OBJECTIVE:To examine associations of laparoscopic sleeve gastrectomy with maternal and perinatal outcomes.
METHODS:We conducted a retrospective case–control study of deliveries that occurred from ...2006 to 2016 at two university hospitals. The study group comprised all women who had undergone laparoscopic sleeve gastrectomy and who delivered during the study period. If a woman had more than one pregnancy during the study period, data from only her first pregnancy were used. A control group was established by matching preoperative body mass index (BMI), age, parity, delivery history, and delivery year.
RESULTS:Data from 238 women were analyzed, 119 post–laparoscopic sleeve gastrectomy and 119 matched control parturients. Among the post–laparoscopic sleeve gastrectomy patients, the median preoperative BMI was 41.7 (interquartile range 39.9–44.4) and the median postoperative BMI was 28.9 (26.6–32.0). Compared with the control group, the study group had lower rates of gestational diabetes mellitus (3.4% vs 17.6%, P=.001), large-for-gestational-age neonates (1.7% vs 19.3%, P=.001), and birth weight greater than 4,000 g (0.8% vs 7.6%, P=.02) but higher proportions of small-for-gestational-age (SGA) neonates (14.3% vs 4.2%, P=.01) and low-birth-weight neonates (12.6% vs 4.2%, P=.03). Rates of gestational hypertensive disorders and prematurity were comparable between the groups. For the study group, hemoglobin levels were lower in early pregnancy (median 12.6 vs 13.2 g/dL, P=.001) and after delivery (10.5 vs 10.8 g/dL, P=.002), and a higher proportion of patients were treated with intravenous iron supplementation during pregnancy (14.3% vs 0.8%, P=.001). Cesarean delivery rates during labor were lower in the study group (10.1% vs 20.2%, P=.04).
CONCLUSION:Laparoscopic sleeve gastrectomy was associated with reduced rates of gestational diabetes mellitus, excessive fetal growth, and cesarean delivery and an increased rate of SGA and low-birth-weight neonates.
ObjectivesTo assess the course of lipid levels over time in postpartum women according to gestational diabetes status, taking into account potential confounders, such as comorbid conditions and body ...weight.MethodsThe data for the present analysis were collected from a 2.3 million member integrated care provider in Israel. Included were all female members aged 15–50 years who performed a 50 g glucose challenge test (GCT) between March 1995 and May 2009. We collected all follow-up lipid consecration tests performed from date of delivery following the GCT (index date) until April 2017. Data analysis was performed for each lipid component individually (triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C)) and the effects of the several risk factors (history of gestational diabetes mellitus (GDM), age at delivery, obesity status and smoking status) were investigated using general linear model taking into account potential confounders.ResultsA total of 160 527 women (6.1 million person-years of actual follow-up) were eligible for the analysis, including 10 234 women with GDM (6.4% of the entire cohort). During the study follow-up period, a total of 2.1 million lipid tests were performed. When adjusting for follow-up time, age at index date, body mass index status, and smoking status, GDM was associated with a 1.8-fold risk (95% CI 1.73 to 1.88) for dyslipidemia defined by TG, 1.45-fold risk (95% CI 1.38 to 1.52) for dyslipidemia defined by LDL-C, and 1.44-fold risk (95% CI 1.39 to 1.50) for dyslipidemia defined by HDL-C.DiscussionThe results of this retrospective cohort analysis indicate that gestational diabetes confers added risk for developing hyperlipidemia post partum, particularly dyslipidemia defined by TG, as compared with women with normal glucose tolerance.
Anti-RhD antibodies are widely used in clinical practice to prevent immunization against RhD, principally in hemolytic disease of the fetus and newborn. Intriguingly, this disease is induced by ...production of the very same antibodies when an RhD negative woman is pregnant with an RhD positive fetus. Despite over five decades of use, the mechanism of this treatment is, surprisingly, still unclear. Here we show that anti-RhD antibodies induce human natural killer (NK) cell degranulation. Mechanistically, we demonstrate that NK cell degranulation is mediated by binding of the Fc segment of anti-RhD antibodies to CD16, the main Fcγ receptor expressed on NK cells. We found that this CD16 activation is dependent upon glycosylation of the anti-RhD antibodies. Furthermore, we show that anti-RhD antibodies induce NK cell degranulation in vivo in patients who receive this treatment prophylactically. Finally, we demonstrate that the anti-RhD drug KamRho enhances the killing of dendritic cells. We suggest that this killing leads to reduced activation of adaptive immunity and may therefore affect the production of anti-RhD antibodies.
