Toms Augustin

Neighborhood psychosocial hazards and cardiovascular disease: The Baltimore Memory Study

OBJECTIVES We examined associations between cardiovascular disease and neighborhood psychosocial hazards, such as violent crime, abandoned buildings, and signs of incivility, to evaluate whether features of place are associated with older adult health. METHODS We analyzed first-visit data from the Baltimore Memory Study of randomly selected residents aged 50 to 70 years (n=1140) of 65 contiguous neighborhoods in Baltimore, Maryland. We looked for associations between self-reports of history of selected cardiovascular diseases and scores on the 12-item neighborhood psychosocial hazards scale. RESULTS After adjustment for established individual risk factors for cardiovascular disease, residents in neighborhoods with scores in the highest quartile of the psychosocial hazards scale had more than 4 times higher odds of a history of myocardial infarction and more than 3 times higher odds of myocardial infarction, stroke, transient ischemic attack, or intermittent claudication compared with residents living in neighborhoods scoring in the lowest quartile. CONCLUSIONS Neighborhood psychosocial hazards were significantly associated with self-reported cardiovascular disease after adjustment for individual-level risk factors. This is consistent with the hypothesis that environmental stress plays a role in the etiology of cardiovascular disease.

Intraductal Papillary Mucinous Neoplasm: A Clinicopathologic Review

Intraductal papillary mucinous neoplasm (IPMN) is an intraductal mucin-producing epithelial neoplasm that arises from the main pancreatic duct (MD-IPMN), secondary branch ducts (BD-IPMN), or both (mixed type; Mix-IPMN). Neoplastic progression from benign adenoma to invasive adenocarcinoma has not been proven but is generally thought to occur. With increasing recognition of IPMN, our understanding of the diagnosis and management of the tumors is evolving. At present, treatment options for patients with IPMN range from observation to pancreatic resection depending on the natural history of the lesion. This review focuses on currently available data that guide management decisions for patients with IPMN.

Failed Surgical Weight Loss Does Not Necessarily Mean Failed Metabolic Effects

The metabolic profile of patients after a failed surgical weight loss procedure is unknown. Long-term clinical outcomes of 31 obese diabetes patients with post-bariatric surgery excess weight loss of ≤25% were assessed. At a median follow-up of 6 years (range, 5-9 years) after surgery, remission and clinical improvement of diabetes occurred in seven (23%) and 13 (42%) patients, respectively. A long-term mean total weight loss of 7.0±4.7% and excess weight loss of 13.7±8.5% were associated with a mean reduction in fasting blood glucose level, from 158.9±66.7 to 128.4±35.3 mg/dL (P=0.03), and a significant decrease in diabetes medication requirements (P<0.001). A significant decrease in systolic blood pressure (11.1±23.4 mm Hg, P=0.01) and level of circulating triglycerides (35.7±73.4 mg/dL, P=0.04) was also observed after surgery. A modest surgical weight loss in the range of 5-10% of initial weight was associated with significant improvement in cardiometabolic risk factors of morbidly obese diabetes patients. The markedly improved glycemic control (65% remission or clinical improvement) may be partly explained by weight-independent antidiabetes mechanisms of certain bariatric surgical procedures.

Obesity and its implications for morbidity and mortality after cholecystectomy: A matched NSQIP analysis

BACKGROUND The risks from super obesity (SO) following cholecystectomy have not been studied. METHODS NSQIP analysis of patients undergoing cholecystectomy from 2005 to 2011. Non-obese (NO) patients (BMI 18.5-30) were matched 1:1 by age, sex, race and comorbidities to morbidly obese (MO) (BMI 35-50), and separately to SO (BMI≥50) individuals. Clavien 4 complications and 30-day mortality were compared. RESULTS 13780 MO and 1410 SO patients were matched to NO patients. Obese patients were more likely to present with chronic (CC) rather than acute cholecystitis (AC). Compared to NO patients, Clavien 4 complications were significantly increased among SO patients overall especially with AC where rate of open surgery was significantly higher. CONCLUSION SO patients have an increased risk of serious morbidity after cholecystectomy especially with AC where rate of open surgery remains high. Aggressive recommendation for cholecystectomy to reduce presentation with AC and increase likelihood for laparoscopic surgery may be beneficial in SO patients.

Tailored surgical treatment of duodenal polyposis in familial adenomatous polyposis syndrome

Background. To review our experience in patients undergoing operative treatment for duodenal polypoisis associated with familial adenomatous polyposis with an emphasis on operative approach and long‐term outcomes. Methods. Duodenal polypoisis associated with familial adenomatous polyposis patients undergoing operative treatment were studied retrospectively excluding patients with preoperative duodenal cancer. Results. Of 767 patients in the database, 63 (8.2%) patients underwent operative treatment: 42 (67%) pancreas‐sparing duodenectomy, 15 (24%) pancreatoduodenectomy, and 6 (9.5%) segmental duodenal resection; the majority for Spigelman stages III and IV polyposis. Overall 9.6% had adenocarcinoma postoperatively (28.6% in the pancreatoduodenectomy group; P = .01). The proportion of Spigelman stages III and IV with cancer were 9.5% and 6.5%, respectively. Pathologic upgrade to cancer in patients with low grade dysplasia and high‐grade dysplasia on preoperative biopsy was 5.7% and 6.7%, respectively (P = .13). At a median follow‐up of 16 years, 7.7% needed a second duodenal polypoisis associated with familial adenomatous polyposis‐related operation. Progression to high grade dysplasia or cancer in the stomach occurred in 15.4% of patients. Median overall survival and recurrence‐free survival was at least 16 years and 15.6 years. No significant group‐based differences were noted on follow‐up. Conclusion. The majority of patients with duodenal polypoisis associated with familial adenomatous polyposis can achieve long‐term, cancer‐free survival with organ‐preserving approaches (pancreas‐sparing‐duodenectomy and segmental‐duodenal‐resection) with survival not dependent on the type of resection.

Postoperative Management of Obesity-Related Diseases

A host of medical conditions and diseases are related to and tend to coexist with obesity. The long-term follow-up and management of the more common of these conditions after weight loss surgery (WLS) are discussed here, with emphasis on the more complicated aspects of treatment that may arise.