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WASHINGTON – Antibiotics given in advance of gastric bypass surgery preferentially alter the microbiome, nudging it toward a more “lean” physiologic profile.

Given before a sleeve gastrectomy, vancomycin, which has little gut penetration, barely shifted the high ratio of Firmicutes to Bacteroidetes, a profile typically associated with obesity and insulin resistance. But cefazolin, which has much higher gut penetration, suppressed the presence of Firmicutes, which metabolize fat, and allowed the expansion of carbohydrate-loving Bacteroidetes – a profile generally seen in lean people.

Cyrus Jahansouz, MD, of the University of Minnesota, Minneapolis, and his colleagues wanted to examine whether a shift in preoperative antibiotics might affect the way the microbiome re-establishes itself in the wake of vertical sleeve gastrectomy. They enrolled 32 patients who were candidates for the procedure. None had undergone prior gastrointestinal surgery, and none had been exposed to antibiotics in the 3 months prior to bariatric surgery. They were similar in age, weight, body mass index, and fasting glucose. The mean HbA1c was about 6%.

Patients were randomized to three groups: maximal diet therapy (800 calories per day) without surgery; vertical sleeve gastrectomy with the usual preoperative antibiotic cefazolin and the postsurgical diet; and vertical sleeve gastrectomy with preoperative vancomycin and the postsurgical diet. All patients gave a fecal sample immediately before surgery and another one 6 days after surgery.

Preoperative cluster analysis of bacterial DNA showed that all of the samples had a similar composition, predominated by Firmicutes species (60%-70%). Bacteroidetes species made up about 20%-30%, with Proteobacteriae, Actinobacteriae, Verrucomicrobia, and other phyla comprising the remainder of the microbiome.

At the second sampling, the diet-only group showed no microbiome changes at all. The vancomycin group showed a very small but not significant expansion of Bacteroidetes and reduction of Firmicutes.

Patients in the cefazolin group showed a significant shift in the ratio – and it was quite striking, Dr. Jahansouz said. Among these patients, Firmicutes had decreased from 70% to 40% of the community. Bacteroidetes showed a corresponding shift, increasing from 20% of the community to 45%. The findings are quite surprising, he noted, considering that only one dose of antibiotic was associated with the changes and that they were evident within just a few days.

Although “a little hard to interpret” because of its small size and short follow-up, the study suggests that antibiotic choice might contribute to the success of weight-loss surgery, Dr. Jahansouz said at the annual clinical congress of the American College of Surgeons.

“There are still several factors in the perioperative period that we have to study to be able to identify what other things might have also influenced the shift,” he said in an interview. “But I do think that, in the future, these changes can be manipulated to benefit metabolic outcomes.”

Two phyla – Bacteroidetes and Firmicutes – dominate the human gut microbiome in a dynamic ratio that is highly associated with the way energy is extracted from food. Bacteroidetes species specialize in carbohydrate digestion and Firmicutes in fat digestion. “In a lean, insulin-sensitive state, Bacteroidetes dominates the human gut microbiome,” Dr. Jahansouz said. “With the progression of obesity and insulin resistance, there is a subsequent shift in the microbiome phenotype, favoring the growth of Firmicutes at the expense and reduction of Bacteroidetes. This is a significant change, because this obesity-associated phenotype has an increased capacity to harvest energy. It’s not the same for a lean person to consume 1,000 calories as it is for an obese person to consume them.”

Bariatric surgery has been shown to alter the gut microbiome, shifting it toward this more “lean” profile (Cell Metab. 2015 Aug 4;22[2]:228-38). This shift may be an important component of the still not fully elucidated mechanisms by which bariatric surgery causes weight loss and normalizes insulin signaling, Dr. Jahansouz said.

Dr. Jahansouz is following this group of patients to explore whether there are differences in weight loss and insulin signaling. He also will track whether the microbiome stabilizes at its early postsurgical profile, or continues to shift, either toward an even higher Bacteroidetes to Firmicutes ratio, or back to a more “obese” profile.

