Quotes of the Month
In this letter, I'm going to feature articles from the American College of Surgeons new periodical, Surgery News, and its traditional Journal. As usual, the content will be mostly Preventive Medicine. The following brief quips are from the above; therefore I will not be noting the source each time.
SCREEN FOR ABDOMINAL AORTIC ANEURISM (AAA) IN MALE SMOKERS AGED 65-75
The U.S. Preventive Services Task Force recommends that men between the ages of 65 and 75 who are smokers or former smokers be screened for AAA with an ultra sound exam of the abdomen. They based this on statistics showing a reduction in mortality with this approach.
ED: The mortality rate on surgery for a ruptured AAA is between 20 and 50% and depends on associated co-morbid medical conditions. The mortality rate for elective surgery is considerably less and also patients having elective surgery may be candidates for the newer less invasive techniques. A small portable ultra sound should be part of a primary care physicians office instruments and they should receive training in medical school and residency, on their use.
ARTICLES ON BARIATRIC (WEIGHT LOSS) SURGERY
A report from the Agency on Healthcare Research and Quality indicated that surgical treatment of obesity was superior to non surgical treatment in patients with a body mass index (BMI) of 40 kg/m2. Some surgical centers have a mortality rate of less than 1%. This is weighed against the many side effects of weight loss drugs and the ineffectiveness of weight loss plans and diets.
David J. Hass, M.D. reported at the annual meeting of The American College of Gastroenterology that overweight patients with Crohn's disease should be operated on sooner than their underweight peers. This statement was based on a study of 148 patients, and it showed a more severe disease patho-physiology in the overweight group. This observation might be explained by an increased amount of tumor necrosis factor alpha in adipose tissue and this can enhance the inflammatory aspect of the disease.
According to Morgan Downey, executive director of the American Obesity Association, operations for obesity went from 20,000/year to 144,000/year over the span of 5 years. With this increase in surgical procedures there has been noted an increase in the number of complications and fatalities in various areas of the country and prompted insurance companies to insist on the procedures being done in preferred centers.
ED: The American Society for Bariatric Surgery has responded to this increase in adverse statistics by forming the Surgical Review Corp. to establish criteria, review applications, and grant certification to hospitals and surgeons. For provisional certification, hospitals and surgeons must: 1) Perform at least 125 procedures per year. 2) Have equipment dedicated to bariatric patient's specific needs. 3) Be able to demonstrate that postoperative personnel can recognize early signs of common complications. 4) Have a program for long term management and followup. 5) Track outcomes. My advice to those of you who are contemplating bariatric surgery is to ask your surgeon for statistics on his personal experience with this surgery and not just quote global stats to you. Also do not agree to being operated on in a small surgery center or boutique specialty hospital. The hospital should have a track record corresponding to the criteria listed above and a well equipped intensive care unit.
CALCIUM AND BREAST COLON CANCER RISK
Andrew Flood, Ph.D et al reported a significant reduction in the incidence of colorectal cancer in women having a high daily dietary calcium consumption. This was based on questionnaires sent to 45,354 in the Breast Cancer Detection Demonstration Project. In colon cancer the reduction was 46% if the women had a high intake from their diet plus supplements.
ED: This is not new but it is comforting that it reinforces previous similar observations.
ANASTROZOLE IS BETTER THAN TAMOXIFEN
Dr. Anthony Howell reported at a breast cancer seminar, sponsored by the Cancer Therapy and Research Center, that the aromatase inhibitor, anastrazole, has replaced Tamoxifen as the endocrine therapy of choice for adjuvant treatment of women with hormone receptor positive early breast cancer.
ED: This is good, for the incidence of side effects, such as endometrial cancer, thromboembolic events, and ischemic stroke, was lower in women taking Arimidex. It is also cost effective.
HELMINTHIC THERAPY AND CROHN'S DISEASE
J. John Cohen, M.D. made an interesting statement at the Colorado Chapter of The American College of Physicians. He said that there has been recent success in treating Crohn's disease by feeding patients live ova of the pig whipworm. He was excited because he thought it also opened a new pathway for the treatment of other auto immune diseases in humans. He further said that this approach came from the observation that the incidence of inflammatory bowel disease is generally limited to the developed world where helminth infestation is low, and in so called third world countries, where parasitic worm infestation is high, the incidence of the bowel disease is rare. The ingestion of the ova causes a brief and self limited colonization in humans but it is enough to stimulate the immune system to counteract the inflammatory bowel disease.
ED: This is an exciting observation and result. Crohn's disease has been a major thorn in the side of surgeons and gastroenterologists ever since its discovery in the early part of the 20th century. It is a distressing disease for patients and often resulted in multiple operations which gradually shortened the length of the intestinal tract so that it was incompatible with life.
PREOP HYDRATION LOWERS POSTOP NAUSEA AND PAIN
C.H. Maharaj, M.B. et al from the National University of Ireland, Galway reported that postoperative nausea and vomiting can be limited, in a high risk group of patients, by the use of preoperative intravenous fluid corresponding to the length of preoperative fasting.
ED: This is an important observation because this is distressing to patients and significantly raises the cost of postoperative care.
PROSTATE CANCER VACCINE
Eric J. Small, M.D. reported at a symposium sponsored by the American Society of Clinical Oncology that patients with aggressive prostate cancer who received a therapeutic vaccine survived longer than patients who received a placebo.
ED: This was a small study (84 patients) but if further studies confirm the results it would be a valuable tool to use in addition to chemotherapy in this stage of the disease. Vaccines have been tried for various malignancies and unfortunately the results have not been as good as hoped for.
MRI AND THROMBOLYSIS FOR ACUTE STROKES
Reports from the 30th International Stroke Conference in New Orleans indicated that favorable patterns of cerebral perfusion seen on magnetic resonance imaging could tell physicians which patients with acute ischemic strokes would benefit from thrombolysis therapy hours after the onset of symptoms.
ED: If this observation holds up with further study then, according to experts in the field, the number of patients benefiting from thrombolytic therapy could triple. Currently when a patient with an acute stroke comes to the ER the ER doctor has to determine with the use of CT scan or MRI whether the stroke is ischemic or hemorrhagic before giving a thrombolytic agent. The latter is contraindicated in a stroke due to hemorrhage in the brain. It was thought that the window of opportunity for reversal of the symptoms with thrombolysis was 3 hours. This study suggests, in some patients, it could be much longer.
QUOTES FOR THE QUARTER
I DO NOT BELIEVE THAT ANY MAN FEARS TO BE DEAD, BUT ONLY THE STROKE OF DEATH.
Take care until next time,
Richard J. Turner, III, M.D., F.A.C.S.
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Winter 2005 - Medical Pearls
Fall 2004 - Women's Health
Summer Trip to Russia
Miscellaneous Medical One Liners
Trip to Ireland
Texas Surgical Society Meeting Notes
The Malpractice Crisis
Treatment and Prevention of Malignant Disease
West Nile/Cancers/Discontent with American Healthcare/Prescriptions
History of Preventive Medicine
Smoking Risks/Depression/The Western Diet
Food Consumption/Cancer and Treatment Relationships