Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes.

OBJECTIVE: The aim of the study was to assess long-term metabolic effects of laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes (T2DM) and to identify predictive factors for long-term diabetes remission and relapse. BACKGROUND: LSG has become the most common bariatric operation worldwide. Its long-term metabolic effects in patients with T2DM are, however, unknown. METHODS: Outcomes of 134 patients with obesity with T2DM who underwent LSG at an academic center during 2005 to 2010 and had at least 5 years of follow-up were assessed. RESULTS: At a median postsurgical follow-up of 6 years (range: 5-9), a mean body mass index loss of -7.8 ±â€Š5.1 kg/m (total weight loss: 16.8% ±â€Š9.7%) was associated with a reduction in mean glycated hemoglobin (HbA1c, -1.3 ±â€Š1.8%, P < 0.001), fasting blood glucose (-37.8 ±â€Š70.4 mg/dL, P < 0.001) and median number of diabetes medications (-1, P < 0.001). Long-term glycemic control (HbA1c <7%) was seen in 63% of patients (vs 31% at baseline, P < 0.001), diabetes remission (HbA1c <6.5% off medications) in 26%, complete remission (HbA1c <6% off medications) in 11%, and "cure" (continuous complete remission for ≥5 years) was achieved in 3%. Long-term relapse of T2DM after initial remission occurred in 44%. Among patients with relapse, 67% maintained glycemic control (HbA1c <7%). On adjusted analysis, taking 2 or more diabetes medications at baseline predicted less long-term remission (odds ratio 0.19, 95% confidence interval 0.07-0.55, P = 0.002) and more relapse of T2DM (odds ratio 8.50, 95% confidence interval: 1.40-49.20, P = 0.02). Significant improvement in triglycerides (-53.7 ±â€Š116.4 mg/dL, P < 0.001), high-density lipoprotein (8.2 ±â€Š12.9 mg/dL, P < 0.001), systolic (-8.9 ±â€Š18.7 mmHg, P < 0.001) and diastolic blood pressure (-2.6 ±â€Š14.5 mmHg, P = 0.04), and cardiovascular risk (13% relative reduction, P < 0.001) was observed. CONCLUSIONS: LSG can significantly improve cardiometabolic risk factors including glycemic status in T2DM. Long-term complete remission and "cure" of T2DM, however, occur infrequently.

Outcomes of a third bariatric procedure for inadequate weight loss.

BACKGROUND AND OBJECTIVES: The robust volume of bariatric surgical procedures has led to significant numbers of patients requiring reoperative surgery because of undesirable results from primary operations. The aim of this study was to assess the feasibility, safety, and outcomes of the third bariatric procedure after previous attempts resulted in inadequate results. METHODS: We retrospectively identified patients who underwent a third bariatric procedure for inadequate weight loss or significant weight regain after the second operation. Data were analyzed to establish patient demographic characteristics, perioperative parameters, and postoperative outcomes. RESULTS: A total of 12 patients were identified. Before the first, second, and third procedures, patients had a mean body mass index of 67.1±29.3 kg/m2, 60.9±28.3 kg/m2, and 49.4±19.8 kg/m2, respectively. The third operations (laparoscopic in 10 and open in 2) included Roux-en-Y gastric bypass (n=5), revision of pouch and/or stoma of Roux-en-Y gastric bypass (n=3), limb lengthening after Roux-en-Y gastric bypass (n=3), and sleeve gastrectomy (n=1). We encountered 5 early complications in 4 patients, and early reoperative intervention was needed in 2 patients. At 1-year follow-up, the excess weight loss of the cohort was 49.4%±33.8%. After a mean follow-up time of 43.0±28.6 months, the body mass index of the cohort reached 39.9±20.8 kg/m2, which corresponded to a mean excess weight loss of 54.4%±44.0% from the third operation. At the latest follow-up, 64% of patients had excess weight loss>50% and 45% had excess weight loss>80%. CONCLUSION: Reoperative bariatric surgery can be carried out successfully (often laparoscopically), even after 2 previous weight loss procedures.

Sodium channel blockade with QRS widening after an escitalopram overdose.

