Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study.

BACKGROUND: Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy. METHODS: In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n = 59 [gastric bypass surgery n = 26, sleeve gastrectomy n = 31, missing n = 2] and controls n = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17-20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5). RESULTS: The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p = 0.228) or development of gestational diabetes (n = 3 [5%] vs. n = 7 [5%], p = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p = 0.030). CONCLUSION: Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Infectious Pseudochromhidrosis: A Case Report and Literature Review.

Infectious pseudochromhidrosis is a rare dermatological disorder, characterized by a change in colour of the sweat from normal skin, caused by pigments from microorganisms. Such pigments are a result of evolutionary competition among microorganisms, which appears to be a decisive factor in their survival, patho-genicity, and virulence. Four bacteria are known to be involved in infectious pseudochromhidrosis: Bacillus spp. (blue colour), Corynebacterium spp. (brown/black colour), Serratia marcescens (red/pink colour), and Pseudomonas aeruginosa (blue-green colour). Infectious pseudochromhidrosis seems to be triggered by certain drugs and conditions causing physiological alterations and/or changes in microflora on the skin surface. The condition can be treated by addressing potential triggers and/or prescribing antibiotic/antiseptic therapies. We report here a case of blue infectious pseudochromhidrosis caused by pigment-producing Bacillus cereus and the results of a literature review.

Kidney stone compositions and frequencies in a Norwegian population.

Objectives: The aim of this study was to investigate frequencies of kidney stone constituents in a Norwegian population and examine trends over time by comparing with an earlier study of this population. Materials and methods: Upper urinary tract calculi consecutively collected from patients who underwent stone surgery at Akershus University Hospital from July 2014 to December 2017, in total 1252 calculi, were analysed by infrared spectroscopy. The results were compared with a study of 500 calculi collected from June 1975 to September 1980 at the same hospital. Results: The male:female ratio was 1.83:1. Single-component stones constituted 39%, 35% were binary, and 25% ternary. Main stone component frequencies were oxalate 71.3%, calcium oxalate monohydrate 53.7% with higher occurrence in males, calcium oxalate dihydrate 17.6%, carbonate apatite 10.8% and struvite 5.7%, both with higher occurrence in females, uric acid 8.9% with a non-significant male predominance, brushite 1.6% and cystine about 1%. Over four decades the frequency of UA stones increased by 4.6-times, whereas struvite and pure carbonate apatite stones decreased and no change was observed for brushite stones. Conclusion: Frequencies of kidney stone types in this Norwegian population are mainly in accordance with other studies, except a large increase in UA stones over four decades, partly caused by a particularly low frequency of UA stones in the old study, a decreased carbonate apatite frequency over four decades, and an unaltered brushite frequency. Also, in contrast to other studies, a relatively small and non-significant male UA stone predominance was found.

Utility and effectiveness of the Scandinavian guidelines to exclude computerized tomography scanning in mild traumatic brain injury - a prospective cohort study.

BACKGROUND: In 2013 the Scandinavian Neurotrauma Committee (SNC) published updated guidelines for the initial management of minimal, mild and moderate traumatic head injuries (MTHI) that included serum analysis of protein S100B as a marker for brain tissue damage. This study reviews the effectiveness of the new guidelines in a clinical setting. METHODS: For all patients admitted to Akershus University Hospital (AHUS) from June 30th 2014 to December 15th 2014 with MTHI a separate form was filled in recording the time, indication and result of any S100B sampling and/or head computer tomography (CT) examinations. Data from these forms were compared to information derived from the electronic patient records for patients with MTHI and related diagnoses and data from the laboratory for all patients that had undergone the S100B analysis within the same period. RESULTS: Five hundred seventy-five patients were identified with MTHI, S100B sampling was indicated for 223 (38.8%) patients and carried out for 188 (84.3%) of these patients. 69 (36.7%) of the patients had a negative S100B test, but a head CT scan was still performed in 31 cases despite the negative S100B test. In total the guidelines were followed for 362 of 575 patients (63.0%). 180 (31.3%) of the MTHI cases were discharged without further observation or CT examinations, including 38 (21.1%) as a direct result of S100B testing. No re-admissions or missed initial traumatic brain injuries were observed. CONCLUSION: The implementation of the updated SNC guidelines resulted in direct discharge of more than one third of the MTHI cases without further observation or CT examinations. One in five of these discharges was a direct result of S100B testing. However, compliance to the guidelines were poor and the guidelines were only followed in 40%. While this study showed benefits of implementing SNC guidelines to reduce the number of CT scans, additional training is needed for optimal use.

