Live in Cinci and hypoglycemic?

On January 19, 2010, in Uncategorized, by Andrea

Go be a labrat.

UC HEALTH LINE: Be Aware of Blood Sugar Post Gastric Bypass

CINCINNATI—People with type 2 diabetes who have gastric bypass surgery often leave the hospital without the need for previously prescribed diabetes medications.

Researchers and doctors believe this health benefit is related to changes in the body’s circulating hormones—particularly an increase of insulin secretion. Insulin is the hormone that controls the level of glucose (sugar) in the blood.

Marzieh Salehi, MD, a diabetologist with UC Health University of Cincinnati Physicians whose research is focused on the effect of weight-loss surgery on glucose metabolism, cautions that although there can be huge benefits for diabetic patients who undergo gastric bypass surgery, a group of patients experience severely low levels of blood sugar (hypoglycemia)—especially following a meal and typically several years after surgery. Symptoms of hypoglycemia often aren’t recognized until they become debilitating or life-threatening.

Salehi says that many patients with type 2 diabetes who qualify for gastric bypass surgery rely on anti-diabetic medications like insulin injections to regulate glucose in the body. These same patients often leave the hospital following surgery with normal glucose control without taking any medications.

“It’s possible,” says Salehi, “that gastric bypass increases gut hormone secretion or nervous system activity, which in turn increases insulin secretion and improves glucose metabolism in a majority of patients after surgery.

“However,” she adds, “there is a population of gastric bypass patients who, following surgery, develop high levels of endogenous insulin secretion, resulting in dangerously low glucose levels, or hypoglycemia. These glucose abnormalities due to too much insulin secretion represent an extreme effect of gastric bypass surgery.”

Salehi, who sees weight-loss surgery patients with glucose abnormalities at the UC Health Diabetes Center, says symptoms of hypoglycemia include shakiness, sweating, dizziness, light-headedness, weakness, confusion and difficulty speaking. More severe symptoms include seizure and cognitive abnormalities. Hypoglycemia can be life-threatening without proper monitoring or treatment.

“If hypoglycemia goes unnoticed, the body can become accustomed to low sugar and patients can then lose their awareness to low sugar. It is essential to seek help if any of these symptoms develop after gastric bypass surgery.”

Salehi is currently conducting a National Institutes of Health-sponsored study to determine how glucose metabolism is affected by gastric bypass surgery. For more information, call Leslie Baum, registered nurse and study coordinator, at (513) 558-0201.

To schedule an appointment with the UC Health Diabetes Center, call (513) 475-8200.

I think I’ve made it very clear in the past that I believe everyone should look at their own labs and watch for trends.  Occasionally, I get the question of “I can ask for my own records?”

YES.

You have the right to your own medical records.  In fact, if you have screwed up insides that many doctors don’t understand, not only do you have the right, you really have an obligation to have your records and to (I’m going to lose a few of you here) understand them.

Now I’m not saying that you understand surgical notes enough that you can go in and perform your own surgery on someone else.  That would just be silly.  But to know what a 1721 means for a B12 level, or a 30ml pouch created, or that you had a cholecystectomy during your RNY are all important things to know and to understand.

You’re going to ask why — and that’s good.  Cause asking “why” is always good – unless you are my almost two year old asking “why?” when I’ve told him not to hit his sister or to stop throwing blocks at the dog, and in that instance asking “why” is liable to make me want to pull my hair out.. but you get my point.  You need to know because you never know when you’re going to run across an idiot with a medical degree.  Please, please, PLEASE do not get blinded by the white coat.  We all want to think that our doctors are the smartest people on the planet, that they are the best surgeon in the world, and we are the most important patient on their roster for the day.  But let’s face facts — we are one of several patients your doctor sees every day, one of hundreds of prescriptions your pharmacist fills each day, one of thousands of people that will walk through a hospital a year.  Mistakes will happen, a degree of detail that you wish would happen will not always happen — and you are the only person that will really have to suffer through the consequences of any mistakes.

So let me concentrate for a moment on lab work.  When you have your labwork done, get copies of every single draw.  Get the interpretation by your doc and your nutritionist — fine, I don’t care.  But put your eyeballs upon it.  Even better, make a spreadsheet.  Be g33ky if you want and put it on the computer, put it on regular note paper, or just compare it time to time — whatever floats your boat.  But look at it.  And here’s what you want to look for — trends.

