Early and Late Outcomes of Multiple Coronary Endarterectomy

Abstract Objectives: Coronary endarterectomy has been shown to be an effective adjunctive technique of revascularization for diffuse coronary artery disease. However, outcomes of multiple coronary endarterectomy (MCE) have not been well investigated. We sought to examine early and late results of this technique. Methods: Between January 1992 and June 2006, 58 consecutive patients underwent coronary endarterectomy in more than one coronary artery territories, representing 6.5% of total coronary endarterectomy during the same period. Early and late outcomes were retrospectively analyzed. Results: The mean age was 64 years. Forty‐one patients (70.7%) had coronary endarterectomy in the left anterior descending artery and right coronary artery territories; five (8.6%) in the left anterior descending artery and circumflex artery territories; eight (13.8%) in the circumflex artery and right coronary artery territories; and four (6.9%) in the left anterior descending artery, circumflex artery, and right coronary artery territories. Operative mortality was 12.1% (7/58). The incidence of perioperative myocardial infarction was 25.9% (15/58). The median length of hospital stay was seven days. Actuarial five‐ and 10‐year survivals were 64% and 36%, respectively. Conclusions: MCE may be a reasonable option for revascularization of multiple diffuse coronary artery disease. However, early and late outcomes are relatively poor and the indication should be carefully considered.     

The effects of prostate cancer on intimate relationships

Prostate cancer (PCA) represents an intensely ‘personal’ medical condition. PCA and its treatments affect intimate aspects of a man's bodily and psychological function, aspects that only the man himself and his partner can fully appreciate. There is growing evidence that the diagnosis of PCA has important adverse psychosocial effects on both the patient and his partner. An understanding of the ways in which a patient's female partner is affected by PCA is beginning to emerge. In this review several key issues for future psychosocial research are outlined and discussed: adjusting to the challenge of the PCA diagnosis, the impact on the couples’ relationship, the dilemma of treatment choice, the desire to conceal treatment side-effects, the effect of gender on the reaction of patients and female partners, and the unique problems facing same-sex couples. Pulling these issues together, the conclusion is drawn that psychosocial interventions designed to help the couple face this ‘relationship disease’ together are the most likely to be acceptable and effective for those affected by this common cancer.     

Periodontal disease and systemic health: current status

The relationship between poor oral health and systemic diseases has been increasingly recognized over the past two decades. Indeed, the clichés "You cannot have good general health without good oral health", "The mouth is part of the body" and "Floss or die", are gaining an increasing momentum. A large number of epidemiological studies have now linked poor oral health with cardiovascular diseases, poor glycaemic control in diabetics, low birthweight preterm babies and a variety of other conditions. The majority have shown an association, although not always strong. As a result, a number of meta-analyses have been conducted and have confirmed the associations and at the same time cautioned that further studies are required, particularly with regard to the effect of periodontal treatment in reducing risk. A number of biologically plausible mechanisms have been put forward to explain the association and there is accumulating evidence in support of them, although at this stage, insufficient to establish causality. Nevertheless, the relationship between poor oral health and systemic diseases has become a significant issue, such that adult oral health can no longer be ignored in overall health strategies. This review provides an update on current understanding of the contribution of poor oral health to systemic diseases, the possible mechanisms involved and the relevance of this for general dental practitioners.     

Television, physical activity, diet, and body weight status: the ARIC cohort

Objective

This study investigated the construct validity of a computerised self-assessment tool to measure psychological, social and environmental influences of young peoples' physical activity. First, analyses of the measure's factorial validity, invariance across, age, gender culture were conducted. Second, the ability of the derived subscales to discriminate between children representing different levels of self-reported and objectively measured physical activity behaviour was examined.

Methods

Participants were 1875 boys and 2078 girls (total = 3958) aged 9–10 years (n = 1955, mean age = 9.65 ± 0.42) and 15–16 years (n = 2003, mean age = 15.49 ± 0.50) from four European countries in Northern, Southern and Eastern Europe who took part in the European Youth Heart Study (EYHS). Children completed the computerised self-assessment tool with support from the researcher if requested. Self-reported exercise and an objective measure of physical activity (Actigraph model 7164) were used for additional construct validation purposes.

