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The research study design is appropriate to buy plaquenil 200mg mastercard arthritis pain relief ointment answer the research question being asked in the study generic plaquenil 200mg without prescription arthritis degenerative neck. Clinical evaluation of the Endoscopic Duodenal-Jejunal Bypass Liner for the management of type 2 diabetes and obesity Clinical evaluation of the Endoscopic Duodenal-Jejunal Bypass Liner for management of type 2 diabetes and obesity Proefschrift Ter verkrijging van de graad van doctor aan de Radboud Universiteit Nijmegen op gezag van de rector magnificus buy plaquenil 200 mg fast delivery arthritis medication no alcohol, prof. No parts of this thesis may be reproduced, distributed, or transmited in any form or by any means, without writen permission from the author or from publisher holding the copy right of the published artcles. Clinical evaluation of the Endoscopic Duodenal-Jejunal Bypass Liner for management of type 2 diabetes and obesity Proefschrift Ter verkrijging van de graad van doctor aan de Radboud Universiteit Nijmegen op gezag van de rector magnificus, prof. Groenen (Rijnstate, Arnhem) Appleid medical Jeroen Bosch Academie Manuscriptcommissie: Prof. Wensing Table of Content Chapter 1 General introduction 11 Chapter 2 the Effect of the Endoscopic Duodenal-Jejunal Bypass Liner on 22 Obesity and Type 2 Diabetes Mellitus, a Multicenter Randomized Controlled Trial Chapter 3 Duodenal-jejunal bypass liner implantation provokes rapid weight 37 loss and improved glycemic control, accompanied by elevated fasting ghrelin levels Chapter 4 Changes in glycemic control and body weight after explantation of 49 the duodenal-jejunal bypass liner Chapter 5 Safety Experience with the Duodenal-Jejunal Bypass Liner: an 61 endoscopic treatment for diabetes and obesity Chapter 6 Feasibility of Endoscopic Implantation of Duodenal-Jejunal bypass 75 Liner under conscious sedation Chapter 7 Is Re-implantation of the Duodenal-Jejunal Bypass Liner Feasible? Therefore, morbid obesity indicates an extend of bodily fat deposition that leads to disease [1]. Obesity is a complex multifactorial chronic disease that develops from an interaction of genotype and the environment [2-4]. If the recent trends continue unabated, in 2030 the absolute numbers of overweight and obese will respectively increase to total of 2. Chapter 1: General introduction | 11 Introduction Obesity is derived from the Latin obesitas, which means fat, or plump and morbid from morbidus which means disease. Obesity is associated with an elevated risk for obesity-related co-morbidities, such as diabetes mellitus type 2, hypertension, hypercholesterolemia, heart disease, osteoarthritis and obstructive sleep apnea [7-9]. Furthermore, obesity is a risk factor for developing breast, endometrium, ovarian, kidney cancer [10, 11] and certain types of gastrointestinal cancer [12]. There is also evidence which shows contribution of the obesity to the liver failure as well, which has been underestimated until now [13]. Chapter 1: General introduction | 11 Obesity from an evolutionary perspective improvement to the risk factors like diabetes and heart diseases. Those who Obesity is considered the result of the imbalance between energy intake and energy expenditure. Overweight and obese individuals are often in search of the next diet, which may person could afford to eat as much as he or she wanted. The discovery of the famous figurine Venus of Willendorf, in 1908 near the town of reduction for a healthy weight on the long term [27, 28]. Archeologists have suggested many the low-fat diets consist of less calories and helps to lose weight. When one takes a closer look into the figurine, it becomes circumference in adults [29]. However, the weight loss with the help obesity Anna Wake painted by Rubens (1627) medicine is modest; weight loss is often not maintained after the drug is discontinued and the use of Obviously, the pathogenesis of obesity medications is often accompanied by many side effects. Factors beyond diet and exercise influence 3 Bariatric surgery obesity and make the consequences of Bariatric surgery is performed for over 50 years to treat morbid obesity and includes a large number bad diet and limited exercise much of different surgical and laparoscopic procedures. Bariatric surgery has proven its effectiveness in worse than they would be otherwise achieving and maintaining weight loss and improving obesity-related co-morbidities, quality of life, [19,20] and survival [39, 40]. This procedure was associated with a high incidence of complications due to the Ancient Greek physician Hippocrates and one of the most prominent figures of the Arabic malnutrition and various deficiency states and was associated with a significant long-term mortality medical tradition Abu Ali Ibn Sina (Avicenna) were aware of the health hazards associated with [42]. In the last few decades, obesity has increased to epidemic proportions and the gastric bypass is a combination of creating a small gastric pouch and