He and his colleagues are also investigating the effect of antibiotics and gastric bypass surgery in mouse models. “I can say that antibiotics seem to have a remarkable impact on the effect of mouse sleeve gastrectomy. We’re not quite there yet with humans,” but the data are compelling.

Dr. Jahansouz said that he had no financial disclosures.

msullivan@frontlinemedcom.com

On Twitter @Alz_Gal

WASHINGTON – Antibiotics given in advance of gastric bypass surgery preferentially alter the microbiome, nudging it toward a more “lean” physiologic profile.

Given before a sleeve gastrectomy, vancomycin, which has little gut penetration, barely shifted the high ratio of Firmicutes to Bacteroidetes, a profile typically associated with obesity and insulin resistance. But cefazolin, which has much higher gut penetration, suppressed the presence of Firmicutes, which metabolize fat, and allowed the expansion of carbohydrate-loving Bacteroidetes – a profile generally seen in lean people.

Cyrus Jahansouz, MD, of the University of Minnesota, Minneapolis, and his colleagues wanted to examine whether a shift in preoperative antibiotics might affect the way the microbiome re-establishes itself in the wake of vertical sleeve gastrectomy. They enrolled 32 patients who were candidates for the procedure. None had undergone prior gastrointestinal surgery, and none had been exposed to antibiotics in the 3 months prior to bariatric surgery. They were similar in age, weight, body mass index, and fasting glucose. The mean HbA1c was about 6%.

Patients were randomized to three groups: maximal diet therapy (800 calories per day) without surgery; vertical sleeve gastrectomy with the usual preoperative antibiotic cefazolin and the postsurgical diet; and vertical sleeve gastrectomy with preoperative vancomycin and the postsurgical diet. All patients gave a fecal sample immediately before surgery and another one 6 days after surgery.

Preoperative cluster analysis of bacterial DNA showed that all of the samples had a similar composition, predominated by Firmicutes species (60%-70%). Bacteroidetes species made up about 20%-30%, with Proteobacteriae, Actinobacteriae, Verrucomicrobia, and other phyla comprising the remainder of the microbiome.

At the second sampling, the diet-only group showed no microbiome changes at all. The vancomycin group showed a very small but not significant expansion of Bacteroidetes and reduction of Firmicutes.

Patients in the cefazolin group showed a significant shift in the ratio – and it was quite striking, Dr. Jahansouz said. Among these patients, Firmicutes had decreased from 70% to 40% of the community. Bacteroidetes showed a corresponding shift, increasing from 20% of the community to 45%. The findings are quite surprising, he noted, considering that only one dose of antibiotic was associated with the changes and that they were evident within just a few days.

Although “a little hard to interpret” because of its small size and short follow-up, the study suggests that antibiotic choice might contribute to the success of weight-loss surgery, Dr. Jahansouz said at the annual clinical congress of the American College of Surgeons.

“There are still several factors in the perioperative period that we have to study to be able to identify what other things might have also influenced the shift,” he said in an interview. “But I do think that, in the future, these changes can be manipulated to benefit metabolic outcomes.”

Two phyla – Bacteroidetes and Firmicutes – dominate the human gut microbiome in a dynamic ratio that is highly associated with the way energy is extracted from food. Bacteroidetes species specialize in carbohydrate digestion and Firmicutes in fat digestion. “In a lean, insulin-sensitive state, Bacteroidetes dominates the human gut microbiome,” Dr. Jahansouz said. “With the progression of obesity and insulin resistance, there is a subsequent shift in the microbiome phenotype, favoring the growth of Firmicutes at the expense and reduction of Bacteroidetes. This is a significant change, because this obesity-associated phenotype has an increased capacity to harvest energy. It’s not the same for a lean person to consume 1,000 calories as it is for an obese person to consume them.”

