Definition determines weight regain outcomes after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is one of the most commonly undertaken bariatric procedures. Weight regain after bariatric surgery, when significant, may be associated with recurrence of diabetes and deterioration in quality of life. Furthermore, it may be more common after SG than bypass procedures. Yet the understanding of the significance of weight regain is hampered by poor reporting and no consensus statements or guidelines. OBJECTIVES: To illustrate how the lack of a standard definition significantly alters reported SG outcomes and to contribute to the discussion of how weight regain should be defined. SETTING: Counties Manukau Health, a public teaching hospital that performs over 150 bariatric procedures per year. METHODS: A retrospective cohort of SG patients followed up at 5 years was used to illustrate how the presence of multiple definitions in the literature significantly affects outcome reporting for weight regain. Post hoc analyses were used to explore the relationship between weight change and clinical outcomes. RESULTS: Applying 6 definitions of weight regain to a retrospective cohort of SG patients resulted in 6 different rates ranging from 9%-91%. Post hoc analyses revealed significant associations between weight change and the Bariatric Analysis Reporting Outcome System (BAROS) score as well as patient opinion. CONCLUSION: The nonuniform reporting of weight regain appears to significantly affect SG outcome reporting. Development of consensus statements and guidelines would ameliorate this problem. Ideally, research groups with access to large robust databases would aid in the development of any proposed weight regain definitions. In the interim, bariatric literature would benefit by all published series clearly reporting how weight regain is defined in the study population.

Antibiotic treatment of women with uncomplicated cystitis before and after allowing pharmacist-supply of trimethoprim.

Background In 2012, New Zealand reclassified trimethoprim to allow specially trained pharmacists to supply it without a prescription to women with symptoms suggesting uncomplicated cystitis, under strict criteria for supply. Objective To assess how this policy change allowing pharmacist supply of trimethoprim affected overall antibiotic supply. Setting Randomly selected community pharmacies throughout New Zealand. Methods Data were collected in pharmacies before the implementation ('baseline') and 1 year later ('post-implementation'). Pharmacy staff recorded prescription and nonprescription supplies for treatment or prevention of suspected urinary tract infections. Women with a prescription for treatment or prevention of presumed urinary tract infection or purchasing a non-prescription medicine for this purpose were invited to self-complete a questionnaire. National prescribing data were extracted for trimethoprim, nitrofurantoin and norfloxacin. Main outcome measure Antibiotic use in women with UTIs from dispensed prescriptions (baseline and post-implementation) and pharmacist-supplied trimethoprim (post-implementation), particularly focusing on women aged 16-65 years with an antibiotic for presumed cystitis without complicating features. Results Baseline data were provided by 139 pharmacies, 120 of which provided post-implementation data. In women with presumed cystitis without complicating features, prescriptions before and after the implementation were primarily for trimethoprim. Overall antibiotic use, and use of second-line agents did not increase post-implementation. Pharmacist-supplies of trimethoprim were modest nearly 1 year after the service started. Conclusion Supply of trimethoprim by specially trained pharmacists working within strict criteria for supply appeared to have little overall effect on antibiotic use. Further research on patient outcomes, resistance and changes over time is recommended.

The epidemiology of plunging ranula in South Auckland.

