Wow.  No wonder my pregnancies sucked. I was fat AND I couldn’t sleep.

From Medscape:

High BMI, Lack of Sleep Linked to Need for Migraine Treatment During Pregnancy

NEW YORK (Reuters Health) Dec 25 – A high pre-pregnancy body mass index (BMI) and a lack of sleep predict whether women will need migraine medications during pregnancy, new research shows.

An estimated 20%-80% of women report migraines during pregnancy, study co-author Dr. Katerina Nezvalova-Henriksen, of the University of Oslo, Norway, and colleagues write in the December issue of Cephalalgia.

“Many migraineurs may experience an exacerbation of their symptoms at the beginning of the first trimester,” the team notes. “Consequently, these women may require pharmacotherapy during this period, which also corresponds to the most vulnerable period of fetal development.”

To narrow down which women were likely to need migraine medications during pregnancy, Dr. Nezvalova-Henriksen and her colleagues analyzed the newest available data from the Norwegian Mother and Child Cohort Study. That effort is an observational, prospective cohort study of 60,435 pregnant women recruited between 1999 and 2006 and conducted by the Norwegian Institute of Public Health.

Overall, 3840 (5.7%) women reported having a migraine during the first 5 months of pregnancy. Of these, 2525 (72.6%) reported using migraine medications during pregnancy.

About 76% of women who reported migraine both prior to and during pregnancy reported using a migraine agent during pregnancy, compared with 51.8% who reported migraine during pregnancy only.

The most common migraine agents used included non-narcotic analgesics (54.1%) and triptans (25.4%).

After adjusting for sociodemographic factors and comorbidities, sleep duration <5 h (odds ratio, OR, 1.5), pre-pregnancy BMI > 25.0 kg/m squared (OR 1.3), and being on sick leave (OR 1.3) were associated with the use of migraine medications during pregnancy.

By contrast, women who reported acute musculoskeletal pain of the back, neck, and/or shoulder were less likely to use migraine medications during pregnancy (OR 0.6).

When it came to particular types of migraine medications, young mothers and those who had more than child were less likely to use triptans, while those who stopped taking serotonin-selective reuptake inhibitors and beta-receptor agonists prescribed before pregnancy were more likely to use triptans.

“Many women need drug treatment for migraine during pregnancy, and the choice of pharmacotherapy during this period may be influenced by maternal sociodemographic factors and comorbidities,” the authors conclude.

Cephalalgia 2009;29:1267-1276.

Sadness.

On December 31, 2009, in Uncategorized, by Andrea

I’m all about the emotions today.

This is a study regarding adolescents undergoing RNY — specifically, it states that those with a lower BMI before surgery will have a lower BMI 1 year after surgery.  Those with a higher BMI prior to surgery (and they were looking at kids — and here’s where the sadness hits — with a BMI between 65 and 95) remain “extremely obese” one year post-op.

This is a limited study — only looking at a limited number of kids (61) and only follow them for one year.  We know that those that are super morbidly obese can continue to lose long past the year mark, so it is not as if the kids in the two groups with the larger BMIs (group 1 had BMIs between 40 and 54.9, group 2 had BMIs between 55 and 64.9, and group 3 had BMIs between 65 and 95) should be written off as “failures” by the medical community.  To do so would be extremely short-sighted and just plain incorrect.

For purposes of reading the study, nadir is defined as “the lowest point.”

From Medscape:

In Adolescents, Baseline BMI Predicts Nadir BMI After Gastric Bypass

NEW YORK (Reuters Health) Dec 29 – In adolescents undergoing gastric bypass surgery, baseline body mass index (BMI) predicts nadir BMI, a new study shows.

But regardless of baseline BMI, gastric bypass improves cardiovascular risk factors and brings BMI down by about 37% in all patients, the authors report in the January Journal of Pediatrics.

“This finding suggests that the timing of surgery for adolescent obesity is an important consideration, as ‘late’ referral for bariatric surgery at higher BMI values may preclude reversal of obesity or extreme obesity within the first post-operative year and may increase the risk of weight regain over the long term,” according to lead author Dr. Thomas H. Inge, of Cincinnati Children’s Hospital Medical Center, Ohio, and colleagues.

“The BMI spectrum for adolescents seeking surgery is broad, with values in the literature ranging from 35 to 95 kg/m squared, with average BMI values much higher than those seen in most adult surgical practices,” Dr. Inge and his co-authors point out.

To determine the effect of preoperative BMI status on outcomes in their younger patients, the investigators followed 61 adolescents for a year after laparoscopic Roux-en-Y gastric bypass. Nearly 70% were female, more than 80% were white, and their average age at surgery was 17.2 years.

