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Ross PA, Newth CJL, Leung D, Wetzel RC, Khemani RG. Obesity and Mortality Risk in Critically Ill Children. Pediatrics 2016; 137:e20152035. [PMID: 26908670 DOI: 10.1542/peds.2015-2035] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Childhood obesity is epidemic and may be associated with PICU mortality. Using a large multicenter PICU database, we investigated the association between obesity and PICU mortality, adjusting for initial severity of illness. We further investigated whether height- and weight-based classifications of obesity compared with a weight-based classification alone alter the mortality distribution. METHODS This retrospective analysis used prospectively collected data from the Virtual PICU Systems database. Height, weight, age, and gender were used to calculate z score groups based on Centers for Disease Control and Prevention and World Health Organization growth curves. A random effects mixed logistic regression model was used to evaluate the association between obesity and PICU mortality, controlling for hospital, initial severity of illness, and comorbidities. RESULTS A total of 127,607 patients were included; the mortality rate was 2.48%. Being overweight was independently associated with increased PICU mortality after controlling for severity of illness with the Pediatric Index of Mortality 2 score and preexisting comorbidities. Mortality had a U-shaped distribution when classified according to weight-for-age or weight-for-height/BMI. When classifying patients using weight-for-age without respect to height, the nadir of the mortality curve was shifted, potentially falsely implying a benefit to mild obesity. CONCLUSIONS Risk-adjusted PICU mortality significantly increases as weight-for-height/BMI increases into the overweight and obese ranges. We believe that height data are necessary to correctly classify body habitus; without such information, a protective benefit from mild obesity may be incorrectly concluded.
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Affiliation(s)
- Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Christopher J L Newth
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Dennis Leung
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Randall C Wetzel
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Robinder G Khemani
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
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102
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Li G, Thabane L, Cook DJ, Lopes RD, Marshall JC, Guyatt G, Holbrook A, Akhtar-Danesh N, Fowler RA, Adhikari NKJ, Taylor R, Arabi YM, Chittock D, Dodek P, Freitag AP, Walter SD, Heels-Ansdell D, Levine MAH. Risk factors for and prediction of mortality in critically ill medical-surgical patients receiving heparin thromboprophylaxis. Ann Intensive Care 2016; 6:18. [PMID: 26921148 PMCID: PMC4769241 DOI: 10.1186/s13613-016-0116-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023] Open
Abstract
Background
Previous studies have suggested that prediction models for mortality should be adjusted for additional risk factors beyond the Acute Physiology and Chronic Health Evaluation (APACHE) score. Our objective was to identify risk factors independent of APACHE II score and construct a prediction model to improve the predictive accuracy for hospital and intensive care unit (ICU) mortality.
Methods We used data from a multicenter randomized controlled trial (PROTECT, Prophylaxis for Thromboembolism in Critical Care Trial) to build a new prediction model for hospital and ICU mortality. Our primary outcome was all-cause 60-day hospital mortality, and the secondary outcome was all-cause 60-day ICU mortality. Results We included 3746 critically ill non-trauma medical–surgical patients receiving heparin thromboprophylaxis (43.3 % females) in this study. The new model predicting 60-day hospital mortality incorporated APACHE II score (main effect: hazard ratio (HR) = 0.97 for per-point increase), body mass index (BMI) (main effect: HR = 0.92 for per-point increase), medical admission versus surgical (HR = 1.67), use of inotropes or vasopressors (HR = 1.34), acetylsalicylic acid or clopidogrel (HR = 1.27) and the interaction term between APACHE II score and BMI (HR = 1.002 for per-point increase). This model had a good fit to the data and was well calibrated and internally validated. However, the discriminative ability of the prediction model was unsatisfactory (C index < 0.65). Sensitivity analyses supported the robustness of these findings. Similar results were observed in the new prediction model for 60-day ICU mortality which included APACHE II score, BMI, medical admission and invasive mechanical ventilation. Conclusion Compared with the APACHE II score alone, the new prediction model increases data collection, is more complex but does not substantially improve discriminative ability. Trial registration: ClinicalTrials.gov Identifier: NCT00182143
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Affiliation(s)
- Guowei Li
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, McMaster University, 25 Main St. West, Suite 2000, 20th Floor, Hamilton, ON, L8P 1H1, Canada
| | - Deborah J Cook
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, McMaster University, 25 Main St. West, Suite 2000, 20th Floor, Hamilton, ON, L8P 1H1, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Critical Care Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anne Holbrook
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, McMaster University, 25 Main St. West, Suite 2000, 20th Floor, Hamilton, ON, L8P 1H1, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Noori Akhtar-Danesh
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.,School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rob Taylor
- Mercy Clinic Adult Critical Care, Mercy Hospital Saint Louis, Saint Louis, MO, USA
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Dean Chittock
- Critical Care Medicine, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Peter Dodek
- Center for Health Evaluation and Outcome Sciences and Division of Critical Care Medicine, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | | | - Stephen D Walter
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Mitchell A H Levine
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. .,Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, McMaster University, 25 Main St. West, Suite 2000, 20th Floor, Hamilton, ON, L8P 1H1, Canada. .,Department of Medicine, McMaster University, Hamilton, ON, Canada.