Bariatric surgery has been shown to alter the gut microbiome, shifting it toward this more “lean” profile (Cell Metab. 2015 Aug 4;22[2]:228-38). This shift may be an important component of the still not fully elucidated mechanisms by which bariatric surgery causes weight loss and normalizes insulin signaling, Dr. Jahansouz said.

Dr. Jahansouz is following this group of patients to explore whether there are differences in weight loss and insulin signaling. He also will track whether the microbiome stabilizes at its early postsurgical profile, or continues to shift, either toward an even higher Bacteroidetes to Firmicutes ratio, or back to a more “obese” profile.

He and his colleagues are also investigating the effect of antibiotics and gastric bypass surgery in mouse models. “I can say that antibiotics seem to have a remarkable impact on the effect of mouse sleeve gastrectomy. We’re not quite there yet with humans,” but the data are compelling.

Dr. Jahansouz said that he had no financial disclosures.

msullivan@frontlinemedcom.com

On Twitter @Alz_Gal

WASHINGTON – Antibiotics given in advance of gastric bypass surgery preferentially alter the microbiome, nudging it toward a more “lean” physiologic profile.

Given before a sleeve gastrectomy, vancomycin, which has little gut penetration, barely shifted the high ratio of Firmicutes to Bacteroidetes, a profile typically associated with obesity and insulin resistance. But cefazolin, which has much higher gut penetration, suppressed the presence of Firmicutes, which metabolize fat, and allowed the expansion of carbohydrate-loving Bacteroidetes – a profile generally seen in lean people.

Cyrus Jahansouz, MD, of the University of Minnesota, Minneapolis, and his colleagues wanted to examine whether a shift in preoperative antibiotics might affect the way the microbiome re-establishes itself in the wake of vertical sleeve gastrectomy. They enrolled 32 patients who were candidates for the procedure. None had undergone prior gastrointestinal surgery, and none had been exposed to antibiotics in the 3 months prior to bariatric surgery. They were similar in age, weight, body mass index, and fasting glucose. The mean HbA1c was about 6%.

Patients were randomized to three groups: maximal diet therapy (800 calories per day) without surgery; vertical sleeve gastrectomy with the usual preoperative antibiotic cefazolin and the postsurgical diet; and vertical sleeve gastrectomy with preoperative vancomycin and the postsurgical diet. All patients gave a fecal sample immediately before surgery and another one 6 days after surgery.

Preoperative cluster analysis of bacterial DNA showed that all of the samples had a similar composition, predominated by Firmicutes species (60%-70%). Bacteroidetes species made up about 20%-30%, with Proteobacteriae, Actinobacteriae, Verrucomicrobia, and other phyla comprising the remainder of the microbiome.

At the second sampling, the diet-only group showed no microbiome changes at all. The vancomycin group showed a very small but not significant expansion of Bacteroidetes and reduction of Firmicutes.

Patients in the cefazolin group showed a significant shift in the ratio – and it was quite striking, Dr. Jahansouz said. Among these patients, Firmicutes had decreased from 70% to 40% of the community. Bacteroidetes showed a corresponding shift, increasing from 20% of the community to 45%. The findings are quite surprising, he noted, considering that only one dose of antibiotic was associated with the changes and that they were evident within just a few days.

Although “a little hard to interpret” because of its small size and short follow-up, the study suggests that antibiotic choice might contribute to the success of weight-loss surgery, Dr. Jahansouz said at the annual clinical congress of the American College of Surgeons.

“There are still several factors in the perioperative period that we have to study to be able to identify what other things might have also influenced the shift,” he said in an interview. “But I do think that, in the future, these changes can be manipulated to benefit metabolic outcomes.”

