Obesity: Collazo-Clavell ML

Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J, Guven S, Anonymous00032, Anonymous00033, Anonymous00034. · No affiliation provided · Obesity (Silver Spring). · Pubmed #19319140 No free full text.

Abstract: American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. · No affiliation provided · Surg Obes Relat Dis. · Pubmed #18848315 No free full text.

Abstract: American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. · No affiliation provided · Endocr Pract. · Pubmed #18723418 No free full text.

This publication has no abstract.

Collazo-Clavell ML. · Division of Endocrinology, Diabetes, Metabolism & Nutrition, 200 First Street SW, Rochester, MN 55905, USA. · Compr Ther. · Pubmed #19137758 No free full text.

Abstract: Bariatric surgery has become an acceptable therapy for the management of the patient with medically complicated obesity. This paper will review important considerations for the primary care provider as they identify, counsel and care for patients interested in these interventions.

Batsis JA, Sarr MG, Collazo-Clavell ML, Thomas RJ, Romero-Corral A, Somers VK, Lopez-Jimenez F. · Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA. · Am J Cardiol. · Pubmed #18805125 No free full text.

Abstract: Obese patients have an increased prevalence of cardiovascular (CV) risk factors, which improve with bariatric surgery, but whether bariatric surgery reduces long-term CV events remains ill defined. A systematic review of published research was conducted, and CV risk models were applied in a validation cohort previously published. A standardized MEDLINE search using terms associated with obesity, bariatric surgery, and CV risk factors identified 6 test studies. The validation cohort consisted of a population-based, historical cohort of 197 patients who underwent Roux-en-Y gastric bypass and 163 control patients, identified through the Rochester Epidemiology Project. Framingham and Prospective Cardiovascular Munster Heart Study (PROCAM) risk scores were applied to calculate 10-year CV risk. In the validation cohort, absolute 10-year Framingham risk score for CV events was lower at follow-up in the bariatric surgery group (7.0% to 3.5%, p <0.001) compared with controls (7.1% to 6.5%, p = 0.13), with an intergroup absolute difference in risk reduction of 3% (p <0.001). PROCAM risk in the bariatric surgery group decreased from 4.1% to 2.0% (p <0.001), whereas the control group exhibited only a modest decrease (4.4% to 3.8%, p = 0.08). Using mean data from the validation study, the trend and directionality in risk was similar in the Roux-en-Y group. The test studies confirmed the directionality of CV risk, with estimated relative risk reductions for bariatric surgery patients ranging from 18% to 79% using the Framingham risk score compared with 8% to 62% using the PROCAM risk score. In conclusion, bariatric surgery predicts long-term decreases in CV risk in obese patients.

McGlinch BP, Que FG, Nelson JL, Wrobleski DM, Grant JE, Collazo-Clavell ML. · Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA. · Mayo Clin Proc. · Pubmed #17036576 No free full text.

Abstract: The epidemic of obesity in developed countries has resulted in patients with extreme (class III) obesity undergoing the full breadth of medical and surgical procedures. The popularity of bariatric surgery in the treatment of extreme obesity has raised awareness of the unique considerations in the care of this patient population. Minimizing the risk of perioperative complications that contribute to morbidity and mortality requires input from several clinical disciplines and begins with the preoperative assessment of the patient. Airway management, intravenous fluid administration, physiologic responses to pneumoperitoneum during laparoscopic procedures, and the risk of thrombotic complications and peripheral nerve injuries in extremely obese patients are among the factors that present special intraoperative challenges that affect postoperative recovery of the bariatric patient. Early recognition of perioperative complications and education of the patient regarding postoperative issues, including nutrition and vitamin supplementation therapy, can improve patient outcomes. A suitable physical environment and appropriate nursing and dietetic support provide a safe and dignified hospital experience. This article reviews the multidisciplinary management of extremely obese patients who undergo bariatric surgery at the Mayo Clinic.

Collazo-Clavell ML, Clark MM, McAlpine DE, Jensen MD. · Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN 55905, USA. · Mayo Clin Proc. · Pubmed #17036574 No free full text.