In all cases, patients were left with a gastric pouch volume of 30 ml, and the jejunum was divided 15 to 20 cm from the ligament of Treitz.

Patients were stratified into three groups based on preoperative BMI (kg/m squared): Group 1, n = 23: BMI 40.0 to 54.9; Group 2, n = 21: BMI 55.0 to 64.9; and Group 3, n = 17: BMI 65.0 to 95.0.

The mean BMI in the overall cohort, which was 60.2 kg/m squared at baseline, fell by 37.4% at 1 year after surgery (p < 0.0001), with little variation in BMI reduction among the groups (37.2% in Group 1, 36.8% in Group 2, and 37.7% in Group 3).

The rate of change in absolute BMI units did vary significantly by group, however, with one-year nadir BMI (kg/m squared) reaching 31 in Group 1, 38 in Group 2, and 47 in Group 3.

Only 10 patients (17%) achieved a BMI of less than 30 kg/m squared at 1 year. Eight of these were from Group 1.

Systolic and diastolic blood pressures fell significantly after surgery by 8.8% and 13.5%, respectively, regardless of baseline BMI (P < 0.0001 for each). Surgery also reduced total cholesterol (by 16.8%; p = 0.0007), triglycerides (by 37.3%; p < 0.0001), and insulin (by 75.8%; p < 0.0001), no matter the baseline BMI.

Albumin levels did not change at 1 year despite the significant weight loss.

“In this investigation, we found that most adolescents within the highest ranges of baseline BMI…remained extremely obese…despite BMI reductions averaging nearly 40%,” the authors write.

Adolescents “who present at higher weights and BMI values lose more weight than those who present at lower weights but also plateau at a higher weight on average,” they add. “The biological and potentially behavioral reasons for this are unclear.”

J Pediatr 2010;156:103-108.

Puzzlement.

On December 31, 2009, in Uncategorized, by Andrea

I don’t write many “opinion” only pieces.  I generally like to keep my thoughts on here to facts only.  Not really sure why — I guess because I’m just a little ‘ole person who blogs.  I don’t have an edumacasion that’s worth anything, so my opinion isn’t really worth a whole lot.  Or so I think.  Maybe, I don’t know.

But today, today I’m puzzled.

Yesterday, I reported that the link between proton pump inhibitors (PPIs) and osteoporosis — something that was thought to be an iron-clad link as reported in JAMA in December of ’06 — was completely obliterated.  I was surprised and shocked that I found it first — and I knew that I had by perusing the Osteoporosis page over at Alltop.

The reaction was lukewarm at best.  Which was … shocking.  This is a medicine that tons of WLSers take on a daily basis to avoid ulcers, and in a community that is already plagued with calcium and bone density problems, the hint that a drug that we need to avoid ulcers might hinder our calcium absorption is scary.  Well, it was to me.  Avoid ulcers or have broken bones?  What a choice!  I mean, both options really suck, especially coming from someone who has lived with both.  So seeing the link between the two broken was a welcome relief and I expected the community to be just as excited as I was.

To see that they weren’t — well, surprising isn’t the word I’d use.  I’m not sure disappointing is the word I’d use because I can’t be disappointed at the lack of reaction from others.. but more than surprised.  Perhaps shocked.

And still not a peep from the osteoporosis community, either.

The mind boggles at what people find intriguing and what they find boring.

Bariatric surgery is safe? Who knew?!?

On December 31, 2009, in Uncategorized, by Andrea

Well.  I guess I did since I’m still breathing.

And my readers who had it do, since, well, they’re reading this.  Unless there’s broadband and Farkle and such in the hereafter — and in that case put me down for a comfy chair, free refills of my coffee, with my current 20MBPS FiOS connection when I pass over to the other side, kthanx.

From Medscape:

How Safe is Bariatric Surgery?

Jacob A. Greenberg; Malcolm K. Robinson

Abstract

The use of bariatric surgery for the treatment of morbid obesity has increased dramatically over the past decade, which has raised concerns about safety, efficacy and cost-effectiveness. A new study by the Longitudinal Assessment of Bariatric Surgery consortium has assessed the safety of these increasingly frequent procedures.

