Increasing the Percentage of Neonates Consuming Human Milk in a Pediatric Cardiothoracic Intensive Care Unit: A Quality Improvement Initiative.

OBJECTIVE: To address a known nutritional deficit and enhance the overall health of critically ill babies, this project sought to increase the percentage of cardiothoracic intensive care unit (CTICU) neonates consuming human milk from a 2019 baseline of 55% to 75% by December 2020 and 90% by December 2021. STUDY DESIGN: This was a quality improvement initiative targeted to all neonates admitted to the CTICU, with baseline data obtained from January 2019 through February 2020. We implemented 11 interventions from March 2020 to January 2022 to address the key drivers of "education of parents and providers," "environment/equipment," and "process." We tracked the monthly percentage of neonates who were human milk fed with a statistical process control p-chart. The balancing measure of critical human milk feeding errors was also monitored. RESULTS: The baseline percentage of CTICU neonates consuming human milk was 55%. This percentage increased to 73% by the end of 2020 and 92% by the year end 2021. Most neonates who received human milk were fed mother's milk with a minority receiving donor human milk. The number of aborted, critical human milk administration errors decreased during the intervention period. CONCLUSIONS: In this quality improvement initiative, we significantly increased the percentage of CTICU neonates consuming human milk without an increase in critical human milk errors. Interventions directly increasing the ease with which lactating mothers can provide/store their milk were likely the most effective.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

A Quality Improvement Initiative Reduces Cast Complications in a Pediatric Hospital.

BACKGROUND: Casts, while frequently used as routine treatment in pediatric orthopaedic practice, are not without complications. At our large tertiary care pediatric hospital, the baseline rate of all casting complications was 5.6 complications per 1000 casts applied (0.56%). We tested the hypothesis that we could use quality improvement (QI) methodology to decrease the overall cast complication rate and improve patient care. METHODS: We initiated a QI program implementing concepts derived from the Institute for Healthcare Improvement models, including Plan-Do-Study-Act cycles, to decrease our cast complication rate. A resident casting education program was developed with a competency "checklist" to ensure that casts are applied, bivalved, and removed in a safe and standardized manner to prevent patient harm. AquaCast Saw Stop Protective Strips were required to be applied with every cast application. A review of our facility's processes and procedures determined adequate measures were in place to effectively manage inventory and maintenance of cast-saw blades. RESULTS: With the multimodal QI intervention, our cast complication rate was reduced to 1.61 complications per 1000 applications, a >90% improvement. CONCLUSIONS: Implementation of QI concepts to perform a QI initiative resulted in a shift toward fewer cast complications, leading to overall improved patient care at a large tertiary pediatric hospital. LEVEL OF EVIDENCE: Level II-prospective cohort study.

Trace element concentrations in feathers and blood of Northern goshawk (Accipiter gentilis) nestlings from Norway and Spain.

Information on trace element pollution in the terrestrial environment and its biota is limited compared to the marine environment. In the present study, we collected body feathers and blood of 37 Northern goshawk (Accipiter gentilis) nestlings from Tromsø (northern Norway), Trondheim (central Norway), and Murcia (southeastern Spain) to study regional exposure, hypothesizing the potential health risks of metals and other trace elements. Blood and body feathers were analyzed by a high resolution inductively coupled plasma mass spectrometer (HR-ICP-MS) for aluminum (Al), nickel (Ni), copper (Cu), zinc (Zn), arsenic (As), selenium (Se), cadmium (Cd), mercury (Hg) and lead (Pb). The influence of regional differences, urbanization and agricultural land usage in proximity to the nesting Northern goshawks was investigated using particular spatial analysis techniques. Most trace elements were detected below literature blood toxicity thresholds, except for elevated concentrations (mean ± SD µgml-1 ww) found for Zn (5.4 ± 1.5), Cd (0.00023 ± 0.0002), and Hg (0.021 ± 0.01). Corresponding mean concentrations in feathers (mean ± SD µgg-1 dw) were 82.0 ± 12.4, 0.0018 ± 0.002, and 0.26 ± 0.2 for Zn, Cd and Hg respectively. Multiple linear regressions indicated region was a significant factor influencing Al, Zn, Se and Hg feather concentrations. Blood Cd and Hg concentrations were significantly influenced by agricultural land cover. Urbanization did not have a significant impact on trace element concentrations in either blood or feathers. Overall metal and trace element levels do not indicate a high risk for toxic effects in the nestlings. Levels of Cd in Tromsø and Hg in Trondheim were however above sub-lethal toxic threshold levels. For holistic risk assessment purposes it is important that the concentrations found in the nestlings of this study indicate that terrestrial raptors are exposed to various trace elements.

