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Posts Tagged ‘diabetes’

After recent changes in the recommendations for the treatment of obesity and diabetes supporting the use of surgery (as previously discussed here) American hospitals have begun aggressively campaigning for medical tourists.. Several hospitals in Tennessee have created Bariatric programs to steer interested patients to their clinics – and in some cases are using TennCare dollars to do so. (TennCare is the Tennessee medicare program – which has been plagued with problems since it’s inception.)

With the FDA lowering the BMI restrictions for Lap-band procedures in particular, this procedure which is often marketed as the ‘easy bariatric surgery’ has taken off in popularity.  This is concerning since much of the research shows this device to be limited in effectiveness, particularly in the treatment of diabetes.

These BMI restrictions which were reduced from a BMI of 35 (with diabetes)  down to 30 can also be viewed as a government endorsement of the Lap-Band device since similar recommendations regarding the more definitive procedures such as Roux-en-Y have not been addressed.  It looks like a double win for this private company (Allergan) as the FDA prepares to approve this device for use in teenagers as young as 14, despite criticisms from the medical community.

Now in the past, I have strongly advocated for better and more aggressive treatment recommendations for diabetes and morbid obesity – but I have also believe in following the scientific data and research findings – which just don’t seem to support Lap-Banding for permanent / effective weight loss or blood sugar reductions.  Like we’ve seen several times before, these ‘easy’ quick fix solutions to try to take short cuts around surgery don’t always work – and in the end, you end off worse off then someone who didn’t have any procedures at all.  If patients want effective solutions to real problems – we should give it to them.  But we need to stop candy coating the risks and dangers, and hard selling devices, and give patients the actual facts.

I’d also like to recommend that interested readers sign up for Medscape.com accounts – it’s free and they have an entire section devoted to obesity/ diabetes/ bariatric procedures that highlights all of the research related to different procedures, and treatments.  I try to re-post when I can but it’s difficult for lengthy articles.

In that spirit – I have re-posted the latest gastric bypass article from Heartwire below.  (Interesting commentary that heartwire has a bariatric surgery section now.) It’s another Reed Miller report dated May 2, 2011:

Gastric Bypass Does More than Reduce Weight

April 29, 2011 (New York, NY) — Gastric-bypass surgery may provide benefits to patients with type 2 diabetes beyond the benefits that can be directly attributed to weight loss, a new study finds [1].

According to Dr Blandine Laferrère (St Luke’s Roosevelt Hospital, New York, NY) and colleagues, recent studies that show a strong correlation between the concentrations of plasma branched-chain amino acids (BCAAs) and related metabolites with insulin resistance and loss of insulin sensitivity raise the possibility that the rapid remission of diabetes seen in many diabetic patients after gastric-bypass surgery may be related to the pronounced changes in BCAAs or other metabolites and not the weight loss alone.

In a study published in the April 27, 2011 issue of Science Translational Medicine, Laferrère et al found the total amino acids and BCAAs decreased in the gastric bypass surgery group but not in a similar group of patients who lost the same amount of weight (10 kg) with diet alone. Also, the metabolites derived from BCAA oxidation decreased only in the surgery group. Levels of acylcarnitines and BCAAs and their metabolites were inversely correlated with proinsulin concentrations, C-peptide response to oral glucose, and the insulin-sensitivity index after weight loss, whereas the BCAAs and their metabolites were uniquely correlated with levels of insulin resistance.

These data suggest that the enhanced decrease in circulating amino acids that follows weight loss after gastric-bypass surgery is caused by a mechanism other than weight loss and may be related to why gastric-bypass patients often show more rapid improvement in glucose homeostasis than similar patients who lose weight without surgery, Laferrère et al conclude. However, the authors caution, “Whether the decrease in these metabolites and the implied activation of fuel oxidation is a cause or consequence of the diabetes remission after gastric bypass remains to be determined. . . . Future studies will further characterize the pathways involved in these metabolic alterations and will seek to understand whether the specific metabolic signature of [gastric-bypass surgery] is related to changes in gut peptides after surgery.”

