Coasting: worth the effort?

A new anesthesia machine incorporates a "coasting mode", but the extent to which a coasting technique can maintain anesthesia at the end of a procedure under optimal conditions (closed circuit anesthesia) remains unknown. Sixty-nine patients undergoing peripheral or abdominal surgery were assigned to 1 of 9 groups, depending on when desflurane coasting (in O2/air) was started (after 4, 9, 16, 25, 36, 49, 64, 81, or 100 min). The end-expired desflurane concentration was maintained at 4.5% in O2/air prior to coasting with a conventional anesthesia machine. After initiating coasting (using a closed-circuit technique), we examined when the end-expired desflurane concentration reached 70, 60, 50, and 40% of its value during maintenance (= 30, 40, 50 and 60% decrement times, respectively). Decrement times increased with increasing duration of anesthesia, and varied widely. After 64 min of maintenance anesthesia, the end-expired desflurane concentration remained at or above 70, 60, 50, and 40% of its maintenance value during 10.3 +/- 2.3, 16.0 +/- 3.5, 25.0 +/- 5.9, and 45.4 +/- 19.3 min, respectively (average +/- standard deviation). Coasting can briefly maintain anesthesia towards the end of a procedure. While savings with an automated coasting mode are likely to be modest per patient, they may become substantial when multiplied by the number of procedures per day per operating room with no increase in the clinical workload of the anesthesia provider.

A nationwide survey on bariatric surgery in Germany--results 2005-2007.

BACKGROUND: Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany). METHODS: In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated. RESULTS: During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall). CONCLUSION: As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

Results of sleeve gastrectomy-data from a nationwide survey on bariatric surgery in Germany.

BACKGROUND: Beginning January 1, 2005, the status and outcomes of bariatric surgery were examined in Germany. Data are registered in cooperation with the An-Institute of quality assurance in surgery at the Otto-von-Guericke-University Magdeburg. The objective of this study was to examine the morbidity and mortality rates secondary to sleeve gastrectomy (SG) in Germany since 2006. METHODS: Data collection occurred prospectively in an online data bank. All primary bariatric procedures performed were recorded as were all re-operations in patients that had already undergone a primary operation. Specific data compiled on the sleeve gastrectomy procedure were evaluated with a focus on operative details and complication rates. RESULTS: The total study cohort contains 3,122 patients. From January 2006 to December 2007, 144 sleeve gastrectomy procedures were performed in the 17 hospitals participating in the study. The mean body mass index (BMI) of all patients was 48.8 kg/m(2). The BMI of patients undergoing SG was 54.5 kg/m(2). In total, 73.8% of the patients were female and 26.2% of the patients were male. There were no significant differences between patients undergoing SG. The general complication rate after SG was 14.1%, and the surgical complication rate was 9.4%. The postoperative mortality rate was 1.4%. CONCLUSIONS: The complication rate during the first 2 years after SG in Germany is similar to that published in the literature. In order to improve the quality of bariatric surgery, an evaluation of data from a German multicenter trial is necessary to evaluate the position of SG in the bariatric algorithm.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature.

BACKGROUND: Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany). METHODS: Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI). RESULTS: Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day. CONCLUSION: In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

Bone cells in culture: morphologic transformation by hormones.

Hormones and purine nucleosides and nucleotides induced cultured bone cells to transform transiently from a spherical to a stellate shape. Cytochalasin B also induced the transformation. The change was blocked by colchicine and vinblastine, but not by lumicolchicine or cycloheximide. This morphologic transformation may provide a dynamic model of hormone action and bone cell modulation in vitro.

Complete genome sequence of a virulent isolate of Streptococcus pneumoniae.

