Pushing The Limits: Is all well that ends well?

from play.google.com

A quandary.  A conundrum. A medical riddle. A dilemma.

We had one recently, and (spoiler alert) all came out well.  But, as is often the case, by the very success we experienced, more questions were raised.

A study of one is not all that scientific in it's conclusion, but this 'one' may possibly lead to a lowered threshold to take a patient to surgery that otherwise may not get there all that soon, or maybe ever.

Enough delay -  Here's the deal...

A 29 y/o BMI 40 patient with quite poorly controlled T2DM (most recent A1C over 11), on Lantus 42 units and mealtime bolus Humalog 25 units at each meal, and Metformin 1000 BID.  She was scheduled for surgery, Gastric Bypass, but unable to be cleared by her PCP due to poor control of her Diabetes, as essentially a standard reasonable precaution for any elective surgery.

Many studies have been done in the General Surgery, as well as other surgical disciplines, demonstrating a notable increased perioperative risk, mostly due to infections.  Since there really isn't anything that can be characterized as an 'emergency' (non-elective) Bariatric surgery, the decision was to wait until better control was achieved through diet, lifestyle, and improved medical management. It was generally agreed that we didn't need a "Normal" A1C (6.5 or less), but heading in the right direction, closer to 8%, with a few weeks to months of better control as the plan.  Hopefully...

Enter Mr. Gall Bladder.  Either from weight loss from our preoperative diet, or retrospectively just because of divine 'timing', she developed RUQ abdominal pain and N/V and when we worked her up we found a normal GB U/S - that is no stones, sludge, wall thickening, or pericholecystic fluid.  However, with persistent symptoms consistent with biliary colic, we did get a PIPIDA which showed positive for significantly decreased EF.

We subsequently had hoped things would quiet down on their own as we headed toward the intended weight loss surgery, but no...

And, add to that, an altered diet (anorexia) from N/V, abdominal pain, especially post prandially.  To make matters worse, BG's were now even higher due to her difficulty knowing 'when' (and 'IF') to take her insulin, and if so how much depending on what she could eat, and what she would keep down.  It was getting messy.

So, it was crystallizing to this.  Do the Laparoscopic Gall Bladder quickly and get out, and then come back another day for the Bypass. Or, take the Gall Bladder, and add the extra 90 minutes or so and do the metabolic surgery (the Gastric Bypass) at the same time as we had originally planned, just that now it would be in a more acute setting, and with not the best antecedent BG control.

*The Benefits of doing both: Get the Gall Bladder out, and get started on a big DM2 benefit and get her started with  better glucose control with greatly reduced meds. One time exposure to anesthesia. Reduced risk of 'losing' her to continued poor DM control and perhaps not having the Bypass and therefore not getting the metabolic benefit from surgery, maybe not ever (it has happened before).

**The Risks:  The standard reasons why we usually do not do it this way, that is performing an elective surgery in the face of poorly controlled blood sugars / Diabetes -  Infection.  Electrolyte issues.  Intravascular volume contraction from glycosuria.  Metabolic issues from a relatively insulinopenic state.

We did get PCP clearance with this unusual instance clarified for this specific case, and then cardiology clearance just to be sure (history of Mom with sudden ?cardiac death in her 40s).

She came in at 289 to the day surgery area on the AM of surgery, mainly owing to a reported low BG issue at 10 PM the night before, and did not take any of her Lantus- I guess it could have been worse - at least she didn't eat after midnight. We scaled her with Novolog in the preop holding area, and got her to high 100's low 200's before, and kept her there during surgery.

Not great, but actually way better than where she had been living the preceding few months when was with us (high 200's / low 300's).

So, surgery went well, both cases done in just over 2 hours. Blood sugars rapidly regulated, after some short acting insulin (Novolog) in the PACU, and followed every 2 hours.  She actually needed very little additional insulin, and we were able to follow a moderate QID scale and she got about 8 additional units total during her two day stay, keeping her BGs in the low to mid 100's.