Are your numbers staying stable?  Are they going up?  Are they going down?  If they are going down, how quickly are they going down?  Why are they going down?  What can you do to make them stop going down?

Why is this important?  Here’s a scenario.

You have a blood draw done at 3 months, another at 6 months, and one planned at 9 months.  At 3 months, your B12 is 800, with a range of 200-900.  At 6 months, B12 is 500, which is still in range.  Because it is still in range, it is not flagged and is not even mentioned by the doctor or nutritionist.  Assuming nothing changes, and everything is equal, what do we guess the 9 month labs to be?  If no one is looking at trends, we are now at deficiency range, something that easily could have been avoided if trends had been watched and measures had been taken to avoid a deficiency in the first place.

It is your right, as a patient, to have access to your medical records.  Take advantage of this right.

It is the right of a hospital or medical facility to charge you for copies of these records.  Many hospitals will charge you $1 per page for copies.  Many doctor’s offices will not.

Yay for math?

On January 19, 2010, in Uncategorized, by Andrea

I admit, I like studies.  Studies make Andrea’s brain happy.  Studies have hard numbers that make sense.  Andrea likes black and white things — these are good things for a g33k (and don’t ever let it escape you — Andrea is a g33k — one who seems to be speaking in the 3rd person today — this is not a good sign).

But sometimes, studies, especially when done by a mathematical computation are not-so-cool.  Like this one that states an average 42 y.o RNY patient with a BMI of 45 would only gain close to 3 years of life by having WLS?  First off, I think that’s off.  Cause if someone is suffering from co-morbidities, those WILL shorten your life expectancy.

The numbers get even more screwbally when looking at younger patients — I apparantly gained more than 5 years.  We don’t know for certain because the numbers were for 35 year olds and I was 25 when I got my guts rearranged.  But we can construe that I got at least the five years.  Yay, me.

I really think patients gain more than a few years.  But then again, I’m not a computer.

Of course, this doesn’t measure the QUALITY of one’s life gained – but of course a computer can’t measure that.

From medpagetoday.com:

Gastric Bypass Extends Life for Most Patients

By John Gever, Senior Editor, MedPage Today
Published: January 18, 2010
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

For most patients in most categories, bariatric surgery increases life expectancy, according to a new mathematical model.Only when short-term mortality following bariatric surgery is expected to be high or the likelihood of success is low will the procedure fail to improve life expectancy, researchers reported in the January Archives of Surgery.

Computer modeling predicted that a hypothetical “base case” patient — a 42-year-old woman with a body mass index of 45 — would gain 2.95 years of additional survival following bariatric surgery, according to Daniel P. Schauer, MD, of the University of Cincinnati, and colleagues.

Surgery failed to be beneficial in the model only when 30-day mortality reached 9.5% or the likelihood that surgery would not add life-years was 2% or less, they found.

Baseline 30-day mortality in the model was 0.2%, and the baseline efficacy of surgery in extending life expectancy was 53%.

“While not all patients are guaranteed a good outcome, our model indicates that gastric bypass increases life expectancy for most patient subgroups,” they concluded.

Their analysis was based on a Markov decision model using published data to estimate 30-day mortality following bariatric surgery and the efficacy of surgery in reducing long-term death rates.

The latter had two components: reduction in excess mortality associated with obesity, and research data on long-term mortality following bariatric surgery.

Excess mortality estimates came from National Health Interview Survey data on some 400,000 participants from 1991 to 1996 linked to the National Death Index. Inputs on surgery efficacy were derived from a 2007 study of nearly 8,000 patients who had undergone gastric bypass and the same number of medically treated or untreated obese controls.

That study found that the procedure cut death rates by half during about seven years of follow-up. (See Missing Link Found: Bariatric Surgery Reduces Mortality)

Schauer and colleagues obtained rates of inhospital mortality following bariatric surgery from the 2005 National Inpatient Survey, then multiplied them by three to estimate 30-day mortality.

The researchers explained that according to earlier research, inhospital death rates typically underestimate 30-day mortality by a factor of two to three.

Their threefold correction factor represents “a conservative estimate that biases the model against gastric bypass surgery,” they wrote.

Schauer and colleagues tested this correction factor and other aspects of the model in sensitivity analyses.

