Overall mortality, incremental life expectancy, and cause of death at 25 years in the program on the surgical control of the hyperlipidemias.

OBJECTIVE: To present the longest follow-up report of any lipid-atherosclerosis intervention trial. SUMMARY OF BACKGROUND DATA: The Program on the Surgical Control of the Hyperlipidemias (POSCH), a secondary, clinical/arteriographic, randomized controlled trial, was the first lipid-atherosclerosis trial to demonstrate unequivocally that low density lipoprotein cholesterol reduction reduced the incidence of coronary heart disease death and myocardial infarction. METHODS: We report POSCH 25 years follow-up for overall mortality, specific cause of death, and certain subgroup analyses, as well as a prediction for increase in life expectancy derived from the POSCH database, supplemented by the 2006 National Death Index, 1989-2006. RESULTS: There were 838 patients randomized in POSCH (421 surgery, 417 control). At 25 years follow-up, the difference in the restricted mean survival and the logrank (Mantel-Haenszel) statistic was statistically significant, with survival probabilities of 0.57 (surgery) and 0.51 (controls). Cause of death data indicated a significant increase in cardiovascular deaths in the control group; cancer deaths were also greater in the control group but this was not significant. The most compelling subgroup analysis was a significant increase in survival, starting at 5 years after randomization, in the surgery group for patients with an ejection fraction > or = 50%, with relative probabilities of 0.61 (surgery) and 0.51 (control). The estimated incremental increase in life expectancy over more than 25 years of follow-up was 1.0 year overall and 1.7 years in the cohort with an ejection fraction > or = 50%. CONCLUSIONS: A 25-year mortality follow-up in POSCH shows statistically significant gains in overall survival, cardiovascular disease-free survival, and life expectancy in the surgery group compared with the control group.

Bariatric surgery training in the United States.

BACKGROUND: To provide evidence of the status of bariatric surgical education in the accredited surgery training programs in the United States. METHODS: A questionnaire was sent by mail to the 251 accredited surgery residency training programs, including the 48 minimally invasive surgery fellowship programs, in the United States. RESULTS: There was a 100% response to the questionnaire. Of the 251 surgery residency training programs and 48 minimally invasive surgery fellowship programs, 185 (73.7%) and 43 (89.6%) performed bariatric surgery, respectively. The open Roux-en-Y gastric bypass was the dominant procedure (85.1%), followed by laparoscopic Roux-en-Y gastric bypass (60.9%), in the residency programs; the laparoscopic Roux-en-Y gastric bypass was the dominant procedure (70.1%) in the minimally invasive fellowship programs. CONCLUSIONS: Bariatric surgery has been mainstreamed into accredited training programs in the United States.

Bariatric surgery worldwide 2003.

BACKGROUND: There is a world epidemic of overweight, obesity, and morbid obesity, encompassing 1.7 billion people. Bariatric surgery today is the only effective therapy for morbid obesity. METHODS: E-mail requests for information were sent to the presidents of the national societies of the 31 International Federation for the Surgery of Obesity (IFSO) nations, or national groupings, plus Sweden. Responses were tabulated; calculation of relative prevalence of specific procedures was done by weighted averages. RESULTS: Responders were 26 of 32 (81%) for the general questions and 24 of 32 (75%) for the question on specific operative percentages. In the year 2002-2003, 146,301 bariatric surgery operations were performed by 2,839 bariatric surgeons; 103,000 of these operations were performed in USA/Canada by 850 surgeons. The earliest start date for bariatric surgery was 1953 in the USA; IFSO was founded in 1995. In the year 2002-2003, 37.15% of operations were open; 62.85% laparoscopic. The 6 most popular procedures by weighted averages were: laparoscopic gastric bypass, 25.67%; laparoscopic adjustable gastric banding, 24.14%; open gastric bypass, 23.07%; laparoscopic long-limb gastric bypass, 8.9%; open long-limb gastric bypass, 7.45%; and open vertical banded gastroplasty, 4.25%. Pooling open and laparoscopic procedures, relative percentages were: gastric bypass, 65.11%; gastric banding, 24.41%; vertical banded gastroplasty, 5.43%; and biliopancreatic diversion/duodenal switch, 4.85%. Categorizing into restrictive/malabsorptive, purely restrictive, and primarily malabsorptive, the relative distribution of procedures was 65.11%, 29.84%, and 4.85%, respectively. The number of countries performing gastric banding was 23 (95%), gastric bypass 21 (88%), vertical banded gastroplasty 19 (79%), and biliopancreatic diversion/duodenal switch 16 (67%). Purely restrictive procedures were performed in 24 (100%) of the countries, restrictive/malabsorptive in 21 (88%), and primarily malabsorptive in 18 (75%). CONCLUSIONS: Bariatric surgery is expanding exponentially to meet the global epidemic of morbid obesity. Operative procedures in bariatric surgery are in flux and specific geographic trends and shifts are evident. Yet, of the patients qualifying for surgery, only about 1% are receiving this therapy--the only effective treatment currently available.

