Increases in morbid obesity in the USA: 2000-2005

Factors Associated With the Ability of US Nursing Homes to Accept Residents With Severe Obesity

OBJECTIVES

Severe obesity in nursing home (NH) residents is associated with specialized care needs, limited mobility, and challenges in daily living. The COVID-19 pandemic strained NH resources and exacerbated staffing shortages. This study aimed to assess the ability of US NHs to accept and care for residents with severe obesity post-COVID, as well as associated NH factors.

DESIGN

Cross-sectional nationwide survey of NH administrators (2021-2022).

SETTING AND PARTICIPANTS

290 NHs from a national sample (n = 224) and a targeted sample in Massachusetts and New Jersey (n = 66).

METHODS

A survey designed to assess how NHs approach admitting and caring for people with severe obesity before and after COVID was fielded from 2021 to 2022. Responses were linked to facility information from the Certification and Survey Provider Enhanced Reports, Minimum Data Set, Nursing Home Compare, Area Health Resources File, and US Diabetes Surveillance System. Multivariable logistic regression was used to assess the effect of organizational and survey response variables.

RESULTS

Of the 2503 surveys sent to US NHs, 1923 were sent to the national NH stratified sample, and 580 were sent to the MA/NJ sample. Overall, 12% (301 of 2503) of NHs surveyed responded. The response rates were similar between the 2 samples. Of 290 NHs with complete data, 34% reported being unlikely to accept residents with severe obesity after COVID-19, compared with 25% before the pandemic (P < .001). The main barriers to acceptance were staffing shortages and difficulties meeting equipment and space needs. NHs with higher proportions of Black residents were more likely to admit individuals with severe obesity.

CONCLUSIONS AND IMPLICATIONS

The decline in acceptance of residents with severe obesity during and after COVID-19 highlights potential challenges that this population faces in accessing care. Our results also raise concerns that an intersection of disparities may exist in Black patients with severe obesity.

The effect of significant weight loss after bariatric surgery on echocardiographic indices: an observational study focusing on left ventricular deformation by 2D speckle echocardiography and right ventricular size

BACKGROUND

Obesity is a known risk factor for atherosclerosis and cardiac disease.

HYPOTHESIS

This study evaluated the effect of significant weight loss following bariatric surgery on myocardial deformation indices and right ventricular size (RV). This was a prospective cohort study. Morbid obese patients scheduled for bariatric surgery from July 2017 to February 2018 at Firoozgar Hospital were included in our study and referred for transthoracic echocardiography at Rajaie Cardiovascular Medical and Research Center.

RESULTS

Thirty-four patients entered the study. The absolute value of global longitudinal strain (GLS) at baseline, 3, and 6 months after surgery was 17.42 ± 2.94%, 18.24 ± 3.09%, and 19.52 ± 2.78%, respectively, with a statistically significant difference from baseline to after six months (P value < 0.001). The absolute value of global circumferential strain (GCS) at baseline, 3, and 6 months after surgery was 20.14 ± 4.22%, 23.32 ± 4.66%, and 24.53 ± 4.52%, respectively, with statistically significant changes (P value < 0.001) from baseline to three months and from baseline to six months and no significant difference from three months to six months. A significant decrease was reported in mechanical dispersion of circumferential strain (38.05 ± 23.81-23.37 ± 20.86 ms, P value = 0.006) 6 months after surgery. Right ventricular size three- and six-month post-surgery showed a significant decrease relative to baseline echocardiography.

CONCLUSIONS

Bariatric surgery could enhance cardiac function, as proven by 2D speckle echocardiography. Changes in RV size may be related to weight loss and should be considered when assessing patients who have undergone bariatric surgery.

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Narrative Review and Consensus Recommendations for the Use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange in Modified Electroconvulsive Therapy

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is a safe, effective, and novel technique that is currently being used in electroconvulsive therapy (ECT). This study aimed to summarize the clinical practices of THRIVE use in ECT to aid physicians and institutions in implementing the best practice guidelines for ECT. Thus, we reviewed the current literature and presented our consensus on the application of THRIVE in ECT in daily clinical practice. This consensus provides information regarding THRIVE use in ECT, including its safety, effectiveness, procedures, precautions, special case management, and application in special populations. Moreover, it guides the standardized use of THRIVE in ECT.

vNOTES (vaginal natural orifice transluminal surgery) gynecologic procedures in morbidly and super-morbidly obese women: five year experience

PURPOSE

To analyze our experience with vNOTES gynecologic procedures in women with morbid and super morbid obesity to determine feasibility and compare outcomes with standard minimally invasive techniques.

METHODS

Gynecologic procedures performed by three surgeons on women with a body mass index (BMI) ≥ 40 kg/m2 from 2017 to 2023. A subset of women with a BMI ≥ 50 kg/m2 was also analyzed.

RESULTS

103 women with a BMI ≥ 40 kg/m2 were identified (Class IV), 19 of whom had a BMI ≥ 50 kg/m2 (Class V). For the entire population the mean BMI was 45.7 kg/m2 (40-62). 29 women were nulliparous and 23 had at least one prior cesarean delivery. 51 had no prior abdominal surgery. The procedures performed were hysterectomy and removal of adnexae in 77 patients, hysterectomy alone in six, adnexal surgery alone in nine, and hysterectomy with adnexectomy and lymph nodes in five. Two surgeries were converted to laparoscopy and five to laparotomy. Average surgical time was 87 min (30-232). Average blood loss was 82 mL (10-400). Mean uterine weight was 206 g (29-2890). 53 procedures were performed as outpatient, 44 had overnight observation, four had a length of stay of 2 days, one each for 4 days and 5 days. The laparoscopies occurred in one patient with an obliterated cul-de-sac and in one patient for lymph node removal. The laparotomies occurred for adnexal adhesions in one, bleeding in two, a cystotomy in one requiring urology consultation, and an obliterated cul-de-sac One patient developed a postoperative vaginal cuff hematoma not requiring intervention.

CONCLUSION

vNOTES gynecologic procedures are feasible in this high-risk population and may result in shorter recovery times and fewer complications than standard laparoscopy or transvaginal surgery. What does this study add to the clinical work: VNOTES approach is feasible in morbidly obese women and may have distinct advantages over conventional laparoscopic, vaginal or open techniques.

Analyzing the Impact of Social and Psychiatric Factors in Patients Who Undergo Body Contouring Procedures

BACKGROUND

As the prevalence of obesity increases, the number of patients seeking body contouring procedures after bariatric surgery for massive weight loss is increasing. Although the positive impact of bariatric surgery on physical and emotional health is well-described, few studies have reported on the psychosocial well-being of patients undergoing body contouring procedures. Psychosocial well-being can impact patient satisfaction and maintenance of weight loss, and is an important area to study.

OBJECTIVE

The aim of this study was to characterize social and psychiatric factors of patients undergoing body contouring surgery, and to evaluate their impact on maintenance of weight loss.

METHODS

A retrospective review was performed of patients who presented to a single institution for body contouring procedures between 2002 and 2018. Demographic details, medical history, psychosocial support, and operative details were collected. Univariate analysis and multinomial logistic regressions were performed with R statistical software (version 1.3.1093).

RESULTS

A total of 1187 patients underwent at least 1 body contouring procedure during the study time frame. Mean BMI at presentation was 31.21 ± 10.49 kg/m2. Patients diagnosed with obesity at age 18 or older had significantly greater odds of suffering from generalized anxiety disorder (odds ratio [OR] 1.08 [95% CI, 1.02-1.15], P = .008). Patients with spousal support had 1.93 times higher odds of having maintained postbariatric weight loss at their 6-month follow-up (OR 1.93 [95% CI, 1.84-2.01], P = .028).

CONCLUSIONS

Social support and age of obesity diagnosis impact psychological well-being and maintenance of weight loss following body contouring procedures.

LEVEL OF EVIDENCE: 3

Long-term Follow-up 15 Years After Duodenal Switch or Gastric Bypass for Super Obesity: a Randomized Controlled Trial

BACKGROUND

In super obesity, Roux-en-Y gastric bypass (RYGB) may be insufficient why some surgeons advocate biliopancreatic diversion with duodenal switch (BPD/DS), a more malabsorptive procedure. There is a paucity of evidence regarding results beyond 10 years, especially after BPD/DS. The aim of this randomized controlled trial was to compare the long-term outcome of BPD/DS, and RYGB in patients with super obesity, i.e., body mass index (BMI) > 50 kg/m2.

METHODS

This is a 13- to 17-year follow-up study of a single-center, single-blinded randomized trial in which 47 patients (BMI > 48 and eligible for bariatric surgery) were randomized 1:1 to BPD/DS and RYGB (25 men, 24 BPD/DS, 39.1 ± 9.9 years, BMI 54.5 ± 6.1 kg/m2). The primary outcome was weight loss. The study was financed by Swedish governmental funding of clinical research (ALF).

TRIAL REGISTRATION NUMBER

ISRCTN10940791.

