Risk of pre-eclampsia after gastric bypass: a matched cohort study

OBJECTIVE

To investigate whether gastric bypass before pregnancy is associated with reduced risk of pre-eclampsia.

DESIGN

Nationwide matched cohort study.

SETTING

Swedish national health care.

POPULATION

A total of 843 667 singleton pregnancies without pre-pregnancy hypertension were identified in the Swedish Medical Birth Register between 2007 and 2014, of which 2930 had a history of gastric bypass and a pre-surgery weight available from the Scandinavian Obesity Surgery Registry. Two matched control groups (pre-surgery and early-pregnancy body mass index [BMI]) were propensity score matched separately for nulliparous and parous births, to post-gastric bypass pregnancies (n_{pre-surgery-BMI}  = 2634:2634/n_{early-pregnancy-BMI}  = 2766:2766) on pre-surgery/early-pregnancy BMI, diabetes status (pre-surgery/pre-conception), maternal age, early-pregnancy smoking status, educational level, height, country of birth, delivery year and history of pre-eclampsia.

MAIN OUTCOME MEASURES

Pre-eclampsia categorised into any, preterm onset (<37⁺⁰  weeks) and term onset (≥37⁺⁰  weeks).

RESULTS

In post-gastric bypass pregnancies, mean pre-surgery BMI was 42.9 kg/m² and mean BMI loss between surgery and early pregnancy was 14.0 kg/m² (39 kg). Post-gastric bypass pregnancies had lower risk of pre-eclampsia compared with pre-surgery BMI-matched controls (1.7 versus 9.7 per 100 pregnancies; hazard ratio [HR] 0.21, 95% CI 0.15-0.28) and early-pregnancy BMI-matched controls (1.9 versus 5.0 per 100 pregnancies; HR 0.44, 95% CI 0.33-0.60). Although relative risks for pre-eclampsia for post-gastric bypass pregnancies versus pre-surgery matched controls was similar, absolute risk differences (RD) were significantly greater for nulliparous women (RD -13.6 per 100 pregnancies, 95% CI -16.1 to -11.2) versus parous women (RD -4.4 per 100 pregnancies, 95% CI -5.7 to -3.1).

CONCLUSION

We found that gastric bypass was associated with lower risk of pre-eclampsia, with the largest absolute risk reduction among nulliparous women.

TWEETABLE ABSTRACT

In this large study including two comparison groups matched for pre-surgery or early-pregnancy BMI, gastric bypass was associated with lower risk of pre-eclampsia.

Morbidity of cholecystectomy and gastric bypass in a national database

Background

There is a strong association between obesity and gallstones. However, there is no clear evidence regarding the optimal order of Roux-en-Y gastric bypass (RYGB) and cholecystectomy when both procedures are clinically indicated.

Methods

Based on cross-matched data from the Swedish Register for Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (GallRiks; 79 386 patients) and the Scandinavian Obesity Surgery Registry (SOReg; 36 098 patients) from 2007 to 2013, complication rates, reoperation rates and operation times related to the timing of RYGB and cholecystectomy were explored.

Results

There was a higher aggregate complication risk when cholecystectomy was performed after RYGB rather than before (odds ratio (OR) 1·35, 95 per cent c.i. 1·09 to 1·68; P = 0·006). A complication after the first procedure independently increased the complication risk of the following procedure (OR 2·02, 1·44 to 2·85; P &lt; 0·001). Furthermore, there was an increased complication risk when cholecystectomy was performed at the same time as RYGB (OR 1·72, 1·14 to 2·60; P = 0·010). Simultaneous cholecystectomy added 61·7 (95 per cent c.i. 56·1 to 67·4) min (P &lt; 0·001) to the duration of surgery.

Conclusion

Cholecystectomy should be performed before, not during or after, RYGB.

Outcomes of laparoscopic gastric bypass in a randomized clinical trial compared with a concurrent national database

BACKGROUND

RCTs are the standard for assessing medical interventions, but they may not be feasible and their external validity is sometimes questioned. This study aimed to compare results from an RCT on mesenteric defect closure during laparoscopic gastric bypass with those from a national database containing data on the same procedure, to shed light on the external validity of the RCT.

METHODS

Patients undergoing laparoscopic gastric bypass surgery within an RCT conducted between 1 May 2010 and 14 November 2011 were compared with those who underwent the same procedure in Sweden outside the RCT over the same time interval. Primary endpoints were severe complications within 30 days and surgery for small bowel obstruction within 4 years.

