Minerals and trace elements in pregnancy in women with previous bariatric surgery consequences on maternal and foetal health.

BACKGROUND: Bariatric surgery (BS) may decrease the risk of these obesity-related complications; however, due to its effect on nutrient intake and absorption, it can also have adverse consequences on maternal and foetal health. The aim of this study is to describe the evolution of electrolytes and trace elements serum levels throughout pregnancy after BS, according to the surgical technique and to evaluate the effect of nutritional deficiencies on the risk of maternal-foetal complications. METHODS: This is a retrospective observational study of the clinical evolution and maternal-foetal complications in a group of women with pregnancies that occurred after BS. Clinical evolution during pregnancy, body weight, and plasma electrolytes, vitamins, and trace elements, as well as their influence on maternal-foetal outcomes were evaluated. Composite neonatal variable (CNV) was defined to evaluate unfavourable foetal outcome. Published reference values for micronutrients during pregnancy have been used. RESULTS: The study includes data on 164 singleton pregnancies in 91 women. A hundred and twenty-seven pregnancies got to full term. The average birth weight was 2966 (546) g., 26.8% < P10 and 13.8% < P3 of a reference population. New-born of gestations after malabsorptive bariatric surgery had a higher risk of having a percentile of birth weight < P3. Plasma electrolytes, trace elements and vitamins throughout pregnancy showed differences depending on the surgical technique, with lower haemoglobin, ferritin, calcium, zinc, copper, vitamin A and vitamin E in the malabsorptive techniques. A high percentage of deficiency was observed, especially in the third trimester (Hb < 11 g/dl: 31.8%; ferritin < 30 mg/ml: 85.7%; zinc < 50 µg/dl: 32.4%, vitamin D < 30 ng/ml: 75.5% and < 20 ng/ml: 53.3%). A decreased plasma copper in the first trimester or zinc in the third trimester were associated with a lower percentile of new-born birth weight. A higher risk of CNV was observed in predominant malabsorptive BS and in pregnancies that had presented at least one vitamin D level lower than 20 ng/ml throughout pregnancy (30.4% vs. 7.1%, p=0.018). CONCLUSIONS: Trace elements and vitamin deficiencies are common in pregnant women after bariatric surgery, especially of iron, zinc, and vitamin D. These deficiencies might negatively affect foetal development. Further studies are needed to better define the role of micronutrients in maternal-foetal health after bariatric surgery.

Does the Prevalence of Obesity in the Different Regions of Spain Influence the Attitudes, Perception, and Barriers to Its Treatment?

INTRODUCTION: The differences in the prevalence of obesity between the various regions of Spain, partly attributed to socioeconomic differences, may influence the approach to this disease. The aim of this study was to compare differences in attitudes, perception, and barriers to the treatment of obesity between people with obesity (PwO) and health care professionals (HCPs), between the different regions of Spain. METHODS: Sub-analysis of the ACTION-IO Spain study, which included 1,500 PwO and 306 HCP, was performed to identify differences in PwQ and HCPs belonging to regions with high prevalence of obesity (>16%, n = 9 regions, high prevalence of obesity [HPO] group) and low prevalence of obesity (<16%, n = 8 regions, low prevalence of obesity [LPO] group) (self-reported data), according to the 2017 National Health Survey of Spain. STATISTICS: comparison of proportions (χ2). RESULTS: A total of 746 PwO belonged to HPO and 754 to LPO group. The PwO in HPO group were younger, had lower income, a lower level of higher education, higher unemployment rate, and fewer comorbidities. Obesity was considered a chronic disease to a higher extent in HPO compared to LPO group (62 vs. 56%), but this difference was not statistically significant. The PwO in HPO group discussed less with the HCPs about their excess weight (57 vs. 70%), did not feel motivated to lose weight in a higher percentage (26 vs. 18%), and felt less emotionally supported (16 vs. 24%). In HPO group, the preference for unhealthy food (51 vs. 36%), and the costs of healthy eating, anti-obesity drugs and bariatric surgery were perceived barriers to losing weight. A higher proportion of PwO in HPO group considered that exercise (58 vs. 40%) was more effective for achieving weight loss. In contrast, LPO group considered diet more effective (48 vs. 32%). HCPs in HPO group felt more motivated to treat obesity (83 vs. 68%) and a higher proportion (14 vs. 5%) identified the economic burden as one of the main reasons why PwO do not start conversations to lose weight. CONCLUSIONS: There is less concern and conversation about excess weight in PwO in regions with a higher prevalence of obesity, with socioeconomic limitations being one of the main perceived barriers to treatment.

