Summary Objective To assess vitamin D status and the influences of race, sun exposure and dietary vitamin D intake on vitamin D levels, and to evaluate two vitamin D repletion regimens in extremely obese patients awaiting bariatric surgery. Methods A cross-sectional analysis of dietary vitamin D, sun exposure, PTH [intact (iPTH) and PTH(1-84)] and 25-hydroxyvitamin D (25OHD; differentiated 25OHD2 and 25OHD3) in 56 obese [body mass index (BMI) > 35 kg/m2] men and women (age 20–64 years). In a pilot clinical trial, 27 subjects with 25OHD levels < 62 nmol/l were randomized to receive ergocalciferol or cholecalciferol for 8 weeks. Results Serum 25OHD was low (mean 45 ± 22 nmol/l) and was inversely associated with BMI (r = − 0.36, P < 0.01). Each BMI increase of 1 kg/m2 was associated with a 1.3 nmol/l decrease in 25OHD (P < 0.01). BMI, sun exposure, African American race and PTH predicted 40% of the variance in 25OHD (P < 0.0001). Serum 25OHD significantly increased at 4 and 8 weeks in both treatment groups (P < 0.001), whereas PTH(1-84) declined significantly in subjects treated with cholecalciferol (P < 0.007) and tended to decrease following ergocalciferol (P < 0.09). Conclusions In severely obese individuals, those who are African American, have higher BMI and limited sunlight exposure are at greatest risk for vitamin D insufficiency. These demographic factors can help to identify at-risk patients who require vitamin D repletion prior to bariatric surgery. Commonly prescribed doses of ergocalciferol and cholecalciferol are effective in raising 25OHD. Further investigation is needed to evaluate whether these regimens have differential effects on PTH, and to determine the optimal regimen for vitamin D repletion in the extremely obese patient.

The objective of this study was to characterize changes in metabolic bone parameters following bariatric surgery. Seventy-three obese adult patients who underwent either gastric banding (GB), Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion with duodenal switch (BPD/DS) were followed prospectively for 18 months postoperatively. Changes in the calcium–vitamin D axis (25-hydroxyvitamin D (25OHD), 1,25-dihydroxyvitamin D (1,25(OH)2D), calcium, parathyroid hormone (PTH)), markers of bone formation (osteocalcin, bone-specific alkaline phosphatase) and resorption (urinary N-telopeptide (NTx)), as well as bone mineral density (BMD) were assessed at 3-month intervals during this time period. Bariatric surgery resulted in significant and progressive weight loss over 18 months. With supplementation, 25OHD levels increased 65.3% (P < 0.0001) by 3 months, but leveled off and decreased <30 ng/ml by 18 months. PTH initially decreased 21.4% (P = 0.01) at 3 months, but later approached presurgery levels. 1,25(OH)2D increased significantly starting at month 12 (50.3% increase from baseline, P = 0.008), and was positively associated with PTH (r = 0.82, P = 0.0001). When stratified by surgery type, median PTH and 1,25(OH)2D levels were higher following combined restrictive and malabsorptive operations (RYGB and BPD/DS) compared to GB. Bone formation/resorption markers were increased by 3 months (P < 0.05) and remained elevated through 18 months. Radial BMD decreased 3.5% by month 18, but this change was not significant (P = 0.23). Our findings show that after transient improvement, preoperative vitamin D insufficiency and secondary hyperparathyroidism persisted following surgery despite supplementation. Postoperative secondary hyperparathyroidism was associated with increased 1,25(OH)2D levels and increased bone turnover markers.

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As the number of Americans with prediabetes and diabetes continues to grow,so too will the number of patients who come into the hospital with hyperglycemia. Although tight glycemic control has been a well-established goal in the outpatient setting, it has only recently gained heightened interest in the inpatient arena. There is a growing body of knowledge supporting the benefits of strict glycemic control in hospitalized patients,yet there is little or no formal didactic training for health care professionals in inpatient management of patients with diabetes. Despite widespread inpatient hypoglycemic and hyperglycemic events, there are few systems in place for effective diabetes care and management. In January 2006, the American Association of Clinical Endocrinologists, the American College of Endocrinology, and the American Diabetes Association convened a meeting titled “Improving Inpatient Diabetes Care: A Call to Action Consensus Development Conference,” which concluded that facilitating these changes required a paradigm shift that involves modifying both individual and institutional beliefs and practices that have been status quo for decades. One of the key consensus recommendations was the formation of an interdisciplinary steering committee to identify deficits, develop strategies, and facilitate the implementation of interventions to improve inpatient care. This article illustrates the planning and implementation of a systems-wide model to conquer inpatient hyperglycemia in an academic medical center.

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Purpose of reviewObesity is a worldwide epidemic. As the rate of obesity continues to soar, so too does the number of bariatric surgeries performed. Many of these surgeries achieve weight loss by limiting food intake or its absorption. The malabsorption results in an increased risk of developing calcium and vitamin D deficiencies. Whether or not this increasing population is at greater risk of osteoporosis or fractures has yet to be determined. Recent findingsA number of studies have shown that after bariatric surgery there are a number of changes in bone metabolism. Increased rates of vitamin D deficiency, secondary hyperparathyroidism, hypocalcemia, bone turnover and bone loss have all been reported. Summary It is clear that bariatric surgery causes changes in bone metabolism. It appears that the degree of change is dependent on the amount of weight loss and malabsorption achieved. Nonsurgical weight loss and purely restrictive procedures cause moderate increases in bone turnover and moderate decreases in bone density. The procedures inducing malabsorption are associated with more significant increases in bone turnover and decreases in bone density. There is also an increased incidence of vitamin D deficiency and secondary hyperparathyroidism.Keywords bariatric surgery, bone metabolism, bone turnover markers, hyperparathyroidism, obesity, vitamin D and calcium deficiency

Background: Low back pain (LBP) and sciatica is a common clinical condition worldwide.The initial treatment of Low back pain is conservative. Epidural steroid injection (ESI) is being slowly established as a reliable mode of conservative management in many orthopaedic centres of the world. This is a preliminary report of ongoing study of the use of epidural steroid injection the management of low back pain cases coming to the orthopaedic department of Government Medical College Jammu. Methods: 150 Patients reporting with low back pain and sciatica not responding to other modes of conservative treatment were prospectively followed over a two year period. The caudal epidural steroid injections were performed, as many as three injections two week apart .The patients were assessed before and after the procedure clinically and the Level of pain, improvement in physical signs and ability to do activities of daily living were noted. Results:150 patients were observed for the duration of 2 years. Average duration of symptoms was for six months. After first epidural steroid injection 80% [120] of patients reported relief within first two weeks. Forty Four (44) patients required two injections and 12 patients required three injections. Twelve (12) patients reported no relief after first injection. The duration between two injections was two to three weeks. Average duration of pain relief was 17days. At the end of three months, good results were seen in 49%, fair in 32% and bad results in 18%. Overall 69% of patients were able to do activities of daily living. Most common complaint of patients after injection was pain at the injection site. No major complications were encountered. Conclusion: Epidural Steroid Injection is a simple, cost effective and minimally invasivemode of treatment of Low Back Pain and sciatica. It provides pain free period to enable the patient for physiotherapy which helps in early recovery.

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