Thirty-Day Readmission Rate Using an Outpatient Infusion Pathway after Laparoscopic Roux-en-Y Gastric Bypass.

The objective of this study was to determine whether implementing an outpatient infusion pathway (OIP) resulted in a decreased 30-day readmission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB). Data were retrospectively gathered on all patients who underwent LRYGB at our institution between April 1, 2015, and March 31, 2016, after instituting an OIP (postinfusion group). Thirty-day readmission rate, length of stay, and 30-day mortality rate were compared with patients who underwent LRYGB between January 1, 2014, and December 31, 2014, before implementing the OIP (preinfusion group). Patients not able to take 40 ounces of fluid orally at discharge after surgery were enrolled in the OIP. One OIP session would include an antiemetic, 1 liter bolus of 0.9 per cent saline, and intravenous multivitamin, thiamine, and folic acid. A total of 174 patients were included for analysis. Seventy-nine patients were in the preinfusion group and 95 patients in the postinfusion group. Of the 95 patients in the postinfusion group, 18 patients (18.9%) met inclusion criteria for the OIP. There was a 45 per cent decrease in 30-day readmission rate after the institution of the OIP for patients who underwent LRYGB, however this was not statistically significant (11.39% vs 6.31%; OR 1.907; 95% confidence interval: 0.648-5.613, P = 0.235). There was no difference in postoperative length of hospital stay (1.65 vs 1.41 days, P = 0.114) or mortality (0.7% vs 0%, P = 0.454), in the pre- and postinfusion groups, respectively. Implementation of an OIP decreased 30-day readmission rate after LRYGB by 45 per cent; however, this was not statistically significant.

Factors Influencing Primary Care Physicians' Referral for Bariatric Surgery.

BACKGROUND AND OBJECTIVES: Bariatric surgery has been shown to be an effective weight loss treatment for the morbidly obese, but some primary care physicians remain hesitant about postoperative treatment and management of patients who have undergone the surgery and recommend it to their obese patients infrequently. The purpose of this study was to evaluate perceptions of primary care physicians of the role of bariatric surgery in the management of obese patients and to identify possible barriers to treatment. METHODS: A survey of PCPs within our institution was conducted to determine attitudes, knowledge, and practices regarding the treatment of morbidly obese patients,with a specific focus on identifying factors that influence referral patterns for bariatric surgery. RESULTS: Among 161 eligible PCPs, 57 (35.4%) responded. Most respondents (59%) reported that at least 1 in 4 of their patients had a BMI 35 kg/m2. Although 39% thought that diet and exercise were an effective means of sustained weight loss, only 12% were satisfied with prescribing nonsurgical interventions. Sixty-three percent agreed that bariatric surgery is generally effective in the long term. All respondents were aware of the commonly established benefits, including improvement of diabetes, hypertension, and hyperlipidemia. In addition, 65% were familiar with the indications for bariatric surgery, and 70% felt comfortable discussing it with patients as a treatment option. Fewer than half of the respondents felt confident in providing postoperative management. Cost was a perceived limitation, with 53%reporting that most of their patients could not afford bariatric surgery. CONCLUSIONS: The general attitude of PCPs toward bariatric surgery is supportive. Physicians are largely aware of the indications and benefits; however, far fewer are comfortable in management of patients after surgery. A lack of supplemental information and concerns regarding the cost of surgery can impede treatment and referrals.

Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy.

OBJECTIVE: To compare outcomes and costs of elective surgery for diverticular disease (DD) with those of other diseases commonly requiring colectomy. DESIGN: Multivariable analyses using the Nationwide Inpatient Sample to compare outcomes across primary diagnosis while adjusting for age, sex, race, year of admission, and comorbid disease. SETTING: A sample of US hospital admissions from 2003-2009. PATIENTS: All adult patients (≥18 years) undergoing elective resection of the descending colon or subtotal colectomy who had a primary diagnosis of DD, colon cancer (CC), or inflammatory bowel disease (IBD). MAIN OUTCOME MEASURES: In-hospital mortality, postoperative complications, ostomy placement, length of stay, and hospital charges. RESULTS: Of the 74,879 patients, 50.52% had DD, 43.48% had CC, and 6.00% had IBD. After adjusting for other variables, patients with DD were significantly more likely than patients with CC to experience in-hospital mortality (adjusted odds ratio, 1.90; 95% CI, 1.37-2.63; P < .001), develop a postoperative infection (1.67; 1.48-1.89; P < .001), and have an ostomy placed (1.87; 1.65-2.11; P < .001). The adjusted total hospital charges for patients with DD were $6678.78 higher (95% CI, $5722.12-$7635.43; P < .001) and length of stay was 1 day longer (95% CI, 0.86-1.14; P < .001) compared with patients with CC. Patients with IBD had the highest in-hospital mortality, highest rates of complications and ostomy placement, longest length of stay, and highest hospital charges. CONCLUSIONS: Despite undergoing the same procedure, patients with DD have significantly worse and more costly outcomes after elective colectomy compared with patients with CC but better than patients with IBD. These relatively poor outcomes should be recognized when considering routine elective colectomy after successful nonoperative management of acute diverticulitis.

Impaired cardiac hypertrophic response in Calcineurin Abeta -deficient mice.

Calcineurin is a calcium-calmodulin-regulated, serine-threonine phosphatase that functions as a key inducer of stress responsive gene expression in multiple cell types through a direct activation of nuclear factor of activated T cells and myocyte enhancer factor 2 transcription factors. In cardiomyocytes, calcineurin signaling has been implicated in the regulation of the hypertrophic response caused by pressure overload or neuroendocrine stimulation. Three separate genes encode the catalytic subunit of calcineurin in mammalian cells, CnAalpha, CnAbeta, and CnAgamma. To evaluate the necessary function of calcineurin as a hypertrophic regulatory factor, the CnAbeta gene was disrupted in the mouse. CnAbeta-deficient mice were viable, fertile, and overtly normal well into adulthood, but displayed a 80% decrease in calcineurin enzymatic activity in the heart that was associated with a 12% reduction in basal heart size. CnAbeta-deficient mice were dramatically impaired in their ability to mount a productive hypertrophic response induced by pressure overload, angiotensin II infusion, or isoproterenol infusion. Analysis of marker genes associated with the hypertrophic response revealed a partial defect in the molecular program of hypertrophy. Collectively, these data solidify the hypothesis that calcineurin functions as a central regulator of the cardiac hypertrophic growth response in vivo.