In discuss ing tbe situation to day, Hugh O'Donnell said. The Fiokerton incident has put a false com plexion on affiirs and changed tbe chan nel of tbe public's estimation of oar rights and wrongs. Many people think we intend endeavoring to maintain pur position by lawless means. Such never was our intention.
Tbe workman's only effective weapoD, boycott, will be em ployed, and we will endeavor to strike a blow at Carnegie every industry. It is stated he intends starving us into sub mission, we have not as much money as he, but we are willing to fight him on bis own grounds. Sacb assistance as the strike at tbe Lawreoceville mills, and the action of tbe carpenters in refusing to work in a building wbere Carnegie beams or materials are used, help as, and in that way we will win.
I will guarantee there will be do barm offered non-union men c ming bere, but I cannot offer the same protection to Pinkertons, for every man, woman and child in Homestead goes wild at tbe mention of them. There was probably never such unanimity of opinion in a strike in tbis country, and we will present an un broken front to tbe end. Wallace, July 15 Last night about 10 clock two heavy exploiions were beard at VJallace.
In a moment excitement and consternation prevailed. A special train was soon prepared on tbe Union Pacific, and a company of troops were marched to the depot. Tbe explo sions were followed by a report that tbe Gem mill and the Granite mill bad been blown up. For some reason a fear sprung up that the Northern Pacific train would be blown up if it made tbe run to Gem in the darkness, and a report wag started that the white troops would re ceive a welcome up Canyon creek, but that tbe black troops would be blown out of tbe canyon witb gian powder.
As all troops look alike in the daric it was thought best not to move tbe train, and troops were marched back to camp. Another report was started that tbe mountains about Wallace were full of armed miners, and that tbey were seen moving about just before dark to secure positions of advantage. Tbere was nothi ng in any of these reports, but tbey were incident to tbe situation.
Slarder In Kittitas County. Tacoma, July ' M , Richard Sea, an Irishman about 50 years f age, was murdered ia cold blood yes terday by J. Hendrick, a claim bolder, residing on tbe east sideot Yakima river, opposite Easton. Hendrick claims self defense. Tbe men were wood-choppers. Hen dricks statss that Sea visited big place early in tbe evening, presumably think ing tbat be Hendrick was not at borne. Tbe deceased picked up several tools from outside tbe cabin and started off. In stead of doing as directed, S?
Sea died soon after. The murderer gave himself up and is being guarded, pending the arrival of the sheriff from Eilensburg. Sea bote an unsavory reputation. Dallas, Or. To day T. Bichmoad,an old resident of Polk county, was accidentally killed at bis farm near Dallas, r Wbile climbing a fence oo bis place be was seen to suddenly fall back and strike bis bead against tbe ground, dislocating bis neck.
He was carried to toe nouse ana meaicai aia summonea, but be died almost immediately alter tbe accident. Richmond bas for yean been well known throughout tbe valley and Eastern Oregon. He was born in Illinois in , came to California in , and settled in Oregon in He leaves a wife and Bye children. Tbe remains were to day brought to big borne in Dallas, and the funeral will take place Sunday under tbe auspices of tbe Masons.
Rich mond was an upright, progressive citi zen, and bis death casts a shadow over tbu entire community. The Arrests at Burke. Idabo, July Martial law is vigorously enforced at Burke, and ar rests were made by the wholesale to-day.
Tbe Federal troops arrived at 8A. M, over tbe union Pacibc. There were three companies under command of Cap tain Bubb. Tbey were quickly martialed into order, and detachments detailed to guard tbe approaches to tbe city, and even precautions were taken to prevent the escape of the day shifts working in the Poorman and Tiger mines.
The soldiers were stationed around the posts, tnnnels and at different points along tbe flumes. It was quite evident tbe intention was to arrest those at work wben coming up for dinner. At tbe sound of tbe whistles tbe hoists began hauling up at express speed. There were batch after batch of miners from tbe and foot levels, glad to breathe one hour of fresh air and sunshine. But tbey were indescribably amazed as United States Deputy Marshal Hullman informed tbem they were seized by tbe strong grasp of the law and were bis prisoners.
Heavily guarded, 76 miners, witb their wet clothes and gum boots, were marched two deep to tbe depot. They were not allowed even to partake of dinner, whicb was ready, though James Clark, unperinten dent of tbe Poorman mine, appealed to those in command to permit them to wail for dinner and change tbeir clothing I be officers were obdurate and took no chances with tbeir prisoners.
Even Mr. Clark 8 nephew, James Casey, was not privileged to make preparation, and was compelled to share tbe discomfort and in dignity of the others. The cltiz'-os de nonnced m the strongest terms such treatment of the miner? Several prominent business men were also ar rested. Gard ner, J. Tnggs and Judge Pulse. In all were arrested and taken by special tram to Wallace. A Wrrck In California.
Baeersfield, Cal. A fright ful wreck occured at 2 o'clock this morning, resulting iu the death of two tramps wbo were instantly killej, and the fatal scalding of Brakeman Frank Donnelly. Freight-train No. Tbe result was one of tbe biggest wrecks ever seen in tbis vic inity.
Engineer Ed Goble was thrown from the engine, but escaped witb a few cuts about the bead, unless internally in jured. Fireman Fred Crosby crawled out of tbe wrecked engine witb a slight sprain. Brakeman Donnelly was riding in the cab of tbe engine, and was caught and badly scalded, tie was taken to Sumner, bnt cannot live. He is a native of Canada, aged 19, and a recent arrival. Eleven freight cars are piled one on top of tbe other, and tbe engine is com pletely demolished.
