Removing abuse-prone prescription medication from fueling the national opioid crisis through community engagement and surgeon leadership: results of a local drug take-back event.

BACKGROUND: To address the national opioid and death from overdose crisis in the United States, take-back programs were created to collect and properly dispose of unused abuse-prone drugs. METHODS: Surgeons at Central Michigan University College of Medicine led a community prescription medication take-back drive, administered surveys, characterized event participant demographics, prescription indications, and type and quantity of medications dropped off for disposal. RESULTS: A total of 74,363 dosing units of unused medication were brought in from the homes of 104 event participants. Returned opioids were often prescribed after surgery. Hydrocodone was collected most. Unused opioids were frequently available in homes with children or youth. Collected opioids and benzodiazepines alone had an estimated trademark retail value of over $20,000. CONCLUSION: This surgeon-led public health initiative helped properly dispose a significant amount of unneeded abuse-prone prescription medicine. It highlighted the presence of excess opioid prescribing in a typical Midwestern community. Issues related to improved physician prescribing, utility of take-back drives, and proper drug disposal to avoid misappropriation and abuse by younger generations are discussed.

Characterization of dedifferentiating human mature adipocytes from the visceral and subcutaneous fat compartments: fibroblast-activation protein alpha and dipeptidyl peptidase 4 as major components of matrix remodeling.

Mature adipocytes can reverse their phenotype to become fibroblast-like cells. This is achieved by ceiling culture and the resulting cells, called dedifferentiated fat (DFAT) cells, are multipotent. Beyond the potential value of these cells for regenerative medicine, the dedifferentiation process itself raises many questions about cellular plasticity and the pathways implicated in cell behavior. This work has been performed with the objective of obtaining new information on adipocyte dedifferentiation, especially pertaining to new targets that may be involved in cellular fate changes. To do so, omental and subcutaneous mature adipocytes sampled from severely obese subjects have been dedifferentiated by ceiling culture. An experimental design with various time points along the dedifferentiation process has been utilized to better understand this process. Cell size, gene and protein expression as well as cytokine secretion were investigated. Il-6, IL-8, SerpinE1 and VEGF secretion were increased during dedifferentiation, whereas MIF-1 secretion was transiently increased. A marked decrease in expression of mature adipocyte transcripts (PPARγ2, C/EBPα, LPL and Adiponectin) was detected early in the process. In addition, some matrix remodeling transcripts (FAP, DPP4, MMP1 and TGFß1) were rapidly and strongly up-regulated. FAP and DPP4 proteins were simultaneously induced in dedifferentiating mature adipocytes supporting a potential role for these enzymes in adipose tissue remodeling and cell plasticity.

NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model.

BACKGROUND: We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure. METHODS: We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy. RESULTS: We studied 12 dogs: 8 had subphrenic balloon implants and 4 had interbowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the "abscess" in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications. CONCLUSION: Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.

CONTEXTE: Nous avons étudié le drainage transcolique par voie naturelle d'abcès intraabdominaux dans un modèle canin de survie afin d'évaluer la difficulté de la péritonoscopie et du drainage des abcès, ainsi que la fiabilité de la fermeture endoluminale de la colotomie. MÉTHODES: Nous avons inséré un ballonnet de latex de 7 cm non stérile empli de solution physiologique par voie intra-abdominale pour simuler ou induire un abcès ou une masse inflammatoire. Sept jours plus tard, nous avons introduit un endoscopeà simple canal par voie transanale jusqu'au sigmoïde de l'animal, procédé à une colotomie et ensuite poussé l'endoscope dans le péritoine. Nous avons vidé l'abcès observé et placé un drain par voie transabdominale. Nous avons ensuite procédé à une fermeture endoluminale de la colotomie avec un système de rapprochement tissulaire utilisant 2 sutures de polypropylène fixées à des pièces métalliques en T. Deux semaines plus tard, nous avons évalué la fermeture de la colotomie par laparotomie. RÉSULTANTS: Notre étude a porté sur 12 chiens : 8 avaient un ballonnet implanté au niveau sous-phrénique et 4, entre les anses intestinales. Onze ont survécu et ont subi la péritonoscopie transcolique; nous avons retracé « l'abcès ¼ chez 9 d'entre eux. La colotomie a été refermée avec succès chez 10 chiens sur 11. Même s'il a été facile de retracer les abcès, la difficulté globale de la péritonoscopie a été jugée de modéréeà marquée. Un chien a eu besoin d'une fermeture de colotomie par laparotomie, tandis que la fermeture endoluminale a réussi chez 9 animaux. Après la fermeture de la colotomie, 8 chiens ont survécu 2 semaines (fin de l'étude) sans complications chirurgicales, sepsis ni infections abdominales localisées. À l'autopsie, toutes les fermeturesétaient intactes, sans atteinte aux organes adjacents ni complications des suites de l'intervention. CONCLUSIONS: La chirurgie endoscopique transluminale par voie naturelle offre une solution de rechange pour le traitement des pathologies intra-abdominales. Il est possible au plan technique de réaliser une péritonoscopie transcolique endoscopique et de drainer un abcès intra-abdominal avec fermeture fiable de la colotomie dans un modèle expérimental chez le chien.

