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Severe obesity is associated with increased risk of kidney disease. Whether bariatric surgery reduces the risk of adverse kidney outcomes is uncertain. To resolve this we compared the risk of estimated glomerular filtration rate (eGFR) decline of ≥30% and doubling of serum creatinine or end-stage renal disease (ESRD) in 985 patients who underwent bariatric surgery with 985 patients who did not undergo such surgery. Patients were matched on demographics, baseline body mass index, eGFR, comorbidities, and previous nutrition clinic use. Mean age was 45 years, 97% were white, 80% were female, and 33% had baseline eGFR 90 ml/min per 1.73 m(2). Mean 1-year weight loss was 40.4 kg in the surgery group compared with 1.4 kg in the matched cohort. Over a median follow-up of 4.4 years, 85 surgery patients had an eGFR decline of ≥30% (22 had doubling of serum creatinine/ESRD). Over a median follow-up of 3.8 years, 177 patients in the matched cohort had an eGFR decline of ≥30% (50 had doubling of serum creatinine/ESRD). In adjusted analysis, bariatric surgery patients had a significant 58% lower risk for an eGFR decline of ≥30% (hazard ratio 0.42, 95% confidence interval 0.32-0.55) and 57% lower risk of doubling of serum creatinine or ESRD (hazard ratio 0.43, 95% confidence interval: 0.26-0.71) compared with the matched cohort. Results were generally consistent among subgroups of patients with and without eGFR 90 ml/min per 1.73 m(2), hypertension, and diabetes. Thus, bariatric surgery may be an option to prevent kidney function decline in severely obese individuals.

Nonalcoholic fatty liver disease (NAFLD) is common in adults with extreme obesity and can impact long-term health and survival. Liver biopsy is the only accurate test for diagnosis and staging, but is invasive and costly. Non-invasive testing offers an attractive alternate, but the overall accuracy remains a significant issue. This study was conducted to determine the accuracy and clinical utility of pre-operative ultrasound and liver transaminase levels, as well as intra-operative hepatic visual inspection, for assessing presence of NAFLD as confirmed by hepatic histology.Data was collected prospectively from 580 morbidly obese adult patients who underwent Roux-en-Y gastric bypass surgery with intraoperative wedge biopsy between January 2004 and February 2009. Complete data for ultrasound, ALT and AST levels, and documented visual inspection was available for 513 patients.The prevalence of NAFLD was 69 % and that of NASH was 32 %. The individual non-invasive clinical assessments demonstrated low sensitivity, specificity, and accuracy for detecting the presence of steatosis, steatohepatitis, or fibrosis. The combination of normal or abnormal results for all tests improved predictive utility. Abnormal tests with all three assessments had a sensitivity of 95-98 % and a specificity of 28-48 % for major histologic findings in NAFLD/NASH. Normal tests with all three assessments had a sensitivity of 12-22 % and a specificity of 89-97 % for major histologic findings in NAFLD/NASH.Although individual clinical tests for NAFLD have limited accuracy, the use of combined clinical tests may prove useful.

Summary Objective We conducted this study to investigate the rate of clinically important, extreme weight gain (EWG; ≥7% body weight gain) among all second generation antipsychotic (SGA) users in two large health care systems in the United States. Study design Retrospective observational cohort study. Methods We used electronic medical record databases of two health systems to identify adults aged 18–79 years who from 1 January 2004 to 31 December 2011 had initiated a SGA medication. All patients had to have a minimum of two weight measures in the medical record: (1) one or more weights in the 180-day pre-treatment (baseline) period; and (2) one or more weights in the first year after initiating SGA treatment. Results We found that EWG occurred in 7.7–17.0% of SGA users. At one year, the average weight gain was nearly 10kg among SGA users who experienced EWG. Olanzapine was the SGA most commonly associated with EWG with a rate of 17.0 per 100 users [95% confidence interval (CI): 14.2–20.5], while ziprasidone was least commonly associated with EWG (7.7 per 100 users; 95% CI: 4.6–13.0). Conclusions We found that clinically-important weight gain was common after the initiation of SGA treatment, and the EWG phenotype was easily identifiable within electronic medical records. There was significant heterogeneity in the rate of EWG across SGA medications. Weight gains of this magnitude are likely to have adverse health consequences and there is a significant unmet opportunity for physicians to identify these events and mitigate the harms of SGA use.

14-Hydroxycodeinone (14-HC) is an α,β-unsaturated ketone impurity found in oxycodone drug substance and has a structural alert for genotoxicity. 14-HC was tested in a combined Modified and Standard Comet Assay to determine if the slight decrease in % Tail DNA noted in a previously conducted Standard Comet Assay with 14-HC could be magnified to clarify if the response was due to cross-linking activity. One limitation of the Standard Comet Assay is that DNA cross-links cannot be reliably detected. However, under certain modified testing conditions, DNA cross-links and chemical moieties that elicit such cross-links can be elucidated. One such modification involves the induction of additional breakages of DNA strands by gamma or X-ray irradiation. To determine if 14-HC is a DNA crosslinker in vivo, a Modified Comet Assay was conducted using X-ray irradiation as the modification to visualize crosslinking activity. In this assay, 14-HC was administered orally to mice up to 320 mg/kg/day. Results showed a statistically significant reduction in percent tail DNA in duodenal cells at 320 mg/kg/day, with a nonstatistically significant but dose-related reduction in percent tail DNA also observed at the mid dose of 160 mg/kg/day. Similar decreases were not observed in cells from the liver or stomach, and no increases in percent tail DNA were noted for any tissue in the concomitantly conducted Standard Comet Assay. Taken together, 14-HC was identified as a cross-linking agent in the duodenum in the Modified Comet Assay.