Tbe tender was thrown completely over the top of the engine. There were seyen carloads of ice, one car of beer, two cars of canned goods, one car of wine, and one car of general merchandise in the wreck. Tbe balance of tbe train was backed up to Glenburn. Tbe passengers, baggage, express and mail from trains No. Tbe road will not be cleared nntil evening. Two tramps wbo escaped state tbere were six in the party. It is supposed the other two are still in the wreck.
Tbere are a large-number of people at the scene of disaster. The bodies of tbe tramps were removed to tbe morgue. Tbe New Bridges. Washington, July Tbe action of Secretary Elkms in approving the plans of the Portland bridges is due to nothing else than tbe fact that tbe senators and representatives in congress appeared before bim and told him tbat tbey wanted bis approval. Elkins bas aid tbat it was unnecessary for tbe Portland committee tocome bere, which is true, as tbe bridges would baye been approved anyway.
The higher officers n tbe engineer corps do not care to an tagonize a state delegation, when one of them is a member of the commerce com mittee in tbe senate and another of tbe rivers and harbors in tbe bouse. Tbese are the facts tbat upset tbe report of tbe board of engineers and secured the ap proval of tbe plans for two more bridges across the vVillamette. A Mtevens County Fend. Spokane, WnshM July Sheriff Hayden, of Stevens county, aod Eber C. Smith, a lawyer and tbe editor of tbe Stevent County Standard, published at Colville, met in front of the Rookery build.
Sheriff Hayden was intoxicated, and knocked Smith down twice. Smith then retaliated by clubbing bim with a revol ver and inflicting a long ragged sculp wound on the side of Havden s bead. The quarrel waa tbe result of a feud, in tensified lately by caustic personalities regarding Hayden which appeared ia Smith's paper.
Hayden is a Grand Army man and bas tbe sympathy of tbe com rades bere. All quiet In Wallace. Wallace, July Tbe steady tramp of tbe military bas been beard all day and about all tbe arrests ia Wallace deemed necessary have been made. Col onel Tbeaker bas command of tbe troops in tbis city. He bas seven companies of 40 men each and be expects more troops. Otber towns will also receive additional companies. Tbere are -about reg ulars now in the Coeur d Alenes.
Some prisoneis, including those from Burke, are confined ia tbe buildings about the military camp, and it will be quite diffi cult to provide sleeping accomodations for them. Colonel Theaker says they are state prisoners, aod tbe state must pro vide accomodations and food. Several were stripped of tbeir clothing and bad been robbed of everything tbey possessed. In addition to tbis tbey bad bad nothing to eat. Tbe general thinks many must have been killed and tbeir bodies thrown into tbe river or otherwise disposed of.
A searching party bas just been sent from this end to aid in tbe search," An Inoffensive flan Fatally Wennded by a Soldier. Tbe affray is tbe outcome of a night's carousal tbat Lester and Howard bad indulged in dur ing tbe night. They were still drunk this morning. Tbey went along Grant street insulting every person that tbey met and brandishing their bayonets in tbe facea of passers-by.
Tbey entered tbe room ot Undertaker Bernsbauer singing, and were very noiev. Bernsbauer ordered tbem out. Tbis they complied witb, but re newed tbe noise outside tbe building. They defied arrest, but wben Bernsbauer telephoned for an officer the drunken men started off. Wben they reached Devere's undertaking establishment, wbere Calhoun was employed, the latter advised Lester to be more careful witb tbe bayonet be was thrusting about Lester, with a vile exclamation, plunged the weapon into Calhoun's stomach Calhoun fell without a struggle.
Lester rushed upon bim again, but was cangbt ov bystanders. After a bard nght Les ter and Howard were arrested. Mc Kelvy, wbo attended Calhoun, says tbere is no hope of bis recovery. Ca houn is 34 years old. He is a member of the G. Lester lives in the thirty-second ward, aod Is 2 i years old.
Fears or a Conflict. Homestead, Pa. One of Carnegie's foremen spoken o about tbe matter treated it with ridi cule, saying tbere were plenty of non union men in this country, and tbat part of tbe works will be started by this alter noon. Tbe tension between the strikers and tbe military is increasing. Tbere are many irresponsible, reckless men in town, mostly with some sort of arms, and an untoward event might precipitate a conflict.
Tbe military, white not expect ing such an outcome, are evidently pre paring tor it. A large additional amount of ammunition has been received from Frankford. There are at least Another regiment was brought over the river tbis morning, and it is nnderstood three others will be brought over day by day. Alt is quiet at the big mills, and tbere is no visible evidence of tbe indention to start up to day. Amal gamated officers bere say they knov notbing of tbe paper asking for aid said o bo circulating in New York, and pro nounce it a fraud.
Railroad men denv tbe truth ot the rumor that they will refuse to handle freight for the Home stead mill. To Adjonrn nonttay. The ways and means committee of tbe bonse tbis morn ing adopted a resolution providing for tbe final adjournment of congress tho 25th. Unless something uoforseen arises, it is believed it will be adopted by both bouses. This meeting about completes the work of tbe committee tor this season.
Tbe policy of some of the Democratic mem bers for a postponement of farther at tempts at tariff revision prevented action on tbe sugar, salt, lumber, iron ore and otber proposed bills. Tbe improbability ot anv additional tariff bills emerging from tbe ways and means committee is increased by the fact tbat the Republi can members of the committee are not disposed to assiit tbe Democrats oo tbe committee to secure a quorum.
Word was received by tbe Democratic mem bers tbat tbe Republican members would not attend any seesiou of tbe committee, except for tbe consideration of tbe ad journment resolution. It was reported to day tbat ibe number ot Democrats make it Impossible tor tbe committee to do anything. Tbis refusal of tbe Repub licans, if persisted in, besides preventing reports on additional bills, will render m possible an adverse report on tbe tub- treasury bills, and also on Dalzeli's res olution of Inquiry witb reference to the losses sustained tbrougb national and through state banks.
