Obesity surgery registrations in the NPR and SOReg have high accuracy and are reliable sources of data to identify patients having undergone obesity surgery. When it is of importance to distinguish between specific surgical procedures, non-gastric bypass surgeries in the NPR should ideally be supplemented with data from other sources.

BackgroundOne-fourth of children with cerebral malaria (CM) retain cognitive sequelae up to 2 years after acute disease. The kynurenine pathway of the brain, forming neuroactive metabolites, e.g. the NMDA-receptor antagonist kynurenic acid (KYNA), has been implicated in long-term cognitive dysfunction in other CNS infections. In the present study, the association between the kynurenine pathway and neurologic/cognitive complications in children with CM was investigated.MethodsCerebrospinal fluid (CSF) concentrations of KYNA and its precursor kynurenine in 69 Ugandan children admitted for CM to Mulago Hospital, Kampala, Uganda, between 2008 and 2013 were assessed. CSF kynurenine and KYNA were compared to CSF cytokine levels, acute and long-term neurologic complications, and long-term cognitive impairments. CSF kynurenine and KYNA from eight Swedish children without neurological or infectious disease admitted to Astrid Lindgren’s Children’s Hospital were quantified and used for comparison.ResultsChildren with CM had significantly higher CSF concentration of kynurenine and KYNA than Swedish children (P < 0.0001 for both), and CSF kynurenine and KYNA were positively correlated. In children with CM, CSF kynurenine and KYNA concentrations were associated with coma duration in children of all ages (P = 0.003 and 0.04, respectively), and CSF kynurenine concentrations were associated with worse overall cognition (P = 0.056) and attention (P = 0.003) at 12-month follow-up in children ≥5 years old.ConclusionsCSF KYNA and kynurenine are elevated in children with CM, indicating an inhibition of glutamatergic and cholinergic signaling. This inhibition may lead acutely to prolonged coma and long-term to impairment of attention and cognition.

Background: Gastric bypass is considered an effective treatment of co-existing gastro-oesophageal reflux (GERD) and obesity. Previous studies have had small sample sizes, short follow-up or substantial loss to follow-up. Aim:To assess the long-term risk of remaining/recurring reflux symptoms after gastric bypass. Methods:This was a nationwide cohort study of all adults with preoperative reflux who underwent gastric bypass in Sweden between 2006 and 2015, with complete follow-up through 2016. The outcome was remaining/recurring reflux symptoms, defined as use of proton pump inhibitors or histamine-2 receptor antagonists for >6 months after surgery. Cumulative incidence and risk factors of reflux were assessed with multivariable Poisson regression.Results: Among 2454 participants (81.7% female; mean age: 46.1 years, SD: 9.8 years), who were followed for median 4.6 years (interquartile range: 3.1-6.3 years), reflux recurred in 48.8% (95% confidence interval [95% CI], 46.8-51.0) of participants within 2 years of gastric bypass and remained stable up to 10 years after surgery (yearly change in incidence rate ratio [IRR] of 1.00; 95% CI, 0.99-1.02). Risk factors for recurring reflux were high preoperative dose of anti-reflux medication (IRR 1.77; 95% CI, 1.60-1.96 compared with low dose), older age (IRR 1.12; 95% CI 1.02-1.24 comparing age >50 with <40 years), female sex (IRR 1.28; 95% CI, 1.16-1.42) and comorbidity (IRR 1.26; 95% CI, 1.14-1.39 comparing Charlson Comorbidity Index ≥2 with 0). Conclusions:Reflux symptoms decrease rapidly after gastric bypass, but around half of operated patients require continuous anti-reflux medication. The treatment efficacy of gastric bypass on reflux symptoms might have been overestimated.

