The effect of laparoscopic gastric bypass on dyslipidemia in severely obese patients: a 5-year follow-up analysis.

BACKGROUND: Dyslipidemia is common in the morbidly obese population. A previous study from our institution demonstrated improved lipid parameters 1 and 2 years after laparoscopic Roux-en-Y gastric bypass (LRYGB) with fewer patients taking lipid-modifying medications postoperatively, suggesting cost-savings over time. Our objective was to evaluate lipid parameters and lipid-modifying medication use at 5 years postoperative. METHODS: The medical records of patients who underwent LRYGB from September 2001 through July 2008 were reviewed. Inclusion criteria consisted of both preoperative and 5-year postoperative lipid values available. RESULTS: Six hundred eighty-two patients underwent LRYGB during the study period; 450 had data available at 5 years postoperative, and 187 patients met the inclusion criteria. Mean age was 46.3 years, and 83 % were women. Mean preoperative body mass index was 47.4 kg/m(2). Total cholesterol was 191.2 ± 35.4 preoperatively and 181.1 ± 33.0 at 5 years postoperative (P = 0.003). Low-density lipoprotein (LDL) was 107.9 ± 30.9 preoperatively and 95.3 ± 29.7 at 5 years postoperative (P < 0.001). High-density lipoprotein (HDL) was 48.7 ± 12.8 preoperatively and 65.1 ± 18.0 at 5 years postoperative (P < 0.001). Triglycerides were 171.3 ± 78.6 preoperatively and 112.9 ± 60.7 5 years postoperative (P < 0.001). Preoperatively, 35 % of patients were on lipid-modifying medications, and at 5 years postoperatively, 26 % required lipid-modifying medications (P = 0.002). CONCLUSIONS: Patients who have undergone LRYGB continue to show favorable change in their lipid profiles at 5 years postoperative. Furthermore, fewer patients were taking lipid-modifying medications at 5 years postoperatively than preoperatively.

Early cost and safety benefits of an inpatient electronic health record.

There is controversy over the impact of electronic health record (EHR) systems on cost of care and safety. The authors studied the effects of an inpatient EHR system with computerized provider order entry on selected measures of cost of care and safety. Laboratory tests per week per hospitalization decreased from 13.9 to 11.4 (18%; p < 0.001). Radiology examinations per hospitalization decreased from 2.06 to 1.93 (6.3%; p < 0.009). Monthly transcription costs declined from $74,596 to $18,938 (74.6%; p < 0.001). Reams of copy paper ordered per month decreased from 1668 to 1224 (26.6%; p < 0.001). Medication errors per 1000 hospital days decreased from 17.9 to 15.4 (14.0%; p < 0.030), while near misses per 1000 hospital days increased from 9.0 to 12.5 (38.9%; p < 0.037), and the percentage of medication events that were medication errors decreased from 66.5% to 55.2% (p < 0.007). In this manuscript, we demonstrate that the implementation of an inpatient EHR with computerized provider order entry can result in rapid improvement in measures of cost of care and safety.

Acute renal failure in patients undergoing cardiothoracic surgery in a community hospital.

INTRODUCTION: Acute renal failure (ARF) following cardiothoracic surgery (CTS) is a major complication that increases postoperative morbidity and mortality. Recognizing patients at risk for ARF may lead to modified operative techniques, preoperative drug choice, or improved informed consent. The study objective was to identify and confirm preoperative and intraoperative risk factors for ARF following CTS in a community-based population. METHODS: A retrospective analysis of the medical records of all patients who underwent CTS at a community hospital between December 1, 1998 and December 31, 2004 was conducted. Off-pump CTS patients, patients younger than 18 years, and patients with end-stage renal disease requiring dialysis prior to surgery were excluded. Data collected included preoperative creatinine concentration, sex, diabetes status, prior myocardial infarction, preoperative medication, hypertension, cross-clamp time, and perfusion time. Analyses included Pearson chi2 and t test for comparison of demographics. Logistic regression was used for calculating odds ratios along with confidence intervals both in the univariate and multivariate models. RESULTS: Of the 2556 patients who underwent CTS, 477 (18.7%) developed ARF postoperatively and 43 (1.7%) developed ARF requiring dialysis. Independent risk factors included preoperative creatinine concentrations > 1.3 mg/dL, type I diabetes, male sex, hypertension, and preoperative diuretics. CONCLUSIONS: This study confirms several variables that predict ARF in patients undergoing CTS in a community-based setting. It is the first to show an independent association between preoperative diuretics and postoperative ARF