RESULTS

Some 2507 patients in the RCT were compared with 8485 patients in the non-RCT group. There were no differences in severe complications within 30 days in the group without closure of the mesenteric defect (odds ratio (OR) for RCT versus non-RCT 0·94, 95 per cent c.i. 0·64 to 1·36; P = 0·728) or in the group with closure of the defect (OR 1·34, 0·96 to 1·86; P = 0·087). There were no differences between the RCT and non-RCT cohorts in reoperation rates for small bowel obstruction in the mesenteric defect non-closure (cumulative incidence 10·9 versus 9·4 per cent respectively; hazard ratio (HR) 1·20, 95 per cent c.i. 0·99 to 1·46; P = 0·065) and closure (cumulative incidence 5·7 versus 7·0 per cent; HR 0·82, 0·62 to 1·07; P = 0·137) groups. The relative risk for small bowel obstruction without mesenteric defect closure compared with closure was 1·91 in the RCT group and 1·39 in the non-RCT group.

CONCLUSION

The efficacy of mesenteric defect closure was similar in the RCT and national registry, providing evidence for the external validity of the RCT.

Formation of the Scandinavian Obesity Surgery Registry, SOReg

BACKGROUND

Obesity surgery is expanding, the quality of care is ever more important, and learning curve assessment should be established. A large registry cohort can show long-term effects on obesity and its comorbidities, complications, and long-term side effects of surgery, as well as changes in health-related quality of life (QoL). Sweden is ideally suited to the task of data collection and audit, with universal use of personal identification numbers, nation-wide registries permitting cross-matching to analyze causes of death, in-hospital care, and health-related absenteeism.

METHOD

In 2004, the Scandinavian Obesity Surgery Registry (SOReg) was initiated and government financing secured. A project group created a national database covering all public as well as private hospitals. Data entry was to be made online, operative definitions of comorbidity were formed, and complication severity scored. Several forms of audit were devised.

RESULTS

After pilot studies, the system has been running in its present form since 2007. Since 15 January 2013, SOReg covers all bariatric surgery centers in Sweden. The number of operations in the database exceeded 40,000 (March 2014), with a median follow-up of 2.94 years. Audit shows that >98% of data are correct. All results are publicized annually on the Internet.

COMMENTS

Using this systematic approach, it has been possible to cover >99% of all bariatric surgery, cross-matching our data with nation-wide registries for in-hospital care, cause of death, and permitting regular nation-wide audit. Several scientific studies have used, or are using, what seems to be the most comprehensive database in obesity surgery.

Unemployment and mortality--a longitudinal prospective study on selection and causation in 49321 Swedish middle-aged men

BACKGROUND

Unemployment is associated with increased risk of mortality. It is, however, not clear to what extent this is causal, or whether other risk factors remain uncontrolled for. The aim of this study was to investigate the association between unemployment and all-cause and cause-specific mortality, adjusting for indicators of mental disorder, behavioural risk factors and social factors over the life course.

METHODS

This study was based on a cohort of 49321 Swedish males, born 1949/51, tested for compulsory military conscription in 1969/70. Data on employment/unemployment 1990-4 was based on information from the Longitudinal Register of Education and Labour Market Statistics. Information on childhood circumstances was drawn from National Population and Housing Census 1960. Information on psychiatric diagnosis and behavioral risk factors was collected at conscription testing in 1969/70. Data on mortality and hospitalisation 1973-2004 were collected in national registers.

RESULTS

An increased risk of mortality 1995-2003 was found among individuals who experienced 90 days or more of unemployment during 1992-4 compared with those still employed (all-cause mortality HR 1.91, 95% CI 1.58 to 2.31. Adjustment for risk factors measured along the life course considerably lowered the relative risk (all cause mortality HR 1.30, 95% CI 1.06 to 1.58). Statistically significant increased relative risk was found during the first 4 years of follow up (all-cause mortality, adjusted HR 1.57, 95% CI 1.13 to 2.18, but not the following 4 years (all cause mortality, adjusted HR 1.17, 95% CI 0.91 to 1.50).

CONCLUSION

The results suggest that a substantial part of the increased relative risk of mortality associated with unemployment may be attributable to confounding by individual risk factors.