The 2,160,837-base pair genome sequence of an isolate of Streptococcus pneumoniae, a Gram-positive pathogen that causes pneumonia, bacteremia, meningitis, and otitis media, contains 2236 predicted coding regions; of these, 1440 (64%) were assigned a biological role. Approximately 5% of the genome is composed of insertion sequences that may contribute to genome rearrangements through uptake of foreign DNA. Extracellular enzyme systems for the metabolism of polysaccharides and hexosamines provide a substantial source of carbon and nitrogen for S. pneumoniae and also damage host tissues and facilitate colonization. A motif identified within the signal peptide of proteins is potentially involved in targeting these proteins to the cell surface of low-guanine/cytosine (GC) Gram-positive species. Several surface-exposed proteins that may serve as potential vaccine candidates were identified. Comparative genome hybridization with DNA arrays revealed strain differences in S. pneumoniae that could contribute to differences in virulence and antigenicity.

Desflurane consumption with the Zeus during automated closed circuit versus low flow anesthesia.

INTRODUCTION: During automated closed-circuit anesthesia (CCA), the Zeus (Dräger, Lübeck, Germany) uses a high initial fresh gas flow (FGF) to rapidly attain the desired agent and carrier gas concentrations, resulting in a desflurane consumption well above patient uptake. Because both FGF and carrier gas composition can affect consumption, we determined the Zeus' agent consumption with automated CCA and with automated low flow anesthesia (LFA) (= maintenance FGF of 0.7 L min(-1)) with 3 different carrier gases. METHODS: After IRB approval, 65 ASA PS I or II patients undergoing general surgery received desflurane in either O2, O2/air, or O2/N2O, with the Zeus to maintain the end-expired concentration (FA) at 6, 6, and 4% and the F1O2 at 1.0, 0.6, and 0.4, respectively. In addition, patients were assigned to either automated CCA (O2 n = 11; O2/air n = 11; O2/N2O n = 11) or automated LFA (selected FGF 0.7 L min(-1)) (O2 n = 12; O2/air n = 11; O2/N2O n = 9). Demographics and desflurane consumption at 2, 4, 6, 8, 10, 20, 30, 40 and 50 min were compared. RESULTS: With the same carrier gas, desflurane consumption was lower with the CCA mode than with LFA mode after 4 min in the O2 groups, 6 min in the O2/air groups, and 30 min in the O2/N2O groups. Within each mode, desflurane consumption in the O2 and O2/air groups was identical at all times. Despite the use of a lower FA in the N2O groups, initial desflurane consumption was higher than in the O2 and O2/air groups, but it was lower later (> or = 15 min) only with LFA. DISCUSSION: After 50 min, desflurane consumption with automated CCA is lower than with automated LFA. However, initial agent consumption is complex, and N2O in particular may increase initial desflurane consumption (though ultimately resulting in lower desflurane usage because of its MAC sparing effect) because initial FGF is increased to rapidly reach the target concentrations. Differences in desflurane consumption only become apparent after FGF has stabilized to the target FGF.

Pulmonary gas exchange is well preserved during robot assisted surgery in steep Trendelenburg position.

INTRODUCTION: During robot assisted hysterectomies and prostatectomies, surgical exposure demands the application of a CO2 pneumoperitoneum with a very steep Trendelenburg position (40 degrees). The extent to which oxygenation and ventilation might be compromised intra-operatively remains poorly documented. METHODS: Dead-space ventilation and venous admixture were determined in 18 patients undergoing robot assisted hysterectomy (n = 6) or prostatectomy (n = 12). Anesthesia was maintained with desflurane in O2 or O2/air, with the inspired O2 fraction left at the discretion of the attending anesthesiologist. Controlled mechanical ventilation was used, but 15 min after assuming the Trendelenburg position and up until resuming the supine position pressure controlled ventilation was used. Dead-space ventilation and venous admixture were determined using Bohr's formula and Nunn's iso-shunt diagram, respectively, at the following 7 stages of the procedure: 15 min after induction; 5 min after applying the CO2 pneumoperitoneum (intra-abdominal pressure 12 mm Hg) but while still supine; 5, 60, and 120 min after assuming the Trendelenburg positioning; and 5 and 15 min after reassuming the supine position. RESULTS: Venous admixture did not change. Dead-space ventilation increased after Trendelenburg positioning, and returned to baseline values after resuming the supine position. However, individual patterns varied widely. DISCUSSION: The lung has a remarkable yet incompletely understood capacity to withstand the effects of a CO2 pneumoperitoneum and steep Trendelenburg position during general anesthesia. While individual responses vary and should be monitored, effects on dead-space ventilation and venous admixture are small and should not be an obstacle to provide optimal surgical exposure during robot assisted prostatectomy or hysterectomy.

