Analysis of the results of sleeve gastrectomy for morbid obesity and the role of ghrelin

To evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG), a relatively new bariatric surgical procedure associated with duodenal switch (DS), we analyzed the findings of ten published studies on LSG. No relationship was found between the excess weight loss and the size of the bougie or the follow-up period. The amount of gastric fundus removed may be an important consideration because most ghrelin-producing cells are in the fundus; however, there is insufficient evidence that lowered ghrelin is the sole reason for the resulting weight loss after this procedure. Laparoscopic sleeve gastrectomy is still considered experimental by many, but the initial results are promising, with one study even suggesting long-term results comparable with those of other bariatric procedures. Ghrelin may play a role in the weight loss associated with LSG, but is unlikely to be the sole reason for its success.     

Tactical increases in operating room block time for capacity planning should not be based on utilization

When a decision has been made to expand operating room (OR) capacity, the choice of surgical subspecialties to receive additional block time and fill the additional OR capacity is a tactical decision. Such decisions are made approximately once a year. Afterwards, typically a few months before the day of surgery, a second stage occurs in which operational decisions allocate OR time and determine the hours of staffing for each specialty based on its expected workload. In practice, cases are not scheduled into block time that has been planned tactically, but instead are scheduled during the second stage into the staffed time that is allocated operationally. This article reviews the literature on tactical decision-making for expansion of OR capacity. When additional OR capacity is available, it should be planned for those subspecialties that have the greatest contribution margin per OR hour, that have the potential for growth, and that have minimal need for limited resources such as intensive care unit beds. Numerous reasons are presented to explain why tactical planning of additional block time should not be based on current or past utilization of block time.     

Unstructured cardiac rehabilitation and secondary prevention in rural South Australia: does it meet best practice guidelines?

Comprehensive cardiac rehabilitation programs that address risk factors, psychological problems, and physical activity are essential in optimizing health and reducing the risk of further cardiac events. Behavioural and lifestyle modification support offered through these programs is predicated on initial identification of risk. Many rural populations in Australia do not have access to structured cardiac rehabilitation (CR) programs, and the level of support available to them in the form of unstructured CR is unclear. A retrospective analysis of medical records of patients presenting to hospital with myocardial infarction in rural South Australia over a 12 month period was undertaken to identify documented evidence of assessment of and intervention for lifestyle and behavioural risk factors in-hospital and at follow up in general practice (GP) clinics. Of 77 eligible participants, permission was received to access the medical records of 55 patients in the hospital setting, and 34 of these 55 patients in GP clinic follow up. Documented evidence of assessment of modifiable risk factors was inadequate for the majority of participants, with the exception of smoking status, hypertension and diabetes. This suggests that the majority of these participants did not receive lifestyle and behavioural interventions in line with current National Heart Foundation Recommendations for Cardiac Rehabilitation. Barriers to comprehensive CR and secondary prevention services in Australia must be addressed, particularly in high risk rural and remote populations. Future research must focus on the ongoing monitoring and evaluation of rural health care services to analyse existing levels of CR and secondary prevention to ensure current guidelines are being implemented, to support the further development and resourcing of CR services and to evaluate the subsequent impact on patient outcomes.     

Endoscopic suture removal at gastrojejunal anastomosis after Roux-en-Y gastric bypass to prevent marginal ulceration

BACKGROUND: After Roux-en-Y gastric bypass (RYGB) surgery, marginal ulcers develop in 3-23% of patients. Marginal ulcers can occur secondary to the use of nonabsorbable sutures to create the gastrojejunostomy. The suture can elicit a foreign body reaction that exposes it to the gastric lumen, irritating the mucosa. Surgical removal is mandated when medical therapy fails to resolve matters. Because endoscopic removal would be less invasive than laparotomy, a technique for the endoscopic removal of the suture was devised. Presented are the results of 6 patients who underwent this procedure. METHODS: A computer search of all patients who had undergone laparoscopic RYGB was done and found 6 women who had undergone endoscopic suture removal. After a double-lumen endoscope was inserted through the mouth, a grasper was used to placed the suture under tension before transecting it with blunt-tip endoshears. The suture was then removed without difficulty. All patients were evaluated at 2 weeks and 6 months postoperatively. RESULTS: Of the patients who underwent laparoscopic RYGB between June 2003 and June 2005 and presented with epigastric pain, 6 women underwent endoscopic stitch removal. These women had a mean age of 57 years, a mean initial body mass index of 55 kg/m(2), and had undergone laparoscopic RYGB a mean of 18 months before presentation. The patients, who had experienced new-onset epigastric pain and "heartburn," underwent endoscopic examination of the stomach, which showed visible suture at the gastrojejunal anastomosis, no ulceration, and edema, and underwent suture removal. No complications developed. At 6 months of follow-up, all patients were without symptoms and had normal findings on upper endoscopy. CONCLUSION: The results of our study have shown that endoscopic suture removal is a feasible and effective means of treating epigastric pain and preventing the suture-induced marginal ulcers that can occur after RYGB.     

