The impact of a preoperative evaluation process on weight reduction and glycemic control in patients undergoing bariatric and metabolic surgery.

Introduction: Metabolic surgery is a sustainable intervention for obesity and type 2 diabetes. Preoperative education optimizes weight loss and glycemic control outcomes. Objective: This study aimed to determine the effect of a generalized preoperative evaluation process (PEP) in patients who underwent bariatric surgery on weight loss and glycemic control pre- and post-surgery. Methods: Data were retrospectively collected and analyzed for patients with type 2 diabetes who underwent bariatric surgery between 2010 and 2016. Patients were categorized into two groups determined by participation in the PEP. The groups were named the PEP group and non-PEP group. The correlation among engagement in the PEP was determined using the chi-square test and t-test. Statistical analysis with p < 0.05 was deemed significant. Results: 129 patients were included in the study; 86 females (67%) and 43 males (33%). Fifty-nine patients (46%) engaged in the PEP and 70 (54%) patients did not engage in the PEP. A greater reduction in weight loss was observed in the PEP group versus the non-PEP group from initial enrollment to pre-surgery (14.3 ± 9.2 kg vs. 11.6 ± 9.2 kg; p = 0.11), and from pre-surgery to 2-years post-surgery (20.6 ± 14.8 kg vs. 16.9 ± 15.6 kg; p = 0.17). A greater reduction in HbA1c from initial enrollment to pre-surgery was seen in the PEP group versus the non-PEP group (0.90 ± 1.28% vs. 0.63 ± 1.07%); however, this was not maintained from pre-surgery to 2-year post-surgery (0.51 ± 1.18% vs. 0.70 ± 1.73%). In both cases, the statistical difference was insignificant. Conclusion: The PEP was not associated with improvements in short-term weight loss or glycemic control pre-surgery and a 2-years post-surgery. Patients may benefit from individually tailored preoperative weight management strategies.

Clinical outcomes and adverse events of bariatric surgery in adults with severe obesity in Scotland: the SCOTS observational cohort study.

Background: Bariatric surgery is a common procedure worldwide for the treatment of severe obesity and associated comorbid conditions but there is a lack of evidence as to medium-term safety and effectiveness outcomes in a United Kingdom setting. Objective: To establish the clinical outcomes and adverse events of different bariatric surgical procedures, their impact on quality of life and the effect on comorbidities. Design: Prospective observational cohort study. Setting: National Health Service secondary care and private practice in Scotland, United Kingdom. Participants: Adults (age >16 years) undergoing their first bariatric surgery procedure. Main outcome measures: Change in weight, hospital length of stay, readmission and reoperation rate, mortality, diabetes outcomes (HbA1c, medications), quality of life, anxiety, depression. Data sources: Patient-reported outcome measures, hospital records, national electronic health records (Scottish Morbidity Record 01, Scottish Care Information Diabetes, National Records Scotland, Prescription Information System). Results: Between December 2013 and February 2017, 548 eligible patients were approached and 445 participants were enrolled in the study. Of those, 335 had bariatric surgery and 1 withdrew from the study. Mean age was 46.0 (9.2) years, 74.7% were female and the median body mass index was 46.4 (42.4; 52.0) kg/m2. Weight was available for 128 participants at 3 years: mean change was -19.0% (±14.1) from the operation and -24.2% (±12.8) from the start of the preoperative weight-management programme. One hundred and thirty-nine (41.4%) participants were readmitted to hospital in the same or subsequent 35 months post surgery, 18 (5.4% of the operated cohort) had a reoperation or procedure considered to be related to bariatric surgery gastrointestinal complications or revisions. Fewer than five participants (<2%) died during follow-up. HbA1c was available for 93/182 and diabetes medications for 139/182 participants who had type 2 diabetes prior to surgery; HbA1c mean change was -5.72 (±16.71) (p = 0.001) mmol/mol and 65.5% required no diabetes medications (p < 0.001) at 3 years post surgery. Physical quality of life, available for 101/335 participants, improved in the 3 years post surgery, mean change in Rand 12-item Short Form Survey physical component score 8.32 (±8.95) (p < 0.001); however, there was no change in the prevalence of anxiety or depression. Limitations: Due to low numbers of bariatric surgery procedures in Scotland, recruitment was stopped before achieving the intended 2000 participants and follow-up was reduced from 10 years to 3 years. Conclusions: Bariatric surgery is a safe and effective treatment for obesity. Patients in Scotland, UK, appear to be older and have higher body mass than international comparators, which may be due to the small number of procedures performed. Future work: Intervention studies are required to identify the optimal pre- and post surgery pathway to maximise safety and cost-effectiveness. Study registration: This study is registered as ISRCTN47072588. Funding details: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 10/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 7. See the NIHR Funding and Awards website for further award information.