PROCEED: Prospective Obesity Cohort of Economic Evaluation and Determinants: baseline health and healthcare utilization of the US sample.

AIM: To summarize baseline characteristics, health conditions, resource utilization and resource cost for the US population for the 90-day period preceding enrolment, stratified by body mass index (BMI) and the presence of abdominal obesity (AO). METHODS: PROCEED (Prospective Obesity Cohort of Economic Evaluation and Determinants) is a multinational, prospective cohort of control (BMI 20-24.0 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI >or= 30 kg/m(2)) subjects with AO and without AO [non-abdominal obesity (NAO)], defined by waist circumference (WC) >102 and 88 cm for males and females, respectively. Subjects were recruited from an Internet consumer panel. Outcomes were self-reported online. Self-reported anthropometric data were validated. Prevalence of conditions and utilization is presented by BMI class and AO within BMI class. Differences in prevalence and means were evaluated. RESULTS: A total of 1067 overweight [n = 474 (NAO: n = 254 and AO: n = 220)] and obese [n = 493 (NAO: n = 39 and AO: n = 454)] subjects and 100 controls were recruited. Self-reported weight (r = 0.92) and WC (r = 0.87) were correlated with measured assessments. Prevalence of symptoms was significantly higher in groups with higher BMI, as were hypertension (p < 0.0001), diabetes (p < 0.0001) and sleep apnoea (p < 0.0001). Metabolic risk factors increased with the BMI class. Among the overweight class, subjects with AO had significantly more reported respiratory, heart, nervous, skin and reproductive system symptoms. Overweight subjects with AO reported a significantly higher prevalence of diabetes (13%) compared with overweight subjects with NAO (7%, p = 0.04). Mean healthcare cost was significantly higher in the higher BMI classes [control ($456 +/- 937) vs. overweight ($1084 +/- 3531) and obese ($1186 +/- 2808) (p < 0.0001)]. CONCLUSION: An increasing gradient of symptoms, medical conditions, metabolic risk factors and healthcare utilization among those with a greater degree of obesity was observed. The independent effect of AO on health and healthcare utilization deserves further study with a larger sample size.

Cancer screening and informed patient discussions. Truth and consequences.

While screening for asymptomatic cancer has become one of the principal clinical activities of primary care physicians, patients are generally not involved directly in screening decisions. To help physicians better communicate the potential benefits and burdens of cancer screening, this article concisely presents information necessary for patients to make a reasoned decision as to whether to proceed with screening: the probability of developing cancer, the operating characteristics of available screening tests, the likelihood that screening will result in an improved outcome for the individual patient, and the potential burdens associated with screening. Screening tests for breast, colorectal, cervical, and prostate cancers are reviewed, including mammography, clinical breast examination, fecal occult blood testing, Papanicolaou smear, digital rectal examination, and prostate-specific antigen. Better communication about cancer screening will promote shared decision making--a central tenet of the physician-patient relationship.

The impact of informed consent on patient interest in prostate-specific antigen screening.

