Postoperative micronutrient changes in bariatric surgery patients compliant with nutritional supplementation.

BACKGROUND: Bariatric surgery is commonly used in patients with body mass indexes over 35 kg/m and obesity-related comorbidities. Despite the significant clinical benefits of bariatric surgery, nutritional deficiencies post-surgery remain a challenge for both patient and healthcare provider [Toninello et al. in Nutrients 13:1565, 2021, Gasmi et al. in Eur J Nutr 61:55-67, 2022]. Nutritional supplementation is a way of reducing the likelihood of postoperative deficiencies; however, prior studies have shown varying degrees of mostly poor to moderate patient adherence [Spetz et al. in Obes Res Clin Pract 16:407-412, 2022, Mahawar et al. in Obes Surg 29:1551-1556, 2019, Santonicola et al. in J Am Nutr Assoc 41:11-19, 2022, Sherf Dagan et al. in Obes Surg 27:2258-2271, 2017]. Our present study aims to provide insights into the micronutrient biochemical profile in patients previously found to be compliant with supplementation following roux-en-y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG). METHODS: An 11-point outpatient survey was administered to consecutive patients ≥ 18 years who had undergone either RYGB or VSG to determine adherence with nutritional supplementation. Medical records were retrospectively reviewed to determine preoperative and postoperative lab values, including vitamins A, B1, B12, and D, thyroid stimulating hormone (TSH), iron binding capacity, transferrin, ferritin, folate, iron, albumin, hemoglobin A1C, zinc, glomerular filtration rate (GFR, and liver function values. Values were classified as "abnormal" or "normal." Preoperative and postoperative values were compared for differences. Postoperative values were also compared between RYGB and VSG. RESULTS: There were no significant differences between preoperative and postoperative values for any nutritional marker aside from vitamin B12. A total of 51/60 patients (85.0%) had normal preoperative B12 measurements, compared with 40/65 (61.5%) patients postoperatively (P = 0.03). Notably, of 25 "abnormal" postoperative measurements, 20 (80%) were elevated values. There were no differences in postoperative deficiencies between RYGB and VSG. CONCLUSIONS: Patients in our sample did not have worsened micronutrient deficiencies following bariatric surgery, and there were no differences in micronutrient deficiencies between surgical technique.

Unravelling the gut-lung axis: insights into microbiome interactions and Traditional Indian Medicine's perspective on optimal health.

The microbiome of the human gut is a complex assemblage of microorganisms that are in a symbiotic relationship with one another and profoundly influence every aspect of human health. According to converging evidence, the human gut is a nodal point for the physiological performance matrixes of the vital organs on several axes (i.e. gut-brain, gut-lung, etc). As a result of COVID-19, the importance of gut-lung dysbiosis (balance or imbalance) has been realised. In view of this, it is of utmost importance to develop a comprehensive understanding of the microbiome, as well as its dysbiosis. In this review, we provide an overview of the gut-lung axial microbiome and its importance in maintaining optimal health. Human populations have successfully adapted to geophysical conditions through traditional dietary practices from around the world. In this context, a section has been devoted to the traditional Indian system of medicine and its theories and practices regarding the maintenance of optimally customized gut health.

Patient perspectives on post-bariatric surgery nutritional supplementation.

BACKGROUND: Bariatric procedures increase patient risk of long-term metabolic complications primarily due to nutrient deficiencies. The mainstay of prevention includes routine vitamin and mineral supplementation; however, patient-reported barriers to daily compliance are poorly understood. METHODS: Post-bariatric surgery patients electively participated in an 11-point outpatient survey at a single academic institution. Surgical procedures included either laparoscopic sleeve gastrectomy (SG) or gastric bypass (GB). At the time of survey, patients ranged from 1-month to 15 years from surgery. Survey items consisted of dichotomous (yes/no), multiple choice, and open-ended free response questions. Descriptive statistics were evaluated. RESULTS: Two hundred and fourteen responses were collected, 116 (54%) underwent SG and 98 (46%) underwent GB. Of these, 49% of samples were during short-term postoperative follow-up visits (0-3 months), 34% intermediate follow-up (4-12 months), and 17% long-term follow-up (> 1 year). A total of 98% of patients reported that insurance did not cover their supplement cost. Most patients reported current vitamin use (95%), with 87% reporting daily compliance. Daily compliance was observed in 94%, 79%, and 73% of SG patients at short-, intermediate-, and long-term follow-up visits, respectively. While GB patients reported daily compliance in 84%, 100%, and 92% of short, intermediate, and long-term responses. Of those who were unable to take vitamins daily, non-compliance was attributed most to forgetting (54%), and less often to side effects (11%), or taste (11%). Patient-reported strategies for remembering to take vitamins included tying into daily routine (55%), use of a pill box (7%), and alarm reminders (7%). CONCLUSIONS: Daily compliance with post-bariatric surgery vitamin supplementation does not appear to vary based on postoperative time-period or surgical procedure. While a minority of patients struggle with daily compliance, factors associated with non-compliance include patient forgetting, side effects, and taste. Widespread utilization of patient-reported daily reminder strategies may lead to improved overall compliance and reduce incidence of nutritional deficiencies.