Two phyla – Bacteroidetes and Firmicutes – dominate the human gut microbiome in a dynamic ratio that is highly associated with the way energy is extracted from food. Bacteroidetes species specialize in carbohydrate digestion and Firmicutes in fat digestion. “In a lean, insulin-sensitive state, Bacteroidetes dominates the human gut microbiome,” Dr. Jahansouz said. “With the progression of obesity and insulin resistance, there is a subsequent shift in the microbiome phenotype, favoring the growth of Firmicutes at the expense and reduction of Bacteroidetes. This is a significant change, because this obesity-associated phenotype has an increased capacity to harvest energy. It’s not the same for a lean person to consume 1,000 calories as it is for an obese person to consume them.”

Bariatric surgery has been shown to alter the gut microbiome, shifting it toward this more “lean” profile (Cell Metab. 2015 Aug 4;22[2]:228-38). This shift may be an important component of the still not fully elucidated mechanisms by which bariatric surgery causes weight loss and normalizes insulin signaling, Dr. Jahansouz said.

Dr. Jahansouz is following this group of patients to explore whether there are differences in weight loss and insulin signaling. He also will track whether the microbiome stabilizes at its early postsurgical profile, or continues to shift, either toward an even higher Bacteroidetes to Firmicutes ratio, or back to a more “obese” profile.

He and his colleagues are also investigating the effect of antibiotics and gastric bypass surgery in mouse models. “I can say that antibiotics seem to have a remarkable impact on the effect of mouse sleeve gastrectomy. We’re not quite there yet with humans,” but the data are compelling.

Dr. Jahansouz said that he had no financial disclosures.

msullivan@frontlinemedcom.com

On Twitter @Alz_Gal

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

Is your 42-year-old patient with well-controlled hypertension and type 2 diabetes dealing with a mood disorder that should be regarded as a psychiatric illness – or is she experiencing demoralization and grief?

In this installment of Mental Health Consult, the patient screens positive for depression but is ambivalent about taking antidepressants. In addition, the patient believes she has a number of coping resources that she can utilize. Finding out whether there is a need for an evidence-based psychotherapy, medication, or if other interventions are appropriate requires four key questions when taking a history.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

Is your 42-year-old patient with well-controlled hypertension and type 2 diabetes dealing with a mood disorder that should be regarded as a psychiatric illness – or is she experiencing demoralization and grief?

In this installment of Mental Health Consult, the patient screens positive for depression but is ambivalent about taking antidepressants. In addition, the patient believes she has a number of coping resources that she can utilize. Finding out whether there is a need for an evidence-based psychotherapy, medication, or if other interventions are appropriate requires four key questions when taking a history.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

Is your 42-year-old patient with well-controlled hypertension and type 2 diabetes dealing with a mood disorder that should be regarded as a psychiatric illness – or is she experiencing demoralization and grief?

In this installment of Mental Health Consult, the patient screens positive for depression but is ambivalent about taking antidepressants. In addition, the patient believes she has a number of coping resources that she can utilize. Finding out whether there is a need for an evidence-based psychotherapy, medication, or if other interventions are appropriate requires four key questions when taking a history.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

LAS VEGAS – Pay attention to GI symptoms in your scleroderma patients. Gut involvement in scleroderma, a result of vasculopathy and fibrosis affecting the GI tract, is common and can be debilitating, said Daniel Furst, MD.

Speaking at the annual Perspectives in Rheumatologic Diseases presented by the Global Academy for Medical Education, Dr. Furst said that the progression often begins at the mouth and esophagus, and progresses through the digestive system, eventually reaching the rectum and anus.

“You think about motility issues early on, in the esophagus,” and early oral symptoms can include mouth dryness, said Dr. Furst, who is associated with the University of California, Los Angeles, the University of Washington, Seattle, and the University of Florence (Italy).

As scleroderma begins to affect the midgut, Dr. Furst said that the secondary results of the decrease in motility are symptoms such as heartburn, nausea, vomiting, and early satiety.

“When you have a decrease in motility, then the normal ... housekeeping waves of the midgut and the colon are decreased,” he said. Bacteria from the colon can then invade the small bowel, causing overgrowth of the midgut by species not normally seen there. Not only gas, but also malnutrition can eventually result, he said.

