Comparison of Diabetic Remission Rates following Roux en-Y Gastric Bypass and Longitudinal Sleeve Gastrectomy

Introduction: Bariatric surgery is being increasingly investigated as treatment for Type II Diabetes Mellitus (T2DM). As Sleeve Gastrectomy (SG) surpasses Roux-en-Y Gastric Bypass (RYGB) as the new standard in bariatric surgery, it is still unknown if its efficacy in achieving remission is comparable to RYGB. This study compared diabetic remission rates between SG and RYGB in order to identify the predictive factors for remission and the mechanisms of achieving remission. Methods: This was a retrospective cohort study comparing all diabetic patients undergoing RYGB and SG at an academic medical center from 1/1/11-7/1/15. Patients were followed preoperatively and at 6 week, 6 month, and 1, 2, and 3 year intervals. We defined diabetic remission as HbA1c under 7 without insulin or hypoglycemic use and excess body weight (EBW) as percent over ideal body weight. Data were analyzed using Cox analysis, Fisher’s Exact Tests, and Student T Tests. Results: During the study, 96 patients underwent RYGB and 89 underwent SG. Preoperatively, patients from both groups had similar age, weight, gender, preoperative weight loss, HbA1c at onset and at surgery, oral hypoglycemic use, insulin use, and HOMA2 parameters. At one year postoperatively, patients who underwent RYGB showed a statistically greater postoperative EBW loss (62% vs. 36% p \u3c 0.0001). Kaplan Meier analysis showed a significantly higher rate of remission, (83% vs. 66%) in patients who underwent SG (p=0.02). After using Cox analysis to account for differences in delta BMI (p=0.04), EBW loss (p=0.04), preoperative HOMA2 parameters (p=0.008-0.011), and preoperative factors such as HbA1c and insulin use (p=0.001 for both), there was no change in RYGB’s impact on diabetic remission compared to SG. Conclusion: Our results confirm that RYGB achieves a significantly greater rate of diabetic remission and a significantly higher weight loss than SG. Additionally, the difference in rate of diabetic remission is not explained by weight loss or preoperative predictors of less reversible diabetes (HOMA2 parameters, use of insulin). Identification of the factor(s) responsible for this differential effect on diabetes may afford opportunity for therapeutic intervention

Differences in Complication Rates Between Roux-en-Y Gastric Bypass and Longitudinal Sleeve Gastrectomy

Introduction: Sleeve Gastrectomy (SG) has surpassed Roux-en-Y Gastric Bypass (RYGB) as the most commonly performed bariatric operation. Though the beneficial effect of SG on Type 2 Diabetes Mellitus is less than that of RYGB, it is perceived to have a lower complication rate. The purpose of this study was to quantify the complication rates between of SG and RYGB in a severely obese diabetic population. Methods: This was a retrospective cohort study that included all diabetic patients undergoing RYGB and SG at an academic medical center from January 1, 2011 to July 1, 2015. Patients were followed at 6 week, 6 month, 1 year, 2 year, and 3 year postoperatively. Outpatient and emergency visits were identified in the EMR system. Continuous data was analyzed using Student T tests and discrete data was analyzed using Fisher’s Exact Test. We defined early complications as those occurring within 30 days postoperatively, and late complications as those after 30 days. Results: A total of 96 patients underwent RYGB and 89 underwent SG. The groups were concurrent and similar with regards to preoperative demographic factors such as age, gender, Hgb-A1c, HOMA2 parameters, excess body weight, BMI, and diabetic medication use. In terms of early complications, the rate of hemorrhage requiring transfusion was higher in the SG group compared to RYGB (10.1% vs. 3.1%, p=0.073). Postoperative length of stay was lower in the SG group (m=1.7 d vs. m=2 d, p=0.02), but the early readmission rate was also higher in the SG group (7.9% vs. 2.1%, p=0.09). For late postoperative complications, there were 4 anastomotic ulcer perforations and one case of internal hernia in the RYGB group. There were 6 late postoperative reoperations in the RYGB group (6% vs. 0%, p=0.03). In addition, 13 patients underwent 16 total upper endoscopies in the RYGB group (13.5% vs. 0%, p=0.0002). The cumulative rate of early and late interventions was higher in the RYGB group (20% vs. 3.4%, p=0.0005). Conclusions: While the rate of early postoperative complication is similar between SG and RYGB, the need for late intervention is higher after RYGB. The cumulative need for reintervention (early and late) is higher after RYGB. This may explain the shift from Roux-en-Y Gastric Bypass to Sleeve Gastrectomy as the most commonly performed bariatric intervention

The Effect of Oral Antibiotics on the Development of Community Acquired Clostridium Difficile Colitis in Medicare Beneficiaries