BACKGROUND: Because of the many uncertainties surrounding screening for prostate cancer, authorities recommend that patients be involved in the screening decision. OBJECTIVE: To determine the impact of informed consent on patient interest in undergoing prostate-specific antigen (PSA) screening. METHODS: Men 50 years or older with no prior PSA testing and no history of prostate cancer presenting to 1 of 4 university-affiliated primary care practices were eligible for enrollment. Patients were randomized to receive either a scripted informational intervention simulating an informed consent presentation (intervention group, n = 103) or a single sentence about the PSA (control group, n = 102). The main outcome measure was patient interest in undergoing PSA screening measured on a 5-point Likert scale. RESULTS: Patients who received the informational intervention were significantly less interested in undergoing PSA screening than controls (mean difference in interest, 0.8 on 5-point scale, P < .001). Informed patients were much less likely to indicate high interest in screening (odds ratio, 0.34; 95% confidence interval, 0.19-0.60; P < .001). In a multivariate model, family history of prostate cancer was associated with increased interest and advancing age with decreased interest in PSA screening, but the informational intervention remained the strongest predictor of interest. CONCLUSIONS: Among primary care patients of predominantly lower socioeconomic status, those who received informed consent were significantly less interested in PSA screening than those who did not. For physicians who offer the PSA as a screening test, this finding highlights the importance of apprising patients of the associated benefits, burdens, and uncertainties and allowing them to participate in the screening decision.

The medical-care cost burden of obesity.

Recent years have seen a dramatic rise in the prevalence of obesity in many countries, stimulating interest in the health and economic consequences of this phenomenon. In this article, we provide a systematic review of the literature on the medical-care cost burden of obesity. Relevant studies were identified using a computerized search of the medical literature for English-language articles published between 1990 and 2001. The 18 studies that met all criteria for inclusion in the review can be classified as modelling or database studies and further distinguished as cross-sectional or longitudinal in nature. The majority of studies that have been conducted are cross-sectional modelling studies, including 10 studies reporting the burden of obesity to national health systems. These suggest that obesity accounts for 5.5-7.0% of national health expenditures in the United States and 2.0-3.5% in other countries for which estimates have been reported. Other studies highlight the burden of obesity from other perspectives, including employers and health plans, as well as the impact of obesity on future disease risks and associated medical-care costs. Despite various methodological limitations, discussed herein, this body of research leads to the inescapable conclusion that obesity exacts an immense economic toll in various countries throughout the world.

Social and economic effects of body weight in the United States.

Given that overweight is clearly associated with increased risk of many major chronic diseases, the United States could have saved approximately $45.8 billion or 6.8% of health care expenditures in 1990 alone if obesity were prevented. The question then arises, economically and socially, what is a healthy body weight? Using a prevalence-based approach to cost of illness, we estimated the economic costs (1993 dollars) associated with illness at different strata of body mass indexes (BMIs, in kg/m2) and varying increments of weight gain to address the questions: At what body weight do we initiate preventive services? What are the direct costs associated with weight gain? Second, using the 1988 National Health Interview Survey (NHIS), we evaluated the marginal increase in certain social indexes reflective of functional impairment and morbidity (ie, restricted-activity days, bed days, and work-loss days) as well as physician visits associated with different strata of BMI. With respect to economic and social indexes, a healthy body weight appears to be a BMI < 25, and weight gain should be kept to < 5 kg throughout a lifetime.

Changes in the expression of CD31 and CXCR3 in CD4+ naïve T cells in elderly persons.

So far, very few studies exist on the naïve T cell population of elderly persons. Only recently an increase in the percentage of long lived CD4(+)CD31(-) naïve T cells has been claimed to occur with aging. We, therefore, characterised CD31(+) and CD31(-) CD45RA(+) CD4(+) T cells in young and healthy elderly persons. The production of IL-2 and IFN-gamma by the different subpopulations was studied following stimulation with PMA and Ionomycin. The expression of CD28, CD11a, CD62L, CXCR3 and CCR7 was also analysed. The results of this study demonstrate a pronounced increase in the percentage of CD31(-) CD45RA(+) T cells within the CD4 subpopulation of elderly persons. Both, CD31(-) and CD31(+) CD45RA(+) cells expressed CD28, CD62L, were CD11a (dim) and produced IL-2 but no IFN-gamma. This phenotype confirms that they were naïve T cells. IL-2 production by naïve T cells was not impaired in elderly persons. Interestingly, CD31(+) as well as CD31(-) naïve T cells contained a subpopulation of CXCR3(+) cells in elderly individuals, but not in young ones. In spite of expressing this chemokine receptor that enables the cells to migrate into inflammatory tissues, they were still CCR7(+) and CD62L(+). We speculate that due to previous contact with local environmental factors, this subset of naïve T cells acquires a different chemokine receptor phenotype, resulting in an altered migratory capacity in old age. Aberrant contact with antigen and effector cell differentiation in unorthodox locations may be the consequence. This could also affect Th1/Th2 polarisation, which is known to be impaired in elderly persons.