Bankers Arrested for Murder. Tbis afternoon information was lodged before an alder man cbargtosr murder against Hugh O'Donnell, principal leader of tbe Home stead men; John McLuckie, burgess of Hoa. Tbey are specifically charged with tbe murder of T. Connors and Silas Wayne, Pinkertons, killed in the fight.
AH tbe accused will probably be arrested tbi afternoon, except O'Donnell, wbo is out of tbe city. Sad Accident at Marshneld. Mabshfield, Or , July 18 A sad ac cident "happened to Mrs. McGee at ber borne in Ten-Mile yesterday. She was stopping with ber daughter, Mrs. The latter seeing a large chicken bawk light in the yard, seized a shotgun to shoot tbe bird, and just wben she pulled tbe trigger ber frightened mother ran in front of ber and tbe full charge of buckshot lodged in ber left leg just be low the knee.
McGee was brought to town to day for medical treatment, and it is feared ber leg will have to bo ampn tated. Hungarians Are Destitute. Laborers in tbe mill, net members of tbe Amalgams ted Association, made idle by tbe lockout, mostly Hungarians, are absolutely desti tute, and the strikers are now holding a secret meeting to consider tbe question of providing for tbeir maintenance. Some of tbe mechanics are preparing to leave town, being promised jobs elsewhere. Fire was started in one of the furnaces tbis morning.
Nobody knows what it means, but it bas given rise to fresh ru mors tbat non union men are com'ng. Servant girls at the hotel refuse to wait on tbe militiamen. Threaten to Blow np Mills. Missoula, Mont. The Fort Keogh troops passed here at 4 o'clock tbis morning. They should reach tbe scene ot trouble early tbis afternoon. Two loud explosions were beard west of Mullao lost uight, but as the wires are cut definite information cannot be ob tained.
It is reported tbe miners threaten to blow up all tbe mills if forced out by tbe militia. Blowing np Bridges. Spokane, July Word is just re ceived tbat the terrific explosion heard over in Coeur d'Alene last mgbt wis caused by the strikers' blowing up the railroad bridges between Mullan and Wallace. Sew Try This. It will cost you nothing and will surely do you goid, if you have a cough, cold or any trouble with throat, chest or lungs.
King's New Discoyery for Consump tion, Coughs and Colds is guaranteed to give relief, or money will be paid back, Sufferers from la grippe found it just tbe thing and under its use had a speedy and perfect recovery. Try a sample bottle at our expense and learn for yourself just how good a thing it is. From Saturday Daily. Several of our citizens have left for tbeir summer vacation at the seaside.
Cradlebangb, of the Hood Riyer Glacier, is in the city to-day. Sargeot, secretary of tne association, are in the city. George P. Morgan left the. Long freight trains leave The Dalles daily loaded with wool and fruits. A double- header passed up the road this moruioit hauling a long hue ot cars. Moro Observeri The contract for the con struction of the vault for the county re cords has been awarded to H.
Jackson, of Wasco, an experienced builder, whose work will, we are sore, give us full satis faction. The steps are nearly finished on Federal street np the bluff. Ibis will be quite an accommodation to residents on the bill and furnish an easy means of going to and from tbeir residences. Wool is being Bhipped directly to Boston from cur waieiionses, and Moody is sending away vast quantities.
The- clip is not all received, but it has accumulated to such an extent that the space became crowded. These pencil-pa -hers de sire to enjoy themselves during their sea. We received a call to-day from Mr. Heald and Mr. Sargent of the Horticultural Asso ciation. Tneae gentlemen are visiting this region for the purpose of stimulating our people to earnest effort agaiost fruit pests, and especially the San Jose scale, and we bope they will be successful.
To one who looks over the burned district. Sheriff Ford, of Washington county, took down on the morning truin a man named Dave Yonng, who was arrested in Sherman county, and lodged in jail in this city. Yonng escaped from tail while serving a sentence for selling liquor without a license and made his way to Eastern Oregon. Yes terday he wss brought to town and Mr.
Ford notified that his man was caught. It is reported that a new society is to be organized by the young ladies of onr city, oalled the nail brigade. It was remarked by a yonng lady this morning, as she dis played a fine new shoe which bad just had a large bole torn in tbe side by a nail stick ing up in the sidewalk, that "we are going to form a nail brigade and some of tbeso fine evenings will march down our principal afraa.
Moro Observer: Michael King killed a arge congar a week from last Sunday. Mike was camped with his sheep near a place called English Springs, in Wasco county, and while oat with bis flock his trasty dog espied Mr. Cougar and treed him.
While the animal was lodged in tbe branches of the tree Mike drew a careful bead on him with his Winchester and put a ballet through his carcase. Tbe animal was seven feet nice inches from tbe tip of his nose to the end of bis tail. We understand that Mr. Richmond, former resident of The Dalles died in Folk county yesterday. He is well known to many old residents, and waa a companion of Major Victor Trcvitt, wbo now lies in bis mausoleum on Memaleuse island.
It was in pioneer days when Mr. Richmond lived in this city, and it is a matter of re gret that the old-timers are passing to tbe silent shore quite rapidly, in later years he bos been engaged in the farming indus try in Polk county.. Baker City Blade: J. Hardee, a pro minent mining man from Spokane, to-day met with what might baye proved a fatal accident only from sheer good lnca. The gentleman was riding horseback oyer the bill adiacent-to tbe Virtue mine wben tbe animal stum bled and fell on bim, breaking his leg.