Bariatric surgery is performed on the stomach and small bowel to help people living with obesity lose weight. Our research study has looked at who is getting bariatric surgery, if they are having problems afterwards, how much weight they lose and if their medical conditions improve. A total of 444 people who were attending bariatric surgery services in Scotland, UK, agreed to take part and 336 had surgery. One hundred and eighty-nine of them completed a questionnaire before their surgery and 85 of them after 3 years, to tell us about how they were feeling physically and mentally. We looked at their computer hospital records to see how long they spent in hospital, any medical problems and changes to diabetes medicines and tests. One in five people taking part did not have surgery after all; they changed their mind or the hospital teams did not think it would be safe or work well for the patient. Those who had surgery lost 19% of their body weight and those with type 2 diabetes needed less or no medication 3 years after the surgery. The effect of physical symptoms on day-to-day activities improved but mental health did not. Compared to other countries, the people taking part were older, heavier and sicker. They spent longer in hospital after surgery and were more likely to be readmitted to hospital. How many appointments they had or what type of health professional they saw before or after surgery did not change these results. We had hoped to have far more people in this study and be able to answer more questions, but not enough people were getting bariatric surgery in Scotland for us to ask them to take part. Further research is needed to find the best ways to care for people living with obesity who would benefit from bariatric surgery.

The sensitivity and specificity of COVID-19 rapid anti-gene test in comparison to RT-PCR test as a gold standard test.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a modern infectious disease, first identified in December 2019 in Wuhan, China. The etiology is via severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in a pandemic manner. The study aimed to compare between RT-PCR and rapid anti-gene tests for COVID-19 with regard to sensitivity and specificity. METHODS: This is a cohort hospital-based study done during the period of July to September 2020. Both rapid anti-gene test kit (SARS-CoV-2) and RT-qPCR were used for the detection of COVID-19 in suspected cases. RESULTS: A total of 148 cases were tested using both the RT-qPCR and rapid test. Twenty-nine (19.6%) of these cases had positive results for RT-qPCR and 119 (80.4%) were negative, whereas 52 (35.1%) patients were positive to rapid anti-gene test and 96 (64.9%) of them negative. The sensitivity of the rapid test was 37.9%, the specificity was 65.5% and the accuracy was 64.44%. Rapid IgG test was positive in 47 (31.8) of cases. Although, rapid IgM test was positive in 18 (12.2%). The rapid IgG test was more sensitive than rapid IgM (Sensitivity 34.48% vs. 3.45%), but it was less specific than rapid IgM test (Specificity 68.91% vs. 85.71%). CONCLUSION: We cannot consider rapid anti-gene test alone as a diagnostic method for COVID-19. We should also conduct RT-PCR test and other investigations like imaging CT scan of chest to confirm the diagnosis. The rapid IgG test is more sensitive than rapid IgM, but it was less specific.

The Effect of Different Types of Bariatric Surgery on Levothyroxine Requirement in Hypothyroid Bariatric Patients.