Single-molecule designs for electric switches and rectifiers.

A design for molecular rectifiers is proposed. Current rectification is based on the spatial asymmetry of a molecule and requires only one resonant conducting molecular orbital. Rectification is caused by asymmetric coupling of the orbital to the electrodes, which results in asymmetric movement of the two Fermi levels with respect to the orbital under external bias. Results from numerical studies of the family of suggested molecular rectifiers, HS-(CH(2))(n)-C(6)H(4)(CH(2))(m)SH, are presented. Current rectification ratios in excess of 100 are achievable for n = 2 and m > 6. A class of bistable stator-rotor molecules is proposed. The stationary part connects the two electrodes and facilitates electron transport between them. The rotary part, which has a large dipole moment, is attached to an atom of the stator via a single sigma bond. Electrostatic bonds formed between the oxygen atom of the rotor and hydrogen atoms of the stator make the symmetric orientation of the dipole unstable. The rotor has two potential minima with equal energy for rotation about the sigma bond. The dipole can be flipped between the two states by an external electric field. Both rotor-orientation states have asymmetric current-voltage characteristics that are the reverse of each other, so they are distinguishable electrically. Theoretical results on conformation, energy barriers, retention times, switching voltages, and current-voltage characteristics are presented for a particular stator-rotor molecule. Such molecules could be the base for single-molecule switches, reversible diodes, and other molecular electronic devices.

Overall mortality in the program on the surgical control of the hyperlipidemias.

BACKGROUND: The Program on the Surgical Control of the Hyperlipidemias (POSCH), a secondary intervention trial, was the only lipid/atherosclerosis randomized clinical trial that used a surgical modality--partial ileal bypass. POSCH provided solid evidence for the clinical and arteriographic benefits of lipid profile normalization. Few longterm followup reports have been published in this field. This report concerns overall mortality, the primary endpoint of POSCH, with a mean followup of 18 years (range 15.5 to 23.0 years). STUDY DESIGN: Overall mortality data were compiled from reports to the POSCH clinics, followup telephone calls, death certificates, and the US National Death Index. RESULTS: There were 144 deaths in the control group (n = 417) and 120 deaths in the intervention group (n = 421), using intent-to-treat analysis. The risk reduction in the intervention group was 0.201 (20%); the risk ratio was 0.799, or 0.8 (95% confidence intervals, 0.628 to 1.018, p = 0.07). The proportion of patients alive was 65.7% in the control group and 72.0% in the intervention group, for a difference of 6.3% in the intervention group (p = 0.05). Kaplan-Meier survival analysis (p = 0.046) and disease-free intervals analysis at 70% survival (p < 0.001) were confirmatory. The gain in life expectancy in the intervention group was 2.7 years. CONCLUSIONS: Longterm followup POSCH data demonstrate that lipid profile normalization will decrease overall mortality and will maintain a persistent and constant increase in life expectancy.

Lipid modulation and liver function tests. A report of the Program on the Surgical Control of the Hyperlipidemias (POSCH).

BACKGROUND: Statin drugs are known to cause dose-dependent abnormalities in liver function tests (LFTs), with elevations three times the upper limits of normal of the aminotransferase enzymes in up to 2.5% of patients on the highest prescribable doses. The Program on the Surgical Control of the Hyperlipidemias (POSCH) trial employed no hypocholesterolaemic drugs and used a surgical procedure, partial ileal bypass, as the intervention modality. METHODS: Serum total bilirubin, alkaline phosphatase and serum glutamic-oxaloacetic transaminase (SGOT) (equivalent to aspartate aminotransferase [AST]), were the LFTs obtained in POSCH at baseline, 3 months, annually for 5 years, and at 7 or 10 years postrandomization. RESULTS: Abnormal values were found for total bilirubin in seven of 416 control group (CG) patients (1.68%) and in 34 of 373 intervention group (IG) patients (9.16%) (P = 0.001); for alkaline phosphatase, in 28 of 378 (7.41%) and in 41 of 326 (12.58%) (P = 0.0214); and for SGOT, in 102 of 412 (24.76%) and in 161 of 372 (43.28%) (P = 0.001). Values twice the upper limit of normal occurred in 1 CG and 1 IG patient for total bilirubin and for alkaline phosphatase, and in 11 CG and 7 IG patients for SGOT (NS). Values three times the upper limit of normal did not occur in any patient for total bilirubin or alkaline phosphatase, and occurred in 3 CG and 5 IG patients for SGOT (NS). CONCLUSIONS: In POSCH, the IG demonstrated statistically significant mild increases for total bilirubin, alkaline phosphatase and SGOT levels, with no significant increases in values twice or greater the upper limits of normal.