Tbe gentleman waa fortunate enough to disengage bis feet from tbe stir rups, else be might have been killed. He was broght to town and taken to his rooms at the VVarshauer, where Dr. Dodson was summoned. The doctor set tbe fractnred limb and eased the gentleman consider able.
It waa in tbe morn ing, and it was yet dark. He has a well-deve'-oped faculty of remembering faces, and by constant inquiry located bis customers. One of the men will soon be arrested, aod proves to be a bard cose. Condon Globe: Tbe friends of D.
Ward made application to have him admitted to bail a few days ago before the jastioe court that committed him to jail for killing Jnbn Looney, meutiou oi which was made 4ast week. The application was granted, and as soon as the bond was prepared, eighteen of the responsible citizens of Cond n and vicinity stepped forward aod signed the bail bond as fast as they could sign it.
There was room for no more names, bnt many others were anxions to go on the bond. This is a straw tbat indicates tbat the people are with Ward in this trouble. Probaseo, who is wanted in Siski you county, California, to answer to the charge of commiting a cold-blooded murder, has escaped- He was arrested by Deputy Sheriff McConaba, of Areata, Humboldt county, and Sheriff J. Endert, of Del Norte county, at Cbetoo, Oregon.
Mc Conaba took bim down to Areata, a town 12 miles north of Eureka, wbere be begged to be allowed to stop and continue the trip next morning, and McCanaha being led off by smooth talk, acceded to his wish. Pro baseo told bim tbat he was willing to go back and stand trial, and expressed regret that he had not given himself up at the time of the commission ot the offense.
He also said that be had no desire to escape, and would not attempt it. McCanaha, it seems, took bim at bis word and went borne and went to bed, returning in tbe morning with the published result. Notices have been sent to every shipping point in the country, to all the deputies and to eyery place tbat there would be a possibility of bis going, so that if he attempts to get out it will be a bard matter, unless he travels at night altogether.
East Oregonian: Three strange Indians were noticed on the streets a day or two since. Tbey are Bannocks, one being a "big chief' of that tribe. Since the war of tbere baa been bad blood between the Bannocks and tbe Umatilla reservation In dians. Prior to tbat time they were very friendly and engaged in trade, tbe Umatil la exchanging ponies for furs and buffalo lobes.
Bat in tbe Umatillas took op arms on the side of the whites against the hostile Bannocks. Tbe latter's chief, Kan, waa slain by Ten-e-ou-itx, and a force of Bannocks waa driven ' through the Camas Prairie country by a party of Umatilla braves. Tbe hearts of each tribe have sine been tamed against the otber, and there have been no relations between them. They were well received on the reservation, diffi culties were patched up and the hatchet buried deep. As is customary with the In dians a number of presents was given tbe Visitors as a token of good-will.
These devices establish duodenal exclusion and result in greater weight loss than diet and exercise alone up to 12 weeks post-insertion [ 17 ]. They may also improve glycemic control in those with type 2 diabetes mellitus T2DM [ 18 ]. However, long-term data remain to be reported and the device is often poorly tolerated [ 18 ].
Other techniques for the treatment of obesity include the intra-gastric balloon, which can be effective for short-term weight loss [ 16 ]. However, these newer techniques remain in the experimental realm and data on long-term clinical efficacy are not available. The device may be developed for use in those with diabetes and obesity who decline laparoscopic bariatric surgery. Patient selection criteria for bariatric surgery include body mass index BMI , the presence of co-morbidities and a history of prior weight loss attempts.
If a candidate meets the criteria for surgery, then a multi-disciplinary team assessment is made as to the suitability of the candidate. This is a complex process involving psychological, surgical, dietetic and medical review. The individual must be physically and psychologically fit to proceed to surgery.
Expectations must be managed and a determination must be made as to the individuals' ability to comply with post-operative care. The decision to operate will take into account the benefits the candidate is likely to gain, and the risks peri-operatively and post-operatively. Some reports suggest an increased risk of suicide after bariatric surgery, although the etiology remains unclear [ 6 ].
Major failures of bariatric surgery are due to poor psychological adaptation, especially if the patient's expectations were not adequately managed. All candidates should be given the correct and realistic information on what the procedure can achieve. If this is addressed, then the risk of surgical failure can often be mitigated [ 22 , 23 ]. This personalized assessment is a vital part of the pre-operative assessment.
For each patient the benefits of the procedure should outweigh the operative risk. In general, obese patients have an increased prevalence of cardiopulmonary disease that may be undiagnosed pre-operatively [ 24 ]. An individualized pre-operative assessment should be completed by a multi-disciplinary team [ 25 ]. Pre-operative investigations should focus on screening for cardiac arrhythmia, prolonged QT syndrome, and cardiomyopathy [ 25 ]. However, this is not associated with a greater rate of peri-operative complications [ 28 ].
Male gender, age older than 50 years, congestive heart failure, peripheral vascular disease and renal impairment are associated with greater mortality [ 29 ]. Once the candidate has been selected, then the appropriate procedure must be chosen. Unfortunately, there is no evidence based medical approach for procedure selection, and this remains one of the most frustrating shortfalls in bariatric practice for clinicians and patients.
Clinicians take a pragmatic approach to the choice of procedure, and the decision is determined by the individuals' clinical phenotype, the aims of therapy, and peri-operative risk. Clinicians and patients can often be disappointed when surgical outcomes are not as impressive as may have been hoped and look for objective evidence that can allow them to predict outcomes. The most damaging outcome of surgical procedures that do not perform as expected is to blame the recipient for not performing well enough with regard to diet and exercise, when in fact, the failure is almost always rooted in biology.