Background Bariatric surgeries are carried out to improve a patient's quality of life, and to reduce respiratory, cardiac, endocrine, and metabolic complications encountered by those with high body mass index (BMI). A complication associated with high hypothyroidism is weight gain, which may lead to obesity. Here, we explore the effect of different bariatric procedures on thyroid function and levothyroxine dosage.  Methods This is a retrospective review of 887 patients referred to a tertiary bariatric service between 2008 and 2020 and treated for hypothyroidism at the time of referral. The study identified 57 patients on thyroxine replacement. Of these, 22 underwent restrictive bariatric procedures, 16 underwent restrictive/malabsorptive procedures, and 19 did not undergo operative intervention. Comparisons were made among each group throughout the timeline of interest. Results Out of 57 patients, 50 (87.7%) were female. The average age for patients was 47.26+/- 8.89 years. The average BMI at baseline was 48.72+/- 8.68 kg/m2. The mean dose of levothyroxine in controls was 115.8+/- 53.5 mcg while that of surgical patients was 149.8+/- 68.4 mcg. There were no statistically significant differences in levothyroxine doses between surgical and control at T0 (baseline), T1 (one-year post-op in surgical patient, or two-year post referral in control patient), T2 (two-year post-op in surgical patient, or three-year post referral in control patient), and T3 (most recent result available). The surgical group was then categorized further into restrictive and restrictive/malabsorptive. When they were compared with the control group, there were no statistically significant differences in doses. A generalized linear mixed model was applied to assess differences in levothyroxine dose with time as a random variable. This was adjusted for age, sex, BMI, T4 level, and hypothyroid cause. Through this assessment, there were several statistically significant differences in levothyroxine dosage between the groups. Control group required on average 28.06 mcg less levothyroxine than the restrictive/malabsorptive group (p=0.015). Also, the restrictive group required on average 23.57 mcg less levothyroxine than the restrictive/malabsorptive group (p=0.033). There were no statistically significant differences observed between the control group and the restrictive group (p=0.67) Conclusion Patients who have bariatric surgery have changes to their anatomy and physiology which may affect both their thyroid hormone homeostasis and levothyroxine pharmacokinetics. Thus, hypothyroid bariatric patients requiring levothyroxine must have their thyroid function monitored regularly. In this study, it was found that hypothyroid patients who underwent restrictive surgery had an overall statistically significant lower levothyroxine requirement to remain euthyroid as compared to the restrictive/malabsorptive group (p=0.033). Additionally, the control group required statistically significantly less levothyroxine than the restrictive/malabsorptive group (p=0.015). These factors may determine the type of surgery chosen by hypothyroid bariatric patients. However, further studies that are randomized, controlled, and multi-center with a higher population are required.

Impact of Bariatric Surgery on Renal Function.

Introduction Bariatric surgery offers superior benefits for weight loss, quality of life and a spectrum of metabolic diseases. Despite these benefits, studies so far have shown varying results on its effect on renal function. Aim In this study, we aim to look at bariatric surgery's effect on renal function at one, two and three year post operation (post-op). Methods This is a retrospective cross-sectional single-center study of patients who underwent bariatric surgery between 11/2008 and 06/2018. Renal function was calculated by using Cockroft-Gault equation, expressed as Creatinine Clearance (CrCl). Statistical analysis used was one-way ANOVA (Welch's) with Games-Howell Post-Hoc Test. Results From 307 patients who underwent bariatric surgery within the time period, 145 were studied. 30.3% (n=44) were male. The average age and body mass index (BMI) at referral were 48.1±8.6 years and 47.96±7.9 kgm-2 respectively, while the average age and BMI at surgery were 49.1±8.8 years and 40.62±4.2 kgm-2 respectively. Mean CrCl at surgery, year 1, year 2, and year 3 post-op were 172.35±53.29 mL/min, 179.20±57.87 mL/min, 142.35±46.05 mL/min, and 119.56±42.46 mL/min. Marginal improvement of CrCl at year one post-op (172.35±53.29mL/min to 179.20±57.87mL/min) was statistically insignificant (p=0.731). Meanwhile, there was statistically significant CrCl decline observed from year 1 to year 3 post-op (p<0.001). Conclusion Statistically insignificant marginal improvement in CrCl at year one post-op was noted. Beyond this, there was steady CrCl decline, albeit remained higher than the lower limit for respective gender. We recommend for further studies that take into account additional factors affecting renal function.

SurgiCal Obesity Treatment Study (SCOTS): a prospective, observational cohort study on health and socioeconomic burden in treatment-seeking individuals with severe obesity in Scotland, UK.