OBJECTIVES/HYPOTHESIS: Estimate the incidence rate and provide basic descriptive epidemiologic characteristics of plunging ranulas in a multi-ethnic population. STUDY DESIGN: Case series with chart review. METHODS: The study group comprised all Counties Manukau Health (CMH, Manukau City, Auckland, New Zealand) patients presenting to the CMH Department of Otolaryngology with a diagnosis of plunging ranula from January 2001 to December 2013, as recorded in the departmental case register. Non-CMH domicile patients were excluded. South Auckland comprised the base population, as serviced by CMH. The 2006 New Zealand census data was used for population demographics. RESULTS: A total of 134 cases of plunging ranula were identified. The overall annual crude incidence rate was 2.4 per 100,000 person-years. The gender specific incidence rate for males was 3.2 per 100,000 (95% confidence interval [CI]: 2.5. 3.9) and for females was 2.0 per 100,000 (95% CI: 1.5, 2.6). The overall age-adjusted annual incidence rate was 2.6 per 100,000 (95% CI: 2.1, 3.0). The age-adjusted incidence was highest among Maori (6.7 per 100,000, 95% CI 4.9, 8.4), followed by Pacific Island (4.4 per 100,000, 95% CI 3.2, 5.6), Asian (0.7 per 100,000, 95% CI 0.2, 1.2), and European population (0.6 per 100,000, 95% CI 0.3, 0.8). CONCLUSION: We have quantified for the first time the age-specific and age-adjusted incidence rates for plunging ranula by gender and ethnicity. The results show a likely underlying genetic predisposition for this condition, possibly with a superimposed environmental acquired factor relating to external, minor blunt trauma to the neck. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2739-2743, 2016.

Cough reflex testing in Dysphagia following stroke: a randomized controlled trial.

BACKGROUND: Significant health issues and service delivery costs are associated with post-stroke pneumonia related to dysphagia. Silent aspiration is known to increase pneumonia and mortality in this population. The utility of cough reflex testing (CRT) for reducing pneumonia in acute stroke patients was the subject of this randomised, controlled trial. METHODS: Patients referred for swallowing evaluation (N = 311) were assigned to either 1) a control group receiving standard evaluation or 2) an experimental group receiving standard evaluation with CRT. Participants in the experimental group were administered nebulised citric acid with test results contributing to clinical decisions. Outcomes for both groups were measured by pneumonia rates at 3 months post evaluation and other clinical indices of swallowing management. RESULTS: Analysis of the data identified no significant differences between groups in pneumonia rate (P = 0.38) or mortality (P = 0.15). Results of CRT were shown to influence diet recommendations (P < 0.0001) and referrals for instrumental assessment (P < 0.0001). CONCLUSIONS: Despite differences in clinical management between groups, the end goal of reducing pneumonia in post stroke dysphagia was not achieved.

Two optimization strategies of multi-stage design in clinical proteomic studies.

We evaluated statistical approaches to facilitate and improve multi-stage designs for clinical proteomic studies which plan to transit from laboratory discovery to clinical utility. To find the design with the greatest expected number of true discoveries under constraints on cost and false discovery, the operating characteristics of the multi-stage study were optimized as a function of sample sizes and nominal type-I error rates at each stage. A nested simulated annealing algorithm was used to find the best solution in the bounded spaces constructed by multiple design parameters. This approach is demonstrated to be feasible and lead to efficient designs. The use of biological grouping information in the study design was also investigated using synthetic datasets based on a cardiac proteomic study, and an actual dataset from a clinical immunology proteomic study. When different protein patterns presented, performance improved when the grouping was informative, with little loss in performance when the grouping was uninformative.

Primary prophylaxis with granulocyte colony-stimulating factor (GCSF) reduces the incidence of febrile neutropenia in patients with non-Hodgkin lymphoma (NHL) receiving CHOP chemotherapy treatment without adversely affecting their quality of life: cost-benefit and quality of life analysis.

