Ashish C. Sinha

A Review of Adolescent Obesity: Prevalence, Etiology, and Treatment

Much of adult obesity has its roots in childhood. One of the tragedies of the current obesity epidemic is the significant and increasing prevalence of obesity in the young. One principal predictor of adult obesity is childhood obesity. We describe here the classification, epidemiology, causality, comorbidities, and treatment of adolescent obesity, both pharmacologic and surgical.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2009

The hybrid operating room is the venue for transcatheter therapy with the convergence of 3 specialties: cardiac surgery, cardiovascular anesthesiology, and interventional cardiology. Transcatheter aortic valve replacement is proof that cardiac specialists have embraced the endovascular revolution. Because pharmacologic conditioning and ischemic myocardial conditioning are safe and effective, they are currently the focus of multiple trials. Angiotensin blockade, anemia, and endoscopic saphenous vein harvesting worsen outcome after coronary artery bypass graft (CABG) surgery. Although off-pump CABG surgery is equivalent to on-pump CABG surgery, it may improve outcomes in high-risk groups. Although percutaneous coronary intervention (PCI) significantly decreases mortality after myocardial infarction, the evidence is less convincing for intra-aortic balloon counterpulsation. Even though prasugrel recently was approved for platelet blockade in PCI, it may be superseded by ticagrelor. Although PCI and CABG surgery appear equivalent for multivessel coronary disease, CABG surgery lowers revascularization rates and also has superior outcomes in diabetics and the elderly. Hetastarch and N-acetylcysteine both increase bleeding and transfusion in cardiac surgery. Factor VII can treat life-threatening bleeding, but its safety requires further evaluation. Because eltrombopag and romiplostim stimulate platelet production, they may have a future role in hemostasis after cardiac surgery. Even though fenoldopam, atrial natriuretic peptide, and sodium bicarbonate are nephroprotective, further trials must confirm these findings. Intensive insulin therapy offers no further outcome advantage and significantly increases hypoglycemic risk. The past year has witnessed the advent of a new clinical venue, new devices, and new drugs. The coming year will most likely advance these achievements.

Methods and Complications of Nasoenteral Intubation

Nasoenteral intubation is among the most common procedures performed by clinicians across all medical specialties. The most common technique for nasoenteral intubation is blind passage, as it does not require the use of sophisticated or expensive medical equipment. Unfortunately, blind placement too frequently results in trauma and is a source of significant morbidity and mortality. It is apparent that altered mental status, a preexisting endotracheal tube, and critical illness put a patient in a higher risk group for malposition and complications. Nasoenteral intubation should be attempted only with an understanding of the possibility for difficult placement and the potential complications that can arise from trauma or malposition.

Evidence-Based Review of the Pharmacoeconomics Related to the Management of Chronic Nonmalignant Pain

ABSTRACT Chronic pain is one of the most common reasons for patients to seek medical care. Chronic pain results in substantial economic losses and remains one of the most costly conditions in modern western society. In 1991, costs were estimated to be approximately

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2010

65 billion annually, comparable to the cost of treating diabetes. Persistent chronic pain and the use of advanced interventional and pharmacological treatments often leads to complex social and psychological maladaptations, health care overutilization, as well as many other substantial direct and indirect costs. Thus, the proper treatment of chronic pain involves intense multidisciplinary management, including pharmacological, behavioral, and psychological interventions. Few studies have assessed the total economic cost of chronic pain. However, many of the chronic pain treatments do not alleviate pain symptoms for most patients and lead to unsuccessful application of resources. The economic consequences of inadequately treated chronic pain translates into lost work days, overutilization of health care resources (excess hospitalizations, and surgical procedures and inappropriate medications) and other out-of-pocket patient expenses. Increasing emphasis on diagnosis and treatment of chronic pain places more importance on the need for efficient and coordinated management of patient with chronic pain. The management of chronic pain is remarkably complex and resource intensive. Therefore, a clear need exists for intensive pharmacoeconomic investigations, specifically evaluating costs related to chronic pain and the associated treatment modalities. Additionally, evaluation of the costs related to chronic pain would measure the economic burden of chronic pain, including an estimate of the amount that could potentially be saved if chronic pain patients are optimally managed.

Does Every Morbidly Obese Patient Need a Complete Preoperative Workup

The aortic valve treatment revolution continues with the maturation of aortic valve repair and the dissemination of transcatheter aortic valve implantation. The recent publication of comprehensive multidisciplinary guidelines for diseases of the thoracic aorta has assigned important roles for the cardiovascular anesthesiologist and perioperative echocardiographer. Although intense angiotensin blockade improves outcomes in heart failure, it might further complicate the maintenance of perioperative systemic vascular tone. Ultrafiltration as well as intensive medical management guided by the biomarker brain natriuretic peptide improves outcomes in heart failure. Continuous-flow left ventricular assist devices have further improved outcomes in the surgical management of heart failure. Major risk factors for bleeding in the setting of these devices include advanced liver disease and acquired von Willebrand syndrome. The metabolic modulator perhexiline improves myocardial diastolic energetics to achieve significant symptomatic improvement in hypertrophic cardiomyopathy. A landmark report was also published recently that outlines the major areas for future research and clinical innovation in this disease. Landmark trials have documented the outcome importance of perioperative cerebral oxygen saturation monitoring as well as the outcome advantages of the Sano shunt over the modified Blalock-Taussig shunt in the Norwood procedure. Furthermore, the development and evaluation of pediatric-specific ventricular assist devices likely will revolutionize the mechanical management of pediatric heart failure. A multidisciplinary review has highlighted the priorities for future perioperative trials in congenital heart disease. These pervasive developments likely will influence the future training models in pediatric cardiac anesthesia.

The epidemiology and aetiology of obesity: A global challenge

The perioperative management of morbidly obese patients is an intimidating challenge for anesthesiologists. Due to the high frequency of many organ system abnormalities, do all morbidly obese patients require a full workup preoperatively? In other words, in the absence of clinical signs or symptoms of pathology, are clinicians obligated to perform testing for cardiac function, coronary artery patency, obstructive sleep apnea, pulmonary, hepatic and renal disease and other common obesity-related diseases that may impact surgical and anesthetic outcome? There is currently insufficient evidence to clearly support either a comprehensive approach, which may be expensive, inefficient and possibly harmful or a workup consistent with the same standard of care as non-obese patients. Nevertheless, there is acceptable safety data and expert opinion that supports a targeted symptom-based approach to preoperative evaluation. For moderate or severe risk procedures, all morbidly obese patients should have a comprehensive metabolic panel and chest X-ray. An EKG is reasonable, but only necessary in the presence of known risk factors. Anesthesiologists must have a high index of suspicion for common obesity-related problems such as obstructive sleep apnea, atrial fibrillation, heart failure, coronary artery disease, decreased functional residual capacity, poor glycemic control and gastro-esophageal reflux and provide appropriate screening questions during the preanesthetic history and physical. A comprehensive workup with testing is likely unnecessary and may not improve outcomes.