Abstract Purpose To examine the association between parity and long-term, all-cause mortality and mortality owing to specific causes in women. Methods This prospective population-based study included ...40,454 mothers who gave birth in Western Jerusalem, Israel, to 125,842 children and were followed for an average of 37 years after the birth of their first child. Cox proportional hazards models were used to evaluate long-term total and specific-cause mortality of women by their parity. Results We found a U-shaped relationship between the number of offspring and risk of all-cause mortality in mothers. After adjustment for sociodemographic characteristics and maternal health and obstetric conditions, higher mortality rates were observed for mothers of 1 child (hazard ratio HR, 1.18; 95% confidence interval CI, 1.04–1.4), mothers of 5 to 9 children (HR, 1.21; 95% CI, 1.09–1.33), and mothers of 10 or more children (HR, 1.49; 95% CI, 1.12–1.99) compared with mothers of 2 to 4 children. Mortality risk from specific causes including coronary disease, circulatory disease, and cancer were increased for multiparous women. Conclusions In this long-term follow-up study, there was an association between number of children and mortality risk for mothers. These findings suggest that maternal pregnancies and postnatal characteristics as reflected by number of children may have consequences for long-term maternal health.
Pharmacomechanical catheter-directed thrombolysis (PCDT) is relatively contraindicated during pregnancy and postpartum. The purpose of this study was to evaluate outcomes of PCDT in this population.
...Data for 11 consecutive patients (aged 21-35 y) undergoing PCDT at a tertiary center for symptomatic pregnancy-related iliofemoral deep vein thrombosis (DVT) were retrospectively reviewed. Details regarding patient presentation, location and extent of thrombus, the PCDT procedure, outcomes, frequency of postthrombotic syndrome (PTS), and subsequent pregnancies were recorded. Two patients who presented in the first trimester terminated their pregnancies after PCDT, 2 patients who presented in the third trimester delayed PCDT until after delivery, and 7 patients who presented with postpartum DVT underwent immediate PCDT.
Thrombus extended into the inferior vena cava in 5 patients (45%) and into popliteal/tibial veins in 7 (64%). Four patients (36%) had synchronous pulmonary embolism and three had May-Thurner compression. Median interval from diagnosis to PCDT was 5 days (range, 2-68 d); median duration of urokinase infusion was 27 hours (range, 16-72 h). Greater than 90% clot lysis was achieved in 9 of 11 patients (82%). Metal stents were placed in 8 of 11 patients (73%). A self-limiting popliteal hematoma developed in 1 patient, and 2 had early recurrent thrombosis requiring repeat PCDT. At median 20-month follow-up, nonocclusive thrombus was seen in 5 patients. No patient developed PTS. Three patients, all with stents, had uneventful pregnancies after PCDT.
Pharmacomechanical catheter-directed thrombolysis achieved encouraging initial outcomes in this series. Validation in prospective trials with larger enrollment and longer follow-up is needed.
Purpose
The purpose of the study was to evaluate the occurrence of subgaleal hemorrhage (SGH) following non-assisted vaginal delivery (normal vaginal delivery or cesarean delivery), and to ...characterize associated factors, clinical course, and outcomes, compared to attempted assisted vaginal delivery (AVD)-associated SGH
Methods
A retrospective cohort study was conducted
.
All cases of SGH encountered following delivery of a singleton neonate at Hadassah, Hebrew University Medical Center during 2011–2018 were included. Maternal, fetal, intrapartum, and neonatal characteristics and outcomes were compared between AVD-related and non-AVD-related SGH groups.
Results
The overall incidence of SGH was 4.5/1000 (369/82,256) singleton deliveries. The incidences of AVD- and non-AVD-related SGH were 44.6/1000 (350/7852) and 0.3/1000 (19/74,404) singleton deliveries, respectively.
