ObjectiveThis retrospective study aimed to evaluate the impact of anti-obesity medication (AOM) initiation, usage and duration on weight loss in a 72-week precision obesity programme. The type of AOM, diet and exercise plan was chosen based upon an individual's biological and psychosocial needs. The 72-week study duration allowed for a fair investigation of the downstream impact of delayed versus early AOM initiation. MethodsParticipants, aged ≥18 years with body mass index ≥30 kg m À2 , enrolled from 1 March 2015 to 1 April 2017, were included. Subgroups were assigned by AOM usage (users versus non-users, early [before 8 weeks] versus delayed [after 8 weeks] AOM initiation and short [<6 months] versus long [≥6 months] AOM duration). Primary endpoints included change in baseline weight at 72 weeks and proportions achieving ≥5%, ≥10% and ≥15% weight loss. Outcomes were compared between subgroups. ResultsMean age and body mass index (N = 129) were 45.0 ± 14.0 years and 37.0 ± 6.0 kg m À2 , respectively; 67% were female. At week 72, AOM users (N = 71) achieved significantly greater mean percentage reduction in baseline weight than non-users (N = 58). On average, baseline weight decreased by 14.04 ± 6.2% in users versus 10.9 ± 6.8% in nonusers (P = 0.008); 84% and 94% of non-user and AOM users lost >5% weight loss (P = 0.006). A higher proportion of users lost ≥15% of weight (45.1% vs. 19.0%; P < 0.001). Mean percentage reduction in weight was greater for early versus delayed starters (À17.60 ± 5.3% vs. À13.95 ± 5.5%; P = 0.024), and longer AOM usage trended towards increased weight loss. ConclusionEarly initiation of AOM may enhance weight loss.

Patient: Male, 60-year-old Final Diagnosis: Mirizzi syndrome Symptoms: Dark stools • jaundice • painless jaundice Medication: — Clinical Procedure: ERCP with stent placement • spyglass cholangioscopy Specialty: Gastroenterology and Hepatology Objective: Unusual clinical course Background: Isolated painless jaundice is an uncommon presenting sign for Mirizzi syndrome, which is typically characterized by symptoms of acute or chronic cholecystitis. We report a rare case of Mirizzi syndrome with an acute onset of painless obstructive jaundice. Case Report: A 60-year-old man with an unremarkable prior medical history presented with 1 week of jaundice, dark urine, and acholic stools. His laboratory studies revealed a pattern of cholestasis with marked direct hyperbilirubinemia. Ultrasound and magnetic resonance imaging studies demonstrated intrahepatic ductal dilation and cholelithiasis, including a stone within the cystic duct. Endoscopic retrograde cholangiopancreatography with SpyGlass cholangioscopy confirmed the diagnosis of Mirizzi syndrome. Conclusions: An atypical presentation of Mirizzi syndrome should be suspected in the setting of biliary obstruction without pain. The differential diagnosis is broad and includes choledocholithiasis, ascending cholangitis, and hepatobiliary malignancy. Evaluation should include laboratory studies and biliary tract imaging. Noninvasive biliary tract imaging can help exclude malignancy and confirm ductal dilation but is not sensitive for Mirizzi syndrome. Endoscopic retrograde cholangiopancreatography can serve both diagnostic as well as therapeutic purposes via stone extraction and stent placement. SpyGlass cholangioscopy can also augment management in the form of Electrohydraulic lithotripsy. Although therapeutic biliary endoscopy can be very effective, cholecystectomy remains the definitive treatment for Mirizzi syndrome.

During constant load exercise, some otherwise healthy obese women experience dyspnea on exertion (+DOE), while others do not (−DOE). We investigated how the subjective quality of respiratory sensations differed between these groups. 80 women were categorized based on their Ratings of Perceived Breathlessness (RPB, Borg 0–10 scale) after 6 minutes of 60 W cycling. 34 women rated RPB ≥ 4 (+DOE) (34 ± 7 yr, 36 ± 5 BMI) and 24 women rated RPB ≤ 2 (−DOE) (33 ± 8 yr, 37 ± 4 BMI). 22 women with RPB = 3 were excluded to better delineate the groups. After exercise, subjects were asked to pick three of fifteen statements that best described their respiratory sensations. Descriptor data were analyzed as frequency statistics and compared using Fisher's exact test. The top descriptors chosen by +DOE women were “Breathing is heavy” (53%, p < 0.05), ”Breathing requires work” (50%), and “Breathing requires effort” (38%); −DOE women selected “I am breathing more” (82%, p < 0.05), “Breathing is rapid” (38%), and “Breathing is shallow” (38%, p < 0.05) most often (p values depict those descriptors that were different between groups). Not only is the intensity of breathlessness significantly different between these groups, but also the qualitative aspects of their breathlessness. +DOE women may have an increased sensation of the work of breathing than − DOE women, which may be related to the elevated RPB.NIH HL096782, King Charitable Foundation Trust.