Inappropriate acute neurosurgical bed occupancy and short falls in rehabilitation: implications for the National Service Framework

Patients undergoing neurosurgical intervention may require different types of organized rehabilitation. A prospective study was performed of the care needs of neurosurgical inpatients between the ages of 16 and 70 years who were in acute wards for more than 2 weeks. Only 58% of bed occupancy days were devoted to essential acute neurosurgical ward management. This figure was even lower for patients admitted with subarachnoid haemorrhage (36%) or traumatic brain injury (38%). Overall, 21% of bed days would have more appropriately spent in 'rapid access'/acute rehabilitation beds, 13% in 'active participation' rehabilitation beds and 5% in cognitive/behavioural rehabilitation units. Addressing this unmet need would increase the availability of acute neurosurgery beds, without needing to build and staff more neurosurgery wards.

Pregabalin in the treatment of spasticity: a retrospective case series

PURPOSE

To evaluate the therapeutic effects of the GABA analogue, pregabalin, on patients with conditions producing spasticity who had not responded to, or experienced problems with side-effects of the available anti-spasticity agents.

METHOD

A retrospective case series review of 22 patients who were prescribed open label Pregabalin as monotherapy for spasticity, starting with 75 mg bd and increasing to 300 mg bd. Twenty one of these patients had previously tried gabapentin, 19 had tried baclofen, 7 had tried tizanidine and 3 had tried dantrolene.

RESULTS

Twelve patients perceived a definite reduction in symptoms of spasticity with pregabalin, and 9 continued to take it. Eight patients experienced significant side-effects which limited its use, 5 experienced no beneficial or adverse effects.

CONCLUSIONS

Pregabalin may be of value as a systemic agent in the treatment of spasticity, although properly controlled studies with clearly defined outcome measures are required to confirm this finding. This is relevant to the study of disability and rehabilitation because of the difficulties encountered in the management of spasticity and the impact that this can have on the rehabilitation of individuals with neurological conditions.

Clinically significant benign pneumoperitoneum as a complication of percutaneous endoscopic gastrostomy

Benign pneumoperitoneum is a complication of percutaneous endoscopic gastrostomy (PEG) feeding tube placement. The rate of occurrence is reported as up to 25%. It is usually an incidental finding that arises immediately following the procedure. We report a case of pneumoperitoneum that developed a significant time after the initial procedure. The patient developed intractable vomiting and had to be fed parenterally. The pneumoperitoneum resolved and the gastrostomy tube feed was re-started.

Gastric bypass surgery in adolescents with morbid obesity

OBJECTIVE

The objective was to review retrospectively all patients undergoing bariatric surgery at a large university medical center.

METHODS

Ten adolescents 17 years or younger underwent gastric bypass surgery; 7 of 10 adolescents had severe obesity-related morbidities. Follow-up >1 year was present in 9 of 10 adolescents.

RESULTS

The average weight before surgery was 148 +/- 37 kg. Postoperative recovery was uneventful in all adolescents; 9 of 10 adolescents had weight loss in excess of 30 kg (mean weight loss was 53.6 +/- 25.6 kg). Obesity related morbidities resolved in all adolescents. Five adolescents had mild iron deficiency anemia, and 3 adolescents had transient folate deficiency. Late complications requiring operative treatment occurred in 4 of the adolescents.

CONCLUSION

Gastric bypass surgery was an effective method for weight reduction in morbidly obese adolescents. The procedure was well tolerated, with few unanticipated side effects. Gastric bypass remains a last resort option for severely obese adolescents for whom other dietary and behavioral approaches to weight loss have been unsuccessful.

Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity

There are no longitudinal data that address weight loss stability and lipid levels in bariatric surgical patients. The goal of this study was to determine whether weight regain adversely affected reduction in lipid levels after gastric bariatric operations. Of 651 consecutive patients undergoing gastric restrictive surgery for morbid obesity, 227 (35%) had increased serum levels of total cholesterol (TC), triglycerides, or both preoperatively. High-density lipoprotein cholesterol (HDL-C) levels were subnormal (</=35 mg/dl) in 45 (20%) of the hyperlipidemic patients. Fasting lipid profiles were determined at 6-month intervals postoperatively. This series included the following three operations: gastroplasty (GP; N = 13), standard Roux-en-Y gastric bypass (RYGB; N = 205), and distal Roux-en-Y gastric bypass (DRY; N = 9). By 6 months postoperatively, patients had a >/=15% mean reduction in TC and a >/=50% mean reduction in triglycerides, both of which were significant in comparison with preoperative levels (P </=0.05). Mean HDL-C levels had increased significantly vs. preoperative levels by 12 months postoperative y (P <0.05) and continued to increase through 5 years. By 18 months both HDL-C and TC were significantly lower after DRY than after GP or RYGB. In 91 patients who were followed for 2 years or longer (mean 48 +/- 25 months), mean excess weight loss was 55% with mean body mass index reduced from 48 to 33 kg/m(2). This group was divided into patients whose weight remained stable (N = 54) and patients who regained >/=15% of their lost weight or lost less than 50% of excess weight (N = 37). Although mean excess weight loss and body mass index were significantly different between the two groups (P <0.0001) at 2 years, there was no difference in the lipid profile (TC/HDL) between the two groups at any interval through 5 years. These results show that abnormal lipid profiles can be permanently improved after gastric bariatric surgery and are not adversely affected by mediocre weight loss or regaining >/=15% of lost weight. DRY appears to be a superior operation for TC reduction in comparison with GP and RYGB.

