Bariatric surgery benefits diminish over time
WHILE bariatric surgery is associated with weight loss and improvements in obesity-related disorders, a follow-up study has found that, over the longer term, patients have significant weight gain and reduced remission rates of diabetes and of other comorbities. The research, published in JAMA Surgery, was based on data collected from all patients who underwent laparoscopic sleeve gastrectomy (LSG) between 2006 and 2013. Of the 443 LSGs performed, all by the same surgical team, complete data were available for 54.4% of patients at 1-year follow-up, for 49.4% at 3 years, and 69.6% at 5 years. The degree of excess weight loss at each year of follow-up was 76.8%, 69.7%, and 56.1%, respectively. Complete remission of diabetes was maintained in 50.7%, 38.2% and 20.0% of patients, respectively, and remission of hypertension was maintained in 46.3%, 48.0% and 45.5%, respectively. The changes in high-density lipoprotein cholesterol and triglyceride levels were significant when compared with preoperative and postoperative measurements. The reduction in low-density lipoprotein cholesterol level was also significant at 1 and 3 years, but the effect at 5 years was not statistically significant, the authors wrote. Changes in total cholesterol levels failed to reach statistical significance for any of the follow-up groups. The authors wrote that their results should be taken into consideration during “the decision-making process for the most appropriate operation for a given obese patient”. An accompanying commentary said more data on bariatric surgery was needed, and that doctors should “avoid a rush to judgement”. In the meantime, “clinicians and prospective patients will need to discuss and weigh the evidence in a dynamic exchange driven not always by final conclusions but by the most current available data”.
Intervene with young “picky” eaters´
RESEARCHERS have suggested health care providers should intervene in instances of even moderate levels of selective eating (SE) in preschool-aged children after finding that both moderate and severe levels of SE were associated with psychopathological symptoms (anxiety, depression, attention-deficit/hyperactivity disorder), both concurrently and prospectively. The research, published in Pediatrics, was based on a population cohort sample of 917 children aged 24‒71 months and their caregivers who were recruited through primary care practices. SE was reported for 20.3% of the children, with 17.7% showing moderate SE (restricted diet only) and 3.0% severe SE (restricted diet that limited their ability to eat with others). The research also showed that the mothers of children with moderate levels of SE were more likely to have sought psychiatric treatment for themselves than the mothers of children with more severe SE, and high maternal anxiety distinguished both clinical groups from controls. The children with moderate levels of SE were also more likely to have mothers with a history of drug abuse. Children with severe SE were more likely to be female. “SE has proved challenging for health care providers, in part because of the prevalence of this eating pattern”, the researchers wrote. “Our findings suggest that the term SE (or “picky eating”) is now obsolete. If an individual presents to primary care with the presenting problem of SE, then impairment is implied.” They said eating patterns might be better characterised using the diagnostic category of avoidant/restrictive food intake disorder, an eating disorder new to the DSM 5.
Most surgical readmissions due to patient factors
AN analysis of patient data after major surgical procedures has found that more than 80% of the variation in 30-day surgical readmission outcomes was attributable to factors related to the individual patient. The research, published in JAMA Surgery, found that only 14.5% of readmission variation was associated with surgical service, while less than 3% was accounted for by surgeon-level factors. The research was based on data collected over 5 years for 22 559 patients who underwent a major surgical procedure performed by 56 surgeons practising in eight surgical subspecialties. Preoperative comorbidity was noted in 65.1% of patients, while postoperative complications were recorded for 21.6% of patients. These varied from 2.1% following breast, melanoma or endocrine surgery to 37.0% after cardiac surgery. The overall 30-day readmission rate was 13.2%, but differed considerably across the eight subspecialties, ranging from 24.8% following transplant surgery to 2.1% after breast, melanoma or endocrine surgery. After adjusting for patient- and surgeon-level variables, factors associated with greater odds of 30-day readmission included African-American race/ethnicity, increasing comorbidity, postoperative complications and an extended length of stay. The researchers wrote that, although some of the variation could be explained by differences in disease pathology and the type of procedure performed, “the overwhelming majority of this variability was attributable to nonmodifiable patient level factors”. They said the study echoed “growing concerns regarding the use of readmission as a quality metric” for hospitals.