Quality Tool School: Improving the Delivery of Quality Improvement Education in a Children's Hospital.

Background: In 2013, Nationwide Children's Hospital's (NCH) Quality Tool School (QTS) was created as an initial Quality Improvement educational series, composed of three separate classes, totaling 5.5 hours of hands-on QI training. QTS complemented the NCH 40-hour Quality Improvement Essentials course. Methods: Over 10 years, the series went through three phases of aims: Phase 1: develop and implement three core courses (Project Tools, Excel, and Control Charts); Phase 2: have participants complete the entire series of all three classes; Phase 3: have participants who complete the entire series of all three classes demonstrate the application of learning through involvement in a quality improvement project. Results: Since initiation, QTS has provided an educational entry point for 1428 NCH employees to participate in QI projects and teams. QTS has shown statistically significant improvement in 2 of the 3 principal aims. The Phase 1 metric of average monthly one-class participation completion percentage showed a statistically significant centerline shift from 9 to 16 students in October 2018. The Phase 3 metric Percentage of QTS participants completing the QTS series of classes and then participating in a QI team began in 2016 with a baseline of 42%. A centerline shift from 42% to 63% occurred in Q4 2018. Conclusions: QTS can provide QI education to healthcare system employees using limited resources. Organizations that strategically integrate a culture of QI into core beliefs can realize substantial improvement gains.

Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative.

Abusive injuries can go unrecognized or improperly managed by medical providers. This study sought to standardize the nonaccidental trauma (NAT) workup and improve NAT evaluation completion for children <7 months with concerning injuries in the pediatric emergency department (PED) and inpatient settings at an urban, tertiary care children's hospital. Methods: The quality improvement (QI) team created hospital guidelines for suspected NAT, including age-based recommendations (care bundle). The team embedded an order for NAT evaluation into the electronic health record (EHR). The QI team provided education on child abuse identification and evaluation across the hospital. Hospital providers received written guides focused on enhancing communication with families. Outcome measures included monthly NAT bundle use and cases between incomplete bundles in children with suspicious injuries. Chart review of incomplete bundles helped accurately identify patients who needed NAT bundles and improved accurate NAT bundle completion for appropriate patients. Results: Appropriate NAT bundle completion increased from 31% during the baseline period in January 2019 to 100% in April 2020 and remained at 100% for the remainder of the study period, ending June 2021. The number of patients between missed bundles was 11 from August 2019 until March 2020, when it increased to 583. There were no missed bundles from March 2020 through June 2021. Conclusions: Standardizing NAT evaluation and creating a NAT care bundle to facilitate the appropriate evaluation preceded an increase in appropriate bundle completion in patients <7 months old with possible NAT in the PED and inpatient units.

Improving Situational Awareness to Decrease Emergency ICU Transfers for Hospitalized Pediatric Cardiology Patients.

Introduction: Failure to recognize and mitigate critical patient deterioration remains a source of serious preventable harm to hospitalized pediatric cardiac patients. Emergency transfers (ETs) occur 10-20 times more often than code events outside the intensive care unit (ICU) and are associated with morbidity and mortality. This quality improvement project aimed to increase days between ETs and code events on an acute care cardiology unit (ACCU) from a baseline median of 17 and 32 days to ≥70 and 90 days within 12 months. Methods: Institutional leaders, cardiology-trained physicians and nurses, and trainees convened, utilizing the Institution for Healthcare Improvement model to achieve the project aims. Interventions implemented focused on improving situational awareness (SA), including a "Must Call List," evening rounds, a visual management board, and daily huddles. Outcome measures included calendar days between ETs and code events in the ACCU. Process measures tracked the utilization of interventions, and cardiac ICU length of stay was a balancing measure. Statistical process control chart methodology was utilized to analyze the impact of interventions. Results: Within the study period, we observed a centerline shift in primary outcome measures with an increase from 17 to 56 days between ETs and 32 to 62 days between code events in the ACCU, with sustained improvement. Intervention utilization ranged from 87% to 100%, and there was no observed special cause variation in our balancing measure. Conclusions: Interventions focused on improving SA in a particularly vulnerable patient population led to sustained improvement with reduced ETs and code events outside the ICU.