RESULTS

Thirty-four (18 BPD/DS) of the living 42 patients (81.0%) participated. BPD/DS resulted in higher BMI loss (20.4 ± 7.9 vs. 12.4 ± 8.6, p = .008) and higher percent of total body weight loss (37.5% ± 12.2 vs. 22.8% ± 14.8, p = .004). BPD/DS was associated with lower fasting glucose, glycated hemoglobin (HbA1c), and low-density lipoprotein (LDL) as well as lower hemoglobin. Adverse events were more common after BPD/DS (2.7 vs. 0.9 per patient, p = .004). The global assessment tool BAROS (Bariatric Analysis and Reporting Outcome System) demonstrated superior scores for BPD/DS (p = .047).

CONCLUSION

When compared to RYGB, BPD/DS results in superior weight loss and metabolic control as well as superior BAROS score, however, at the cost of more adverse events.

A Systematic Review and Meta-Analysis of Vitamin D Status of Patients with Severe Obesity in Various Regions Worldwide

INTRODUCTION

Managing nutritional deficiencies is an essential component in the treatment of severe obesity. Vitamin D deficiency is often reported in investigations in severely obese cohorts. However, no prior study has summarized findings on this topic. Consequently, the aim of this systematic review and meta-analysis was to investigate the 25-hydroxyvitamin D [25(OH)D] status in individuals with severe obesity in different regions worldwide. We also evaluated levels of calcium, parathyroid hormone (PTH), and magnesium as secondary outcome measures.

METHODS

We searched Medline, PubMed, Scopus, the Cochrane Library, and EMBASE for relevant observational studies published in English from 2009 to October 2021. The heterogeneity index among the studies was determined using the Cochran (Q) and I2 tests. Based on the heterogeneity results, the random-effect model was applied to estimate the prevalence of vitamin D deficiency.

RESULTS

We identified 109 eligible observational studies. Overall, 59.44% of patients had vitamin D deficiency [25(OH)D <20 ng/mL], whereas 26.95% had vitamin D insufficiency [25(OH)D 20-30 ng/mL]. Moreover, the mean 25(OH)D level was 18.65 ng/mL in 96 studies. The pooled mean estimate of the serum calcium, PTH, and magnesium was 9.26 mg/dL (95% confidence interval [CI]: 9.19-9.32, I2 = 99.7%, p < 0.001), 59.24 pg/mL (95% CI: 54.98, 63.51, I2 = 99.7%, p < 0.001), and 0.91 mg/dL (95% CI: 0.84, 0.98, I2 = 100.0%, p < 0.001), respectively. The results of the subgroup analysis indicated that the mean estimates of 25(OH)D were highest in North America (21.71 ng/mL [19.69, 23.74], [I2 = 97.2%, p < 0.001]) and lowest in Southeast Asia (14.93 ng/mL [14.54, 15.33], [I2 = 0.0%, p = 0.778]).

CONCLUSION

The results obtained showed a significant prevalence of vitamin D deficiency among severely obese individuals in various geographical regions, whereas the highest and lowest mean estimates were reported for North America and Southeast Asia, respectively.

The Effect of Obesity on Distal Radius Fractures: An Analysis from the NSQIP Database

The rate and severity of obesity has risen over the past 40 years, and class III (formerly morbid) obesity presents additional sequelae. The effect of obesity on the incidence and recovery of hand and wrist fractures remains unclear. We sought to quantify the relationship between class III obesity and postoperative distal radius fracture (DRF) complications.

Methods

We performed a retrospective analysis of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database for surgical DRF patients more than 50 years old from 2015 to 2020. We then stratified patients into class III obese (BMI > 40) and compared the rates of postoperative complications to a control group with BMI less than 40.

Results

We included 10,022 patients (570 class III obese vs. 9,452 not class III obese). Patients with class III obesity had significantly increased odds of experiencing any complication (OR 1.906, p<0.001), adverse discharge (OR 2.618, p<0.001), delayed hospital stay of longer than three days (OR 1.91, p<0.001), and longer than seven days (OR 2.943, p<0.001) than controls. They also had increased odds of unplanned reoperation (OR 2.138, p = 0.026) and readmission (OR 2.814, p < 0.001) than non-class III obese patients. Class III obese patients had a significantly longer average operation time (79.5 min vs. 72.2 min, p < 0.001). They also spent more time in the hospital postoperatively (0.86 days vs. 0.57 days, p = 0.001).

Conclusion

Class III obese patients undergoing DRF repair are more likely to experience postoperative complications than non-class III obese patients.

Long-term evaluation of patients with BMI = 50kg/m2 who underwent Bariatric Surgery

PURPOSE

to determine the risks and benefits of bariatric surgery in patients with super obesity (SO) in comparison with obesity grades II and III.

METHODS

retrospective cohort that included a study group of 178 patients with SO and a control group of 181 patients with BMI 35-49.9Kg/m2. The groups were formed in a 1:1 nearest neighbor matching. The main variables were pre- and postoperative BMI and comorbidities, occurrence of severe postoperative complications, bowel obstruction, marginal ulcer, fistulae and 30-day death, besides the necessity of emergency room (ER) admission and abdominal computed tomography (CT) scans in the postoperative period due to acute abdomen.

RESULTS

the study group comprised 74.0% of women while the control group had 56.7%. The mean follow-up time was similar between both groups (5.48 x 6.09 years, p=0.216). There was no statistically significant difference on the prevalence of hypertension and T2D between the groups according to the surgical technique. All deaths occurred in the Study group (BMI = 50kg/m2) who underwent RYGB. There was no difference between the groups regarding the occurrence of severe complications. Data on ER admissions and the need for abdominal CT to investigate postoperative abdominal pain did not show statistically significant difference between the groups.

CONCLUSION

despite the high risk related to bariatric surgery in patients with SO, the benefits related to the remission of comorbidities are significant; although being lower than those found in patients with milder grades of obesity.

Bariatric surgery and weight loss in the short- and long-term: Evidence from NHANES 2015-2018

The present study aimed to examine short- and long-term weight change in a nationally representative sample of US adults who reportedly underwent bariatric surgery. Individuals aged 20-64 at survey from the US National Health and Nutrition Examination Survey 2015-2018 were included in the analyses (n = 6776). The primary comparison groups include 62 participants who underwent bariatric surgery, 1531 eligible but did not receive surgery, and 5183 not eligible for bariatric surgery. After adjusting for demographic characteristics and comorbidity, adults who reported receiving bariatric surgery were 5.0 times (4.0-6.0) more likely to achieve at least 20% weight loss from maximum weight relative to those who were eligible but reported no surgery. The likelihood appeared to be higher when surgery was performed within 10 years (short-term, PR 5.5, 95% CI: 4.0, 7.0) relative to surgeries that were performed for 10 or more years (long-term, PR 3.6, 95% CI: 2.0, 5.3). In this nationally representative sample of US adults, respondents who received bariatric surgery achieved substantial and significant weight loss compared with those who were eligible and did not receive bariatric surgery. Weight loss appeared to be most apparent in the short term and persisted over the long term.

The Optimal Cesarean Skin Incision in Patients with Super Obesity

OBJECTIVE

This study aimed to evaluate if supraumbilical midline vertical incision performed in patients with a hanging pannus (umbilicus at the level of the pubic bone) is a reasonable alternative to the Pfannenstiel in patients with body mass index (BMI) ≥ 50 kg/m² undergoing cesarean delivery.

STUDY DESIGN

Retrospective cohort study in patients with BMI ≥ 50 kg/m² undergoing cesarean delivery at a single center from 2016 to 2020. Study groups were Pfannenstiel's versus supraumbilical vertical skin incision. If patients had a hanging pannus (umbilicus at the level of the pubic bone), vertical incisions were performed. Otherwise, Pfannenstiel's incision was performed. Decision for the incision was made prospectively. Primary outcome was a composite of need for blood transfusion, presence of immediate surgical complications, and presence of delayed surgical complications. Secondary outcomes included the individual components of the primary outcome, the median surgical blood loss, total operative time, time from skin incision to delivery of neonate, hysterotomy type, and neonatal outcomes. MedCalc 19.5.1 was used for analysis.

RESULTS

A total of 103 patients with BMI ≥50 kg/m² were included. Of those, 68 (66%) had Pfannenstiel's and 35 (34%) had supraumbilical vertical incisions. There was no statistically significant difference in the incidence of the primary outcome (12 vs. 11%, p = 0.96). There was neither significant difference in immediate or delayed postoperative complications nor in neonatal outcomes. However, patients in the vertical midline incision group were more likely to have a classical hysterotomy (52%) compared with the Pfannenstiel group (6%; p < 0.05), increased overall median surgical blood loss (1,000 vs. 835 mL, p < 0.05), and increased total surgical time by a median of 30 minutes (p < 0.05).

CONCLUSION

In patients with super obesity and hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and implications in future pregnancies.