When scleroderma affects the lower gut, patients can have bloating, diarrhea, and constipation, and finally, incontinence of the bowel, a condition with often devastating psychosocial consequences.

The choice of promotility agents depends on the area affected; erythromycin and metoclopramide help in the upper GI tract, while tegaserod can be helpful in the lower gut.

Global Academy for Medical Education and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Pay attention to GI symptoms in your scleroderma patients. Gut involvement in scleroderma, a result of vasculopathy and fibrosis affecting the GI tract, is common and can be debilitating, said Daniel Furst, MD.

Speaking at the annual Perspectives in Rheumatologic Diseases presented by the Global Academy for Medical Education, Dr. Furst said that the progression often begins at the mouth and esophagus, and progresses through the digestive system, eventually reaching the rectum and anus.

“You think about motility issues early on, in the esophagus,” and early oral symptoms can include mouth dryness, said Dr. Furst, who is associated with the University of California, Los Angeles, the University of Washington, Seattle, and the University of Florence (Italy).

As scleroderma begins to affect the midgut, Dr. Furst said that the secondary results of the decrease in motility are symptoms such as heartburn, nausea, vomiting, and early satiety.

“When you have a decrease in motility, then the normal ... housekeeping waves of the midgut and the colon are decreased,” he said. Bacteria from the colon can then invade the small bowel, causing overgrowth of the midgut by species not normally seen there. Not only gas, but also malnutrition can eventually result, he said.

When scleroderma affects the lower gut, patients can have bloating, diarrhea, and constipation, and finally, incontinence of the bowel, a condition with often devastating psychosocial consequences.

The choice of promotility agents depends on the area affected; erythromycin and metoclopramide help in the upper GI tract, while tegaserod can be helpful in the lower gut.

Global Academy for Medical Education and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Pay attention to GI symptoms in your scleroderma patients. Gut involvement in scleroderma, a result of vasculopathy and fibrosis affecting the GI tract, is common and can be debilitating, said Daniel Furst, MD.

Speaking at the annual Perspectives in Rheumatologic Diseases presented by the Global Academy for Medical Education, Dr. Furst said that the progression often begins at the mouth and esophagus, and progresses through the digestive system, eventually reaching the rectum and anus.

“You think about motility issues early on, in the esophagus,” and early oral symptoms can include mouth dryness, said Dr. Furst, who is associated with the University of California, Los Angeles, the University of Washington, Seattle, and the University of Florence (Italy).

As scleroderma begins to affect the midgut, Dr. Furst said that the secondary results of the decrease in motility are symptoms such as heartburn, nausea, vomiting, and early satiety.

“When you have a decrease in motility, then the normal ... housekeeping waves of the midgut and the colon are decreased,” he said. Bacteria from the colon can then invade the small bowel, causing overgrowth of the midgut by species not normally seen there. Not only gas, but also malnutrition can eventually result, he said.

When scleroderma affects the lower gut, patients can have bloating, diarrhea, and constipation, and finally, incontinence of the bowel, a condition with often devastating psychosocial consequences.

The choice of promotility agents depends on the area affected; erythromycin and metoclopramide help in the upper GI tract, while tegaserod can be helpful in the lower gut.

Global Academy for Medical Education and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Dermatologists need to be alert for amyotrophic dermatomyositis in patients with rash where lupus might be considered, because of the need for vigilant surveillance for cancer and lung disease in this population.

Ruth Ann Vleugels, MD, walked attendees through a series of dermatomyositis diagnostic pearls at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

“When a patient has dermatomyositis but doesn’t have muscle disease, you really have to rely on the skin findings,” since you’re lacking the tipoff of muscle disease at presentation, Dr. Vleugels, professor of dermatology at Brigham and Women’s Hospital, Boston, said in an interview. This is especially true because, on biopsy, “the pathological findings are identical to that of lupus,” she said.