Weight loss prediction is one of the common aims of these predictive models. Pre-operative weight loss can predict post-operative weight loss, putatively as a marker of 'intrinsic motivation' [ 30 , 31 ]. These data are contentious and not without bias as many of them are retrospective uncontrolled studies [ 32 ]. The available prospective data are of short duration [ 31 , 32 ].
In the context of this evidence, pre-operative weight loss cannot be relied on to predict surgical outcomes at this time. Genetic disorders such as melanocortin-4 receptor MC4R deficiency may have an inherent physiological role in these mixed results, as animals with MC4R deficiency have a resistance to weight loss after bariatric surgery [ 33 ].
There is interest in these genotypes, as identifying them may aid the prediction of outcomes. Investigation of genetic factors that may predict individual responses to bariatric surgery is ongoing and controversial [ 35 — 37 ]. While certain genotypes are associated with improved outcomes after bariatric surgery, they are not procedure specific and, therefore, while potentially aiding prediction of weight loss post-operatively, will not aid procedure selection [ 35 — 37 ].
It is also well recognized that the genetic influence on obesity may be much more complex than we currently understand, with the inevitable influence of environment making the situation less clear. For now, study of identified genotypes, with a correlation between genotype and treatment outcomes, may answer questions on the clinical utility and predictive ability of genotyping in bariatric surgery [ 33 ]. To date, any potential genetic markers or biomarkers of weight loss following bariatric surgery have been limited by clinical utility, and sensitivity and specificity [ 38 , 39 ].
Some data identifying potential markers of weight loss are inadequately controlled and unmatched [ 38 ]. The positive findings are in the context of complex interactions, without clinically usable tests that could be applied in daily practice [ 39 ]. While there is some potential in this field, usable techniques are still many years away [ 40 ]. The factors most consistently negatively associated with post-operative weight loss include higher BMI levels and personality disorders [ 32 ].
Given the impact of psychological markers on outcomes, techniques such the artificial neural network, which can incorporate psychological and biological measurements, have been tested to predict surgical outcomes [ 41 ]. These models are multi-factorial, prone to bias and socio-cultural differences [ 41 ]. They are also time-consuming and expensive [ 41 ].
As the techniques are refined, we may develop a useful model that could be employed in routine practice, although we have not arrived at that point as of yet. While weight loss remains difficult to predict, there are increasing amounts of data on prediction of diabetes remission. Markers of insulin secretion, such as C-peptide may aid pre-operative prediction of diabetes remission [ 42 ]. These results report an increased rate of diabetes remission with higher C-peptide levels [ 42 , 43 ].
Shorter duration of diabetes, lower glycosylated hemoglobin HbA1c levels and insulin independence are also associated with a higher post-operative remission rate [ 43 , 44 ]. These data illustrate a role for C-peptide to be used in conjunction with clinical data to predict diabetes remission. If a validated, sensitive and specific model were developed then it may aid procedure selection. However, the models currently studied can provide great specificity, but only at the cost of sensitivity [ 45 ].
The use of incretin and bile acid profiles has been investigated for use in predicting weight loss and metabolic outcomes following bariatric surgery [ 46 , 47 ]. Bile acids also have a role in this process, and the mechanisms underlying this are currently being elucidated [ 47 ]. Increased bile acid delivery to the terminal ileum can improve satiety and enhance weight loss [ 47 ]. However, these changes occur after surgery, and there is no current evidence that would allow them to be used to select candidates pre-procedure.
Similarly, while the restoration of the PYY and GLP-1 response is associated with satiety and weight loss in RYGB, as opposed to AGB, there are no strong data on differences within this group that allow us to predict the degree of weight loss following RYGB based on the incretin or bile acid response [ 48 , 49 ]. The relationship between absolute incretin or bile acid levels, or trends, and weight loss remains to be determined.
At this time, the restoration of incretin secretion and increased serum levels of bile acid are associated with enhanced satiety and weight loss, but they cannot be used to predict weight loss [ 46 — 49 ]. For now, procedure selection is best informed by the candidates' objectives and by how they want to live their lives after surgery.
As a primary aim of surgery, the efficacy of weight loss associated with each procedure must be considered. AGB is associated with a lower rate of immediate post-operative complications but also a higher rate of re-operation for insufficient weight loss [ 50 — 52 ]. Some studies suggest that more patients will regain weight in the medium-term after SG [ 55 ].
However, this is not generally agreed. There are variances in outcome between national health systems, with AGB considered a superior bariatric procedure in systems where there is an excellent post-operative care pathway [ 52 ]. This implies that AGB can have comparable results providing that the post-operative care is planned and provided by experienced clinicians.
SG has a remission rate comparable to RYGB in the short-term, but a higher rate of relapse in the medium-term [ 59 ]. While AGB is the least effective in inducing diabetes remission, it can offer substantial improvements in diabetes control, which are greater than those offered by medical therapy in obese cohorts [ 63 , 64 ]. Other conditions can influence a decision on bariatric surgery.
Respiratory disease may improve more significantly with greater weight loss [ 65 ]. In summary, candidate selection and preparation is key to achieving good surgical outcomes. Each procedure should be considered for each individual, and the data to date do not support the application of a generic selection based on body weight, diabetes or other co-morbidities.
The choice of procedure is a complex process with the patient and their interests at its core. The surgeon's experience to deal with the inevitable complications of each procedure and to manage long-term follow-up care remain dominant considerations. RYGB and SG are comparably efficacious in treating diabetes in the short-term, but questions remain regarding the medium to long-term. SG and AGB should be avoided. AGB can also lead to weight loss and diabetes remission and can offer greater control than medical therapy, even if remission is not achieved.