KEY POINTS

· Patients with BMI >50 kg/m2 were allocated to different incision types based on subcutaneous fat distribution pattern. If umbilicus was at level of pubic bone, supraumbilical vertical skin incision was made. · There were no significant differences between Pfannenstiel's and supraumbilical vertical incisions in terms of the composite outcome and immediate or delayed postoperative complications and neonatal outcomes.. · In patients with a hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and subsequent implications in future pregnancies..

Exercise Training Program Improves Subjective Sleep Quality and Physical Fitness in Severely Obese Bad Sleepers

BACKGROUND

Sleep quality is an important modulator of neuroendocrine function, as sleep problems are related to metabolic and endocrine alterations.

OBJECTIVE

The main objective was to determine the effects of an exercise training program on the sleep quality of severely obese patients with sleep problems. The secondary objective was to determine the relationship between fitness and anthropometric parameters with sleep quality scores.

METHODS

Thirty severely obese patients participated in 16 weeks of PA intervention (age: 39.30 ± 11.62 y, BMI: 42.75 ± 5.27 kg/m²). Subjective sleep quality, anthropometric parameters, and fitness (i.e., handgrip strength and cardiorespiratory fitness) were measured.

RESULTS

Two groups were defined as good sleepers (n = 15, 38.06 ± 12.26, men = 1) and bad sleepers (n = 15, 40.53 ± 11.23, men = 3). The good sleeper group reported improvement in cardiorespiratory fitness (61.33 ± 68.75 m vs. 635.33 ± 98.91 m, p = 0.003) and handgrip strength (29.63 ± 9.29 kg vs. 31.86 ± 7.17 kg, p = 0.049). The bad sleeper group improved their cardiorespiratory fitness (472.66 ± 99.7 m vs. 611.33 ± 148.75 m, p = 0.001). In terms of sleep quality dimensions, the bad sleeper group improved their subjective sleep quality (p < 0.001), sleep latency (p = 0.045), sleep duration (p = 0.031), and habitual sleep efficiency (p = 0.015). Comparing the changes in both groups (∆), there were differences in subjective sleep quality scores (∆ = 2.23 vs. ∆ = -3.90, p = 0.002), where 86.6% of the bad sleeper group improved sleep quality (p = 0.030). An increase in handgrip strength was correlated to improving sleep quality scores (r = -0.49, p = 0.050).

CONCLUSIONS

Severely obese bad sleepers improved their subjective sleep quality, the components of sleep, and cardiorespiratory fitness through an exercise training program. Improvement in subjective sleep quality was linked to an increase in handgrip strength.

The Social Distance Impacts from COVID-19 Pandemic on the Development of Two Orders of a Concurrent Training Programme for Morbidly Obese Patients

BACKGROUND

Although there is relevant information regarding the consequences of the coronavirus SARS-CoV-2 (COVID-19), little is known about the impact of the imposed social confinement (at home) on the development of exercise training programmes in populations with morbid obesity.

AIM

To describe the effects of the imposed COVID-19 confinement on the cardiometabolic health benefits acquired through a concurrent training programme that started before the pandemic in populations with morbid obesity.

METHODS

This was an experimental randomized clinical study, in which sedentary morbidly obese women were assigned 1:1 to a high-intensity interval training (HIIT) plus resistance training (RT) group (HIIT + RT; n = 11; BMI 42.1 ± 6.6) or to the same exercise dose, but in different order group of RT plus HIIT group (RT + HIIT; n = 7; BMI 47.5 ± 8.4). Both groups undertook two sessions/week. When COVID-19 confinement at home started, a post-test was applied in January 2020 (Post1) and after 20 months (Post2). The main outcomes were waist circumference (WC), systolic (SBP) and diastolic blood pressure (DBP), high-density lipids (HDL-c), triglycerides (Tg), and fasting plasma glucose (FPG).

RESULTS

In the HIIT + RT group, the WC showed significant increases from Post1 to Post2 (Δ + 3.1 cm, p = 0.035); in the RT + HIIT group, it decreased from Post1 to Post2 (Δ - 4.8 cm, p = 0.028). In the HIIT + RT group, SBP showed significant increases from Post1 to Post2 (Δ + 6.2 mmHg, p = 0.041); the RT + HIIT group decreased SBP from Pre0 to Post1 (Δ - 7.2 mmHg, p = 0.026) and increased DBP from Pre0 to Post1 (Δ + 8.1 mmHg, p = 0.015). Tg in the HIIT + RT group decreased from Pre0 to Post1 (Δ - 40.1 mg/dL, p = 0.023) but increased from Post1 to Post2 (Δ + 86.3 mg/dL, p < 0.0001).

CONCLUSIONS

The COVID-19 social confinement worsened metabolic syndrome (MetS) outcomes that had improved from 20 weeks' RT + HIIT during the training period, such as WC, SBP, and Tg from HIIT + RT, when, worryingly, SBP increased to another more serious clinical classification in both groups.

Characterizing the interindividual postexercise hypotension response for two order groups of concurrent training in patients with morbid obesity

Background: Postexercise hypotension (PEH) is a common physiological phenomenon occurring immediately after endurance training (ET), resistance training (RT), and ET plus RT, also termed concurrent training (CT); however, there is little knowledge about the interindividual and magnitude response of PEH in morbidly obese patients.

Aim: The aims of this study were (1) to investigate the effect of CT order (ET + RT vs. RT + ET) on the blood pressure responses; 2) characterize these responses in responders and nonresponders, and 3) identify potential baseline outcomes for predicting blood pressure decreases as responders.

Methods: A quasi-experimental study developed in sedentary morbidly obese men and women (age 43.6 ± 11.3 years; body mass index [BMI] ≥40 kg/m²) was assigned to a CT group of ET plus RT (ET + RT; n = 19; BMI 47.8 ± 16.7) or RT plus ET order group (RT + ET; n = 17; BMI 43.0 ± 8.0). Subjects of both groups received eight exercise sessions over four weeks. Primary outcomes include systolic (SBP), diastolic (DBP), mean arterial pressure [MAP], heart rate at rest [HR], and pulse pressure [PP] measurements before and after 10 min post-exercise. Secondary outcomes were other anthropometric, body composition, metabolic, and physical fitness parameters. Using the delta ∆SBP reduction, quartile categorization (Q) in “high” (Rs: quartile 4), “moderate” (MRs: quartile 3), “low” (LRs: quartile 2), and “nonresponders” (NRs: quartile 1) was reported.

Results: Significant pre–post changes were observed in ET + RT in session 2 for SBP (131.6 vs. 123.4 mmHg, p = 0.050) and session 4 (131.1 vs. 125.2 mmHg, p = 0.0002), while the RT + ET group showed significant reductions in session 4 (134.2 vs. 125.3 mmHg, p < 0.001). No significant differences were detected in the sum of the eight sessions for SBP (∑∆SBP) between ET + RT vs. RT + ET (−5.7 vs. −4.3 mmHg, p = 0.552). Interindividual analyses revealed significant differences among frequencies comparing Q1 “NRs” (n = 8; 22.2%), Q2 “LRs” (n = 8; 22.2%), Q3 “MRs” (n = 9; 25.0%), and Q4 “HRs” (n = 11; 30.5%), p < 0.0001. Quartile comparisons showed significant differences in SBP changes (p = 0.035). Linear regression analyses revealed significant association between ∑∆SBP with body fat % (β –3.826, R² 0.211 [21.1%], p = 0.031), skeletal muscle mass [β –2.150, R² 0.125 (12.5%), p = 0.023], fasting glucose [β 1.273, R² 0.078 (7.8%), p = 0.003], triglycerides [β 0.210, R² 0.014 (1.4%), p = 0.008], and the 6-min walking test [β 0.183, R² 0.038 (3.8%), p = 0.044].

Conclusion: The CT order of ET + RT and RT + ET promote a similar ‘magnitude’ in the postexercise hypotensive effects during the eight sessions of both CT orders in 4 weeks of training duration, revealing “nonresponders” and ‘high’ responders that can be predicted from body composition, metabolic, and physical fitness outcomes.