The biggest gains in life expectancy occurred in younger women with relatively high BMI values, the model showed.

The age effect was less important than BMI at the time of surgery. A 35-year-old woman with BMI of 45 would gain about 3.2 years of extra life, whereas at 55, a similarly obese woman would gain about 2.5 extra years.

But a 35-year-old woman with BMI of 55 could expect to live five more years with surgery, the model indicated.

Men in general derived less survival benefit from bariatric surgery, particularly with advancing age at the time of the procedure.

At 35, the difference in life expectancy gained was roughly 10%, but by age 75 it had grown to about 50%.

The sensitivity analyses found that relatively large changes in most parameters used in the model did not affect the overall results substantially.

The effect of 30-day mortality on whether or not surgery was beneficial for long-term survival was related to BMI and gender.

For women with a BMI of 40, 30-day mortality of more than 5% would mean surgery was not helpful, but short-term mortality had to exceed 15% for surgery not to be preferable for those with BMI of 55 or more. These thresholds were about 10% higher for men.

The efficacy of surgery in reducing mortality was less important for older men, the analysis also showed. A 75-year-man with a BMI of 35 could expect only a very slight gain in life span — perhaps one or two months.

“Younger patients have lower surgical risk and more time over which to realize the benefits of surgery. For older patients, the gain is smaller, and for some, gastric bypass surgery will decrease life expectancy,” Schauer and colleagues wrote.

However, they identified several potentially serious limitations to the analysis.

The study of long-term mortality following bariatric surgery was conducted at a single center and was not randomized. Additionally, long-term complications, such as need for repeat surgery, were not addressed in the model. Certain other risks that might be heightened after bariatric surgery were excluded as well, and quality of life was not modeled.

“The decision analysis presented here is a step forward in understanding optimal patient selection but also highlights some of the areas for which better data are needed,” the researchers wrote.

The National Institute of Diabetes and Digestive and Kidney Diseases funded the study.

No potential conflicts of interest were reported.

Update: Medscape has included their take:

Gastric Bypass Surgery May Prolong Lives of Morbidly Obese

Nancy Fowler Larson

January 19, 2010 — Morbidly obese Americans could live up to 3 years longer after undergoing gastric bypass surgery, the most popular bariatric surgical procedure, according to a computerized model-based study published in the January issue of the Archives of Surgery.

“While no large-scale randomized controlled trials have compared bariatric surgery with intensive medical management for the morbidly obese, there is evidence from large controlled trials and numerous case series that bariatric surgery is currently the only effective therapy for promoting clinically significant weight loss and improving obesity-associated conditions among adults with a body mass index (BMI) of 40 or higher (calculated as weight in kilograms divided by height in meters squared),” write Daniel P. Schauer, MD, MSc, from the University of Cincinnati Academic Health Center, Ohio, and colleagues. “Several retrospective cohort studies and 1 prospective study suggest that bariatric surgery also improves survival.”

The study sought to weigh the benefits of gastric bypass surgery against its risks in the morbidly obese, who make up 5.1% of the US population.

The researchers created a decision analytic Markov state transition model with multiple logistic regression as inputs to analyze the differences between having gastric bypass, the leading surgery (>65% of all patients who receive bariatric surgery) for the morbidly obese in the United States, vs undergoing no surgery. A 42-year-old woman and 44-year-old man, both with BMIs of 45 kg/m2, were chosen for the researchers’ base case analysis.

To determine in-hospital mortality risk, the authors used 23,281 cases from the 2005 National Inpatient Interview Survey and then adjusted the data for 30-day mortality. During each such cycle, patients’ risk for death was calculated using their BMI, surgical status, age, and sex.

Data from more than 399,000 participants from the 1991 to 1996 National Health Interview Survey were used to calculate excess mortality’s relationship with obesity. Bariatric surgery’s effect on mortality was assumed only in connection with excess deaths associated with obesity. Information about the surgery’s effectiveness was gathered from a recently conducted, substantial observational trial.

Younger, Higher-BMI Participants Had Best Results

The ultimate multivariable logistic regression model used 7 factors — BMI, BMI2, age, age2, sex, sex × BMI, and age × sex — to predict mortality, with a good fit to the data (Hosmer-Lemeshow goodness-of-fit, P > .05; c statistic, 0.83).