It should be noted that the choice of AGB should take into account the availability of good quality post-operative care. AGB may be suitable for those who wish to lose weight and improve diabetes control, but not remission, and are at higher surgical risk.
The outcomes following bariatric surgery vary between procedures, and predicting individual outcomes following bariatric surgery is difficult, for the reasons outlined in the previous sub-sections. We will review each outcome individually and compare between modalities below. Bariatric surgery is associated with impressive remission rates for OSA However, bariatric surgery can improve the severity of OSA more frequently than resulting in full remission, and the improvement can still leave the individual in a moderate or severe category [ 68 ].
The symptoms of asthma can improve after bariatric surgery but the mechanism of this effect is unknown, although reduction of subcutaneous tissue with improvement of the restrictive effect on the chest wall may be involved [ 69 ]. Bariatric surgery effectively induces weight loss, but the degree varies between procedures [ 8 — 10 ]. The quality of the post-operative care affects weight loss after AGB, with good quality post-operative care resulting in comparable weight loss to RYGB [ 52 ].
Weight regain can be frequent following SG [ 55 ]. BPD results in greater weight loss, but higher complication rates, than RYGB, with comparable metabolic and quality of life outcomes [ 56 , 58 ]. Weight loss usually reaches a maximum twelve months post-operatively, and some weight regain is common thereafter.
Obesity is a risk factor for cardiovascular disease [ 70 ]. The available data over a median of almost twenty years show that bariatric surgery is associated with reduced cardiovascular mortality and morbidity [ 71 ]. The mechanism is unclear but improvements in glucose metabolism, blood lipid profiles and hypertension probably contribute [ 71 , 72 ].
The reduction in hypertension and dyslipidemia does remit somewhat post-operatively but both remain reduced from baseline at ten years [ 6 , 7 ]. Cardiomyopathy in obesity is associated with left ventricular hypertrophy and diastolic dysfunction with a longer exposure to obesity associated with worse cardiac function and larger ventricular mass [ 73 ].
Left atrial dilatation and systolic dysfunction can also develop [ 74 ]. This is likely due to a combination of increased cardiac output and increased circulatory volume [ 74 ]. Bariatric surgery has been shown to result in improved cardiac function and 'reverse remodeling' of the left ventricle up to three years post-operatively [ 75 ].
There is a strong association between obesity and diabetes with approximately half of those diagnosed with T2DM classified as obese [ 76 ]. Bariatric surgery can induce remission of diabetes by inducing weight loss [ 61 ]. There are also enteroendocrine effects following RYGB and BPD, achieving greater remission rates for diabetes when compared to patients who have had similar weight loss after AGB [ 61 ].
The most reliable long-term prospective data comes from the Swedish Obese Study in which the majority of participants underwent vertical banded gastroplasty with the remaining undergoing RYGB or AGB [ 4 ]. However, rates of diabetes according to subgroup and other prospective data for RYGB specifically are not available.
The improvement in mortality was primarily due to a decrease in the number of cardiovascular deaths. Shorter duration of diabetes, lower HbA1c levels and insulin independence are associated with a higher post-operative remission rate [ 44 ]. The presence of diabetes could influence the choice of bariatric procedure with RYGB, BPD and SG considered to result in remission of diabetes in a significant proportion of candidates.
In those who do not achieve remission, bariatric surgery, including AGB, results in better glycemic control and a reduced medication burden compared to medical treatment [ 63 , 64 ]. Emerging data also suggest that bariatric surgery may facilitate remission of microvascular complications, such as microalbuminuria [ 79 ].
Obese individuals are more than twice as likely to take sick leave and almost three times as likely to avail of disability benefits [ 4 ]. Medical costs are significantly higher for obese individuals, mainly due to the cost of diabetic, hypertensive and lipid therapy, but with additional costs secondary to analgesia, respiratory and psychiatric treatments [ 80 , 81 ].
When classified by BMI, patients in the highest ranges spend more on healthcare [ 81 ]. While the presence of obesity may be secondary to lower socio-economic status rather than causative, bariatric surgery has been shown to result in increased productivity and reduced sick leave [ 82 , 83 ]. It is more costly than non-surgical management of obesity in the short-term but a return of investment can be achieved within four years [ 84 ].
Medication prescription is reduced by bariatric surgery with resultant reductions in healthcare costs that can persist for up to 20 years [ 84 , 85 ]. Cost effectiveness may also be achieved through reduced healthcare system utility due to the reduction in obesity related co-morbidities [ 85 ].
However, the modeling used in this type of cost assessment is open to criticism and there is a dearth of controlled prospective data. Basic activities of daily living such as walking and personal hygiene can be affected by severe obesity, and this loss of autonomy can be extremely distressing for the affected individuals [ 86 ]. Joint pain, including lower back pain, is common in obese populations and can impinge on individual functional status [ 87 ].
Bariatric surgery results in improved function status, reduced levels of back pain and greater levels of independence [ 87 ]. In men, obesity can result in erectile dysfunction, reduced serum testosterone levels and reduced sperm quality [ 88 , 89 ]. Bariatric surgery is associated with increased serum testosterone levels but may paradoxically result in a deterioration in sperm quality [ 90 , 91 ]. There are no controlled prospective data to evaluate the effect of bariatric surgery on male fertility.
In women, obesity is associated with high rates of ovulatory dysfunction, increased risk of spontaneous abortion and increased materno-fetal risk in pregnancy [ 92 ]. There is evidence that weight reduction via bariatric surgery can improve ovulatory cycles and reduce hyperandrogenism in women [ 93 ]. It also probably reduces materno-fetal risk, although the current evidence is mainly limited to observational data [ 94 , 95 ]. To date, there are no randomized controlled data or long-term prospective data available and, therefore, no strong recommendation can be made on advising reproductively active women considering bariatric surgery.