Micronutrients in Pregnancy after Bariatric Surgery: A Narrative Review.

Bariatric surgery is increasingly used in women of childbearing age due to the rising prevalence of obesity and the effectiveness and availability of this treatment. Pregnancy in women with previous bariatric surgery deserves special attention. Weight loss induced by surgery reduces the risks that obesity poses to pregnancy. But on the other hand, decreased intake and malabsorption may increase the risk of malnutrition and micronutrient deficiency and negatively affect maternal and foetal health. The aim of this narrative review is to provide an updated analysis of the impact of different bariatric surgery techniques on mineral and micronutrient nutritional status during pregnancy and the possible effect on maternal-foetal health.

Evaluation of Myocardial Function Following SADI-S.

PURPOSE: The aim of this study was to compare myocardial mechanics using global longitudinal strain (GLS) before and after single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). MATERIALS AND METHODS: A total of 21 obese patients undergoing SADI-S were prospectively included. Transthoracic echocardiography was performed before and after the procedure, and left ventricle (LV) and right ventricle (RV) strain was assessed by two-dimensional speckle-tracking imaging (2DST). RESULTS: Mean time between pre-procedural and post-procedural echocardiograms was 9.2 ± 3.3 months. Postoperatively, %total weight loss (%TWL) was 33.0 ± 1.7 and % excess weight loss (%EWL) was 75.5 ± 3.6. Body mass index (BMI) significantly decreased after surgery (45.6 ± 1.2 vs 29.6 ± 1.0; p < 0.001). Postoperatively, LV GLS experienced a significant improvement (-19.8% ± 0.5 vs -22.2% ± 0.4; p < 0.001). Regarding other relevant functional parameters, RV free-wall strain was equally recovered (-19.1% ± 0.7 vs -21.0% ± 0.8; p 0.047). CONCLUSIONS: This study demonstrates important and favourable changes in cardiac deformation parameters after performing SADI-S. Malabsorptive bariatric techniques such as SADI-S induce significant weight loss, leading to an improvement in subclinical myocardial function in patients with obesity.

Obesity and SARS-CoV-2: Considerations on bariatric surgery and recommendations for the start of surgical activity. / Obesidad y SARS-CoV-2: consideraciones sobre la cirugía bariátrica y recomendaciones para el inicio de la actividad quirúrgica.

The SARS-CoV-2 pandemic has a great impact worldwide, being Spain one of the most affected countries. The delay in bariatric surgery can have fatal consequences since up to 50% of the patients who are on the waiting list develop a new comorbidity during the time they remain on it and 1.5% of patients die while waiting for the intervention. That is why bariatric surgery should not be delayed, if the occupation of the hospital by COVID-19+ patients decreases significantly, and sufficient resources and safety are available to restart surgery in patients with benign pathology. This document contains the main recommendations for the bariatric surgery programs in our country from the point of view of safety, bariatric patient preparation and follow up during the SARS-CoV-2 pandemia.

The SEEN comprehensive clinical survey of adult obesity: Executive summary. / Abordaje clínico integral SEEN de la obesidad en la edad adulta: resumen ejecutivo.

Obesity is one of the great challenges in healthcare nowadays with important implications for health so requiring comprehensive management. This document aims to establish practical and evidence-based recommendations for the diagnosis and management of in Spain, from the perspective of the clinical endocrinologist. A position statement has been made that can be consulted at www.seen.es, and that has been agreed by the Obesity Group of the Spanish Society of Endocrinology and Nutrition (GOSEEN), together with the Nutrition Area (NutriSEEN) and the Working Group of Endocrinology, Nutrition and Physical Exercise (GENEFSEEN).