Clostridium difficile infection (CDI) is increasingly prevalent among community dwelling Americans. Older Americans are particularly vulnerable to community-acquired Clostridium difficile (CACD), in part to increasing use of antibiotics. We studied the association between outpatient antibiotics and CACD among Medicare beneficiaries. Case-control study utilizing a 5% sample of Medicare beneficiaries (2009-2011). Patients with CACD severe enough to warrant hospitalization were identified by a primary diagnosis code for CDI and no exposure to a healthcare environment within 90-days of admission. 1,514 CACD cases were matched to ten controls each on birth year and sex. Potential controls with exposure to healthcare environment were excluded. Outpatient oral antibiotic exposure was classified into three groups: ≤30 days, 31-60 days, or 61-90 days prior to case subject’s index admission. Metronidazole and Vancomycin were excluded because they are used to treat CDI. Multivariable models were utilized to determine the independent effect of antibiotics on the development of CACD while controlling for several patient associated characteristics. Cases of CACD had more outpatient antibiotic exposure in each time period examined: ≤30 days = 40.0% vs 8.4%; 31-60 = 10.7% vs 5.0%; and 61-90 = 5.5% vs 4.4% (all p-values \u3c 0.05). Subjects exposed to antibiotics ≤30 days prior to admission had a markedly higher risk of being admitted with CACD compared with those not exposed (OR 8.09, 95% CI 7.13, 9.19). Similarly, subjects taking antibiotics 31-60 days and 61-90 days prior to admission had increased risk of CDI admission (OR 3.65, 95% CI 3.02, 4.41) and (OR 2.06, 95% CI 1.61, 2.63) respectively. Recent exposure to outpatient oral antibiotics increases the risk of CACD among community dwelling elderly with the risk persisting as long as 90 days after exposure. Inappropriate antibiotic usage must be minimized and older Americans who require outpatient antibiotic treatment may warrant close observation for signs of CDI

Impact of Pre-Injury Warfarin Use Among Medicare Beneficiaries With Head Trauma

Introduction: The effect of warfarin on outcomes of head injured patients remains controversial. Yet more than 2 million Americans, many of them elderly, are started on warfarin annually. Meanwhile, with the aging US population, elderly Americans are becoming an increasingly large proportion of head injured patients. We studied a national cohort of Medicare beneficiaries with head injuries to determine the effects of pre-injury warfarin on outcomes. Methods: A retrospective review of a 5% random sample of Medicare claims data (2009-2010) was performed for enrollees with at least 1 year of Medicare eligibility. Head injury cases were identified using ICD-9 codes for intracranial hemorrhage with or without accompanying skull fractures. Using Part D prescription drug claims, warfarin exposure was defined as \u3e2 warfarin prescriptions filled within 60 days prior to injury. Characteristics and outcomes (mortality, length of stay (LOS), ICU LOS) between warfarin users and patients not on warfarin (non-users) were compared using univariate tests of association. Multivariable models adjusting for patient characteristics, concomitant torso injuries/long-bone fractures, and need for ICU care were conducted to measure the independent effect of warfarin on in-hospital mortality. Results: We identified 3,420 head injured patients,6.6% of whom were treated with warfarin. Warfarin users were more likely to be female (74.2%vs.65.6%, p Conclusion: Anticoagulation with warfarin increases risk of mortality after head injury nearly two fold in Medicare beneficiaries even after adjusting for other risk factors. As new, more difficult to reverse, agents are introduced for chronic anticoagulation this problem may be exacerbated. Physicians should exercise caution when initiating chronic anticoagulation in patients over the age of 65

Quadrimodal Distribution of Death after Trauma: Predictors of Death in the Fourth Peak

Introduction: Patterns of death after trauma are changing due to diagnostic and treatment advances. We examined mortality in critically injured patients at risk of death after discharge. Methods: We reviewed all critically injured (Injury Severity Score≥25 AND death in Emergency Room , death within 24hrs, OR ICU admission\u3e24hrs) adults (age≥18) admitted to a Level 1 trauma center (01/01/2000-12/31/2010) and determined death post-discharge (Social Security Death Index) of patients discharged alive. We compared demographics, injury data, and critical care resource utilization between those who died during follow-up and survivors using univariate tests and Cox proportional hazards models. Results: Of 1,695 critically injured patients, 1135 (67%) were discharged alive. As of 05/1/2012, 977 (58%) index survivors were alive (median follow-up 62mos (IQR35,96)). Of 158 deaths post-discharge, 75 (47%) occurred within the first year. Patients who died post-discharge had longer hospital (24dys (IQR13,38) vs. 17dys (IQR10,27)) and ICU LOS (17dys (IQR6,29) vs. 8dys (IQR4,19)) and were more likely to undergo tracheostomies (36.1% vs. 15.6%, p16dys increased risk of death at one year (HR1.94 (1.22,3.06)) and by the end of follow-up (HR2.19 (1.58,3.04)) compared to shorter ICU stays. Conclusion: We propose the first year after discharge as the fourth peak of trauma related mortality. Duration of ICU LOS during index hospitalization is associated with post-discharge mortality

Clinical and Financial Impact of Readmissions Following Colorectal Resection: An Analysis of Predictors, Outcomes, and Cost