Sustaining Improvements in CLABSI Reduction in a Pediatric Cardiac Intensive Care Unit.

Central line-associated bloodstream infections (CLABSIs) are preventable events that increase morbidity and mortality. The objective of this quality project was to reduce the incidence of CLABSIs in a pediatric cardiothoracic intensive care unit. Methods: Institutional review of an unacceptably high rate of CLABSIs led to the implementation of 4 new interventions. These interventions included: the use of sequential cleaning between line accesses, Kamishibai card audits, central line utilization and entry audits, and proctored simulation of line access. Results: There was a reduction in CLABSI rate from 1.52 per 1,000 central line days in 2018 to 0.37 per 1,000 central line days in 2020 and 0.32 in 2021. Additionally, central line days per 100 patient days decreased from 77 to 70 days over the study period. The cardiothoracic intensive care unit went 389 days without a CLABSI from October 2020 to November 2021. Conclusions: Implementation of multiple interventions led to a successful reduction in the incidence of CLABSIs in our unit, with a sustained reduction over 1 year.

A Quality Improvement Approach to Influence Value-based Mucolytic Use in the PICU.

INTRODUCTION: High-cost medication administration, despite lacking evidence for use, results in poor healthcare value. This work aimed to reduce dornase-alfa utilization in critically ill mechanically ventilated children. METHODS: The project employed an observational pre-post design to develop a value-based clinical pathway to guide provider choice in mucolytic utilization in a quaternary pediatric intensive care unit. This pathway was designed to continue using low-cost mucolytic aerosols (hypertonic saline, N-acetylcysteine) but decrease new starts and total doses per 100 patient days (P100PD) dornase-alfa among patients for whom there is little to no supporting evidence. Interventions included a departmental journal club for fellow and attending physicians and a rolling introduction of the pathway to residents and respiratory therapists. Control charts serially tracked ordering changes and location-specific dornase alfa orders. RESULTS: New dornase-alfa starts P100PD decreased by 53% (1.17-0.55), and total doses P100PD decreased by 75% (16-4). N-acetylcysteine ordering more than doubled; however, total doses of P100PD remained unchanged after the intervention. The use of 3% sodium chloride increased significantly from 0.28 to 4.15 new starts and 4.37 to 38.84 total doses P100PD. Mechanical ventilation days P100PD decreased, suggesting there were no measured adverse effects of pathway implementation. The reduction in dornase-alfa utilization resulted in a cumulative and sustained 59% mucolytic cost reduction ($2183.08-$885.77 P100PD). CONCLUSION: A clinical pathway prioritizing pharmacoeconomics when evidence for use is lacking can improve health care value without adversely affecting patient outcomes.

Standardization of Care Reduces Length of Stay for Postoperative Congenital Heart Disease Patients.

Congenital heart disease (CHD), the most common congenital malformation, often requires surgical correction. As surgical mortality rates are low, a common quality marker linked with surgical outcomes is hospital length of stay (LOS). Reduced LOS is associated with better long-term outcomes, reduced hospital-acquired complications, and improved patient-family satisfaction. This project aimed to reduce aggregate median postoperative LOS for four CHD lesions from a baseline of 6.2 days by 10%. METHODS: This single-center study utilized the Institute for Healthcare Improvement model to achieve the project aim. A diuretic wean protocol implemented in April 2018 entailed weaning to a homegoing diuretic regimen upon transfer from the cardiac intensive care unit to the inpatient step-down unit. A discharge milestone checklist implemented in September 2018 contained milestones necessary for discharge and an anticipated date of discharge. Outcome measures included aggregate median postoperative LOS and ∆LOS. Balancing measures included cardiac intensive care unit bounce back, pleural chest tube replacement, and readmission rates. RESULTS: Our baseline aggregate median postoperative LOS for the lesions studied was 6.2 days. Following diuretic protocol implementation, the aggregate median LOS decreased to 4.4 days. Baseline ∆LOS decreased from 5.5 to 0.42 days. Postoperative cost fell by an average of $11,874. Balancing measures demonstrated no unintended consequences. CONCLUSIONS: Implementation of a diuretic wean protocol led to sustained improvement in postoperative LOS, and ∆LOS in a subset of CHD patients with no unintended consequences supporting that standardization of postoperative care is effective for improvement efforts and can reduce overall practice variation.