Interaction between age and vitamin D deficiency in severe COVID-19 infection.

INTRODUCTION: Background: coronavirus disease 2019 (COVID-19) can induce an exaggerated inflammatory response. Vitamin D is a key modulator of the immune system. We hypothesized that vitamin D deficiency (VDD) could increase the risk of developing severe COVID-19 infection. Methods: patients with confirmed COVID-19 seen at the emergency department of our hospital with recent measurements of 25(OH)D were recruited. We explored the association of vitamin D deficiency (VDD), defined as 25-hydroxyvitamin D < 20 ng/mL, with a composite of adverse clinical outcomes. Results: we included 80 patients, of which 31 (39 %) presented the endpoint. VDD tended to predict an increased risk of developing severe COVID-19 after adjusting for age, gender, obesity, cardiac disease, and kidney disease [OR 3.2 (95 % CI: 0.9-11.4), p = 0.07]. Age had a negative interaction with the effect of VDD on the composite outcome (p = 0.03), indicating that the effect was more noticeable at younger ages. Furthermore, male gender was associated with VDD and with severe COVID-19 at younger ages. Conclusions: in this retrospective study, vitamin D deficiency showed a signal of association with severe COVID-19 infection. A significant interaction with age was noted, suggesting VDD may have a greater impact in younger patients. These findings should be confirmed in larger, prospective, adequately powered studies.

INTRODUCCIÓN: Antecedentes: la enfermedad por coronavirus 2019 (COVID-19) puede inducir una respuesta inflamatoria exagerada. La vitamina D es un modulador clave del sistema inmune. Planteamos que la deficiencia de vitamina D (VDD) podría aumentar el riesgo de desarrollar infección grave por COVID-19. Métodos: se reclutaron pacientes consecutivos que acudieron al servicio de urgencias de nuestro centro con diagnóstico de COVID-19 confirmado (PCR-COVID-19 positiva) y mediciones recientes de 25(OH)D. Exploramos la asociación de la deficiencia de vitamina D (VDD), definida como una 25-hidroxivitamina D < 20 ng/ml, con un compuesto de resultados clínicos adversos. Resultados: se incluyeron 80 pacientes, de los cuales 31 (39 %) presentaron el criterio de valoración primario. El VDD tendió a predecir un mayor riesgo de desarrollar COVID-19 grave después de ajustar edad, sexo, obesidad, enfermedad cardíaca y enfermedad renal [OR: 3,2 (IC 95 %: 0,9-11,4), p = 0,07]. La edad tuvo una interacción negativa con el efecto de la VDD en el resultado compuesto (p = 0,03), lo que indica que el efecto fue más notable a edades más tempranas. Además, el género masculino se asoció con la VDD y con la COVID-19 grave en las edades más jóvenes. Conclusiones: en este estudio retrospectivo, la deficiencia de vitamina D mostró una tendencia de asociación con la infección grave por COVID-19. Se observó una interacción significativa con la edad, lo que sugiere que la VDD puede tener un mayor impacto en los pacientes más jóvenes. Estos hallazgos deben confirmarse en estudios más grandes, prospectivos y con potencia adecuada.

Effect of Roux-en-Y gastric surgery on ciprofloxacin pharmacokinetics: an obvious effect?

