Leukemoid reaction and chronic lung disease in infants with very low birth weight

Objectives: To analyze the relationship between the leukemoid reaction and chronic lung disease in very-low-birth-weight (VLBW) infants. Methods: Neonates born weighing less than 1500 g without evidence of congenital anomalies and admitted to our hospital from October 1985 to December 1999 comprised our study. Leukemoid reaction was defined as a peripheral white blood cell (WBC) count of ≥ 50 × 10³/μl. The infants who demonstrated a leukemoid reaction formed the study group, while the remainder formed the control group. The relationship between neonatal variables and WBC counts was studied. Results: Fourteen of the 486 infants demonstrated WBC counts of ≥ 50 × 10³/μl, with an incidence of 2.9%. Univariate analysis demonstrated a significant association between a leukemoid reaction and chronic lung disease following intrauterine infection. Conclusion: A leukemoid reaction was observed in 2.9% of VLBW infants in our neonatal intensive care unit. A significant association was demonstrated between the leukemoid reaction and chronic lung disease following intrauterine infection.     

Kidney Stones: A Fetal Origins Hypothesis

Kidney stones are common, with a multifactorial etiology involving dietary, environmental, and genetic factors. In addition, patients with nephrolithiasis are at greater risk of hypertension, diabetes mellitus, metabolic syndrome, and osteoporosis, although the basis for this is not fully understood. All of these renal stone–associated conditions have also been linked with adverse early‐life events, including low–birth weight, and it has been suggested that this developmental effect is due to excess exposure to maternal glucocorticoids in utero. This is proposed to result in long‐term increased hypothalamic‐pituitary‐axis activation; there are mechanisms through which this effect could also promote urinary lithogenic potential. We therefore hypothesize that the association between renal stone disease and hypertension, diabetes mellitus, metabolic syndrome, and osteoporosis may be related by a common pathway of programming in early life, which, if validated, would implicate the developmental origins hypothesis in the etiology of nephrolithiasis. © 2013 American Society for Bone and Mineral Research.     

Secular Trends in Hip Fractures Worldwide: Opposing Trends East Versus West

Despite wide variations in hip rates fractures worldwide, reasons for such differences are not clear. Furthermore, secular trends in the age‐specific hip fracture rates are changing the world map of this devastating disease, with the highest rise projected to occur in developing countries. The aim of our investigation is to systematically characterize secular trends in hip fractures worldwide, examine new data for various ethnic groups in the United States, evidence for divergent temporal patterns, and investigate potential contributing factors for the observed change in their epidemiology. All studies retrieved through a complex Medline Ovid search between 1966 and 2013 were examined. For each selected study, we calculated the percent annual change in age‐standardized hip fracture rates de‐novo. Although occurring at different time points, trend breaks in hip fracture incidence occurred in most Western countries and Oceania. After a steep rise in age‐adjusted rates in these regions, a decrease became evident sometimes between the mid‐seventies and nineties, depending on the country. Conversely, the data is scarce in Asia and South America, with evidence for a continuous rise in hip fracture rates, with the exception of Hong‐Kong and Taiwan that seem to follow Western trends. The etiologies of these secular patterns in both the developed and the developing countries have not been fully elucidated, but the impact of urbanization is at least one plausible explanation. Data presented here show close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures. Once the proportion of the urban population stabilized, hip fracture rates also stabilize or begin to decrease perhaps due to the influence of other factors such as birth cohort effects, changes in bone mineral density and BMI, osteoporosis medication use and/or lifestyle interventions such as smoking cessation, improvement in nutritional status and fall prevention. © 2014 American Society for Bone and Mineral Research.     

Effect of Bariatric Surgery on Obstructive Sleep Apnea and Hypopnea Syndrome, Electrocardiogram, and Pulmonary Arterial Pressure

Background: We evaluated the impact of surgically-induced weight loss on Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS), electrocardiographic changes, pulmonary arterial pressure and daytime sleepiness in morbidly obese patients. Methods: 16 women and 13 men (n=29) underwent bariatric surgery in a 3-year period. The following tests were performed before and 1 year after surgery: nocturnal polysomnography, daytime Multiple Sleep Latency Test (MSLT), and echocardiogram. Results: Mean age was 37.9±11 years (range 20-56). Preoperative body mass index was 56.5±12.3 kg/m² and it was 39.2±8.5 kg/m² at 13.7±6.6 months follow-up. Performed surgical procedures included: vertical banded gastroplasty in 6, Roux-en-Y gastric bypass in 12, and Distal Roux-en-Y gastric bypass in 11. Weight loss induced by surgery eliminated OSAHS in 46% of obese patients with an important improvement in oxygen saturation. Neck, thorax, waist and hip circumferences decreased significantly after surgical intervention but only neck circumference correlated significantly with the apnea/hypopnea index (Spearman rho=0.63, P <0.0001). Electrocardiographic abnormalities were present in 9 patients (31%) before surgery (sinus arrhythmia, ventricular arrhythmias, and sinus arrest). The number of electrocardiographic abnormalities decreased after surgery but new abnormalities appeared in some patients. Systolic pulmonary arterial pressure significantly decreased in the group of patients in whom OSAHS disappeared after surgery. Daytime sleepiness persisted after surgery in most patients. Conclusion: Bariatric surgery effectively reduces respiratory disturbances during sleep and improves pulmonary hypertension. Electro cardiographic abnormalities change after surgery. Daytime sleepiness appeared not to be related to respiratory disturbances during sleep.     