Type 2 diabetes mellitus (“T2D” or “diabetes,” herein) has significant medical and socioeconomic implications.1 Roux-en-Y gastric bypass (RYGB) surgery is an effective intervention in humans that remits T2D,2 with approximately 60% of patients achieving temporary resolution or durable T2D remission.3,4 RYGB has also been proposed as a therapy for T2D resolution even in cases where weight loss may not be the primary objective5 and particularly for cases with low body mass index (BMI) ranging from 25 to 35 kg/m2.6 Durable T2D remission has been associated with early-stage diabetes7 and significant percent excess body weight loss,8 whereas inability to achieve long-term remission has been associated with inadequate weight loss.9 Glycemic response to gastric bypass has also been correlated with BMI, duration of diabetes, fasting C peptide, and weight loss.10 Young age and low BMI (25–35 kg/m2) have also been associated with long-term T2D remission,6 whereas use of insulin, high HbA1c, and low percent excess body weight loss have been associated with decreased rate of remission after RYGB surgery.11 In the Swedish obese subjects study, 72% of patients experience remission of diabetes within 2 years after surgery but only 36% remained in remission after 10 years.12 In a recent study, patients not taking insulin before RYGB surgery had significantly higher remission rates than patients using insulin (53.8% vs 13.5%).3 Elsewhere, approximately 70% of patients using insulin did not remit diabetes 2 years after RYGB surgery, whereas among noninsulin users only approximately 15% of patients did not remit.13 In general, preoperative use of insulin is associated with low remission rates after RYGB surgery over 5 years.3,13 Here, we show that preoperative addition of incretins could significantly improve remission rates for this group of patients.

Fibroblast growth factors 19 and 21 (FGF19 and FGF21) have been implicated, independently, in type 2 diabetes (T2D) but it is not known if their circulating levels correlate with each other or whether the associated hepatic signaling mechanisms that play a role in glucose metabolism are dysregulated in diabetes. We used a cross-sectional, case/control, experimental design involving Class III obese patients undergoing Roux-en-Y bariatric surgery (RYGB), and measured FGF19 and FGF21 serum levels and hepatic gene expression (mRNA) in perioperative liver wedge biopsies. We found that T2D patients had lower FGF19 and higher FGF21 serum levels. The latter was corroborated transcriptionally, whereby, FGF21, as well as CYP7A1, β-Klotho, FGFR4, HNF4α, and glycogen synthase, but not of SHP or FXR mRNA levels in liver biopsies were higher in T2D patients that did not remit diabetes after RYGB surgery, compared to T2D patients that remitted diabetes after RYGB surgery or did not have diabetes. In a Phenome-wide association analysis using 205 clinical variables, higher FGF21 serum levels were associated with higher glucose levels and various cardiometabolic disease phenotypes. When serum levels of FGF19 were < 200 mg/mL and FGF21 > 500 mg/mL, 91% of patients had diabetes. These data suggest that FGF19/FGF21 circulating levels and hepatic gene expression of the associated signaling pathway are significantly dysregulated in type 2 diabetes.

The current work assessed the independent contributions of age, comorbidities, tumor features, and treatment approach to the outcome of elderly patients with breast cancer.Records of consecutive women agedor = 70 years with a histologic diagnosis of first invasive breast cancer between 1971 and 2001 and available medical information were reviewed. Restaging to the 2002 TNM system and comorbidity data abstraction were performed. Primary outcomes were overall survival (OS) and breast cancer-specific survival (BCSS).There were 992 patients with a median diagnosis age of 76 years, of whom 840 were approached with a curative intent. Significant comorbidities were recorded as none andor = 3 in 13% and 44% of patients, respectively. The 5- and 10-year OS rates were 59% and 34%; corresponding BCSS rates were 74% and 62%, respectively. Of 693 patients who died during the study period, only 298 (43%) died from their tumors. Stage emerged as the strongest predictor determining OS and BCSS (P = 0.001). In curatively approached patients, age was the next dominant factor affecting survival length (P = 0.001). The comorbidities with significant effect on OS differed by stage and included heart failure, diabetes, and other common comorbidities in early tumors but only extremely debilitating ones in advanced-stage disease (P0.05). Significant favorable effect of systemic therapy emerged only in the univariate model.This study confirms tumor stage as the strongest predictor of survival in elderly patients with breast cancer. It also indicates a significant role for age and comorbidities that varies by stage. Treatment effect should be interpreted with caution because of the retrospective study nature.