INTRODUCTION: Escitalopram is rarely associated with prolongation of the QTc interval; however, there are no reported cases of QRS complex widening associated with escitalopram overdose. We report a case of a patient who presented with both QRS complex widening and QTc interval prolongation after an escitalopram overdose. CASE: A 16-year-old girl presented to the emergency department after ingestion of escitalopram, tramadol/acetaminophen, and hydrocodone/acetaminophen. Laboratory results were significant for 4-hour acetaminophen 21.1 µg/mL. Serum electrolytes including potassium, magnesium, and calcium were all normal. Initial electrocardiogram (ECG) revealed a widened QRS with an incomplete right bundle branch pattern. After administration of 100-mEq sodium bicarbonate, a repeat ECG revealed narrowing of the QRS complex and a prolonged QTc interval. Magnesium sulfate 2 g intravenous and sodium bicarbonate drip were initiated. A repeat ECG, 1 hour after the second, revealed normalization of the QRS complex and QTc interval. DISCUSSION: Prolongation of the QTc interval is an expected effect of escitalopram. Both escitalopram and citalopram are metabolized to the cardiotoxic metabolite S-didesmethylcitalopram and didesmethylcitalopram, respectively, which have been implicated in numerous cardiac abnormalities including widening of the QRS complex. Although never previously described with escitalopram, this mechanism provides a reasonable explanation for the QRS complex widening and incomplete right bundle branch block that occurred in our patient. CONCLUSIONS: Both QRS complex widening and QTc interval prolongation should be monitored in cases of escitalopram and citalopram overdoses.

Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus.

OBJECTIVE: Evaluate the long-term effects of bariatric surgery on type 2 diabetes (T2DM) remission and metabolic risk factors. BACKGROUND: Although the impressive antidiabetic effects of bariatric surgery have been shown in short- and medium-term studies, the durability of these effects is uncertain. Specifically, long-term remission rates following bariatric surgery are largely unknown. METHODS: Clinical outcomes of 217 patients with T2DM who underwent bariatric surgery between 2004 and 2007 and had at least 5-year follow-up were assessed. Complete remission was defined as glycated hemoglobin (A1C) less than 6% and fasting blood glucose (FBG) less than 100 mg/dL off diabetic medications. Changes in other metabolic comorbidities, including hypertension, dyslipidemia, and diabetic nephropathy, were assessed. RESULTS: At a median follow-up of 6 years (range: 5-9) after surgery (Roux-en-Y gastric bypass, n = 162; gastric banding, n = 32; sleeve gastrectomy, n = 23), a mean excess weight loss (EWL) of 55% was associated with mean reductions in A1C from 7.5% ± 1.5% to 6.5% ± 1.2% (P < 0.001) and FBG from 155.9 ± 59.5 mg/dL to 114.8 ± 40.2 mg/dL (P < 0.001). Long-term complete and partial remission rates were 24% and 26%, respectively, whereas 34% improved (>1% decrease in A1C without remission) from baseline and 16% remained unchanged. Shorter duration of T2DM (P < 0.001) and higher long-term EWL (P = 0.006) predicted long-term remission. Recurrence of T2DM after initial remission occurred in 19% and was associated with longer duration of T2DM (P = 0.03), less EWL (P = 0.02), and weight regain (P = 0.015). Long-term control rates of low high-density lipoprotein, high low-density lipoprotein, high triglyceridemia, and hypertension were 73%, 72%, 80%, and 62%, respectively. Diabetic nephropathy regressed (53%) or stabilized (47%). CONCLUSIONS: Bariatric surgery can induce a significant and sustainable remission and improvement of T2DM and other metabolic risk factors in severely obese patients. Surgical intervention within 5 years of diagnosis is associated with a high rate of long-term remission.

Nausea, vomiting, and diarrhea in a 9-year-old girl.

Cryptosporidiosis is reported in an otherwise healthy child. Her history was significant for playing in natural waters during a camping trip 1 week prior. Several days later, she began improving despite an incorrect diagnosis and inappropriate antibiotic therapy. Nitazoxanide was given once the diagnosis was established. Obtaining a thorough patient history, administering appropriate antibiotics, and counseling patients on preventive measures are critical steps in treating and managing the transmission of this parasite. The case emphasizes the value of stool ova and parasite examination for proper diagnosis of pediatric diarrheal illness in the emergency setting. In addition, the often overlooked diagnosis of cryptosporidiosis is reviewed as an important cause of diarrheal illness in the immunocompetent pediatric population.