PURPOSE: To evaluate pharmacokinetic parameters of ciprofloxacin in patients undergoing Roux-en-Y gastric surgery (RYGS). METHODS: Controlled, single-dose, open-label study in patients undergoing RYGS. Healthy overweight/obese patients 18-60 years old were included. The assessment was performed once in control patients and three times in case patients (before surgery and 1 and 6 months after surgery). In each visit, the subjects received a single oral dose of ciprofloxacin 500 mg. Venous blood samples were obtained at baseline and 0.5, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 8 and 14 h after ciprofloxacin intake. Pre- and post-surgery variables were compared using paired ANOVA or the Wilcoxon tests and control vs cases using ANOVA or Mann Whitney. Given the post-surgery change in body weight, the parameters were corrected by dose (mg)/body weight (kg). The analysis was performed using SPSS. RESULTS: Ciprofloxacin Cmax was significantly reduced 1 month after surgery (1840.9 ± 485.2 vs 1589.6 ± 321.8 ng/ml; p = 0.032) but not 6 months after. Cmax on the sixth month was lower than Cmax in control group (2160.4 ± 408.6 vs 1589.6 ± 321.8 ng/ml; p < 0.001). After correcting by the dose (mg)/patient's body weight, both Cmax and AUClast showed significant decrease 1 and 6 months after surgery: Cmax, 289.1 ± 65.3 and 263.5 ± 52.1 (ng/ml)/(dose (mg)/weight (kg)) respectively vs 429.3 ± 127.6 (ng/ml)/(dose (mg)/weight (kg)) at baseline; AUC, 1340.6 ± 243.0 and 1299.2 ± 415.4 (h × ng/ml)/(dose (mg)/weight (kg)) respectively vs 1896.7 ± 396.8 (h × ng/ml)/(dose (mg)/weight (kg)) at baseline. Cmax 1 month post-surgery showed lower values than the control group (375.4 ± 77.4 vs 263.5 ± 52.1 ng/ml; p < 0.001). CONCLUSION: Ciprofloxacin absorption is impaired 1 month and 6 months after RYGS. The effect on Cmax and AUClast faded on the sixth month due to weight loss. It is no necessary to modify the doses of ciprofloxacin in these patients.

Squamous Cell Carcinoma of the Peristomal Skin of a Gastrostomy: Case Study.

BACKGROUND: Primary skin tumors that develop at enteral feeding stomas are extremely rare. Ongoing surveillance of these stomas, including the peristomal skin, is essential to early diagnosis and treatment of these tumors. CASE: A 73-year-old man with an esophageal chemical burn caused by swallowing sodium hypochlorite (bleach) approximately 50 years earlier that was initially managed with esophageal exclusion and placement of a gastrostomy device for enteral feeding presented with an exophytic and painful mass of the skin adjacent to his gastrostomy site. The pathologic report confirmed differentiated squamous cell skin carcinoma. CONCLUSION: Skin tumors arising from chronic wounds or ulcers of the skin surrounding a gastrostomy device are rare but should be considered if hypergranulation tissue or a peristomal lesion appears to be nonhealing. WOC nurses are frequently consulted for care of granulomas, and close monitoring is essential for avoiding this potentially fatal complication.

HELICOBACTER PYLORI (HP) INFECTION IN OBESE PATIENTS UNDERGOING ROUXEN- Y GASTRIC BYPASS; EFFICACY OF TWO DIFFERENT TREATMENT REGIMENS IN HP ERADICATION.

INTRODUCTION: the ultimate cause for the increased incidence of gastric ulcer following Roux-en-Y gastric bypass (RYGB) remains unclear. Treatment of HP infection is recommended before surgery in countries with high prevalence such as Spain in other to diminish the risk. However, the current regimens used might not be adequate in view of the high failure rate for HP eradication. METHODS: we reviewed 243 patients retrospectively undergoing RYGB and found 111 patients (45%) with HP infection. Therefore, we compared the eradication rate between 2 different regimens. RESULTS: 70 patients received OCA(Omeprazole:20 mg/12h, Clarithromycin 500 mg/12h and Amoxicillin 1 gram/12h for 10 days) while 41 patients received OLA (Omeprazole 20 mg/12 hours, Levofloxacin 500 mg/12hours and Amoxicillin 1 gram/12h for 10 days) for HP eradication. In 56/70 (80%) patients receiving OCA therapy HP was eradicated compared to 37/41 (91%) receiving OLA as first line therapy (p = 0.283). When used as second line therapy, in 13/14 (92%) patients receiving OLA HP was eradicated. CONCLUSION: clarithromycin resistance remains a matter of concern in this population while OLA seems to be a good alternative therapy for HP eradication, especially when OCA regimen fails.

