity.

This study examines the effect of Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) on renal function for at least 5 years post-operatively in a tertiary referral center for bariatric surgery. This prospective cohort study of patients undergoing RYGB and LAGB measured renal function, blood pressure, and diabetes status pre-operatively and then 1 and 5 years post-operatively. Renal function was assessed using the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Cockcroft-Gault formulae. Hypertension and diabetes were defined by the European Society of Hypertension and European Society of Cardiology joint guidelines and American Diabetes Association guidelines, respectively. A sub-group who had completed 10 years post-operative follow-up was also included. Estimated glomerular filtration rate (eGFR) increased over 5 years after RYGB (N = 190; 94 ± 2 mL/min/1.73 m2 to 102 ± 22 mL/min/1.73 m2, p = 0.01) and LAGB (N = 271; 88 ± 1 to 93 ± 22 mL/min/1.73 m2, p = 0.02). In a sub-group with up to 10 years post-operative date, this trend was maintained. In patients with renal impairment, eGFR improved over 5 years (52 ± 2 to 68 ± 7 mL/min/1.73 m2, p = 0.01). Remission of hypertension was greater after RYGB than LAGB at 1 year (32 vs. 16 %, p = 0.008) and at 5 years post-operatively (23 vs. 11 %, p = 0.02). Bariatric surgery stabilizes eGFR post-operatively for at least 5 years. In a sub-group with renal impairment, eGFR is increased in the first post-operative year and this is maintained for up to 5 years. RYGB is an effective procedure in achieving blood pressure control.

Bariatric surgery can effectively reduce body weight and treat obesity associated metabolic diseases such as diabetes mellitus. There are also benefits for an individual's functional status and psychological health. A multi-disciplinary evaluation should be offered to the individual as the first essential step in considering bariatric surgery as a treatment. This evaluation should include a thorough medical assessment, as well as psychological and dietetic assessments. In this best practice article, we outline the current recommendations for referral for bariatric surgery. We also present the data for pre-operative assessment before bariatric surgery, with particular reference to cardiovascular disease and obstructive sleep apnoea. We describe the literature on outcomes after bariatric surgery, including the results for mortality, weight loss, remission of diabetes and associated endocrine disorders such as hypogonadism. Within this review, we will illustrate the impact of bariatric surgery on self-image, psychological health and perceived health and functional status. Finally, we briefly detail the potential complications of bariatric surgery, and offer advice on post-operative care and surveillance.

Objective. Robot-assisted sleeve gastrectomy has the potential to treat patients with obesity and its comorbidities. To evaluate the learning curve for this procedure before undergoing Roux en-Y gastric bypass is the objective of this paper.Materials and Methods. Robot-assisted sleeve gastrectomy was attempted in 32 consecutive patients. A survey was performed in order to identify performance variables during completion of the learning curve. Total operative time (OT), docking time (DT), complications, and length of hospital stay were compared among patients divided into two cohorts according to the surgical experience. Scattergrams and continuous curves were plotted to develop a robotic sleeve gastrectomy learning curve.Results. Overall OT time decreased from 89.8 minutes in cohort 1 to 70.1 minutes in cohort 2, with less than 5% change in OT after case 19. Time from incision to docking decreased from 9.5 minutes in cohort 1 to 7.6 minutes in cohort 2. The time required to dock the robotic system also decreased. The complication rate was the same in the two cohorts.Conclusion. Our survey indicates that technique and outcomes for robot-assisted sleeve gastrectomy gradually improve with experience. We found that the learning curve for performing a sleeve gastrectomy using the da Vinci system is completed after about 20 cases.

Background Reductions in urinary protein excretion after Roux-en-Y gastric bypass (RYGB) surgery in patients with diabetic kidney disease have been reported in multiple studies. Objectives To determine the weight loss dependence of the effect of RYGB on urinary protein excretion by comparing renal outcomes in Zucker diabetic fatty rats undergoing either gastric bypass surgery or a sham operation with or without weight matching. Setting University laboratories. Methods Zucker diabetic fatty rats underwent surgery at 18 weeks of age. A subgroup of sham operated rats were weight matched to RYGB operated rats by restricting food intake. Urinary protein excretion was assessed at baseline and at postoperative weeks 4 and 12. Renal histology and macrophage-associated inflammation were assessed at postoperative week 12. Results Progressive urinary protein excretion was attenuated by both RYGB and diet-induced weight loss, albeit to a lesser extent by the latter. Both weight loss interventions produced equivalent reductions in glomerulomegaly, glomerulosclerosis, and evidence of renal macrophage infiltration. Conclusion Weight loss per se improves renal structure and attenuates renal inflammatory responses in an experimental animal model of diabetic kidney disease. Better glycemic control post-RYGB may in part explain the greater reductions in urinary protein excretion after gastric bypass surgery.