Apolipoprotein-E Genotype and the Risk of Developing Cholelithiasis following Bariatric Surgery: a Clue to Prevention of Routine Prophylactic Cholecystectomy

Background: Obesity and especially rapid weight loss following bariatric surgery are known risk factors for cholelithiasis. Since the risk may be high, prophylactic cholecystectomy has been advocated. Apolipoprotein (Apo) E, an important carrier protein in cholesterol metabolism and trafficking, is believed to play a role in gallstone pathogenesis. In particular, the Apo E4 allele has been suggested to be associated with cholesterol cholelithiasis. The aim of this study was to assess the incidence of postoperative cholelithiasis in our patient population and to determine a possible correlation with the Apo-E genotype. Methods: 134 morbidly obese patients undergoing gastric restrictive surgery [laparoscopic assisted gastric banding (LAGB) or silastic ring vertical gastroplasty (SRVG)] had abdominal ultrasound before and 6 to 12 months after operation, to determine the presence of gallstones. None of the patients enrolled in the study had gallstones before surgery.They did not have a prophylactic cholecystectomy or receive bile salt treatment. Apo-E genotypes were determined by Polymerase Chain Reaction restriction enzyme analysis. Results: 10 patients (7.5%) developed postoperative cholelithiasis. The incidence of cholelithiasis in each ApoE genotype was: E2/E3 - 1/20 (5%), E3/E3 - 3/91 (3%), E3/E4 - 6/21 (29%), and E4/E4 - 0/2. ApoE allele frequencies in the study population were identical to those of a healthy control population. The mean BMI dropped from 43.6 to 29.4 kg/m². Conclusions: The occurrence of postoperative gallstones was low in our population. However, in subjects with the Apo-E3/E4 genotype, the incidence is of practical significance. These data suggest that Apo-E genotyping may be useful in selecting patients for gallstone prevention (surgical or medical) when undergoing bariatric surgery.Further testing in larger patient populations may be able to give more definite guidelines in the future.     

An Alternative Technique for Creating the Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass: Experience with 28 consecutive patients

Background:This study illustrates our experience in laparoscopic Roux-en-Y gastric bypass (LRYGBP) using a new technique for creating the gastrojejunostomy. Methods: Between April and November 1999, 28 patients underwent LRYGBP. In the first 10 patients the transoral route with endoscopic guidance was utilized for placement of the anvil in the gastric pouch. A new totally intra-peritoneal approach was utilized in the next 18 patients, avoiding the transoral route. Results:There were 23 women and 5 men with an average age of 36 years (range 24-51). The mean BMI was 47, with range 41-64. Of the patients, 82% had one or more associated co-morbid conditions (hypertension, diabetes, sleep apnea, arthritis). Average operative time in the first 10 patients using the trans-oral route with endoscopic guidance was 340 minutes (range 240-390 min). The next 18 patients underwent totally intra-peritoneal anvil placement with a 240-minute average operating time (range 150-310 min). There were no open conversions or mortalities.There were 4 complications, including 2 wound infections, one urinary tract infection, and one intra-abdominal abscess. The two wound infections occurred in the first 10 patients that underwent trans-oral introduction of the anvil. Conclusions: LRYGBP was a safe and feasible operation. We believe that our technique is easily reproducible, avoiding the trans-oral route for introducing the anvil. This technique may also decrease operative time and possibly the incidence of wound infections, although we are still in the learning curve and final conclusions cannot be made.     

Variables Affecting BMI Evolution at 2 and 5 Years after Vertical Banded Gastroplasty

Background: Vertical banded gastroplasty (VBG) has been found to result in significant reduction in body mass index (BMI) during the first postoperative year.We investigated the impact of some intrinsic and extrinsic factors on long-term BMI evolution in morbidly obese patients who underwent VBG, with the aim of establishing a long-term weight-loss prognosis. Methods: 67 consecutive morbidly obese patients who underwent VBG were followed for 2 years; of these, 34 were followed 3 more years, for a total follow-up of 5 years. BMI was monitored and correlated with demographic (preoperative BMI, obese relatives, age and gender) and lifestyle variables (physical activity, habitual dietary transgression and occupational status). Results: Global BMI fell from 47.5 at the time of the intervention to 32.1 when patients were examined 12 months after surgery. From the second year, an upward trend was observed, and at 5 years, mean BMI was above 35, considered in the high-risk range. Modifiable variables affecting lifestyle have shown significantly favorable effects on BMI evolution. Among intrinsic variables, BMI before surgery and obese parents also affect long-term evolution. Conclusion: Different variables should be considered in order to establish a long-term weight-loss prognosis for each patient, thus making it possible to act more specifically on modifiable variables.     