Prevention of Pressure Ulcers in a Pediatric Cardiac Intensive Care Unit.

BACKGROUND: Pressure ulcer (PU) is an injury to skin or underlying tissue as a result of pressure or pressure with shear stress. We classify PUs by the level of tissue injury: stage I-IV, unstageable, suspected deep tissue injury. This quality project was aimed to reduce the incidence of PUs > stage II in the cardiothoracic intensive care unit. METHODS: We reviewed PUs > stage II from March 2010 to December 2017. Interventions included: PU bundle (April 2010, revised January 2013); multidisciplinary huddles for PUs > stage II (October 2011); multidisciplinary weekly skin rounds (March 2010, revised August 2012); unit specific workgroup (October 2012); caregiver input form (December 2012). The PU bundle included diaper barrier cream, pulse oximeter probe rotation, turning schedule, pressure reduction surfaces, heel pressure release, head of the bed elevation. RESULTS: Between 2010 and 2014, PUs decreased from 15.7 events per 1,000 patient days to a new baseline of 2.9 events per 1,000 patient days. We have sustained this rate for 3 years. PUs related to immobility decreased from 35 in 2010-2011 to 4 in 2016-2017. PU related to medical devices decreased from 34 in 2010-2011 to 15 in 2016-2017. CONCLUSIONS: Institution of PU bundle, multidisciplinary weekly skin rounds, and huddles for PUs > stage II reduced PUs related to immobility, allowed for earlier identification of stage II PUs and reduced stage III PUs. Challenges remain in reducing PUs related to medical devices. Importantly, we sustained this improvement over the past 3 years.

Guidelines for Diuretic Utilization Reduce High Charge Medications.

Decreasing practice variation and following evidence-based clinical guidelines improve patient outcomes and often reduce cost. Essentially all postsurgical cardiac patients require diuretics. The approach to diuresis in the pediatric cardiothoracic intensive care unit (CTICU) is not standardized. Our objective was to develop and implement guidelines for diuretic utilization in the CTICU to reduce high charge medication utilization while maintaining the delivery of high-quality care. METHODS: Two of the top 10 medications by charge in the CTICU during 2016 were diuretics [fenoldopam and intravenous (IV) chlorothiazide]. Standardized diuretic utilization guidelines were developed to reduce the utilization of fenoldopam and IV chlorothiazide. We implemented guidelines in April 2017. The utilization of fenoldopam and IV chlorothiazide, as well as overall diuretic charges, before and after guideline implementation were compared. RESULTS: We normalized all comparisons to 100 CTICU patient-days. Fenoldopam starts were reduced from 1.1 in 2016 to 0.03 in 2019 (through February); days of fenoldopam use were reduced from 4 in 2016 to 0.15 days in 2019 (through February); IV chlorothiazide doses decreased from 20 in 2016 to 8 in 2019 (through February). These changes reduced the mean charges for diuretics from $25,762 in 2016 to $8,855 in 2019 (through February). CTICU average daily census did not change significantly during the study period (12.8 in 2016 vs 11.8 in 2018). CONCLUSION: Value-added implementation of standardized diuretic utilization guidelines in the CTICU successfully reduced the use of high-charge diuretics without unfavorably impacting the quality of care delivery.

swLORETA: a novel approach to robust source localization and synchronization tomography.

Standardized low-resolution brain electromagnetic tomography (sLORETA) is a widely used technique for source localization. However, this technique still has some limitations, especially under realistic noisy conditions and in the case of deep sources. To overcome these problems, we present here swLORETA, an improved version of sLORETA, obtained by incorporating a singular value decomposition-based lead field weighting. We show that the precision of the source localization can further be improved by a tomographic phase synchronization analysis based on swLORETA. The phase synchronization analysis turns out to be superior to a standard linear coherence analysis, since the latter cannot distinguish between real phase locking and signal mixing.

Treating diabetes in the morbidly obese by laparoscopic gastric banding.