Background: Following passage of the Affordable Care Act, 30day readmissions have come under greater scrutiny, with penalties levied for higher than expected readmission rates. We examined risk factors for 30day readmission following colorectal resection and evaluated the financial impact of readmissions on the healthcare system. Methods: The University HealthSystem Consortium Clinical Database was queried for adults undergoing colorectal surgery for cancer, diverticular disease, inflammatory bowel disease, or benign tumors from 2008-2012. Predictors of 30day readmission were assessed with multivariable logistic regression. Additional endpoints included time to readmission, readmission diagnosis, readmission length of stay (LOS), and readmission cost. Results: A total of 70,484 patients met study inclusion criteria, 13.7% (9,632) of which were readmitted within 30 days of discharge. The strongest independent predictors of readmission were: LOS ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.54; 95% CI 1.46-1.51), and non-home discharge (OR 1.68; 95% CI 1.57-1.81). Of those readmitted, half occurred within 7 days, 13% required ICU care, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was over two times higher ($26,917 v.$13,817; p\u3c0.001) than non-readmitted patients. Compared with late readmissions, those readmitted within 7 days were more likely to have a reoperation (8% v. 4%, p\u3c0.001), be admitted to the ICU (14% vs. 12%, p\u3c0.001), and had a longer median readmission LOS (5d vs. 4d, p\u3c0.001). CONCLUSIONS: 30-day readmissions following colorectal resection occur frequently and incur a significant financial burden on the healthcare system. Highest-risk patients include those with longer LOS, stoma, and non-home discharge. Future studies aimed at targeted interventions may reduce readmissions and curb escalating healthcare costs

A New Look at the Volume and Outcome Relationship in Surgery for Colorectal Cancer

Purpose: Surgeon and hospital factors have a significant impact on treatment outcomes for colorectal cancer (CRC). Limited research has been done to assess cost and quality of treatment by surgeon-volume. We aim to identify the surgeon factors impacting cost and quality of surgical care for CRC. Methods: The University HealthSystem Consortium database was queried for patients who underwent colon resection for cancer from 2008 to 2012. Patients were grouped by surgeon-volume. Outcomes of interest were postoperative complications, ICU admission, readmission rate, inpatient hospital length of stay (LOS) and direct hospital cost. Average surgeon-volume per year was categorized as high (\u3e6) or low (16) based on the distribution of surgeon-volume. Results: 29,972 patients over age 18 were identified for inclusion. 25,426 underwent resection by high-volume surgeons (HVS) and 4,547 by low-volume surgeons (LVS). LVS were more likely to admit patients to the ICU than HVS (21% v 33%, p Conclusions: Surgeons who perform greater than 6 colectomies per year for colon cancer are more likely to use laparoscopy, less likely to admit patients to the ICU, have lower complication and readmission rates, and shorter LOS. Hospital cost is significantly lower in patients operated on by high volume surgeons. As health care costs continue to escalate and health care reform efforts gain momentum, factors leading to high-quality, cost-effective care need to be identified

Rates of Insurance for Injured Patients before and after Health Care Reform in Massachusetts: Another Case of Double Jeopardy?

Background: As a result of healthcare reform (HCR), insurance rates among Massachusetts (MA) residents increased from 86.6% (2006) to 94.4% (2010) and conferred a 7.6% higher probability of being insured compared to neighboring states. The effect of an individual mandate on insurance rates among trauma patients is unknown. Methods: This was retrospective analysis of adult (18-64yrs) trauma patients from MA and surrounding states (NH, RI, CT, NY, VT) treated at our level 1 trauma center in central MA before (2004-2005) and after (2009-2010) MA-HCR. We estimated changes in insurance rates across time-periods and state-residence. Results: Before MA-HCR, 76.7% (1647/2,148) of injured MA residents had insurance compared to 84.3% (2088/2477) post-HCR (p Conclusions: In this single center study, time rather than HCR resulted in modest increases in insurance rates. However, MA-HCR was ineffectual at increasing insurance among trauma patients to levels comparable to the general public, suggesting certain factors may place certain subgroups in “double jeopardy” by simultaneously increasing risk of injury and precluding compliance with an individual mandate

GeneSigDB: a manually curated database and resource for analysis of gene expression signatures

GeneSigDB (http://www.genesigdb.org or http://compbio.dfci.harvard.edu/genesigdb/) is a database of gene signatures that have been extracted and manually curated from the published literature. It provides a standardized resource of published prognostic, diagnostic and other gene signatures of cancer and related disease to the community so they can compare the predictive power of gene signatures or use these in gene set enrichment analysis. Since GeneSigDB release 1.0, we have expanded from 575 to 3515 gene signatures, which were collected and transcribed from 1604 published articles largely focused on gene expression in cancer, stem cells, immune cells, development and lung disease. We have made substantial upgrades to the GeneSigDB website to improve accessibility and usability, including adding a tag cloud browse function, facetted navigation and a ‘basket’ feature to store genes or gene signatures of interest. Users can analyze GeneSigDB gene signatures, or upload their own gene list, to identify gene signatures with significant gene overlap and results can be viewed on a dynamic editable heatmap that can be downloaded as a publication quality image. All data in GeneSigDB can be downloaded in numerous formats including .gmt file format for gene set enrichment analysis or as a R/Bioconductor data file. GeneSigDB is available from http://www.genesigdb.org