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    <recommendedItem id="20100101_19_466"
                     title="Surgery Trumps Lifestyle Change for Teen Weight Loss (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/Pediatrics/Obesity/tb/18397?impressionId=1265795365385"
                     
      &lt;p&gt;Gastric banding resulted in significantly greater weight loss in obese teens than an intensive lifestyle modification program, a randomized trial showed.&lt;/p&gt;
&lt;p&gt;In the two-year study, 84% of patients in the surgery group lost at least half of their excess weight, compared with 12% who underwent the lifestyle intervention (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Paul O&apos;Brien, MD, of Monash University in Melbourne, Australia, and colleagues.&lt;/p&gt;
&lt;p&gt;None of the teens who had surgery had metabolic syndrome at the end of follow-up, compared with 22% in the control group (&lt;em&gt;P&lt;/em&gt;=0.025), the researchers reported in the Feb. 10 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Although the improvements were substantial, O&apos;Brien and his colleagues stressed that &quot;the gastric banding approach to weight loss is not a quick fix.&quot;&lt;/p&gt;
&lt;p&gt;&quot;For optimal effectiveness,&quot; they wrote, &quot;it requires long-term supportive follow-up by trained health professionals.&quot;&lt;/p&gt;
&lt;p&gt;They also noted that the study demonstrates that lifestyle interventions can be effective for some teens and should remain the first option.&lt;/p&gt;
&lt;p&gt;Surgeons contacted for comment on the study unanimously touted the results as evidence that bariatric surgery can be a safe and effective means of weight loss for obese adolescents, a topic that remains controversial.&lt;/p&gt;
&lt;p&gt;J. Christopher Eagon, MD, a bariatric surgeon at Washington University in St. Louis, noted in an e-mail that the significance of the study lies in the fact that participants were randomized between surgery and medical management of weight.&lt;/p&gt;
&lt;p&gt;&quot;This helps to eliminate biases that may have been present in other studies of the effectiveness of bariatric surgery and should make the case for the benefits of surgery more compelling,&quot; Eagon wrote.&lt;/p&gt;
&lt;p&gt;There are more than five million obese adolescents in the U.S., according to O&apos;Brien and his colleagues, and obesity-related complications, once rare in pediatric populations, are becoming more common.&lt;/p&gt;
&lt;p&gt;Because of the generally disappointing results of lifestyle programs aimed at improving diet, increasing exercise, and modifying unhealthy behaviors, bariatric surgery, widely used in adults, has been explored as a strategy for reducing weight in these patients.&lt;/p&gt;
&lt;p&gt;But no randomized trials of bariatric surgery had been conducted in adolescents.&lt;/p&gt;
&lt;p&gt;So O&apos;Brien&apos;s group randomized 50 obese teens ages 14 to 18 (mean 16.5) to laparoscopic adjustable gastric banding or an intensive, supervised lifestyle modification program.&lt;/p&gt;
&lt;p&gt;The participants all had a body mass index of at least 35 kg/m&lt;sup&gt;2&lt;/sup&gt; and had obesity-related complications, such as hypertension, metabolic syndrome, asthma, back pain, physical limitations, and psychosocial difficulties.&lt;/p&gt;
&lt;p&gt;All had previously failed to lose weight through lifestyle changes.&lt;/p&gt;
&lt;p&gt;Before the study began, prospective participants attended a two-month program teaching them about healthy eating and the importance of physical activity.&lt;/p&gt;
&lt;p&gt;Those randomized to the lifestyle intervention were on a diet of 800 to 2,000 calories a day, and were instructed to increase activity and decrease sedentary behavior at regular visits with a physician, dietitian, exercise coordinator, nurse, and sports medicine physician. The program included six weeks with a personal trainer.&lt;/p&gt;
&lt;p&gt;Teens in the surgery group were given instructions on correct eating and exercising at regular visits.&lt;/p&gt;
&lt;p&gt;Through two years, all but one of the teens in the surgery group completed the study; 18 of 25 in the lifestyle group completed.&lt;/p&gt;
&lt;p&gt;The mean weight loss was significantly greater in the surgery group (76.3 pounds versus 6.6), which equated to a significantly greater percentage of excess weight lost (78.8% versus 13.2%).&lt;/p&gt;
&lt;p&gt;The mean decrease in BMI was 12.7 kg/m&lt;sup&gt;2&lt;/sup&gt; in the surgery group and 1.3 kg/m&lt;sup&gt;2&lt;/sup&gt; in the lifestyle modification group.&lt;/p&gt;