Acute and chronic effects of biliopancreatic diversion with duodenal switch surgery on plasma visfatin and apelin levels in patients with severe obesity.

BACKGROUND: Visfatin is an adipokine linked to obesity and inflammation, and it has insulin-mimetic properties. Apelin is an adipokine with positive cardiac inotropic effects, and it may be related to inflammatory molecules. Variations in plasma visfatin and apelin levels following bariatric surgery remain controversial. METHODS: In this study, patients who underwent a biliopancreatic diversion with duodenal switch (BPD-DS) were compared to a severely obese group (control group). Anthropometric measures and blood samples were taken before surgery, on days 1 and 5, as well as at 6 and 12 months after surgery in the BDP-DS group. For the control group, the tests were performed at baseline and at 6 and 12 months. RESULTS: Seventy subjects in the BPD-DS group and 28 in the control group were included. The expected reduction in body weight at 1 year after a BPD-DS was observed (85.9 ± 18.5 vs. 136.6 ± 27.7 kg at baseline; p < 0.001). Plasma visfatin levels decreased at day 1 (16.13 ± 5.56 vs. 18.82 ± 7.36 ng/mL at baseline; p = 0.001), while plasma apelin levels decreased at day 5 (0.50 ± 0.28 vs. 0.55 ± 0.33 ng/mL at baseline; p = 0.040) after surgery. There were no changes at 6 and 12 months compared to baseline, and no changes were observed in the control group. CONCLUSIONS: Our data show that 1-year weight loss induced by BPD-DS did not influence the overall plasma visfatin and apelin levels in severely obese patients.

Blood pressure assessment in severe obesity: validation of a forearm approach.

OBJECTIVE: Obesity is frequently associated with systemic hypertension. Blood pressure measure is inaccurate in severely obese patients because of poor cuff size fitting. The aim of the study is to assess the degree of agreement between the intra-arterial method as the gold standard vs. noninvasive methods, i.e., forearm blood pressure and upper-arm blood pressure measures. DESIGN AND METHODS: A total of 1285 measures of intra-arterial and forearm blood pressure were taken in 51 severely obese patients in a supine position in the operating and the recovery room. A subset of 352 upper-arm measures were taken in the recovery room and compared to the intra-arterial and the forearm methods. RESULTS: Correlation between the intra-arterial and the forearm measures was 0.90 (P < 0.001) for the 2570 data (systolic and diastolic). Compared to intra-arterial, the forearm method overestimated systolic (6 ± 16 mm Hg, P < 0.001) and underestimated diastolic blood pressure (2 ± 11 mm Hg, P = 0.03). Compared to intra-arterial, upper-arm underestimated systolic (8 ± 16 mm Hg, P < 0.01) and overestimated diastolic blood pressure (9 ± 7 mm Hg, P < 0.001). CONCLUSION: The magnitude of differences between the intra-arterial and forearm method was less than differences between the intra-arterial and upper-arm method. Our results suggest that forearm method may be a more accurate alternative to upper-arm measurement to assess blood pressure in severely obese patients.

Perioperative complications in a consecutive series of 1000 duodenal switches.

BACKGROUND: In the past 10 years, most bariatric surgeries have seen an important reduction in the early complication rate, partly associated with the development of the laparoscopic approach. Our objective was to assess the current early complication rate associated with biliopancreatic diversion with duodenal switch (BPD-DS) since the introduction of a laparoscopic approach in our institution, a university-affiliated tertiary care center. METHODS: A consecutive series of 1000 patients who had undergone BPD-DS from November 2006 to January 2010 was surveyed. The primary endpoint was the mortality rate. The secondary endpoints were the major 30-day complication rate and hospital stay >10 days. The data are reported as a mean ± SD, comparing the laparoscopic (n = 228) and open (n = 772) groups. RESULTS: The mean age of the patients was 43 ± 10 years (40 ± 10 years in the laparoscopy group versus 44 ± 10 years in the open group, P < .01). The preoperative body mass index was 51 ± 8 kg/m(2) (47 ± 7 laparoscopy versus 52 ± 8 kg/m(2) open, P < .01). The conversion rate in the laparoscopy group was 2.6%. There was 1 postoperative death (.1%) from a pulmonary embolism in the laparoscopy group. The mean hospital stay was shorter after laparoscopic surgery (6 ± 6 d versus 7 ± 9 d, P = .01), and a hospital stay >10 days was more frequent in the open group (4.4% versus 7%, P = .04). Major complications occurred in 7% of the patients, with no significant differences between the 2 groups (7% versus 7.4%, P = .1). No differences were found in the overall leak or intra-abdominal abscess rate (3.5% versus 4%, P = .1); however, gastric leaks were more frequent after open surgery (0% versus 2%, P = .02). During a mean 2-year follow-up, 1 additional death occurred from myocardial infarction, 2 years after open BPD-DS. CONCLUSION: The early and late mortality rate of BPD-DS is low and comparable to that of other bariatric surgeries.

Impact of gastrointestinal surgery on cardiometabolic risk.