Objective Surgical treatment of severe obesity is the most rapidly growing specialty area of surgery. The rapid expansion of bariatric surgery has raised questions and concerns regarding possible increased surgical mortality and morbidity rates in both academic and community settings. The purpose of this study was to evaluate postoperative outcomes and risk factors for bariatric gastric surgery for severe obesity. Methods A community experience of 1009 consecutive patients who underwent open surgical treatment of morbid obesity during a 9-year period was reviewed from a prospective database. The series included 858 primary gastric bypass operations and 151 revision operations. Perioperative outcomes, late complications, and weight loss results were recorded. Morbidity and mortality rates were analyzed according to patient age, body mass index (BMI), and gender. Results The mortality rate in the series was 0.6%, and the morbidity rate was 20%. The major complication rate was 6.6%. There were no deaths in the 151 revision patients. The gastrointestinal leak rate was 0.8%, and the thromboembolism rate was 1%. Statistical analysis indicates that BMI is a risk factor for surgical complications. Conclusion Open gastric surgery for morbid obesity can be carried out in the community setting with low mortality and morbidity rates. BMI is a proven surgical risk factor.

We attempted to determine if aggressive detection of angiographic adverse events during coronary intervention could predict subsequent creatine kinase (CK)-MB elevations. During coronary intervention, both fluoroscopy and cine angiography were used to detect angiographic adverse events. At least one angiographic adverse event occurred in 133/251 (53%) of procedures. CK-MB elevation occurred in 24% of procedures. Slow flow during the procedure (P = 0.002) and chest discomfort at the end of the procedure (P = 0.007) were the strongest predictors of CK-MB elevation. Among procedures with no angiographic adverse events, CK-MB elevation occurred in 15/121 (12%), accounting for 25% of CK-MB elevations. We conclude that CK-MB elevation occurs after angiographically uncomplicated coronary interventions even when angiographic adverse events are aggressively detected. Routine monitoring of cardiac enzymes is necessary to detect all patients who will experience myocardial injury after coronary intervention. Catheter Cardiovasc Interv 2004;63:31–41. © 2004 Wiley-Liss, Inc.

Cloud computing is widely associated with major capital investment in mega data centres, housing expensive blade servers and storage area networks. In this paper we argue that a modular approach to building local or regional data centres using commodity hardware and open source hardware can produce a cost effective solution that better addresses the goals of cloud computing, and provides a scalable architecture that meets the service requirements of a high quality data centre. In support of this goal, we provide data that supports three research hypotheses: 1. that central processor unit (CPU) resources are not normally limiting; 2. that disk I/O transactions (TPS) are more often limiting, but this can be mitigated by maximizing the TPS-CPU ratio; 3. that customer CPU loads are generally static and small. Our results indicate that the modular, commodity hardware based architecture is near optimal. This is a very significant result, as it opens the door to alternative business models for the provision of data centres that significantly reduce the need for major up-front capital investment.

Although the benefit from adjuvant chemotherapy has been established clearly in patients with Stage III colon carcinoma, the degree to which elderly patients with colon carcinoma can tolerate such therapy generally has remained unknown.The authors reviewed all patients in their Tumor Registry with Stage II and Stage III adenocarcinoma of the colon who underwent potentially curative resection for their disease at the Geisinger Medical Center between January 1990 and September 2000. One hundred twenty patients underwent complete resection of their colon carcinoma and received 5-fluorouracil-based (5-FU) adjuvant chemotherapy.The 5-year disease free survival rate for patients ageor =65 years (Group A) was 70% compared with 56% for patients age65 years (Group B) (P = 0.085). The 5-year overall survival rate for patients in Group B was 77% compared with 62% for the patients in Group A (P = 0.143). In a Cox regression model, age was not a predictor of disease free survival (P = 0.633) or overall survival (P = 0.900) when it was analyzed as a continuous variable. Only 19 patients were age75 years, and the disease free and overall survival rates for this group were similar but were underpowered compared with the rates for the patients ages between 65-75 years. When gender and disease stage were included in the model, age remained a nonsignificant variable (P = 0.400 for disease free survival; P = 0.615 for overall survival). Nine of 56 patients in Group A (16%) experienced Grade 3-4 toxicity compared with 14 of 64 patients in Group B (22%) (P = 0.420). The lack of a correlation between toxicity and age was maintained after controlling for disease stage and patient gender (P = 0.343). There were no correlations between preoperative carcinoembryonic antigen level, tumor grade, or lymph node involvement and patient age (P = 0.258, P = 0.256, and P = 0.519, respectively).Elderly patients with Stage II and Stage III colon carcinoma benefit from 5-FU-based adjuvant therapy without a significant increase in toxicity compared with their younger counterparts. Adjuvant chemotherapy should be presented to elderly patients with high-risk, resected colon carcinoma. The data regarding age cannot be generalized to patients age75 years.