Effects of different respiratory maneuvers on esophageal sphincters in obese patients before and during anesthesia

BACKGROUND

Data on esophageal sphincters in obese individuals during anesthesia are sparse. The aim of the present study was to evaluate the effects of different respiratory maneuvers on the pressures in the esophagus and esophageal sphincters before and during anesthesia in obese patients.

METHODS

Seventeen patients, aged 28-68 years, with a BMI ≥ 35 kg/m², who were undergoing a laparoscopic gastric by-pass surgery, were studied, and pressures from the hypopharynx to the stomach were recorded using high-resolution solid-state manometry. Before anesthesia, recordings were performed during normal spontaneous breathing, Valsalva and forced inspiration. The effects of anesthesia induction with remifentanil and propofol were evaluated, and positive end-expiratory pressure (PEEP) 10 cmH₂O was applied during anesthesia.

RESULTS

During spontaneous breathing, the lower esophageal sphincter (LES) pressure was significantly lower during end-expiration compared with end-inspiration (28.5 ± 7.7 vs. 35.4 ± 10.8 mmHg, P<0.01), but barrier pressure (BrP) and intra-gastric pressure (IGP) were unchanged. LES, BrP (P<0.05) and IGP (P<0.01) decreased significantly during anesthesia. BrP remained positive in all patients. IGP increased during Valsalva (P<0.01) but was unaffected by PEEP. Esophageal pressures were positive during both spontaneous breathing and mechanical ventilation. Esophageal pressures increased during PEEP from 9.4 ± 3.8 to 11.3 ± 3.3 mmHg (P<0.01).

CONCLUSION

During spontaneous breathing, the LES pressure was the lowest during end-expiration but there were no differences in BrP and IGP. LES, BrP and IGP decreased during anesthesia but BrP remained positive in all patients. During the application of PEEP, esophageal pressures increased and this may have a protective effect against regurgitation.

Body positions and esophageal sphincter pressures in obese patients during anesthesia

BACKGROUND

The lower esophageal sphincter (LES) and the upper esophageal sphincter (UES) play a central role in preventing regurgitation and aspiration. The aim of the present study was to evaluate the UES, LES and barrier pressures (BP) in obese patients before and during anesthesia in different body positions.

METHODS

Using high-resolution solid-state manometry, we studied 17 patients (27-63 years) with a BMI>or=35 kg/m(2) who were undergoing a laparoscopic bariatric surgery before and after anesthesia induction. Before anesthesia, the subjects were placed in the supine position, in the reverse Trendelenburg position (+20 degrees) and in the Trendelenburg position (-20 degrees). Thereafter, anesthesia was induced with remifentanil and propofol and maintained with remifentanil and sevoflurane, and the recordings in the different positions were repeated.

RESULTS

Before anesthesia, there were no differences in UES pressure in the different positions but compared with the other positions, it increased during the reverse Trendelenburg during anesthesia. LES pressure decreased in all body positions during anesthesia. The LES pressure increased during the Trendelenburg position before but not during anesthesia. The BP remained positive in all body positions both before and during anesthesia.

CONCLUSION

LES pressure increased during the Trendelenburg position before anesthesia. This effect was abolished during anesthesia. LES and BPs decreased during anesthesia but remained positive in all patients regardless of the body position.

Growth and reduction of microorganisms in sediments collected from a greywater treatment system

AIMS

To study the effects of competitive microbiota, temperature and nutrient availability on Salmonella, Enterococcus, Campylobacter spores of sulphite reducing anaerobes and bacteriophages MS2 and phiX174 in sediments from a greywater treatment system.

METHODS AND RESULTS

Standard culture methods were used. Bacteria died off rapidly under normal conditions (20 degrees C, competitive microbiota) but remained stable or grew in the other conditions studied. When the sediments became nutrient depleted after 2 weeks, a log-linear die-off was observed for Salmonella, which was higher at 20 degrees C than at 4 degrees C. Bacteriophage decay was shown to be log-linear from day 0, with T90 values ranging from 9 (phiX174, 20 degrees C) to 55 days (phiX174, 4 degrees C). The MS2 phage had a significantly higher decay rate in tyndallized sediments (T90 = 17 days) than in original sediments (T90 = 47 days) (P < 0.001), with temperature not shown to affect the decay rate. Spores of sulphite-reducing anaerobes were not significantly reduced during the study period (35 days). Campylobacter died-off rapidly or entered a viable but non-culturable state and subsequently results were not provided.