In an accompanying perspective [2], Drs Robert E Gerszten and Thomas J Wang (Harvard University, Boston, MA) agree that “further work is needed to establish whether the reduction in concentrations of circulating amino acids after weight loss is the cause or a consequence of improvements in insulin sensitivity.”

Circulating amino-acid concentrations are likely to be determined partly by genetics and partly by environmental and nutritional factors, they explain, so “dissecting these effects will require nutritional manipulation studies with a variety of amino acids to be conducted in human subjects, especially given the availability of profiling technologies that permit characterization of the molecular consequences of such interventions,” the editorialists state.”

To the multiple readers who emailed me for more bariatric surgery/ diabetes information – I usually post whenever new or interesting information gets published. If you send specific questions about procedures, indications or related matter – I will try and address it in a future post.

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Intra – Operative Myocardial Infarction 

One of the most feared, yet preventable complications is intra-operative / post operative myocardial infarction (heart attack).  Alarmingly, a new paper published on Medscape by Reed Miller suggests that too often we aren’t doing enough to prevent this devastating complication and miss the diagnosis of this condition when it does occur*.

In many cases, patients are asymptomatic, which is no cause for relief – since the thirty day mortality after post-operative infarction is frightening high.  Part of my job in my practice as an acute care nurse practitioner in cardiovascular and thoracic surgery is to perform pre-operative risk stratification and risk reduction for this, and other potentially preventable complications.

There are several important, but easy things we can do to reduce the risk of our patients having a heart attack during or immediately after surgery:

Pre-operative Evaluation:

1. First, screen your patient for the presence of anginal symptoms and associated risk factors – before scheduling an operation.  Surprisingly, many patients are experiencing atypical angina, dyspnea on exertion and other symptoms in their daily lives, yet ascribe these symptoms to “being out-of-shape” or “getting old”.

If there is one thing, I’ve learned after greeting people in the cardiac cath lab to tell them they need heart surgery – it’s that the majority of people tend to ignore or overlook subtle signs until acute chest pain, or an infarction brings them to the hospital.  So, ask you patients about these symptoms, so you aren’t surprised in the operating room.

Ask yourself, What other risk factors do they have?

–     Diabetes, (of any duration) should prompt consideration for pre-operative cardiology workup and a possible exercise stress test.

–     Claudication (peripheral vascular disease), carotid stenosis (or hx of TIAs) or any other history suggestive of arterial disease

–     Elevated cholesterol or unknown cholesterol status, history of cholescystetomy or gallbladder disease or visible xanthomas (particularly on the face)

–    Advanced age – anyone over the age of 65

–    Hypertension, particularly if poorly controlled

–    Anemia, of any origin

–    Poor overall health, poor exercise tolerance (again this may be related to undiagnosed angina)

2. Secondly, Pre-operative Maximization!! This is important for  all major surgeries, but often isn’t implemented for orthopedic, general surgery and other large surgeries.  The other thing to realize is, this isn’t the anesthesia team’s job; it’s the attending surgeon and the primary care physician (jointly).  This means controlled, or correcting all of the items listed  in the previous section (as much as possible):

– cardiac evaluation for patients at medium / high risk for cardiac disease – and having an index of suspicion for people with vague  symptoms.

– treating underlying disease conditions – for example, if your patient has a hemoglobin A1c of 9.0 – delay elective cases until glucose is better managed.  Remember to monitor and manage glucose in the operating room too – unfortunately, this is often only done in cardiac surgery, but it’s important during all surgeries.  Intraoperative Hyperglycemia is an independent risk factor for myocardial infarction/ and is considered a ‘marker’ for infarction.

And check everyone, not just diagnosed diabetics – since hyperglycemia occurs in some normal individuals under physiological stress, and diabetes is grossly underdiagnosed.

Don’t discontinue statins pre-operatively – not only does evidence suggest that statins are protective against intraoperative strokes and sepsis, but the evidence to support discontinuing these medications preoperatively is slim.  Too often, we
discontinue patients needed medications as part of a routine, not an individualized treatment plan.  (Now clopidogrel (Plavix) and warfarin are a little different, but sometimes we continue these medications too – in very
select cases..)

