Which Is Better - Gastric Banding or Gastric Bypass?

Gastric surgery has made great progress in helping obese people limit their food intake and reduce their weight dramatically.  At present, there are two main types bariatric surgery, as this type of operation is called.  An adjustable silicone gastric band – commonly called a “lap band” - is applied, during laparoscopy, around the upper part of the stomach; it creates a small pouch or fore-stomach, which is controllable by adjusting the band.  The other procedure, known as a “gastric bypass”, is the Roux-en-Y procedure.  A small stomach pouch is created with a stapler device, and connected to the small intestine: the upper part of the small intestine is then reattached in a Y-shaped configuration.  Which approach is better?  A study from Switzerland compared the two procedures in a head-to-head comparison.  The results are reported in the Archives of Surgery.

A total of 442 severely obese patients (BMI 40 to 50) were treated laparoscopically by the same surgeon, either by lap band or gastric bypass; those given a bypass were matched according to gender, age, and body mass index (BMI) to patients given a lap band – lap-band patients without a match were excluded.  Follow-up averaged 6 years.

The significant outcome differences between the two groups were:

·       There were more early complications after bypass than banding – 17.2% vs.5.4%

·       But there was a lower 6-year long-term complication rate for bypass than for banding – 19% vs. 42%

·       Weight loss was quicker with bypass - maximum at 18 weeks, vs. 36 months after banding.

·       Weight loss was greater with bypass – 88% of excess weight lost with bypass vs. 65% with banding.  The lowest BMI with bypass was 26.7 vs. 29.4 with banding.

·       There were more failures (BMI over 35 or complications) at 6 years after banding than after bypass – 48% vs. 12%.

·        There were more reoperations after banding than bypass – 26.7% vs. 12.7%

The bottom line: Roux-en-Y gastric bypass is likely to provide better weight loss than gastric banding, but it’s accompanied by a higher rate of early complication.  One caveat expressed by a Johns Hopkins specialist concerns the qualifications and experience of the surgeon.  A well-done banding procedure is likely to produce better results than a poorly-done gastric bypass.  And remember, banding is more easily reversible.

“Surgery Is the Best Analgesic for Hip Fractures”

UK experts in orthopedics, geriatrics, emergency medicine, and anesthesia have produced a consensus document that addresses the clinical problems and controversies surrounding the optimal treatment of hip fracture in older patients.  It’s published in the journal Anesthesia.  One of the guiding principles is the need to fast-track the patient through the emergency department and get them to surgery as soon as reasonably possible.  Delay may be only a problem in the UK – reportedly hip fracture patients in 20% of UK hospitals wait 2 days for surgery – but there’s no doubt the list of recommendations contains good advice for US hospitals too.  Here are other points the experts want to make:

1.  Protocol-driven, fast-track admission
2. Multidisciplinary care, led by an orthogeriatrician (an orthopedic surgeon specializing in geriatric patients)
3. Surgical repair within 48 hours of admission
4. Anesthetists must be trained in geriatric orthopedic emergencies
5. High-quality communication between all the experts
6. Early postoperative mobilization is key
7. Establish plans for the patient’s discharge pre-operatively
8. Take all measures to prevent secondary falls

In the UK, the average hospital stay with a hip fracture is 16 days.  More than 8% of patients die within 30 days, and 30% die within a year.  Half of postoperative deaths are potentially preventable; 44% can be discharged to their home and 22% to a residential or nursing home.  In the USA, these numbers are probably lower; for instance, hospital stays are up to 2 weeks, and the one-year mortality is approximately 20%.  Nevertheless, there’s little doubt that US hospital can certainly benefit from some of the approaches recommended by the UK doctors.  And if you nearest and dearest is taken to the ED with a hip fracture, you can help by encouraging a sense of urgency in the approach to care . . .

Wasteful Screening Tests

One of the reasons for burgeoning healthcare costs is the large number of unnecessary but expensive screening procedures.  These are sometimes ordered by physicians because they fear a possible malpractice lawsuit if a diagnosis is missed.  Now a listing of clinical situations that frequently lead to wasteful diagnostic tests has been elaborated by a committee set up by the American College of Physicians; the members invite interested people to complete a survey in the Annals of Internal Medicine inviting opinions on tests considered probably wasteful.  Here are 10 of the 37 tests listed:

1. Obtaining an ECG to screen for heart disease in patients at low to average risk of coronary disease
2. Obtaining an exercise ECG for screening in low-risk adults without symptoms
3. Ordering imaging studies (e.g. X-rays or MRI) for nonspecific low back pain
4. Using MRI instead of mammography to screen for breast cancer in women at average risk
5. Blood serology testing for suspected early Lyme disease
6. Annual blood lipid screen (cholesterol etc:) in patients not on a lipid-lowering drug or diet therapy without good reason for changing lipid profiles
7. Repeat screening ultrasound for abdominal aortic aneurism following a negative study
8. Ordering CA 125 antigen levels for screening women for ovarian cancer in the absence of increased risk
9. PSA (prostate specific antigen) screening for prostate cancer in men aged 75 and older or with a life expectancy of less than 10 years
10. Brain imaging studies CT or MRI) in evaluating simple syncope (fainting) and a normal neurological examination

This selection should give you an idea of the sort of diagnostic and screening test that are up for review. Their cost is not inconsiderable. A Congressional Budget Estimate has reported that up to 5% of the nation's gross national product is spent on tests and procedures that do not improve patient outcomes.  