rerouting the small intestine. To face this was initially considered a restrictive and malabsorptive procedure in one. We know that 10% of total body weight loss produces substantial 12 | Thesis: the Endoscopic Duodenal-Jejunal Bypass Liner in type 2 diabetes and obesity Chapter 1: General introduction | 13 Obesity from an evolutionary perspective improvement to the risk factors like diabetes and heart diseases. This ability to store surplus fat from the least possible amount of food intake may have made the difference between 1 Conservative management (diet and behavioral) life and death, not only for the individual but also more importantly for the species. From a historical point of view obesity was the symbol of unlimited approaches to weight loss like: low-, very low-, and moderate-fat diets, high-protein diets, and low wealth and good health. Lowering the proportion of energy different ways of understanding its significance. The first suggestion is that it was a "Venus figure" or intake from fat was associated with lower body weight (by 1. Not only caloric intake contradicted with the current knowledge of the risks of obesity to overall wellbeing and in particular should be restricted; a healthier diet is also very important.

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There are over 1 million spine injuries per year in the United States alone; 50 200mg plaquenil fast delivery early onset arthritis in neck,000 of these injuries include fractures to buy generic plaquenil 200mg on line severe arthritis in neck and back the bony spinal column plaquenil 200mg rheumatoid arthritis longevity. The improvement in automobile restraint systems has increased survival rates from major spinal column injury. An estimated 16,000 people sustain spinal cord injuries each year, with 11,000 of the injured surviving to reach the hospital. Organized football accounts for 42 cervical fractures and 5 cases of quadriplegia per year. Injuries are most commonly missed in patients with a decreased level of consciousness, intoxication, head trauma, or polytrauma. The presence of one obvious spinal injury increases the chance of missing another, more subtle injury. Red flags to alert the practitioner to subtle spine injury are facial trauma, calcaneus fracture, hypotension, and localized tenderness or spasm. Incomplete cord syndromes reflect injuries in which only part of the cord matter is damaged. For children older than 8 to 10 years, the spine behaves biomechanically like an adult. More than half of these children will have delayed onset of neurologic symptoms, and therefore close and repeated exams are needed. Because there is little ligamentous injury associated with civilian weapons, most can be treated closed with external immobilization. Directly examine the back by log-rolling the patient while maintaining in line traction on the neck. Ecchymosis, lacerations, or abrasions on the skull, spine, thorax, and abdomen suggest that force was imparted to underlying spinal elements. After radiographs and a secondary survey have excluded major instability, transfer the patient to a regular bed. High-dose steroid protocols are no longer considered standard of care in the acute management of spinal cord injury. Because the cord ends at the L1-L2 disk space, the level of injury to the spinal column may not match the level of cord injury. The room available for the cord and the native stability of the spinal column vary signi? In the upper cervical spine, the bony elements are highly mobile and stability comes from the ligaments. In the lower cervical spine, the narrow canal leaves little room for translation before cord compression. The mobile lower lumbar spine has a large canal with ample room for the nerve roots. Nerve roots are more resilient than the spinal cord, so injuries at this level tend to be less neurologically devastating. A distraction vector, for example, lengthens the spinal column by tearing its ligaments. Therefore higher energy compression-flexion injuries require operative stabilization. The most severe flexion-compression injury?the flexion teardrop fracture?is the most devastating of all cervical spine injuries compatible with life. The lateral radiograph demonstrates a large triangular fragment of anteroinferior vertebral body with marked kyphosis at the injured level leading to subluxation or dislocation of the facets. Complete disruption of the disk and all the ligaments at the level of injury leads to translation and rotation of the involved vertebrae. How are vertical compression injuries differentiated from compression-flexion injuries? In cervical spine trauma, this is the only mechanism wherein the bony injury is more important than the ligamentous injury. The absence of ligamentous disruption allows some of these injuries to heal in a halo. In higher level injuries or those with neurologic injury, anterior decompression and fusion is recommended. As the spine displaces, the superior end plate of the subjacent vertebra may compress, but this should not be confused with flexion-compression injuries.