The usage of fasting glucose and glycated hemoglobin for the identification of unknown type 2 diabetes in high risk patients with morbid obesity.

BACKGROUND: In spite of increased vigilance of undiagnosed type 2 diabetes (DM2), the prevalence of unknown DM2 in subjects with morbid obesity is not known. AIM: To assess the prevalence of undiagnosed DM2 and compare the performance of glycated A1c (HbA1c) and fasting glucose (FG) for the diagnosis of DM2 and prediabetes (preDM) in patients with morbid obesity. PATIENTS AND METHODS: We measured fasting glucose and HbA1c in 537 consecutive patients with morbid obesity without previously known DM2. RESULTS: A total of 49 (9%) patients with morbid obesity had unknown DM2 out of which 16 (33%) fulfilled both the criteria for HbA1c and FG. Out of 284 (53%) subjects with preDM, 133 (47%) fulfilled both the criteria for HbA1c and FG. Measurements of agreement for FG and HbA1c were moderate for DM2 (κ = 0.461, p < .001) and fair for preDM (κ = 0.317, p < .001). Areas under the curve for FG and HbA1c in predicting unknown DM2 were 0.970 (95% CI 0.942, 0.998) and 0.894 (95% CI 0.837, 0.951) respectively. The optimal thresholds to identify unknown DM2 were FG ≥6.6 mmol/L and HbA1c ≥ 6.1% (43 mmol/mol). CONCLUSIONS: The prevalence of DM2 remains high and both FG and HbA1c identify patients with unknown DM2. FG was slightly superior to HbA1c in predicting and separating patients with unknown DM2 from patients without DM2. We suggest that an FG ≥6.6 mmol/L or an HbA1c ≥6.1% (43 mmol/mol) may be used as primary cut points for the identification of unknown DM2 among patients with morbid obesity.

Osteoprotegerin concentrations in patients with suspected reversible myocardial ischemia: observations from the Akershus Cardiac Examination (ACE) 1 Study.

Increased circulating osteoprotegerin (OPG) levels have been associated with the prevalence and severity of coronary artery disease and the risk of cardiovascular death. OPG is a cytokine of the tumor necrosis factor receptor superfamily and is expressed in various cell types in the body, including osteoblasts, inflammatory cells, vascular smooth muscle cells/endothelial cells and cardiomyocytes. The main sources determining OPG levels in the circulation however, are not well understood, and whether reversible myocardial ischemia influences OPG levels are not known. Accordingly, OPG levels were measured in 198 patients referred for exercise stress testing and myocardial perfusion imaging (MPI). In addition OPG levels were measured in 8 healthy control subjects performing a maximal bicycle stress test. Plasma samples were collected before, immediately after, 1.5h and 4.5h after exercise stress testing with MPI. OPG levels at baseline were not different in patient with reversible myocardial ischemia (n=19) and patients without reversible ischemia (n=179) (4.7 [3.6-5.5]pmol/L vs. 4.3 [3.4-5.2]pmol/L, p=0.21), and there was an increase in OPG levels immediately after exercise regardless of whether or not the patient had reversible ischemia on MPI (absolute increase: 0.2 [0-0.55]pmol/L vs. 0.3 [0-0.5]pmol/L, p=0.72). OPG levels also increased immediately after stress in the 8 control subjects (3.5 (3.2-3.8)pmol/L at baseline to 3.8 (3.5-4.7), p=0.008). In conclusion, OPG levels increase acutely during exercise stress testing, but this increase is likely caused by mechanisms other than myocardial ischemia.

Troponin I measured by a high-sensitivity assay in patients with suspected reversible myocardial ischemia: data from the Akershus Cardiac Examination (ACE) 1 study.