The computerized model showed that the 42-year-old female model lived 2.95 years longer (35.03 vs 32.08 years) after undergoing surgery. When 30-day surgical mortality increased to more than 9.5% (baseline 30-day mortality, 0.2%) or when surgical efficacy declined to 2% or less (baseline efficacy, 53%), surgery was not preferred.

The 44-year-old male model would live 2.57 years longer (26.82 vs 24.25 years) after undergoing surgery, according to the model. Surgical treatment was not preferred when 30-day surgical mortality rose above 8.6% (baseline 30-day mortality, 0.55%) or when the effectiveness of the surgery fell to 3% or less (baseline efficacy, 53%).

In both sexes, those who were younger and had a higher BMI had the largest life expectancy increases. In men, the increase was slightly lower for all ages and subgroups.

“The optimal decision for individual patients varies depending on the balance of risks between perioperative mortality, excess annual mortality associated with increasing BMI, and the efficacy of surgery; however, for the average morbidly obese patient, gastric bypass surgery increases life expectancy,” the authors write.

Multiple Study Limitations

The authors noted several limitations to their assessments:

  • Available data do not include BMI and other clinical variables.
  • All data for calculating surgery efficacy are from a single state (Utah).
  • The authors did not model long-term, postsurgical complications, including any necessary revision.
  • Life expectancy was the sole outcome metric, as there are no longitudinal studies exploring quality-of-life improvements.

Acknowledging that not all gastric bypass surgeries produce good results, the study authors concluded that their findings of longer life spans for most subjects will help physicians determine which patients are the best candidates.

“We believe results of this analysis can be used to better inform both patients’ and physicians’ decisions regarding gastric bypass surgery,” the authors write.

The National Institute of Diabetes and Digestive and Kidney Diseases supported the study. The study authors have disclosed no relevant financial relationships.

Arch Surg. 2010;145:57-62.

Non-surgical treatment for kids

On January 18, 2010, in Uncategorized, by Andrea

Kids need help.  Badly.  Pediatric obesity is not on the rise — it’s reaching epidemic levels.  And given that many that are affected are low-income, there needs to be options for those families to afford treatment.  Treatment should not be relegated just to those who can afford it.

From MSNBC.com:

Obesity treatment for kids works, panel says

Advice could transform how doctors deal with overweight children

CHICAGO – An influential advisory panel says school-aged youngsters and teens should be screened for obesity and sent to intensive behavior treatment if they need to lose weight — a move that could transform how doctors deal with overweight children.

Treating obese kids can help them lose weight, the panel of doctors said in issuing new guidelines Monday. But that’s only if it involves rigorous diet, activity and behavior counseling.

Just five years ago, the same panel — the U.S. Preventive Services Task Force — found few benefits from pediatric obesity programs. Since then, the task force said, studies have shown success. But that has only come with treatment that is costly, hard to find and hard to follow.

Story continues below ↓

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The good news is, “you don’t have to throw your arms up and say you can’t do anything,” said task force chairman Dr. Ned Calonge. “This is a recommendation that says there are things that work.”

Calonge said the panel recognizes that most pediatricians are not equipped to offer the necessary kind of treatment, and that it may be hard to find, or afford, places that do. The recommendations merely highlight scientific evidence showing what type of programs work — “not whether or not those services are currently available,” he said.

The new advice, published online in the journal Pediatrics, could serve as a template for creating obesity programs. It also might remove one important cost barrier: Calonge said insurers will no longer be able to argue that they won’t provide coverage because treatment programs don’t work.

Evidence the panel evaluated shows intensive treatment can help children lose several pounds — enough for obese kids to drop into the “overweight” category, making them less prone to diabetes and other health problems. The treatment requires appointments at least once or twice a week for six months or more.

The recommendations follow government reports last week that showed obesity rates in kids and adults have held steady for about five years. Almost one-third of kids are at least overweight; about 17 percent are obese.

The task force is the same group of government-appointed but independent experts whose new mammogram advice startled many women in November. That guidance — that most women don’t need routine mammograms until age 50 — is at odds with the American Cancer Society and several doctor groups.

Costly programs
In this case, the task force advice mirrors that of the American Academy of Pediatrics. Many pediatricians already measure their young patients’ height, weight and body mass index at yearly checkups.