&lt;p&gt;All differences were significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001.&lt;/p&gt;
&lt;p&gt;Insulin sensitivity improved in both groups, but to a larger extent in the surgery group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Quality of life was also improved in the surgery group.&lt;/p&gt;
&lt;p&gt;Overall, adverse events occurred at similar rates in the surgery (48%) and lifestyle modification (44%) groups.&lt;/p&gt;
&lt;p&gt;There were no perioperative adverse events in the surgery group, but seven patients required revisional procedures during follow-up, for proximal pouch dilatation or tubing injury.&lt;/p&gt;
&lt;p&gt;The researchers said eating small meals slowly is an important way to avoid these problems.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Edward Livingston, MD, a surgeon at the University of Texas Southwestern Medical Center in Dallas, said the high rate of revisional procedures is significant because the study authors &quot;are among the most experienced group in the world with these operations, suggesting that these complication rates will probably be higher in actual community practice.&quot;&lt;/p&gt;
&lt;p&gt;Added Jonathan Schoen, MD, a bariatric surgeon at the University of Colorado Hospital in Denver, in an e-mail: &quot;One thing to keep in mind is that the results they get in Australia with the band are the best in the world and are not uniformly reproducible.&quot;&lt;/p&gt;
&lt;p&gt;In addition to the uncertain generalizability to other settings, the researchers said the study may be limited by its length, which may not be long enough to assess outcomes from the surgery over time.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by a grant from the National Health and Medical Research Council. The laparoscopic adjustable gastric bands used in the study were provided by the manufacturer, Allergan. The Center for Obesity Research and Education receives an unrestricted research support grant from Allergan.&lt;/p&gt;&lt;p&gt;O&apos;Brien did not make any financial disclosures. One of his co-authors reported having relationships with Allergan, Bariatric Advantage, Scientific Intake, SP Health Co., Optifast, Abbott Australasia, Eli Lilly Australia, Merck Sharp &amp;amp; Dohme Australia, Nestle Australia, and Roche Products Australia.&lt;/p&gt;&lt;p&gt;Livingston did not make any financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_182"
                     title="Kids with Bionic Ears Have Trouble Controlling Their Voices (CME/CE)"
                     score="-0.003"
                     href="http://www.medpagetoday.com/Surgery/Otolaryngology/tb/18018?impressionId=1265795365385"
                     
      Although children who are deaf may be able to hear when fitted with cochlear implants in both ears, they have a more difficult time controlling their voices than kids with normal hearing, a single-center study showed.&lt;br&gt;
&lt;br&gt;Children with bilateral implants had deficits in controlling both the pitch and loudness of their voices when making a sustained &quot;ahh&quot; sound (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for both), according to Karen Gordon, PhD, of the Hospital for Sick Children in Toronto, and colleagues.&lt;br&gt;
&lt;br&gt;Pitch control, however, improved significantly the longer the implants were used (&lt;em&gt;P&lt;/em&gt;=0.03), the researchers reported in the January issue of &lt;em&gt;Archives of Otolaryngology  --  Head &amp;amp; Neck Surgery.&lt;/em&gt;&lt;br&gt;
&lt;br&gt;&quot;The more experience one has with hearing, the better able to produce voice they have,&quot; Gordon said in an interview.&lt;br&gt;
&lt;br&gt;The number of children who receive cochlear implants for deafness has been increasing steadily over the past two decades, and it is now common, she said.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;The implants directly stimulate the auditory nerve to compensate for a nonfunctioning cochlea, regardless of the reason for the deafness.&lt;/p&gt;
&lt;p&gt;At the Hospital for Sick Children, a multidisciplinary team  --  including an audiologist, otolaryngologist, social worker, speech language pathologist, and auditory verbal therapist  --  assesses each child&apos;s suitability for the implants.&lt;/p&gt;
&lt;p&gt;&quot;We really look at the child, their candidacy from a hearing point of view, their expectations for what the implant can do for them, whether they&apos;re up for the surgery, and whether they&apos;re up for the therapy that&apos;s involved afterward,&quot; Gordon said.&lt;/p&gt;
