Tag Archives: patient education

In the OR with Los Doctores, Dr. Ham & Dr. Abril

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Haven’t had time to sit down and write about my trip to the operating room with Dr. Horacio Ham and Dr. Rafael Abril until now, but that’s okay because I am going back again on Saturday for a longer case at a different facility.  Nice surprise to find out that Dr. Octavio Campa was scheduled for anesthesia.  Both Dr. Ham and Dr. Abril told me that Dr. Campa is one their ‘short list’ of three or four preferred anesthesiologists.  That confirms my own impressions and observations and what several other surgeons have told me.

campa

Dr. Campa (left) and another anesthesiologist at Hispano Americano

That evening we were at Hispano – Americano which is a private hospital that happens to be located across the street from the private clinic offices of several of the doctors I have interviewed.  It was just a quick short case (like most laparoscopy cases) – but everything went beautifully.

As I’ve said before, Dr. Campa is an excellent anesthesiologist so he doesn’t tolerate any hemodynamic instability, or any of the other conditions that make me concerned about patients during surgery.

Dr. Ham  and Dr. Abril work well together – everything was according to protocols – patient sterilely prepped and draped, etc..

laparoscopy

laparoscopy with Dr. Ham & Dr. Abril

I really enjoy talking with the docs, who are both fluent in English – but I won’t get more of an interview with Dr. Abril until Saturday.

w/ Dr. Ham

with Dr. Horacio Ham in the operating room after the conclusion of a successful case

Then – on Wednesday night – I got to see another side of the Doctors Ham & Abril on the set of their radio show, Los Doctores.  They were interviewing the ‘good doctor’ on sympathetectomies for hyperhidrosis – so he invited me to come along.

Los Doctores invited me to participate in the show – but with my Spanish (everyone remembers the ‘pajina’ mispronunciation episode in Bogotá, right?)  I thought it was better if I stay on the sidelines instead of risking offending all of Mexicali..

Los Doctores

on the set of Los Doctores; left to right: Dr. Rafael Abril, Dr. Carlos Ochoa, Dr. Mario Bojorquez and Dr. Horacio Ham

It really wasn’t much like I expected; maybe because all of the doctors know each other pretty well, so it was a lot more relaxed, and fun than I expected.  Dr. Abril is the main host of the show, and he’s definitely got the pattern down; charming, witty and relaxed, but interesting and involved too.. (my Spanish surprises me at times – I understood most of his jokes…)  It’s an audience participation type show – so listeners email / text their questions during the show, which makes it interesting but prevents any break in the format, which is nice.  (Though I suppose a few crazy callers now and then would be entertaining.)

Dr. Ochoa did a great talk about sympathectomy and how life changing it can be for patients after surgery, and took several questions.  After meeting several patients pre and post-operatively for hyperhidrosis, I’d have to say that it’s true.  It’s one of those conditions (excessive palmar and underarm sweating) that you don’t think about if you don’t have – but certainly negatively affects sufferers.  I remember an English speaking patient in Colombia telling me about how embarrassing it was to shake hands -(she was a salesperson) and how offended people would get as she wiped off her hands before doing so.  She also had to wear old-fashioned dress shields so she wouldn’t have big underarm stains all the time..  This was in Bogota (not steamy hot Cartagena), which is known for it’s year-round fall like temperatures and incredibly stylish women so you can imagine a degree of her embarrassment.

It (bilateral sympathectomy) is also one of those procedures that hasn’t really caught on in the USA – I knew a couple people in Flagstaff who told me they had to travel to Houston (or was it Dallas?) to find a surgeon who performed the procedure..  So expect a more detailed article in the future for readers who want to know more.

Tomorrow, (technically later today) I head back to San Luis with the good doctor in the morning to see a couple of patients – then back to the hospital.. and then an interview with a general surgeon.. So it should be an interesting and fun day.

The Pros & Cons of Bariatric Surgery

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As my loyal readers know, I do my best to try to give fair and balanced depictions of surgical procedures, as well as reviews of medical and surgical news and research.  Over at Medscape.com – there is a new video discussion by Dr. Anne Peters, MD.  Dr. Peters is an endocrinologist and a certified diabetic education.  In this video – she talks about the realities of bariatric surgery, and these are things I think that people need to hear.

For more on Bariatric surgery – see my other posts

One of the points that she makes, is (in my opinion) critical.  While bariatric surgery has been shown to cure diabetes in many individuals – there is no medical/ surgical or other treatment to cure much of the pathology related to the development of obesity in the first place.  Obesity is more than poor dietary and exercise habits – it is a psycho-social and cultural phenomenon as well.