Ten (53%) of the 19 non-AVD-related SGH were diagnosed after vaginal delivery and 9 (47%) after an urgent cesarean section. SGH severity was mild, moderate, and severe in 68%, 16%, and 16% of the cases, respectively. SGH severity did not differ between the attempted AVD group and the non-AVD-related SGH group
.
A higher proportion of neonates with non-AVD SGH required phototherapy treatment than did those diagnosed with AVD-related SGH (56% vs. 24%,
P
= 0.003). Other neonatal outcomes, including Apgar scores, maximal bilirubin level, length of stay, and the rate of composite adverse outcomes, did not differ between the groups.
Conclusions
SGH, although rare, may be diagnosed after unassisted vaginal or cesarean delivery in the absence of an AVD attempt. We advocate continuing education for all medical staff who participate in peripartum and neonatal care, regarding the possible occurrence of non-AVD-related SGH.
Women with congenital heart disease (CHD) are at risk for peripartum cardiac deterioration. Previous studies focused on women after one or two pregnancies. We investigated effects of multiple births ...on maternal cardiac status by comparing women with CHD and ≥3 live births to women with <3 live births.
Participants were identified from the Adult CHD clinic (2010–2018). Women with CHD and ≥3 live births were matched with women with <3 live births and similar CHD and age (±5 years). New York Heart Association class (NYHA), and cardiac impairment on echocardiography, scored by a cardiologist blinded to parity, medication, and arrhythmia were compared.
For 58 women in 29 matched pairs mean age was 42.4 (SD 14.2). Pregnancy modified WHO risk score was mild (I,II) in 71% and moderate-severe (II-III-IV) in 29%. Mean number of births was 1.2 (SD 0.8) for <3 live births group, 5 (SD 2.3) for ≥3 live births group. Mean difference in live births between pairs was 3.8 (SD 2.5). Seventeen (58.6%) pairs had concordant NYHA for women with ≥3 live births and those with <3 live births. Echocardiography score was concordant in 19 (65.5%) pairs. Women with ≥3 live births had lower NYHA in 8 (27.6%) pairs and lower echocardiography scores in 6 (20.6%) pairs. Differences were not significant (p = 0.129, p = 0.801). No difference was found in medication use or arrhythmia.
Cardiac status was not different for women with mainly mild-moderate CHD when comparing women with ≥3 live births to those with <3 live births.
•Little is known on how several births affect cardiac status in women with CHD.•The study matched women with CHD and ≥3 children to similar women with <3 children.•On average there was a difference of 3.8 children between matched pairs.•Cardiac function by echo and NYHA class was found to be similar between groups.•In this study having more children did not seem to adversely affect cardiac status.
The greatest challenges facing healthcare systems include ensuring a sufficient supply of primary care physicians and physicians willing to work in rural or peripheral areas. Especially challenging ...is enticing young physicians to practice primary care in rural/peripheral areas. Identifying medical students interested in primary care and in residencies in Israel's periphery should aid the healthcare leadership. It may be particularly important to do so during the clinical years, as this is the stage at which many future physicians begin to crystallize their specialty and location preferences.
Questionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University - Hadassah School of Medicine, from 2010 to 2016, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and whether one-time monetary grants authorized in the 2011 physicians' union contract would attract students to residencies in the periphery.
Completed questionnaires were returned by 511 of 740 (69%) students. Ninety-eight (19%) were interested in a primary care residency, 184 (36%) were unsure and 229 (45%) were not interested. Students interested in primary care were significantly less interested in specialties that perform procedures/surgeries and in joining a medical school faculty, while being more inclined towards specialties dealing with social problems, controllable lifestyles and working limited hours. The percentage of students interested in primary care was stable during the study period. Forty-eight of the students indicated interest in residencies in the country's periphery, and 42% of them were also interested in primary care residencies. Overall, only 3.7% of students were interested in both a primary care residency and a residency in the periphery. Thirty percent of the students indicated that the monetary incentives tempted them to consider a residency in the periphery. Fifty-three percent of these students reported that they did not yet know the geographic area where they wished to do their residency, as compared to only 22% among those not interested in incentives.