Predictors of interest in prostate-specific antigen screening and the impact of informed consent: what should we tell our patients?

PURPOSE: Screening for prostate cancer with the prostate-specific antigen (PSA) remains highly controversial. We sought to discern which patient factors predict interest in the PSA and how informed consent impacts these predictors. PATIENTS AND METHODS: In a randomized trial that found that informed consent decreases patient interest in PSA screening, potential predictors of interest were analyzed separately in the uninformed (n = 102) and informed (n = 103) cohorts to examine the effects of the informational intervention. RESULTS: Univariate predictors of PSA screening interest (P < 0.05) among uninformed patients included perceived efficacy of screening, perceived seriousness of an abnormal PSA, and willingness to accept treatment risks. Among patients who had been informed about PSA screening, univariate predictors included family history of prostate cancer, perceived susceptibility to prostate cancer, age (inverse association), and perceived efficacy, although informed patients rated PSA efficacy significantly lower than uninformed patients (P < 0.001). In multivariate logistic regression modeling for the uninformed cohort, perceived screening efficacy (P < 0.001), perceived seriousness (P < 0.05), and willingness to accept treatment risks (P < 0.05) together were significant predictors of PSA screening interest. Among informed patients, perceived efficacy (P < 0.001), perceived susceptibility (P = 0.01), and younger age (P = 0.01) together predicted interest in screening. CONCLUSIONS: In contrast to uninformed patients, patients given information about PSA screening and prostate cancer are more likely to be interested in screening if they have a family history of prostate cancer, are younger, or otherwise consider themselves susceptible to developing prostate cancer. Uninformed patients are more likely to base their screening interest on the perceived seriousness of prostate cancer and on their willingness to accept treatment risks.

Retroviral vector-transduced cells expressing the core polyprotein induce feline immunodeficiency virus-specific cytotoxic T-lymphocytes from infected cats.

The core polyprotein of feline immunodeficiency virus (FIV) was expressed in primary feline T-lymphocytes using a retroviral vector. These cells were used as antigen-presenting stimulator cells (APSC) for the in vitro induction of cytotoxic T-lymphocytes (CTL) from feline peripheral blood mononuclear cells (PBMC). CTL from 4 cats chronically infected with the Petaluma strain of FIV specifically lysed autologous FIV-infected targets in an MHC-restricted manner. The CD8 phenotype of more than 70% of the induced effector cells (97% for cells from one cat) was consistent with MHC class I-restricted cytotoxicity. In addition, it was possible to detect low levels of core polyprotein-specific lysis from effector cells of two of the FIV-infected cats. When observed, the level of lysis, measured as a percentage of specific 111In release, was lower for the transgenic gag-expressing targets than for FIV-infected targets. The difference in killing may reflect the low level of core CTL were not detected in either PBMC stimulated with cells transduced by a retroviral vector without the FIV gag sequence or PBMC from an uninfected cat stimulated with autologous transgenic APSC. The detection of FIV-specific CTL from infected cats following stimulation with transgenic APSC suggests a role for retroviral vectors in determining CTL specific for individual lentiviral proteins in protective immunity.

Clinical assessment of cirrhosis in severe chronic active liver disease: specificity and sensitivity of physical and laboratory findings.

