Hypothyroidism and levothyroxine therapy following bariatric surgery: a systematic review,meta-analysis,network meta-analysis,and meta-regression

BackgroundMany health benefits of bariatric surgery are known and well-studied, but there is scarce data on the benefits of bariatric surgery on the thyroid function.ObjectiveWe aimed to make a meta-analysis regarding the impact of bariatric surgery on thyroid-stimulating hormone (TSH) levels, levothyroxine dose, and the status of subclinical hypothyroidism.SettingSystematic review and meta-analysis.MethodsPubMed, EMBASE, and Cochrane Library were searched up to December 2020 for relevant clinical studies. Random-effects model was used to pool results. Network meta-analysis was performed, incorporating direct and indirect comparisons among different types of bariatric surgery. Meta-regression analysis was performed to evaluate the impact of moderator variables on TSH levels and required levothyroxine dose after surgery. We followed the PRISMA guidelines for data selection and extraction. PROSPERO registry number: CRD42018105739.ResultsA total of 28 studies involving 1284 patients were included. There was a statistically significant decrease in TSH levels after bariatric surgery (mean difference = ?1.66 mU/L, 95%CI [?2.29, ?1.03], P < .0001). In meta-regression analysis, we found that the following moderator variables: length of follow-up, mean age, baseline TSH, and preoperative thyroid function, could explain 1%, 43%, 68%, and 88% of the between-study variance, respectively. Furthermore, subclinical hypothyroidism was completely resolved in 87% of patients following bariatric surgery. In addition, there was a statistically significant decrease of levothyroxine dose in frank hypothyroid patients following bariatric surgery (mean difference = ?13.20 mcg/d, 95%CI [?19.69, ?6.71]). In network meta-analysis, we found that discontinuing or decreasing levothyroxine dose was significant following Roux-en-Y gastric bypass, 1 anastomosis gastric bypass, and sleeve gastrectomy, (OR = 31.02, 95%CI [10.34, 93.08]), (OR = 41.73, 95%CI [2.04, 854.69]), (OR = 104.03, 95%CI [35.79, 302.38]), respectively.ConclusionsBased on our meta-analysis, bariatric surgery is associated with the resolution of subclinical hypothyroidism, a decrease in TSH levels, and a decrease in levothyroxine dose.     

Time from Onset of SIRS to Antibiotic Administration and Outcomes after Subarachnoid Hemorrhage

Introduction

The interval from presentation with systemic inflammatory response syndrome (SIRS) to the start of antibiotic administration affects mortality in patients with sepsis. However, patients with subarachnoid hemorrhage (SAH) often develop SIRS directly from their brain injury, making it a less useful indicator of infection. We therefore hypothesized that SIRS would not be a suitable trigger for antibiotics in this population.

Methods

We examined the time from the development of SIRS until antibiotic initiation and its relationship to long-term neurological outcomes in patients with nontraumatic SAH. Patients’ baseline characteristics, time of antibiotic administration, and hospital course were collected from retrospective chart review. The primary outcome, 6-month functional status, was prospectively determined using blinded, structured interviews incorporating the modified Rankin Scale (mRS).

Results

Sixty-six of 70 patients with SAH during the study period had 6-month follow-up and were included in this analysis. SIRS developed in 57 patients (86 %, 95 % CI 78–95 %). In ordinal logistic regression models controlling for age and illness severity, the time from SIRS onset until antibiotic initiation was not associated with 6-month mRS scores (OR per hour, 0.994; 95 % CI 0.987–1.001).

Conclusions

In this cohort of patients with SAH, time from SIRS onset until antibiotic administration was not related to functional outcomes. Our results indicate that SIRS is nonspecific in patients with SAH, and support the safety of withholding antibiotics in those who lack additional evidence of infection or hemodynamic deterioration.     

Signal peptides and trans-membrane regions are broadly immunogenic and have high CD8+ T cell epitope densities: Implications for vaccine development

Cell mediated immune response has a major role in controlling the elimination of infectious agents. The rational design of sub-unit peptide vaccines against intracellular pathogens or cancer requires the use of antigenic sequence/s that can induce highly potent, long lasting and antigen-specific responses in the majority of the population. A promising peptide selection strategy is the detection of multi-epitope peptide sequences with an ability to bind multiple MHC alleles. While past research sought the best epitopes based on their specific antigenicity, we ask whether specific defined domains have high epitope densities. Signal peptides and trans-membrane domains were found to have exceptionally high epitope densities. The improved MHC binding of these domains relies on their hydrophobic nature and, in signal peptides, also on their specific sequence. The high epitope density of SP was computed using in-silico methods and corroborated by the high percentage of identified SP epitope in the IEDB (immune epitope database). The enhanced immunogenicity of SP was then experimentally confirmed using a panel of nine peptides derived from Mycobacterium tuberculosis (MTb) proteins used in human PBMC proliferation assays and T cell lines functional assays. Our results show the exceptionally high antigen specific response rates and population coverage to SP sequences compared with non-SP peptide antigens derived from the same proteins. The results suggest a novel scheme for the rational design of T cell vaccines using a domain based rather than an epitope based approach.     