Results

Overall evidence of good fit indicating satisfactory factorial validity and cross-cultural, age and gender invariance for 3 of the 4 measurement models were obtained. The majority of measures were also significantly different for those with high versus low levels of physical activity.

Conclusion

Overall, the computerised questionnaire holds promise for use cross-culturally with male and female children and adolescents to measure perceived personal, social and environmental influences on physical activity. Further development of the measures pertaining to perceived environmental influences seems warranted.     

Cost-Effectiveness of Bariatric Surgery for Severely Obese Adults With Diabetes

OBJECTIVE

To analyze the cost-effectiveness of bariatric surgery in severely obese (BMI ≥35 kg/m²) adults who have diabetes, using a validated diabetes cost-effectiveness model.

RESEARCH DESIGN AND METHODS

We expanded the Centers for Disease Control and Prevention–RTI Diabetes Cost-Effectiveness Model to incorporate bariatric surgery. In this simulation model, bariatric surgery may lead to diabetes remission and reductions in other risk factors, which then lead to fewer diabetes complications and increased quality of life (QoL). Surgery is also associated with perioperative mortality and subsequent complications, and patients in remission may relapse to diabetes. We separately estimate the costs, quality-adjusted life-years (QALYs), and cost-effectiveness of gastric bypass surgery relative to usual diabetes care and of gastric banding surgery relative to usual diabetes care. We examine the cost-effectiveness of each type of surgery for severely obese individuals who are newly diagnosed with diabetes and for severely obese individuals with established diabetes.

RESULTS

In all analyses, bariatric surgery increased QALYs and increased costs. Bypass surgery had cost-effectiveness ratios of $7,000/QALY and $12,000/QALY for severely obese patients with newly diagnosed and established diabetes, respectively. Banding surgery had cost-effectiveness ratios of $11,000/QALY and $13,000/QALY for the respective groups. In sensitivity analyses, the cost-effectiveness ratios were most affected by assumptions about the direct gain in QoL from BMI loss following surgery.

CONCLUSIONS

Our analysis indicates that gastric bypass and gastric banding are cost-effective methods of reducing mortality and diabetes complications in severely obese adults with diabetes.In recent years, bariatric surgery has emerged as a popular treatment to reduce body weight and improve obesity-related complications, particularly in the diabetic population. Several studies have shown that surgery can lead to significant weight loss, with excess body weight reduced by >50% (1,2). Although weight loss declines over time, the Swedish Obese Subjects (SOS) Study found significant weight loss even 10 years after surgery (3,4). In addition to sustained weight loss, bariatric surgery may provide additional benefits to people with diabetes. Among severely obese patients with diabetes, bariatric surgery often leads to diabetes remission, with remission rates that are as high as 80% in the short run (1) and that remain significant in the long run (3,4).Although the evidence suggests that bariatric surgery is a successful long-term treatment of obesity for people with diabetes, it is an expensive procedure. The average cost of surgery exceeds $13,000 (5), with additional costs possible in the months following surgery (6). This raises the question of whether bariatric surgery is cost-effective for severely obese people with diabetes.Several studies have estimated the cost-effectiveness of bariatric surgery and found that surgery is either cost-effective (7–10) or that it leads to cost savings over time (6,11–13). The existing studies tend to be relatively simple, and only two (10,13) focus on people with diabetes. The studies generally do not model the microvascular complications associated with diabetes, the effect of surgery on blood pressure and cholesterol levels, or the resulting outcomes.This study used the Centers for Disease Control and Prevention (CDC)-RTI Diabetes Cost-Effectiveness Model to analyze the cost-effectiveness of bariatric surgery in severely obese adults with diabetes. We separately estimated the cost-effectiveness of gastric bypass surgery relative to usual diabetes care and the cost-effectiveness of gastric banding surgery relative to usual diabetes care. Gastric bypass and gastric banding are the two forms of bariatric surgery most commonly studied (1). We examined the cost-effectiveness of each type of surgery for severely obese people who are newly diagnosed with diabetes (no more than 5 years after diagnosis) and for people with established diabetes (at least 10 years after diagnosis).     