BACKGROUND: Remission of diabetes following Roux-en-Y gastric bypass has been postulated to occur partly by bypass of the foregut. Laparoscopic adjustable gastric banding (LAGB) also reduces food intake but does not bypass the foregut, and its effects on diabetes have yet to be elucidated. METHODS: Patients with diabetes or a history of diabetes and >6 months follow-up after LAGB were studied. Follow-up was conducted separately by a surgeon with regard to weight loss and potential morbidity and by a physician with regard to diabetic control. RESULTS: 14 patients had had gestational diabetes, and diabetes was controlled by diet in 25, oral hypoglycemics in 38 and insulin in 11 patients. Reduction in body mass index (BMI) and percentage of excess weight loss (%EWL) were similar in these 4 subgroups, with a median reduction in BMI of 11.7 kg/m(2) and %EWL of 51.1% at 24 months. 26 of 38 patients controlled with oral hypoglycemic medication and 6 of 11 insulin-dependent diabetics had all medication stopped at a median of 6.5 months following LAGB. Univariate and multivariate analyses identified %EWL > or = 30.6% at 6 months as the only significant predictor of remission of diabetes. CONCLUSION: Two-thirds of the diabetic patients have had remission of diabetes following LAGB. LAGB is an effective treatment for diabetes in obese patients.

Laparoscopic gastric banding and crural repair in the obese patient with a hiatal hernia.

BACKGROUND: A hiatal hernia is present in up to 50% of patients undergoing bariatric surgery. It has been claimed that laparoscopic adjustable gastric banding (LAGB) can both improve and induce reflux symptoms. The effect of a simultaneous crural repair and gastric banding has not yet been reported. METHODS: Since 1999, all patients undergoing LAGB have a simultaneous crural repair if a hiatal hernia is present. Gastroesophageal reflux disease and dysphagia were assessed preoperatively and postoperatively using the modified DeMeester symptom-scoring system and the use of anti-reflux medication. RESULTS: 62 patients with a hiatal hernia have undergone simultaneous LAGB and crural repair, with a median follow up of 14 (3-38) months. There was no mortality, and complications occurred in 3 patients, namely pulmonary embolus, slippage requiring repositioning of the band and persistent dysphagia requiring band removal. 24 months following LAGB and crural repair, median BMI had fallen from 43 to 31 kg/m2 and median excess weight loss was 53%. Modified DeMeester symptom-score fell from a preoperative median of 3 (0-5) to a postoperative median of 0 (0-2) (P < 0.01, Mann Whitney U), and the number of patients on anti-reflux medication decreased from 44 to 6 (P < 0.01, Chi-squared). CONCLUSION: Crural repair in addition to LAGB does not increase the risk of slippage or dysphagia, significantly improves reflux symptoms and decreases the need for anti-reflux medication.

Laparoscopic gastric banding in morbidly obese adolescents.

BACKGROUND: 4% of adolescents in the U.S.A. are obese, 80% of whom will become obese adults. Obesity in adolescence is associated with increased mortality and morbidity in adulthood. Is laparoscopic adjustable silicone gastric banding a safe and effective method of weight loss in morbidly obese adolescents? METHODS: Since 1996, data has been prospectively collected on all patients undergoing laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patients are reviewed at 6 and 12 weeks following surgery, then at 3 monthly intervals. Weight loss is measured in absolute terms, reduction in body mass index (BMI) and as percentage of excess weight loss. RESULTS: 17 patients with a median age of 17 (12 to 19) years underwent LAGB. Median follow-up was 25 (12 to 46) months. 2 complications occurred, 1 slipped band and 1 leaking port. BMI fell from a preoperative median of 44.7 to 30.2 kg/m2 at 24 months following surgery, corresponding to a median loss of 35.6 kg or 59.3% of excess weight. 13 of 17 patients (76.5%) lost at least 50% of their excess weight, and 9 of 11 patients (81.8%) had a BMI < 35 kg/m2 at 24 months following surgery. CONCLUSION: LAGB is a safe and effective method of weight loss in morbidly obese adolescents, at least in the medium term. Its role in preventing obesity and obesity-related disease in adulthood remains to be determined as part of our long-term study.

Symptomatic vitamin A deficiency following biliopancreatic diversion.

BACKGROUND: Biliopancreatic diversion (BPD) is an effective operation for morbid obesity. Fat-soluble vitamin deficiencies are known complications of this procedure, with incidence rates reported as high as 6%. CASE REPORT: A-36-year old morbidly obese female with BMI 60.6 kg/m(2) underwent laparoscopic adjustable gastric banding, followed 2 years later by BPD in an attempt to control her weight. Following BPD, she failed to attend outpatient appointments and was poorly compliant with daily multivitamins and monitoring of serum vitamin and mineral levels. She developed symptomatic vitamin A deficiency, with vitamin A levels <0.1 micromol/L, and night blindness, as well as deficiencies of vitamins D, E and K, zinc and selenium. Her vitamin deficiencies were corrected with appropriate supplements and her night blindness resolved. DISCUSSION: This case raises the issues of preoperative screening of patients and compliance, as well as life-long postoperative monitoring of serum vitamin and mineral levels. With better compliance with outpatient appointments, prescribed multivitamins and oral vitamin A tablets, as well as regular monitoring of serum vitamin and mineral levels, vitamin deficiencies and their consequences, such as night blindness, may be avoided.