&lt;p&gt;Although children with cochlear implants are able to hear, it&apos;s unclear exactly what their perception of sound is, she said. All must go through therapy lasting about two years to be able to interpret what they&apos;re hearing.&lt;/p&gt;
&lt;p&gt;However, the voicing of children with the implants compared with that of kids with normal hearing has not been extensively studied.&lt;/p&gt;
&lt;p&gt;So Gordon and her colleagues evaluated how 27 children with bilateral implants  --  ages 3 to 15  --  were able to control their voices, finding poorer control of long-term frequency perturbation (pitch) and long-term amplitude perturbation (loudness) compared with those with normal hearing.&lt;/p&gt;
&lt;p&gt;&quot;Despite the incredible opportunities that cochlear implants provide for auditory and linguistic development, abnormalities in acoustic voice outcomes persist,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;However, through a four-month follow-up, pitch control  --  but not loudness control  --  improved significantly with increased implant use.&lt;/p&gt;
&lt;p&gt;&quot;This result underlines the importance of early recognition and treatment of children with hearing loss to provide auditory experience as soon as possible,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;However, the use of cochlear implants is not free of complications, according to another study in the same issue of the journal by Natalie Loundon, MD, of the H&amp;#244;pital d&apos;Enfants Armand-Trousseau in Paris, and colleagues.&lt;/p&gt;
&lt;p&gt;Among 434 children younger than 16 who received the devices, 9.9% had complications, nearly two-thirds of which occurred more than eight days after implantation (mean 2.2 years).&lt;/p&gt;
&lt;p&gt;Major complications included severe cutaneous infections or hematoma, magnet displacement, meningitis, cholesteatoma, cerebrospinal fluid leak, and electrode misplacement.&lt;/p&gt;
&lt;p&gt;Minor complications included vertigo, soft-tissue infection, persistent otitis media, and facial nerve palsy.&lt;/p&gt;
&lt;p&gt;A large minority of those with complications (30.2%) required reimplantation.&lt;/p&gt;
&lt;p&gt;Trauma to the mastoid area and inner ear malformations were risk factors for delayed major complications and early minor complications, respectively (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for both).&lt;/p&gt;
&lt;p&gt;Age at implantation was not associated with complication risk.&lt;/p&gt;
&lt;p&gt;&quot;The finding of complications several years after surgery highlights the need for long-term medical follow-up in this population and the importance of repeatedly providing information to the patients and their family,&quot; Loundon and colleagues wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;None of the authors of either of the studies made any financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_183"
                     title="Gastric Bypass Extends Life for Most Patients (CME/CE)"
                     score="-0.003"
                     href="http://www.medpagetoday.com/PrimaryCare/Obesity/tb/18020?impressionId=1265795365385"
                     
      &lt;p&gt;For most patients in most categories, bariatric surgery increases life expectancy, according to a new mathematical model.&lt;/p&gt;
&lt;p&gt;Only when short-term mortality following bariatric surgery is expected to be high or the likelihood of success is low will the procedure fail to improve life expectancy, researchers reported in the January &lt;em&gt;Archives of Surgery&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Computer modeling predicted that a hypothetical &quot;base case&quot; patient  --  a 42-year-old woman with a body mass index of 45  --  would gain 2.95 years of additional survival following bariatric surgery, according to Daniel P. Schauer, MD, of the University of Cincinnati, and colleagues.&lt;/p&gt;
&lt;p&gt;Surgery failed to be beneficial in the model only when 30-day mortality reached 9.5% or the likelihood that surgery would not add life-years was 2% or less, they found.&lt;/p&gt;
&lt;p&gt;Baseline 30-day mortality in the model was 0.2%, and the baseline efficacy of surgery in extending life expectancy was 53%.&lt;/p&gt;
&lt;p&gt;&quot;While not all patients are guaranteed a good outcome, our model indicates that gastric bypass increases life expectancy for most patient subgroups,&quot; they concluded.&lt;/p&gt;
&lt;p&gt;Their analysis was based on a Markov decision model using published data to estimate 30-day mortality following bariatric surgery and the efficacy of surgery in reducing long-term death rates.&lt;/p&gt;