PURPOSE: Treatment of non-Hodgkin lymphoma (NHL) with cyclophosphamide, vincristine, doxorubicin and prednisone (CHOP) is known to be associated with a significant risk of febrile neutropenia (FN) of up to 50% [Osby et al. 2003 Blood 101(10): 3840-3848; Lyman and Delgado 2003 Cancer 98(11): 2402-2409]. This study sought to examine the impact of primary granulocyte colony-stimulating factor (GCSF) prophylaxis on the incidence of FN, quality of life and overall cost. METHODS: In this retrospective cohort study, a group of 65 consecutive patients who received CHOP chemotherapy for NHL between December 2006 and October 2009 was studied. Patients either received filgrastim (300 mcg, average of seven doses), pegylated filgrastim (6 mg, single dose), or no GCSF prophylaxis. In addition, 19 patients were asked to complete Functional Assessment of Cancer Therapy: General quality-of-life questionnaires. RESULTS: Overall, patients who received primary GCSF prophylaxis had significantly fewer FN compared to those who did not (5 vs. 60%, p < 0.0001; numbers needed to treat of 1.8; 95% confidence interval, 1.6-2.9). Cost-benefit analysis showed that the GCSF prophylaxis was associated with only a small increase in direct financial cost ($238 NZD [US$189] more to give primary GCSF prophylaxis per patient vs. no prophylaxis). The quality of life assessment showed that the patients' quality of life scores were similar to the published data from the validation study population (466 patients with mixed cancers) for Functional Assessment of Cancer Therapy. CONCLUSIONS: Our study shows that primary GCSF prophylaxis is effective in preventing FN in patients receiving CHOP chemotherapy for NHL without adversely affecting their quality of life, and is cost effective.

Assessments of right ventricular volume and function using three-dimensional echocardiography in older children and adults with congenital heart disease: comparison with cardiac magnetic resonance imaging.

BACKGROUND: The utility of three-dimensional echocardiography (3DE) for right ventricular (RV) assessment is uncertain in older children and adults with congenital heart disease (CHD), in whom the right ventricle is often dilated and dysfunction is common. METHODS: RV assessments using 3DE were compared with manual tracing and automated border detection (ABD) with magnetic resonance imaging (MRI) as the reference method. Twenty-eight of 54 consecutive patients (52%; median age, 17 years) with CHD had adequate three-dimensional echocardiographic data sets for analysis. RESULTS: There were wide ranges of RV size (mean RV end-diastolic volume index, 143 +/- 43 mL/m(2)) and function (mean RV ejection fraction [EF], 48 +/- 10%) on MRI. End-diastolic volume was underestimated on 3DE by 20% (P < .001) and to a greater degree in larger ventricles (P < .001). There was no significant difference in EF measurements between 3DE methods and MRI except for ABD (-2.6 +/- 6, P = .03). The mean analysis time for ABD was 5 minutes, compared with 19 minutes for manual tracing (P < .0001). CONCLUSION: Approximately half the patients with CHD had adequate three-dimensional echocardiographic images. Three-dimensional echocardiography accurately estimated EF but underestimated volume, particularly when the right ventricle was dilated. ABD minimally underestimated EF but offered a significant reduction in analysis time.

The antiplatelet effect of six non-steroidal anti-inflammatory drugs and their pharmacodynamic interaction with aspirin in healthy volunteers.

Patients with cardiovascular disease taking aspirin and some nonsteroidal anti-inflammatory drugs (NSAIDs) appear to have increased vascular events. This study was conducted to compare the ex vivo antiplatelet effects of 6 commonly used NSAIDs and to determine whether these agents antagonize the effect of aspirin. Platelet function was assessed by Platelet Function Analyzer 100 closure time in normal subjects in a randomized, blinded, multiple-crossover study. Platelet function was measured 12 hours after the administration of each NSAID. The NSAID was then given 2 hours before aspirin 300 mg, and platelet function was reassessed 24 hours later. At 12 hours after the administration of naproxen and tiaprofenic acid, closure time was significantly prolonged, whereas the other NSAIDs did not cause significant prolongations. Compared with placebo plus aspirin, closure time was significantly reduced when ibuprofen, indomethacin, naproxen, or tiaprofenic acid was given before aspirin. In conclusion, ibuprofen, indomethacin, naproxen, and tiaprofenic acid all block the antiplatelet effect of aspirin. Sulindac and celecoxib did not demonstrate any significant antiplatelet effect or reduce the antiplatelet of aspirin and, therefore, of the NSAIDs evaluated may be the drugs of choice for patients requiring aspirin and NSAIDs.