BACKGROUND: Whether cardiac troponin concentrations are increased by reversible myocardial ischemia is controversial. Differences in the structure of cardiac troponin I (cTnI) and cTnT may have implications for diagnostic utility. METHODS: cTnI was measured with a prototype high-sensitivity (hs) assay in 198 patients referred for myocardial perfusion imaging (MPI) before exercise stress testing, immediately after, and 1.5 and 4.5 h later. We categorized patients according to MPI results and compared hs-cTnI concentrations with hs-cTnT concentrations. RESULTS: Baseline hs-cTnI was higher in patients with reversible myocardial ischemia (n = 19) vs the other patients (n = 179): median 4.4 (quartiles 1-3: 2.3-7.1) vs 2.5 (1.4-4.3) ng/L, P = 0.003. Baseline hs-cTnI and hs-cTnT concentrations were correlated (r = 0.46, P < 0.001) and the areas under the ROC curve for hs-cTnI and hs-cTnT in diagnosing reversible ischemia were similar: 0.71 vs 0.69, P = 0.77. Whereas hs-cTnI increased immediately after exercise (P < 0.001 vs baseline measurements) in patients without ischemia, it increased after 4.5 h in patients with reversible ischemia (P = 0.01). The increment in hs-cTnI concentrations was comparable between groups; thus, measuring hs-cTnI after exercise stress testing did not improve diagnostic accuracy over baseline measurements, and hs-cTnI concentrations were not found to be associated with reversible myocardial ischemia in multivariate analysis. By linear regression analysis, age, male sex, history of hypertension, angiotensin-converting enzyme inhibitor use, and lower left ventricular ejection fraction were associated with higher baseline hs-cTnI concentrations. CONCLUSIONS: In patients referred to MPI, hs-cTnI concentrations were not closely associated with reversible myocardial ischemia, but rather were influenced by variables associated with structural alterations of the myocardium.

Diagnostic utility of a single-epitope sandwich B-type natriuretic peptide assay in stable coronary artery disease: data from the Akershus Cardiac Examination (ACE) 1 Study.

OBJECTIVES: To assess the merit of a novel single-epitope sandwich (SES) assay specific to the stable part of BNP in patients with reversible myocardial ischemia as post-translational modifications of BNP may influence assay performance. DESIGN AND METHODS: We measured BNP concentration by a conventional assay and the SES-BNP assay in 198 patients referred for myocardial perfusion imaging (MPI). BNP concentration was determined before and immediately after exercise stress testing, and 1.5 and 4.5h later. Patients were categorized according to MPI results. RESULTS: BNP concentration was higher with both assays at all time points in patients with reversible myocardial ischemia (n=19) compared to the other patients (n=179). Measuring BNP after stress testing or calculating the changes in BNP concentration did not improve diagnostic accuracy compared to baseline measurements: SES-BNP: AUC 0.71 (95% CI 0.58-0.84) vs. conventional BNP: 0.71 (0.59-0.83), p=0.96. By linear regression analysis, reversible myocardial ischemia was significantly associated with baseline SES-BNP concentration (p=0.043), but not with measurements by the conventional assay (p=0.089). In multivariate logistic regression models, only baseline measurement with the SES-BNP assay was significantly associated with reversible myocardial ischemia: odds ratio [logarithmical transformed BNP] 2.00 (95% CI 1.16-3.47), p=0.013. The SES-BNP assay, but not the conventional BNP assay, reclassified a significant proportion of the patients towards their correct category on top of the best clinical model of our data set: NRI=0.47, p=0.04. CONCLUSIONS: The SES-BNP assay was significantly associated with reversible myocardial ischemia as assessed by several statistical indices, while a conventional BNP assay was not.

Cardiac troponin T levels and exercise stress testing in patients with suspected coronary artery disease: the Akershus Cardiac Examination (ACE) 1 study.

Whether reversible ischaemia in patients referred for exercise stress testing and MPI (myocardial perfusion imaging) is associated with changes in circulating cTn (cardiac troponin) levels is controversial. We measured cTnT with a sensitive assay before, immediately after peak exercise and 1.5 and 4.5 h after exercise stress testing in 198 patients referred for MPI. In total, 19 patients were classified as having reversible myocardial ischaemia. cTnT levels were significantly higher in patients with reversible myocardial ischaemia on MPI at baseline, at peak exercise and after 1.5 h, but not at 4.5 h post-exercise. In patients with reversible ischaemia on MPI, cTnT levels did not change significantly after exercise stress testing [11.1 (5.2-14.9) ng/l at baseline compared with 10.5 (7.2-16.3) ng/l at 4.5 h post-exercise, P=0.27; values are medians (interquartile range)]. Conversely, cTnT levels increased significantly during testing in patients without reversible myocardial ischaemia [5.4 (3.0-9.0) ng/l at baseline compared with 7.5 (4.6-12.4) ng/l, P<0.001]. In conclusion, baseline cTnT levels are higher in patients with MPI evidence of reversible myocardial ischaemia than those without reversible ischaemia. However, although cTnT levels increase during exercise stress testing in patients without evidence of reversible ischaemia, this response appears to be blunted in patients with evidence of reversible ischaemia. Mechanisms other than reversible myocardial ischaemia may play a role for acute exercise-induced increases in circulating cTnT levels.