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103
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Goh R, Darvall J, Wynne R, Tatoulis J. Obesity Prevalence and Associated Outcomes in Cardiothoracic Patients: A Single-Centre Experience. Anaesth Intensive Care 2016; 44:77-84. [DOI: 10.1177/0310057x1604400112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The objective of this study was to investigate the prevalence of obesity and its relationship with adverse outcomes in ICU cardiothoracic patients. We performed a retrospective analysis of cardiothoracic patients admitted to The Royal Melbourne Hospital ICU between 2002 and 2014. Eight thousand and sixty-four patients who underwent coronary artery bypass, valve replacement/repair, or both, were divided into six categories of body mass index using World Health Organization criteria. Prevalence of obesity over time in the ICU was measured and compared to prevalence of obesity in the adult Australian population. The association between obesity and adverse postoperative outcomes was then analysed. Obesity is currently 1.2 times more prevalent in the Royal Melbourne Hospital ICU cardiothoracic patients than in the adult Australian population, with 33.5% of patients having a body mass index ≥30 kg/m2. Over time, this was relatively constant, but an increasing proportion were morbidly obese. Obesity, but not morbid obesity, was associated with reduced 30-day mortality (odds ratio [OR] 0.41). Both obese and morbidly obese patients had reduced odds of return to theatre for bleeding (OR 0.49 and OR 0.19, respectively), but increased odds of new-onset renal failure (OR 1.62 and OR 3.17, respectively). Morbidly obese patients had double the odds of an ICU stay longer than 14 days (OR 2.05). In summary, a growing proportion of our obese ICU patients are morbidly obese, with a dramatically increased length of ICU stay. This has major implications for resource allocation in the ICU, and may inform modelling of future bed utilisation. Obesity, but not morbid obesity, conferred a mortality benefit.
