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 (npre-surgery-BMI = 2634:2634/nearly-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 < 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 < 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.

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.

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.

Present practice of electroconvulsive therapy in Scandinavia.

We have set up guidelines for the practice of electroconvulsive therapy, based on Scandinavian clinical experience and research. Because the therapeutic effect is a result of the cerebral seizure, and the organic side effects partly consequences of the electrical stimulation, the aim should be to induce maximal seizure activity using minimal electrical energy. Essential features of optimal therapy are (1) absence of therapy with benzodiazepines and other anticonvulsant drugs, (2) superficial narcosis, (3) abundant oxygen supply, (4) threshold stimulation with brief-pulse stimuli, and (5) unilateral, parietotemporal, nondominant application of the electrodes. Seizure duration should always be measured to make sure that maximum seizure activity has taken place.

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.

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(++).

Use and misuse of electroconvulsive treatment.

For the continued availability of electroconvulsive therapy (ECT) in clinical practice on equal footing with other treatments, and without judicial interference, the following points are essential: ECT should be used or not used on the basis of scientific evidence and not because of public opinion or antipsychiatric propaganda. There should be no hesitation to use ECT in conditions where its omission would mean prolonged suffering, risk of suicide, or death from other causes (deep melancholic syndromes, acute lethal catatonia, psychogenic confusion). ECT should not be used where the effect is short-lived or must be paid at the price of an organic syndrome (schizophrenia, paranoid states, organic confusions). Efficiency should be optimal (oxygen, superficial narcosis, absence of benzodiazepines, generalized tonic-clonic seizures of at least 30-sec duration, maintenance treatment with antidepressive drugs). Safety should be optimal, not only for life but also for cerebral functioning (anesthesiological management, unilateral nondominant stimulation, pulse wave stimuli, appropriate number of treatments, not too closely spaced). The mechanism of action should be the object of further investigation. Such research will open possibilities for finding drugs that can compete with ECT.

A theory of convulsive therapy in endogenous depression: significance of hypothalamic functions.

The repeated induction of seizures (convulsive therapy) relieves the symptoms of severe depressive mood disorders, particularly those accompanied by vegetative symptoms. Neuroendocrine abnormalities characterize patients with endogenous depression, and the abnormalities are reversed by convulsive therapy. Tests of neuroendocrine functions provide criteria for the classification of such cases, and probably will be useful in defining suitable cases for convulsive therapy. We postulate that the antidepressant efficacy of convulsive therapy results from the increased release and more widespread cerebral distribution of hypothalamic peptides with behavioral effects. Such a hypothesis provides a basis for clinical trials of centrally active peptides in cases of endogenous depression, and for studies of neuroendocrine functions as predictors of outcome in convulsive therapy.

[Unilateral and bilateral shock therapy: mechanism of action (author's transl)]. / La sismothérapie uni- et bilatérale: mécanisme d'action.

The unilateral and bilateral therapy differ in psycho-organic effects but have the same antidepressive efficiency. This is due to the facts that the organic effects are mainly caused by the electrical current whereas the antidepressive effect is dependent on the seizure activity. Compared to the bilateral treatment, unilateral gives reduced confusion, anterograde and retrograde amnesia as well as reduced experience of memory impairment. The difference is explained by a lower density of current in the brain. The unilateral treatment should be the treatment to be chosen. The antidepressive action of ECT fits the amine hypothesis, ECT causes a sustained increase of the synthesis of norepinephrine and of the sensitivity of amine receptors and creates conditions for alleviating both "low-output" and "low-sensitivity" depression. The antidepressive action is probably mediated by release of hypothalamic neurohormones.

[Infantile botulism caused by honey]. / Infantil botulisme forårsaget af honning.

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.

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.