Abstract: The number of bariatric surgical procedures performed in the United States has increased steadily during the past decade. Currently accepted criteria for consideration of bariatric surgery include a body mass index (calculated as weight in kilograms divided by the square of height in meters) of 40 kg/m2 or greater (or >35 kg/m2 with obesity-related comorbidities), documented or high probability of failure of nonsurgical weight loss treatments, and assurance that the patient is well informed, motivated, and compliant. Appropriate patient selection is important in achieving optimal outcomes after bariatric surgery. In this article, we review our approach to the medical and psychological assessment of patients who want to undergo bariatric surgery. The medical evaluation is designed to identify and optimally treat medical comorbidities that may affect perioperative risks and long-term outcomes. The psychiatric and psychological assessment identifies factors that may influence long-term success in maintaining weight loss and prepares the patient for the lifestyle changes needed both before and after surgery.

Collazo-Clavell ML. · Division of Endocrinology, Metabolism, Nutrition and Internal Medicine, Mayo Clinic Rochester, Minn 55905, USA. · Mayo Clin Proc. · Pubmed #10593355 No free full text.

Abstract: The prevalence of overweight and obesity has increased dramatically in the recent decades, and obesity is now a major public health problem. Obesity negatively influences an individual's health by increasing mortality and raising the risk for multiple medical conditions such as type 2 diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease. In addition, the obese individual is often the brunt of social discrimination. Weight loss has been shown to reduce the risk for many of these comorbid conditions. A multifaceted approach to the obese patient should include identifying potential causes for weight gain, outlining medical conditions that would benefit by weight loss, and tailoring a weight loss program that is safe and effective for the individual. Components of a successful weight loss program include dietary intervention, recommendations for physical activity, behavior modification, and, in a select group of patients, pharmacologic or surgical intervention.

Batsis JA, Clark MM, Grothe K, Lopez-Jimenez F, Collazo-Clavell ML, Somers VK, Sarr MG. · Section of General Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA. · Appetite. · Pubmed #19501761 No free full text.

Abstract: BACKGROUND: Eating behaviors often predict outcomes after bariatric surgery, and in this regard, self-efficacy has been shown to predict long-term behavior. We examined current eating self-efficacy in post-bariatric surgery patients comparing them to obese non-surgery patients to determine whether weight loss is associated with increased self-efficacy in post-bariatric surgery patients. METHODS: We performed a population-based study of patients evaluated for Roux-en-Y gastric bypass and administered a survey using the Weight Efficacy Lifestyle (WEL) Questionnaire. There were 148 surgical and 88 non-operative patients who responded. Overall WEL score was assessed using linear regression models. Predictors of an increased self-efficacy score were also examined. RESULTS: Follow-up was 4.0 and 3.8 years in the operative and non-operative groups, respectively. Operative responders were slightly older and had a lesser BMI compared to non-responders, otherwise the demographics were similar. Difference in overall WEL between groups was 25.5+/-5.3 points on a 0-180 scale. A 25% change in weight was associated with a difference of 15.4 points on the total WEL between groups. Current self-efficacy scores were highly related to weight loss and correlated to quality of life at follow-up (rho=0.36). CONCLUSION: Profound weight loss after bariatric surgery is associated with increased eating self-efficacy in a population of obese adults seeking medical treatment for obesity.

Batsis JA, Romero-Corral A, Collazo-Clavell ML, Sarr MG, Somers VK, Lopez-Jimenez F. · Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA. · Mayo Clin Proc. · Pubmed #18674474 links to  free full text

Abstract: OBJECTIVE: To assess the effect of weight loss by bariatric surgery on the prevalence of the metabolic syndrome (MetS) and to examine predictors of MetS resolution. PATIENTS AND METHODS: We performed a population-based, retrospective study of patients evaluated for bariatric surgery between January 1, 1990, and December 31, 2003, who had MetS as defined by the American Heart Association/National Heart, Lung, and Blood Institute (increased triglycerides, low high-density lipoprotein, increased blood pressure, increased fasting glucose, and a measure of obesity). Of these patients, 180 underwent Roux-en-Y gastric bypass, and 157 were assessed in a weight-reduction program but did not undergo surgery. We determined the change in MetS prevalence and used logistic regression models to determine predictors of MetS resolution. Mean follow-up was 3.4 years. RESULTS: In the surgical group, all MetS components improved, and medication use decreased. Nonsurgical patients showed improvements in high-density lipoprotein cholesterol levels. After bariatric surgery, the number of patients with MetS decreased from 156 (87%) of 180 patients to 53 (29%); of the 157 nonsurgical patients, MetS prevalence decreased from 133 patients (85%) to 117 (75%). A relative risk reduction of 0.59 (95% confidence interval [CI], 0.48-0.67; P<.001) was observed in patients who underwent bariatric surgery and had MetS at follow-up. The number needed to treat with surgery to resolve 1 case of MetS was 2.1. Results were similar after excluding patients with diabetes or cardiovascular disease or after using diagnostic criteria other than body mass index for MetS. Significant predictors of MetS resolution included a 5% loss in excess weight (odds ratio, 1.26; 95% CI, 1.19-1.34; P<.001) and diabetes mellitus (odds ratio, 0.32; 95% CI, 0.15-0.68; P=.003). CONCLUSION: Roux-en-Y gastric bypass induces considerable and persistent improvement in MetS prevalence. Our results suggest that reversibility of MetS depends more on the amount of excess weight lost than on other parameters.