For people who don’t want to go to the Medscape site – I have re-posted a transcript of the video from Medscape.com below.

Bariatric Surgery a ‘Magic Bullet’ for Diabetes?

Anne L. Peters, MD, CDE

Transcript
Hi. I’m Dr. Anne Peters from the University of Southern California. Today I’m going to talk about the role of bariatric surgery in the treatment of type 2 diabetes.

There have been a number of recent studies that show just how good bariatric surgery can be for patients with type 2 diabetes.[1,2] In many cases, it seems to cure type 2 diabetes (at least for now), and I think it is an important tool for treating patients with obesity and diabetes.

However, I also have concerns about bariatric surgery, concerns that go back for years as I watched its increased use. When I was a Fellow, I developed a sense of the benefit of extreme caloric restriction for the treatment of type 2 diabetes. I will never forget the first patient I had, an extremely obese man with type 2 diabetes who was on 200 units of insulin per day. His blood sugar levels remained high no matter what we did. He was a significant challenge in terms of management.

One day, he got sick. I don’t remember how or why he got sick, but he ended up in the hospital and I thought that his management would continue to be incredibly difficult. In fact, it was miraculously easy. Within 2 days, he was completely off of insulin and his blood glucose levels remained normal for the entire time he was in the hospital.

This was only a short-lived benefit, however. After he was discharged, he went back to his old habits. He started eating normally, regained the weight, and went back on several hundred units of insulin per day. But it really impressed me how acute severe caloric restriction could, in essence, treat type 2 diabetes.

I have seen many overweight and obese patients with diabetes over the years, and I have seen the frustration as patients go on drugs (such as insulin) that are weight-gain drugs, and they keep gaining more weight. Although I am a big advocate for lifestyle change, many patients can’t do much better. They can’t lose appropriate amounts of weight by their own will or through weight loss programs, or increase their exercise. Therefore, bariatric surgery remains a reasonable option.

For many of my patients who have a body mass index > 35 and type 2 diabetes, I recommend that they at least consider bariatric surgery. Interestingly, very few of my patients actually go for the procedure and I ponder why this is. In part, I think it’s because of the initial evaluation, when you are told what bariatric surgery is like and how much you have to change your habits after the procedure. Before surgery, you are eating however you want to eat and, although you may be trying to diet, there is no enforcement of that diet. After surgery, you have to change how you eat, the portions you eat, and when you eat. I know that people feel fuller, and this is a lot more than just changing one’s anatomy. I think there are significant changes in gut hormones that regulate appetite and satiety. Nonetheless, it is a big change, and many people don’t want to change their habits that much. I know I would be somewhat leery if I were to undergo a surgical procedure that would change my whole way of being. For lots of people, food has many different associations. It’s not just caloric intake; it’s festival, it’s party, it’s joy, it’s sadness. It’s something people like to do, and it hasn’t a lot to do with just maintaining a positive or neutral caloric balance.

I find that people are reluctant to change, and that is understandable. We also don’t know the long-term complications of the procedure. As an endocrinologist, I see 2 things. First, I tend to get sicker patients, so my patients who are on insulin when they undergo bariatric surgery may not get off insulin entirely. They become very disappointed because they think that bariatric surgery will cure them of their diabetes. I also see patients who are too thin, who are nutritionally deficient, who have severe hypoglycemia, or who have significant issues from the surgery itself. In some cases, these patients have needed a takedown of the surgical procedure, restoring them back to their native anatomy.

I think of bariatric surgery as a tool. It is one of many ways to treat our patients with type 2 diabetes. I am a little concerned because we don’t have long-term follow-up data. I think that all bariatric surgery programs, in addition to doing a very thorough preoperative evaluation and counseling, need to do long-term, lifelong follow-up of these patients to see how they do, to see if their obesity returns. In many cases, this does happen. [Patients need to be followed up] to see what happens to their lipids, their blood pressure, and their blood sugar levels over time, and to monitor for other complications.

I think [bariatric surgery] is something that we need to recommend to our patients, and for those in whom it’s appropriate, it is a reasonable step. This has been Dr. Anne Peters for Medscape.

 References
  1. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012 Mar 26. [Epub ahead of print]
  2. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; Mar 26. [Epub ahead of print]

Life after Bariatric Surgery

There is also an excellent article by two nurse practitioners about the long-term interventions and health monitoring needed for wellness promotion and health maintenance after bariatric surgery.  While this article is written for other health care providers – it gives an excellent look at life after bariatric surgery, as well as an overview of the surgical techniques, pre-operative evaluation and anticipated post-operative outcomes.