Introducción: las causas implicadas en el aumento de incidencia de úlcera gástrica tras el bypass en Y de Roux no son completamente conocidas. El tratamiento de la infección por HP se recomienda antes de la cirugía en países cuya prevalencia sea elevada, como el caso de España, de cara a disminuir dicha complicación. Sin embargo, las pautas actuales de tratamiento pueden no ser adecuadas dados los elevados índices de resistencia. Pacientes y métodos: análisis retrospectivo de 243 pacientes operados de bypass en Y de Roux. De ellos, 111 pacientes (45%) presentaban infección por HP. Objetivo principal: comparación de la eficacia de dos terapias de erradicación de la infección por HP. Resultados: 70 pacientes recibieron OCA( Omeprazol 20 mg/12 h, Claritromicina 500 mg/12 h y Amoxicilina 1 g/12h durante 10 días), mientras que 41 pacientes recibieron OLA (Omeprazol 20 mg/12 h, Levofloxacino 500 mg/12 h y Amoxicilina 1 g/12 h durante 10 días). En 56/70 pacientes (80%) que recibieron OCA HP fue erradicado, comparado con 37/41 (91%) del grupo que recibió OLA como primera terapia (p = 0,283). La terapia con OLA usada de segunda línea fue eficaz en 13/14 pacientes con HP resistente a la terapia OCA. Conclusión: la resistencia de HP a Claritromicina es significativa en nuestra serie de pacientes, siendo la terapia con OLA una alternativa adecuada en las cepas resistentes.

[1991-2004 follow-up of a Spanish general population cohort. Mortality and raising risk factors in the DRECE III Study (Diet and Risk of Cardiovascular Diseases in Spain)]. / Seguimiento de 1991 a 2004 de la mortalidad y los factores de riesgo emergentes en una cohorte de población general española. Estudio Drece III (Dieta y Riesgo de Enfermedades Cardiovasculares en España).

BACKGROUND: The DRECE III study is based on the follow up of a cohort representative of the Spanish general population. The mortality, its main causes and relevant risk factors have been analyzed. METHODS: The DRECE cohort is composed of 4783 subjects followed since 1991 to 2004 (70930 person-years). In 1991 a general medical exam including blood analysis and nutritional questionnaire was undertaken. Currently the age spam is from 18 to 73 years. Vital status and mortality causes were provided by the National Institute of Statistics. RESULTS: In this period, 125 deaths were registered: 53 persons (42.4%) due to cancer; 31 persons (24.8%) due to circulatory causes, of which 24 were due to cardiovascular origin. The remaining 41 (32.8%) deaths were included under the ICD 10 "Other chapters". For the all causes mortality the independent associated variables were: creatinina 1.5 mgr/dl, HR 3.78 (95% CI: 1.52-9.40); diabetes, HR 2.80 (95% CI: 1.74-4.46); male sex, HR 2.39 (I95% CI: 1.61-3.55); age, HR 1.08 (I95% CI: 1.07-1.10); and gammaglutamil transpeptidasa, HR 1.001 (I95% CI: 1.000-1.003). In the case of cancer mortality the risk factors founded were: age, HR 1.12 (I95% CI: 1.09-1.16); and tobacco, HR 1.33 (I95% CI: 1.14-1.54). For cardiovascular mortality were creatinina 1.5 mg/dl, HR 19.40 (I95% CI: 5.45-69.12); diabetes, HR 9.82 (I95% CI: 4.19-23.04); and age, HR 1.10 (I95% CI: 1.05-1.15). CONCLUSIONS: We obtain a mortality pattern where cancer is the most frequent cause. Classic risk factors appear associated to main death causes. Diabetes mellitus has an outstanding role as risk factor associated to early mortality. No specific diet data was associated neither to all causes mortality, nor to cardiovascular or cancer.

Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique.

Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy is a new bariatric technique based on the biliopancreatic diversion with duodenal switch in which after the sleeve gastrectomy, the duodenum is anastomosed to the ileum in a Billroth-II fashion. A 200-cm common channel-alimentary limb is devised. Anticipating an appropriate weight loss, at least similar to that obtained after gastric bypass, theoretical benefits for operated patients are a shorter operative time, the performance of only one anastomosis, and no mesentery opening. A prospective trial is now being conducted to find out the results of the procedure and to compare them to those obtained with gastric bypass and standard duodenal switch.