Concurrent training and interindividual response in women with a high number of metabolic syndrome risk factors

The non-responders (NRs) after exercise training have been poorly studied in populations with morbid obesity. The purpose of this study was to determine the NR prevalence after 20 weeks of concurrent training of morbidly obese women with a high or low number of metabolic syndrome (MetS) risk factors. Twenty-eight women with morbid obesity participated in an exercise training intervention and were allocated into two groups distributed based on a high (≥3, n = 11) or low number (<3, n = 17) of MetS risk factors. The main outcomes were waist circumference (WC), fasting plasma glucose (FPG), high-density lipids (HDL-c), triglycerides (Tg), and systolic (SBP) and diastolic (DBP) blood pressure, and secondary outcomes were body composition, anthropometric and physical fitness, determined before and after 20 weeks of concurrent training. NRs were defined as previously used technical error cut-off points for the MetS outcomes. Significantly different (all p < 0.05) prevalences of NRs between the H-MetS vs. L-MetS groups (respectively) in WC (NRs 18.2 % vs. 41.1 %, p < 0.0001), SBP (NRs 72.7 % vs. 47.0 %, p = 0.022), DBP (NRs 54.5 % vs. 76.4 %, p < 0.0001), FPG (NRs 100% vs. 64.8 %, p < 0.0001), and HDL-c (NRs 90.9 % vs. 64.7 %, p = 0.012) were observed. In addition, the H-MetS group evidenced significant changes on ΔSBP (−10.2 ± 11.4 mmHg), ΔFPG (−5.8 ± 8.2 mg/dl), ΔHDL-c (+4.0 ± 5.9 mg/dl), and ΔTg (−8.8 ± 33.8 mg/dl), all p < 0.05. The L-MetS group only showed significant changes in ΔWC (−3.8 ± 5.0 cm, p = 0.009). Comparing H-MetS vs. L-MetS groups, significant differences were observed in ∆FPG (−5.8 ± 8.2 vs. +0.3 ± 3.2 mg/dl, p = 0.027), but not in other MetS outcomes. In conclusion, 20 weeks of concurrent training promotes greater beneficial effects in morbidly obese patients with a high number of MetS risk factors. However, the NR prevalence for improving MetS outcomes was significantly superior in these more-diseased groups in SBP, FPG, and HDL-c, independent of their major training-induced effects.

Mechanical Behavior of Subcutaneous and Visceral Abdominal Adipose Tissue in Patients with Obesity

The mechanical characterization of adipose tissues is important for various medical purposes, including plastic surgery and biomechanical applications, such as computational human body models for the simulation of surgical procedures or injury prediction, for example, in the evaluation of vehicle crashworthiness. In this context, the measurement of human subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) mechanical properties in relation to subject characteristics may be really relevant. The aim of this work was to properly characterize the mechanical response of adipose tissues in patients with obesity. Then, the data were exploited to develop a reliable finite element model of the adipose tissues characterized by a constitutive material model that accounted for nonlinear elasticity and time dependence. Mechanical tests have been performed on both SAT and VAT specimens, which have been harvested from patients with severe obesity during standard laparoscopic sleeve gastrectomy intervention. The experimental campaign included indentation tests, which permitted us to obtain the initial/final indentation stiffnesses for each specimen. Statistical results revealed a higher statistical stiffness in SAT than in VAT, with an initial/final indentation stiffness of 1.65 (SD ± 0.29) N/30.30 (SD ± 20) N compared to 1.29 (SD ± 0.30) N/21.00 (SD ± 16) N. Moreover, the results showed that gender, BMI, and age did not significantly affect the stiffness. The experimental results were used in the identification of the constitutive parameters to be inserted in the constitutive material model. Such constitutive characterization of VAT and SAT mechanics can be the starting point for the future development of more accurate computational models of the human adipose tissue and, in general, of the human body for the optimization of numerous medical and biomechanical procedures and applications.

Clinical outcomes of single-stage versus two-stage laparoscopic Roux-en-y gastric bypass in the management of obesity (BMI ≥ 50 kg/m2): a retrospective cohort study

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with obesity, BMI ≥ 50 kg/m², can be a challenging operation. Weight loss with intra-gastric balloon (IGB) insertion prior to LRYGB may improve operative outcomes.

METHODS

Between June 2000 and June 2020, patients with a BMI ≥ 50 kg/m² underwent either IGB insertion followed by LRYGB (two-stage group), or LRYGB as the definitive bariatric procedure (single-stage group) in our institution. The two-stage procedure was adopted for high risk individuals. Primary outcome measures were percentage total weight loss (%TWL) at 24 months, length of stay and postoperative morbidity. Propensity score analysis was used to account for differences between groups.

RESULTS

A total of 155 (mean age 42.9 years ± 10.60; mean BMI 54.6 kg/m² ± 4.53) underwent either the two-stage (n = 30) or single-stage procedure (n = 125) depending on preoperative fitness. At 6 months following LRYGB, there was a significant difference in %TWL between the groups in a matched analysis (11.9% vs 23.7%, p < 0.001). At 24 months, there was no difference in %TWL (32.0% vs 34.7%, p = 0.13). Median hospital stay following LRYGB was 2.0 (1-4) days with the two-stage vs 2.0 (0-14) days for the single-stage approach (p = 0.75). There was also no significant difference in complication rates (p = 0.058) between the two groups.

CONCLUSIONS

There was no difference in weight loss after one or two-stage procedures in the treatment of patients with a BMI ≥ 50 kg/m² super obesity in a propensity score weighted analysis at 24 months. Length of stay and perioperative complications were similar for high risk patients; however, the two-stage approach was associated with delayed weight loss. Single-stage management is recommended for moderate risk patients, particularly with significant metabolic disorders, whilst two-stage approach is a safe and feasible pathway for high risk individuals.

Does BMI Matter? A 10-Year Single Institutional Experience on 571 Bariatric Surgery Patients With BMI >50 kg/m2

INTRODUCTION

Patients undergoing bariatric surgery with body mass index (BMI) >50 kg/m2 are at a higher risk of surgical morbidity when compared with less obese patients, however, there is limited data correlating surgical risk and efficacy with increasing BMI in patients with severe obesity. We hypothesize that regardless of the degree above 50 kg/m2 their BMI, patients with severe obesity respond similarly to bariatric surgery.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with BMI >50 kg/m2 who underwent biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, or sleeve gastrectomy at a single institution. Outcomes were compared in patients with a BMI between 50 and 60 kg/m2 to patients with a BMI >60 kg/m2 and included percent total weight loss as well as early and late complications. Statistical analyses were performed using logistic regression, univariate, and multivariate models.

RESULTS

There were 571 patients with BMI >50 kg/m2 who underwent bariatric surgery at our center, 170 (29.8%) had a BMI >60 kg/m2. Percent total weight loss was statistically significant between the BMI 50 and 60 kg/m2 and BMI >60 kg/m2 groups at 24 months (P=0.047) but not at 60 months (P=0.54). No significant difference was found in the incidence of early complications in a univariate (P=0.46) or a multivariate (P=0.06) analysis. The BMI >60 subgroup was associated with a higher rate of late complications in univariate analysis (heart rate=2.37; 1.03-5.47, P=0.04), but not in multivariate analysis (P=0.78).

CONCLUSIONS

Efficacy and complication rates of bariatric surgeries are similar in patients with BMI 50 to 60 kg/m2 and >60 kg/m2, providing evidence supporting similar management of patients despite specific subgroups.

Roux-en-Y Gastric Bypass in Patients with Super Obesity: Primary Response Criteria and Their Relationship with Comorbidities Remission

BACKGROUND

The prevalence of super obesity has increased considerably in recent years, representing up to the 0.5% of the population. Even though bariatric surgery induces significant weight loss in these patients, it has been reported that up to 50% of the patients with super obesity will fail according to the current primary response criteria.

OBJECTIVE

To evaluate and compare different primary response criteria and their impact regarding comorbidities remission.

PATIENTS AND METHODS

A total of 104 patients with super obesity who underwent Roux-en-Y gastric bypass (RYGB) were identified in our institution from March 2004 to February 2019. An evaluation of the primary response at a 2-year follow-up was made using different criteria. A multivariate analysis was made to evaluate related variables to comorbidities remission.

RESULTS

Two years later, the rate of patients who achieved an EWL > 50%, %EWL > 70%, and BMI < 35 kg/m² were 84.5%, 52.1%, and 62%, respectively. Regarding the comorbidities, 85%, 84.8%, and 81.1% of the patients improved or remitted T2D, HBP, and hyperlipidemia, respectively. An EWL > 50% 2 years later was related to complete remission of hyperlipidemia (p = 0.047), whereas weight regain above 10% is a risk factor for failure of complete remission of HBP in 3 years.

CONCLUSIONS

More than 75% of patients with super obesity yield an EWL > 50% 2 years later. In terms of hyperlipidemia, it is desirable to achieve an EWL of at least 50%. Whereas for T2D and HBP, a minimum of 25% TWL yields 72% and 60.5% of complete remission.

Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport

Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs. Also, careful and deliberate planning is required to address the specific anatomic and physiologic characteristics of this population if intubation and mechanical ventilation are needed. Finally, their dimensions and weight also have distinct consequences on transport vehicle considerations. This article reviews the pathophysiology, management, and critical care transport considerations for this unique patient population in respiratory distress and failure.

Total hip arthroplasty through the direct anterior approach in morbidly obese patients

Aims

There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients.

Methods

Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m² who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m². Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed.

Results

No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041).

Conclusion

Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons.

Cite this article: Bone Jt Open 2022;3(1):4–11.

Protective effect of D-(-)-quinic acid as food supplement in modulating AMP-activated protein kinase signalling pathway activation in HFD induced obesity

BACKGROUND

Dietary quinic acid given as the nutritional supplement, which may leads to tryptophan and nicotinamide production in the intestinal tract and NAD⁺ precursor which can prevent from the negative consequences of high fat diet (HFD) consumption.

OBJECTIVE

The present study was designed to assess in vivo and in vitro effect of D-(-)-Quinic acid in high-fat diet induced hyperlipidemia in mice.