OBJECTIVES: There is a lack of evidence to inform the delivery and follow-up of bariatric surgery for people with severe obesity. The SurgiCal Obesity Treatment Study (SCOTS) is a national longitudinal cohort of people undergoing bariatric surgery. Here, we describe characteristics of the recruited SCOTS cohort, and the relationship between health and socioeconomic status with body mass index (BMI) and age. PARTICIPANTS/METHODS: 445 participants scheduled for bariatric surgery at any of 14 centres in Scotland, UK, were recruited between 2013 and 2016 for this longitudinal cohort study (1 withdrawal); 249 completed health-related preoperative patient-reported outcome measures. Regression models were used to estimate the effect of a 10-unit increase in age or BMI, adjusting for sex, smoking and socioeconomic status. RESULTS: Mean age was 46 years and median BMI was 47 kg/m2. For each 10 kg/m2 higher BMI, there was a change of -5.2 (95% CI -6.9 to -3.5; p<0.0001) in Rand 12-item Short Form Survey Physical Component Summary (SF-12 PCS), -0.1 (95% CI -0.2 to -0.1; p<0.0001) in EuroQoL 5-level EQ-5D version index score and 14.2 (95% CI 10.7 to 17.7; p<0.0001) in Impact of Weight on Quality of Life-Lite Physical Function Score. We observed a 3.1 times higher use of specialist aids and equipment at home (OR: 3.1, 95% CI 1.9 to 5.0; p<0.0001). Broadly, similar results were seen for each 10-year higher age, including a change of -2.1 (95% CI -3.7 to -0.5; p<0.01) in SF-12 PCS. CONCLUSIONS: A higher BMI combined with older age is associated with poor physical functioning and quality of life in people seeking bariatric surgery treatment. Policy-makers must consider the health and care needs of these individuals and invest to provide increased access to effective weight management. TRIAL REGISTRATION NUMBER: ISRCTN47072588.

Preoperative Bariatric Surgery Predictors of Type 2 Diabetes Remission.

Obesity represents a significant proportion of the global public health burden, with the World Health Organization (WHO) estimating more than 600 million people are affected worldwide. Unfortunately, the epidemic of obesity is linked to the increased prevalence of associated metabolic diseases such as type 2 diabetes mellitus (T2DM). Bariatric surgery as an intervention has been shown to provide sustainable weight loss, and also leads to superior short- and long-term metabolic benefits including T2DM remission. Despite this added advantage conferred by bariatric surgery, emerging evidence has shown that not all patients with T2DM achieve remission postoperatively. As such, to improve patient selection and optimize preoperative counselling, research has focused on the preoperative predictors of T2DM remission following bariatric surgery. Herein, we provide a critical review of the current literature addressing preoperative predictors of T2DM remission and highlight the current gaps in the literature. The review comprised a multistage advanced electronic search of the Ovid/Medline, Embase, and Cochrane online libraries to identify available studies published over the last decade.

Atraumatic idiopathic splenic rupture induced by granulocyte-colony stimulating factor (G-CSF) for the treatment of pancytopenia, managed successfully by laparoscopic splenectomy.

Splenic rupture is a potentially life-threatening condition and an uncommon short-term complication of granulocyte-colony stimulating factor (G-CSF) administration. It may present as acute abdominal pain or suddenly precipitously worsening anaemia with haemodynamic instability that requires urgent operative intervention for survival. We present a case of an atraumatic idiopathic splenic rupture in University Hospital, Ayr in a patient who received G-CSF treatment for chemotherapy-induced (methotrexate) pancytopenia and was successfully managed by laparoscopic splenectomy.

Pre-specified Weight Loss Before Bariatric Surgery and Postoperative Outcomes.