Objective. To compare the outcomes of blunt trauma victims with systolic blood pressure ≤90 mm Hg who received prehospital fluids with the outcomes of those who did not receive prehospital fluids. Methods. This matched-pairs case-control study used records of blunt trauma patients with scene systolic blood pressure ≤90 mm Hg obtained from the Pennsylvania Trauma Systems Foundation. Patients who received >500 mL prehospital fluids (n = 75) were matched by Injury Severity Score (ISS) and systolic blood pressure on scene with those who did not receive any prehospital fluids (n = 75). Outcomes compared included change in systolic blood pressure, survival to discharge, and length of hospital stay. Results. Those who received fluids were more likely to have an increase in systolic blood pressure at arrival to the emergency department [odds ratio for fluid use = 2.41; 95% confidence interval (95% CI) = 1.02, 5.73; p = 0.046]. There was no significant difference in survival to discharge (odds ratio for fluid use ...

My purpose for conducting the critical self-reflective research described in this article was a desire to improve my effectiveness as a teacher in the field of First Peoples’ education. The impetus for undertaking this research was a critical incident in my teaching career that I refer to as My Story of Sal. Writing autoethnographically, I use personal narrative as method, and show My Story of Sal as a representation of curriculum and pedagogy in my teaching praxis. I apply a critical lens of whiteness studies to the narrative to reveal whiteness in my classroom.

Background: Several reports have shown an increased prevalence of gastrointestinal (GI) symptoms in obese subjects in community-based studies. To better understand the role of the gastrointestinal tract in obesity, and because there are limited clinic-based studies, we documented the prevalence of upper and lower GI symptoms in morbidly obese individuals in a clinic setting Objective The aim of our study was to compare the prevalence of gastrointestinal symptoms in morbidly obese individuals in a weight management clinic with non-obese individuals with similar comorbidities as morbidly obese individuals in an Internal Medicine clinic. Methods Class II and III obese patients BMI>35 kg/m2 (n = 114) and 182 non-obese patients (BMI

Little is known about the relationship between weight change and dietary patterns (DP) in older adults, especially in those of advanced age (≥ 75 years). We examined the association of DP with obesity and five-year weight change in community-dwelling older adults (n = 270; mean ± SD age: 78.6 ± 3.9 years). Dietary data were collected from four, random, 24-hour dietary recalls over a 10-month period. Weight change was examined as: (1) 10-pound weight loss; (2) 10-pound weight gain; (3) 10% weight loss; and (4) 10% weight gain. Cluster analysis was used to derive 3 DP ("Health-conscious," "Sweets and dairy," and "Western"). Kaplan-Meier plots and Cox proportional hazards regression models were used. About 39% of participants lost at least 10 pounds during follow up. In the unadjusted model, five-year weight loss was not associated with dietary pattern. However, when stratified by gender, females who were characterized by the Sweets and Dairy and the Western DP were three and two times more likely to lose 10 pounds, respectively, compared to those in the Health-conscious DP (P < 0.05). These observations suggest that it is appropriate to recommend a Health-conscious DP for women 75 years and older who may be at risk for weight loss.

The Beck Depression Inventory-II (BDI-II) is frequently used to evaluate bariatric patients in clinical and research settings; yet, there are limited data regarding the factor structure of the BDI-II with a bariatric surgery population.Exploratory factor analysis (EFA) using principal axis factoring with oblimin rotation was employed with data from 1228 consecutive presurgical bariatric candidates. Independent t tests were used to examine potential differences between sexes. Confirmatory factor analysis (CFA) was conducted with the next 383 consecutive presurgical patients to evaluate the proposed model based on EFA results.EFA revealed three factors: negative perceptions, diminished vigor, and cognitive dysregulation, each with adequate internal consistency. Six BDI-II items did not load significantly on any of the three factors. CFA results largely supported the proposed model.Results suggest that dimensions of depression for presurgical bariatric candidates vary from other populations and raise important caveats regarding the utility of the BDI-II in bariatric research.

This study compared pre- and post-surgical data and outcomes among gastric bypass patients based on the type of insurance (Medicaid, Medicare, or private).Data were examined from 2553 consecutive RYGB patients at a rural ASMBS Center of Excellence.Participants were primarily female (80.5 %), Caucasian (97.1 %), and middle-aged (45.9 years). Medicaid patients' BMI at consultation was significantly higher than the other two groups (p 0.001). Time to surgery was significantly longer for Medicaid (13.2 %) and Medicare (7.1 %) patients compared with privately insured patients (p 0.001). Pre-surgical weight loss and post-surgical percent of excess weight loss nadir did not differ among the groups. Type 2 diabetes remission rates were comparable across insurance groups.Medicaid patients, although demographically different from their privately insured and Medicare counterparts, will benefit from surgery with comparable weight loss results and overall diabetes remission rates.

Health care in the United States is expensive and quality is variable. The aim of this study was to investigate whether our integrated health system, composed of academic hospitals, a practice plan, and a managed care payer, could reliably implement an evidence-based program for gastric bypass surgery. A secondary aim was to evaluate the impact of the program on clinical outcomes.A standardized program for delivery of clinical best-practice elements for patients undergoing initial open or laparoscopic Roux-en-Y gastric bypass was implemented in 2008. Best-practice elements were embedded into the workflow. The best-practice elements were refined after reviewing failures observed during the early implementation period. The study period was divided into 3 groups: group α = year preceding program implementation (control), group β = first year of implementation (unreliable), and group Ω = 2nd to 4th years of implementation (reliable). Outcomes data were collected for all patients who had undergone Roux-en-Y gastric bypass between May 2008 and April 2012 and were compared with a control group from the preceding year using multiple logistic regression analysis.Two thousand and sixty-one patients were studied, with no significant demographic differences between study groups. Best-practice elements delivery was 40% in group β, but was90% for group Ω (p0.001). Length of stay for group α was 3.5 days and improved to 2.2 days (p0.001) for group Ω. Complications and readmission rates improved considerably with reliable delivery of best-practice elements.Standardization of evidence-based care delivery for Roux-en-Y gastric bypass was feasible and reliable delivery of this pathway improved clinical outcomes.