Community trial of home-based exercise therapy for intermittent claudication.

Peripheral arterial disease (PAD) is a common disease, and intermittent claudication (IC) is a life-changing symptom. Exercise therapy has been demonstrated to be an effective treatment for IC in a supervised setting; however, most insurance carriers do not reimburse for exercise therapy. As a result, non-supervised programs have largely replaced supervised programs, despite limited evidence of their benefit. In this retrospective study of the results of our routine care, we analyzed the outcomes of a structured 6-month home-based exercise program for IC. A total of 120 patients with PAD and IC were enrolled in a home-based exercise program. Forty-one patients fulfilled program requirements, for a 34.2% completion rate. Those who completed the program demonstrated an 86.4% improvement in their initial claudication distance and a 19.8% improvement in their absolute claudication distance. No patient factors identified those who did not complete the program versus those who completed the program and thus attained the observed benefit. We did observe that 47% of those who did not complete the program dropped-out by not keeping their follow-up appointment. Although patients who completed our program improved from baseline, it was less dramatic than reported in studies of supervised programs. The design of home-based programs should include mechanisms that maximize compliance in returning for follow-up appointments.

Does the use of standardized history and physical forms improve billable income and resident physician awareness of billing codes?

OBJECTIVES: Resident physician knowledge of financial reimbursement guidelines for patient encounters is limited. We determined whether the use of standardized history and physical examination forms by residents for hospital admissions plus a brief lecture would increase the level of billing codes, increase billable income, and increase resident awareness of billing guidelines. METHODS: Residents used history and physical examination forms after a brief documentation lecture. Pretrial and posttrial surveys measured awareness of billing guidelines. The admission billing codes for a 6-month period were obtained, and the percentages were compared with a control 6-month period. RESULTS: There was an absolute increase of 14.5% in the highest code between the two study periods (P < 0.0001). Billable income increased by $10,385. Resident documentation awareness also increased (P < 0.001). CONCLUSIONS: The use of history and physical examination forms, combined with a brief lecture, significantly increased the percentage of highest billing codes, which increased billable income. Resident awareness of documentation requirements significantly improved.

Nicotine replacement therapy and cardiovascular disease.

Smoking is a well-established and important risk factor for cardiovascular disease. Cessation of smoking clearly decreases the chances of a first or subsequent cardiovascular event. Nicotine replacement therapy (NRT) is a proven adJunctive therapy to increase the probability of quitting smoking. Anecdotal reports of adverse events in patients using NRT have led some to question its safety. Is nicotine, whether in tobacco products or in NRT, the cause of the cardiovascular consequences associated with tobacco use? Is using NRT to assist with smoking cessation safer than smoking? Should health care professionals avoid recommending NRT for patients with established cardiovascular disease? This article summarizes the mechanisms of harm associated with smoking and reviews the safety of NRT in both the general population and the population with cardiovascular disease. Recommendations for NRT use are offered.

Furazolidone-induced pulmonary hypersensitivity.