The Role of Preoperative Vitamin D in Spine Surgery.

PURPOSE OF REVIEW: Vitamin D is an essential micronutrient for human bone health and maintenance. Patients undergoing orthopaedic surgery with hypovitaminosis D may be at greater risk for worsened clinical outcomes. This narrative review aims to compile the current literature studying the effects of low preoperative vitamin D on spine surgery outcomes, creating a resource that clinicians can use to inform their practice. RECENT FINDINGS: Vitamin D deficiency predisposes to worse outcomes following spine surgery. Vitamin D supplementation may be beneficial in reducing the risk for adverse postoperative events; however, the literature is inconclusive regarding its efficacy in improving bone density and fracture risk. Spine clinicians should be aware of the increased risk for poor outcomes in patients with preoperative vitamin D deficiency. Future investigations are needed to better evaluate the benefits of preoperative vitamin D screening and supplementation on improving surgical outcomes in spine patients. These studies must also consider the effects on perioperative healthcare costs.

Exposure to polylactic acid induces oxidative stress and reduces the ceramide levels in larvae of greater wax moth (Galleria mellonella).

Plastic biodegradation by insects has made significant progress, opening up new avenues for the treatment of plastic waste. Wax moth larvae, for example, have attracted the attention of the scientific community because they are known to chew, ingest, and biodegrade natural polymer bee waxes. Despite this, we know very little about how these insects perform on manufactured plastics or how manufactured plastics affect insect metabolism. As a result, we studied the metabolism of greater wax moths (Galleria mellonella) fed on molasses-supplemented polylactic acid plastic (PLA) blocks. An analysis of the central carbon metabolism (CCM) metabolites was performed using liquid chromatography triple quadrupole mass spectrometry (LC-QQQ-MS), while an analysis of untargeted metabolites and lipids was conducted using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QToF-MS). In total, 169 targeted CCM metabolites, 222 untargeted polar metabolites, and 196 untargeted nonpolar lipids were identified within the insect samples. In contrast, compared to control larvae, PLA-fed larvae displayed significantly different levels of 97 CCM metabolites, 75 polar metabolites, and 57 lipids. Purine and pyrimidine metabolisms were affected by PLA feeding, as well as amino acid metabolism, carbohydrates, cofactors, vitamins, and related metabolisms. Additionally, PLA exposure disrupted insect energy metabolism and oxidative stress, among other metabolic disturbances. The larvae fed PLA have lower levels of several lipids, suggesting a reduction in lipid reserves, and ceramide levels are likely to have changed due to apoptosis and inflammation. The study indicates that G. mellonella larvae could ingest PLA but this process causes some metabolic stress for the host. Future studies of the molecular pathways of this biodegradation process might help to provide strategies for stress reduction that would speed up insect digestion of plastic.

Fatal low-dose methotrexate toxicity: A case report and literature review.