Mercury Speciation and Total Organic Carbon in Marine Sediments Along the Mediterranean Coast of Israel

Along the Israeli Mediterranean Coast, three areas are considered “hot spots” of mercury (Hg) pollution: (1) Northern Haifa Bay (NHB), (2) the lower Qishon River at the southern part of Haifa Bay, and (3) a marine outfall of activated sewage sludge at the southern coast off Palmachim (sewage-sludge disposal site [SDS]). Even though the total Hg (HgT) concentrations in the sediments at the three areas are of the same order of magnitude (250–500?μg?kg^?1), Hg was shown to bioaccumulate in fish and benthic fauna from Haifa Bay but not in benthic fauna or in commercial fish caught along the southern Mediterranean Coast of Israel near the SDS outfall. The primary goal of this study was to measure the concentrations of Hg species (HgT, methyl-Hg [MeHg], and Hg in different biogeochemical fractions)—in conjunction with organic carbon—in sediments of NHB and the lower Qishon River to assess its impact on Hg transitions among the species as characterized by different bioavailability and bioaccessibility. HgT concentrations in NHB and the Qishon River ranged from 249 to 347 and 165 to 667?μg?kg^?1, respectively. MeHg was significantly higher in the Qishon River (6.3–34.0?μg?kg^?1) than in NHB (0.22–0.70?μg?kg^?1) as were total organic carbon (TOC) concentrations (average 2.5 vs. 0.13?%). The relative Hg distribution in the biogeochemical fractions in NHB was 2.3?% in the most bioaccessible fractions (F1?+?F2), 55?% in the organo-chelated species fraction (F3), 42?% in the strong-complexed species fraction (F4), and 0.7?% in the mercuric-sulfide fraction (F5). In the Qishon River, the bioavailable F1?+?F2 and F3 fractions were lower than in NHB (<0.01 and 23?%, respectively) and the more refractory F4 and F5 fractions higher (73 and 3.3?%, respectively). The fractionation of Hg in Qishon River sediments was similar to the distribution found in polluted stations at the SDS. TOC and MeHg were positively and negatively correlated, respectively, in Qishon River and NHB sediments. Methylation depended on TOC availability when its concentration was in the range of 2–4 wt%. It is possible that TOC in the sediment controlled Hg speciation: Hg in F3 decreased and in F4 increased with increasing TOC concentrations. In contrast, MeHg/HgT was significantly positively correlated with TOC and Hg in the stable F4 fraction and negatively correlated with Hg in the F3 fraction. It was therefore assumed that higher TOC concentrations enhanced microbial activity and decomposition of organic matter. Hg was released from the F3 fraction and was either transferred to the F4 fraction or made available for methylation processes.     

Emotional distress and satisfaction in life among Holocaust survivors--a community study of survivors and controls

Results are reported from a large population study (of working people) comparing Holocaust survivors and a control group in regard to emotional distress, satisfaction in life and psychosomatic symptoms. It was found that, even 40 years after the traumatic experience, this group of survivors exhibited a slightly higher degree of emotional disorders than controls who were not under Nazi occupation during WWII. These long-term effects were usually more prominent in women than in men, and the relationship to age was minimal.     

Psychological adaptation of anxiety disorder patients following repeated exposure to emergency situations

Thirty one patients in treatment for anxiety disorders and 31 controls were interviewed within hours after both the first and second Iraqi missile attacks on Israel during the Gulf war. After the first attack patients did not report higher anxiety levels, nor were they more pessimistic about the war and their fate in the war than the control subjects. Anxiety disorder patients tended to be engaged in cognitive-behavioral tactics for self-calming, while control subjects clearly preferred to cope by interacting with their social and physical environments. Following the second missible bombardment, patients were more inclined to retain their initial levels of anxiety and pessimism, while controls seem to have better adapted and showed significant improvements in those variables. The results are discussed in terms of coping skills and vulnerability as factors influencing adaptation to prolonged emergency situations.     

Oral drug therapy following bariatric surgery: an overview of fundamentals,literature and clinical recommendations

Bariatric surgery is the most effective solution for severe obesity and obesity with comorbidities, and the number of patients going through bariatric surgery is rapidly and constantly growing. The modified gastrointestinal anatomy of the patient may lead to significant pharmacokinetic alterations in the oral absorption of drugs after the surgery; however, because of insufficient available literature and inadequate awareness of the medical team, bariatric surgery patients may be discharged from the hospital with insufficient instructions regarding their medication therapy. In this article, we aim to present the various mechanisms by which bariatric surgery may influence oral drug absorption, to provide an overview of the currently available literature on the subject, and to draw guidelines for the recommendations bariatric surgery patients should be instructed before leaving the hospital. To date, and until more robust data are published, it is essential to follow and monitor patients closely for safety and efficacy of their medication therapies, both in the immediate and distant time post‐surgery.     

Oral levothyroxine therapy postbariatric surgery: Biopharmaceutical aspects and clinical effects

Background

Bariatric surgery can lead to changes in the oral absorption of many drugs. Levothyroxine is a narrow therapeutic drug for hypothyroidism, a common condition among patients with obesity.

Breast cancer,psychological distress and life events among young women

Since 1983, studies have suggested an interaction between the severe life events, psychological distress and the etiology of Cancer. However, these associations are still under dispute.