Evaluation and treatment of patients with cardiac disease undergoing bariatric surgery.

BACKGROUND: Bariatric surgery is a proven tool in reducing the co-morbidities associated with morbid obesity. The aim of the present review was to assess the current data and discuss the strategies for preoperative evaluation, preoperative treatment, and intraoperative management of the obese patient with cardiac disease seeking bariatric surgery, including those who have undergone previous angiographic intervention with coronary stenting and/or antiplatelet therapy. The setting was a university hospital in the United States. METHODS: A search of the English-language reports using the keywords morbid obesity, bariatric surgery, perioperative risk assessment, coronary artery disease, coronary stents, and antiplatelet therapy was conducted. RESULTS: The methods of preoperative cardiac risk assessment found in the published studies included the use of certain criteria, stress echocardiography, and single-photon emission computed tomography. Preoperative medical treatment optimization with ß-blockers and statins is recommended. Perioperative antiplatelet therapy in the form of aspirin 81 mg can be safely continued, but clopidogrel should be stopped and reinitiated with caution. CONCLUSION: Preoperative assessment of morbidly obese patients with coexisting cardiac issues presents unique challenges. Safe patient care and good clinical outcomes can be achieved with adherence to evidence-based practice.

A glycolytic burst drives glucose induction of global histone acetylation by picNuA4 and SAGA.

Little is known about what enzyme complexes or mechanisms control global lysine acetylation in the amino-terminal tails of the histones. Here, we show that glucose induces overall acetylation of H3 K9, 18, 27 and H4 K5, 8, 12 in quiescent yeast cells mainly by stimulating two KATs, Gcn5 and Esa1. Genetic and pharmacological perturbation of carbon metabolism, combined with (1)H-NMR metabolic profiling, revealed that glucose induction of KAT activity directly depends on increased glucose catabolism. Glucose-inducible Esa1 and Gcn5 activities predominantly reside in the picNuA4 and SAGA complexes, respectively, and act on chromatin by an untargeted mechanism. We conclude that direct metabolic regulation of globally acting KATs can be a potent driving force for reconfiguration of overall histone acetylation in response to a physiological cue.

A novel, web-based application for assessing and enhancing practice-based learning in surgery residency.

INTRODUCTION: Practice-Based Learning and Improvement (PBLI) is 1 of 6 integral competencies required by the Accreditation Council for Graduate Medical Education (ACGME) for proof of adequate resident training and accreditation of residency programs. Moreover, the Outcome Project of the ACGME is beginning to enforce the provision of documented, objective evidence of resident PBLI. Current assessment tools, such as resident portfolios and performance evaluations, by faculty tend to be qualitative in nature. However, few objective, outcome-based, and quantitative evaluation tools have been developed. METHODS: A web-based application was designed to assess every consultation performed by senior residents at a university-affiliated general surgery residency. In real time, residents documented patient presentations along with their initial impression and plan. As patient outcomes became available, they were also documented into this application, which allowed residents to self-assess whether their impressions and plans were correct. A running "batting average" (BA) is then calculated based on percentage correct. RESULTS: Seven senior residents participated in this study, which included a total of 459 consults: 222 documented by PGY4 residents and 237 documented by PGY5 residents. The average BA of PGY4 residents in their first 3 months was 82.9%, which was followed by 85.9%, 88.7%, and 94.3% for each of the next 3 quarters. For PGY5 residents, the corresponding results were 96.4%, 94.4%, 93.8%, and 96.4% respectively. CONCLUSIONS: A web-based outcome-tracking program is useful for conducting rapid and ongoing evaluation of residents' practice-based learning, generating data for analysis of individual resident knowledge gaps, stimulating self-assessment and targeted learning, as well as providing objective data of PBLI for accreditation purposes.