Background and aim: Clinical guidelines recommend endoscopy surveillance at given intervals or endoscopic therapy for Barrett's esophagus with low-grade dysplasia (LGD) and high-grade dysplasia (HGD). Whether these guidelines are followed in clinical practice is unknown and was assessed in this study. Methods: This nationwide Swedish cohort study included patients with Barrett's esophagus with histologically verified LGD or HGD from 50 centers in 2006-2013. These patients were followed up using nationwide registers. Adherence to clinical guidelines was explored. Eight potential risk factors for deviation from guidelines were assessed using multivariable logistic regression, providing adjusted odds ratios (OR) with 95% confidence intervals (95%CI). Results: Among 211 patients with Barrett's esophagus (mean age 67.0 years, standard deviation 9.7 years, 81% male), 71% had LGD and 29% had HGD. During median 3.9 years of follow-up, 84% underwent a follow-up endoscopy, 17% received endoscopic therapy and 8% underwent esophagectomy. The clinical management deviated from guidelines in 60% of all patients (69% in LGD and 39% in HGD), which was mainly due to under-surveillance (86%). Risk factors for deviation from guidelines were LGD compared to HGD (OR 3.4, 95%CI 1.7-6.8), longer Barrett's segment length (OR 2.0, 95%CI 1.0-3.9, comparing 3 cm with <3 cm), and treatment at gastroenterology compared to surgery departments (OR 2.3,. Age, sex, calendar period and university hospital status were not associated with deviation from surveillance guidelines. Conclusions: Adherence to guidelines for dysplastic Barrett's esophagus is poor, particularly for LGD. Efforts to implement clinical guideline recommendations are needed. ARTICLE HISTORY

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Background Individuals with Barrett’s esophagus (BE) are at increased risk of high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC), but the cost-effectiveness of general surveillance of BE is low. This study aimed to identify a risk prediction model for tumor progression in individuals with BE based on age, sex, and risk factors found at upper endoscopy, enabling tailored surveillance. Methods This nested case–control study originated from a cohort of 8171 adults diagnosed with BE in 2006–2013 in the Swedish Patient Registry. Cases had EAC/HGD ( n = 279) as identified from the Swedish Cancer Registry, whereas controls had no EAC/HGD ( n = 1089). Findings from endoscopy and histopathology reports were extracted from medical records at 71 Swedish hospitals and from the Swedish Patient Registry. Multivariable logistic regression provided odds ratios (OR) with 95% confidence intervals (CIs). Results Older age (OR 1.02 [95% CI 1.01–1.03] per year), male sex (OR 2.8 [95% CI 1.9–4.1]), and increasing maximum BE length (OR 2.3 [95% CI 1.4–3.9] for segments 3–8 cm and OR 4.3 [95% CI 2.5–7.2] for segments ≥ 8 cm) increased the risk of EAC/HGD, while the circumferential extent of the BE, hiatal hernia or reflux esophagitis did not. A model based on age, sex, and maximum BE length predicted 71% of all EAC/HGD cases. Conclusions A simple combination of the variables age, sex and maximum BE length showed fairly good accuracy for predicting tumor progression in BE. This clinical risk prediction model may help to tailor future surveillance programs. Electronic supplementary material The online version of this article (10.1007/s00464-018-6590-5) contains supplementary material, which is available to authorized users.

Aims We compared the incidence of cardiovascular disease (CVD) in transgender participants with a diagnosis of gender dysphoria (GD) with and without gender-affirming hormone therapy (GAHT) to the incidence observed in the general population. Methods and Results The population-based cohort included all individuals &gt;10 years in Sweden linked to Swedish nationwide healthcare Registers (2006-2016). Two comparator groups without GD/GAHT were matched (1:10) on age, county of residence, and on male and female birth-assigned sex, respectively. Cox proportional models provided hazard ratios (HR) and 95% confidence intervals (CI) for CVD outcomes. Among 1779 transgender individuals (48% birth-assigned males [AMAB], 52% birth-assigned females [AFAB]) 18 developed CVD, most of which were conduction disorders. The incidence of CVD for AFAB individuals with GD was 3.7 per 1000 person-years (95%CI: 1.4-10.0). AMAB individuals with GD had an incidence of CVD event of 7.1 per 1000 person-years (95%CI: 4.2-12.0). The risk of CVD event was 2.4 times higher in AMAB individuals (HR: 2.4, 95%CI: 1.3-4.2) compared to cisgender women, and 1.7 higher compared to cisgender men (HR: 1.7, 95%CI: 1.0-2.9). Analysis limited to transgender individuals without GAHT yielded similar results to those with GAHT treatment. Conclusion The incidence of CVD among GD/GAHT individuals was low, although increased compared to matched individuals without GD and similar to the incidence among GD/no GAHT individuals, thus not lending support for a causal relationship between treatment and CVD outcomes. Larger studies with longer follow-up are needed to verify these findings, as well as possible effect modification by comorbidity.

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