Looking Beyond Age and Co-morbidities as Predictors of Outcomes in Paraesophageal Hernia Repair

Introduction  Paraesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially modifiable variables leading to improved outcomes. Methods  We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database over a 5-year period (2001–2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality. Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary, and thromboembolic events, (VTE)). Results  Of the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients, while adjustment for cardiac complications or pneumothorax did not eliminate the difference. Conclusions  While PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events.     

Suboptimal Weight Loss after Gastric Bypass Surgery: Correlation of Demographics, Comorbidities, and Insurance Status with Outcomes

Although Roux-en-Y gastric bypass surgery (RYGBP) is safe and effective at achieving weight loss in the majority of severely obese patients, a subset fails to achieve expected weight loss outcomes. Factors associated with poor weight loss are not well defined. Patients undergoing open RYGBP using a standardized surgical technique and clinical pathway by a single surgeon at a dedicated bariatric center were reviewed. Suboptimal weight loss was defined as failure to lose at least 40% excess body weight by 12 months postoperatively. Of 555 consecutive patients who underwent RYGBP from 1999 to 2004, a 12-month follow-up was available for the 495 (89%). Suboptimal weight loss occurred in 55 (11%) and was associated on unadjusted bivariate analysis with increased body mass index (BMI; p = 0.0002), diabetes mellitus (p = 0.0002), Medicaid insurance (p = 0.04), and male sex (p = 0.01). On adjusted multivariate analysis, increased BMI (p = 0.003), diabetes (p = 0.002), and male gender (p = 0.04) were associated with suboptimal weight loss, but type of insurance (p = 0.11) was not. Medicaid patients were younger (p = 0.01) and had higher BMI (p = 0.0002). Suboptimal weight loss after RYGBP appears to be associated with greater BMI, male sex, and diabetes but not type of insurance. This study may help identify patients who could benefit from increased perioperative education and counseling or selection of procedures with greater malabsorption. Presented at the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington DC, May 19–24, 2007.     

Does perioperative use of aprotinin reduce the rejection rate in heart transplant recipients?

Objective: Allograft rejection continues to be one of the most common causes of mortality after heart transplantation. We investigated if perioperative use of antifibrinolytics such as aprotinin and tranexamic acid can decrease the rate of rejection after heart transplant and their effect on transfusion. Methods: A retrospective analysis was conducted on the data from patients who received a first heart transplant at Papworth Hospital between 2000 and 2005. Transplant registry and audit data were used for the study. Rejection biopsy results and treatment were used to designate rejection episodes as mild (grades 1A, 1B or 2 untreated) or severe (grades 2 treated, grades 3 and 4). The relationship between antifibrinolytics and rejection episodes was assessed using univariate and multiple Poisson regression. Kaplan–Meier methods and Kruskal–Wallis tests, respectively, were used to analyse survival/time to first rejection and transfusion. Results: There were 225 patients who underwent a first heart transplant between January 2000 and December 2005. Of these, 101 patients (44.9%) had received aprotinin, 63 (28.0%) tranexamic acid, 2 (0.9%) both (aprotinin and tranexamic acid) and 59 (26.2%) no antifibrinolytics. There was no difference in time to first rejection by antifibrinolytic treatment (p = 0.20). There was no difference in the rate of treated rejection per 100 patient-days between aprotinin and tranexamic acid groups between 0 and 3 months post-transplant, (0.6 in both), but aprotinin had a small clinical effect when compared to no treatment (0.6 vs 0.8, p = 0.54). Between 4 and 6 months, the treated and severe rejection rates were lower in the patients receiving aprotinin as compared to those receiving tranexamic acid, but these differences again did not reach statistical significance (0.1 vs 0.3, p = 0.14, 0.2 vs 0.4, p = 0.18). Aprotinin was associated with higher postoperative blood loss and transfusion requirements in the subgroup of patients that had a ventricular assist device, prior sternotomy or anticoagulant therapy. Conclusions: The use of aprotinin in heart transplant surgery may be associated with a small decrease in the incidence of treated/severe rejection within 6 months of transplantation. The perioperative use of antifibrinolytics did not influence time to first rejection or reduce blood transfusion.     

Distortion product emissions and sensorineural hearing loss

Distortion product emissions (DPEs) are intimately linked to normal outer hair cell function. Outer hair cell function is itself intimately linked with normal auditory thresholds. We sought to correlate frequency-specific DPE measurements with auditory thresholds, in seven frequency regions from 700 Hz to 6 kHz, in each of 21 ears. Eleven of these ears had thresholds below 25 dB SPL at every test frequency, whereas 10 ears demonstrated some degree of purely sensorineural hearing loss. An analysis of the correlation between DPE measurements and sensory thresholds suggests that DPE measures can predict frequency-specific auditory thresholds to within 10 dB over a range of sensory thresholds from 0 dB SPL to 60 dB SPL. Distortion product emissions promise to provide an objective, non-invasive measure of sensory thresholds. The clinical value of DPE measurement is enhanced by that fact that it is brief and requires minimal subject participation. A clinical test based on the DPE measurement will not displace conventional audiometry or auditory brain stem response measurement. It promises to provide new information about cochlear function to both the clinician and auditory physiologist.     

