Chronic psychiatric diagnoses increase emergency department utilization following bariatric surgery.

INTRODUCTION: This study aims to evaluate the impact mental health disorders have on emergency department (ED) utilization following bariatric surgery. We hypothesize that the presence of preexisting psychiatric diagnoses is predictive of increased post-bariatric surgical ED usage as compared to a matched cohort without psychiatric comorbidities. METHODS AND PROCEDURES: We utilized the Colorado All Payers Claim Database to identify patients undergoing laparoscopic sleeve gastrectomy, gastric band, or gastric bypass, (N = 5393). Patients with preexisting diagnoses of schizophrenia or bipolar disorder (PSY), and no concomitant mental health diagnosis were included (N = 427). Patients without a psychiatric diagnosis (CON) were used for comparison. Propensity score matching in a 1:1 ratio was done matching for age, sex, BMI, procedure type, and comorbidities. Baseline ED utilization was calculated over the year preceding surgery. RESULTS: A total of 240 patients with bipolar disorder or schizophrenia were identified. After matching, baseline ED utilization was 62% higher in the PSY group (ED visits per person per month (EDVPP) of 0.17 (95%CI 0.16-0.18) in the PSY group compared to 0.10 (95%CI 0.09-0.12) in the CON group). ED utilization increased dramatically in the month following surgery for both PSY and CON groups (EDVPP 0.58 (95%CI 0.52-0.65) vs 0.34 (95%CI 0.28-0.41)), but visits returned to baseline for the CON but not PSY patients by three months after surgery (11% vs 60% above baseline, respectively). In the PSY group, ED utilization remained elevated at 18% above baseline for two years post-surgery (EDVPP 0.20 (95%CI 0.19-0.22). CONCLUSIONS: Bariatric patients with schizophrenia or bipolar disorder have higher baseline ED usage compared to a matched cohort. ED usage increases post-operatively in all patients but to a greater extent in patients with these diagnoses. Such patients would benefit from intensive outpatient follow-up to limit ED visits.

Toll-Like Receptor-4 Is a Mediator of Proliferation in Esophageal Adenocarcinoma.

BACKGROUND: Chronic inflammation from reflux disease has been implicated as part of the development of esophageal adenocarcinoma. Toll-like receptors (TLRs), a component of the innate immune system, have been implicated in mediating hyperplasia and metaplasia in response to inflammatory stimuli. Increased TLR4 in human esophageal cancer has been correlated with its carcinogenesis. We hypothesized that TLR4 mediates proliferation of human esophageal adenocarcinoma cells. METHODS: Normal human esophageal (HET1A) and adenocarcinoma (OE33, FLO-1) cell lines were cultured using standard techniques. TLR4 was measured at baseline and in response to reflux stimuli. All cell lines were treated with the TLR4 agonist lipopolysaccharide for 48 hours, and growth response was measured. Changes in myeloid differentiation primary response 88 (MyD88), tumor necrosis factor receptor associated factor 6 (TRAF6), and nuclear factor-κB (NF-κB) activity were measured during lipopolysaccharide treatment. All cell lines had NF-κB inhibited, and growth rate response was measured. RESULTS: TLR4 was expressed in all cell lines, with increased baseline expression in adenocarcinoma cell lines (p < 0.05). Reflux stimuli increased TLR4 expression (p < 0.01) in normal esophageal cells. After treatment with lipopolysaccharide, all cell lines showed significant increases in proliferation (p < 0.05) due to the NF-κB pathway, and their growth rate was reduced with NF-κB inhibition (p < 0.05). CONCLUSIONS: TLR4 is consistently detectable in esophageal cell lines and most highly expressed in adenocarcinoma. TLR4 expression increases in an inflammatory model of reflux disease. TLR4 activation results in increased proliferation due to the TLR4-MyD88-TRAF6-NF-κB signaling pathway, and inhibition of NF-κB leads to decreased esophageal cell growth. These findings suggest TLR4 may be a target to suppress esophageal cancer growth.

Chest Wall Resection and Reconstruction: Management of Complications.

The main indications for chest wall resection continue to be tumors, infection, and radiation injury. Complications surrounding chest wall resection procedures include respiratory failure, wound complications, and prosthetic complications. The main risk factors for complications are size of defect, age, and concomitant lung resection. Most complications related to either the wound or the prosthesis are late postoperative events. The identification of complications related to chest wall reconstruction requires clinical examination and the use of detailed imaging studies. The management of both prosthetic and wound complications often requires reoperation and removal of the prosthesis combined with soft tissue wound management.

A collaborative cardiologist-pharmacist care model to improve hypertension management in patients with or at high risk for cardiovascular disease.