No Lantus needed.  No infections.  No cardiac issues or tachycardia.  No surgical complications.

Huge Win-Win.

Just seen at her 1 week followup, she remains well, no further nausea or abdominal pain as she had with her Gall Bladder, and her BGs are in the 100-130 range as she advances her diet and is just on Metformin 1000 mg BID.

Surgery truly is powerful medicine.

And while we don't have this dilemma all that often, when we did, we have always leaned toward delaying surgery until it was 'safer' by standard best practices, that is with near optimal BG control before surgery.

With our experience here, maybe our threshold to do a weight loss / metabolic surgery will be lowered, taking into account the potentially rapid benefit of glucose regulation that lifestyle and medicines had been unable to deliver up until that point.

How Low Can You Go? How High Can You Fly??

from slantmouth.com

Highs and lows.

Lows and highs.

How often are you on the correct side of both in the same context?  In my experience, not that often. But, when you are, its a time to celebrate and take note!

Such an occurrence occurred in the Bariatric Surgery field recently, from an article published in the January 2015 JAMA entitled "Association between Bariatric surgery and Long term Survival".

The study of 2,500 VA patients not only showed that weight loss surgery prevents, resolves, or improves diseases such as obesity, type II DM, and certain kinds of cancer, but can lead to a longer life.

The study followed patients 5-14 years post surgery between 2000 and 2011. On average, the mean age was 52 years old, and the average BMI was 47. Mix of procedures was 74% Bypass, 15%Sleeve, and 10% Band; 1% 'other'.

As time passed in the study, the curve of those patients that had surgery clearly diverged from matched controls who did not have the surgery. As measured at both 5 years and 10 years into the study prospectively, the surgery patients showed significant all cause mortality reductions, even across different sub groups defined by diabetes, diagnosis, age, and sex.

All these 'highs' of resolving and / or improving comorbidites, and the 'low' of markedly reduced mortality for 10 years out from bariatric surgery in this study.

A win -win scenario for sure.

How many other surgical procedures can boast of such glowing attributes, that even get a fraction of the scrutiny of weight loss surgery?

We're Not in Kansas Anymore, Toto

From Kaitlinwatteron.com

I was just thinking, now that the New Year is fully upon us, how things have changed ever so 'slightly' in our practice, and likely yours over the past year.

In fact, looking back over just the past couple of years, it seems like the changes are many and significant, and there is seemingly no end in sight now that we have started down this path.  Are the changes accelerating, or is it me that is stuck in my ways, already looking back to my 'glory days' despite my age only still in my forties?

Oh, some of these changes are certainly for the best.  Some are meant to be for the best, but fall notably short. And some... I have no idea.  In fact, their very name or label for a new part of the medical practice sometimes couldn't be farther from the truth. Does the term "Meaningful use" sound familiar?

So here is a list, in no special order of a few of the changes that have entered our practice, and your as well, and are now part of the current state of Electronic Medicine as we all are well into this next generational phase.

The Electronic Medical Record. A topic of topics unto itself.

Istop.

E-Prescribing for most meds, soon to be all meds in NYS.

Sorian Clinicals (clinical platform) and Sorian Financials(billing and scheduling platform).

Computer Physician Order Entry.

HIXNY.

Patient Portals.

E-Discharge orders in addition to order entry.

Meaningful Use with regular updates of new mandates required every quarter.

This list is a bit more daunting than it may appear.  And yes, all do bring a new level of potential benefit to the general care of a patient by a provider, but the pace of the new rollouts, and the often additional skill set development required to manage each "App", and that aspect itself for me leads to instantly less user-friendliness than intended.

Add to that the often non-interactive nature of these individual Apps, that in a perfect world should work together in compatibility, and do not. Such as in our system, our Sorian Financials that didn't play nice with our EMR platform.  Or the hospital side of diagnostic tests and reports and hospital admission data that again doesn't easily flow to the EMR platform, thus requiring manual 'scanning in' to make the EMR useful and approaching the completeness and usability that I think the database was intended to provide.

And, those "Meaningful Use" criteria that appear to be progressively nickel and diming their way to more irrelevance as they additively take more and more time to process a patient visit, for often no perceptibly added gain in quality to an office visit.

But in summation, probably the most substantial negative common denominator for all these additions to our medical system in the recent past is more Time.

Time - a commodity that was short to begin with, and now so much less is available to maintain anywhere close to the productivity that was once a sense of pride and purpose in how I approached my day, every day.  Not just to maintain financial stability for an employer, but the ever-present challenge to maintain a personal standard of high quality, efficiency, and personal connectedness to each patient I see. That's much more difficult now, even that the learning curve for our EMR, for example, is nearing its 1 year mark.

What I still have hope in, is that somehow we will acclimate, and we all will be soon getting back to a sense of what it means to truly participate in the care of a patient, and that these new tools, and even those that are mandated to be used, can be put together to comprehensively offer true advantage to us as providers, and the patient-provider relationship,  actively taking advantage of newly available technological means.  That's what Meaningful Use would mean to me.

Because, what I am discovering, as I look at a printout of 2-3 pages for a follow up office visit with all sorts of "meaningful" information - is that which is often the first casualty to save time with these new modern era office visits of checking all the boxes on all the necessary components of the visit - is the connectedness that I so enjoyed with how medicine was in the past.  "Medicine" as a whole is now not the same as it once was.  Not by a long shot. I miss Kansas.  And, (Toto) I miss the Rain down in Africa...

And you know what? Even worse?  Providers aren't the only ones who are a bit taken aback by this new electronic era of medicine. Patients have noticed as well, and some of them are not too happy either with the change.

So, enough ranting already.  Back to Bariatric issues and insights soon!

Happy New Year.

An Ounce of Prevention...

From NCDHHS.gov

Good old Ben.

Essentially always true, this adage holds even more weight (pun intended) in light of an article that a friend brought to my attention recently regarding T2DM  and the metabolic effects of Bariatric surgery.

The superlative and far-reaching benefits of bariatric / metabolic surgery for patients with Diabetes and obesity are quite well known.  I have wondered for some time if this can translate into a prevention of sorts for these high risk patients, and if so, how could it be studied and presented in a way that was believable and evidence-based.

The article is actually not a newly published study, but rather from an article published in the NEJM in August of 2012, by a group of physicians that prospectively reviewed the Swedish Obesity Study data,  looking for evidence of a preventative effect on the development of T2DM in Bariatric Surgery patients vs. obese matched controls who were treated with 'usual care'.

The authors found that bariatric surgery appeared to be markedly more efficient than usual care (diet, weight loss, and medicines) in the prevention of T2DM in obese persons.

Some more nitty gritty bullet points:

*  Whereby both patient groups (surgery vs. usual care) had no evidence of T2DM at the start of the study (no reported DM meds, FBG <110, Random BG if measured <126), the bariatric surgery group developed Diabetes in 110 of the patients studies vs. 392 participants in the control group.

*  The disparity in the  rate of developing T2DM are even more noteworthy when it is noted that the surgery group had a significantly higher BMI and additional comorbidities vs. the non-surgical group.

*  The mix of surgical procedures was based on what would be a percentage mix that would not be seen in this current era: Banding (19%), Vertical Banded Gastroplasty (69%), and Gastric Bypass (12%).  Our current mix for cases is likely in the 60% Bypass / and near 40% for Sleeves, with a few percentage points for Bands. VBG's are not currently done all that often to my knowledge, but the procedure does involve gastric stapling and division, and therefore did confer some metabolic benefit.

*  Running the numbers, the authors calculated a 78% reduction in the long term incidence of T2DM in obese patients.