Content

Clinicians are still struggling to find a solution to the world’s growing weight problem. New diets, prescriptions pills and exercise videos become available every week. Unfortunately, however, these weight-loss strategies fail to produce substantial, durable weight reduction for the vast majority of patients with morbid obesity. As a consequence, patients and physicians have turned to a more drastic approach to weight loss: bariatric surgery. Despite the 10-fold rise in bariatric procedures in the US—from 16,200 surgeries in 1994 to 171,000 procedures in 2005—the safety and advisability of such an extremely invasive therapy is often questioned. The Longitudinal Assessment of Bariatric Surgery (LABS) consortium have published the results of their first study, LABS-1, in the New England Journal of Medicine, which indicate that the overall risk of adverse outcomes of bariatric surgical procedures is low and contingent on patient characteristics.[1]

LABS-1 was a prospective, multicenter, observational study, which measured the 30-day morbidity and mortality of 4,776 patients who underwent one of the three most frequent bariatric surgical procedures performed in the US. The investigators found an overall mortality rate of 0.3% and a major complication rate of 4.1%, both of which are comparable to other major abdominal surgical procedures. Furthermore, they noted that patients with obstructive sleep apnea, poor functional status (for example, the inability to walk more than 100 feet), or a history of prior thrombotic events had increased complication rates.

The procedures evaluated in this study included open and laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding. Roux-en-Y gastric bypass involves the creation of a small upper stomach pouch and its attachment to the jejunum, which results in bypass of the rest of the stomach and the duodenum. This bypass leads to weight loss by restriction of food intake, as well as through a variety of poorly understood neurohormonal changes that enhance satiety. During the procedure of laparoscopic gastric banding, a small stomach pouch is generated by placement of an adjustable band around the upper stomach. Weight loss predominantly occurs as a result of restricted food intake, although neurohormonal changes that enhance satiety can also occur with this procedure. The LABS-1 investigators found that the 30-day composite end point of death, major thrombotic complication, reintervention and prolonged hospitalization was 1.0% for laparoscopic adjustable gastric banding, 4.8% for laparoscopic Roux-en-Y gastric bypass surgery, and 7.8% for open Roux-en-Y gastric bypass surgery.

The literature is rife with data on both the short-term and the long-term outcomes of bariatric surgery; however, the LABS-1 study differs from previous studies in a variety of ways. Previous data on clinical outcomes of bariatric surgery cannot be generalized, as they are derived from retrospective studies published by individual surgeons or institutions.[2,3] Inclusion of data from centers that do not practice state-of-the-art care within a comprehensive bariatric program might have added to the perception of increased adverse outcomes after bariatric surgery compared with other abdominal surgical procedures.

By contrast, the LABS-1 researchers analyzed data from patients treated by 33 different surgeons at 10 different clinical sites. Pertinent data points such as the primary endpoint and the presence or absence of specific prior comorbidities, were clearly defined and the data were managed by trained data collectors. Some critics might argue that the LABS-1 data underestimates the true morbidity and mortality of bariatric surgery, as the procedures analyzed were performed by highly skilled surgeons at high-volume centers of excellence which perform more than 100 laparoscopic Roux-en-y gastric bypasses annually. Previous research, however, has revealed that outcomes of both high-volume and low-volume programs are similar between centers of excellence and centers without said designation.[4] The data analyzed in LABS-1, therefore, represents the current state of the art in bariatric surgery and the study provides both surgeons and patients with realistic expectations of postoperative safety of three different bariatric procedures.

What LABS-1 does not address is the efficacy of bariatric surgery. Clinicians must be careful not to recommend a type of bariatric surgery on the basis of safety data alone. For example, although laparoscopic adjustable gastric banding is currently considered the safest bariatric procedure, gastric bypass might be the best option for patients who require substantial and durable weight loss.[5] In addition, bariatric procedures vary not only in the time until weight loss is achieved or the mechanisms that effect weight reduction, but also in their effects on glycemic control. After placement of an adjustable gastric band, improvements in glycemic control are dependent on weight loss, and patients might not see appreciable improvements in blood glucose control for some time.[6] After Roux-en-Y gastric bypass, most patients see an improvement in their glycemic control before any weight loss occurs. Although the mechanisms behind these changes are complex and not entirely clear, an alteration in the release of gut peptides seems to improve glycemic control independent of weight loss.[7] These effects, coupled with safety and other factors, must all be taken into account when a bariatric procedure is recommended for an individual patient. The results of the long-term LABS-2 study, currently in progress, will hopefully shed light on these efficacy issues and treatment recommendations.