Methotrexate (MTX) is a chemotherapeutic agent that acts primarily by inhibiting the folic acid cycle. In addition to its application for treating malignancies, MTX is also used to treat chronic inflammatory diseases including psoriasis. Adverse effects have been reported even at low doses (up to 25 mg/week), and there is risk of toxicity in the form of myelosuppression, hepatotoxicity, or pulmonary fibrosis. Here, we report a case of a 67-year-old male with a past medical history of end stage renal disease on peritoneal dialysis and moderate-to-severe psoriasis with psoriatic arthritis presented with abdominal pain, diarrhea, rash, mucositis, and mucocutaneous ulcers and erosions. The patient was taking methotrexate 10 mg weekly without folic acid supplementation and was found to be pancytopenic. Despite treatment, the patient developed multiorgan failure and passed away after 16 days of hospitalization. Myelosuppression is considered the most serious side effect with the highest risk of mortality. Risk factors for toxicity include renal insufficiency, advanced age, lack of folate supplementation, drug interactions, and medication errors. Importantly, serum levels of MTX do not correlate with toxicity; therefore, folinic acid rescue therapy should be started as soon as MTX toxicity is suspected. MTX toxicity is rare with low dose, proper dose scheduling, and adherence to the recommended guidelines. It is imperative that physicians considering therapy with low dose MTX for dermatologic indications take into consideration a patient's risk factors for toxicity and monitor appropriately.

Corrigendum: Pre-conceptional Maternal Vitamin B12 Supplementation Improves Offspring Neurodevelopment at 2 Years of Age: PRIYA Trial.

[This corrects the article DOI: 10.3389/fped.2021.755977.].

Analyzing the Impact of Cannabinoids on the Treatment of Spinal Disorders.

PURPOSE OF REVIEW: Cannabis is among the most used illicit substances globally, with medical applications, increased legalization, and shifting social attitudes leading to increased use in recent years. Cannabinoids are a group of psychoactive substances found within the cannabis plant, with the most common being Δ9-tetrahydrocannabinol and cannabidiol. Due to the high prevalence of use, it is increasingly important to evaluate the effects of cannabis and cannabinoids on spine patients, in both operative and nonoperative settings. RECENT FINDINGS: Cannabis and cannabinoids may be effective in treating patients with chronic conditions such as back pain and spinal cord injuries. Longitudinal effects and implications on surgical outcomes and complications are poorly understood. High-quality, outcomes-focused research can inform approaches for clinicians to approach cannabis and cannabinoid use. Studies to elucidate the standardization of cannabis regimens can help develop guidelines for potential therapeutic applications. Cannabis and cannabinoids may be useful alternatives or additions for many spine patients, but future research is needed for recommendations to be determined. Our manuscript reviews the available literature regarding cannabis use and various spinal conditions, organizing our findings into the following narrative themes: (1) the management of chronic lower back pain, (2) perioperative outcomes, (3) cannabis use in general orthopaedic procedures, and (4) spinal cord injuries.

Pre-conceptional Maternal Vitamin B12 Supplementation Improves Offspring Neurodevelopment at 2 Years of Age: PRIYA Trial.

Background: The first thousand days window does not include the pre-conceptional period. Maternal pre-conceptional health has a profound influence on early embryonic development (implantation, gastrulation, placentation etc). Nutrition provided by B-complex vitamins is important for fetal growth, especially neural development. We report effects of a maternal pre-conceptional vitamin B12 and multi micronutrient (MMN) supplementation on offspring neurodevelopmental performance. Methods: In the Pune Rural Intervention in Young Adolescents trial (PRIYA), adolescents (N = 557, 226 females) were provided with vitamin B12 (2 µg/day) with or without multiple micronutrients, or a placebo, from preconception until delivery. All groups received mandatory iron and folic acid. We used the Bayley's Scale of Infant Development (BSID-III) at 24-42 months of age to investigate effects on offspring neurodevelopment. Results: Participants had similar baseline B12 levels. The levels improved in the B12 supplemented groups during pre-conception and pregnancy (28 weeks gestation), and were reflected in higher cord blood holotranscobalamin (holo-TC) levels compared to the placebo group. Neurodevelopmental outcomes in the B12 alone group (n = 21) were better than the placebo (n = 27) in cognition (p = 0.044) and language (p = 0.020) domains (adjusted for maternal baseline B12 levels). There was no difference in neurodevelopmental outcomes between the B12 + MMN (n = 26) and placebo group. Cord blood Brain Derived Neurotrophic Factor (BDNF) levels were highest in the B12 alone group, though not significant. Conclusion: Pre-conceptional vitamin B12 supplementation improved maternal B12 status and offspring neurodevelopment at 2 years of age. The usefulness of cord BDNF as a marker of brain development needs further investigation. Our results highlight the importance of intervening during pre-conception.