*  Among those patients who fit the definition of Impaired fasting glucose, bariatric surgery reduced the risk by 87%, and T2DM did not develop in 10 of 13 patients that underwent bariatric surgery.  This effect was twice as large as observed with lifestyle interventions in moderately obese, prediabetic persons.

*  This last point is probably the best takeaway action step that certainly mirrors other such information that is at the heart of this blog's purpose as a whole:

"Type 2 Diabetes is a progressive disease, and the ability to produce insulin declines with time.

  Improvement of insulin sensitivity by means of weight loss may not be enough 

to induce the remission of diabetes if the destruction of beta cells is advanced, 

and the diabetes remission rate is 

inversely related to the duration of diabetes at the time of bariatric surgery.  

...this suggests that the disturbances of  glucose metabolism might be treated early, even before T2DM is diagnosed."

I will let you read between the lines as far a that action step - one I suspect you have heard here many times before.

Thinfluence Book Report

Finally! Done reading and ready to do the report.

I do feel like I am back in 5th grade (shout out to Mr. Mandarano!), when these types of assignments were much more commonplace. Even the phrase "book report" sends me down memory lane.

So, as for my overall impression on the book: I am surprised. Yes, happily surprised!

I am surprised at my reaction to this well-written book, and the lack of what I expected to be a bias against personal responsibility in a book about one's personal health, more specifically in the emotionally-charged area of weight and obesity.

As I stated before I started reading the book, I was hoping that the book wasn't going to dismiss a large chunk of the responsibility from the person who was looking to deal with their weight issue, but I was skeptical that that may have been the case.  Maybe it's this era of acceptance for diminished personal responsibility that lowered my expectations? actually   I digress...

I actually got a much different feeling from reading the book.  Yes, there was the detailed descriptions about many of the 'outside' factors that directly or indirectly contribute to weight, or at least the environment in a way that is obesogenic. Some of these were commonsense, and some were uniquely thought-provoking as to their cause and effect.

Take for instance, the disparity (evidence-based / studied) surrounding the fact that even though one's battle against obesity / weight issues is a highly individualized and personal matter( and very reinforced and dictated to by societal norms), patients actually do much better hitting their goals when engaged in group dynamics on may levels.

Whether it is a regularly meeting exercise group, a workplace weight challenge, a group benefit walk, or another group of people with a focus on weight and health, or even social media groups, studies did show that the rate of weight loss and healthy goal achievement was much in participants in those groups than in solo efforts.

And, taking that same approach to many similar levels of "influence" in our personal environment, based on the "Circles of Influence" graph depicted below, the book thoroughly described each one in light of their effect on a person's decisions and actions.

Photo by M Clock

The circle graph represents many different areas of influence, with the matters that we have the most direct control over in the center (Inner Self) of the concentric circles, and as we go further out from the center, less direct personal control (Environment and Societal Factors).

Reviewed and described as far as their effect and influence, were the areas of the Inner Factors, Relationships (family, friends, and work associates), the food and media "diet", and Policy factors of local to national laws and regulations.

Each chapter also had a final section that had an interactive action plan and a quiz to encourage the reader to put in place real change based on the information that was provided in the chapter. Pretty practical steps and input, I thought, without being patronizing.  Real examples were also provided of actual patients at Harvard, and how they realized their own results and attained heir heath / weight goals based on the chapter's content.

And, last but not least, and also studied in an evidence-based format, was the fact that people as individuals can have an impact on others and their pursuit of a healthier lifestyle.

The authors further encouraged people to realize more control over the areas that can variably be controlled, acknowledging less capability to do so as the circle graph extends away from the individual.  They also urged all those in search of  healthier weight and lifestyle to be a force for good for others, and in the foreseeable future, the US could be a much healthier place in the process.

Thinfluence? A Book Report

photo by M Clock

Okay, time to change it up a bit.

This post will be brief, and serve as an introduction to a new book I picked up at the library the other day.

"Thinfluence" caught my eye in the recently released section.  The cover defines the term as "the powerful and surprising effect family, work, and environment have on weight".

Written by two physicians that work at Harvard, and with the addition of evidence-based information and perspective, I thought it might be worth the read.  My bias against significantly relieving a patient's responsibilities with obesity, comorbidities,  and decreasing quality of life from self-care and purposeful attentiveness are well reinforced.  I am interested as to how well the cover-style marketing of this book, and it's "It's not really all your fault" initial message will stand up to my experience with patients, human nature and my day in day out interaction with the psyche of the patients we serve.

So, it is with some acknowledged bias that I start this book.  As often is the case, I at least  hope to gain some nuggets of evidence-based wisdom as to how patients can recognize and take advantage of their environment, perhaps in new and effective ways, and even be an influence, as the book details on its back cover, for others undergoing similar weight and health issues.

Sounds benign enough - right?

And, for the record, I don't think I am a totally half empty kind of guy... just a realist that may appear that way from time to time.

Trust but verify...

See what I mean?  Only now on page 6 and I've got to see how they qualify this....

More information on my 'book report' soon.

Genitourinary Issues with Obesity

Seeing patients in the office last week, I heard one patient excitedly say that she had an unexpected improvement in her 'health' despite just being only 1 month post op from her surgery.

She described her prior 'normal' habits of urinary stress incontinence with straining, exercise, lifting groceries, or laughing / coughing / sneezing.  She admitted an average of 5-7 times per week the utter embarrassment of such events, as well as the ever-present anticipatory dread, that such events could occur at the most inopportune of times.

She was down in weight only 30# from her start weight (pre op), yet recounted a diminution in events now only 1-2 x per month now.  Talk about quality-of-life improvement.  This was a woman in her early 50s, obviously was morbidly obese, and the mom of 2 prior NSVDs.

As luck would have it, I just so happened to come across a study reported recently that was done at the University of California San Francisco School of Medicine, by Dr. Leslee Subak, professor of obstetrics, gynecology, and reproductive sciences there.

She led a team that looked at the rates of incontinence in a specific bariatric surgery patient population, and the resolution of those urinary tract symptoms in that same group.

She found that nearly 50% of the women in her study group, namely 775 of 1500, reported episodes of urinary incontinence at least 1 time per week preoperatively.

71% of those patients had Gastric Bypass, the remainder had Gastric Banding.

Demographically, the average age was 46 y/o, most were caucasian, and most lost at least 30% of their body weight by one year and maintained that through 3 years from their surgery date.

The findings from the completed annual questionnaires?

 From an average of 11 instances of incontinence per week, the frequency dropped to only 4 per week at two and three years post-surgery. Further, the remission rate — less than 1 weekly episode over the past 3 months — was about 61 percent after 3 years. And 25 percent of the women had had no episodes in the previous 3 months, they reported at 3-year post-surgery.

Obesity and stress incontinence certainly do have a causal relationship.  Not only can the long term pressure on the pelvic floor cause muscular and sphincteric laxity and dyscoordination, the effects of often comorbid Diabetes can further complicate the issue by adding neuromuscular dysfunction.

While incontinence is not one of the major players in the comorbidity strata, especially in terms of insurance reimbursement for surgery approval with a BMI of the 35 - 40 range patient, I am sure if you asked a patient how much negative lifestyle impact it has, you might be a little surprised. (Especially if you do not 'know' about the entity personally.)

So, there you go: Another reported / studied benefit of weight loss surgery, something to be mindful of, or mention to a patient when considering someone who would be a good candidate for surgery.  

It's not too hard to remember the BIG benefits of mortality reduction and improvements in HTN, DM2, Lipids, and DJD / joint pain, as well as OSA improvements among others - disease processes all mentioned numerous times throughout the history of this Blog.

And, despite no one likely ever dying directly of incontinence, that doesn't mean that a patient with that affliction hasn't wished at one or more times they had - when that inopportune moment struck...

From Flickr.com