OBJECTIVE: To report a case of pulmonary hypersensitivity associated with furazolidone use and review the literature on this topic. CASE SUMMARY: A 43-year-old white female presented with fever and dyspnea. She had recently completed a course of furazolidone 125 mg 4 times daily for 10 days for enteritis. Investigations revealed bibasilar interstitial infiltrates on chest X-ray, hypoxia, and 21% eosinophilia. Her fever, hypoxia, and dyspnea rapidly abated following discontinuation of furazolidone and administration of corticosteroids. DISCUSSION: Furazolidone is a bactericidal agent used to treat infectious enteropathies. It is chemically similar to nitrofurantoin, which is well known to cause pulmonary hypersensitivity reactions. Application of the Naranjo probability scale suggests that a furazolidone adverse reaction in this patient was probable. A MEDLINE search from 1966 to October 2004 revealed 2 previously reported cases suggestive of furazolidone pulmonary hypersensitivity. All published reports closely resemble each other and descriptions of nitrofurantoin-associated pulmonary hypersensitivity reactions. CONCLUSIONS: Furazolidone may induce pulmonary hypersensitivity reactions; clinicians should be aware of this potentially serious adverse effect.

The effect of laparoscopic gastric bypass surgery on dyslipidemia in severely obese patients.

BACKGROUND: Dyslipidemia is common in the morbidly obese population. Lipid parameters typically improve after bariatric surgery, but the effects have been inconsistent and may depend on the surgical procedure performed. If bariatric surgery consistently improves dyslipidemia, there may be associated cost savings in lipid-modifying medications. METHODS: Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (RYGB) for morbid obesity had lipid analyses performed preoperatively and 1 and 2 years postoperatively. The number of lipid-modifying medications taken was documented by an electronic medical record review. RESULTS: A total of 168 patients were enrolled. Of these, 96 patients had preoperative and 1-year postoperative data and 18 had preoperative and 2-year postoperative data. In the 1-year cohort, total cholesterol (TC) decreased by 12.5%, low-density lipoprotein cholesterol (LDL) decreased by 19.4%, high-density lipoprotein cholesterol (HDL) increased by 23.2%, triglycerides (TG) decreased by 41.2%, and the percentage of dyslipidemic patients decreased from 82.3% to 28.1% (P < .001 for all). In the 2-year cohort, TC decreased by 7.2% (P = .036), LDL decreased by 21.7% (P < .001), HDL increased by 40.3% (P < .001), TG decreased by 27.3% (P = .015), and the percentage of dyslipidemic patients decreased from 94.4% to 27.8% (P < .001). In the 1-year cohort, 26.0% of patients were taking lipid-modifying medications preoperatively, compared with 14.6% postoperatively (P = .049). CONCLUSIONS: Laparoscopic RYGB improved all lipid parameters studied and decreased the percentage of dyslipidemic patients. Furthermore, fewer patients were taking lipid-modifying medications postoperatively, suggesting a substantial medication cost savings over time.

Lansoprazole-induced thrombocytopenia.

OBJECTIVE: To describe a case of thrombocytopenia associated with the administration of lansoprazole. CASE SUMMARY: An 85-year-old white man presented with an upper gastrointestinal hemorrhage from a gastric ulcer. His platelet count was normal on admission. He was started on oral lansoprazole 60 mg twice daily and, on hospital day 2, his platelet count decreased to 102 x 10(3)/mm(3); on hospital day 3, the platelet count was 36 x 10(3)/mm(3). Lansoprazole was discontinued, and the platelet count returned to normal. He has not had any further episodes of thrombocytopenia to date. DISCUSSION: After exclusion of other causes, the onset of thrombocytopenia after administration of lansoprazole, the resolution of the adverse reaction after discontinuation of the drug, and the fact that no other medicines were introduced during this time frame lead us to believe that this was most likely an idiosyncratic thrombocytopenic response to lansoprazole. To date, this is the first reported case of what appears to be isolated thrombocytopenia associated with lansoprazole. CONCLUSIONS: Clinicians should be aware of the possible association of thrombocytopenia with lansoprazole and discontinue the drug if thrombocytopenia becomes apparent.