CONCLUSIONS

Competition was the most important factor to suppress pathogenic bacterial growth in an eutrophic environment. When nutrient depleted conditions prevailed, temperature was more important and log-linear decay of microorganisms could be observed.

SIGNIFICANCE AND IMPACT OF THE STUDY

These findings suggest that the normally occurring microbiota will suppress pathogenic bacterial growth in nutrient rich sediments. With lower nutrient status, temperature is the more important factor in reducing pathogens.

Rational design of enantioselective enzymes requires considerations of entropy

Entropy was shown to play an equally important role as enthalpy for how enantioselectivity changes when redesigning an enzyme. By studying the temperature dependence of the enantiomeric ratio E of an enantioselective enzyme, its differential activation enthalpy (Delta(R-S)DeltaH(++)) and entropy (Delta(R-S)DeltaS(++)) components can be determined. This was done for the resolution of 3-methyl-2-butanol catalyzed by Candida antarctica lipase B and five variants with one or two point mutations. Delta(R-S)DeltaS(++) was in all cases equally significant as Delta(R-S)DeltaH(++) to E. One variant, T103G, displayed an increase in E, the others a decrease. The altered enantioselectivities of the variants were all related to simultaneous changes in Delta(R-S)DeltaH(++) and Delta(R-S)DeltaS(++). Although the changes in Delta(R-S)DeltaH(++) and Delta(R-S)DeltaS(++) were of a compensatory nature the compensation was not perfect, thereby allowing modifications of E. Both the W104H and the T103G variants displayed larger Delta(R-S)DeltaH(++) than wild type but exhibited a decrease or increase, respectively, in E due to their different relative increase in Delta(R-S)DeltaS(++).

[Infantile botulism caused by honey]

We report a case of a 5-week-old infant admitted with respiratory arrest. He had been fed with honey for two weeks. Infant botulism was suspected and confirmed by the finding of Clostridium botulinum toxin in the serum and faeces, and in the honey. The infant needed 7.5 months of ventilatory support.

Accidental deaths from asphyxia. A 10-year retrospective study from Sweden

Accidental mechanical asphyxia is an unusual cause of death. In reviewing 73 cases occurring during a 10-year-period in Sweden, young boys and elderly women seemed to be most prone to this type of fatality. A striking number of victims had deliberately put a noose-like structure around the neck, and yet another group became entangled in some part of their clothing. Thoracic immobilization was seen in a number of cases, also involving work-related accidents. Hospitalized patients, asphyxiophilics and inebriated victims represent other risk groups. A case involving the use of a helmet is reported in view of the growing frequency with which Swedish children use bicycle helmets. The material contains only a few cases where the victim was not alone at the time of the accident, and it seems plausible that supervision could have prevented many of the reported fatalities. Public knowledge of accident mechanisms may increase the awareness of hazardous situations and activities. Spreading of the medical examiner's knowledge may thus form a basis for accident prevention.

Septic shock in rats treated with terbutaline alone and in combination with chemotherapeutics, dexamethasone, and infusion of 3% albumin

The effects of a beta 2-receptor agonist, terbutaline, on haematocrit and survival were studied in rats in which septic shock had been induced by intraperitoneal injection of a mean (SD) dose of 6.0 (4.5) x 10(8) live E. coli. Untreated septic animals developed haemoconcentration, the mean (SD) haematocrit increasing from 47.5 (1.4) to 53.1 (2.2). Mean (SD) survival time was 8.9 (0.6) hours, and no animal survived for 24 hours. Terbutaline given as the only treatment in doses of 0.1, 0.5, and 2.5 mg/kg before injection of E. coli significantly reduced the haemoconcentration, with haematocrit of 51.9, 46.6 and 47.9, respectively, at 4 hours. Survival was not significantly prolonged. When terbutaline was started 5.5 hours after injection of E. coli and given in addition to a chemotherapeutic drug (trimethoprim + sulphamethoxazole) and dexamethasone, haematocrit were reduced, 24 hour survival improved from 44% to 68%, and 7 day survival improved from 20% to 48%. We conclude that terbutaline given alone counteracts the loss of plasma volume during septicaemia and, when combined with a chemotherapeutic and dexamethasone, significantly improves long term survival.