Garza CA, Pellikka PA, Somers VK, Sarr MG, Seward JB, Collazo-Clavell ML, Oehler E, Lopez-Jimenez F. · Division of Cardiovascular Diseases, Department of Medicine, 200 First St SW, Rochester 55905, MN, USA. · Eur J Echocardiogr. · Pubmed #18490311 links to  free full text

Abstract: AIMS: To assess long-term changes in left atrial (LA) volume in patients with morbid obesity [body mass index (BMI) >or=35 kg/m(2) with co-morbidities] and extreme obesity (BMI >or=40 kg/m(2)), after surgically-induced weight loss (WL) after gastric bypass surgery. METHODS AND RESULTS: We reviewed 57 patients who underwent gastric bypass surgery and had echocardiograms both before and after the operation. A control group was frequency-matched for BMI, sex, age, and for duration of follow-up. After a mean follow-up of 3.6 years, LA volume did not change significantly in patients who underwent bariatric surgery, but increased in the control group by 15 +/- 28 ml (P < 0.0001), and 0.1 +/- 0.2 ml (P < 0.0001) for height-indexed LA volume, with a difference between cases and controls that remained significant after adjusting for potential confounders (P = 0.01). In the study population as a whole, there was a positive correlation between change in body weight and change in LA volume (r = 0.22, P = 0.006) independent of clinical conditions associated with LA enlargement. CONCLUSION: Change in body weight is associated with change in LA size independent of obesity-associated co-morbidities. Successful WL induced by bariatric surgery prevents the progressive increase in LA volume.

Lieske JC, Kumar R, Collazo-Clavell ML. · Department of Internal Medicine, Mayo Clinic College of Medicine Rochester, MN 55905, USA. · Semin Nephrol. · Pubmed #18359397 No free full text.

Abstract: Surgical intervention has become an accepted therapeutic alternative for the patient with medically complicated obesity. Multiple investigators have reported significant and sustained weight loss after bariatric surgery that is associated with improvement of many weight-related medical comorbidities, and statistically significant decreased overall mortality for surgically treated as compared with medically treated subjects. Although the Roux-en-Y gastric bypass (RYGB) is considered an acceptably safe treatment, an increasing number of patients are being recognized with nephrolithiasis after this, the most common bariatric surgery currently performed. The main risk factor appears to be hyperoxaluria, although low urine volume and citrate concentrations may contribute. The incidence of these urinary risk factors among the total post-RYGB population is unknown, but may be more than previously suspected based on small pilot studies. The etiology of the hyperoxaluria is unknown, but may be related to subtle and seemingly subclinical fat malabsorption. Clearly, further study is needed, especially to define better treatment options than the standard advice for a low-fat, low-oxalate diet, and use of calcium as an oxalate binder.

Romero-Corral A, Somers VK, Sierra-Johnson J, Thomas RJ, Collazo-Clavell ML, Korinek J, Allison TG, Batsis JA, Sert-Kuniyoshi FH, Lopez-Jimenez F. · Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, MN 55905, USA. · Int J Obes (Lond). · Pubmed #18283284 No free full text.