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Non-surgical and non-pharmacotherapeutical treatment options include diet cheap plaquenil 200 mg line arthritis in neck causes, exercise buy generic plaquenil 200 mg cure to arthritis in the knee, behaviour modification and psychological support order plaquenil 200mg amex arthritis in back and feet. The effect size has been reported with a single digit weight loss in kilograms which can be maintained. In contrast to experimental settings, implementing life-style interventions in routine primary care that reduce morbidity at population level have proven to be difficult. No current pharmacotherapy possesses the efficacy needed to produce clinically significant weight loss (at least 5 to 10% weight loss) in a large proportion of morbidly obese patients in the long-term. More research is needed on whom to treat, adherence factors and the regain of body weight after discontinuation of pharmacotherapy to more adequately evaluate the cost-effectiveness of pharmaceutical therapy. It has been challenging to develop pharmacotherapy that has gained acceptance by medicines regulatory authorities or remained available for a long time due to their adverse benefit/risk profiles that have emerged with use. Bariatric surgery is currently the only intervention providing significant and long-term weight loss for the morbidly obese (approximately 20% weight loss after ten years) which improves diabetes, hypertension and quality-of-life. However, it is associated with surgical risks (mortality less than 1%), long-term digestive problems and nutritional deficiencies. Savings might be achieved six years after the surgery for the health care systems but whether there are savings after ten years is unclear. Obesity is a chronic and multi-factorial disease which is characterized by an excess of body fat. Since then, the global numbers on obesity have doubled, and in some countries it has tripled. In 2008, worldwide more than half a billion adults were obese (205 million men and 297 million women). In some countries such as Italy the obesity epidemic has come to a halt over the last decade. In some countries, such as France and Spain, only a modest increase in the magnitude of obesity was recorded (2 to 3% increase). In China, the overall rate of obesity is less than 5%, but in some cities it is more than 20%. According to global projected trends it is expected that in 2030, one billion people will suffer from obesity. The same is true for 33% of ischaemic heart disease and ischaemic strokes, 50% of hypertensive disease and 25% of osteoarthritis. An obese person incurs 25% more health expenditure than a person of normal weight. There are control strategies at individual and population levels, some aimed at preventing further overweight and obesity, and others at treating those already affected. In the following sections we will first briefly describe preventative strategies at population level and individual non-pharmacotherapeutic treatment. The main focus of the background paper will be on pharmacotherapeutic interventions that are currently available. As a key indicator for progress, the Member States chose prevalence of obesity, particularly in children and adolescents. Along with the Action Plan, a structure for its implementation was created which includes (1) the High Level Group on Nutrition and Physical Activity, (2) promotion of concrete stakeholder-driven action, and (3) ensuring reliable, comparable and regularly updated data. There are a variety of policy measures (voluntary or statutory) that governments can use to promote the consumption of healthier food. Apart from fiscal measures, governments have been encouraged to consider putting a ban on the sales of certain products: the City of New York put a sales ban on sweetened beverages in containers of more than 480 ml (16 Oz). However, changes in diet habits and increased physical activity are very challenging for most people, although achievable through either community support or strong motivation; for instance, it has been estimated that with dietary and lifestyle modification around 80% of highly motivated patients are unable to achieve weight loss long-term. This is primarily due to mechanized transportation and labour-saving technology at home. For instance, in both children and adults there is an association between hours of viewing television and the risk of obesity. It has shown encouraging results for small cities in lowering childhood obesity and more studies are underway to test whether it also worked in larger urban or very rural areas.

