Anastomotic stenosis after Roux-en-Y gastric bypass: A rational approach to treatment.

BACKGROUND: Anastomotic stenosis, a common sequela to Roux-en-Y gastric bypass, has a reported incidence of 1.6-27% and recurs in 17-33%. No universal guidelines for optimal treatment exist. The aim of this study was to develop guidelines to treat stenosis that achieve the lowest rate of recurrence while avoiding the complications of excessive dilation. METHODS: This prospective 2-part study enlisted consecutive patients undergoing Roux-en-Y gastric bypass who developed an anastomotic stenosis. In the first part, all patients, regardless of the grade of stenosis, underwent dilation to 12 mm and were followed up for recurrence. In the second part, patients underwent dilation according to the grade of stenosis (12 mm for low, 13.5 mm for medium, 15 mm for high) and were followed up for recurrence. RESULTS: Among 1345 consecutive Roux-en-Y gastric bypass patients, 204 developed an anastomotic stenosis (15.2%). No differences were found in gender, mean age, preoperative body mass index, or weight loss at 1 year. In part 1, the recurrence rate for low-, medium-, and high-grade stenosis was 2.6%, 34.4%, and 35.9%. In part 2, the corresponding rates were 9.7%, 26.3%, and 43.6%. The corresponding mean number of additional dilations per patient with recurrence in part 1 was 1.0, 1.5, and 2.1 and, in part 2, were 1.0, 1.0 and 1.2. CONCLUSION: The results of this study have shown that the stenosis grade can predict the risk of recurrence and determine the optimal balloon size. Definitive treatment was achieved in >90% of patients with low-grade stenosis dilated to 12 mm. Medium- and high-grade stenosis predicted > or =25% recurrence, but increasing the balloon size reduced the number of additional dilations required for patients with recurrence.     

Physical activity and quality of life in older adults: Influence of health status and self-efficacy

Background: Physical activity has been positively linked to quality of life (QOL) in older adults. Measures of health status and global well-being represent common methods of assessing QOL outcomes, yet little has been done to determine the nature of the relationship of these outcomes with physical activity.Purpose: We examined the roles played by physical activity, health status, and self-efficacy in global QOL (satisfaction with life) in a sample of older Black and White women.Method: Participants (N = 249, M age = 68.12 years) completed multiple indicators of physical activity, self-efficacy, health status, and QOL at baseline of a 24-month prospective trial. Structural equation modeling examined the fit of 3 models of the physical activity and QOL relationship.Results: Analyses indicated that relationships between physical activity and QOL, self-efficacy and QOL were all indirect. Specifically, physical activity influenced self-efficacy and QOL through physical and mental health status, which in turn influenced global QOL.Conclusions: Our findings support a social cognitives model of physical activity’s relationship with QOL. Subsequent tests of hypothesized relationships across time are recommended. Funding for this study was provided by the National Institute on Aging (Grant AG 20118). We extend our sincere appreciation to April Bell for all of her efforts on this project.     

Postprandial acid reflux is reduced by delayed gastric emptying.

The aim of this study was to investigate influence of delayed gastric emptying on postprandial reflux in esophageal pH. Sixty-nine consecutive patients underwent 24 hour (h) esophageal pH monitoring and gastric emptying. In 24 h esophageal pH monitoring, % postprandial reflux pH<4 for 2 h after each meal (% PRT) was extracted from the 24 h pH profile. After solid test meal (1 mCi, Tc99m) was given, gastric emptying was measured with a gamma detector placed transnasally 5 cm below lower esophageal sphincter. % PRT was similar among the 34 normal, 26 delayed and 9 rapid gastric emptying rate patients. Thirty-five with a positive pH study and 34 with a negative had a similar prevalence of gastric emptying disorder. In the positive pH study group, patients with normal gastric emptying had significantly higher % PRT than those with delayed gastric emptying (22.0 vs 12.1%, P<0.05). In the same population, patients with a normal %PRT had a significantly higher prevalence of delayed gastric emptying compared with those with a positive % PRT (6/8 vs 9/27, P<0.05). In patient with abnormal acid exposure but normal % PRT on 24 h esophageal pH monitoring, gastric emptying may be delayed.     

A "grapple hook" technique using a deflectable tip catheter to facilitate complex proximal circumflex interventions.

We present two patients with angulated, proximal left circumflex lesions, one a chronic total occlusion and one an acute subtotal occlusion. In both cases, use of the deflectable tip Venture Catheter (Velocimed, Minneapolis, MN) facilitated guide wire passage and successful percutaneous coronary intervention (PCI) after prior attempts at guide wire passage with standard wires were unsuccessful.     

Necrotizing staphylococcal pneumonia in a neonate.

Hospitalized neonates are commonly colonized soon after birth with Staphylococcus aureus. The majority of neonates do not develop infectious sequelae; however, premature neonates appear to be more susceptible to serious infections, such as pneumonia. We report a case of an extremely low birth weight infant who developed necrotizing pneumonia due to methicillin-resistant Staphylococcal aureus (MRSA). The MRSA isolate from this neonate is identical to the strains that have been causing primarily community-associated skin and soft tissue infections. The severe course of this patient may be attributed to the presence of the Panton-Valentine leukocidin gene, a well-known virulence factor leading to soft tissue and pulmonary infections.     

Therapeutic challenges in hepatitis C-infected injection drug using patients

Hepatitis C Viral (HCV) infection in the injection drug user (IDU) population is a major medical concern. Concurrent substance abuse, co-morbid mental health conditions, poor socioeconomic status and a complex treatment protocol that is often incompatible with the life styles of IDUs combine to account for poor uptake and completion of HCV treatment. This article discusses HCV antiviral treatment issues relevant to IDUs chronically infected with this virus. The effect of non-injected substances of abuse on treatment outcome is considered. Priority issues requiring research are discussed.     

Perioperative haemotherapy: I. Indications for blood component transfusion

The practice of transfusion medicine has undergone substantial change over the last decade. Much of the impetus for the change has come from the isolation of human immunodeficiency virus (HIV) and the linkage of HIV transmission to blood transfusion. The purpose of this paper is to collate and review the literature relating to the indications for blood transfusion and provide recommendations for the appropriate utilization of blood products. Peer-reviewed and published studies and reviews relating to aspects of clinical blood transfusion were identified through computer searches and searching of the bibliographies of identified articles. Emphasis was placed on the literature published within the last decade and particularly in the years 1985-91. Material was chosen which was of proved clinical importance and in which findings were consistent among different investigators or different centres. Less emphasis was placed on material reporting new findings of uncertain clinical relevance or findings that were not consistent with majority reports. It is concluded that the only indication for red cell transfusion is to increase the oxygen carrying capacity of the blood and that an adjustment downwards in the haemoglobin concentration at which blood is transfused (transfusion trigger) from the traditional level of 100 g.L-1 is supported by the physiological and clinical data. Perioperative haemoglobin concentrations of 80 g.L-1 are acceptable in otherwise healthy young patients. The transfusion trigger should be adjusted upwards from this in medically compromised patients and in the elderly (greater than 60 yr). Fresh frozen plasma (FFP) is only indicated when there are documented deficiencies of coagulation factors. Platelet concentrates (PC) are indicated for the treatment of clinical coagulopathy resulting from thrombocytopaenia or platelet dysfunction. Routine or prophylactic administration of either FFP or PC after cardiopulmonary bypass or during resuscitation from haemorrhage is not indicated.