Thomas, C. M. & Morritt Taub, L. F. (2011).  Monitoring and preventing the long-term sequelae of bariatric surgery.  J of the American Academy of Nurse Practitioners, 2011, 23 (9).

Bariatric Surgery Safety: More than your weight is at risk!

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Dying to be thin?  These patients are… A look at the Get-Thin clinics in Beverly Hills, California..

This series from LA Times writers, Michael Hiltzik and Stuart Pfiefer highlights the importance of safety and the apparent lack of regulation in much of the bariatric procedure business here in the United States.

In these reports – which follow several patient deaths from lap-band procedures, both surgeons and surgical staff alike have made numerous reports against the ‘Get Thin” clinics operating in Beverly Hills and West Hills, California.  These allegations include unsafe and unsanitary practices.  One of the former surgeons is involved in a ‘whistle-blower’ lawsuit as he describes the dangerous practices in this clinic and how they led to several deaths.

Regulators ignore complaints against Beverly Hills clinics despite patient deaths  – in the most recent installment, Hiltzik decries the lack of action from regulatory boards who have ignored the situation since complaints first arose in 2009!

House members call for probe into Lap-Band safety, marketing – California legislators call for action, but the clinics stay open. (article by Stuart Pfiefer)

Plaintiffs allege ‘gruesome conditions’ at Lap-Band clinics – mistakes and cover-ups at the popular weight loss clinics.  (article by Stuart Pfiefer)  This story detailing a patient’s death made me ill – but unfortunately reminded me of conditions I had seen at a clinic I wrote about in a previous publication..  The absolute lack of the minimum standards of patient care – is horrifying.  This woman died unnecessarily and in agony.  It proves my point that anesthesiologists need to be detailed, and focused on the case at hand.. (not iPhones, crosswords or any of the other distractions I’ve seen in multiple cases.. Now this case doesn’t specifically mention a distracted anesthesiologist – but given the situation described in the story above, he couldn’t have been paying attention, that’s for sure.

Nurse Practitioners and Medscape

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A couple of new articles over at Medscape highlight the role of Nurse Practitioners (and Physician’s Assistants) in patient care.

The Role of Nps and PAs with MDs in today’s care

A study from Loyola showed that surgical NPs reduced emergency room visits  : here’s a link to the article abstract by Robles et al. (2011).

Reducing cardiovascular risk with NPs: the Coach trial

And yet again, Nurse Practitioners trump physicians in patient satisfaction surveys.

This is just a sampling of the articles featured over at Medscape’s NP perspective.

From the free-text files: a selection of articles showing the growing use of Nurse Practitioners around the world

Nurse practitioners improve quality of care in chronic kidney disease: two-year results of a randomised study.  – a study from the Netherlands

A Parallel Thrombolysis Protocol with Nurse Practitioners As Coordinators Minimized Door-to-Needle Time for Acute Ischemic Stroke.  A taiwanese study showing the impact of nurse practitioners in reducing door-to-needle time in acute coronary syndromes.

Helping patients attain and maintain asthma control: reviewing the role of the nurse practitioner.

Type 2 diabetes, cardiovascular disease and the utilisation of primary care in urban and regional settings.  An Austrailian study discussing the impact of NPs in rural care.

Hospital General de Mexicali

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Following surgery at Hospital Alamater, we proceed to the Hospital General de Mexicali.  This is the largest public facility in Mexicali, and is surprisingly small.  After a recent earthquake, only three floors are currently in use, with the two remaining upper floors undergoing demolition for repair after earthquake-related damage.  The facility is old and dated, and it shows.  There are ongoing construction projects and repairs throughout the facility.

On the medical and surgical floors there are dormitory style accommodations with three patients in each room.  Sandwiched across from the nursing station are several rooms designated as ‘Intermediate’ care.  These rooms are full with patients requiring a higher level of care, but not needing the intensive care unit which is located downstairs adjacent to the operating theater.

 

surgical nurses at Hospital General

The intensive care unit itself is small and crowded with patients.  There are currently five patients, all intubated and in critical condition.  Equipment is functional and adequate but not new, with the exception of hemodynamic monitors.  There is no computerized radiology (all films are printed and viewed at bedside.)

We visit several post-operative patients upstairs on the surgical floors, and talk with the patients at length.  All of the patients are doing well, including several patients who were hospitalized after holiday-related trauma (stabbing with chest and abdominal injuries.) The floors are busy with internal medicine residents and medical students on rounds.