Amino acid supplementation for enhancing recombinant protein production in E. coli.

Recombinant protein production (RPP) in Escherichia coli (E. coli) often induces metabolic burden to the cells that compromise their overall growth and productivity. Amino acid starvation due to RPP is a major contributor of the metabolic burden on the cells and induces global stress response known as a stringent-like response. In this study, the effect of amino acid supplementation in a chemically defined medium on cellular growth and recombinant pramlintide production was investigated. Based on the consumption profile, few amino acids were categorized as growth-promoting (GP1) and protein production promoting (GP2). Feeding strategies of GP1 and GP2 were tested in shake flasks followed by scale up into the bioreactor. A 40% increase in the recombinant pramlintide (rPramlintide) production (protein concentration of 3.09 ± 0.12 g/L and yield of 227.69 ± 19.72 mg pramlintide per gram dry cell weight) was realized. Furthermore, transcriptomics data indicated the downregulation of several genes associated with global stress response and genes involved in amino acid biosynthesis in test culture, supported by proteomics analysis. These results signify that the external supply of critical amino acids decreases cellular stress during RPP and improves process productivity.

Use of concomitant aspirin in patients with atrial fibrillation: Findings from the ROCKET AF trial.

BACKGROUND: We aimed to investigate the relationship between aspirin use and clinical outcomes in patients enrolled in Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF), in particular, those with known coronary artery disease (CAD). METHODS: Patients in ROCKET AF, comparing rivaroxaban and warfarin, were analyzed. Aspirin use was assessed at baseline. Stroke and systemic embolism, myocardial infarction, death, and major or nonmajor clinically relevant (NMCR) bleeding were compared between groups. Multivariable modeling was done adjusting for baseline risk factors. RESULTS: A total of 5,205 (36.5%) patients were receiving aspirin at baseline (mean dose 99.2mg); 30.6% of those had known CAD. Patients receiving aspirin were more likely to have prior myocardial infarction (22% vs 14%; P<.001) and heart failure (68% vs 59%; P<.001). Relative efficacy of rivaroxaban versus warfarin was similar with and without aspirin use for both stroke/systemic embolism (P=.95 for interaction), and major or NMCR bleeding (P=.76 for interaction). After adjustment, aspirin use was associated with similar rates of stroke/systemic embolism (hazard ratio [HR] 1.16, 95% CI 0.98-1.37; P=.094) but higher rates of all-cause death (HR 1.27, 95% CI 1.13-1.42; P<.0001) and major or NMCR bleeding (HR 1.32, 95% CI 1.21-1.43; P<.0001). There was a significant interaction between no CAD at baseline and aspirin for all-cause death (P=.009). CONCLUSIONS: Aspirin use at baseline was associated with an increased risk for bleeding and all-cause death in ROCKET AF, a risk most pronounced in patients without known CAD. Although these findings may reflect unmeasured clinical factors, further investigation is warranted to determine optimal aspirin use in patients with AF.

Pharmacological properties of guggulsterones, the major active components of gum guggul.

Oleo gum resin secreted by Commiphora mukul, also known as gum guggul, has been used widely as an ayurvedic drug. Commiphora mukul is a short thorny shrub that is native to the Indian subcontinent. Oleo gum resin extracted by incision of the bark is a very complex mixture of gum, minerals, essential oils, terpenes, sterols, ferrulates, flavanones and sterones. Its active constituents, the Z- and E-guggulsterones, have been demonstrated to exhibit their biological activities by binding to nuclear receptors and modulating the expression of proteins involved in carcinogenic activities. Guggulsterones have also been reported to regulate gene expression by exhibiting control over other molecular targets including transcription factors such as nuclear factor (NF)-κB, signal transducer and activator of transcription (STAT) and steroid receptors. Considerable scientific evidence indicates the use of gum guggul as a therapeutic agent in the treatment of inflammation, nervous disorders, hyperlipidaemia and associated cardiac disorders such as hypertension and ischaemia, skin disorders, cancer and urinary disorders. This review highlights the taxonomic details, phytochemical properties and pharmacological profile of gum guggul.