Bariatric surgery has gained acceptance as the only treatment with long-term efficacy for severe obesity. Recent publications emphasize the usefulness of bariatric surgery in the reduction of long-term cardiometabolic risk, cardiovascular disease incidence and mortality, and the management of uncontrolled type 2 diabetes (T2DM), an important cardiovascular risk factor in individuals with severe obesity. The present review article offers a brief overview of the literature published over the past several months relevant to cardiometabolic outcomes in bariatric surgery patients. A recent report from the Swedish Obese Subjects (SOS) study specifically reported a reduced incidence of cardiovascular events on long-term prospective follow-up after bariatric surgery. In addition, abundant studies have been recently published on gastric bypass surgery showing high T2DM remission rates as well as improved blood lipids and inflammatory markers after surgery. Sleeve gastrectomy is increasingly performed as a stand-alone operation. Recent reports on this surgery pertaining to cardiometabolic risk showed variable T2DM remission rates that may possibly be explained by age of the patients and duration of T2DM. Available data suggest a possible favorable impact of the surgery on CRP levels and improvements in the blood lipid profile. How sleeve gastrectomy compares to other surgical approaches will require further study. Biliopancreatic diversion with duodenal switch has been reported to offer some of the best long-term weight loss for obese patients. Approximately 9 out of 10 patients treated with this surgical procedure show long-term remission rates of T2DM. Significant improvements in the cardiometabolic risk profile are also observed after BPD-DS; they are especially pronounced regarding dyslipidemia. In conclusion, bariatric procedures improve the cardiometabolic risk profile, a phenomenon that appears to be only partly explained by the magnitude of the weight loss. Significant variations are observed with respect to the type of surgery and patient characteristics. More research is clearly needed on the short and long-term cardiometabolic outcome of obesity surgeries.

Pancreatic islet isolation after gastric bypass in a rat model: technique and initial results for a promising research tool.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) affords a high remission rate of type 2 diabetes mellitus among morbidly obese diabetic patients. We report the use of the isolated islet technique to assess pancreatic function and glucoregulatory mechanisms after RYGB surgery. METHODS: A total of 15 adult, male, Sprague Dawley diet-induced obese rats were randomly divided into 3 experimental groups: sham, RYGB, and pair-fed, with 5 rats in each group. The body weight was measured at baseline and every week for 4 weeks. Pancreatic islet function was assessed in vitro according to the amount of insulin secreted from isolated islets incubated in 2 mM and 20 mM glucose for 1 hour at 37 °C. Fasting plasma glucose, insulin, glucagon-like peptide-1, PYY3-36, and glucose-dependent insulinotropic peptide were measured at baseline and 28 days after surgery. RESULTS: The baseline body weight was 917 ± 61, 831 ± 42, and 927 ± 43 g for the sham, RYGB, and pair-fed groups, respectively. The RYGB group lost 32% body weight compared with 16% for the sham and 24% for the pair-fed groups. Glucose-stimulated insulin secretion from the isolated islets in the RYGB group was greater than in the comparison groups (P = .04) at 4 weeks after surgery. Fasting plasma glucagon-like peptide-1 and PYY3-36 were significantly increased at 4 weeks in the RYGB group. CONCLUSION: Islet isolation and stimulation in the present animal model was feasible, affords a direct measurement of pancreatic islet function, and might provide a useful tool to study the effects of RYGB on pancreatic function and the relationship between islet cell function and incretin production after bariatric surgery.

Weight loss interventions in chronic kidney disease: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Obesity is an independent risk factor for development and progression of chronic kidney disease (CKD). We conducted a systematic review to assess the benefits of intentional weight loss in patients with non-dialysis-dependent CKD and glomerular hyperfiltration. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We searched MEDLINE, SCOPUS, and conference proceedings for randomized, controlled trials and observational studies that examined various surgical and nonsurgical interventions (diet, exercise, and/or antiobesity agents) in adult patients with CKD. Results were summarized using random-effects model. RESULTS: Thirteen studies were included. In patients with CKD, body mass index (BMI) decreased significantly (weighted mean difference [WMD] -3.67 kg/m(2); 95% confidence interval [CI] -6.56 to -0.78) at the end of the study period with nonsurgical interventions. This was associated with a significant decrease in proteinuria (WMD -1.31 g/24 h; 95% CI -2.11 to -0.51) and systolic BP with no further decrease in GFR during a mean follow-up of 7.4 mo. In morbidly obese individuals (BMI >40 kg/m(2)) with glomerular hyperfiltration (GFR >125 ml/min), surgical interventions decreased BMI, which resulted in a decrease in GFR (WMD -25.56 ml/min; 95% CI -36.23 to -14.89), albuminuria, and systolic BP. CONCLUSIONS: In smaller, short-duration studies in patients with CKD, nonsurgical weight loss interventions reduce proteinuria and BP and seem to prevent further decline in renal function. In morbidly obese individuals with glomerular hyperfiltration, surgical interventions normalize GFR and reduce BP and microalbuminuria. Larger, long-term studies to analyze renal outcomes such as development of ESRD are needed.