Bariatric surgery is increasing exponentially to address the steep rise in the prevalence of severe obesity. Most centers require pre-specified preoperative weight loss before allowing patients to receive surgery. We examined the current evidence surrounding the potential benefits of this requirement on postoperative outcomes. We reviewed the current literature by conducting a multistage advance electronic search in Ovid®/MEDLINE® and PubMed for publications indexed after 2008 reporting preoperative weight loss and postoperative outcomes. Thirteen original publications, three randomized control trials (RCT), and five systematic reviews that met inclusion criteria were included. These were analyzed with regards to weight loss before surgery and postoperative outcomes. There were varied reports regarding the significant effect of preoperative weight loss. Six of the original articles (50%) did not identify a significant difference in the outcome while two of the RCT (essentially the same patient population, started in 2007 and reanalyzed in 2009) demonstrated some advantage. A later RCT (2012) did not show any advantage, albeit in the short term. The results of the systematic reviews, some with heterogenic designs, show no conclusive evidence that weight loss before surgery conferred improved postoperative outcomes. There is not enough high-quality evidence to back up the requirement of pre-specified preoperative weight loss before receiving surgery. Further validation of the possible benefits of pre-specified preoperative weight loss may need to be carried out.

Diabetic Control Outcomes Amongst Patients Who Had Bariatric Surgery in a District General Hospital.

Bariatric surgery remains the most effective weight loss treatment. It leads to significant and sustained weight loss and improvement in various metabolic diseases such as type 2 diabetes (T2DM). This piece of work aimed to investigate the remission of T2DM amongst patients who had laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomies (LSG). This was achieved by carrying out a retrospective review of prospective data of 82 T2DM diabetic patients who had above bariatric surgery at the University Hospital Ayr from 2010 to 2016. Outcomes were assessed at two years postoperatively and documented. The main outcome measure was based on the achievement of partial or complete remission. The average age of patients in this study was 49.6±8.1 with 52% female (n=49) and 48% male (=33). Preoperative body mass index (BMI) averaged at 42.6±6.2 kgm2. The majority (n= 43) of cases had a Roux-en-Y gastric bypass (RYGB) while (n=39) had laparoscopic sleeve gastrectomy (LSG). The average glycated haemoglobin (HbA1c) was 6.7±1.8 units. Fourteen patients who had diet-controlled diabetes were excluded. Of the patients left (n=68), partial or complete remission was achieved by 73.3% (n =50). Remission rates following RYGB, 87.2% (n=43) were higher than those following LSG (55.2%). Age, duration of diabetes, and HbA1c showed a statistically significant difference amongst both cohorts. No statistically significant difference was seen in BMI both at referral and at surgery between both cohorts of patients. We concluded that preoperative BMI plays a very limited role in determining which patients go into remission in the short-term postoperative phase.

Giant Gallbladder Presenting as a Right Iliac Fossa Mass Removed by Mini-laparoscopic Cholecystectomy.

Giant gallbladder (GGB) is a rare condition that can result from cholelithiasis or chronic cholecystitis. Although there are no clear-cut definitions, gallbladders of >14 cm and ≥1.5 L have been regarded as GGBs. To date, most GGBs have been managed by laparotomic removal. This report describes a patient with a GGB that presented as a right iliac fossa mass. The GGB was successfully removed by mini-laparoscopic cholecystectomy. A 63-year-old woman presented with painful swelling in her right lower abdomen associated with dyspepsia and a palpable right iliac fossa mass. Computed tomography of the abdomen revealed a markedly enlarged gall bladder (19.5 x 5.4 x 5.6 cm) containing stones. Magnetic resonance cholangiopancreatography ruled out extra- and intrahepatic ductal dilatation and stones. She underwent a mini-laparoscopic cholecystectomy, and her postoperative recovery was uneventful.

Does Preoperative Weight Loss Predict Significant Postoperative Weight Loss Among Patients who Underwent Laparoscopic Sleeve Gastrectomy?

