Metabolic Characterization of Nondiabetic Severely Obese Patients Undergoing Roux-en-Y Gastric Bypass: Preoperative Classification Predicts the Effects of Gastric Bypass on Insulin–Glucose Homeostasis

Introduction Obese individuals may have normal insulin–glucose homeostasis, insulin resistance, or diabetes mellitus. Whereas gastric bypass cures insulin resistance and diabetes mellitus, its effects on normal physiology have not been described. We studied insulin resistance and β-cell function for patients undergoing gastric bypass. Methods One hundred thirty-eight patients undergoing gastric bypass had fasting insulin and glucose levels drawn on days 0, 12, 40, 180, and 365. Thirty-one (22%) patients with diabetes mellitus were excluded from this analysis. Homeostatic model of assessment was used to estimate insulin resistance, insulin sensitivity, and β-cell function. Based on this model, patients were categorized as high insulin resistance if their insulin resistance was >2.3. Results Body mass index did not correlate with insulin resistance. Forty-seven (34%) patients were categorized as high insulin resistance. Correction of insulin resistance for this group occurred by 12 days postoperatively. Sixty (43%) patients were categorized as low insulin resistance. They demonstrated an increase of β-cell function by 12 days postoperatively, which returned to baseline by 6 months. At 1 year postoperatively, the low insulin resistance group had significantly higher β-cell function per degree of insulin sensitivity. Conclusions Adipose mass alone cannot explain insulin resistance. Severely obese individuals can be categorized by degree of insulin resistance, and the effect of gastric bypass depends upon this preoperative physiology.     

Post-operative esophageal leak treated with removable silicone-covered polyester stent

Self-expanding removable covered stents are increasingly being used for the treatment of benign esophageal diseases such as leaks or perforations and stenosis. They are easy to place and remove and good outcomes have been reported. We report a case of a postoperative esophageal leak successfully managed with a removable silicone-covered polyester stent.     

National survey of ethical issues presented to drug information centers

Whether and how drug information centers respond to calls from the public that involve ethical issues was studied. A survey describing six ethical dilemmas typical of those presented by calls from the public was mailed to pharmacists in 154 drug information centers to see how the questions would be handled. Centers that had written policies governing responses to questions with ethical implications were asked to submit those policies. One hundred twenty-six centers (82%) responded to the survey; of these, 81 (64.3%) answered questions from the public. There were no significant differences in characteristics between centers that did and did not respond to public calls. The case analyses, completed only by pharmacists in centers that responded to public calls, covered such issues as invasion of privacy, social responsibility, personal liability, and interference with the patient-physician relationship. Respondents exercised a wide degree of discretion in determining if they would answer a question; for example, while only 4% would not answer a question concerning the efficacy of a weight-loss diet patch, 77% reported they would not respond to a caller asking for information on drugs that could interfere with the results of a polygraph test. Although respondents often cited institutional policy as the reason for failing to respond to a question, none submitted a copy of such a policy. The pharmacists' responses indicated a high degree of moral and social sensitivity; nonetheless, written policies should be developed to assist drug information center staff members in handling questions that have ethical implications.     

Transduodenal Sphincteroplasty and Transampullary Septectomy for Papillary Stenosis

Twenty patients received transduodenal sphincteroplasty and transampullary septectomy between 1987 and 1993. Seven patients had post-cholecystectomy pain which was much improved or abolished in 5 of 7 patients at a mean follow-up of 4 years and 5 months. Four of five patients with chronic pancreatitis were improved at 3 years and 2 months. Three of five patients with recurrent acute pancreatitis were improved at 4 years and 5 months. One of three patients with chronic abdominal pain of hepatobiliary origin was improved at 3 years. Transduodenal sphincteroplasty and transampullary septectomy can relieve pain in patients with post-cholecystectomy pain, recurrent acute pancreatitis, chronic pancreatitis, and chronic abdominal pain of hepatobiliary origin, presumably by improving drainage of the obstructed ducts.     

Closed neural tube defects: neurologic, orthopedic, and gait outcomes.

PURPOSE: The purpose of our study was to obtain a clear understanding of the various diagnoses within the closed neural tube defect (NTD) groups included in the large database of clients in our Spina Bifida Clinic and a clear picture of the outcomes for the various NTD groups. METHODS: One hundred and four clients with closed NTD were categorized using a classification system devised by Tortori-Donati et al. Various clinical markers were investigated, including ambulation and the need for orthoses and wheelchairs. RESULTS: Most clients are ambulatory, requiring an orthoses, but not a wheelchair, despite the high incidence of ankle/foot abnormalities. CONCLUSIONS: This classification system has enhanced our knowledge of this group of clients, provided a greater understanding of the varied outcomes of these children and clinical management required.     

Beta 2 transferrin application in otology.

The diagnosis and management of perilymphatic fistula has received considerable attention in recent years. Despite the use of sophisticated technology, the diagnosis of perilymphatic fistula continues to rest primarily upon clinical suspicion and the exclusion of other disorders. In addition, the confirmation of a perilymphatic fistula during surgical exploration is usually based upon the subjective observation of fluid pooling in niches of the middle ear. A sensitive and objective laboratory test for identifying perilymph in the middle ear would be a useful adjunct for the diagnosis and management of perilymphatic fistula. The objective of this paper is to demonstrate the potential utility of beta 2 (beta 2) transferrin assay in the diagnosis of perilymphatic fistula. To accomplish this objective, we confirmed that beta 2 transferrin is present in living human perilymph and is absent in the normal or inflamed middle ear. In addition, the utility of beta 2 transferrin assay in the diagnosis of cerebrospinal fluid otorrhea is presented.