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Second Opinion

Readers discuss depression, bugs, drugs and natural orifice surgery.

Spring 2009

Depression’s Open Door

Imperiled Partners” (Fall 2008), in which the author recounts her struggle living in the shadow of her husband’s depression, is both evocative and sad. The notion that depression is simply biological, with no context, no connection to an inner emotional life and no possibility of deepening relationships with loved ones, leads to the isolation your writer describes.

Feelings—even sad and despairing ones—are not anyone’s fault; they are (or can be) gateways into people’s emotional lives. Depression can be an opportunity for engagement. Though medication can help alleviate the intensity of painful feelings, it can also free the individual to communicate with his or her partner about the individual and shared meaning of their lives, their developmental transitions and their interpersonal world.

Edward R. Shapiro // Medical Director/CEO, Austen Riggs Center, Stockbridge, Mass.

Antibiotic Overload

While “The War on Superbugs” (Fall 2008) described how researchers are trying to thwart antibiotic resistance, there’s another crucial aspect to the fight: preventing resistance in the first place. Antibiotic stewardship—monitoring antibiotic prescriptions for appropriate use or dosing—is a focus at VHA Inc., a national health care alliance that works with hospitals to improve clinical and operational performance. The VHA Bugs and Drugs Program analyzes a hospital’s antibiotic utilization data, then recommends antibiotic stewardship strategies. Hunterdon Medical Center, a 178-bed community hospital in Flemington, N.J., piloted this program in 2006. The hospital significantly improved antibiotic effectiveness against strains of E. coli, K. pneumoniae, P. aeruginosa and S. aureus. In the end, that can mean better clinical outcomes for hospitalized patients and may even affect the overall cost of care.

Vivien Ng // Director, Performance Improvement, VHA East Coast, Trevose, Pa.

Bypass by Mouth

I’d like to offer updates to two stories—“Bypassing Diabetes” (Fall 2008), in which you describe the use of gastric bypass surgery as a cure for type 2 diabetes, and “Down the Hatch” (Spring 2006), which presents a novel surgical approach of reaching internal organs via the mouth or other orifices, called natural orifice translumenal endoscopic surgery (NOTES).

Our team at Columbia University Medical Center recently performed a weight-loss surgery called TOGA (for transoral gastroplasty) that uses the natural orifice method. Though still highly experimental, the procedure is the latest harbinger of NOTES’s bright future.

Several hundred NOTES procedures, as well as hybrid operations (in which one or two abdominal incisions are made for laparoscopic instruments) have been performed so far, from such basic operations as gall bladder removal to more complex procedures, such as liver resection. The biggest challenge now lies in adapting limited technology to the tasks required to perform surgery through a flexible scope. The ultimate goal is to make surgery as simple and painless as a colonoscopy, with no abdominal incision required, and patients discharged hours after the procedure. If this promise can be realized, it will make surgical intervention more palatable for patients, many of whom shun interventions, including gastric bypass.

Marc Bessler // Director, Minimal Access Surgery Center, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York City

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