Background Some bariatric practices, mainly those conducted under public-funded services, have adopted achieving a target preoperative weight loss (PrWL) before offering surgery. There are varied opinions on the correlation between preoperative and postoperative weight loss (PoWL) for the different surgical options. This study investigated the impact of target PrWL on PoWL for patients who underwent laparoscopic sleeve gastrectomy (LSG). Materials and methods A longitudinal retrospective cohort study was carried out on patients who had documented preoperative weight before LSG (n=155) from the authors' institution between February 2008 to October 2017. Patients were grouped into two cohorts based on meeting the 5% target PrWL or not. The endpoint included percent postoperative weight loss (% PoWL) at one year and two to three years. Results A total of 155 individuals were identified and analysed. Of these patients, 78.7% of them (n=122) achieved the 5% target PrWL (target group) while 21.3% (n= 33) did not (non-target group). At one year, there was no statistical significant difference in the mean % PoWL between the non-target and target groups (22.3 ± 8.1% versus 19.4 ± 11.8% p value= 0.08). A similar observation was made at two-three years, where the mean % PoWL in the non-target group was 14.7 ± 10.7% versus 16.3 ± 14.4% in the target group (p value= 0.07). Our further analysis highlighted a statistically significant weak inversely proportional correlation between % PrWL and % PoWL at one year and two to three years. Conclusion Meeting target PrWL does not significantly impact on PoWL after LSG. Therefore, it should not serve as exclusion criteria for eligible patients who are in need of surgery.

ACE gene polymorphism and its association with serum erythropoietin and hemoglobin in Iraqi hemodialysis patients.

PURPOSE: To evaluate the frequencies of angiotensin-converting enzyme gene polymorphism in Iraqi hemodialysis patients and to examine the association between this polymorphism and serum erythropoietin and hemoglobin levels. . METHODS: In this study, 70 chronic renal failure Iraqi patients on maintenance hemodialysis (patient group) and 20 healthy subjects (control group) were genotyped for angiotensin-converting enzyme gene polymorphism. The distribution of genotype and allele frequencies of this polymorphism in these subjects were also evaluated. . RESULTS: The distribution of angiotensin-converting enzyme genotypes between groups was similar, and the ID genotype was the most frequent, followed by DD and II genotypes ( 50% , 37% , and 13%). The control group had a nonsignificant difference in serum erythropoietin levels among different angiotensin-converting enzyme genotypes, while patients with ID and DD genotypes displayed significant elevation in serum erythropoietin with time. No significant differences in hemoglobin levels were observed in patient and control groups. A significant positive correlation was observed between serum erythropoietin and hemoglobin in the control group with different angiotensin-converting enzyme genotypes, while a nonsignificant negative correlation was observed in the patient group throughout the study. . CONCLUSIONS: Chronic kidney disease did not significantly alter angiotensin-converting enzyme genotypes, and angiotensin-converting enzyme gene polymorphism had a significant effect on serum erythropoietin levels and a non significant effect on hemoglobin levels. .

Idiopathic intracranial hypertension and bariatric surgery: a literature review and a presentation of two cases.

OBJECTIVE: There is paucity of data concerning the impact of bariatric surgery on idiopathic intracranial hypertension (IIH). We therefore present the clinical course of two cases that were managed at our centre, which is a regional referral centre for bariatric surgery and present a literature review of patients with IIH who underwent bariatric surgery for the treatment of obesity. METHOD: Two patients were referred for bariatric surgery who were both morbidly obese and were diagnosed with IIH. One patient underwent bariatric surgery; the other patient's weight was managed conservatively. We followed up both patients for 2 years. PubMed was searched for published studies of patients with IIH undergoing bariatric surgery. RESULTS: The patient that underwent weight loss surgery achieved sustained weight loss from 108kg to 87kg and gross resolution of their symptoms. The patient whose weight was managed conservatively lost weight initially and then put the weight back on. Her IIH symptoms persisted despite CSF shunt therapy. The literature review identified 12 original studies, containing 51 patients. Weight loss after bariatric surgery was reported for 84% of patients and improvement or resolution of IIH symptoms was reported for 84% of patients. CONCLUSION: In light of the literature review and our experience, bariatric surgery appears to be a potential treatment option for IIH alongside the comorbidities associated with obesity. However, more robust studies are needed.

Interleukin-6 gene polymorphisms and serum erythropoietin and hemoglobin in hemodialysis Iraqi patients.

