Nutritional Deficiencies in Gastric Bypass Patients; Incidence, Time of Occurrence and Implications for Post-operative Surveillance

Background: Post-operative nutritional deficiencies are a common complication following bariatric surgery. The incidence and time of occurrence are not clear, and the efficacy of supplementation remains questionable. Clear guidelines for nutritional follow-up and counselling are needed.Methods: Preoperative and post-operative deficiencies were determined in a group of 427 gastric bypass patients. The predictive value of preoperative laboratory findings for the development of post-operative deficiencies, the time of occurrence and the effect of supplementation of common deficiencies was studied.Results: Most common preoperative deficiencies were of folic acid (21.3 %), vitamin D3 (17.5 %) and iron (21.8 %). Post-operative, a significant increase in the number of patients with anaemia and deficiencies of ferritin and vitamin B12 was found. Most deficiencies occur between 12 and 15 months post-operatively, but vitamin D3 deficiency occurs significantly earlier at 9.7 months. A preoperative iron, folic acid or ferritin deficiency results in a significant higher risk for developing a post-operative deficiency despite supplementation, and ferritin deficiency occurs significantly earlier in these patients. Oral treatment of post-operative vitamin B12 and vitamin D3 deficiencies was successful in more than 80 % of the patients in contrast to oral treatment of anaemia which was only successful in 62.5 % of the patients.Conclusion: Our study emphasizes the importance of preoperative assessment and treatment of nutritional deficiencies in morbidly obese patients undergoing gastric bypass surgery. Despite limited efficacy, post-operative oral supplementation should be encouraged as it decreases the incidence of deficiencies

Nutritional Deficiencies in Gastric Bypass Patients; Incidence, Time of Occurrence and Implications for Post-operative Surveillance

Background: Post-operative nutritional deficiencies are a common complication following bariatric surgery. The incidence and time of occurrence are not clear, and the efficacy of supplementation remains questionable. Clear guidelines for nutritional follow-up and counselling are needed.Methods: Preoperative and post-operative deficiencies were determined in a group of 427 gastric bypass patients. The predictive value of preoperative laboratory findings for the development of post-operative deficiencies, the time of occurrence and the effect of supplementation of common deficiencies was studied.Results: Most common preoperative deficiencies were of folic acid (21.3 %), vitamin D3 (17.5 %) and iron (21.8 %). Post-operative, a significant increase in the number of patients with anaemia and deficiencies of ferritin and vitamin B12 was found. Most deficiencies occur between 12 and 15 months post-operatively, but vitamin D3 deficiency occurs significantly earlier at 9.7 months. A preoperative iron, folic acid or ferritin deficiency results in a significant higher risk for developing a post-operative deficiency despite supplementation, and ferritin deficiency occurs significantly earlier in these patients. Oral treatment of post-operative vitamin B12 and vitamin D3 deficiencies was successful in more than 80 % of the patients in contrast to oral treatment of anaemia which was only successful in 62.5 % of the patients.Conclusion: Our study emphasizes the importance of preoperative assessment and treatment of nutritional deficiencies in morbidly obese patients undergoing gastric bypass surgery. Despite limited efficacy, post-operative oral supplementation should be encouraged as it decreases the incidence of deficiencies

Is dangling of the lower leg after a free flap reconstruction necessary? Study protocol for a large multicenter randomized controlled study

textabstractBACKGROUND: Within the field of plastic surgery, free tissue transfer is common practice for knee and lower leg defects. Usually, after such free flap reconstruction, patients undergo a dangling protocol in the postoperative phase. A dangling protocol is designed to gradually subject the free flap to increased venous pressure resulting from gravitational forces. Worldwide there are multiple variations of dangling protocols. However, there is no evidence available in the literature that supports the use of a dangling protocol. METHODS: This is a multicenter randomized controlled trial that includes patients with a free flap lower leg reconstruction. The primary outcome is to assess whether a no-dangling protocol is not inferior to a dangling protocol, in terms of proportion of partial flap loss, 6 months after surgery. Secondary objectives are to identify differences in major and minor complications, length of stay, and costs, and to objectify blood gaseous changes during dangling. Furthermore, at 2 years we will assess difference in physical function, infection rates, and osseous union rates. DISCUSSION: The primary outcome of this study will give a more decisive answer to the question of whether a dangling protocol is necessary after a free flap reconstruction of the lower leg. The secondary outcomes of this study will provide a better insight into the physical functions, infection rates, and union rates in these patients. TRIAL REGISTRATION: Central Committee on Research Involving Human Subjects (CCMO), NL63146.041.17. Registered on 11 July 2018. Netherlands Trial Register, NTR7545 . Registered on 10 October 2018

Effect of single- versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double-blind, randomised controlled superiority trial

Objective: To evaluate whether double-layer uterine closure after a first caesarean section (CS) is superior compared with single-layer uterine closure in terms of postmenstrual spotting and niche development in the uterine caesarean scar. Design: Multicentre, double-blind, randomised controlled superiority trial. Setting: Thirty-two hospitals in the Netherlands. Population: A total of 2292 women aged ≥18 years undergoing a first CS were randomly assigned to each procedure (1:1): 1144 women were assigned to single-layer uterine closure and 1148 women were assigned to double-layer uterine closure. Methods: Single-layer unlocked closure and double-layer unlocked closure, with the second layer imbricating the first. Main outcome measures: Number of days with postmenstrual spotting during one menstrual cycle 9 months after CS. Secondary outcomes: perioperative and menstrual characteristics; transvaginal ultrasound measurements. Results: A total of 774 (67.7%) women from the single-layer group and 770 (67.1%) women from the double-layer group were evaluable for the primary outcome, as a result of drop-out and amenorrhoea. The mean number of postmenstrual spotting days was 1.33 (bootstrapped 95% CI 1.12–1.54) after single-layer closure and 1.26 (bootstrapped 95% CI 1.07–1.45) after double-layer closure (adjusted mean difference −0.07, 95% CI −0.37 to 0.22, P = 0.810). The operative time was 3.9 minutes longer (95% CI 3.0–4.9 minutes, P < 0.001) and niche prevalence was 4.7% higher (95% CI 0.7–8.7%, P = 0.022) after double-layer closure. Conclusions: The superiority of double-layer closure compared with single-layer closure in terms of postmenstrual spotting after a first CS was not shown. Long-term obstetric follow-up of our trial is needed to assess whether uterine caesarean closure guidelines should be adapted. Tweetable abstract: Double-layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single-layer closure performs slightly better on other outcomes

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log10 increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence