Laparoscopy With Percutaneous Transgastric Endoscopy for the Assessment of Gastric Cancer in the Excluded Stomach of a Roux-en-Y Gastric Bypass Patient.

Primary adenocarcinoma in the excluded stomach of Roux-en-Y gastric bypass (RYGB) patients is extremely rare. As such, the most effective diagnostic approach has not yet been determined. In typical patients, endoscopic ultrasound (EUS) is the first-line technique for evaluating suspected gastric cancer. However, RYGB patients require a more personalized approach. Endoscopic evaluation of the excluded stomach in RYGB patients, whether by EUS-directed, enteroscopy-assisted, or percutaneous means, is undoubtedly more complex than in patients with normal anatomy. In addition, gastric cancer is often diagnosed at an advanced stage due to its asymptomatic early course. With the added complexity of endoscopy in RYGB patients, a laparoscopic-assisted endoscopic approach may have a more favorable diagnostic and therapeutic utility in the case of gastric remnant malignancy in RYGB patients. The following case describes this comprehensive laparoscopic and endoscopic approach for the diagnosis of gastric cancer of the excluded stomach in an RYGB patient.

Racing and sales performance after unilateral or bilateral single transphyseal screw insertion for varus angular limb deformities of the carpus in 53 thoroughbreds.

OBJECTIVE: To evaluate the racing and sales performance of Thoroughbred horses with varus angular limb deformities of the carpus treated by unilateral or bilateral single transphyseal screw (STS) placement. STUDY DESIGN: Case series. ANIMALS: Thoroughbred horses (n=53). METHODS: Medical records (January 1, 2005-December 31, 2006) of yearling Thoroughbreds treated for carpal angular limb deformity by transphyseal screw insertion in the distal aspect of the radius were reviewed. Retrieved data were sex, surgery, and screw removal dates, surgical site, appearance, limb(s) affected, type of angular limb deformity, and degree of angular deviation measured by a goniometer. Racing and sales data were collected for analysis from an online racing site for all treated horses and their maternal siblings. RESULTS: No significant differences were identified between treated horses and their maternal siblings in yearling sale price, 2-year-olds in training sale price, percent starters, percent winners, and starts, earnings, and earnings/start made during the 2- and 3-year old years. CONCLUSIONS: No deleterious effects on sales or racing performance were identified after use of STS in the distal aspect of the radius of Thoroughbreds for the treatment of varus angular limb deformities of the carpus.

Comprehensive coronary artery disease care in a safety-net hospital: results of Get With The Guidelines quality improvement initiative.

BACKGROUND: Adherence to published coronary artery disease (CAD) guidelines is suboptimal, particularly among minorities and the poor. While hospital-based quality-improvement programs may increase the use of evidence-based therapies, little data exist regarding the impact of such programs in sociodemographically disadvantaged (vulnerable) populations. Vulnerable patients in the United States are cared for primarily within the safety-net health system, which comprises urban public hospitals and outpatient community health centers. Denver Health is an example of an integrated system that encompasses both types of facilities. OBJECTIVE: To assess evidence-based medication use in CAD patients after initiation of an inpatient quality-improvement program at Denver Health. METHODS: We reviewed the medical records of 499 patients with angiographically proven CAD who were hospitalized between July 1998 and December 2002. Patients were prospectively identified through a multidisciplinary intervention led by a nurse manager, and their records were input retrospectively into the American Heart Association's Get With The Guidelines patient management tool. The association's program, which recommends initiating 4 cardioprotective drug classes while patients are hospitalized, was started 2 years into the observation period (August 2000). Treatment rates were compared over the ensuing years. We evaluated temporal trends in discharge use of 4 drugs: (1) betablockers, (2) angiotensin-converting enzyme inhibitors (ACEIs), (3) hydroxymethylglutaryl coenzyme A reductase inhibitors (statins), and (4) aspirin. We calculated the proportion of eligible patients (no documented contraindication) who were prescribed each drug category as well as the proportion who received all 4 drug categories, our principal composite outcome. If any one drug was absent, the composite criterion was considered unmet. RESULTS: We observed progressive improvement in discharge use of the 4- drug composite: 18% in 1998-1999 (95% confidence interval [CI], 12%-25%), 50% in 2000 (95% CI, 37%-63%), 62% (95% CI, 54%-70%) in 2001, and 72% (65%-79%) in 2002 (P <0.001 for between-year differences). Among eligible patients discharged in 2002, 90% received beta-blockers, 91% received ACEIs, 86% received statins, and 93% received aspirin. CONCLUSIONS: Implementation of a multidisciplinary program led by a nurse manager was associated with increased CAD guideline compliance among sociodemographically disadvantaged patients. This compliance exceeded national averages. Achievement of the composite measure of use of all 4 recommended drug categories at discharge improved from 18% in 1998-1999 to 72% in 2002.