Chronic kidney disease (CKD) is characterized by elevated levels of pro-inflammatory cytokines. Interleukin-6 (IL-6) is a pleiotropic and pro-inflammatory cytokine involved in different biological activities such as hematopoiesis, inflammation, and acute-phase response. The rate of IL-6 synthesis and degradation is affected by single nucleotide polymorphisms. This study aimed to evaluate the frequencies of 174G/C IL-6 gene promoter polymorphism in Iraqi hemodialysis (HD) patient and to examine the association between the allelic variations and serum erythropoietin (EPO) and hemoglobin (Hb) levels. The frequencies of IL-6 gene polymorphism were studied in 70 chronic renal failure patients on maintenance HD (patients group) and in 20 healthy participants (control group). Genotyping of IL-6 gene was performed by conventional polymerase chain reaction-restriction fragment length polymorphism. The distribution of IL-6 genotypes between groups was similar, and GG genotype is the most frequent followed by CG and CC genotypes. Control group had a nonsignificant difference in serum EPO levels among different IL-6 genotypes, while patients with GG genotype displayed significant elevation in serum EPO with time, followed by CG and CC genotypes. No significant differences in Hb levels were observed in patients and control groups. A significant positive correlation was observed between serum EPO and Hb in control group with different IL-6 genotypes, while a nonsignificant negative correlation was observed in patients group throughout the study. CKD did not significantly alter IL-6 genotypes, and IL-6 gene polymorphism had a significant effect on serum EPO levels and a nonsignificant effect on Hb levels.

Variations in bariatric surgical care pathways: a national costing study on the variability of services and impact on costs.

BACKGROUND: We undertook a survey of all bariatric centres in Scotland in order to describe current pre- and post-operative care, to estimate their costs and explore differences in financial impact. METHODS: A questionnaire was distributed to each health centre. Descriptive statistics were used to present average cost per patient along with 95% confidence intervals, and the range of costs. RESULTS: Results show nearly a five-fold difference in costs per patient for pre-operative services (range £226 - £1071) and more than a three-fold difference for post-operative services (range £259 - £896). CONCLUSIONS: There is a lack of evidence base and a clear requirement for the evaluation of bariatric surgical services to identify the care pathways pre- and post-surgery which lead to largest improvements in health outcomes and remain cost-effective.

Malnutrition, inflamation and atherosclerosis (MIA syndrome) in patients with end stage renal disease on maintenance hemodialysis (a single centre experience).

BACKGROUND: Inflammation and malnutrition play an important role in endothelial dysfunction, atherosclerosis and excessive cardiovascular morbidity and mortality in ESRD patients AIM OF THE STUDY: The primary objective is to determine the prevalence of inflammation, malnutrition and atherosclerosis in patients on maintenance haemodialysis. Secondary objective was to determine the association for atherosclerosis with inflammation and malnutrition. PATIENT AND METHODS: One hundred and one adult patients with end stage renal disease on maintenance haemodialysis who are met with the exclusion criteria were enrolled in this cross sectional study from haemodialysis unit of Baghdad teaching hospital over the period of July/2015 - June 2016. All patients were thoroughly examined and many variables were evaluated (age, gender, blood pressure, diabetes mellitus, serum lipid profile, smoking habits, serum albumin, CRP, calcium, Phosphate, Parathyroid hormone and haemoglobin measurements). All patients underwent a carotid Doppler ultrasound study. RESULTS: Atherosclerosis was present in 65.3%: 58.4% of patients had malnutrition and 43.6% had inflammation. The association for atherosclerosis and high CRP and low serum albumin is strong and independent of other atherosclerosis risk factors. There is significant inverse and independent correlation between CRP and albumin. CONCLUSION: Inflammation (high serum CRP) and malnutrition (low serum albumin) in patients on haemodialysis are significantly associated with carotid atherosclerosis. Inflammation was more prevalent in the malnourished patients than in those with normal nutritional status.

Prediction of autonomic neuropathy in chronic kidney disease (stage 5) Iraqi patients (case control study).