Despite it’s unattractive facade, and limited resources – the operating room is similar to operating rooms across the United States.. Some of the equipment is older, or even unavailable (Dr. Ochoa brings his own sterile packages of surgical instruments for cases here.)  However, during a case at the facility – all of the staff demonstrate appropriate knowledge and surgical techniques. The anesthesiologist invites me to look over his shoulder (so to speak) and read through the chart..

Since respiratory therapy and pulmonary toileting is such an important part of post-operative care of patients having lung surgery – we stopped in to check out the Respiratory department.  I met with Jose Luis Barron Oropeza who is the head of Respiratory Therapy.  He graciously explained the therapies available and invited me to the upcoming symposium, which he is chairing.  (The symposium for respiratory therapy in Mexicali is the 18th thru the 20th of this month.  If anyone is interested in attending, send me an email for further details.)

After rounding on patients at the General Hospital – despite the late hour (it is after midnight) we make one more stop, back at the Hospital Alamater for one last look at his patients there.  Dr. Ochoa makes a short stop for some much-needed food at a small taco stand while we make plans to meet the next morning.

Due to the limitedavailable resources, I wouldn’t recommend this facility for medical tourists.  However, the physicians I encountered were well-trained and knowledgeable in their fields.

Fired!!

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As I review the few short film clips I delegated to my ‘cameraman’ (my husband) – all I can say is that he is totally, and completely fired!!  (and I am pretty irritated.)

All I needed was a few background clips of Mexicali for the first new video cast for the iTunes series – I took all the stills, interviewed the surgeons and got all the intra-operative footage..  He just needed to get about two minutes worth – for the introductory segments..

Totally.  Fired.

So, readers, I apologize but my first iTunes video cast won’t be the wonderful, glossy creation I had hoped for.. More like a schizophrenic, slightly generic – art house production.

But we’ll try again on our next journey – (with a new cameraman!)

In the operating room with Dr. Carlos Ochoa, thoracic surgeon

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Mexicali, Baja California (Mexico)

Dr. Carlos Cesar Ochoa Gaxiola, Thoracic Surgeon

We’ve back in the city of Mexicali on the California – Mexico border to interview Dr. Carlos Cesar Ochoa Gaxiola as part of the first of a planned series of video casts.   You may remember Dr. Ochoa from our first encounter back in November 2011.  He’s the personable, friendly thoracic surgeon for this city of approximately 900,000 residents.  At that time, we talked with Dr. Ochoa about his love for thoracic surgery, and what he’s seen in his local practice since moving to Mexicali after finishing his training just over a year & a half ago.

Now we’ve returned to spend more time with Dr. Ochoa; to see his practice and more of his day-to-day life in Mexicali as the sole thoracic surgeon.  We’re also planning to talk to Dr. Ochoa about medical tourism, and what potential patients need to know before coming to Mexicali. He greets me with the standard kiss on the cheek and a smile, before saying “Listo?  Let’s go!”  We’re off and running for the rest of the afternoon and far into the night.  Our first stop is to see several patients at Hospital Alamater, and then the operating room for a VATS procedure.

He is joined in the operating room by Dr. Cuauhtemoc Vasquez, the newest and only full-time cardiac surgeon in Mexicali.  They frequently work together during cases.  In fact, that morning, Dr. Ochoa assisted in two cases with Dr. Vasquez, a combined coronary bypass/ mitral valve replacement case and a an aortic valve replacement.

Of course, I took the opportunity to speak with Dr. Vasquez at length as well, as he was a bit of a captive audience.  At 32, he is just beginning his career as a cardiac surgeon, here in Mexicali.  He is experiencing his first frustrations as well; working in the first full-time cardiac surgery program in the city, which is still in its infancy, and at times there is a shortage of cases[1].  This doesn’t curb his enthusiasm for surgery, however and we spend several minutes discussing several current issues in cardiology and cardiac surgery.  He is well informed and a good conversationalist[2] as we debate recent developments such as TAVI, carotid stenting and other quasi-surgical procedures and long-term outcomes.

We also discuss the costs of health care in Mexicali in comparison to care just a few short kilometers north, in California.   He estimates that the total cost of bypass surgery (including hospital stay) in Mexicali is just $4500 – 5000 (US dollars).  As readers know, the total cost of an uncomplicated bypass surgery in the USA often exceeds $100,000.