In this study, we examined the relationship between pre-operative internalized weight bias and 12-month post-operative weight loss in adult bariatric surgery patients. Bariatric surgery patients (n = 170) from one urban and one rural medical center completed an internalized weight bias measure (the weight bias internalization scale, WBIS) and a depression survey (Beck depression inventory-II, BDI-II) before surgery, and provided consent to access their medical records. Participants (BMI = 47.8 kg/m2, age = 45.7 years) were mostly female (82.0 %), White (89.5 %), and underwent gastric bypass (83.6 %). The average WBIS score by item was 4.54 ± 1.3. Higher pre-operative WBIS scores were associated with diminished weight loss at 12 months after surgery (p = 0.035). Pre-operative WBIS scores were positively associated with depressive symptoms (p

Individuals with type 2 diabetes have an increased risk of developing non-alcoholic fatty liver disease (NAFLD), and NAFLD patients are also at greater risk for developing type 2 diabetes. Although the relationship between type 2 diabetes and NAFLD is highly interconnected, the pathogenic mechanisms linking the two diseases are poorly understood. The goal of this study was to identify genetic determinants of hepatic lipid accumulation through association analysis using histological phenotypes in obese individuals. Using the Illumina HumanOmniExpress BeadChip assay, we genotyped 2,300 individuals on whom liver biopsy data were available. We analyzed total bilirubin levels, which are linked to fatty liver in severe obesity, and observed the strongest evidence for association with rs4148325 in UGT1A (P

Background/Aims Geisinger bariatric surgery patients complete questionnaires at various points throughout the program as part of their standard care. Until recently, this was done using paper copies completed at home, resulting in unacceptably low response rates. Opportunities to capture missed responses exist, but are difficult to identify in a busy medical clinic. The purpose of this study is to improve patient questionnaire completion rate using in-clinic capture while minimizing the impact on clinic efficiency.

In forecasting the future of cardiovascular disease (CVD), the American Heart Association calls for preventive strategies with particular attention to obesity. The association between obesity and CVD, including coronary artery disease (CAD) and diabetes, is well established. The rising prevalence of obesity in the workforce may have additional implications for employers and employees besides the demonstrated effects on absenteeism and workers' compensation.This study was undertaken to determine the impact of population obesity on care utilization and cost of cardiovascular conditions such as hypertension, CAD, and cerebrovascular disease (or stroke) in a large US population of employees engaged in a major corporate wellness program.Using data from a single large industrial employer across 29 geographically distinct worksites in the United States, 179,708 episodes of care from 2004 to 2007 for 10,853 employees were included.The population-based economic impact of obesity was calculated on the basis of the frequency of episodes of care per 1000 employees and on the amount eligible for payment per episode of care in US dollars. Data were obtained from a wellness program databases, episode of illness inventories, and pharmacy and medical claims. High and low prevalence rates of obesity, by obesity quartile, were used to create linear mixed models to examine associations with disease outcomes, while controlling for correlation within each worksite.Worksites with a high rate of obesity (ie, in the fourth quartile) had 348.4 more episodes of care of any kind per 1000 employees (P.001), 38.6 more hypertension episodes of care per 1000 employees (P.001), and 2.5 more cerebrovascular disease episodes of care per 1000 employees (P = .017) compared with worksites in the lower 3 quartiles. A worksite in the fourth obesity rate quartile had $223 greater cost per any kind of episode (P.001), $169 greater cost per hypertension episode (P = .003), and $1620 more per CAD episode (P = .005) compared with worksites in the lower 3 quartiles. The overall economic impact per 1000 employees was calculated by combining episode frequency and eligible amount for payment per episode. For sites in the lower 3 quartiles of obesity, the eligible amount per 1000 employees for any kind of care was $4.01 million. However, for sites in the highest obesity quartile, the eligible amount for payment per 1000 employees was $5.26 million. This translates into $1250 greater cost per employee. Similar calculations were used to evaluate the effect of obesity on the amount eligible for payment per employee for hypertension, CAD, and cerebrovascular disease episodes, with an estimated $69, $89, and $8 greater cost, respectively, per employee.Worksites with greater obesity prevalence rates were associated with numerically more frequent and more expensive episodes of care than worksites with low obesity prevalence.