The Vision First Check Program in British Columbia: a preschool vision screening program for children age two and age three

The Vision First Check Program was developed in consultation with ophthalmology and optometry representatives on the provincial Vision Advisory Committee and piloted by participating optometrists in four communities in BC between January and June 1998. This preschool vision screening program provides for one vision screening for children aged two and three at no cost to the family or the Medical Services Plan of BC. The screening is by optometrists, the marketing of the program is coordinated through public health, and the data collection is coordinated through the Medical Services Plan as a no-fee item.

Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass?

Although iron, vitamin B12, and folate deficiency have been well documented after gastric bypass operations performed for morbid obesity, there is surprisingly little information on either the natural course or the treatment of these deficiencies in Roux-en-Y gastric bypass (RYGB) patients. During a 10-year period, a complete blood count and serum levels of iron, total iron-binding capacity, vitamin B12, and folate were obtained in 348 patients preoperatively and postoperatively at 6-month intervals for the first 2 years, then annually thereafter. The principal objectives of this study were to determine how readily patients who developed metabolic deficiencies after Roux-en-Y gastric bypass responded to postoperative supplements of the deficient micronutrient and to learn whether the risk of developing these deficiencies decreases over time. Hemoglobin and hematocrit levels were significantly decreased at all postoperative intervals in comparison to preoperative values. Moreover, at each successive interval through 5 years, hemoglobin and hematocrit were decreased significantly compared to the preceding interval. Folate levels were significantly increased compared to preoperative levels at all time intervals. Iron and vitamin B12 levels were lower than preoperative measurements and remained relatively stable postoperatively. Half of the low hemoglobin levels were not associated with iron deficiency. Taking multivitamin supplements resulted in a lower incidence of folate deficiency but did not prevent iron or vitamin B12 deficiency. Oral supplementation of iron and vitamin B12 corrected deficiencies in 43% and 81% of cases, respectively. Folate deficiency was almost always corrected with multivitamins alone. No patient had symptoms that could be attributed to either vitamin B12 or folate deficiency Conversely, many patients had symptoms of iron deficiency and anemia. Lack of symptoms of vitamin B12 and folate deficiency suggests that these deficiencies are not clinically important after RYGB. Conversely, iron deficiency and anemia are potentially serious problems after RYGB, particularly in younger women. Hence we recommend prophylactic oral iron supplements to premenopausal women who undergo RYGB.

Unsuspected cirrhosis discovered during elective obesity operations

OBJECTIVE

To determine the incidence and outcome of cirrhosis encountered unexpectedly during gastric bariatric operations.

DESIGN

A cohort study.

SETTING

A tertiary care center.

PATIENTS

One hundred twenty-five patients in whom cirrhosis was discovered during gastric bariatric operations. Cirrhosis may have been caused by severe obesity in 93 (74%) of the patients.

INTERVENTIONS

A questionnaire survey of bariatric surgeons worldwide, including one of us (R.E.B.).

RESULTS

One hundred twenty-six (52%) of the 243 surgeons responded to the survey. Planned bariatric operations were performed in 91 (73%) of the cases. Seventeen (14%) of the remaining cases were closed after the discovery of cirrhosis. There were no intraoperative deaths. However, the perioperative mortality rate was 4% and there were 7 late deaths, 6 due to complications of liver disease. Eleven other patients are described as alive with progressive hepatic dysfunction. The remaining 50 patients are "alive and well." The survey also included opinion questions. Regarding the appropriate operation to perform after discovering cirrhosis, 40% replied "perform liver biopsy only and close"; the remaining 60% would perform a bariatric procedure. Regarding bariatric operations that can be safely performed in patients with cirrhosis, 59% would perform banded gastroplasty, 39% would perform standard Roux-en-Y gastric bypass, 5% would perform biliopancreatic bypass, and 27% would perform none of the above.

CONCLUSION

Although operative mortality is higher in cirrhotic vs other bariatric patients, most surveyed surgeons believe that gastric restrictive operations can be performed safely in this group of patients.

Mutagenicity and genotoxicity of the major DNA adduct of the antitumor drug cis-diamminedichloroplatinum(II)

The mutagenicity and genotoxicity of cis-[Pt(NH3)2[d(GpG)-N7(1),-N7(2)]] (G*G*), the major DNA adduct of the antitumor drug cisplatin, has been investigated in Escherichia coli. A duplex bacteriophage M13 genome was constructed to contain the G*G* adduct at a specific site in the (-) strand. The singly platinated duplex genome exhibited a survival of 22% relative to that of the unplatinated control genomes, and this value rose to 38% in cells treated with ultraviolet light to induce the SOS response. Singly platinated single-stranded genomes were also produced. Replication of the single- and double-stranded genomes in vivo yielded SOS-dependent, targeted mutations at frequencies of 1.3% and 0.16%, respectively. The mutagenic specificity of G*G* in both single- and double-stranded DNA was striking in that 80-90% of the mutations occurred at the 5'-platinated G. Approximately 80% of the mutations were G-->T transversions at that site. A model of mutagenesis is presented to explain this mutational specificity with respect to current understanding of platinum-DNA adduct structure.