If you feel your doctor should be ordering a test for you and you meet with refusal, outline to him or her your understanding of the pros and cons of such a test;  your discussion may teach you more about your problem that the result of a test can provide!

Waiting for the Flu

By now we’ve all had our flu shots, haven’t we?  So where’s the epidemic?  Perhaps it’s waiting for a change in the weather . . .  Back in September La Niña, which contributed to extreme weather around the globe during the first half of 2011, had re-emerged in the tropical Pacific Ocean and was forecast to gradually strengthen and continue into winter.  Now researchers have reported in the Proceedings of the National Academy of Scientists that the 4 most recent human influenza pandemics (1918, 1957, 1968, and 2009) were preceded by La Niña conditions in the equatorial Pacific.  So maybe we should anticipate the emergence of an epidemic in late spring.

Apart from having an anti-flu shot, there’s not much the average person can do to avoid infection and its consequences. But a new factor has recently emerged.  Older people can mitigate the effects of influenza if they are taking a statin drug, according to a publication in the Journal of Infectious Diseases.

The Centers for Disease Control and Prevention (CDC) provided data on people hospitalized with laboratory-confirmed influenza from 10 states during the 2007 to 2008 season.  Thirty-day mortality from over 3,000 patients was analyzed.  Their average age was 70, and 56% were women.  One third of them were taking a statin drug; statin users were more likely to be older, male, and white, and to have been vaccinated against flu.  They were also more likely to have chronic medical conditions.

The overall 30-day mortality was 5%.  After adjusting for the most likely biasing factors (age, race, chronic diseases, vaccination, and medications) those subjects taking statins had a 41% lower mortality rate than those not taking a statin.  This association between statin use and improved mortality can possibly be attributed to the drugs’ anti-inflammatory and immune-system effects.  While the findings don’t provide a reason for otherwise healthy people to start taking a statin as a preventive measure, they should help ensure that regular statin users to continue to take the drug during a bout with flu.

Nicotine Patch – Not So Good for Quitting Smoking, but Alzheimer’s?

The news recently has been full of the results of a study from Harvard showing that the nicotine patch isn’t much help in people wanting to quit smoking.  However, there’s just been a report published in the journal Neurology of the use of the nicotine patch in treating mild cognitive impairment.  The results from this small study are encouraging.

Vanderbilt University, Tennessee, scientists randomized nonsmoking volunteers with mild cognitive impairment (MCI) – chiefly affecting memory – to use nicotine or placebo patches for 6 months.  The dose of nicotine applied was 15 mg daily.  The chief outcome measure was the Connors Continuous Performance Test (CPT), which is used for assessing overall attention performance.  The Clinical Global Impression of Change was a self-assessment of clinical improvement.  Other tests included short-term memory (Immediate Paragraph Recall Test) and delayed recall (Paragraph Recall Test).

There were 74 subjects at enrollment, and 67 completed the study (34 nicotine, 33 placebo).  Their average age was 76.  After 6 months, the subjects in the nicotine patch group improved significantly in reaction time in the CPT, while placebo subjects showed deterioration.  The clinical global improvement test showed no statistically significant differences between the two groups, but more subjects rated themselves improved (8) with nicotine than those taking the placebo (3).  Nicotine patch subjects showed better results for short-term memory and delayed recall, too.

This study was too small to determine all the benefits and possible drawbacks of nicotine patches in cognitive impairment, and for displaying any disease–altering effects on progression to dementia.  But it serves as an impetus for further studies, which we can hope will provide results to allow the more widespread use of nicotine in preventing mental decline.  We must try to show show patience.  Certainly it’s no excuse to start smoking!

The Importance of Potassium in Acute Myocardial Infarction (MI)

One of the things that are monitored in patients who’ve had a heart attack (myocardial infarction, or MI) is the serum potassium level.  Emergency physicians and cardiologists have learned that it’s important that potassium levels are kept between 4.0 and 5.0 mEq/L.  This is because too little or too much potassium in the blood can have serious effects.  Too little, and abnormal heart rhythms can result, especially in people with existing heart disease; the most dangerous arrhythmia, ventricular fibrillation, is often lethal.  Too much potassium, however, can also lead to sudden death from cardiac arrhythmias.  Consequently, measuring and replacing lost potassium is a time-honored activity in treating acute MI patients.  A new study from Emory University, published in the Journal of the American Medical Association, suggests the target level for potassium control needs to be changed to between 3.5 and 4.5 mEq/L.

Over 38,500 patients with a confirmed acute MI and had in-hospital serum potassium level measurements on admission were allocated tone of 7 categories: potassium level below 3.0, 3.0 to below 3.5, 3.5 to below 4.0, 4.0 to below 4.5, 4.5 to below 5.0, 5.0 to below 5.5, and 5.5 or above.  The in-hospital all-cause mortality and ventricular fibrillation or cardiac arrest rates were calculated for each potassium category.