Abstract: BACKGROUND: Body mass index (BMI) is the most widely used measure to diagnose obesity. However, the accuracy of BMI in detecting excess body adiposity in the adult general population is largely unknown. METHODS: A cross-sectional design of 13 601 subjects (age 20-79.9 years; 49% men) from the Third National Health and Nutrition Examination Survey. Bioelectrical impedance analysis was used to estimate body fat percent (BF%). We assessed the diagnostic performance of BMI using the World Health Organization reference standard for obesity of BF%>25% in men and>35% in women. We tested the correlation between BMI and both BF% and lean mass by sex and age groups adjusted for race. RESULTS: BMI-defined obesity (> or =30 kg m(-2)) was present in 19.1% of men and 24.7% of women, while BF%-defined obesity was present in 43.9% of men and 52.3% of women. A BMI> or =30 had a high specificity (men=95%, 95% confidence interval (CI), 94-96 and women=99%, 95% CI, 98-100), but a poor sensitivity (men=36%, 95% CI, 35-37 and women=49%, 95% CI, 48-50) to detect BF%-defined obesity. The diagnostic performance of BMI diminished as age increased. In men, BMI had a better correlation with lean mass than with BF%, while in women BMI correlated better with BF% than with lean mass. However, in the intermediate range of BMI (25-29.9 kg m(-2)), BMI failed to discriminate between BF% and lean mass in both sexes. CONCLUSIONS: The accuracy of BMI in diagnosing obesity is limited, particularly for individuals in the intermediate BMI ranges, in men and in the elderly. A BMI cutoff of> or =30 kg m(-2) has good specificity but misses more than half of people with excess fat. These results may help to explain the unexpected better survival in overweight/mild obese patients.

Sinha MK, Collazo-Clavell ML, Rule A, Milliner DS, Nelson W, Sarr MG, Kumar R, Lieske JC. · Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA. · Kidney Int. · Pubmed #17377509 No free full text.

Abstract: Roux-en-Y bypass surgery is the most common bariatric procedure currently performed in the United States for medically complicated obesity. Although this leads to a marked and sustained weight loss, we have identified an increasing number of patients with episodes of nephrolithiasis afterwards. We describe a case series of 60 patients seen at Mayo Clinic-Rochester that developed nephrolithiasis after Roux-en-Y gastric bypass (RYGB), including a subset of 31 patients who had undergone metabolic evaluation in the Mayo Stone Clinic. The mean body mass index of the patients before procedure was 57 kg/m(2) with a mean decrease of 20 kg/m(2) at the time of the stone event, which averaged 2.2 years post-procedure. When analyzed, calcium oxalate stones were found in 19 and mixed calcium oxalate/uric acid stones in two patients. Hyperoxaluria was a prevalent factor even in patients without a prior history of nephrolithiasis, and usually presented more than 6 months after the procedure. Calcium oxalate supersaturation, however, was equally high in patients less than 6 months post-procedure due to lower urine volumes. In a small random sampling of patients undergoing this bypass procedure, hyperoxaluria was rare preoperatively but common 12 months after surgery. We conclude that hyperoxaluria is a potential complicating factor of RYGB surgery manifested as a risk for calcium oxalate stones.

Batsis JA, Romero-Corral A, Collazo-Clavell ML, Sarr MG, Somers VK, Brekke L, Lopez-Jimenez F. · Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA. · Obesity (Silver Spring). · Pubmed #17372329 No free full text.

Abstract: OBJECTIVE: Our goal was to assess the effect of bariatric surgery on cardiovascular risk estimations of preventable, long-term adverse outcomes. RESEARCH METHODS AND PROCEDURES: We performed a population-based, historical cohort study between 1990 and 2003 of 197 consecutive patients from Olmsted County, MN, with Class II to III obesity (defined as BMI > or = 35 kg/m2) treated with Roux-en-Y gastric bypass and 163 non-operative patients assessed in a weight-reduction program. We used the observed change in cardiovascular risk factors and risk models derived from data from the National Health and Nutrition Examination Survey (NHANES) I and the NHANES I Epidemiological Follow-up Study (NHEFS) to calculate the predicted impact on cardiovascular events and mortality for the operative and non-operative groups. RESULTS: Mean follow-up was 3.3 years. Hypertension, diabetes, and dyslipidemia all improved after bariatric surgery. The estimated 10-year risk for cardiovascular events for the operative group decreased from 37% at baseline to 18% at follow-up, while the estimated risk for the non-operative group did not change from 30% at baseline to 30% at follow-up. Risk modeling to predict 10-year outcomes estimated 4 overall deaths and 16 cardiovascular events prevented by bariatric surgery per 100 patients compared with the non-operative group. CONCLUSIONS: Bariatric surgery induces an improvement in cardiovascular risk factors in patients with Class II to III obesity. Weight loss predicts a major, 10-year reduction in cardiovascular events and deaths. Bariatric surgery should be considered as an alternative approach to reduce cardiovascular risk in patients with Class II to III obesity.