Nonadherence to asthma medications is associated with increased emergency department visits and hospitalizations. If adherence is to be improved, first-fill adherence is the first goal to meet after the physician and patient have decided to begin treatment. Little is known about first-fill adherence with asthma medications and the factors for no-fill.The goal of the study was to examine the proportion of patients who fill a new prescription for an asthma medication and analyze characteristics associated with this first-fill.This retrospective cohort study linked electronic health records with pharmacy claims. The cohort was comprised of 2023 patients aged 18 years or older who sought care from the Geisinger Clinic, had Geisinger Health Plan pharmacy benefits, and were prescribed an asthma medication for the first time between 2002 and 2006. The primary outcome of interest was first-time prescription filled by the patient within 30 days of the prescription order date. Covariates examined included factors related to the patient (ie, age, sex, and ethnicity), comorbidities and utilization (ie, Charlson comorbidity index, number of office visits, number of additional medications), asthma treatment (ie, delivery route, pharmacologic class), and pharmacy copay amount. A logistic-regression model was used to determine covariates associated with first-fill.The overall first-fill rate for new asthma medications was 78%. First-fill rate was lower for patients with a copay above the mean of $12 (odds ratio = 0.76; 95% confidence interval, 0.58-0.99) and higher for patients prescribed oral plus inhaled medications (versus inhaled only, odds ratio = 3.91; 95% confidence interval, 2.15-7.11).SEVERAL FACTORS ASSOCIATED WITH FAILING TO FILL AN INITIAL PRESCRIPTION FOR ASTHMA CAN BE ADDRESSED THROUGH SIMPLE INTERVENTIONS: screening for difficulties a patient may have in filling prescriptions, avoiding nonformulary medications, and recognizing the barrier that high copays present. In addition, for employers and policymakers, decreasing copay may improve adherence and, therefore, asthma control.

A variety of health-related data are commonly deposited into electronic health records (EHRs), including laboratory, diagnostic, and medication information. The digital nature of EHR data facilitates efficient extraction of these data for research studies, including genome-wide association studies (GWAS). Previous GWAS have identified numerous SNPs associated with variation in total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG). These findings have led to the development of specialized genotyping platforms that can be used for fine-mapping and replication in other populations. We have combined the efficiency of EHR data and the economic advantages of the Illumina Metabochip, a custom designed SNP chip targeted to traits related to coronary artery disease, myocardial infarction, and type 2 diabetes, to conduct a GWAS for lipid traits in a population with extreme obesity. Our genome wide analysis identified association of SNPs residing at previously lipid associated loci with all lipid phenotypes, as well as 14 of 24 previously identified lipid-associated SNPs, although for a number of known lipid SNPs and body weight SNPs no association was found. Association analysis using several approaches to adjust for use of lipid lowering medications resulted in fewer and less strongly associated SNPs. The availability of phenotype data from the EHR and the economic efficiency of the specialized Metabochip can be exploited to conduct multi-faceted analyses for GWAS.

To determine the associations between diet quality, body mass index (BMI), and health-related quality of life (HRQOL) as assessed by the health and activity limitation index (HALex) in older adults.Multivariate linear regression models were used to analyze associations between Dietary Screening Tool (DST) scores, BMI and HALex score, after controlling for gender, age, education, living situation, smoking, disease burden and self-vs. proxy reporting.Geisinger Rural Aging Study, Pennsylvania.5,993 GRAS participants were mailed HRQOL and DST questionnaires with 4,009 (1,722 male, 2,287 female; mean age 81.5 ± 4.4) providing complete data.HALex scores were significantly lower for participants with dietary intakes categorized as unhealthy (60) (0.70, 95% CI 0.69, 0.72, p0.05) or borderline (60-75) (0.71, 95% CI 0.70, 0.73, p0.05) compared to those scoring in the healthy range (75) (0.75, 95% CI 0.73, 0.77) based on DST scores. HALex scores were significantly lower for underweight (0.67, 95% CI 0.63, 0.72, p0.05), obese class II (0.68, 95% CI 0.66, 0.71, p0.05) and class III participants (0.62 95% CI 0.57, 0.67, p0.05) compared to those with BMI 18.5-24.9.Poor diet quality, as assessed by the DST, is associated with lower HRQOL in adults ≥ 74 years of age.

Challenges of specimen extraction during laparoscopic sleeve gastrectomy and other resectional laparoscopic procedures can often be proven to be time consuming and frustrating, and the risk of wound infection and port site tumor implantation increases. In this paper, we discuss our experience with an efficient approach to specimen extraction utilizing a novel technique for deployment of a very small self-expanding wound protector through a 12- or 15-mm port. We also report our observations with regard to the learning curve of this technique and the influence of BMI to retractor insertion times and specimen extraction times during laparoscopic sleeve gastrectomy.

Thresholds for defining successful weight loss following bariatric surgery range from 40 to 70 % of excess body weight lost, with some degree of long-term weight regain occurring in many patients. The main classes of surgical procedures currently in general use, including the two most commonly performed operations, the Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB), also continue to evolve. RYGB creates a small gastric pouch to restrict the size of the stomach to cause early satiety, as well as a bypass of the proximal small intestine to decrease nutrient absorption. This procedure in the morbidly obese usually induces about 65–70 % excess body weight loss (EBWL), although weight loss plateaus at 1–2 years, often with some regain, and a subgroup of patients remain resistant to weight loss. Analysis of variables associated with weight loss following these procedures has shown little consistency; thus long-term sustained weight loss may depend upon as yet unidentified factors. The purpose of this chapter is to discuss the known variables, clinical and biological, that are associated with differential weight loss outcomes following Roux-en-Y gastric bypass surgery.