MATERIAL AND METHODS

Thirty six albino mice were randomly divided in six groups and each group had six mice. Group I, controlled mice given normal pellet diet, Group-II mice, administered with high fat diet (HFD), Group-III mice given standard drug, Atorvastatin (20 mg/kg, p.o.) along with HFD to mice and Group IV, V and VI mice received D-(-)-Quinic acid at a dose of 75, 150 and 300 mg/kg, respectively in separate group along with HFD to mice. After completion of trial (49 days) the animals were sacrificed and evaluated for body weight, organ fat pad weight, and changes in weight of liver, heart and kidney and also for biochemical parameters, expression of adipogenic and inflammation markers in adipose tissues, and histology examination of liver tissue.

RESULTS

In vitro testing results showed, D-(-)-Quinic acid potentially inhibit α-glucosidase enzyme activity as compared to acarbose. The D-(-)-Quinic acid showed significant hypolipidemic activity by decreasing the increased level of cholesterol, triglyceride level, LDL, VLDL and other hepatic parameters like SGOT and SGPT in serum. D-(-)-Quinic acid reduces the mRNA expression level of PPAR-γ2, TNF-α, IL-1β and IL-6 in adipose tissue in hyperlipidemic mice.

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures

Objective

To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures.

Design

Retrospective 1:1 matched cohort study.

Setting

Single-level 1 trauma center.

Participants

One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups.

Intervention

Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture.

Main Outcome Measurement

Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores.

Results

Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group.

Conclusions

Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.

The Effects of Two Different Concurrent Training Configurations on Markers of Metabolic Syndrome and Fitness in Women With Severe/Morbid Obesity: A Randomised Controlled Trial

Concurrent training (CT), characterised by combining both aerobic and resistance training modalities within the same session, is recognised to improve metabolic syndrome (MetS) markers, but little is known about the effects of different configurations (i.e., order) of these exercise modalities on MetS markers and the interindividual responses. The purpose of the present study was to describe the effects, and the interindividual variability, of 20weeks of two CT configurations (i.e., high intensity interval training (HIIT) plus resistance training (RT), compared with RT plus HIIT) in women with severe/morbid obesity. Overall, 26 women with severe/morbid obesity were assigned either to HIIT+RT [n=14, mean and 95%CI, 45.79 (40.74; 50.83) or RT+HIIT (n=12), 33.6 (25.30; 41.79) years]. MetS-related outcomes were waist circumference (WC, cm), systolic (SBP, mmHg) and diastolic (DBP, mmHg) blood pressure, high-density lipoprotein cholesterol (HDL-c), triglycerides (Tg), and fasting plasma glucose (FPG). Secondary outcomes were other anthropometrics, body composition, lipids, muscle strength, and the six-minute walk test (6Mwt). There were significant differences in the prevalence of nonresponders (NRs) only for WC comparing HIIT+RT 2 (18.1%) vs. RT+HIIT group 5 (50.0%), p<0.0001, but not for SBP 4 (27.2%) vs. 4 (40.0%), DBP 8 (72.7%) vs. 7 (70.0%), FPG 8 (72.7%) vs. 9 (90.0%), HDL-c 7 (63.6%) vs. 8 (80.0%), and Tg 7 (63.6%) vs. 8 (80.0%), all p>0.05. Additionally, the RT+HIIT group showed significant reductions in WC (∆ –3.84cm, p=0.015), SBP (∆ –8.46mmHg, p=0.040), whereas the HIIT+RT group elicited significant reductions only in SBP (∆ –8.43mmHg, p=0.022). The HIIT+RT promoted a lower prevalence of NRs than the RT+HIIT configuration on WC, and overall, there were slightly more beneficial training-induced effects on markers of MetS in the RT+HIIT group compared to the HIIT+RT group.

Lycopene modulates lipid metabolism in rats and their offspring under a high-fat diet

The purpose of this study was to investigate the effects of lycopene supplementation on lipid metabolism in rats and their offspring. The experiment was conducted on 60 female rats divided into four groups: normal diet, normal diet with 200 mg kg^-1 lycopene, high-fat diet, and high-fat diet with 200 mg kg^-1 lycopene. The plasma levels of TG, LDL-C, AST and ALT in female rats fed a high-fat diet were significantly increased (P < 0.05). Lycopene supplementation reduced the plasma TG, LEP and AST levels (P < 0.05). In addition, the activity of ACC and mRNA expression of SREBP1c, FAS, PPARγ, CPT1, HMGCR, ACC, PLIN1 and FATP1 in the liver were also increased after feeding a high-fat diet (P < 0.05), whereas the expression of HSL was decreased (P < 0.05). Lycopene increased the activity of HSL and the expression of ATGL in the liver (P < 0.05), and the activity of ACC and mRNA expression of HMGCR and ACC were decreased (P < 0.05). For the offspring, maternal feeding of a high-fat diet reduced the plasma HDL-C levels (P < 0.05), but lycopene supplementation reduced the plasma TC levels (P < 0.05). Maternal high-fat diet also decreased the activity of HSL and the expression of CD36, PLIN1 and FATP1 in the liver while increasing the expression of PPARγ (P < 0.05). Maternal lycopene supplementation decreased the activities of ACC and FAS in the liver and decreased the expression of PPARγ, ACC and PLIN1 (P < 0.05). Maternal feeding of a high-fat diet increased the level of oxidative stress in the liver, the level of blood lipids in plasma and the rate of lipid production in the liver of rats and their offspring. Maternal lycopene supplementation can reduce the level of oxidative stress in rats and their offspring, reduce the level of blood lipids in plasma, and also reduce the rate of lipid production in the liver of rats and offspring.

Incidence of Colorectal Adenomas After Bariatric Surgery: Pre-operative Super Morbid Obesity Is Independently Associated with Increased Risk

PURPOSE

The impact of pre-bariatric surgery BMI on the incidence of colorectal adenomas in the post-operative period is unknown. Here we aim to evaluate the incidence of colorectal adenomas after bariatric surgery and to assess super morbid obesity (SMO) as a risk factor for post-operative colorectal adenomas.

MATERIALS AND METHODS

An inception cohort of 1639 patients that underwent bariatric surgery between 2011 and 2019 in a referral center was retrospectively analyzed. SMO was defined as BMI > 50.0 kg/m². Cox regression analysis was performed to assess the influence of pre-operative BMI on the primary outcome.

RESULTS

A total 381 patients (23.2% of the cohort) underwent colonoscopy and included in the analysis. Mean age was 51.1 years (± 10.6) with mean BMI of 42.2 kg/m² (± 6.2), and 49 patients (12.9%) had SMO. Median time to colonoscopy was 3.5 years. One hundred nine patients (28.6%) had colorectal polyps, and 38/109 (34.8%) had advanced adenoma. Two patients had colorectal cancer (CRC). Pre-procedural SMO was associated with diagnosis of colorectal polyp (HR 2.4, 95% CI 1.5-3.9, p < 0.001) and advanced adenomas (HR 4.2, 95% CI 2.0-8.9, p < 0.001) upon adjustment to previously reported risk factors of CRC.

CONCLUSION

Pre-procedural SMO is associated with increased risk of colorectal adenomas after bariatric surgery compared to obese and morbidly obese individuals. Pre-operative BMI should be incorporated into post-operative screening plan in this population.

Prevention of COVID-19 in Thoracic Surgery Patients: Lessons Learned during the First Pandemic Wave

BACKGROUND

 The aim of this retrospective study was to investigate the implementation of measures to prevent perioperative COVID-19 in thoracic surgery during the first wave of the COVID-19 pandemic 2020 allowing a continued surgical treatment of patients.

METHODS

 The implemented preventive measures in patient management of the thoracic surgery department of the Asklepios Lung Clinic Munich-Gauting, Germany were retrospectively analyzed. Postoperative COVID-19 incidence before and after implementation of preventive measures was investigated. Patients admitted for thoracic surgical procedures between March and May 2020 were included in the study. Patient characteristics were analyzed. For the early detection of putative postoperative COVID-19 symptoms, typical post-discharge symptomatology of thoracic surgery patients was compared to non-surgical patients hospitalized for COVID-19.

RESULTS

 Thirty-five surgical procedures and fifty-seven surgical procedures were performed before and after implementation of the preventive measures, respectively. Three patients undergoing thoracic surgery before implementation of preventive measures developed a COVID-19 pneumonia post-discharge. After implementation of preventive measures, no postoperative COVID-19 cases were identified. Fever, dyspnea, dry cough and diarrhea were significantly more prevalent in COVID-19 patients compared to normally recovering thoracic surgery patients, while anosmia, phlegm, low energy levels, body ache and nausea were similarly frequent in both groups.

CONCLUSIONS

 Based on the lessons learned during the first pandemic wave, we here provide a blueprint for successful easily implementable preventive measures minimizing SARS-CoV-2 transmission to thoracic surgery patients perioperatively. While symptoms of COVID-19 and the normal postoperative course of thoracic surgery patients substantially overlap, we found dyspnea, fever, cough, and diarrhea significantly more prevalent in COVID-19 patients than in normally recovering thoracic surgery patients. These symptoms should trigger further diagnostic testing for postoperative COVID-19 in thoracic surgery patients.