Weight gain in early life predicts risk of islet autoimmunity in children with a first-degree relative with type 1 diabetes

OBJECTIVE—In a prospective birth cohort study, we followed infants who had a first-degree relative with type 1 diabetes to investigate the relationship between early growth and infant feeding and the risk of islet autoimmunity.RESEARCH DESIGN AND METHODS—Infants with a first-degree relative with type 1 diabetes were identified during their mother''s pregnancy. Dietary intake was recorded prospectively to determine duration of breast-feeding and age at introduction of cow''s milk protein, cereals, meat, fruit, and vegetables. At 6-month reviews, length (or height) and weight, antibodies to insulin, GAD65, the tyrosine phosphatase-like insulinoma antigen, and tissue transglutaminase were measured. Islet autoimmunity was defined as persistent elevation of one or more islet antibodies at consecutive 6-month intervals, including the most recent measure, and was the primary outcome measure.RESULTS—Follow-up of 548 subjects for 5.7 ± 3.2 years identified 46 children with islet autoimmunity. Weight z score and BMI z score were continuous predictors of risk of islet autoimmunity (adjusted hazard ratios 1.43 [95% CI 1.10–1.84], P = 0.007, and 1.29 [1.01–1.67], P = 0.04, respectively). The risk of islet autoimmunity was greater in subjects with weight z score >0 than in those with weight z score ≤0 over time (2.61 [1.26–5.44], P = 0.01). Weight z score and BMI z score at 2 years and change in weight z score between birth and 2 years, but not dietary intake, also predicted risk of islet autoimmunity.CONCLUSIONS—Weight gain in early life predicts risk of islet autoimmunity in children with a first-degree relative with type 1 diabetes.Identical twin studies and geographic and temporal variations in incidence argue for a critical role of the environment in the development of type 1 diabetes (1). Environmental influences potentially initiate or accelerate the autoimmune destruction of the pancreatic islets. The incidence of type 1 diabetes is increasing in populations worldwide with an earlier age of onset described in European and Oceania populations (1). This rise in childhood incidence parallels in time the overweight/obesity epidemic in Western childhood populations.The accelerator hypothesis proposes that weight and associated insulin resistance accelerate loss of β-cells in both type 1 and type 2 diabetes, such that they are distinguished only by their rate of progression (2). Proposed accelerators include genes, insulin resistance, and autoimmunity. Although the full implications of this hypothesis are being debated, there is increasing evidence of the importance of weight, BMI, and relative insulin insensitivity in the development of type 1 diabetes. Younger age of onset of type 1 diabetes is associated with higher BMI at diagnosis in large cohorts (3), and in one study, the association was seen only in children with lower fasting C-peptide levels (4). We and others have shown that surrogate markers of insulin resistance and BMI predict progression to type 1 diabetes in subjects with islet autoimmunity (5,6). These findings support weight and relative insulin insensitivity as accelerating β-cell loss after the development of islet autoimmunity when insulin secretion is falling rather than before. However, only prospective studies from birth can resolve this question.Retrospective case-control studies in Europe link increased linear growth and weight gain in childhood, particularly in the first 2 years of life, with later onset of type 1 diabetes (7–9). In one study, infant growth was related to detection of tyrosine phosphatase-like insulinoma antigen (insulinoma-associated protein 2 [IA2]) antibodies at diagnosis (9). Reports from Scandinavia, Germany, and Colorado in the U.S. and our own data have provided prospective data from birth (10–17), but there are no data examining the effect of weight gain on the development of islet autoimmunity or type 1 diabetes in birth cohort studies. Diet, in terms of introduction and intake of cow''s milk protein, cereals, ω-3 fatty acids, fruits, and root vegetables, is a putative influence on the development of islet autoimmunity (12–17).The Australian Baby Diab Study has prospectively followed from birth infants who have a first-degree relative with type 1 diabetes and live in Victoria or South Australia (10,11). We aimed to investigate the relationship between early growth (weight, length, and height gain) and infant feeding and the risk of development of islet autoimmunity.