Task force recommendations in 2005 said there wasn’t enough evidence to encourage routine obesity screening and treatment. The update is based on a review of 20 studies, most published since 2005, involving more than 1,000 children.

The review excluded studies on obesity surgery, which is only done in extreme cases.

The panel stopped short of recommending two diet drugs approved for use in older children, Xenical and Meridia, because of potential side effects including elevated heart rate, and no evidence that they result in lasting weight loss.

Calonge, chief medical officer for Colorado’s public health department, said evidence is lacking on effective treatment for very young children, so the recommendations apply to ages 6 to 18.

The most effective treatment often involves counseling parents along with kids, group therapy and other programs that some insurers won’t cover. But adequate reimbursement “would be critical” to implementing these programs, Dr. Sandra Hassink, a member of the American Academy of Pediatrics’ board of directors, said in a Pediatrics editorial.

Dr. Helen Binns, who runs a nutrition clinic at Chicago’s Children’s Memorial Hospital, says such programs are scarce partly because they’re so costly. Her own hospital — a large institution in one of Chicago’s wealthiest neighborhoods — doesn’t have one.

Many families with obese or overweight children can’t afford that type of treatment. And it’s not just cost. Many aren’t willing to make the necessary lifestyle changes, she said.

“It requires a big commitment factor on the part of the parent, because they need to want to change themselves, and change family behavior,” Binns said.

LabRat

On January 16, 2010, in Minerals, by Andrea

Well, it’s been a month.  Or close to it since I started my experiment with Proferrin.

Due to some other issues that I was fairly certain were unrelated to my WLS, I decided to bite the bullet, go ahead and get my yearly lab draw out of the way.  I mean, last year I had hit my deductible by the first week in February when I had an outpatient surgery so I wanted to see if I could at least come close to cleaning out the FSA with my lab work and some blood work the kids are bound to have next week.  It’s a morbid little game I play that is somewhat depressing, but reminds me that I have it so much better of than many others out there.

In any case, I needed to have a draw done to rule out some other issues.  So I figured I’d update the status of the Proferrin experiment.

Unfortunately, not all of the values are identical, and the labs were not the same labs that did the testing — but I think we can get enough out of this to draw a few conclusions.  If not, you’re going to nod sagely, pretend that we could because it’s 10:20pm, the youngest is refusing to go to bed, it’s been a long day, and that’s that.  Kay?  That’s what I thought.

Ranges are for the lab that did the draw.  Remember, different labs, thus different ranges.  Hey, I wish there were standardized ranges, too.

12/2/2009
HGB – 12.6  (12.0 – 18.0 g/dl)
HCT – 39.7%  (37.0 – 51.0%)
Ferritin – 11.1  (11-137 ng/ml)
Iron – 41  (37 – 170 ug/dl)
TIBC – 310  (265 – 497 ug/dl)
Iron Saturation – 13%  (20-55%)

1/4/2010

HGB – 13.13  (12.0 – 15.0 g/dl)
HCT – 38.21%  (35.0 – 49.0%)
Ferritin – 16.3  (6 – 81 ng/ml premenopausal *which seems odd cause post is 14-186….?*)
Iron – 45  (28 – 182 ug/ml)
UIBC – 326  (130 – 375 ug/dl)
TIBC – 371  (180 – 545 ug/dl)
Iron Sat – Not measured

So what happened?

Well, in a month, my ferritin shot up 5 points and my serum iron went up 4.  Even the TIBC went up quite a bit, which would make me think that iron saturation would have if it had been measured by the second lab (which was asked for, by the way.. along with some other things that weren’t reported.. I’m hoping they were just delayed)

Now, all of this is assuming that the labs are accurate across the board.  For the sake of argument — THEY ARE.  I mean, there’s no way to say they are or aren’t and we have to trust something in this world, so let’s let this be one of those things that we trust.  That the labs are somewhat on an even keel in the measurement of things.

So for now, I am going to continue the Proferrin as planned — 3x a day.  It seems to be working.. and will retest.  I see my GI doc, who is convinced he is the one following my iron in February and I plan to get a lab slip from him to test all of this at the end of the experiment.  So we’ll get a better idea as to what the true answer is.

But so far?  Yeah, it’s working for me.  And I have to admit, the whole not having to wait 2 hours around calcium thing is pretty nice.

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