Pre-operative beta blockade – the evidence is overwhelming
in favor of pre-operative beta blockade, yet some people are still neglecting
this (or even stopping these medications in people already on them.)  Continue metoprolol, carvedilol, propanolol, and make sure to ask why patients are taking them in the first place.  “Heart medicine” is an answer that should prompt further investigation.

– Consider and re-consider before discontinuing Aspirin.  In our thoracic (and cardiac ) surgery patients – we always continue aspirin, safely, and have had no increase in bleeding complications.  Often, surgeons can very safely operate on patients taking aspirin – but discontinuing it in these patients may contribute to the risk of intraoperative/ postoperative infarction.

Intraoperatively:

–  Control that heart rate!  We KNOW through decades of research that
slower is better.  Keep the heart rate at sixty or below to reduce cardiac demand.

–   Prevent hypotension – keep the MAP at 70 or above (and be particularly intolerant of hypotension in anyone with a cardiac history –you don’t want to collapse those grafts.
Remember that patients with vasculopathic disease don’t tolerate low
blood pressure as well as you or I – and don’t allow it (low blood pressure) to happen.

–    Monitor for changes in telemetry during the case.

–    Monitor and control hyperglycemia (as mentioned above.)

Article Re-Post from Medscape (Reed Miller):

MIs After Noncardiac Surgery are Often Overlooked

April 20, 2011 (Hamilton, Ontario) — A new study from the Perioperative Ischemic Evaluation (POISE) trial suggests that monitoring non–cardiac-surgery patients for asymptomatic MIs in the first few days after surgery could dramatically reduce their short-term mortality risk [1].

The study shows that “consistently, all over the world, people are at substantial risk of suffering a heart attack after surgery, and if they do, they’re at substantial risk to die or suffer a major event in the coming days, and we need to do a better job to detect them and manage them,” primary author Dr PJ Devereaux (McMaster University, Hamilton, ON) told heartwire. “We want to make the broader cardiology world aware that this is a huge emerging epidemic that’s going to confront cardiology, because there are 200 million adults having surgery every year in the world. . . . We need to get a lot more aggressive about monitoring for these events and recognizing that the majority of people won’t have symptoms when they have these events.”

Devereaux and colleagues followed 8351 patients at 190 centers in 23 countries with four cardiac biomarker assays for three days postsurgery. All of the patients were part of the original POISE trial, reported by heartwire, which showed that beta blockers reduce the risk of MI but increase the risk of severe stroke and overall death in patients undergoing non–cardiac surgery (including orthopedic, cancer, and noncardiac vascular surgeries). Results of the new study by Devereaux et al are published in the April 19, 2011 issue of the Annals of Internal Medicine.

“Surgery is sort of the ultimate stress test. It does everything that is relevant to causing acute coronary syndrome. It’s very proinflammatory, and it activates the sympathetic system, coagulation, and platelets. That’s why we have this problem of people having myocardial infarction after surgery, [and yet until now] there’s not that much research on the outcomes of heart attacks after surgery,” Devereaux told heartwire. Patients and physicians are often unaware of an MI during this early postoperative period because most of the patients are on high doses of narcotics that “blunt the discomfort of the surgery but may mask ischemic symptoms,” Devereaux said.

Within 30 days of randomization, 415 patients in the study (5.0%) showed evidence of a perioperative MI, defined as either autopsy findings of acute MI or an elevated level of a cardiac biomarker or enzyme assay plus ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI. Nearly three-quarters of the MIs happened within 48 hours of the surgery, but almost two-thirds of the MI patients did not did not experience ischemic symptoms. In fact, patients with a periprocedural MI without ischemic symptoms had a higher mortality rate (12.5%) than those who had symptoms (9.7%).

The short-term prognosis for patients who suffer periprocedural MIs is very poor, with 11.6% mortality at 30 days postprocedure compared with 2.2% for patients who did not suffer a periprocedural MI (p<0.001). Furthermore, Devereaux noted that a recent meta-analysis by his group found that people who suffer a periprocedural MI continue to be at higher risk for death than those who do not for at least a year after the surgery.

Nobody thinks twice about being incredibly assertive about managing an MI in the emergency room . . . [and yet] those MIs have a much better prognosis than these MIs, and we’re ignoring these MIs for the most part.