Severe maternal morbidity and mortality during delivery hospitalization of class I, II, III, and super obese women

BACKGROUND

Previous studies show that obesity predisposes patients to higher risks of adverse pregnancy outcomes. Data on the relationship between increasing degrees of obesity and risks of severe maternal morbidity, including mortality, are limited.

OBJECTIVE

We examined the association of increasing classes of obesity, especially super obesity, with the risk of severe maternal morbidity and mortality at the time of delivery hospitalization.

STUDY DESIGN

Using New York City linked birth certificates and hospital discharge data, we conducted a retrospective cohort study. This study identified delivery hospitalizations for singleton, live births in 2008-2012. Women were classified as having obesity (class I, II, III, or super obesity), as opposed to normal weight or overweight, based on prepregnancy body mass index. Cases of severe maternal morbidity were identified based on International Classification of Diseases, Ninth Revision diagnosis and procedure codes according to Centers for Disease Control and Prevention criteria. Multivariable logistic regression was used to evaluate the association between obesity classes and severe maternal morbidity, adjusting for maternal sociodemographic characteristics.

RESULTS

During 2008-2012, there were 570,997 live singleton births with available information on prepregnancy body mass index that met all inclusion criteria. After adjusting for maternal characteristics, women with class II (adjusted odds ratio, 1.14; 95% confidence interval, 1.05-1.23), class III (adjusted odds ratio, 1.34; 95% confidence interval, 1.21-1.49), and super obesity (adjusted odds ratio, 1.99; 95% confidence interval, 1.57-2.54) were all significantly more likely to have severe maternal morbidity than normal and overweight women. Super obesity was associated with specific severe maternal morbidity indicators, including renal failure, air and thrombotic embolism, blood transfusion, heart failure, and the need for mechanical ventilation.

CONCLUSION

There is a significant dose-response relationship between increasing obesity class and the risk of severe maternal morbidity at delivery hospitalization. The risks of severe maternal morbidity are highest for women with super obesity. Given that this is a modifiable risk factor, women with prepregnancy obesity should be counseled on the specific risks associated with pregnancy before conception to optimize their pregnancy outcomes.

Ventilatory response to exercise is preserved in patients with obesity hypoventilation syndrome

STUDY OBJECTIVES

Blunted ventilatory responses to hypoxia and hypercapnia during resting conditions are common findings in patients with obesity hypoventilation syndrome (OHS). Exercise increases the work and oxygen cost of breathing and produces excessive carbon dioxide (CO₂). The aim of this investigation was to study ventilatory responses to incremental exercise in patients with OHS.

METHODS

Sixty-eight obese adults with OHS (n = 15), eucapnic obstructive sleep apnea (n = 26), or simple obesity (n = 27) participated in an incremental exercise test on a cycle ergometer and an in-laboratory sleep study.

RESULTS

The peak oxygen uptake (peak VO₂) and peak pulse oxygen was decreased in patients with OHS compared with patients with either obstructive sleep apnea or simple obesity. The ventilatory response to exertional metabolic demand (nadir VE/VCO₂, ∆VE/∆VCO₂ slope, and VE/VCO₂ at peak exercise) did not significantly differ among the 3 groups. Minute ventilation, tidal volume, respiratory frequency, tidal volume/respiratory frequency, and inspiratory time/total time ratio at a given work rate were comparable among the 3 groups. Among the whole cohort, apnea-hypopnea index was not independently associated with peak VO₂, and no association was found between the ∆VE/∆VCO₂ slope and resting arterial partial pressure of CO₂.

CONCLUSIONS

The ventilatory response to incremental exercise is preserved in patients with OHS compared with patients with obstructive sleep apnea and simple obesity who were matched for age and body mass index. This result highlights the complexity of the respiratory control system during exercise for patients with OHS, which may be uncoupled with the ventilatory response during sleep and resting conditions.

Prevalence of constipation in adults with obesity class II and III and associated factors

Background

Constipation and obesity have common risk factors. However, little is known about the occurrence of constipation in individuals with severe obesity and the associated factors.

Objective

To evaluate the prevalence of intestinal constipation and its associated factors in adults with obesity class II and III.

Method

This study analyzed baseline data from a randomized clinical trial with adults aged 18–64 with a Body Mass Index (BMI) ≥ 35 kg/m², living in the metropolitan region of Goiânia, Brazil. Data were collected using a questionnaire containing sociodemographic, lifestyle, level of obesity, presence of comorbidities, water intake and food consumption variables. The outcome variable was constipation assessed by the Rome III criteria and the Bristol Stool Form Scale. Multiple Poisson regression analysis was used to assess the association between explanatory variables and the outcome.

Results

Among the 150 participants, the prevalence of constipation was 24.67% (95% CI: 17.69–31.64). After multiple regression analyses constipation was associated with polypharmacy (adjusted PR: 2.99, 95% CI: 1.18–7.57, p = 0.021), younger age group i.e. 18–29 years (adjusted PR: 3.12, 95% CI: 1.21–8.06, p = 0.019) and former smoking (adjusted PR: 3.24, 95% CI: 1.28–9.14, p = 0.014). There was no statistically significant association between constipation and daily consumption of fiber-rich foods, however, the non-consumption of whole grains was borderline significant (adjusted PR: 2.92, 95% CI: 1.00 to 8.49, p = 0.050).

Conclusion

A high prevalence of constipation was found in adults with obesity class II and III. Constipation was significantly associated with the simultaneous use of five or more medications, younger age group and being a former smoker.

Automated quantitative thin slice volumetric low dose CT analysis predicts disease severity in COVID-19 patients

PURPOSE

This study aimed to identify predictive (bio-)markers for COVID-19 severity derived from automated quantitative thin slice low dose volumetric CT analysis, clinical chemistry and lung function testing.

METHODS

Seventy-four COVID-19 patients admitted between March 16th and June 3rd 2020 to the Asklepios Lung Clinic Munich-Gauting, Germany, were included in the study. Patients were categorized in a non-severe group including patients hospitalized on general wards only and in a severe group including patients requiring intensive care treatment. Fully automated quantification of CT scans was performed via IMBIO CT Lung Texture analysis™ software. Predictive biomarkers were assessed with receiver-operator-curve and likelihood analysis.

RESULTS

Fifty-five patients (44% female) presented with non-severe COVID-19 and 19 patients (32% female) with severe disease. Five fatalities were reported in the severe group. Accurate automated CT analysis was possible with 61 CTs (82%). Disease severity was linked to lower residual normal lung (72.5% vs 87%, p = 0.003), increased ground glass opacities (GGO) (8% vs 5%, p = 0.031) and increased reticular pattern (8% vs 2%, p = 0.025). Disease severity was associated with advanced age (76 vs 59 years, p = 0.001) and elevated serum C-reactive protein (CRP, 92.2 vs 36.3 mg/L, p < 0.001), lactate dehydrogenase (LDH, 485 vs 268 IU/L, p < 0.001) and oxygen supplementation (p < 0.001) upon admission. Predictive risk factors for the development of severe COVID-19 were oxygen supplementation, LDH >313 IU/L, CRP >71 mg/L, <70% normal lung texture, >12.5% GGO and >4.5% reticular pattern.

CONCLUSION

Automated low dose CT analysis upon admission might be a useful tool to predict COVID-19 severity in patients.

Weight stigma experiences and self-exclusion from sport and exercise settings among people with obesity

BACKGROUND

A central strategy to tackle the health risks of obesity is regular physical activity (PA), exercising and participating in sports. However, people with obesity regularly experience weight-related stigma and discrimination in sport and exercise settings. Research has indicated that they often cope with such experiences by simply excluding themselves from sport and exercise. Meanwhile, self-exclusion as a coping strategy has not been fully understood and it remains unclear to what extent self-exclusion from PA settings is accompanied by general inactivity among people with obesity. The goal of this interview study was to determine to what extent physical inactivity among adults with obesity is the result of weight stigma-induced self-exclusion in and from sport and PA settings.

METHODS

We conducted semi-structured interviews with thirty adult men and women with obesity (average BMI: 40.64) and asked them about experiences with their body, weight stigma and coping behaviours in sport and exercise settings across their lifespans. Employing constant comparative analysis and a thematic network approach, we analysed the interview data to identify the most common reasons for and different strategies of self-exclusion.

RESULTS

Participants reported that they excluded themselves from sport and exercise settings due to traumatic weight stigma experiences, self-discrimination and fear of stigma, using a variety of strategies. Exposure to discrimination was prevented by selectively avoiding certain settings or strategically frequenting them at certain times only, but also by exercising in 'safe' spaces, e.g. at home. Furthermore, people with obesity reported strategically managing their social relations in order to avoid stigmatising reactions by others in exercise settings, for example by exercising individually and avoiding social PA. Most notably, our results strongly indicate that not all self-excluding coping strategies result in less exercising.