This study provides the healthcare leadership with information on the characteristics of the students at a centrally-located medical school who tend to be more interested in primary care and in working in the periphery. Specifically, the study found that students interested in primary care desire a positive life/work balance, something that Israeli non-hospital primary care practice provides. Students considering residencies in the periphery were similarly inclined. Moreover, about a third of students had positive thoughts about monetary incentives for residencies in peripheral hospitals. These students should be identified early during their clinical experience so that attempts to recruit them to the periphery can commence before their specialty and location preferences have fully crystallized. Parallel studies should be performed at additional Israeli medical schools.
Israeli medical school classes include a number of student subgroups. Therefore, interventions aimed at recruiting medical students to the various specialties should to be tailored to each subgroup.
...Questionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University - Hadassah School of Medicine, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and the importance of finding a specialty interesting and challenging when choosing a residency.
Completed questionnaires were returned by 540 of 769 (70%) students. The decision processes for choosing a medical specialty and choosing a residency program were different. Family and colleagues had minimal influence on choosing a specialty, while family and their residential locality had much influence on choosing a residency, especially among women. Older age, marriage, and spousal influence were positively associated with choice of a specialty. Two-thirds of the students had completed military service, 20% were attending medical school prior to military service, 5% had completed national service and 9% had entered medical school without serving. Despite the pre-military subgroup being younger and having another 7 years of medical school, internship and military service before residency, they had begun thinking about which specialty to choose, just like the post-military students. When choosing a residency program, post-military women were more influenced by their families and family residential locality than their pre-military counterparts; differences ascribed to the older and often married post-military women having or wanting to begin families. This difference was reinforced by fewer post- than pre-military women willing to wait 2-3 years for a residency in the specialty that interested them most and were willing to begin residency immediately after internship in a specialty that interested them less.
Medical school classes are composed of various subgroups, each with its own characteristics. It is important to differentiate between choosing a specialty and a residency program. Choosing a specialty is a uniquely personal decision with some spousal influence among married students. It is of central importance even among pre-military students not slated to begin residency for many years. In contrast, choosing a residency program is influenced by family, where one grew up and other family-related considerations.
During their final year of medical school, Israeli students must consider which specialty to choose for residency. Based on the vocational counseling literature we presumed that choices are made by ...selecting from a cluster of related specialties while considering professional and socio-economic issues.
Questionnaires distributed to final-year medical students at two Israeli medical schools ascertained inclinations toward various medical specialties and the importance of various selection criteria. Analysis focused on seven specialties where >20% of students reported they had positive inclinations. For each such specialty, the specialty and selection criteria query were compared using unpaired two-tailed Student's t-tests to determine differences between students with positive inclinations toward the specialty with those not so inclined. These data were placed in tables, with the significant differences highlighted to facilitate visual recognition of cluster patterns.
Completed questionnaires were obtained from 317 of 455 students. Students often had positive inclinations toward more than one specialty (specialty clusters) associated with a group of selection criteria (selection criteria clusters). For example, interest in internal medicine was clustered with interest in internal medicine subspecialties, cardiology and research. Furthermore, there was a "reciprocal" aspect to some specialty cluster patterns. For example, those interested in internal medicine had little interest in surgical specialties. Selection criteria clusters revealed occupational interests and socio-environmental factors associated with the specialty clusters. For example, family medicine, which clustered with pediatrics and psychiatry, had a sub-cluster of: Bedside specialty with family orientation affording long-term patient care. Another sub-cluster was time for childrearing and family, only daytime work and outpatient care. Clusters also revealed students' perceptions that differed from expected: Cardiology is changing from a cognitive to a procedure-oriented subspecialty, clustering not only with internal medicine and its subspecialties but also with emergency medicine, surgical subspecialties and anesthesiology.
The concept that career choice involves selecting from a cluster of related specialties provides information about the specialties students might be considering. Moreover, students are not only looking for individual aspects of a specialty, but for a package including clusters of socio-economic and occupational features. Practically, examining clusters can help in career counseling of medical students and assist residency program directors in marketing their specialties.
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