Regression analysis of the data showed that relatively simple therapies could have prevented many of these deaths. In the study, patients on aspirin had about half the 30-day mortality risk as those not on aspirin, while statins reduced the 30-day mortality rate by about three-quarters. Only 64.8% of patients who suffered an MI in the trial were on aspirin, only 17.8% were receiving clopidogrel or ticlopidine, 52.0% were receiving a statin, and 55.4% were receiving an ACE inhibitor or angiotensin-receptor blocker.

“Patients expect us to look for things that are modifiable and change their risks of very serious events quickly, and perioperative MI is definitely in that category,” Devereaux said. “Nobody thinks twice about being incredibly assertive about managing an MI in the emergency room, which is completely appropriate, but those MIs have a much better prognosis than these MIs, and we’re ignoring these MIs for the most part.”

Commenting on the study by Devereaux et al, Dr Adrian Banning (John Radcliffe Hospital, Oxford, UK) told heartwire, “We are not optimizing medical therapy before surgery. There are existing guidelines and risk scores that are probably underused. Preoperative testing for ischemia and revascularization is probably overused in a minority of patients, leaving an occult majority without simple medical measures that are likely to be beneficial–including aspirin, statins, and good perioperative blood-pressure control.”

More Research Needed to Clarify Who Is at Risk and How to Treat Them

Devereux’s group is currently enrolling patients into the 40 000-patient prospective cohort VISION study, which is intended to define the optimal approach for predicting major perioperative vascular events, the extent to which troponin measurement after surgery can identify asymptomatic MIs, and these patients’ risk of vascular-related death within one year.

The first 20 000 patients in the study have been monitored with “fourth-generation” troponin assays, and the next 20 000 will be monitored with higher-sensitivity troponin assays. Commenting on the research, Dr Stephen Ellis (Cleveland Clinic, OH) pointed out that with the advent of highly sensitive troponin tests, more research will be needed to define what degree of troponin change is clinically important. “I’m sure there’s some level of troponin where you see a bump that doesn’t mean anything.” For example, Banning and colleagues recently completed a study that suggests the current standard troponin cutoff used to detect an MI has been arbitrarily set too low and leads to an overestimate of the number of MIs.

Dr John French (University of New South Wales, Australia) added that future research should also try to risk-stratify these patients by collecting both pre- and postprocedural troponin levels. Elevated preprocedural troponin may also be a risk marker, he told heartwire.

Devereaux hopes there will also soon be a large national trial to evaluate the best way to manage non–cardiac-surgery patients in the vulnerable perioperative period. Ellis agreed that “we don’t really understand the benefits of some of the medical treatments that we have in our armamentarium in this patient population. . . . There may be some other treatments that are less utilized at present that could cut down on the incidence of perioperative infarction.”

Banning agreed that further research is needed to understand how to prevent these perioperative MIs, not merely detect them. “Troponin measurement postoperatively can help define a risk group with adverse outcome, [but] it is uncertain that we can influence that adverse outcome once the event has happened in those patients already on optimal medical therapy,” he said. “There will be a group identified by routine troponin testing where this event is the first declaration of occult coronary disease, and perhaps this group potentially has the most to gain.”

Although the best approach to managing these patients has yet to be clearly defined, Devereaux emphasized that “in the short term, there’s a lot of intuitive things that we can do better that will likely improve the outcomes, and there’s lots of reasons to be optimistic that, even if we just start monitoring them, we can improve the outcomes.” Devereaux recommends that physicians caring for a surgery patient order a troponin test sometime between six and 12 hours after the surgery and then repeat tests for the first three days after surgery.

His institution has made perioperative MI prevention a priority for its cardiologists. “We’ve changed cardiology from regular cardiology to cardiology and perioperative vascular medicine,” he said. All surgery patients’ cardiac biomarkers are monitored, and the patients are triaged to the coronary care unit or less-intensive care based on their MI risk. He expects his group will be able to present data on the impact of this approach within the next year.

This study was supported by the Canadian Institutes of Health Research, the Commonwealth Government of Australia’s National Health and Medical Research Council, the Instituto de Salud Carlos III in Spain, the British Heart Foundation, and AstraZeneca.

part of patient education series – Ask your doctor about your risk for peri-operative MI, and what he’s doing to reduce your risk.