A comparison of laparoscopic adjustable gastric banding and biliopancreatic diversion in superobesity.

BACKGROUND: Controversy exists regarding the best surgical treatment for superobesity (BMI >50 kg/m(2)), and a comparison of the 2 most commonly performed procedures in Europe, namely biliopancreatic diversion (BPD) and laparoscopic adjustable gastric banding (LAGB), has not yet been reported. METHODS: BPD has been performed in 134 morbidly obese patients since 1996, and as the primary bariatric procedure in 23 superobese patients. 23 sex-matched patients who most closely resembled the age and BMI of the 23 BPD patients were chosen from 1319 patients who had undergone LAGB since 1996. These groups were compared using appropriate statistical tests. RESULTS: BPD was performed laparoscopically in 12 patients. Median excess weight loss at 24 months was 64.4% following BPD and 48.4% following LAGB. Hospital stay and complication rate were significantly greater with BPD, although the majority of complications were related to the laparotomy wound in patients undergoing open BPD. Rate of resolution of obstructive sleep apnea, hypertension and diabetes mellitus following LAGB was similar to BPD. CONCLUSION: BPD results in significantly greater weight loss than LAGB in superobese patients, but is associated with a longer hospital stay and a higher complication rate in patients undergoing open BPD.

Calcium and vitamin D depletion and elevated parathyroid hormone following biliopancreatic diversion.

BACKGROUND: Biliopancreatic diversion (BPD) is associated with a 70% excess weight loss (EWL) at 10 years, but there are concerns regarding long-term nutritional sequelae. Metabolic bone disease has been documented following Roux-en-Y gastric bypass. METHODS: Patients who underwent a BPD from 1998 to 2001 were studied. A questionnaire was designed to review BPD patients and collect information on weight loss, frequency of gastrointestinal disturbances and compliance with multivitamin recommendations. The review included a blood test for vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium. RESULTS: Of the 82 patients who underwent BPD during this period, the median %EWL at 36 months was 73.0%. 75.6% suffered diarrhea. At median follow-up of 32 months (18-50), 25.9% of patients were hypocalcemic, 50% had low vitamin D, 23.8% had elevated ALP, and 63.1% had elevated PTH, despite 82.9% taking multivitamins. CONCLUSION: BPD results in significant weight loss. However, 1 in 4 patients are hypocalcemic, and 1 in 2 have a low vitamin D, despite multivitamin supplementation. BPD patients require routine calcium and vitamin D supplementation for life. Long-term sequelae from these abnormal serum levels are not known.

Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery.

Weight loss after biliopancreatic diversion or duodenal switch is due to decreased calorie absorption secondary to fat malabsorption. Fat malabsorption may also cause essential fat-soluble vitamin deficiencies, which may have severe clinical consequences and alter calcium metabolism. Serum vitamins A, D, E, and K, zinc, parathyroid hormone, corrected calcium, and alkaline phosphatase levels were measured in a cohort of patients who had previously undergone biliopancreatic diversion. Two bariatric surgery units were involved in the study: New York University School of Medicine (New York, NY), and the Wesley Medical Center (Brisbane, Australia). A total of 170 patients completed the study. The incidence of vitamin A deficiency was 69%, vitamin K deficiency 68%, and vitamin D deficiency 63% by the fourth year after surgery. The incidence of vitamin E and zinc deficiency did not increase with time after surgery. The incidence of hypocalcemia increased from 15% to 48% over the study period with a corresponding increase in serum parathyroid hormone values in 69% of patients in the fourth postoperative year. There is a progressive increase in the incidence and severity of hypovitaminemia A, D, and K with time after biliopancreatic diversion and duodenal switch. Calcium metabolism is affected with an increasing incidence of secondary hyperparathyrodisim and evidence of increased bone resorption in 3% of patients. Long-term nutritional monitoring is necessary after malabsorptive operations for morbid obesity.