Heterophilic antibody interference in commercial immunoassays; a screening study using paired native and pre-blocked sera.

BACKGROUND: Heterophilic antibodies are still an important source of interference in immunoassays. We have conducted a screening study for interference in a panel of commercially available assays using two sera known to contain high titer Fc-reactive heterophilic antibodies. METHODS: The sera were distributed to laboratories participating in the Nordic External Quality Assessment cooperation (EQANord). Duplicate samples pre-blocked with aggregated murine monoclonal MAK33 were also supplied. Discrepancies (>50%) between the results for native and blocked samples were used to classify the tested assays as susceptible to interference. A total of 170 different assay kits covering 91 analytes were tested. RESULTS: We found that 21 assays, covering 19 different analytes, were susceptible to interference from the heterophilic antibodies in the two sera. Many of these are clinically and commercially important assays. Some of the false results were grossly elevated and could have been detrimental to patient care in a clinical setting. CONCLUSIONS: Heterophilic antibodies with Fc-reactivity remain a threat. A more widespread use of antibody fragments and aggregated immunoglobulin could potentially improve the heterophilic antibody resistance of assays intended for clinical use.

Radiation exposure to family members of patients with thyrotoxicosis treated with iodine-131.

PURPOSE: The purpose of this study was twofold: (1) to measure the radiation exposure to family members of out-patients with thyrotoxicosis treated with radioiodine, 131I, using the recommendations from the European Commission (EC) guidance and age-specific periods for behaviour restrictions; (2) to use the results to identify necessary restrictions to ensure recommended dose constraints. METHODS: The study population comprised 76 family members (46 adults and 30 children below the age of 18) of 42 patients. The patients were treated with an average activity of 417 MBq (range 260-600 MBq). They received oral and written EC recommendations about behaviour restrictions (translated into Norwegian). On the day of treatment we repeated the oral instructions to the patient and an adult family member. The time periods for restrictions were 14 days for children aged 0-10 years, 7 days for persons aged 11-59 years and 3 days for persons aged 60 years and older. Family members wore a thermoluminescent dosimeter (TLD) on each wrist day and night for 2 weeks. The doses received were adjusted to give an estimate of the expected values if the TLDs had been worn indefinitely. RESULTS: Radiation doses well below the recommended dose constraints were measured for all adult family members and children, except one 2-year-old child; in the latter case the mother probably did not comply with the instructions given. CONCLUSION: The radiation dose to family members of thyrotoxic patients treated with up to 600 MBq of radioiodine is well below recommended dose constraints if EC instructions are given and compliance is adequate. The duration of restrictions for various age groups used in this study may be considered when establishing guidelines in Norway.

[Subarachnoidal haemorrhage with spectrophotometric detection of bilirubin in the spinal fluid as the only pathological result]. / Subaraknoidalblødning med kun spektrofotometrisk påvist bilirubin i spinalvaesken.

In the examination of a patient with acute headache in which subarachnoid haemorrhage is suspected, a CT scan of the brain should be performed without delay. If the CT scan does not confirm subarachnoid haemorrhage, the next step is a lumbar puncture. This should not take place before twelve hours have elapsed from the start of the headache, so as to allow for the formation of sufficient amounts of bilirubin to be detected in a possible subarachnoid haemorrhage. Bilirubin colours the spinal fluid characteristically yellow and is detectable for at least two weeks following a subarachnoid haemorrhage. Spectrophotometric detection of bilirubin in the spinal fluid is considered more sensitive than visual detection. We present a case in which the spectrophotometric detection of bilirubin in the spinal fluid was the only pathological test result in the examination of a patient with acute headache. The spectrophotometric detection revealed an intracranial aneurysm, for which the patient received subsequent lifesaving surgical treatment. Spectrophotometric examination of spinal fluid has a high sensitivity rate. The test is simple to perform, is not expensive, and is within the scope of most laboratories. We present our method for spectrophotometric investigation of spinal fluid, along with practical advice.