Overall, 6.9% of the patients died in hospital.  There was a U–shaped relationship between the average postadmission potassium level and mortality: the mortality rates for the 7 categories outlined above were: 46%, 11.4%, 4.8%, 5.0%, 10%, 24.8%, and 61.4%.  Taking the “best” level (3.5 to below 4.0 mEq/L) as the ideal target, mortality was twice as great for potassium levels of 4.5 to below 5.0 mEq/L, and even greater for higher potassium levels; similarly, mortality rates were higher for potassium levels below 3.5 mEq/L.  Rates of ventricular fibrillation or cardiac arrest were higher only among patients with potassium levels below 3.0 mEq/L or above 5.0 mEq/L. 

These findings suggest that the new target serum potassium level in acute MI care should be between 3.5 and 4.5 mEq/L.  This may seem like a minor change, but it would be easier for practical implementation (the overall average on admission in this study was 4.2 mEq/L) and would probably improve survival.

Eat More Antioxidants!

A Swedish study from the Karolinska Institute in Stockholm has confirmed the benefits of antioxidant consumption in the prevention of stroke – at least in women.  It’s published online in the journal Stroke.  So maybe some of the claims for these ‘nutrichemicals’ are indeed true?

The subjects in the study came from the Swedish Mammography Cohort.  Diet at baseline was assessed using a food frequency questionnaire, and the total antioxidant capacity of the diet was calculated from the oxygen radical absorbance capacity of the individual food items.  Stroke cases in the study population during follow-up were ascertained using the national hospital discharge registry. 

A total of 36,715 women were enrolled - 31,035 of them had no history of cardiovascular disease, and 5,860 had a history of such disease at baseline. Their ages ranged from 49 to 83 years.  The average follow-up period was 11 years, during which time 1,322 cases of stoke were recorded in the cardiovascular-free women (988 ischemic strokes, 226 hemorrhagic, and 108 unspecified strokes), and 1,007 strokes in women with a cardiovascular history (796 ischemic, 100 hemorrhagic, and 111 unspecified strokes).

Both groups of patients were categorized into 5 classes, or quintiles, according to their total antioxidant capacity at baseline.  In the women without prior cardiovascular disease those in the quintile with the highest antioxidant intake had a 17% lower risk of having a stroke than those in the lowest antioxidant intake quintile.  In the women with a cardiovascular history, the highest quintile had a non-significant decrease in total stroke risk (10%, not statistically significant), but there was a 45% decreased in the risk for hemorrhagic stroke.   

The subjects in the highest antioxidant quintile ate twice as much fruit and vegetables and drank 17 times more tea than those in the lowest quintile.  The findings from this study, and from an analysis from the Rotterdam Study, suggest that the antioxidant capacity of the diet is important in helping prevent stroke.  It’s also important to note that the benefits only accrue with an antioxidant-containing diet, not with antioxidant supplements.  So eat plenty of fruit, berries, nuts, and veggies; the list of antioxidant foods is long.

Statins and the Risk of Diabetes – What to Do?

The media have greeted the arrival of generic Lipitor with reports of a study appearing this month in the Archives of Internal Medicine.  Analyses of data from the Women’s Health Initiative (WHI) prove further evidence of a link between the use of statin drugs and the occurrence of diabetes in postmenopausal women.  But the study is not the first to suggest such an association.  An analysis of 13 randomized clinical studies, published in the Lancet in 2010, found that statin users had a 9% increased risk for diabetes. Another meta-analysis of 5 controlled studies, published in the Journal of the American Medical Association last June, described an increase in risk in patients taking high rather than moderate doses of statins.

The new study echoes the findings of the two earlier ones.  Almost 154,000 women from the WHI, with an average age of 63, were followed for 12 years, during which time 10,200 of them had developed type 2 diabetes.  Statin use, which was recovered at enrollment and after 3 years, was established in 7% of the participants.  After adjusting for potential confounding factors (e.g. family history, excess body weight), it emerged that statin users were 1.48-times more likely to develop diabetes than non-users;  the rate for new diabetes during the study rose from 6.4% in the women not taking statins to 9.9% in the statin users.  This increased risk applied to all the statin drugs taken.

Taken together, these reports show a clear relationship between statin use and diabetes, but it is not a very close association.  Statins have a proven beneficial effect on heart attack, stroke, and mortality in patients with cardiovascular risk factors (e.g. high blood pressure, obesity, or existing diabetes), but these benefits are less obvious in healthy people.  As one expert has put it: “Every woman taking a statin needs to know her risk of heart disease, and she should ask her doctor if the statin is really necessary.” 

It’s probable that the study finding applies equally to men, although we shall have to wait for another study to show this.  In the meantime, there’s one important conclusion to be drawn: statins shouldn’t be given to perfectly healthy people, as some have suggested (“they should put it in the water”).  And the dose should be kept as low as possible in order to achieve the desired effect on blood lipids.  A piece on the USA Today website summarizes the situation pretty well.