Pharmaceutical Company Websites as Sources of Information for Consumers

Although the advantages of disseminating health information on the world wide web are well recognized, there has been considerable concern about the quality of online information. There has also been some debate as to whether organizations with a vested interest in a product, such as pharmaceutical companies, can provide balanced and appropriate information on the web. However, there is very little published information about the content, quality or impact of pharmaceutical websites. This paper considers the issues, arguments and empirical evidence for and against the practice of direct-to-consumer advertising by pharmaceutical companies. It also describes a selected set of pharmaceutical company sites that provide consumer information about major public health problems or about health conditions corresponding to frequently used search engine terms. The pharmaceutical sites surveyed were characterized both by positive attributes (such as a breadth and depth of information, specification of medication adverse effects, and inclusion of potentially useful consumer aids such as symptom diaries and screening tests) and negative features (such as failure to disclose authorship and scientific sources, failure to provide clear and accessible information about the absolute and relative efficacy of the treatments mentioned, and absence of an editorial board or independent review process).We note that these attributes are not necessarily indicative of the quality of the content or the utility of websites and argue that there is a need for systematic studies comparing the accuracy of the content of pharmaceutical sites and nonpharmaceutical sites. Such studies would need to be conducted by content experts using evidence-based information as a gold standard. Many consumers are not in a position to assess the quality of the content of pharmaceutical sites and do not place a high level of trust in pharmaceutical companies. We suggest that it might be in the interests of the companies to encourage the independent review and certification of their sites. A consortium of companies could contribute funds to an independent authority that in turn could contract third party content evaluators to undertake quality assessments of pharmaceutical sites. In the future, initiatives such as the MedCERTAIN collaboration might provide consumers with certification information on a range of health sites including pharmaceutical websites. Not only would such evaluations provide a means for consumers to identify high quality sites, they might also assist pharmaceutical companies to optimize the quality and credibility of the health information they provide on the web.     

Prevalence and predictors of postoperative thiamine deficiency after vertical sleeve gastrectomy

Background

As the vertical sleeve gastrectomy (VSG) becomes increasingly popular, its effect on postoperative micronutrient levels, such as thiamine, becomes more important. We previously found a 1.8% prevalence of thiamine deficiency in bariatric patients before surgery.

FISH Diagnosis of 22q11.2 Deletion Syndrome

The 22q11.2 deletion syndrome is the most common microdeletion syndrome. Although once thought to be separate disorders, cardiac anomalies, abnormal face, thymic hypoplasia, cleft palate, hypocalcemia, and chromosome 22 deletions (CATCH 22); DiGeorge syndrome; velocardiofacial syndrome; and conotruncal anomaly face syndrome are now known to be part of the same 22q11.2 deletion syndrome. Diagnosis of this syndrome is extremely challenging because of wide variability in phenotypic presentations. When the deletion is suspected, genetic testing is typically ordered. Conventional karyotyping is only capable of detecting a small percentage of chromosome deletions. However, fluorescence in situ hybridization (FISH) is capable of detecting many deletions and microdeletions. This article discusses the pathophysiology and presentation of chromosome 22q11.2 deletion syndrome. The use of FISH as a diagnostic tool is also described, including the FISH process, its use, and its accuracy and reliability in the diagnosis of chromosome 22q11.2 deletion syndrome in the fetus and/or newborn.     

Cardiac ischaemic stress: cardiomyocyte Ca²⁺, sex and sex steroids

1. Important sex differences exist in ischaemic heart disease. Oestrogen has been conventionally regarded as providing a cardioprotective benefit and testosterone frequently perceived to exert a deleterious effect. However, there is accumulating evidence that argues against this simple dichotomy, suggesting that the influence of oestrogen and testosterone conferring benefit or detriment may be context specific. 2. Cardiomyocyte calcium (Ca(2+)) loading is recognized to be a major factor in acute ischaemia-reperfusion pathology, promoting cell death, contractile dysfunction and arrhythmogenic activity. Ca(2+)/calmodulin-dependent kinase II (CaMKII) is a mediator of many of the cardiomyocyte Ca(2+)-related pathologies in ischaemia-reperfusion. Cardiomyocyte Ca(2+)-handling processes have been shown to be modulated by the actions of oestrogen and testosterone. A role for these sex steroids in influencing CaMKII activation is argued. 3. Although many experimental studies of oestrogen manipulation can identify a cardioprotective role for this sex steroid, there are also numerous reports that fail to demonstrate sex differences in postischaemic recovery. Experimental studies report that testosterone can be protective in ischaemia-reperfusion in males and females in some settings. 4. Further studies of sex steroid influence in the ischaemic heart will allow the development of therapeutic interventions that are specifically targeted for male and female hearts.