Hmm.. Looks like I may have to investigate Dr. Vasquez’s operating room on a subsequent visit – so I can report back to readers here.  But for now, we return to the case at hand, and Dr. Ochoa.

The Hospital Alamater is the most exclusive private hospital in the city, and it shows.   Sparkling marble tile greets visitors, and patients enjoy attractive- appearing (and quiet!) private rooms.  The entire hospital is very clean, and nursing staff wears the formal pressed white scrub uniforms, with the supervisory nurse wearing the nursing cap of yesteryear with special modifications to comply with sanitary requirements of today.

The operating rooms are modern and well-lit.  Anesthesia equipment is new, and fully functional.  The anesthesiologist is in attendance at all times[3].  The hemodynamic monitors are visible to the surgeon at all times, and none of the essential alarms have been silenced or altered.  The anesthesiologist demonstrates ease and skill at using a double lumen ETT for intubation, which in my experience as an observer, is in itself, impressive.  (You would be surprised by how often problems with dual lumen ETT intubation delays surgery.)

Surgical staff complete comprehensive surgical scrubs and surgical sterility is maintained during the case.  The patient is well-scrubbed in preparation for surgery with a betadine solution after being positioned safely and correctly to prevent intra-operative injury or tissue damage.  Then the patient is draped appropriately.

The anesthesiologist places a thoracic epidural prior to the initiation of the case for post-operative pain control[4].  The video equipment for the case is modern with a large viewing screen.  All the ports are complete, and the thoracoscope is new and fully functioning.

Dr. Ochoa demonstrates excellent surgical skill and the case (VATS with wedge resection and pleural biopsy) proceeds easily, without incident.  The patient is hemodynamically stable during the entire case with minimal blood loss.

Following surgery, the patient is transferred to the PACU (previously called the recovery room) for a post-operative chest radiograph.  Dr. Ochoa re-evaluates the patient in the PACU before we leave the hospital and proceed to our next stop.

Recommended.  Surgical Apgar: 8

[1] There is another cardiac surgeon from Tijuana who sees patients in her clinic in Mexicali prior to sending patients to Tijuana, a larger city in the state of Baja California.  As the Mexicali surgery program is just a few months old, many potential patients are unaware of its existence.

[2] ‘Bypass surgery’ is an abbreviation for coronary artery bypass grafting (CABG) aka ‘open-heart surgery.’  A ‘triple’ or ‘quadruple’ bypass refers to the number of bypass grafts placed during the procedure.

[3] If you have read any of my previous publications, you will know that this is NOT always the case, and I have witnessed several cases (at other locations) of unattended anesthesia during surgery, or the use poorly functioning out-dated equipment.

[4] During a later visit with the patient, the patient reported excellent analgesia (pain relief) with the epidural and minimal adjuvant anti-inflammatories.

French implant update

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More scary news for women around the globe – as the manufacturer, PIP discloses frightening information regarding their defective implants.  It has been discovered that the company knew that the implants were defective since 2005 – but continued to sell the implants for use world-wide, particularly in Latin America.

More disturbingly, this manufacturer did not use medical grade materials – instead opting for cheaper, construction grade chemicals including petroleum and fuel additives, components which have never been tested for [internal] human use.  The health effects of exposure to these materials is unknown.  The risks associated with the use of these materials is enhanced due to the high rate of rupture among this brand of implant.  These chemicals certainly have carcinogenic potential and the implications for thousands and thousands of women are terrifying.

French officials have urged women to have their implants surgically removed.

A preliminary search of PubMed and other published research shows mixed results – and primarily discusses the results of exposure to benzene (and other petroleum derivatives) via water contamination, or occupational exposure.   (In fact, only limited information is available regarding the safety of breast implants in general, and the material is fairly dated.)

As we stated in a previous story, while researching Bogota! and interviewing plastic surgeons – I investigated the types of implants used by the surgeons profiled in the book.  (None of the surgeons used this company’s implants at the time of my interviews in Winter/ Spring 2011).

Update:  In fact, the Colombian government has offered to pay for the removal of PIP implants.  More on this story here.

Aortic Valve Replacement & the elderly

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I just read an interesting article in the Annals of Thoracic Surgery.

Unfortunately, the full-text article is not available for free – but I did find a nice article abstract (which I’ve posted below.)  It confirms some of the previous discussions we’ve had here at Cartagena Surgery on the role of surgery in Aortic Stenosis, even in ‘elderly’ patients.  [I put elderly in quotes since the definition can be fairly elastic depending on who is doing the judging.]

The article below is from Medscape.com

Aortic valve replacement in the elderly: the real life.