Renal dysfunction and disease, including hyperfiltration, proteinuria and hypofiltration, are commonly associated with obesity. Diabetic kidney disease is also common in obese cohorts. Weight loss interventions, including bariatric surgery, can effectively reduce weight and improve renal outcomes. Some of this effect may be due to the remission of Type 2 diabetes and hypertension. However, other mechanisms, including the resolution of inflammatory processes, may also contribute. The effect of bariatric surgery on renal function has only recently become a focus of particular investigation. In this study, we will review the effects of bariatric surgery on obesity-associated kidney disease. We will discuss the pitfalls in assessing renal function in obese cohorts and will examine the effect of bariatric surgery on renal function and urinary protein excretion using different mechanisms. We will give particular attention to the evidence for bariatric surgery in cohorts with established renal disease and suggest future directions. In particular, we will outline the evidence for inflammation as an important therapeutic target, and the emerging medical therapies being considered to exploit this target in obesity- and diabetes-related kidney disease.

Purpose of review Duodenal-jejunal bypass liners (DJBLs) are a novel therapy with potential treating a range of metabolic diseases. This review discusses the weight loss and glycaemic improvements observed following the use of the DJBL. Recent findings We summarize the evidence for the clinical application of DJBL to date. Within this, we outline the evidence available on the mechanisms of the observed effects. Summary Based on the most recent trials, we cannot fully mimic the clinical or physiological effects of bariatric surgery with this device, but we are getting closer.

As well as the pronounced effect on body mass index (BMI), bariatric surgery is increasingly recognized as being associated with improvements in morbidity and mortality in a range of conditions, from airways disease to cancer. In metabolic disease, the impact of bariatric surgery is particularly obvious with marked improvements in glycemic control in patients with type 2 diabetes mellitus, to the point of effecting diabetes remission in some. Hypertension and dyslipidemia, key components of the metabolic syndrome, also respond to bariatric surgery. Despite the increasing evidence of benefit in metabolic disease, the major national guidelines for selecting candidates for bariatric surgery retain their emphasis on body weight. In these guidelines, a BMI ≥35 kg/m2 is needed to indicate surgery, even in those with profound metabolic disturbance. The recent International Diabetes Federation guidelines have identified the need to reorientate our focus from BMI to metabolic disease. In this review, we examine the developing indications for the use of bariatric surgery in metabolic disease. We will focus on type 2 diabetes mellitus and the metabolic syndrome. Within this, we will outline the data for using bariatric surgery as metabolic surgery, including those with a BMI 2.

Background Obesity predisposes general surgical patients to infections such as surgical site infection and respiratory tract infection. The infection rates vary by surgical approach and the type of surgery undertaken. Bariatric surgery is increasingly used to treat obesity and obesity related co-morbidities. However, little is known about the relationship between postoperative infections and patient characteristics, such as body mass index (BMI) or diabetes status, in bariatric cohorts. The objective of this study was to examine the rates of all postoperative infection in patients after bariatric surgery in relation to known risk factors. Results A total of 815 patients were included in the final analysis. During the first month after surgery, 5.2% of patients experienced an infection-related event, and surgery-related infections were most prevalent. Between the second and twelfth month postoperatively, a further 4.7% of patients experienced an infection-related event, and nonsurgical related infections were most prevalent. Infection was associated with increased length of stay in Roux-en-Y gastric bypass (RYGB) ( P P = .011) but not in laparoscopic adjustable gastric banding (LAGB) ( P = .41). Diabetes status and BMI were not associated with increased infection rates during the first month after surgery. Conclusion Infection rates after bariatric surgery are relatively low and are associated with a prolonged length of hospital stay. Reassuringly, neither diabetic status nor BMI appear to increase the risk of postoperative infection after bariatric surgery.

Iatrogenic diaphragmatic hernias are a rarely reported complication of abdominal surgery. We present a case of an iatrogenic diaphragmatic hernia diagnosed 2 years after an adrenalectomy. Corrective laparoscopic surgery was performed, and the postoperative course was uneventful. The patient remained asymptomatic 6 months after the repair. To our knowledge, this is the first such case to be reported.

Obesity is recognized as a global health crisis. Bariatric surgery offers a treatment that can reduce weight, induce remission of obesity-related diseases, and improve the quality of life. In this article, we outline the different options in bariatric surgery and summarize the recommendations for selecting and assessing potential candidates before proceeding to surgery. We present current data on post-surgical outcomes and evaluate the psychosocial and economic effects of bariatric surgery. Finally, we evaluate the complication rates and present recommendations for post-operative care.