Lopez-Jimenez F, Bhatia S, Collazo-Clavell ML, Sarr MG, Somers VK. · Department of Internal Medicine and Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA. · Mayo Clin Proc. · Pubmed #16178495 links to  free full text

Abstract: OBJECTIVE: To determine the safety and efficacy of bariatric surgery in obese patients with documented coronary artery disease (CAD). PATIENTS AND METHODS: Among patients with class II or III obesity who underwent bariatric surgery between March 1995 and January 2002 at the Mayo Clinic in Rochester, Minn, the rates of major in-hospital cardiovascular complications and mortality of 52 patients with clinical CAD were compared with those of 507 patients without CAD. The efficacy of bariatric surgery was measured by changes in body weight and other cardiovascular risk factors at follow-up. RESULTS: There were no in-hospital deaths in either group. Three patients with documented CAD (5.8%; 95% confidence interval, 0%-12.2%) and 7 patients without CAD (1.4%; 95% confidence interval, 0.4%-2.4%) had cardiovascular complications (P=.06). After a mean follow-up of 2.5 years (range, 77-2403 days) of patients with CAD, the following values decreased postoperatively (all at P<.001): weight, from 147+/-36 kg to 103+/-22 kg; body mass index, from 50+/-11 kg/m2 to 36+/-9 kg/m2; fasting serum glucose, from 149+/-52 mg/dL to 113+/-31 mg/dL; glycosylated hemoglobin, from 9%+/-3% to 6%+/-2%; and blood pressure, from 142/82 mm Hg to 132/73 mm Hg. Low-density lipoprotein cholesterol decreased postoperatively from 116+/-31 mg/dL to 75+/-26 mg/dL, and triglycerides decreased from 198+/-85 mg/dL to 119+/-52 mg/dL (P<.01 for both). CONCLUSION: Bariatric surgery should be considered for treating patients with CAD and class II or III obesity.

Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV. · Department of Surgery, Mayo Clinic and Foundation, Rochester, MN, USA. · N Engl J Med. · Pubmed #16034010 links to  free full text

Abstract: We describe six patients (five women and one man; median age, 47 years; range, 39 to 54) with postprandial symptoms of neuroglycopenia owing to endogenous hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass surgery. Except for equivocal evidence in one patient, there was no radiologic evidence of insulinoma. Selective arterial calcium-stimulation tests, positive in each patient, were used to guide partial pancreatectomy. Nesidioblastosis was identified in resected specimens from each patient, and multiple insulinomas were identified in one. Hypoglycemic symptoms diminished postoperatively. We speculate that hyperfunction of pancreatic islets did not lead to obesity but that beta-cell trophic factors may have increased as a result of gastric bypass.

Collazo-Clavell ML, Jimenez A, Hodgson SF, Sarr MG. · Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic Rochester, Rochester, Minnesota 55905, USA. · Endocr Pract. · Pubmed #15310536 No free full text.

Abstract: OBJECTIVE: To emphasize the potential for Roux-en-Y gastric bypass treatment of morbid obesity to result in late development of metabolic bone disease and to illustrate the error of treating a low bone mineral density with bisphosphonates in the presence of unrecognized osteomalacia. METHODS: We conducted a retrospective case review of clinical, laboratory, and radiologic details in a patient who underwent Roux-en-Y gastric bypass as well as a review of the literature relative to metabolic bone disease associated with bariatric surgical procedures. RESULTS: A 42-year-old woman was diagnosed with high bone turnover osteoporosis and failed to respond to bisphosphonate (alendronate) therapy. Her past medical history included corticosteroid-dependent asthma and a Roux-en-Y gastric bypass surgical procedure for obesity approximately 6 1/2 years before the current assessment. Evaluation revealed vitamin D deficiency in conjunction with pronounced secondary hyperparathyroidism and biochemical evidence of osteomalacia. Aggressive calcium and vitamin D supplementation corrected the vitamin D-deficient state and was accompanied by rapid improvement in clinical symptoms, biochemical variables, and bone mineral density. CONCLUSION: This case exemplifies two principles: (1) the potential for a Roux-en-Y gastric bypass surgical procedure to lead to the development of metabolic bone disease and (2) the importance of recognizing mineralization defects as a cause for low bone mineral density, before initiation of therapy with bisphosphonates.

Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J, Anonymous00003, Anonymous00004, Anonymous00005. · No affiliation provided · Endocr Pract. · Pubmed #18463039 No free full text.

This publication has no abstract.