Ann Thorac Surg. 2012; 93(1):70-8 (ISSN: 1552-6259)

Langanay T; Flécher E; Fouquet O; Ruggieri VG; Tour Bde L; Félix C; Lelong B; Verhoye JP; Corbineau H; Leguerrier A Department of Cardiovascular and Thoracic Surgery, University Hospital, Rennes, France.

BACKGROUND: Aortic stenosis is of concern in the elderly. Although aortic valve replacement provides good long-term survival with functional improvement, many elderly patients are still not referred for surgery because of their age. Percutaneous aortic valve implantation offers an alternative to open-heart surgery. Concerns about the management of aortic valve stenosis in the elderly will be reviewed.

METHODS: We retrospectively analyzed 1,193 consecutive aortic valve replacements, performed in octogenarians since January 2000. A total of 657 patients (55%) had at least one associated comorbidity (eg, respiratory failure) and 381 (32%) associated coronary lesions. Valve replacement was the only procedure in 883 patients (74%), and was associated with coronary revascularization in 262 cases, or with another cardiac procedure in 48 patients.

RESULTS: Overall operative mortality was 6.9% (83 of 1,193 patients); 5.5% for single replacement and 11.5% if associated with coronary artery bypass surgery. Univariate and multivariate analyses identified 11 operative risk factors related to general status, cardiologic condition, and the procedure itself: older age (p< 0.015); respiratory failure (p <0.03); aortic regurgitation (p <0.001); emergency surgery (p <0.0029); New York Heart Association class IV (p < 0.0007); right heart failure (p < 0.03); atrial fibrillation (p < 0.04); impaired ejection fraction (p < 0.001); coronary disease (p < 0.01); redo surgery (p < 0.02); associated coronary revascularization (p < 0.008).

CONCLUSIONS: Today, valve replacement has acceptable low hospital mortality, even in the elderly. Thus, older patients should not be denied surgery due to their advanced age alone. Conventional surgery remains the gold standard treatment for aortic stenosis; the decision should be made on an individual basis. If several risk factors suggest very high-risk surgery, then percutaneous valve implantation should be considered instead.

In more disturbing news:

As predicted, the unproven ‘easy option’ of TAVI is now being pursued by more low-risk patients.  These lower risk patients are people who should have been encouraged to undertake the more durable, safe and proven surgical therapy [Aortic Valve Replacement.]  I guess this just shows how quickly those new recommendations [for patient protection and safety] were thrown out the window.

In this article (posted below) by Kurt Ullman at Medpage Today – German researchers discuss their preliminary findings and discuss the use in low risk patients.

The bar for transcatheter aortic valve implantation (TAVI) is dropping as more lower-risk patients are undergoing the procedure and their outcomes are favorable, a single-center study from Germany found. [Unfortunately – as we’ve seen so many times in the past, and as I am finding out while preparing this presentation on the Syntax trial – studies such as this can be quite deceiving – and LONG term data is needed. – Cartagena Surgery].

When stratified by quartiles based on enrollment date, Q1 patients had higher logistic EuroSCOREs, higher Society of Thoracic Surgeons (STS) scores, and higher median N-terminal pro-B-type natriuretic peptide levels compared with those enrolled later in Q4, noted Nicolo Piazza, MD, PhD, and colleagues from the German Heart Center in Munich.

Although there were significant decreases in 30-day and six-month mortality from Q1 to Q4 in the crude analysis, after adjustments for baseline characteristics, the significant differences disappeared (HR 0.29 for 30-day mortality and HR 0.67 for six-month mortality), according to the study published online in the Journal of the American College of Cardiology.

“These results suggest that underlying comorbidities play an important role in acute and intermediate-term survival after TAVI,” the researchers wrote.

The researchers noted anecdotal information suggesting a shift toward using TAVI in patients who are less sick than those enrolled in premarket trials. Additionally, the next wave of trials involving the CoreValve (Medtronic) and the Sapien XT (Edwards Lifesciences) devices will involve intermediate to high surgical risk patients, providing “yet another indication that TAVI is being directed at the treatment of lower and lower surgical risk patients,” Piazza and colleagues wrote.  [There are significant ethical considerations here which seem to be ignored – similar to criticisms of the Syntax trial – Cartagena Surgery.]

A single-center French study of low-risk TAVI patients found the procedure to be safe in this population. The study was presented at the European Society of Cardiology meeting in Paris.

The impact on this shift in patient selection was uncertain, they said, prompting a retrospective review of 420 patients who underwent TAVI at their institution from June 2007 to June 2010.