&lt;p&gt;The latter had two components: reduction in excess mortality associated with obesity, and research data on long-term mortality following bariatric surgery.&lt;/p&gt;
&lt;p&gt;Excess mortality estimates came from National Health Interview Survey data on some 400,000 participants from 1991 to 1996 linked to the National Death Index. Inputs on surgery efficacy were derived from a 2007 study of nearly 8,000 patients who had undergone gastric bypass and the same number of medically treated or untreated obese controls.&lt;/p&gt;
&lt;p&gt;That study found that the procedure cut death rates by half during about seven years of follow-up. (See &lt;a href=&quot;http://www.medpagetoday.com/PrimaryCare/Obesity/6480&quot; mce_href=&quot;http://www.medpagetoday.com/PrimaryCare/Obesity/6480&quot; target=&quot;_blank&quot;&gt;Missing Link Found: Bariatric Surgery Reduces Mortality&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Schauer and colleagues obtained rates of inhospital mortality following bariatric surgery from the 2005 National Inpatient Survey, then multiplied them by three to estimate 30-day mortality.&lt;/p&gt;
&lt;p&gt;The researchers explained that according to earlier research, inhospital death rates typically underestimate 30-day mortality by a factor of two to three.&lt;/p&gt;
&lt;p&gt;Their threefold correction factor represents &quot;a conservative estimate that biases the model against gastric bypass surgery,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Schauer and colleagues tested this correction factor and other aspects of the model in sensitivity analyses.&lt;/p&gt;
&lt;p&gt;The biggest gains in life expectancy occurred in younger women with relatively high BMI values, the model showed.&lt;/p&gt;
&lt;p&gt;The age effect was less important than BMI at the time of surgery. A 35-year-old woman with BMI of 45 would gain about 3.2 years of extra life, whereas at 55, a similarly obese woman would gain about 2.5 extra years.&lt;/p&gt;
&lt;p&gt;But a 35-year-old woman with BMI of 55 could expect to live five more years with surgery, the model indicated.&lt;/p&gt;
&lt;p&gt;Men in general derived less survival benefit from bariatric surgery, particularly with advancing age at the time of the procedure.&lt;/p&gt;
&lt;p&gt;At 35, the difference in life expectancy gained was roughly 10%, but by age 75 it had grown to about 50%.&lt;/p&gt;
&lt;p&gt;The sensitivity analyses found that relatively large changes in most parameters used in the model did not affect the overall results substantially.&lt;/p&gt;
&lt;p&gt;The effect of 30-day mortality on whether or not surgery was beneficial for long-term survival was related to BMI and gender.&lt;/p&gt;
&lt;p&gt;For women with a BMI of 40, 30-day mortality of more than 5% would mean surgery was not helpful, but short-term mortality had to exceed 15% for surgery not to be preferable for those with BMI of 55 or more. These thresholds were about 10% higher for men.&lt;/p&gt;
&lt;p&gt;The efficacy of surgery in reducing mortality was less important for older men, the analysis also showed. A 75-year-man with a BMI of 35 could expect only a very slight gain in life span  --  perhaps one or two months.&lt;/p&gt;
&lt;p&gt;&quot;Younger patients have lower surgical risk and more time over which to realize the benefits of surgery. For older patients, the gain is smaller, and for some, gastric bypass surgery will decrease life expectancy,&quot; Schauer and colleagues wrote.&lt;/p&gt;
&lt;p&gt;However, they identified several potentially serious limitations to the analysis.&lt;/p&gt;
&lt;p&gt;The study of long-term mortality following bariatric surgery was conducted at a single center and was not randomized. Additionally, long-term complications, such as need for repeat surgery, were not addressed in the model. Certain other risks that might be heightened after bariatric surgery were excluded as well, and quality of life was not modeled.&lt;/p&gt;
&lt;p&gt;&quot;The decision analysis presented here is a step forward in understanding optimal patient selection but also highlights some of the areas for which better data are needed,&quot; the researchers wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The National Institute of Diabetes and Digestive and Kidney Diseases funded the study.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
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                     title="ISET: Adult Congenital Heart Re-Repair Highlighted"
                     score="-0.005"
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