Iatrogenic kwashiorkor after distal gastric bypass surgery: the consequences of receiving multinational treatment.

Protein-calorie malnutrition or kwashiorkor is extremely rare after gastric bypass surgery. We report a case of a woman referred to a weight management clinic in the United Kingdom who developed bilateral leg oedema 2 years after gastric bypass surgery in Tunisia. Her serum albumin concentration was 24 g/l, and her body mass index was 16.2 kg/m(2). A review of the postoperative report of her bariatric surgery revealed that she had undergone a distal bypass with anastomosis of the intestine at 1 m proximal to the ileocaecal valve. She required gastrostomy feeding for 6 months before undergoing revisional surgery to a proximal Roux-en-Y gastric bypass in order to restore healthy weight. We recommend that if patients are having their bariatric surgery outside of their country of residence, they should always obtain a copy of the operative notes so that these are readily available if complications arise.

Is using WHO criteria for impaired fasting glycaemia appropriate as an indication for OGTT in patients at high risk of developing diabetes?

AIM: Impaired fasting glycaemia (IFG) is an indication for oral glucose tolerance test (OGTT). World health organisation and International Diabetes Federation define IFG as fasting plasma glucose (FPG) levels of 6.1­6.9 mmol/l. However, American Diabetes Association still recommends a range of 5.6­6.9 mmol/l as IFG.We performed an audit to assess the outcome of OGTT at various cut offs of FPG levels in patients at high risk of developing diabetes. METHODS: Laboratory dataon OGTT performed over a period of 1 year in a district general hospital were collected. Patients with FPG levels between 5.6 and 6.9 mmol/l were selected and the outcome was analysed. RESULTS: Our audit shows that in patients with FPG levels of 5.6­6.0 mmol/l, 19% had diabetes and 43% had impaired glucose tolerance (IGT). CONCLUSION: The percentage of subjects with abnormal OGTT in our study is much higher than that of Decode study [Diabetologica, 42 (1999) 647] (7% diabetes and 29% IGT). However, Decode study had included general population whereas our data were collected from subjects who are at high risk of developing diabetes. We conclude that in these subjects the lower cut off level of 5.6 mmol/l for FPG should be used as an indication for OGTT.

Hyperlipidaemia and primary prevention of coronary heart disease: are the right patients being treated?

BACKGROUND: In 1997, the Standing Medical Advisory Committee report suggested that patients with a coronary heart disease risk of 3% per year or greater should be considered appropriate for lipid-lowering medication. The report stated that cholesterol concentration alone is a poor predictor of absolute risk of coronary heart disease and recommended the Sheffield table as a method of estimating the coronary heart disease risk. OBJECTIVE: To assess the impact of the Standing Medical Advisory Committee report on the management of patients with hyperlipidaemia in the primary prevention of coronary heart disease in primary care. METHOD: A survey questionnaire giving the clinical details of 20 patients with various coronary heart disease risk factors was sent to 200 general practitioners in the West Midlands, UK. RESULTS: Forty-eight percent of the respondents used clinical assessment/perception as the sole means of risk assessment and 26% used the Sheffield table. In patients who did not require treatment, 40.1% of the decisions were inappropriate and, in patients who required treatment, 35.1% of the decisions were inappropriate. Overall, inappropriate decisions were made in 37.9% of the responses. Despite the clear advice in the Standing Medical Advisory Committee report on the importance of incorporating multiple risk factors in estimating absolute coronary heart disease risk, only total cholesterol and triglycerides were significant in influencing treatment decisions. CONCLUSIONS: The Standing Medical Advisory Committee recommendations on the management of hyperlipidaemia in primary prevention of coronary heart disease are not widely used. Large savings could be made by correctly identifying and treating individuals at high risk. We recommend use of the full Framingham risk score in assessment of coronary heart disease risk in primary care.