The consensus that a patient was suitable for TAVI was derived from a team that comprised cardiologists, cardiac surgeons, and anesthesiologists. This team approach is exemplified by the recent announcement that the American College of Cardiology and the Society of Thoracic Surgeons will jointly sponsor a TAVI registry to monitor the safety and efficacy of the procedure as it rolls out in the U.S.

Patients received either the CoreValve or Sapien device, the latter of which was just approved for use in the U.S. based on the PARTNER trial. PARTNER found that TAVI was as good as surgery in high-risk patients with severe aortic stenosis. [‘as good as’ – ah.. another ‘non-inferiority’ study….. view with skepticism folks..]

Researchers divided patients into four quartiles of 105 patients each. Those in Q1 were seen earlier in the study time frame than those in Q4.

Compared with Q4, Q1 patients had higher EuroSCOREs (25.4% versus 17.8%, P<0.001), STS scores (7.1% versus 4.8%, P<0.001), and NT-proBNP levels (3,495 versus 1,730 ng/dL, P<0.046).

There were significantly less transfemoral access approaches from Q1 to Q4, with a concomitant rise in transapical approaches. There also were significantly less intubations moving from Q1 to Q4, and the use of contrast significantly decreased over time.

Researchers noted that transfemoral complications decreased by 17% from Q1 to Q4 (P=0.008), but found no significant differences in the rate of stroke or transient ischemic attack or the need for a permanent pacemaker.

However, there was a shift in the later quartiles toward the treatment of younger patients with fewer comorbidities and lower surgical risk scores, Piazza and colleagues wrote.

Univariable analysis for 30-day mortality showed it was associated with age, STS score, atrial fibrillation, previous heart surgery, and previous stroke (P<0.10).

The factors associated with six-month mortality were age, logistic EuroSCORE, STS score, left ventricular ejection fraction, atrial fibrillation, previous cardiac surgery, chronic obstructive pulmonary disease, and N-terminal pro-B type natriuretic peptide (P<0.10).

Because only baseline characteristics were included, the authors noted the possibility that procedure-, operator-, or device-related factors might influence both 30-day and six-month mortality. The study is also limited by potential unmeasured confounding.

The investigators cautioned that little is known of the long-term durability of these devices should they be routinely implanted in younger patients with a longer expected life span.  [especially since the lifespan of the patients these valves were designed for was six months to one year..]

Piazza is a consultant and proctor for Medtronic and CardiAQ. Other authors revealed consultant status with Medtronic and Edwards Lifesciences, or instuctors for Medtronic

French Implants recalled

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Hundreds of thousands of french made breast implants have been recalled – sending women all over the globe into a panic.  These implants which are no longer in use in France, have been linked to an increased rate of rupture, and possible increased incidence of cancer.

But good news for readers – as you may recall from my interviews with several of the surgeons (as written in the book) – none of the surgeons I interviewed used french implants.  The majority used FDA approved implants (only one brand currently FDA approved.)  Several others use german made implants*.. But this is an example of the details I’ve ferreted out for my readers..

* Brand information and other details are available in the book, “Bogota: a hidden gem guide to surgical tourism.”

More stories about fake docs including this one about a phony performing liposuction while smoking a cigar on AWAKE patients..

This guy was actually a doctor, but that didn’t stop ten of his patients from dying after bariatric procedures..

Cartagena on CNN

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It looks like our Hidden Gem of a city is finally getting some of the attention it deserves – earlier this month, the city of Cartagena was featured as a ‘secret treasure’ on CNN Travel.    The article talks about the Caribbean flavor of this bright, diverse and colorful city and its rich history.

photo by CNN

Across ‘the pond’ in the UK – the Telegraph was also singing the praises of this tropical, elegant paradise and it’s status as a ‘cultural capital’..

Diabetes and Soft drinks

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If I can get readers to make one significant change to improve their health today  – Stop drinking soft drinks (and juices.)  These high sugar containing drinks are more than just empty calories, and this one small change can significantly reduce your risk of developing diabetes!

(P.S.)  Substituting for diet drinks is no improvement since diet sodas etc. have been linked to an increased incidence of strokes and high blood pressure (HTN) – switch to coffee, tea or water!!)  Coffee has even been shown in several studies as reducing the risk of diabetes, pancreatic disease.