Background. Current patient education and informed consent regarding weight loss expectations for bariatric surgery candidates are largely based on averages from large patient cohorts. The variation in weight loss outcomes illustrates the need for establishing more realistic weight loss goals for individual patients. This study was designed to develop a simple web-based tool which provides patient-specific weight loss expectations.Methods. Postoperative weight measurements after Roux-en-Y gastric bypass (RYGB) were collected and analyzed with patient characteristics known to influence weight loss outcomes. Quantile regression was used to create expected weight loss curves (25th, 50th, and 75th %tile) for the 24 months after RYGB. The resulting equations were validated and used to develop web-based tool for predicting weight loss outcomes.Results. Weight loss data from 2986 patients (2608 in the primary cohort and 378 in the validation cohort) were included. Preoperative body mass index (BMI) and age were found to have a high correlation with weight loss accomplishment (P<0.0001for each). An electronic tool was created that provides easy access to patient-specific, 24-month weight loss trajectories based on initial BMI and age.Conclusions. This validated, patient-centered electronic tool will assist patients and providers in patient teaching, informed consent, and postoperative weight loss management.

Study Objective: This study compares selected laboratory values of blood samples obtained by means of venipuncture and by means of a peripheral intravenous catheter after a normal saline solution bolus. Methods: In this prospective experimental study, each participant served as his or her own control. Hospital employees volunteered in the emergency department of a tertiary-care teaching hospital. Participants had a peripheral catheter placed in one upper extremity and received a 200-mL bolus of normal saline solution during a 10-minute period. After a 2-minute wait period, a 12-mL aspirate was withdrawn directly from the saline solution lock. A second 12-mL aspirate was also obtained. Concurrently, venipuncture was performed on the other upper extremity. All 3 samples were analyzed for CBC, electrolytes, blood urea nitrogen, creatinine, glucose, liver function tests, and prothrombin time/international normalized ratio (PT/INR). Limits of agreement analysis based on the definition of clinical equivalence, as determined by surveying residency-trained and board-certified emergency physicians, was used to compare the results of catheter aspirates with those of venipuncture aspirates. Results: Thirty-three volunteers participated. When comparing venipuncture versus first aspirate, 16 of the 19 laboratory tests evaluated had 99% agreement intervals that were within the predetermined definition of clinical equivalence. Potassium, bicarbonate, and glucose did not demonstrate clinical equivalence, and this difference persisted after a 12-mL discard volume. Conclusion: This study supports the use of blood samples obtained by means of aspiration from a peripheral catheter when testing for CBC, blood urea nitrogen, creatinine, liver function tests, and PT/INR in healthy-appearing patients. Catheter aspiration, when testing for electrolytes and glucose, may be reasonable in a more select group of patients. [Zlotowski SJ, Kupas DF, Wood GC. Comparison of laboratory values obtained by means of routine venipuncture versus peripheral intravenous catheter after a normal saline solution bolus. Ann Emerg Med. November 2001;38:497-504.]

The multivariate tolerance (MT) model is used to model multi-agent bioassay survival responses. When the MT model is appropriate, it can aid in identifying the biological mechanism of the survival response or motivate tolerance-based error reduction. A bootstrap test for the goodness-of-fit of the MT model is proposed. The proposed test has little level error, useful power, and makes a novel adjustment for the multiple testing character of the question of MT model goodness-of-fit. This adjustment may be more generally applicable in bootstrap testing.

Background/AimsBariatric surgery is the only effective long-term treatment for morbid obesity. The bariatric program includes commitment to lifestyle changes that may have a collateral effect on co-inhabitants. Studies of the collateral impact are limited by small sample sizes and results have been conflicting, with studies showing both weight loss and weight gain in family members of surgery patients. This is the largest study to investigate the impact of bariatric surgery on the BMI of adults living in the same household.MethodsAdult co-inhabitants of Roux-en-Y gastric bypass patients were identified by matching addresses from an electronic health record. The sample was limited to co-inhabitants with BMI measures within the year prior and within a year after their household member’s surgery. Paired t-tests and repeated measures regression was used to determine if change in BMI from pre- to post-surgery was associated with the co-inhabitants’ age, gender, and BMI.ResultsOf 443 co-inhabitants (from 388 bariatric patients), 61% (n = 269) were male, and 21% (n = 91), 50% (n= 223), and 29% (n = 129) were aged 40kg/m2) in 12% (n = 54), 26% (n = 116), 46% (n = 205), and 15% (n = 68), respectively. The overall change in the co-inhabitants’ BMI was not significant (pre-surgery mean = 32.9, post-surgery mean = 32.8, paired t-test p-value = 0.072). Change in BMI from pre- to post-surgery was not associated with gender (P = 0.231) or pre-surgery BMI (P = 0.129). Older age was associated with significant decrease in BMI. Co-inhabitants aged ≥60 had a significant decrease in BMI (pre-surgery mean = 32.3 kg/m2, post-surgery mean = 31.9, P = 0.0002).ConclusionsOlder co-inhabitants (aged ≥60) of bariatric surgery patients had a significant reduction in BMI, while younger age, gender, and initial BMI were not associated with BMI change. The lifestyle changes required of bariatric surgery patients might have more of an impact on older co-inhabitants who are less likely to be influenced by competing lifestyle behaviors in the workplace than their younger counterparts. With more than 60 percent of co-inhabitants obese prior to surgery, it is critical to identify strategies for broadening the positive impact of bariatric surgery to co-inhabitants in all age groups.

