Archive for August, 2007

Sodium bicarbonate better than Mucomist to prevent contrast nephropathy

Published at August 24, 2007 in Cardiology and Nephrology. 0 Comments

Here’s a useful little study from the American Heart Journal. Researchers from the Dokuz Eylul University School of Medicine in Izmir, Turkey compared pretreatment with three different regimens to prevent contrast-induced nephropathy: sodium bicarbonate, N-acetylcysteine (commonly known as Mucomist) and saline.

All patients had baseline creatinine greater than 1.2. Two hundred and sixty-four patients were randomized to receive, for six hours before and six hours after angioplasty, either:

  • One hundred cc/hour of saline,
  • 154 mL of 1000-mEq/L sodium bicarbonate added to 846 mL of 5% dextrose in water, or
  • Saline plus Mucormist 600 mg twice daily

The findings:

When we head-to-head compared each treatment group, the incidence of contrast induced nephropathy was significantly lower in the sodium bicarbonate group (4.5%) compared with the sodium chloride group (13.6%, P = .036) and tended to be lower than in the NAC group (12.5%, P = .059)

This is a common and difficult situation - a patient with renal insufficiency who needs cardiac catheterization. You try to avoid doing the cath, because you don’t want to land the patient on dialysis by damaging the kidnies further with a big dose of contrast dye. When you have no choice (working kidnies won’t help the patient much if she dies of a massive heart attack), you would at least like a regimen to minimize the renal damage.

The convention at our hospital has been saline and Mucomist. Perhaps we should consider sodium bicarbonate instead.

Comparison of three regimens to prevent contrast-induced nephropathy

Study shows dramatic health benefit from obesity surgery

Published at August 23, 2007 in Obesity. 2 Comments

The big article in today’s New England Journal is on weight loss surgery. It saves lives. In fact, the benefit is quite dramatic.

The authors studied 9,949 patients who had undergone weight loss surgery, and compared them to a control group of 9,628 severely obese individuals who did not have the surgery.

The findings:

  • Overall mortality decreased by 40% in the patients who had surgery.
  • There were 56% fewer deaths due to coronary disease,
  • 96% fewer deaths due to diabetes
  • and 60% fewer deaths due to cancer.

Long Term Mortality After Gastric Bypass Surgery.pdf

The accompanying editorial warns:

The lowest surgical mortality is seen among surgeons who have performed more than 50 operations and preferably more than 100 operations.

We know that obesity is an increasing epidemic in this country, and we know it’s killing people. The lives saved by obesity surgery is one measure of the mortality attributable to obesity.

Clinically, I would have to say that this study shows bariatric surgery is a good option for morbidly and perhaps even moderately obese individuals. An article in the Voice of San Diego observes that the study:

…should put to rest uncertainties about the benefits and risks of weight-loss surgery and may cause governments and insurers to rethink who should qualify for the procedure, some doctors said.

“It’s going to dispel the notion that bariatric surgery is cosmetic surgery and support the notion that it saves lives,” said Dr. Philip Schauer, director of bariatric surgery at the Cleveland Clinic in Ohio, who had no role in the research.

On a broader level, though, this is a social problem and a preventive health issue. We are grossly overfed in this country. Food processing, distribution and marketing has made food overabundant, cheap, and highly gratifying to consume. We have learned to eat for pleasure rather than for nourishment.

I try to counsel my patients to change their attitudes toward food. We need far less to run our bodies than what we actually eat.

I have started giving as much attention to dietary counseling as I do to tobacco cessation. Obesity causes as many deaths now as smoking.

One good online resource for patients looking for info on healthy eating and weight loss is the National Heart, Lung and Blood Institute Obesity Initiative. You can calculate your body mass index and your risk of weight-related diseases. The site also has information on diet plans, menus and exercise.

If you really want to get serious about healthy eating, you could buy Mark Hyman’s book, “Ultra-metabolism”. Another terrific resource for understanding and shedding the habit of over-consumption is “Hooked! Buddhist writings on greed, desire and the urge to consume”, by Stephanie Kaza.

In the Berkshires, if you are interested in the possibility of weight loss surgery, the guy to see is Andrew Lederman. The program is relatively new, but the patients I’ve sent to him so far are satisfied.