UNLABELLED: Physician led collaborative drug therapy management utilizing clinical pharmacists to aid in the medication management of patients with hypertension has been shown to improve blood pressure control. With recommendations for lower blood pressures in patients with coronary artery disease, a cardiologist-pharmacist collaborative care model may be a novel way to achieve these more rigorous goals of therapy. OBJECTIVE: The purpose of this project was to evaluate this type of care model in a high cardiac risk patient population. METHODS: A retrospective cohort study determined the ability of a cardiologist-pharmacist care model (n=59) to lower blood pressure and achieve blood pressure goals (< 130/80 mmHg) in patients with or at high risk for coronary artery disease compared to usual cardiologist care (n=58) in the same clinical setting. RESULTS: The cardiologist-pharmacist care model showed a higher percentage of patients obtaining their goal blood pressure compared to cardiologist care alone, 49.2% versus 31.0% respectively, p=0.0456. Greater reductions in systolic blood pressure (-22 mmHg versus -12 mmHg, p=0.0077) and pulse pressure (-15 mmHg versus -7 mmHg, p=0.0153) were noted in the cardiologist-pharmacist care model. No differences in diastolic blood pressure were found. There was a shorter duration of clinic follow-up (7.0 versus 13.2 months, p=0.0013) but a higher frequency of clinic visits (10.7 versus 3.45, p<0.0001) in the cardiologist-pharmacist care model compared to usual care. The number of antihypertensive agents used did not change over the time period evaluated. CONCLUSIONS: This study suggests a team-based approach to hypertensive care using a collaborative cardiologist-pharmacist care model improves blood pressure from baseline in a high cardiac risk patient population and was more likely to obtain more stringent blood pressure goals than usual care.

A collaborative cardiologist-pharmacist care model to improve hypertension management in patients with or at high risk for cardiovascular disease / Modelo de atención colaborativo entre cardiólogo y farmacéutico para mejorar la gestión de la hipertensión en pacientes con o en riesgo de enfermedad cardiovascular

Physician led collaborative drug therapy management utilizing clinical pharmacists to aid in the medication management of patients with hypertension has been shown to improve blood pressure control. With recommendations for lower blood pressures in patients with coronary artery disease, a cardiologist-pharmacist collaborative care model may be a novel way to achieve these more rigorous goals of therapy. Objective: The purpose of this project was to evaluate this type of care model in a high cardiac risk patient population. Methods: A retrospective cohort study determined the ability of a cardiologist-pharmacist care model (n=59) to lower blood pressure and achieve blood pressure goals (< 130/80 mmHg) in patients with or at high risk for coronary artery disease compared to usual cardiologist care (n=58) in the same clinical setting. Results: The cardiologist-pharmacist care model showed a higher percentage of patients obtaining their goal blood pressure compared to cardiologist care alone, 49.2% versus 31.0% respectively, p=0.0456. Greater reductions in systolic blood pressure (-22 mmHg versus -12 mmHg, p=0.0077) and pulse pressure (-15 mmHg versus -7 mmHg, p=0.0153) were noted in the cardiologist-pharmacist care model. No differences in diastolic blood pressure were found. There was a shorter duration of clinic follow-up (7.0 versus 13.2 months, p=0.0013) but a higher frequency of clinic visits (10.7 versus 3.45, p<0.0001) in the cardiologist-pharmacist care model compared to usual care. The number of antihypertensive agents used did not change over the time period evaluated. Conclusion: This study suggests a team-based approach to hypertensive care using a collaborative cardiologist-pharmacist care model improves blood pressure from baseline in a high cardiac risk patient population and was more likely to obtain more stringent blood pressure goals than usual care (AU)

La gestión de la terapéutica en colaboración con los médicos utilizando farmacéuticos clínicos para ayudar con la medicación de pacientes con hipertensión ha demostrado mejorar el control de la presión arterial. Con las recomendaciones de menores presiones arteriales para los pacientes con enfermedad coronaria, un modelo de colaborativo cardiólogo-farmacéutico puede ser un método novedoso de conseguir resultados terapéuticos más rigurosos. Objetivo: El propósito de este proyecto fue evaluar este tipo de cuidados en una población de pacientes en alto riesgo cardiovascular. Métodos: Un estudio de cohorte retrospectiva (n=59) determinó la capacidad de que un modelo de cuidados cardiólogo-farmacéutico baje la presión arterial y alcance los objetivos de presión arterial (<130 mmHg) en pacientes con o en riesgo de enfermedad coronaria comparado con el cuidados normales de un cardiólogo (n=58) en el mismo establecimiento clínico. Resultados: El modelo de cuidados cardiólogo-farmacéutico mostró un mayor porcentaje de pacientes alcanzando su objetivo de presión arterial comparado con el cuidado del cardiólogo solo, 49,2% vs 31,0%, respectivamente, p=0,0456. Se encontraron mayores reducciones de presión arterial sistólica (-22 mmHg vs. -12 mmHg, p=0.0077) y presión de pulso (-15 mmHg vs. -7 mmHg, p=0.0153) en el modelo de cuidados cardiólogo-farmacéutico. No se encontraron diferencias en la presión arterial diastólica. Hubo menor duración del seguimiento (7.0 vs. 13.2 meses, p=0.0013) pero mayor frecuencia de visitas a la clínica (10.7 vs. 3.45, p<0.0001) en el modelo colaborativo comparado con el cardiólogo solo. El número de antihipertensivos utilizado no cambió durante el periodo evaluado. Conclusión: Este estudio sugiere que un abordaje de los cuidados de la hipertensión en equipo usando un modelo de cuidados colaborativo cardiólogo-farmacéutico mejora la presión arterial en una población de pacientes en riesgo cardiaco elevado, y alcanzó los objetivos de presión arterial más rigurosamente que la atención normal (AU)