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Others the diagnosis of discogenic thoracic spinal pain requires claim to buy 200mg plaquenil with mastercard rheumatoid arthritis diet restrictions localise the problem to generic 200mg plaquenil fast delivery arthritis walk a specific segment or segments cheap plaquenil 200mg otc psoriatic arthritis diet book, confirmation by an appropriate response to selective anaes based principally on finding altered joint or muscle function, thetisation or provocation discography of the painful disc. It is not surprising, therefore, that to rigorous tests of reliability and validity of diagnostic tests, or efficacy of treatment. The tests serve principally to exclude non-mechanical causes of only study on this topic simply demonstrated that thoracic pain. H owever, some proponents of mechanical models of discography could be performed (Schellhas et al. Zygapophyseal Joint Pain Conditions Referring Pain to the Thoracic Spine the strongest evidence pertains to the zygapophyseal joints as a the thoracic spine may be the source of referred pain, or a site source of pain. Therefore the location of pain volunteers and in those with thoracic spinal pain who have had in the thoracic region does not necessarily im ply a local their pain relieved by blocks of these joints (Dreyfuss 1994). The pain may be referred from the cervical zygapophyseal joints and felt paravertebrally or just lateral to the paravertebral Somatic Sources of Pain There are no clinical or epidemiological studies; however the region (Fukui 1996). Experimental studies in normal volunteers and in patients have Because costovertebral joints are innervated they are poten demonstrated that pain from structures in the cervical spine tially a source of pain, however as the techniques of blocking can be referred into the upper thoracic spinal region. Referred these joints have not been described, the prevalence of pain pain in this region can arise from the lower cervical zygapophy arising from these joints is unknown. The thoracic spinal dura mater, longitudinal ligaments and 1996), the cervical muscles (Feinstein et al. Referral of pain from visceral structures should always be Pain of M echanical Origin considered, especially when there are no clear mechanical Pain of mechanical origin should include any pain that is features to the pain and other non-spinal sym ptom s are somehow related to movement or sustained posture. Visceral conditions that may refer pain to the thoracic ical sense, however, this category specifically excludes serious spine are listed in Table 5. Synonyms for mechanical pain, include: pain or heaviness and sometimes nausea, but occasionally pres-. Spondylogenic or non-radicular pain ents with pain radiating to the back (Kelley 1997). No causal relationship was estab region and is often accompanied by nausea and vomiting. Cervical causes of the may refer pain to the back, around the level of the thora arm and head symptoms were not excluded. The pain of acute pancreatitis may be so Some authorities have reported that in some 40% of cases severe that there may be difficulty determining whether it orig of low back pain, the origin of the pain is in the thoracic spine inates in the abdomen or the back. Prevalence of Conditions Causing Conditions Referring Pain from the Thoracic Spine Acute Thoracic Spinal Pain Although this document is focused on pain within the anatom the Australian Institute of Health and W elfare (2000) describes ical limits of the thoracic spine, a brief discussion of sites to the prevalence and incidence of back pain but does not distin which thoracic spinal pain can refer is warranted as this is often guish thoracic spinal pain. Three estimates of the prevalence of a feature of the presentation of thoracic spinal pain. A pain clinic in the Netherlands reported a rela have demonstrated that pain from thoracic spinal structures tive incidence of cervical, thoracic and lumbar spinal pain in can be referred to the posterior and anterior chest wall and into their patient cohort as 5:2:20, respectively (Stolker et al. Such patterns of referred pain have been In a primary care series of 1,975 ambulatory patients with back dem onstrated for the thoracic interspinous ligam ents pain, approximately 16% had thoracic spinal pain as their chief (Feinstein et al. In a Hawaiian study of 645 W hitty 1967), and the thoracic zygapophyseal joints (Dreyfuss postmenopausal women the prevalence in the preceding 4. This type of referred pain is years of pain in the neck and above the shoulder blades was described as dull and aching; it tends to be poorly localised, reported as 7. The prevalence of pain between the shoulder not corresponding to dermatomes, and is felt deeply in the blades and the lowest rib level was 4. Pain from distended zygapophyseal joints of normal Prevalence data for particular conditions underlying presenta volunteers between T3 and T10 follows reasonably constant tions are presented in Table 5. Referral zones spread from one half of a segment superior to two and a half segments >History inferior to the joint and extend laterally to no further than the this chapter deals with aspects of history-taking that are specific posterior axillary line. Pain from the C7?T1, T1?2 and T1?3 to the problem of acute thoracic spinal pain and differ from the is referred variably to an area including the suprascapular elements of history-taking for other pain problems. For a discus region, the medial angle of the scapula and the midscapular sion of pain history in acute musculoskeletal pain in general, the region (Fukui et al.