The usefulness of certain physical and laboratory findings in predicting the morphologic diagnosis of cirrhosis in severe chronic active liver disease was determined in 101 patients, 39 of whom had cirrhosis. Hypoalbuminemia (69%) and hypergammaglobulinemia (67%) were the most common findings in cirrhosis, but they lacked specificity. Thrombocytopenia, hepatic encephalopathy, and ascites, which were the most specific and sensitive abnormalities, implicated cirrhosis with 85% assurance when present and occurred in the majority of patients with cirrhosis (56%). No single feature was pathognomonic of cirrhosis, although absence of all clinical findings excluded the diagnosis; Eight or more clinical abnormalities were invariably associated with cirrhosis, but only 18% of patients had such florid manifestations. The presence of at least five abnormalities was associated with a 76% likelihood of cirrhosis and was encountered in 56% of cirrhotic patients. Patients with three or fewer findings seldom had cirrhosis (24%), and only the presence of ascites reliably implicated the lesion in these patients. We conclude that in severe chronic active liver disease, recognition of certain specific findings or a constellation of abnormalities permits confident identification of cirrhosis in the majority of patients with this disorder.

A prospective study of the antisecretory and therapeutic effects of cimetidine and glucagon in human acute pancreatitis.

Nasogastric suction, glucagon, and cimetidine are proposed treatments for human acute pancreatic because they may reduce gastric acid and exocrine pancreatic secretion. However, the functional status of gastric and pancreatic secretion during human acute pancreatitis is unknown. Thus, we compared the effects of nasogastric suction, intravenous glucagon (5 microgram/kg per hour), and cimetidine (2 mg/kg per hour) on the output of acid and pancreatic enzymes and the clinical course of human acute pancreatitis. In three subjects with acute alcoholic pancreatitis, gastric acid secretion was increased above normal and was decreased by glucagon and cimetidine used alone and in combination. In two of the three patients, duodenal output of trypsin and lipase was normal or increased and was reduced by glucagon and cimetidine given alone or in combination. Twenty patients with documented acute pancreatitis randomly received treatment with nasogastric suction, cimetidine alone, or the combination of cimetidine and glucagon. Four of the five complications observed during the trial occurred in the combination-treatment group (P less than 0.05). Administration of cimetidine alone or with glucagon did not improve the outcome when compared with nasogastric suction.

Cost-effective bariatric surgery in Germany today.

BACKGROUND: The reason for this inquiry was to assess the actual state of Bariatric Surgery in Germany, especially relating to the much discussed economic aspect. METHOD: A questionnaire was sent to those hospitals in Germany in which we knew that obesity surgery was performed, concerning the year 1997. RESULTS: To our regret, the feedback was only 37%, although this must be considered an adequate response for Germany. Nevertheless, some interesting trends are easily seen. CONCLUSION: Bariatric Surgery in Germany could pay for itself by saving the costs associated with conservative therapy and preventing co-morbidities in patients with morbid obesity.

BAROS: an effective system to evaluate the results of patients after bariatric surgery.

BACKGROUND: Success in bariatric surgery is most often evaluated by a sufficient loss of excess weight and an improvement in the medical conditions. The expected increase in quality of life (QoL) after weight loss, however, has not often been systematically analyzed. BAROS (Bariatric Analysis and Reporting Outcome System) is a scoring system which, along with easy handling, allows comparisons to be made internationally. METHODS: 386 morbidly obese patients who had undergone bariatric surgery in our hospital were evaluated with BAROS. Five categories- failure, fair, good, very good, excellent- were taken from the scoring system that BAROS offers. This system has three major points: excess weight loss, medical co-morbidities and QoL. Points are subtracted for reoperations and defined complications. The operations performed were silastic ring vertical gastroplasty (72%), adjustable gastric banding (23%), biliopancreatic diversion (3%), vertical banded gastroplasty (1%) and gastric banding of Molina (1%). RESULTS: In 1991 and 1993, we had a fair result in 3% and 10% of the patients. A good score with a mean of 3.6 to 4.1 was reached in 1992, 1994 and 1995. In the last 3 years, 1996 to 1998, the mean score was 5.0 to 5.7, which is a very good result when compared with the scoring key. CONCLUSION: BAROS is a valuable tool to access the QoL of patients who have undergone bariatric surgery.