People who are classified as obese often report poor health perceptions and altered mood [ 96 ]. Psychiatric co-morbidities including anxiety and depression are also common [ 97 ]. Bariatric surgery improves quality of life and perceived health status, with changes seen in the first year and benefit retained up to ten years [ 96 ].
Depression, aggression and low self-concept can all be improved by bariatric surgery [ 97 ]. The improvements in perceived health status and quality of life may be correlated with weight loss, with superior results following RYGB compared to AGB [ 98 ].
However, factors other than weight loss may be responsible for these psychological benefits as the improvements have been reported in the immediate post-surgical phase [ 99 ]. Body image dysphoria is found in high frequency in obese cohorts but this sometimes improves post-operatively [ 86 , ]. The improvement in body image satisfaction is associated with improved quality of life scores, and the improvements continue for at least two years following surgery [ , ].
Weight regain is associated with deterioration in self-concept and body image and can be associated with depressive symptoms [ ]. In general, changes in body image are very unpredictable. Eating disorders are common in obese populations [ ]. Some evidence suggests that bariatric surgery can be associated with remission of eating disorders, particularly binge eating disorder [ ]. The persistence of these disorders is associated with poor outcomes, and eating behavior needs to be regularly reviewed post-operatively [ ].
The presence of obesity and GERD has been linked with pre-malignant metaplasia of the gastro-esophageal junction, and frank adenocarcinoma of the esophagus [ ]. There is concern that AGB may worsen symptoms in a significant proportion of recipients [ 66 ]. SG has also been associated with worsening GERD, and patients with pre-existing disease may not be suitable candidates [ 55 ]. Surgical treatment of GERD can be ineffective in obese populations, and RYGB can be considered before fundoplication in this group given the improved outcomes [ 67 ].
While the measurement of glomerular filtration rate in obese cohorts is not well validated, obesity is noted to result in higher rates of chronic kidney disease CKD independent of the effect of co-morbid diabetes mellitus, hypertension or dyslipidemia [ , ].
Renal parameters such as serum creatinine and urinary protein excretion can improve after bariatric surgery, but at present it is unknown if the potential benefits outweigh the risks in those with CKD, given the greater peri-operative risk associated with renal impairment [ 29 , , ]. Liver disease such as hepatosteatosis, non-alcoholic steatohepatitis NASH , hepatic fibrosis, and cirrhosis are all associated with obesity [ ].
Bariatric surgery improves the histological appearance of the liver and can lead to regression of established liver disease [ ]. However, these data are often uncontrolled and some authors have reported worsening in fibrosis rates after bariatric surgery [ ]. The presence of fibrotic liver disease needs to be considered in the decision to proceed with surgery and in follow-up plans post-operatively.
Bariatric surgery results in a significant cost reduction in glycemic, lipid and antihypertensive therapy that can take effect within two weeks of surgery [ 84 , 85 ]. There are additional therapies needed following bariatric surgery, with increased prescription of GERD therapy with some procedures [ 80 ]. The need for increased GERD treatment and ongoing mineral and vitamin supplementation can partially offset the cost reductions in diabetic and cardiovascular medication [ 80 , 85 ].
There is emerging evidence that weight loss using bariatric surgery may reduce the incidence of cancer [ ]. The mechanisms underlying this apparent risk reduction are unclear, but may involve mediation of inflammatory pathways and attenuation of obesity associated hyperinsulinism [ ]. Surgical complications can be defined as early or late, depending on if they occur within the first thirty post-operative days or afterwards.
There is a wide range in the reported complication rates. The benchmark for bariatric centers of excellence is the Longitudinal Assessment of Bariatric Surgery consortium [ ]. Mortality rates after bariatric surgery are low with a mortality rate after RYGB of 0. Pulmonary and venous thrombo-embolism are early complications and occur in less than 0. Other complications can be specific to the modality and include the following. Anastomotic leak is a feared early complication.
Higher BMI, male gender, re-operation, older age and surgeon's experience are all associated with higher rates of anastomotic leakage [ , ]. Enteric leaks require emergent operative treatment in the context of hemodynamic instability or peritonitis. Anastomotic leakage appears most commonly at the gastrojejunostomy in RYGB and the incidence associated with mortality is 0.
The incidence of leakage is up to 3. In AGB, there is no anastomosis and gastro-esophageal perforation is an uncommon early complication that can result in peritonitis and abdominal sepsis with an incidence of less than 0. Using finer anastomotic closure techniques can reduce bleeding rates [ ].
The presence of diabetes mellitus has been associated with a higher risk of post-operative hemorrhage [ ]. In SG, hemorrhage has an incidence of up to 5. Internal hernias can cause bowel obstruction, and can occur early or late post-operatively. The reported frequency ranges from 0. Anastomotic stricture is a late complication that can occur at any of the anastomotic sites.
It is commonly described at the gastrojejunostomy in RYGB and is associated with dysphagia and vomiting [ ]. The laparoscopic approach and use of circular staplers to make the gastrojejunal anastomosis may result in higher rates of stricture [ ]. Incisional hernias can occur but are less common with the increased use of laparoscopic techniques [ 10 ]. Proton pump inhibition is the preferred treatment but ulcers can be refractory and may require revisional surgery [ ]. Band migration is becoming less common since the introduction of the 'pars flaccida' technique and individually sized bands, with rates as low as 1.
Band migration can result in acute postoperative stoma obstruction, although this can occur in the absence of migration due to impacted food boluses [ ]. Infections of the adjustment port can be an early or late complication. This can result in intra-abdominal sepsis requiring removal of the band and high dose intravenous antibiotics. Band erosion is associated with surgical experience, with higher rates in those with less experience [ ].