ObjectiveTo assess the association of diet-related practices and BMI with diet quality in rural adults aged ≥74 years.DesignCross-sectional. Dietary quality was assessed by the twenty-five-item Dietary Screening Tool (DST). Diet-related practices were self-reported. Multivariate linear regression models were used to analyse associations of DST scores with BMI and diet-related practices after controlling for gender, age, education, smoking and self- v. proxy reporting.SettingGeisinger Rural Aging Study (GRAS) in Pennsylvania, USA.SubjectsA total of 4009 (1722 males, 2287 females; mean age 81·5 years) participants aged ≥74 years.ResultsIndividuals with BMI < 18·5 kg/m2 had a significantly lower DST score (mean 55·8, 95 % CI 52·9, 58·7) than those individuals with BMI = 18·5–24·9 kg/m2 (mean 60·7, 95 % CI 60·1, 61·5; P = 0·001). Older adults with higher, more favourable DST scores were significantly more likely to be food sufficient, report eating breakfast, have no chewing difficulties and report no decline in intake in the previous 6 months.ConclusionsThe DST may identify potential targets for improving diet quality in older adults including promotion of healthy BMI, breakfast consumption, improving dentition and identifying strategies to decrease concern about food sufficiency.

To determine sex bias in the selection of strategies to evaluate patients with acute myocardial infarction (AMI), and determine if the choice of strategy influences survival.Controversy exists regarding the role of female sex in the use of invasive evaluation for AMI and its possible effect on adverse outcomes.Electronic health record data from the Geisinger Acute Myocardial Infarction Cohort (GAMIC) was analyzed which included 1,968 men and 1,047 women admitted to the Geisinger Medical Center between January 2001 and December 2006 with acute myocardial infarction (AMI).Multivariate logistic regression analyses were used to determine independent correlates of an invasive evaluation. Multivariate logistic regression modeling stratified on sex was used to determine when invasive evaluation was done and whether there was a correlation with mortality.In unadjusted analyses, male sex was a significant predictor for the use of invasive evaluation (odds ratio = 1.71, 95% CI = [1.46, 2.00]). Adjusted for baseline differences (like age, renal function, co-morbid conditions) multivariate analyses found no significant relationship between male sex and invasive evaluation (OR = 1.02, 95% CI = [0.82, 1.23]). Females in the STEMI group were found to be less revascularized. No difference was observed in the one-year mortality between women and men regardless of invasive evaluation or revascularization.Sex was not independently associated with the occurrence of an invasive evaluation of a MI. Females in the STEMI group were less revascularized. There was no strong gender effect on survival irrespective of the performance on an invasive evaluation or revascularization.

Importance Weight loss after bariatric surgery varies, yet preoperative clinical factors associated with long-term suboptimal outcomes are not well understood. Objective To evaluate the association between preoperative clinical factors and long-term weight loss after Roux-en-Y gastric bypass (RYGB). Design, Setting, and Participants From June 2001 to September 2007, this retrospective cohort study followed up RYGB patients before surgery to 7 to 12 years after surgery. The setting was a large rural integrated health system. Of 1033 eligible RYGB patients who consented to participate in longitudinal research and completed surgery before October 2007, a total of 726 (70.3%) had a weight entered in the electronic medical record 7 or more years after surgery and were included in the analyses after exclusions for pregnancy and mortality. Date of the long-term weight measurement was recorded between August 2010 and January 2016. Main Outcomes and Measures The primary outcome was percentage weight loss (%WL) at 7 to 12 years after surgery. Preoperative clinical factors (>200) extracted from the electronic medical record included medications, comorbidities, laboratory test results, and demographics, among others. Results Among the 726 study participants, 83.1% (n = 603) were female and 97.4% (n = 707) were of white race, with a mean (SD) preoperative body mass index (calculated as weight in kilograms divided by height in meters squared) of 47.5 (7.4) . From the time of surgery to long-term follow-up (median, 9.3 postoperative years), the mean (SD) %WL was 22.5% (13.1%). Preoperative insulin use, history of smoking, and use of 12 or more medications before surgery were associated with greater long-term postoperative %WL (6.8%, 2.8%, and 3.1%, respectively). Preoperative hyperlipidemia, older age, and higher body mass index were associated with poorer long-term postoperative %WL (−2.8%, −8.8%, and −4.1%, respectively). Conclusions and Relevance Few preoperative clinical factors associated with long-term weight loss after RYGB were identified. Preoperative insulin use was strongly associated with better long-term %WL, while preoperative hyperlipidemia, higher body mass index, and older age were associated with poorer %WL. Our findings provide additional insight into preoperative identification of RYGB patients at higher risk for long-term suboptimal outcomes.