High Fructose Corn Syrup

High fructose corn syrup was a uniquely American product that was initially created as a result of a government subsidy for farmers which has since spread to the UK, Japan and several other nations.  With these government subsidies, corn syrup became a cheaper sweetening agent in comparison to cane sugar.  This led to the pervasive use of corn syrup in many American food products.   Today it is used extensively, and avoiding this additive requires considerable effort and extensive examination of product labeling.  One of the main products that uses large amounts of high fructose corn syrup are soft drinks such as Pepsi and Coca-Cola.

As the American obesity (and corresponding Diabetes) epidemics continue unchecked, multiple researchers have attempted to pinpoint causes for these phenomena.  High fructose corn syrup has emerged as a likely culprit.  (However, even this scientific research is politically charged, as mega-corporations attempt to discredit findings that hurt their bottom line, similar to tobacco manufacturers in the past[1].)

Stanhope & Havel (2010), researchers at UC Davis recently compared the effects of fructose ( high fructose corn syrup is a mixture of fructose and sucrose) to sucrose (regular table sugar.)  They found that fructose use increased visceral adiposity (fat around internal organs), dylipidemia and decreased insulin sensitivity.  Decreased insulin sensitivity is a hallmark of the development of diabetes and is one of the ways that Diabetes in Americans differs from diabetes in other countries.  This means that people need more insulin to do the same job (transport nutrients into the cells).  This is also why we see people requiring more insulin that ever before.  In the past, patients could often be managed with 5 units of insulin (per meal).  Now, more commonly, due to this insulin resistance, similar patients are requiring 50 units of insulin (per meal).

But the problem isn’t just high fructose corn syrup – it’s our overall sugar consumption in general – Americans are just consuming WAY, WAY too much sugar – in “energy’ drinks, colas,  designer coffee drinks, ‘sweet teas’ and the so-called ‘healthy fruit juice.’  [I cringe every time I see a parent give their child juice as a ‘healthy alternative.’]

This sugar is KILLING us, by causing a myriad of health problems which in turn have a domino effect causing even greater health problems..  Sugar —->  Obesity/ High cholesterol ——>diabetes , hypertension,  atherosclerosis ——-> coronary artery disease (heart attacks), renal failure, vascular disease (ischemia/ limb loss/ strokes)..  The obesity epidemic, and sugary drink consumption has also been linked to fatty liver disease.

Now Malik, et. al. (2010) over at Harvard/ Brighams performed a meta-analysis on this subject.  Now if it’s been a while since you’ve read a lot of scientific literature, then let me remind you that meta-analyses are fairly high-powered studies because they take  ALL of the existing data, compiled it, and report the findings.. This is much stronger evidence that some six person study looking at cinnamon and diabetes.  (Yet – the media blazed that study everywhere – so  now plenty of people are putting cinnamon in everything.)

Readers:

Starting today – I want you to care about your health, more than drinking that coke, pepsi or kool-aid.  Don’t try to cheat – with ‘diet’ options – because you are only cheating/ fooling yourself..

Make this one change:  switch to water, coffee (not loaded down with sugar/ cream) or UNSWEET tea.

Try it for at least thirty days..  and let’s start from there..   Just this one small change, not because I asked – but because you love yourself.  (And if you don’t love yourself – we need to work on that too!)

Additional references:

This study says diet sodas don’t cause diabetes but does link it to strokes..   It’s from MSN health which is an ‘okay’ site for consumer health information (articles are not always well written.)

Four reasons to avoid sodas – Health content from Yahoo! – it’s actually a reader’s digest article, which I typically avoid because they are usually poorly written, and not factually based.

[1] A good rule of thumb:  Whenever an industry starts advertising for their product (versus individual brands) than strong scientific evidence has probably emerged implicating the product in serious health conditions.  Think of the recent corn syrup ads, and “Beef – it’s for dinner,” and other campaigns in the past.

Thoracic Surgery portal

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Over at our sister site – we’ve published the first few discussions on lung surgery, and lung diseases as part of our new lung surgery portal.

It is the first tentative steps towards a fully integrated lung surgery site – CirugiadeTorax.org
which I hope to one build into a one stop site for patients looking for information, the latest treatment and facilities for lung surgery, and lung cancer. I envision a site eventually filled with articles, links to treatment options/ and facilities along with physician profiles from different surgeons around the world, so patients have access to the newest, and most effective treatments possible.

It’s a big task to take on – but it all starts somewhere, and who better than I, a practicing acute care nurse practitioner, in cardiothoracic surgery?
I am already travelling, meeting thoracic surgeons, learning about new and different treatments at every opportunity..

Just posted new articles on Malignant effusions and Preventing post-operative atrial fibrillation..