Dr. Vleugels emphasized that it’s important not to miss a more subtle, less violaceous heliotrope eruption, especially in lighter-skinned patients; similarly, Gottron’s papules are not always papular and limited to the knuckle pads, but can be more macular and linear, with psoriasiform scaling. Nail findings such as dilated capillary loops with dystrophic and hypertrophied cuticles are also a big clue. Photodistributed erythema – the “shawl sign” – can be subtle, but offers additional support for a dermatomyositis diagnosis.

Though the erythematous midface rash of lupus resembles a dermatomyositis rash in many ways, there’s a critical differentiator of the two rashes, Dr. Vleugels said. “In dermatomyositis patients, it very classically hugs, or involves, the nasolabial folds, whereas in our systemic lupus patients, the erythema of the cheeks spares the nasolabial folds.”

Global Academy for Medical Education and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Dermatologists need to be alert for amyotrophic dermatomyositis in patients with rash where lupus might be considered, because of the need for vigilant surveillance for cancer and lung disease in this population.

Ruth Ann Vleugels, MD, walked attendees through a series of dermatomyositis diagnostic pearls at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

“When a patient has dermatomyositis but doesn’t have muscle disease, you really have to rely on the skin findings,” since you’re lacking the tipoff of muscle disease at presentation, Dr. Vleugels, professor of dermatology at Brigham and Women’s Hospital, Boston, said in an interview. This is especially true because, on biopsy, “the pathological findings are identical to that of lupus,” she said.

Dr. Vleugels emphasized that it’s important not to miss a more subtle, less violaceous heliotrope eruption, especially in lighter-skinned patients; similarly, Gottron’s papules are not always papular and limited to the knuckle pads, but can be more macular and linear, with psoriasiform scaling. Nail findings such as dilated capillary loops with dystrophic and hypertrophied cuticles are also a big clue. Photodistributed erythema – the “shawl sign” – can be subtle, but offers additional support for a dermatomyositis diagnosis.

Though the erythematous midface rash of lupus resembles a dermatomyositis rash in many ways, there’s a critical differentiator of the two rashes, Dr. Vleugels said. “In dermatomyositis patients, it very classically hugs, or involves, the nasolabial folds, whereas in our systemic lupus patients, the erythema of the cheeks spares the nasolabial folds.”

Global Academy for Medical Education and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Dermatologists need to be alert for amyotrophic dermatomyositis in patients with rash where lupus might be considered, because of the need for vigilant surveillance for cancer and lung disease in this population.

Ruth Ann Vleugels, MD, walked attendees through a series of dermatomyositis diagnostic pearls at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

“When a patient has dermatomyositis but doesn’t have muscle disease, you really have to rely on the skin findings,” since you’re lacking the tipoff of muscle disease at presentation, Dr. Vleugels, professor of dermatology at Brigham and Women’s Hospital, Boston, said in an interview. This is especially true because, on biopsy, “the pathological findings are identical to that of lupus,” she said.

Dr. Vleugels emphasized that it’s important not to miss a more subtle, less violaceous heliotrope eruption, especially in lighter-skinned patients; similarly, Gottron’s papules are not always papular and limited to the knuckle pads, but can be more macular and linear, with psoriasiform scaling. Nail findings such as dilated capillary loops with dystrophic and hypertrophied cuticles are also a big clue. Photodistributed erythema – the “shawl sign” – can be subtle, but offers additional support for a dermatomyositis diagnosis.

Though the erythematous midface rash of lupus resembles a dermatomyositis rash in many ways, there’s a critical differentiator of the two rashes, Dr. Vleugels said. “In dermatomyositis patients, it very classically hugs, or involves, the nasolabial folds, whereas in our systemic lupus patients, the erythema of the cheeks spares the nasolabial folds.”

Global Academy for Medical Education and this news organization are owned by the same parent company.

koakes@frontlinemedcom.com

On Twitter @karioakes