CONCLUSIONS

In order to successfully promote physical activity among people with obesity, the various forms of self-exclusion should be taken into account as pathways of stigma regarding physical activity. People with obesity may exclude themselves from certain PA settings, yet could still be exercising on their own or in other ways. One focus of public health strategies should thus be directed at the potentially socially isolating effects.

Avoiding Venous Anastomotic Dehiscence of an Arteriovenous Graft in a Super-Obese Patient

Surgeons avoid creating arteriovenous fistulae in obese patients owing to deep vessels, cannulation complications, and inconsistent outcomes. We describe placing an arteriovenous polytetrafluoroethylene (PTFE) graft between the brachial artery and axillary vein to avoid these complications. A 39-year-old super-obese woman with end-stage renal disease had undergone several hemodialysis access procedures on both arms. We traced the course of the arteriovenous graft course with the patient sitting and lying down. The ideal course was more accurate with the patient sitting; thus, the patient sat when the course was drawn, before lying on the operating bed. The PTFE graft was placed between the right brachial artery and axillary vein, according to the course in the opposite arm. No anastomotic dehiscence or pseudoaneurysm has taken place during 2 years of follow-up. In super-obese patients, the ideal course for arteriovenous grafts should be drawn while they are sitting, avoiding skin folds. This tip could avoid anastomotic dehiscence and pseudoaneurysm between the axillary vein and a PTFE graft.

Ventral hernia repair in bariatric patients

Morbid Obesity is increasing worldwide at fast pace with associated co-morbidities also on the rise. Considering that Obesity is one of the main risk factors for developing a Ventral Hernia this will results that in the future we will experience a rise in those hernia in patients undergoing any abdominal surgery. There is no clarity on the best timing and choice for procedures. We are well aware also on the difficulties in hernia repair surgery and the relative outcome so adding obesity as co-factors amplify the challenges. In fact, today both general surgeons with expertise in abdominal wall repair and bariatric surgeons are faced with a new dilemma: the obese patient with an abdominal wall hernia. This article will briefly review the impact of obesity on the natural history of hernia, its associated complication, management strategies and outcome.

Differential Outcomes and Clinical Challenges of NAFLD With Extreme Obesity

Nonalcoholic fatty liver disease (NAFLD) is closely associated with obesity. The prevalence of extreme obesity, defined as body mass index (BMI) of 50 kg/m² or higher, is rising more rapidly than overall obesity. We aimed to compare the clinical outcomes and performance of noninvasive fibrosis assessment tools in NAFLD with or without extreme obesity. A retrospective analysis was performed in 304 patients with NAFLD with extreme obesity and compared them to patients with NAFLD with BMI of 40 kg/m² or less, matched for age, gender, race, and liver fibrosis stage. The mean age of the NAFLD with extreme obesity cohort was 55.9 years, BMI 55 kg/m², and 49.7% had cirrhosis at initial evaluation. Baseline cirrhosis and coronary artery disease were associated with increased risk of death, and dyslipidemia with decreased risk of mortality. Age, insulin use, hypertension, albumin and platelet count were associated with cirrhosis. Fifteen percent of patients had weight‐loss surgery, but this was not associated with survival or risk of cirrhosis. Of the 850 abdominal ultrasound scans performed in 255 patients, 24.1% were deemed suboptimal for hepatocellular carcinoma screening. The mean NAFLD fibrosis score (NFS) in the extreme obesity cohort, versus a propensity‐matched cohort with BMI of 40 kg/m² or less, was significantly different for both low fibrosis (F0‐F2) (0.222 vs. −1.682, P < 0.0001) and high fibrosis (F3‐F4) (2.216 vs. 0.557, P < 0.001). Conclusion: NAFLD with extreme obesity is associated with increased risk of liver‐related and overall mortality. Accurate noninvasive assessment of liver fibrosis, low rates of weight loss surgery, and high failure rate of ultrasound were identified as clinical challenges in this population.

Effects of Blood Pressure Lowering Agents on Cardiovascular Outcomes in Weight Excess Patients: A Systematic Review and Meta-analysis

BACKGROUND

Obesity hypertension is an ongoing pandemic. The first-line medications to treat this condition are still subject to debate. We compared diuretics, calcium-channel blockers (CCB), beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) as an initial antihypertensive therapy for prevention of cardiovascular morbimortality of hypertensive individuals who are overweight or obese.

METHODS

We conducted a search of the literature for randomized clinical trials in which at least 50% of the participants were overweight or obese. The primary outcomes were all-cause mortality, cardiovascular mortality, acute myocardial infarction (MI), heart failure (HF), stroke, or end-stage renal disease.

RESULTS

Our search yielded 16 randomized studies. Comparisons of two classes of drugs with at least two studies indicated that (1) CCB and ACEI increased the risk of HF [relative risk (RR) = 2.26; 95% confidence interval (CI) 1.16-4.40] and stroke [hazard ratio (HR) = 1.13; 1.00-1.26]), respectively, compared to diuretics; and (2) CCB showed a reduction in stroke (HR = 0.77; 0.66-0.89) and total mortality (HR = 0.94; 0.87-1.01) compared to the BB atenolol. Comparisons of two classes of antihypertensive medications with only one study showed that the risk of MI was higher with ARB valsartan versus CCB (HR = 1.19; 95% CI 1.02-1.38, p = 0.02). In contrast, losartan lowered the risk of a composite cardiovascular outcome compared to atenolol (HR = 0.87; 95% CI 0.77-0.98, p = 0.02).

CONCLUSIONS

In hypertensive subjects with excess weight, diuretics are more effective for preventing HF and stroke than CCB and ACEI, respectively. CCB are a good first-line choice for prevention of cardiovascular disease, except HF.

Poor Sleep Quality Decreases Concurrent Training Benefits in Markers of Metabolic Syndrome and Quality of Life of Morbidly Obese Patients

Background: Sleep quality (SQ) plays a role in multiple activities of daily living, but little is known about its role in concurrent training [CT, high-intensity interval (HIIT) plus resistance training (RT)] adaptations for metabolic syndrome (MetS) and health-related quality of life (HRQoL) markers. The aim of the present study was to determine the effects of a 20-week CT programme on MetS and HRQoL markers according to the SQ of morbidly obese patients. Methods: Twenty-nine morbidly obese patients were allocated to one of two groups: good sleep quality (GSQ, n = 15, 38.07 ± 12.26 years) and poor sleep quality (PSQ, n = 14, 40.79 ± 11.62 years). HRQoL, body mass index, waist circumference (WC), systolic and diastolic blood pressure (SBP and DBP, respectively), and plasma outcomes were measured. Results: The GSQ group reported significant changes (pre- vs. post-intervention) in WC (114.0 ± 3.1 vs. 110.4 ± 3.4 cm, p = 0.012), SBP (137.0 ± 4.3 vs. 125.6 ± 1.8 mmHg, p = 0.006), and HRQoL general health (51.33 ± 21.08 vs. 64.33 ± 16.24, p = 0.020). By contrast, the PSQ group showed significant changes only in SQ (9.00 ± 2.42 vs. 5.36 ± 2.84, p = 0.004). Conclusions: Morbidly obese PSQ patients showed a lower response for improving MetS and HRQoL markers after a 20-week CT programme than GSQ peers. However, there was a greater effect size for decreasing WC and SBP in favour of the GSQ compared with the PSQ group, suggesting that there are limitations to CT benefits on these outcomes in the PSQ group. These results call for more complex future studies.

Opportunities and Challenges From Leading Trends in a Biomonitoring Project: Canadian Health Measures Survey 2007-2017

Background: Biomonitoring can be conducted by assessing the levels of chemicals in human bodies and their surroundings, for example, as was done in the Canadian Health Measures Survey (CHMS). This study aims to report the leading increasing or decreasing biomarker trends and determine their significance.

Methods: We implemented a trend analysis for all variables from CHMS biomonitoring data cycles 1–5 conducted between 2007 and 2017. The associations between time and obesity were determined with linear regressions using the CHMS cycles and body mass index (BMI) as predictors.

Results: There were 997 unique biomarkers identified and 86 biomarkers with significant trends across cycles. Nine of the 10 leading biomarkers with the largest decreases were environmental chemicals. The levels of 1,2,3-trimethyl benzene, dodecane, palmitoleic acid, and o-xylene decreased by more than 60%. All of the 10 chemicals with the largest increases were environmental chemicals, and the levels of 1,2,4-trimethylbenzene, nonanal, and 4-methyl-2-pentanone increased by more than 200%. None of the 20 biomarkers with the largest increases or decreases between cycles were associated with BMI.

Conclusions: The CHMS provides the opportunity for researchers to determine associations between biomarkers and time or BMI. However, the unknown causes of trends with large magnitudes of increase or decrease and their unclear impact on Canadians' health present challenges. We recommend that the CHMS plan future cycles on leading trends and measure chemicals with both human and environmental samples.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.