* Diagnosing MI after surgery is another article.

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Another example in the realm of surgery where easiest doesn’t equal most effective: gastric banding (lap-band). This is one of those procedures highly touted in American medicine – and heavily advertised on television as an ‘easy’ way to lose weight..

First, let’s get some things clear – the ‘easy’ mentality needs to go away in medicine, and so does the pushing of this concept with patients.. None of this; not surgery, weight loss drugs, or conventional treatment is easy for the patient..It’s all hard work, so don’t mislead your patients – that sets them up for failure..

In the article linked here (from the LA times, February 2011) the two doctors interviewed do their best to avoid answering the easy/ effective question. “I let the patient decide,” which is a royal cop-out. Patients come to doctors for expert opinions and recommendations not wishy-washy information that doesn’t present the facts and evidence. The picture accompanying the article is disturbing as well, since it’s captioned as a patient awaiting lap-band.. The patient is clearly morbidly obese – yet is undergoing the least effective option available!

What makes this frustrating to me – is that in talking to patients – is that it’s usually such a long road to even get to bariatric surgery.. Contrary to popular belief and tabloid reporting, the majority of overweight people don’t jump to bariatric surgery.. These patients spend years (sometimes decades) dieting, gaining and losing weight..
This isn’t always the case in other countries where surgery is more readily available – but in the USA where insurance coverage or lack there of, usually dictates care – bariatric surgery is usually the end of a long, frustrating road..

I know I’ve discussed this before on the site – but I feel that there needs to be transparency in treatment options – and that we need to do away with the ‘easy’ concept whether it’s bariatric surgery, stents or even medications.. Don’t sell people easy – give them safe, proven and effective.

I’ll be updating the article over the next few days with links for more information – and hard facts about surgical options and obesity surgery.

Related Articles: Free full-text links: (my titles, the actual titles are a bit longer)

1. It’s Not Easy – a study looking at the patients perspective, and perceptions before and 2 years after bariatric surgery.

2. Current treatment guidelines and limitations – a discussion of current treatment guidelines in the USA and Canada

3. German study with 14 year outcomes after gastric banding – this is a nice study because they use terms that are easily understood for laypeople – and shows decent outcomes for patients with this procedure

4. Single port bariatric surgery – this has been a hot topic over at the sister site. This article discusses the most recent innovations in surgical techniques for bariatric surgery.

5. A review of the current data (2008) surrounding bariatric surgery, obesity, and diabetes and the cost of care.
This is a particularly good article (reviews often are) because it gives a nice summary of multiple other studies – so intead of reading about eight patients in Lebanon or some other small group – you are getting a good general overview..also it gives a good idea the scope of the problem..

I’m trying to collect a wide range of articles for patient education; unfortunately, since surgeons in Latin America are on the forefront of bariatric surgery – a lot of the most interesting articles are in Spanish and Portuguese (or paid articles). i haven’t posted the translations since they are secondary source and all of the other citations are primary source.

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There’s a great new article over at Medscape by David Lautz, MD; Florencia Halperin, MD; Ann Goebel-Fabbri, PHD; Allison B. Goldfine, MD
that was recently published in Diabetes Care 2011;34(3):763-770 entitled

“The Great Debate: Medicine or Surgery: What Is Best for the Patient With Type 2 Diabetes?”

It’s quite lengthy so I won’t repost here – but it’s definitely recommended reading for my diabetic readers out there. I have included some highlights from the discussion – which correlate with much of what we’ve previously discussed here.

Re-post from article:
“Recent observational studies demonstrate that bariatric surgical procedures reduce the incidence of type 2 diabetes and lead to substantial improvement or “resolution” for many patients with preexisting disease. Type 2 diabetes has “resolved” (defined in the surgical literature as maintenance of normal blood glucose after discontinuation of all diabetes-related medications, in most studies with HbA1c 35 kg/m2 and raise the question of whether surgical interventions should be considered earlier in the course of disease or for lesser magnitude of excess weight and specifically for the treatment of diabetes as opposed to treatment of obesity.”