Autism plus psychosis: A ‘one-two punch’ risk for tragic violence?

In the recent series of mass murders in Connecticut, Colorado, Norway and elsewhere, a pattern appears to emerge: young men whose social isolation borders on autism apparently become prey to psychotic ideation, and under its influence commit horrific violence. We argue that in some of these tragic cases two concomitant diagnoses may be at play, namely autism and psychosis. Autism itself is not an intrinsically violent disorder, and individuals with autism spectrum disorder (ASD) are no more prone to violent behaviors than the general population. The additional presence of psychotic illness, however, may dramatically change the picture. Based on an examination of historical and contemporary data regarding psychosis and violence in patients without developmental disability we explore three points relevant to the possibility of violence in individuals with comorbid ASD and psychosis. (1) Individuals with ASD have an elevated risk of comorbid psychopathology, including psychosis, which is strongly associated with violence. (2) The content of psychotic ideation has become increasingly violent and lethal in recent decades. (3) It is possible that individuals with ASD are readier than others to act on psychotic impulses.     

Causes of death in persons with human immunodeficiency virus infection.

PURPOSE: Pneumocystis carinii pneumonia (PCP) was reported to be the predominant cause of human immunodeficiency virus (HIV)-related deaths prior to 1988, the year that effective prophylaxis against PCP entered routine use. Our study was performed to study the causes of HIV-related death since January 1988 in a region where patient tracking is virtually complete. PATIENTS AND METHODS: We surveyed physicians associated with the Brown University Acquired Immunodeficiency Syndrome (AIDS) Program who cared for greater than 95% of known HIV-positive patients in Rhode Island. These physicians identified all those HIV-infected persons who had died under their care between January 1988 and July 1990, and determined these patients' causes of death by chart review. For comparison, death certificates of identified persons were also reviewed at the Rhode Island Department of Vital Statistics. RESULTS: Among 126 deaths since January 1988, bacterial infections were the most common cause of death (30%), whereas PCP was responsible for only 16% of deaths. Persons not receiving any form of PCP prophylaxis were more likely to die from PCP than were those who received prophylaxis (26% versus 11% [p = 0.04]). Cause of death as recorded on actual death certificates was imprecise, although bacterial infections were again the most common cause indicated. Only one death occurred in a patient with a CD4 count greater than 200/mL, and this was not HIV-related. CONCLUSION: PCP has not been the leading cause of death in our region since January 1988. Bacterial infections contribute substantially to mortality, and this may influence future prophylactic regimens. HIV-related deaths in patients with CD4 counts greater than 200/mL are unusual.     

The ambulatory care of HIV-infected persons

Objective:To describe the use of various counseling practices, examinations, and laboratory tests used by general internists in the primary care of HIV-infected persons. Design:Mailed questionnaire survey. Subjects:Random sampling of members of the Society of General Internal Medicine. Results:Based on a 64% response rate (131/205), there are many areas of physician agreement in the ambulatory care of HIV-infected persons. Greatest physician consensus was seen in the use of viral serologic testing, vaccinations, and Pap tests. Most (70–80%) primary care physicians do not use surrogate markers such as β ₂-microglobulin and p24 antigen to follow disease progression; instead, they rely mostly on CD4 lymphocyte counts. Sixty percent of physicians continue to order CD4 lymphocyte counts when a baseline count is under 200 cells/mm ³.All studies are ordered more frequently for patients with more advanced disease. As a group, those physicians following the largest number of patients do not manage patients significantly differently from the less HIV-experienced physicians. Conclusions:Despite some variation, there is substantial consensus on the “routine” management of HIV-infected persons. Clinical guidelines would be one mechanism for defining appropriate care of HIV-infected patients. The majority judgments of the practitioners studied here could be one component among various sources of information used by expert panels to define guidelines except where studies clearly indicate a different and more effective approach. Such incorporation might increase guideline acceptance by practicing clinicians. Received from the Division of General Internal Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02903.