BACKGROUND: The presence of autonomic neuropathy in association with end stage chronic kidney disease have not yet been established. An extending studies need to evaluate the presence of autonomic neuropathy in different stages of chronic kidney disease. OBJECTIVES: To estimate the prevalence rate of autonomic neuropathy in stage 5 chronic kidney disease. METHODS: 35 patients with end stage CKD were selected (patient group), compared with 100 person had CKD of different stages other than stage 5 CKD (control group). A sequence of questionnaires (6 questions) were applied to both groups, followed by testing for postural hypotension using as a complementary test for ANP with the cold immersion test. Any subject failed to show an increment in BP was labeled as having test positive and hence having ANP. RESULTS: The distribution of ANP according to the questionnaire was higher in the patient's group than the controls (p<0.0001). Postural hypotension was more in patients versus the control (p 0.026). The Cold immersion test was positive in 23 subject in patients (65.7%) than the control only 11 subject (11%), (p<0.0001).

Laparoscopic Repair of Intrathoracic Stomach: Clinical and Health-related Quality of Life Outcomes.

BACKGROUND: This study aims to evaluate the clinical and quality of health outcomes in patients undergoing laparoscopic repair of intrathoracic stomach with or without gastric volvulus. MATERIALS AND METHODS: From January 2007 to December 2013, a prospectively maintained data, of patients undergoing surgical repair of intrathoracic stomach, with or without gastric volvulus, was reviewed. Patient demographics, ASA grade, diagnostic technique, semiurgent/emergency status, type of volvulus if present, details of surgery and perioperative complications were recorded. Validated SF-36 questionnaires were completed by patients to record preoperative and postoperative quality of life (QoL) status. Patients managed by nonoperative measures were excluded from the study. RESULTS: Thirty patients were identified with intrathoracic stomach. Fourteen patients had gastric volvulus. Twenty-seven patients (10 emergency, 17 semiurgent) underwent laparoscopic repair of intrathoracic stomach and were included in the study. Mean operating time was 156 (SD, 37.5; range, 105 to 230) minutes. All 27 operations were completed by laparoscopic approach. There was no conversion to open procedure or mortality at 30 days. Mean hospital stay was 5.2 (range, 1 to 15) days. There were 3 (11%) early postoperative complications. One (3.7%) patient developed recurrence at 2 years which required reoperation. Mean follow-up was 10.5 (range, 1 to 36) months. ASA grade and operative time determined the postoperative hospital stay (P=0.001, 0.001, respectively), whereas body mass index and age were shown to have no influence. Patient-reported QoL scores improved across all scales of the health questionnaire after surgery especially bodily pain, social functioning, and physical functioning. CONCLUSIONS: Laparoscopic surgery is a safe and effective treatment option for intrathoracic stomach, with or without gastric volvulus. It is associated with low rates of complications and recurrence. Self-reported patient data shows significant improvement to overall QoL after surgery for intrathoracic stomach.

Delayed Graft Function in Living-Donor Kidney Transplant: A Middle Eastern Perspective.

With an increased incidence of living-donor kidney transplants, in response to increasing unmet needs for renal transplant, a clear understanding of determinants of posttransplant outcomes is essential. The importance of delayed graft function in deceased-donor kidney transplant is now part of conventional medical wisdom, due to the large amount of evidence focused on this aspect. However, the same is not true for living-donor kidney transplant, partly due to lack of evidence on this crucial clinical question and partly due to lack of awareness about this issue. The current review aims to highlight the importance of delayed graft function as a crucial determinant of outcomes in living-donor kidney transplant. An exhaustive search of online medical databases was performed with appropriate search criteria to collect evidence about delayed graft function after living-donor kidney transplant, with a special focus on studies from the Middle East. Data on incidence, impact, risk factors, and possible prevention modalities of delayed graft function in patients undergoing living-donor kidney transplant are presented. A key finding of this review is that contemporary incidence rates reported from the Middle East are comparatively higher than those reported from outside the region. Although in absolute terms the incidence is lower than deceased donor kidney transplant, the effects of delayed graft function on graft rejection and graft and patient survival are sufficiently large to warrant the formulation of specific treatment protocols. Key to formulating prevention and treatment strategies is identifying discrete risk factors for delayed graft function. Although this evidence is scant, an overview has been provided. Further studies examining different aspects of delayed graft function incidence after living-donor kidney transplant are urgently needed to address a so far little known clinical question.