It’s a nice well-balanced article, which discusses the theories behind the resolution of diabetes after surgery (Roux-en-Y gastric bypass), as well as the concerns of endocrinologists about the use of surgery for diabetes management. The authors give a nice detailed description of the various bariatric surgery procedures and nonsurgical treatment options, in a fair and balanced manner. It’s a timely article, coming on the heels of the recent AHA statement – which harks back to an era of blaming the patient and ignoring the problem..

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In honor of the Latin-American Bariatric Surgery Congress, currently in progress in Cartagena – (since I couldn’t make time in my research to go) I am posting a brand new article about bariatric surgery and the severely obese. It seems American medicine is finally starting to catch up, and take notice..

It’s hard concept out there – and I still have trouble with it myself, sometimes.. In our society, it seems we are too busy blaming ourselves, and others for being overweight and attaching labels; ‘lazy’, to really see how fundamentally things need to change to improve our health as a nation.

From my perspective, down here in Bogota – it’s interesting, because I am seeing Colombians just beginning to start to struggle with obesity – as more and more imported snack foods, and fast foods replace traditional diets. Obese people are still very rare here – and after several months, I can still say I’ve not seen a single super-obese person here, but the ‘chubbies’ are starting to grow in number..

At the same time, by being in such a walkable city, and having access to (cheap!), delicious, ripe fruit every day, I’ve managed to lose over ten pounds with almost no effort.. I’ve been tracking my walking, and I walk about 6 to 10 miles a day with my various errands. But these are things that aren’t readily available – in the urban sprawl of American life.. A week’s worth of fruit for several meals for ten dollars? Not hardly, unless you gorged yourself on bananas every single day..

Surgery as a solution seems drastic to American healthcare providers, myself including.. Removing/ destroying a perfectly functioning organ.. But then – when you look at the drastic effects, and the desperate states our patients are in – Bariatric surgery really is as lifesaving as cardiac surgery for many people.. Until we change society as a whole (which may never happen), we need to help these individuals regain their health,and their lives..

Bariatric Surgery for the Severely Obese

In the meantime, everyone, stay away from soft drinks (all soft drinks, including ‘diet drinks’, juices and fruit drinks, sweet tea) and stick to water, plain tea. Coffee too – if you remember not to load it up with too many calories.. Try it for a month, and I wager you will be unable to go back to the supersurgery drinks you formerly enjoyed out cringing..

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As some of you know – I took on the coffee challenge in graduate school after a few stupid comments from classmates over my coffee drinking habit (I like about four cups a day).. So as part of a grad school assignment I reviewed the literature surrounding coffee, and the active ingredients in coffee and it’s kin (cocoa) and wrote about the health benefits of the methylxanthines; theophylline, theobromide, and caffeine.. I talked about the use of theophylline to prevent anoxic injury to the brain and to help restore spontaneous circulation in people after brady/asystolic arrest..
I also debunked some of the common myths surrounding ‘theophylline toxicity’ and it’s unwarrented and tarnished reputation.**

** (check the potassium level, everyone – and know that the effective / therapuetic range is actually 5 to 10 not 10 to 20)

Since then I hae been ardent follower of coffee drinking/ health stories..
– We now know it doesn’t precipitate atrial fibrillation – as demonstrated in several very large studies last year..

– It’s protective against diabetes and pancreatic cancer..

and now, ladies – it appears the health effects extend to a stroke benefit as well.. Now, maybe it isn’t all true – but the next time someone makes a smarmy comment about coffee harming your health – here’s some ammo to fire right back at them..

Here’s some links to the story- which was widely reported, and picked up by AP.

Coffee reduces Stroke

http://news.yahoo.com/s/ap/20110310/ap_on_he_me/us_med_coffee_stroke

http://consumer.healthday.com/Article.asp?AID=650753

LA timesNow – just make sure you haven’t ruined it with 300 calories worth of fat and sugar..

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Many people assume that lives change after a heart attack or heart surgery.. Unhappily, most of us in medical field know that this just isn’t true.. Radical diet and lifestyle changes are the exception, not the norm..

Life after Heart Surgery – LA Times

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