RECENT FINDINGS

This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

Prevention of Oxygen Desaturation in Morbidly Obese Patients During Electroconvulsive Therapy: A Narrative Review

In general, preoxygenation is performed using a face mask with oxygen in a supine position, and oxygenation is maintained with manual mask ventilation during electroconvulsive therapy (ECT). However, hypoxic episodes during ECT are not uncommon with this conventional method, especially in morbidly obese patients. The most important property of ventilatory mechanics in patients with obesity is reduced functional residual capacity (FRC). Thus, increasing FRC and oxygen reserves is an important step to improve oxygenation and prevent oxygen desaturation in these individuals. Head-up position, use of apneic oxygenation, noninvasive positive pressure ventilation, and high-flow nasal cannula help increase FRC and oxygen reserves, resulting in improved oxygenation and prolonged safe apnea period. Furthermore, significantly higher incidence of difficult mask ventilation is common in morbidly obese individuals. Supraglottic airway devices establish effective ventilation in patients with difficult airways. Thus, the use of supraglottic airway devices is strongly recommended in these patients. Conversely, because muscle fasciculation induced by depolarizing neuromuscular blocking agents markedly increases oxygen consumption, especially in individuals with obesity, the use of nondepolarizing neuromuscular blocking agents may contribute to better oxygenation in morbidly obese patients during ECT.

Laparoscopic Roux-En-Y gastric bypass versus one anastomosis (loop) gastric bypass for obesity: A prospective comparative study of weight loss and complications

Introduction

Most Bariatric units perform Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and One Anastomosis Gastric Bypass (OAGB) for weight loss and metabolic purposes with satisfactory results and low complication profile.

Objectives

This study compares LRYGB and OAGB outcomes in a high volume single bariatric unit.

Methods

Data was collected prospectively and analysed retrospectively for all LRYGB and OAGB performed between Jan 2014 to Dec 2016. The follow up period was for 2 years. Patients who were lost to follow up or had prior bariatric procedure were excluded. Excess weight loss percentage (EWL %), total weight loss percentage (TWL %) and post-operative complications were compared in both groups.

Results

1268 procedures performed. 113 patients were excluded. At 2 years, for LRYGB and OAGB groups mean TWL % was 31% and 35.4% respectively (P < 0.0001); and mean EWL % was 70.1% and 74.8% respectively (P = 0.0119). Gastroesophageal reflux symptoms were higher in OAGB group 17 (8.5%), with 7 patients needing further surgery, versus 26 (2.7%) in LRYGB (P = 0.0003). There was no difference in incidence of marginal ulcers between LRYGB and OAGB 2.7% vs 5% respectively (P = 0.1115). Internal hernia was seen only in LRYGB patients, 22 (2.2%). There was no significant difference in the re-operation rates following LRYGB 52 (5.4%) and OAGB 16 (8%) (P = 0.1824).

Conclusion

OAGB had superior short-term weight loss and low complications profile. Both procedures demonstrated no difference in either marginal ulcers or re-operation rates. Reflux symptoms have remained a major side effect of OAGB.

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One anastomosis gastric bypass has shown to have a safe operative profile and effective weight loss outcomes.

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No difference in marginal ulcerations or reoperation rate between One anastomosis gastric bypass and Laparoscopic Roux en y.

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We recommend strict selection criteria for patient undergoing OAGB.

Biomechanics of stomach tissues and structure in patients with obesity

Even though bariatric surgery is one of the most effective treatment option of obesity, post-surgical weight loss is not always ensured, especially in the long term, when many patients experience weight regain. Bariatric procedures are largely based on surgeon's expertise and intra-operative decisions, while an integrated in-silico approach could support surgical activity. The effects of bariatric surgery on gastric distension, which activates the neural circuitry promoting satiety, can be considered one of the main factors in the operation success. This aspect can be investigated trough computational modelling based on the mechanical properties of stomach tissues and structure. Mechanical tests on gastric tissues and structure from people with obesity are carried out, as basis for the development of a computational model. The samples are obtained from stomach residuals explanted during laparoscopic sleeve gastrectomy interventions. Uniaxial tensile and stress relaxation tests are performed in different directions and inflation tests are carried out on the entire stomach residual. Experimental results show anisotropic, non-linear elastic and time-dependent behavior. In addition, the mechanical properties demonstrate to be dependent on the sample location within the stomach. Inflation tests confirm the characteristics of time-dependence and non-linear elasticity of the stomach wall. Experimental activities developed provide a unique set of data about the mechanical behavior of the stomach of patients with obesity, considering both tissues and structure. This data set can be adopted for the development of computational models of the stomach, as support to the rational investigation of biomechanical aspects of bariatric surgery.

The long-term benefits of bariatric surgery in elderly and super-obese populations

PURPOSE

to assess the long-term benefits of bariatric surgery in super-obese (body mass index [BMI] ≥ 50) and in elderly obese (age > 60 years) populations.

METHODS

one hundred and twenty one patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy in a university hospital were retrospectively subdivided into the following groups: BMI < 50 vs ≥ 50 and age < 60 vs ≥ 60 years. Weight loss, body composition and comorbidity outcomes were registered after one and six months and one, two, three and five years with 100%, 93%, 89%, 80%, 75% and 60% successful follow-up.

RESULTS

the percentage of excess BMI loss (%EBMIL) was comparable between BMI groups and age groups and the difference in the long-term follow up was not statistically significant (p > 0.05). Complication rates, comorbidity resolution, reduction in body fat and increase in fat-free mass were comparable between BMI groups and age groups. Gastric bypass resulted in a greater weight loss compared to sleeve gastrectomy. The % EBMIL was 65.2% vs 46.7% (p = 0.002), 65.8% vs 44.9% (p = 0.004), 64.4% vs 30.5% (p = 0.001), 55.6% vs 17.6% (p = 0.016) at one, two, three and five years postoperative, respectively. Similarly, in the super-obese group, weight loss was more pronounced after gastric bypass versus sleeve gastrectomy.

CONCLUSIONS

bariatric surgery in super-obese and elderly populations is an effective and safe weight loss measure with a good comorbidity resolution in the long-term. Gastric bypass is superior to sleeve gastrectomy in terms of long-term weight loss and comorbidity resolution in all the groups investigated.

Ten-year risk of complication and mortality after total hip arthroplasty in morbidly obese patients: a population study

Background

The relationship between morbid obesity and long-term patient outcomes after primary total hip arthroplasty (THA) has been understudied. The purpose of this study was to determine the association between morbid obesity and 10-year complications (revision surgery, reoperation, dislocation) and mortality in patients undergoing primary THA.

Methods

We conducted a population-based cohort study of patients aged 45–74 years who underwent primary THA for osteoarthritis between 2002 and 2007 using Ontario administrative health care databases. Patients were followed for 10 years. We estimated risk ratios (RRs) of mortality, reoperation, revision and dislocation in patients with body mass index (BMI) greater than 45 kg/m2 (morbidly obese patients) compared with patients with a BMI of 45 kg/m2 or less (nonmorbidly obese patients).

Results

There were 22 251 patients in the study cohort, of whom 726 (3.3%) were morbidly obese. Morbid obesity was associated with higher 10-year risk of death (RR 1.38, 95% confidence interval [CI] 1.18–1.62). Risks of revision (RR 1.43, 95% CI 0.96–2.13) and dislocation (RR 2.38, 95% CI 1.38–4.10) were higher in morbidly obese men than in nonmorbidly obese men; there were no associations between obesity and revision or dislocation in women. Risk of reoperation was higher in morbidly obese women than in nonmorbidly obese women (RR 1.59, 95% CI 1.05–2.40); there was no association between obesity and reoperation in men.

Conclusion

Morbidly obese patients undergoing primary THA are at higher risk of long-term mortality and complications. There were differences in complication risk by sex. The results of this study should inform perioperative counselling of patients considering THA.

Pharmacokinetic changes post-bariatric surgery: A scoping review

Bariatric surgeries induce structural changes that can alter the absorption of drugs in patients already at risk of polypharmacy. This scoping review aimed to explore pharmacokinetic changes of orally administered drugs in patients post-bariatric surgery, and assess the quality and level of bias. Electronic databases were searched for articles relating to bariatric surgery and pharmacokinetics published between 1998 and 2019. Pre-post studies reporting on pharmacokinetic parameters were included, and the Newcastle-Ottawa Scale was used to assess risk-of-bias. A total of 21 studies were included in this review, and changes in absorption were reported in all included studies across 29 drugs. In 11 studies, this change was reported as statistically significant (p<.05), while six reported a nonsignificant change. More drugs exhibited a shorter Tmax and higher Cmax after surgery than otherwise, however changes in AUC were variable. Four studies were assessed as having fair quality while the remainder of the included studies were of good quality and low risk-of-bias. Bariatric surgery alters the absorption of drugs and several mechanisms are implicated to be responsible. Short and long-term monitoring is recommended in patients post-surgery for clinical changes in response to medications. Future research with a higher number of participants and greater control of variables, such as concurrent medications, malabsorptive disorders, and body composition should be considered.