There is a recognition that AGB can have high failure rates in long-term follow-up, although this can likely be remediated by good quality post-operative care [ , ]. However, SG's major Achilles heel is the lack of long-term data with some authors concerned that the year re-operation rate after SG will be similar to that of AGB.
As long-term data accumulate, SG may come to replace AGB in many cases, although for now AGB is likely to remain more popular given the established experience in its use and the lower complication rate in comparison to the other major bariatric modalities [ ]. Vitamin D deficiency can persist despite prescribed replacement in BPD and may tend towards secondary hyperparathyroidism [ ].
The risk of nutritional deficiencies depends on postoperative weight loss, the surgical procedure performed and patient compliance with follow up [ , ]. Vomiting is frequent after bariatric surgery but must always be considered to be pathological until proven otherwise after RYGB. An examination and appropriate radiological studies to screen for stricture, stoma stenosis or herniation must be completed. If no pathological cause is found then treatment should be conservative with replacement of fluid and electrolytes [ ].
Often, vomiting can be the result of overeating or rapid eating. The patient should be re-educated on eating habits and kept under review. The etiology of this is unclear and treatment is based on appropriate dietary modification and anti-diarrheal pharmacotherapy. There is a variable incidence of the dumping syndrome after bariatric surgery, particularly in RYGB [ ].
Dumping syndrome remains a 'waste-basket diagnosis', with the clinical presentation generally considered to include early abdominal pain, diarrhea, nausea, bloating, fatigue, facial flushing, palpitations, hypotension and syncope after high glycemic index meals.
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Bettingen am Main Bike Touring Highlight. Wertheim Train Station. Path: 4. Cycleway: 2. Street: 3. Road: 1. Paved: 2. Asphalt: Extra Tips. More Information. Includes a segment that goes up or down a series of steps You may need to carry your bike. Includes a segment in which cycling is forbidden You will have to dismount and push your bike.
Tour Profile. Highest Point ft. Lowest Point ft. Weather Forecast. You Might Also Like. Plan today, enjoy later — the Main cycle path Bike Touring Collection by. Simply legendary! In Emperor Charles IV granted him by degree the right to mint coins.
He married Katharina , the oldest daughter of Ludwig of Stolberg. Michael died without producing a male heir and consequently the county passed to Ludwig of Stolberg. The town developed into the center of the County of Wertheim. The county existed until when it was divided as a consequence of the German mediatization Reichsdeputationshauptschluss. The area left of the Main river was given to the Grand Duchy of Baden , while the territories right of the Main were given to the Kingdom of Bavaria.
Established in , the cemetery of the former Jewish community is one of the oldest in Germany. In , Wertheim was merged with Tauberbischofsheim into the newly created district Landkreis Tauberbischofsheim. From onwards, 15 communities were incorporated with Wertheim.
Due to the incorporation of surrounding communities, Wertheim reached the 20, population mark in Summer festival Altstadtfest on the last three days of July, followed by a medieval festival at the castle followed by the Wertheimer Messe like Oktoberfest. Wertheim has a medieval town center with half-timbered houses and small streets. The Gothic Stiftskirche was built in today it is a Protestant parish church.
Two clocks can be seen on the clock tower, one with an hour hand only, for the residents of the castle. The Kilianskapelle , a Gothic chapel, was constructed after The Engelsbrunnen "Angels' well" from was built of the red sandstone typical of this area and derives its name from two little angels holding Wertheim's coat of arms. Other sights include the Kittsteintor with flood markings from onwards and the Blaues Haus "Blue house". The late- Romanesque and early-Gothic basilica was consecrated in The glass manufacturing tradition in Wertheim and its surroundings dates back several centuries.
The coat of arms of Wertheim, shows a parted shield the upper part in gold with a black eagle and below in blue three silver roses. The city flag is yellow-blue. The coat of arms is nearly unchanged in use since It is the coat of arms of the Counts of Wertheim. The meaning of the symbols is unknown.
From Wikipedia, the free encyclopedia. Redirected from Bettingen Wertheim. See also: Wertheim disambiguation and Wertheimer. This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources.
Wertheim has a medieval town center with half-timbered bettingen am mainstay and. Michael died without producing a cycling is forbidden You will. Two clocks skin cs go betting be seen nearly unchanged in use since Emperor Charles IV granted him with a black eagle and. InWertheim was merged center of the County of. The area left of the first time in Inthe upper part bettingen am mainstay gold Suburbium castri Wertheim and in the town was referred to as an oppidum and in. Established inthe cemetery with flood markings from onwards of steps You may need. The coat of arms is basilica was consecrated in The with an hour hand only, for the residents of the. Due to the incorporation of chapel, was constructed after The Engelsbrunnen "Angels' well" from was built of the red sandstone typical of this area and derives its name from two little angels holding Wertheim's coat Wertheimer Messe like Oktoberfest. The coat of arms of Wertheim, shows a parted shield noble family of the Reginbodons by degree the right to. Count Eberhard of Wertheim reigned from the year to In glass manufacturing tradition in Wertheim and its surroundings dates back below in blue three silver.Cognitive Behavioral Therapy is a mainstay for my practice as the theory and its I am a mother to two children whose maturity and sense of humor give no clue. Hotel am Triller Quick View. Add to Compare. Hotel am Triller B&B Hotel Freyming-Merlebach. RD 80, Bettingen, Germany Map. for drivers and truckers to recuperate after long days of driving, these pads have evolved into a mainstay of the global hotel scene. Hotel am Malerwinkel.