Oxygen consumption and central hemodynamics in septic shock treated with antibiotics, fluid infusions, and corticosteroids

The multidimensional pathophysiology of septic shock is poorly understood and treatment modalities are controversial. The present study evaluates the relative importance of three therapeutic measures: antibiotics (trimethoprim and sulphamethoxazole [TS]); fluid infusions (lactated Ringer's solution [RL] and 3% albumin [Alb]), and pharmacologic doses of corticosteroids (CS) (dexamethasone [DM]), using central hemodynamics (plasma volume [PV], cardiac output, oxygen consumption [VO2]), and survival as end-points. Septic shock was induced by intraperitoneal injection of live Escherichia coli bacteria. At 5 h in untreated septic rats, PV had dropped to 76%, cardiac output to 69%, and VO2 to 71% of preshock levels. Untreated septic animals had a mean survival time of 9.7 +/- 1.7 (SD) h, with none surviving 24 h. Regardless of therapy, cardiac output and VO2 at 10 h were predictors of survival time (p less than .01). Treatment was initiated at 5.5 h after bacterial injection, at a time when TS therapy alone had not improved the 24-h survival rate. Animals treated with DM, RL, and Alb, in this order, exhibited progressively improved central hemodynamics, and 24-h survival rate increased to 60% compared with 0 in untreated animals (p less than .001). The combination of DM and RL produced no further improvement. However, DM combined with 3% Alb restored VO2, cardiac output, and PV to 81%, 100%, and 125%, respectively, increasing the 24-h survival rate to 97% (29/30), significantly greater than that achieved by any other treatment modality (p less than .05).

Intravenous versus intrapulmonary administration of corticosteroids in combination with fluid infusion in experimental septic shock

Three different routes of corticosteroid administration (intravenous (IV), intratracheal instillation (IT), and aerosol inhalation (AE)) were evaluated for the treatment of an experimental septic shock induced by E. coli, given intraperitoneally. The corticosteroids, dexamethasone and budesonide, were given alone and in combination with 3% albumin infusion. Shock induced a plasma volume loss to 69% of control levels. This was partially prevented by corticosteroids alone, and prevented completely by 3% albumin infusion. The two corticosteroids were identical with respect to prolongation of survival time and hematocrit changes, regardless of the route of administration. Plasma steroid concentrations of budesonide were similar after IT and IV administration. Increasing doses of corticosteroids up to 8 mg/kg significantly prolonged mean survival time from 9 to 13 hours. When antibiotics and 3% albumin infusions were combined, survival time increased to 15 hours. Corticosteroids added to antibiotics and 3% albumin increased 24-hour survival rate from 0 to 60% (p less than 0.001). Intrapulmonary administration of corticosteroids is as effective as the intravenous route, and offers an important alternative, with obvious clinical implications. Further pharmacological modifications of the corticosteroids are necessary in order to evaluate local pulmonary versus the systemic effects.

Experimental septic shock: relative effects of treatment with antibiotics, crystalloid or colloid solution infusions and corticosteroids

This study evaluates the relative effects of 2 combined antibiotics, a crystalloid solution, 4 3% colloid solutions, and a pharmacologic dose of corticosteroids, given alone and in combination for the treatment of Escherichia coli-induced septic shock. All treatments began 5.5 h after bacterial injection. Untreated septic rats had a mean survival time of 9.9 h. Antibiotics (trimethophrim and sulfamethoxazole) alone did not significantly increase mean survival time (11.0 h). No rats in either of these two groups survived 24 h. When antibiotics and dexamethasone were combined, 40% (4/10) rats lived longer than 24 h (p less than .05). With Ringer's solution infusion, the mean survival time was 8.7 h and 30% (3/10) lived longer than 24 h. When a 3% colloid solution was given, 50% (20/40) lived more than 24 h and 20% (8/40) lived more than 7 days. There was no significant difference between the 4 colloid solutions (albumin, dextran-40, dextran-70, hydroxyethyl starch). When Ringer's solution was combined with dexamethasone and antibiotics, 80% (8/10) lived more than 24 h and 20% (2/10) were long-term survivors. When the antibiotic drug was combined with a colloid solution and dexamethasone, all animals lived more than 24 h and 90% (9/10) lived more than 7 days. This study demonstrates the therapeutic value of an effective antibiotic drug for control of the infective organism, a colloid solution infusion to maintain blood volume and circulation, and corticosteroids for still largely unknown reasons.