In light of the imminent health-care reform proposed by the Obama administration, questions of cost-effectiveness must be addressed for all treatments, and bariatric surgery is no exception. The long-term health benefits after bariatric surgery include improved cardiovascular-related and diabetes-related outcomes. These improvements in comorbidities are associated with a decrease in mortality that ranges from 24-40% compared to patients treated non-surgically, as indicated by two other important studies published in the New England Journal of Medicine.[2,5] Ameliorations in overall health can lead to compensatory decreases in cost, if patients require fewer medications and less frequent hospitalizations than previously. At this point, however, it remains to be determined whether these decreases in cost are equivalent to the upfront cost of surgery and perioperative care. Further research through long-term cost-benefit analyses is needed before these questions can be answered adequately.

The prevalence of obesity and obesity-related disorders is on the rise in young adults, adolescents, and even in the pediatric population. Hence, this problem is unlikely to be resolved in the near future. In a perfect world, primary prevention through diet and exercise would alleviate the need for any surgical intervention. Unfortunately, until we begin to see success with primary prevention or develop equally effective medical management, bariatric surgery will remain an important—and reasonably safe—tool in our armamentarium for the treatment of obesity.

Do PPIs Increase the Risk of Bone Fracture?

On December 30, 2009, in Minerals, by Andrea

In December, 2006, JAMA published a study linking a popular post-WLS drug — the proton pump inhibitor or PPI — and increased hip fracture.  It was hypothesized that the PPIs interfered with calcium absorption through achlorhydria or through inhibition of osteoclastic vacuolar proton pumps.

Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture

Yu-Xiao Yang, MD, MSCE; James D. Lewis, MD, MSCE; Solomon Epstein, MD; David C. Metz, MD

JAMA. 2006;296:2947-2953.

Context Proton pump inhibitors (PPIs) may interfere with calcium absorption through induction of hypochlorhydria but they also may reduce bone resorption through inhibition of osteoclastic vacuolar proton pumps.

Objective To determine the association between PPI therapy and risk of hip fracture.

Design, Setting, and Patients A nested case-control study was conducted using the General Practice Research Database (1987-2003), which contains information on patients in the United Kingdom. The study cohort consisted of users of PPI therapy and nonusers of acid suppression drugs who were older than 50 years. Cases included all patients with an incident hip fracture. Controls were selected using incidence density sampling, matched for sex, index date, year of birth, and both calendar period and duration of up-to-standard follow-up before the index date. For comparison purposes, a similar nested case-control analysis for histamine 2 receptor antagonists was performed.

Main Outcome Measure The risk of hip fractures associated with PPI use.

Results There were 13 556 hip fracture cases and 135 386 controls. The adjusted odds ratio (AOR) for hip fracture associated with more than 1 year of PPI therapy was 1.44 (95% confidence interval [CI], 1.30-1.59). The risk of hip fracture was significantly increased among patients prescribed long-term high-dose PPIs (AOR, 2.65; 95% CI, 1.80-3.90; P<.001). The strength of the association increased with increasing duration of PPI therapy (AOR for 1 year, 1.22 [95% CI, 1.15-1.30]; 2 years, 1.41 [95% CI, 1.28-1.56]; 3 years, 1.54 [95% CI, 1.37-1.73]; and 4 years, 1.59 [95% CI, 1.39-1.80]; P<.001 for all comparisons).

Conclusion Long-term PPI therapy, particularly at high doses, is associated with an increased risk of hip fracture.
Author Affiliations: Division of Gastroenterology (Drs Yang, Lewis, and Metz), Center for Clinical Epidemiology and Biostatistics (Drs Yang and Lewis), Department of Biostatistics and Epidemiology (Drs Yang and Lewis), and Division of Endocrinology (Dr Epstein), University of Pennsylvania School of Medicine, Philadelphia; and Department of Medicine, Doylestown Hospital Research Center, Doylestown, Pa (Dr Epstein).

Well.  Fast forward to today.

I’m on Medscape and see this post:  Do PPIs Increase the Risk of Bone Fracture? and I think to myself.. “Well, duh.  This was answered awhile back.”  I go in, and find a video by prof citing a study that’s coming out from Manitoba Canada where, aparantely the government really likes to track PPI usage as well as fractures and there’s no significant correllation.

Wait.  What?

But.  Wait.  Say that again?

I thought that the osteoclasts, which are, in essence little proton pumps in their own little rights, were also being shut down by the PPIs and so bone resorption was a problem and the hopes and dreams was a osteoclast specific PPI to help prevent osteoporosis down the road and then the world would be glitter and rainbows and sunshine once again?  No?

Oh.

Here’s the video.  Go watch it.  It’s worth the 6 minutes, 40 something seconds of your life it will take.

I’m looking forward to reading the full article when it comes out.  But for now, if you’ll excuse me, it’s time for my Prilosec.


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