The pill associated with reduced risk of endometrial cancer
THE longer women use oral contraceptives (OCs), the greater the reduction in risk of endometrial cancer, according to a meta-analysis published in The Lancet Oncology. Data for 27 276 women with endometrial cancer and 115 743 controls in 36 epidemiological studies from North America, Europe, Asia, South Africa and Australia were analysed. The median age of women when first diagnosed with endometrial cancer was 63 years. The authors found that 35% of those with endometrial cancer and 39% of those without cancer had previously used OCs for a median duration of 3.0 and 4.4 years, respectively. Each 5 years of OC use was associated with a risk ratio of 0.76, the authors wrote. This risk reduction persisted for more than 30 years after OC use had ceased, and there was no apparent difference in the risk reduction associated with OC use during the 1960s, 1970s and 1980s, despite the higher oestrogen doses in pills earlier decades. However, the reduction in risk associated with ever having used OCs differed according to tumour type, being greater for carcinomas than sarcomas. The authors said their results suggested that about 200 000 cases of endometrial cancer before the age of 75 years had been prevented in developed countries by OCs in the past decade. Most of the analysed studies probably involved combined OCs, which might protect against endometrial cancer by minimising exposure to unopposed oestrogen during the follicular phase of the menstrual cycle, therefore inhibiting oestrogen-induced cell proliferation, the authors wrote. An accompanying comment said the research highlighted the need for women to be more aware of “the unintended benefits and the risks of oral contraceptives, so that they can make informed decisions”.
Music in operating theatre a safety hazard
A SMALL UK study has found that music played in the operating theatre can interfere with team communication, but is seldom recognised as a potential safety hazard. The research, published the Journal of Advanced Nursing, was based on video recordings of 20 operations over 6 months in two UK operating theatres. Each case was logged using a request/response sequence identified by interactional analysis, with a total of 5203 observations documented. The study revealed that repeated requests were five times more likely to occur during operations where music was played than in those without music. The authors wrote that each repeated request could add between 4 and 68 seconds to operation time, and increased tensions due to frustration at ineffective communication. “Our observations suggested that team members often increased the volume when a song was particularly liked”, the researchers wrote. “When music was very loud (as judged by the research team), communication was clearly disrupted (as noted by the team members themselves).” They wrote that the potential dangers of instructions going unnoticed or being misheard, the implications of avoidable noise on team members with hearing or attentional problems, and that music could be perceived by some as an “irksome distraction rather than a relaxing mood enhancer”, pointed to the need to urgently address music at both the practical and policy levels. “The study recommends frank discussions with team members and clinical managers about playing music during operations.”
Combined impact of smoking and early menopause
A LARGE prospective cohort study has confirmed that the effects of age at menopause and of smoking interact in predicting mortality, suggesting that smoking exaggerates the effects of oestrogen deficiency in women who experience menopause at younger age. The study, published in Menopause, was based on 25 474 Swedish women aged 48–83 years who between 1987 and 1990 completed a questionnaire on lifestyle, diet, anthropocentric traits, general health and women’s health. In 1997, women who were still living completed a second questionnaire that included additional items, such as smoking status and physical activity. Across 16 years of follow-up, the difference in median age at death between women who underwent menopause at 40 years or 60 years was 1.3 years. The authors found that the median age at death for former smokers and those who had never smoked was greater than that for current smokers by 2.5 years and 3.6 years, respectively. The difference in age at death for current smokers who underwent menopause at 40 years or at 60 years was 2.6 years. The authors wrote that, unlike previous research, this study found a non-significant association between age at menopause and mortality among those who had never smoked. They said that hormone therapy might be related to smoking, age at menopause and mortality, and that “future studies might further investigate its role in the examined scenario”.