Assessment of the 4Ts pretest clinical scoring system as a predictor of heparin-induced thrombocytopenia.

STUDY OBJECTIVE: To evaluate the utility of the 4Ts clinical scoring system as a pretest probability method for the detection of heparin-induced thrombocytopenia (HIT). DESIGN: Prospective observational study. SETTING: Medical and surgical inpatients at a tertiary care medical center. PATIENTS: Eighty consecutive patients with suspicion of HIT who had a polyspecific enzyme-linked immunosorbent assay (ELISA) performed between December 1, 2008, and April 1, 2009, for detection of platelet factor 4 (PF4)-heparin antibodies. MEASUREMENTS AND MAIN RESULTS: The predictive value of the 4Ts scoring system as determined by using a standard laboratory marker of HIT--the ELISA--and the interrater reliability of the scoring system were assessed. Sixty-seven (84%) of the 80 patients had low clinical probability of HIT based on the calculated 4Ts score. The ELISA result was negative for PF4-heparin antibodies in 74 patients (93%). Based on the results of the ELISA, the negative predictive value of the 4Ts score was 91%. Each 4Ts score was calculated by two independent investigators and adjudicated by a third investigator when necessary. The interrater reliability of the scoring system was fair (Cohen κ coefficient 0.362, 95% confidence interval [CI] 0.222-0.502; weighted κ coefficient 0.554 (95% CI 0.441-0.667). Determination of the timing of HIT was associated with the largest number of discrepancies (16) between evaluators, followed by other causes of thrombocytopenia (15), degree of decline in platelet count (14), and the presence of thrombosis or other sequelae (2). CONCLUSION: A low 4Ts score supports a low probability of HIT based on the results of the polyspecific ELISA. Overall, the interrater reliability of the scoring system was fair. Components of the 4Ts scoring system need to be further clarified or modified in order to improve interrater reliability and thereby increase the clinical utility of this pretest probability model.

Predicting pertussis in a pediatric emergency department population.

Cases of pertussis, a potentially life-threatening illness in infants younger than 6 months of age, are at a 40-year high. Children frequently present to emergency departments for initial evaluation. Quick recognition of the illness allows rapid triage, isolation, and prevention of nosocomial transmission. A retrospective, case-control chart review was conducted of pediatric emergency department patients (0 to 18 years of age) presenting between January 1, 2003, and December 31, 2004. Analysis focused on the exploration of medical history and physical examination variables as predictors using laboratory verification of the presence of pertussis as a binary outcome variable. Infants younger than 2 months who have a cough or choking associated with cyanosis, as well as a cough and rhonchi on physical examination, have a high likelihood of pertussis and should be identified in triage, isolated immediately, and tested for pertussis. This may lead to appropriate therapy for this population and decrease the transmission of pertussis to other patients and staff in the pediatric emergency department.

High-dose ibuprofen therapy associated with esophageal ulceration after pneumonectomy in a patient with cystic fibrosis: a case report.

BACKGROUND: Lung disease in patients with cystic fibrosis is thought to develop as a result of airway inflammation, infection, and obstruction. Pulmonary therapies for cystic fibrosis that reduce airway inflammation include corticosteroids, rhDNase, antibiotics, and high-dose ibuprofen. Despite evidence that high-dose ibuprofen slows the progression of lung disease in patients with cystic fibrosis, many clinicians have chosen not to use this therapy because of concerns regarding potential side effects, especially gastrointestinal bleeding. However, studies have shown a low incidence of gastrointestinal ulceration and bleeding in patients with cystic fibrosis who have been treated with high-dose ibuprofen. CASE PRESENTATION: The described case illustrates a life-threatening upper gastrointestinal bleed that may have resulted from high-dose ibuprofen therapy in a patient with CF who had undergone a pneumonectomy. Mediastinal shift post-pneumonectomy distorted the patient's esophageal anatomy and may have caused decreased esophageal motility, which led to prolonged contact of the ibuprofen with the esophagus. The concentrated effect of the ibuprofen, as well as its systemic effects, probably contributed to the occurrence of the bleed in this patient. CONCLUSIONS: This report demonstrates that gastrointestinal tract anatomical abnormalities or dysmotility may be contraindications for therapy with high-dose ibuprofen in patients with cystic fibrosis.