Continuous Positive Airway Pressure (CPAP) Changes in Bariatric Surgery Patients Undergoing Rapid Weight Loss

Background: Obstructive sleep apnea (OSA) is a common condition in morbidly obese patients, with the reported prevalence ranging from 12-78%. There is increasing recognition of the need to diagnose and treat/manage OSA both preoperatively and postoperatively. Nasal CPAP is the preferred treatment of OSA; however, weight loss is associated with a reduction in required pressures. We evaluated the CPAP pressure requirements in a group of patients undergoing rapid weight loss following Roux-en-Y gastric bypass . Methods: 15 patients who had been diagnosed with OSA before surgery were retrospectively evaluated. All patients had demonstrated compliance on home CPAP therapy, were minimally 3 months post-surgery and had follow-up reports that their CPAP was less effective. We obtained data on age, sex, weight, BMI, and apnea/hypopnea index (AHI). Optimal CPAP pressure was obtained initially through attended in-laboratory complex polysomnography. Follow-up CPAP pressure was obtained using an auto-titrating PAP device at home. These data were used to evaluate the pressure changes that accompanied weight loss. Results: This group of patients had lost an average of 44.5 ± 19.4 kg. Four patients had achieved their goal weight. Their starting CPAP pressures averaged 11 ± 3.0 cm H₂O, with a range of 7-18 cm H₂O. Follow-up CPAP pressures averaged 9 ± 2.7 cm H₂O, with a range of 4-12 cm H₂O, representing an overall reduction of 18%. The subgroup of patients who had achieved goal weight had a pressure reduction of 22% (9 ± 2.0 to 7 ± 1.0 cm H₂O). Conclusion: CPAP pressure requirements change considerably in bariatric surgery patients undergoing rapid weight loss. Auto-titrating PAP devices have promise for facilitating the management of CPAP therapy during this time. Consideration should also be given to the use of autotitrating PAP units as the treatment of choice in these patients.     

Psychosocial Predictors of Success following Bariatric Surgery

Background: Bariatric surgery is the treatment of choice for morbid obesity, but it does not lead to equal results in every patient. In addition to surgery, a number of non-surgical and psychological factors may influence patients' ability to adjust to the postoperative condition. Understanding the relationship between potential predictive variables and success after bariatric surgery will enable better patient selection, and the development of interventions to improve outcome. Methods: A systematic literature search identified relevant variables, such as demography, preoperative weight, motivation, expectations, eating behavior, psychological functioning, personality, and psychiatric disorders, which may have predictive value for success after bariatric surgery. Results: Greater success following bariatric surgery appears to occur in patients who are young and female, and have a high self-esteem, good mental health, a satisfactory marriage, and high socio-economic status, who are self-critical and cope in a direct and active way, are not too obese, were obese before the age of 18, suffer from and are concerned about their obesity, have realistic expectations and undisturbed eating behaviors. Occasionally, these variables may have poor or no predictive value. Although reliable predictors are lacking, most treatment teams propose their own exclusion criteria. Conclusion: The existing literature about potential predictors of success after bariatric surgery is far from conclusive; it is still uncertain which factors can predict success. Even where psychosocial functioning does not predict outcome, it is important to identify patients' characteristics which may be linked to their prognosis and to provide necessary pre- and postoperative psychosocial interventions.     

Obstructive Symptoms Associated with the 9.75-cm Lap-Band® in the First 24 Hours using the Pars Flaccida Approach

Background: For some patients, especially those with a higher BMI, a non-selective Lap-Band? placement using the pars flaccida approach with application of the small-diameter bands (9.75 and 10 cm) may be too tight or may require significant gastroesophageal junction dissection and thinning. In such a case, the major perioperative complication is acute obstruction immediately after surgery. We review the etiology of obstructive complications that present postoperatively in the first 24 hours. Case Reports: Acute postoperative stoma obstruction (esophageal outlet stenosis) was observed in 5 patients who underwent 9.75-cm Lap-Band? placement for morbid obesity. 2 of these patients had a postoperative upper GI series showing a misplaced band with gastric slippage, and repeat operation was required. 3 patients had gastric obstruction without slippage. Of the latter, 1 patient insisted that the band be removed rather than being replaced with a longer one, and the remaining 2 were managed with conservative treatment, involving extended hospitalization until the edema subsided and the patient slowly regained the ability to swallow. Conclusion: Obstructive symptoms associated with the Lap-Band? using the pars flaccida approach can be addressed conservatively in most patients or by minimally invasive surgery; however we believe that routine use of the 11-cm Lap-Band? for the pars flaccida approach could easily prevent this early complication.