Cesarean delivery complications in women with morbid obesity

Objective: To compare cesarean complication rates between women with body mass index (BMI) 40–49.9?kg/m² and BMI?≥?50?kg/m² and associations with surgical techniques.

Methods: This retrospective cohort study from 2009 to 2014 included women who underwent cesarean with delivery BMI?≥?50 and an equal number with BMI 40–49.9. Wound infections and/or separations were compared. We also examined wound complication rates between skin closure techniques and self-retaining retractor use.

Results: Among 498 patients (249 with BMI?≥?50 and 249 with BMI 40–49.9) there were no differences in estimated blood loss >1000?mL, blood transfusion, deep vein thrombosis or endometritis. Among those with outpatient follow-up (144 with BMI?≥?50 and 162 with BMI 40–49.9), those with BMI?≥?50 had a significantly higher rate of wound separations (p?=?0.01) but not infections. There were no differences in wound complication rates between skin closure techniques or self-retaining retractor use, though the study was not powered for these comparisons.

Conclusion: Wound complications, particularly separations, increase with BMI?≥?50 compared to a lesser degree of morbid obesity. Skin closure techniques and self-retaining retractor use were not associated with cesarean wound complications in patients with morbid obesity.     

The Effects of Bariatric Procedures on Bowel Habit

Background

Bariatric procedures are increasingly being used to combat the rising obesity epidemic. The aim of this study was to assess the effect of these interventions on bowel habit.

Methods

We recruited obese adults listed for a bariatric procedure. Demographic data, medical history, medications and anthropometric measurements were recorded. Bowel habit was characterized using a 7-day Bristol Stool Form Scale (BSFS) diary. A validated food frequency questionnaire (FFQ) was used to assess diet.

Results

Twenty-six patients were assessed pre-operatively and at a median of 6.4 months post-operatively. Nineteen had a Roux-en-Y gastric bypass (RYGB), five had a sleeve gastrectomy (SG) and two had an intra-gastric balloon (IGB) with median percentage excess weight loss (% EWL) of 67.9, 52.4 and 31.3 %, respectively. Dietary fibre intake decreased from 24.4 (±12.1) g/day pre-operatively to 17.5 (±7.3) g/day post-operatively (P?=?0.008). Frequency of bowel motions decreased from 8.6 (±3.5) to 5.7 (±3.5) motions/week (P?=?0.001). Mean usual BSFS score decreased (towards firmer stool) from 4.1 (±1.3) pre-operatively to 3.1 (±1.9) post-operatively (P?=?0.016). Constipation increased from 8 to 27 %, but this did not reach statistical significance (P?=?0.125).

Conclusions

Constipation is a common problem after bariatric surgery. The decrease in bowel motion frequency and change towards firmer stools suggest prolonged intestinal transit time after bariatric procedures. Reduction in dietary fibre intake is likely to be a contributory factor.

     

A preliminary study of spiritual self-schema (3-S(+)) therapy for reducing impulsivity in HIV-positive drug users

The purpose of this study was twofold. First, pretreatment correlations are presented among impulsivity, intoxicant use, HIV risk behavior, spirituality, and motivation in a sample of 38 HIV-positive drug users. Second, treatment outcomes are presented from a preliminary study of spiritual self-schema (3-S(+)) therapy - a manual-guided psychotherapy integrating cognitive and Buddhist psychologies - for increasing motivation for abstinence, HIV prevention, and medication adherence. Impulsivity was negatively correlated with spiritual practices and motivation for recovery, and was positively related to intoxicant use and HIV risk behavior. Relative to a standard care comparison condition, patients completing 3-S(+) therapy reported greater decreases in impulsivity and intoxicant use, and greater increases in spiritual practices and motivation for abstinence, HIV prevention, and medication adherence.     

Best practice in primary care pathology: review 10

This tenth best practice review examines four series of common primary care questions in laboratory medicine: (i) antenatal testing in pregnant women; (ii) estimated glomerular filtration rate calculation; (iii) safety testing for methotrexate; and (iv) blood glucose measurement in diabetes. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus rather than evidence-based. They will be updated periodically to take account of new information.     

Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems

Timely and convenient access to primary healthcare is essential for the health of the population as delays can incur additional health and financial costs. Access to health care is under increasing scrutiny as part of the drive to contain escalating costs, while attempting to maintain equity in service provision. The objective was to compare primary care services in Republic of Ireland and Northern Ireland, and to report on perceived and reported access to GP services in universal access and mixed private/public systems. A questionnaire study was performed in Northern Ireland (NI) and the Republic of Ireland (ROI). Patients of 20 practices in the ROI and NI were contacted (n = 22,796). Main outcome measures were overall satisfaction and the access to GP services. Individual responses and scale scores were derived using the General Practice Assessment Questionnaire (G-PAQ). The response rate was 52% (n = 11,870). Overall satisfaction with GP practices was higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than in NI (69.2% and 57.0% respectively) Less than 1 in 10 patients in ROI waited two or more working days to see a doctor of choice (8.1%) compared to almost half (45.0%) in NI. In NI overall satisfaction decreased as practice size increased; 82.8%, 80.4%, and 75.8%. In both systems, in large practices, accessibility is reduced when compared to smaller practices. The faster access to GP services in ROI may be due to the deterrent effect of the consultation charge freeing up services although, as it is the poorest and sickest who are deterred by the charge this improved accessibility may come at a significant cost in terms of equity. The underlying concern for policy makers centres around provision of equitable services.     

The rat mammary gland: morphologic changes as an indicator of systemic hormonal perturbations induced by xenobiotics

The development and morphology of the rat mammary gland are dependent upon several hormones including estrogens, androgens, progesterone, growth hormone and prolactin. In toxicology studies, treatment with xenobiotics may alter these hormones resulting in changes in the morphology of reproductive tissues such as the mammary gland. In the rat, male and female mammary glands exhibit striking morphologic differences that can be altered secondary to hormonal perturbations. Recognizing these morphologic changes can help the pathologist predict potential xenobiotic-induced perturbations in the systemic hormonal milieu. This review examines the development of the rat mammary gland and the influence of sex hormones on the morphology of the adult male and female rat mammary gland. Specific case examples from the literature and data from our laboratory highlight the dynamic nature of the rat mammary gland in response to hormonal changes.     

Enrichment improves cognition in AD mice by amyloid-related and unrelated mechanisms

Lifelong cognitive stimulation is associated with a lower risk of Alzheimer's disease (AD), but causality is difficult to prove. We therefore sought to investigate the preventative potential of environmental enrichment (EE) using mice expressing both human mutant presenilin-1 and the amyloid precursor protein (PS1/PDAPP). At weaning, mice were placed into either an enriched or standard housing environment. Behavioral testing at 4.5-6 months showed that environmentally enriched PS1/PDAPP mice outperformed mice in standard housing, and were behaviorally indistinguishable from non-transgenic mice across multiple cognitive domains. PS1/PDAPP mice exposed to both environmental enrichment and behavioral testing, but not to EE alone, showed 50% less brain beta-amyloid without improved dendritic morphology. Microarray analysis revealed large enrichment-induced changes in hippocampal expression of genes/proteins related to Abeta sequestration and synaptic plasticity. These results indicate that EE protects against cognitive impairment in AD transgenic mice through a dual mechanism, including both amyloid dependent and independent mechanisms.