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Affiliation(s)
- R. Goh
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria
| | - J. Darvall
- Department of Anaesthesia and Pain Management and Intensive Care Unit, Royal Melbourne Hospital and Senior Lecturer in Medical Education – Critical Care, University of Melbourne, Melbourne, Victoria
| | - R. Wynne
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital and Senior Lecturer, Department of Nursing, University of Melbourne, Parkville, Victoria
| | - J. Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital and University of Melbourne, Parkville, Victoria
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van de Klundert N, Holman R, Dongelmans DA, de Keizer NF. Data Resource Profile: the Dutch National Intensive Care Evaluation (NICE) Registry of Admissions to Adult Intensive Care Units. Int J Epidemiol 2015; 44:1850-1850h. [DOI: 10.1093/ije/dyv291] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 01/04/2023] Open
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105
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Veronese N, Cereda E, Solmi M, Fowler SA, Manzato E, Maggi S, Manu P, Abe E, Hayashi K, Allard JP, Arendt BM, Beck A, Chan M, Audrey YJP, Lin WY, Hsu HS, Lin CC, Diekmann R, Kimyagarov S, Miller M, Cameron ID, Pitkälä KH, Lee J, Woo J, Nakamura K, Smiley D, Umpierrez G, Rondanelli M, Sund-Levander M, Valentini L, Schindler K, Törmä J, Volpato S, Zuliani G, Wong M, Lok K, Kane JM, Sergi G, Correll CU. Inverse relationship between body mass index and mortality in older nursing home residents: a meta-analysis of 19,538 elderly subjects. Obes Rev 2015; 16:1001-15. [PMID: 26252230 DOI: 10.1111/obr.12309] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 06/30/2015] [Indexed: 12/13/2022]
Abstract
Body mass index (BMI) and mortality in old adults from the general population have been related in a U-shaped or J-shaped curve. However, limited information is available for elderly nursing home populations, particularly about specific cause of death. A systematic PubMed/EMBASE/CINAHL/SCOPUS search until 31 May 2014 without language restrictions was conducted. As no published study reported mortality in standard BMI groups (<18.5, 18.5-24.9, 25-29.9, ≥30 kg/m(2)), the most adjusted hazard ratios (HRs) according to a pre-defined list of covariates were obtained from authors and pooled by random-effect model across each BMI category. Out of 342 hits, 20 studies including 19,538 older nursing home residents with 5,223 deaths during a median of 2 years of follow-up were meta-analysed. Compared with normal weight, all-cause mortality HRs were 1.41 (95% CI = 1.26-1.58) for underweight, 0.85 (95% CI = 0.73-0.99) for overweight and 0.74 (95% CI = 0.57-0.96) for obesity. Underweight was a risk factor for higher mortality caused by infections (HR = 1.65 [95% CI = 1.13-2.40]). RR results corroborated primary HR results, with additionally lower infection-related mortality in overweight and obese than in normal-weight individuals. Like in the general population, underweight is a risk factor for mortality in old nursing home residents. However, uniquely, not only overweight but also obesity is protective, which has relevant nutritional goal implications in this population/setting.
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Affiliation(s)
- N Veronese
- Department of Medicine - DIMED, Geriatrics Section, University of Padova, Padova, Italy
| | - E Cereda
- Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - M Solmi
- Department of Neurosciences, University of Padova, Padova, Italy
| | - S A Fowler
- Becker Medical Library, Washington University, St. Louis, MO, USA
| | - E Manzato
- Department of Medicine - DIMED, Geriatrics Section, University of Padova, Padova, Italy.,National Research Council, Institute of Neuroscience, Padova, Italy
| | - S Maggi
- National Research Council, Institute of Neuroscience, Padova, Italy
| | - P Manu
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA.,Hofstra North Shore LIJ School of Medicine, Hempstead, New York, USA.,The Feinstein Institute for Medical Research, Manhasset, New York, USA.,Albert Einstein College of Medicine, Bronx, New York, USA
| | - E Abe
- Gunma University Graduate School of Health Sciences, Maebashi, Gunma, Japan
| | - K Hayashi
- Gunma University Graduate School of Health Sciences, Maebashi, Gunma, Japan
| | - J P Allard
- Toronto General Hospital, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - B M Arendt
- Toronto General Hospital, University Health Network, Toronto, Canada
| | - A Beck
- Research Unit for Nutrition (EFFECT), Herlev University Hospital, Herlev, Denmark
| | - M Chan
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore
| | - Y J P Audrey
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore
| | - W-Y Lin
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - H-S Hsu
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - C-C Lin
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - R Diekmann
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Germany
| | | | - M Miller
- Nutrition and Dietetics, Flinders University, Adelaide, Australia
| | - I D Cameron
- Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, Australia
| | - K H Pitkälä
- Unit of Primary Health Care, Department of General Practice, Helsinki University Central Hospital, Helsinki, Finland
| | - J Lee
- The S. H. Ho Center for Gerontology and Geriatrics, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - J Woo
- The S. H. Ho Center for Gerontology and Geriatrics, The Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - K Nakamura
- Division of Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - D Smiley
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - G Umpierrez
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - M Rondanelli
- Department of Public Health, Experimental and Forensic Medicine, Section of Human Nutrition, Endocrinology and Nutrition Unit, University of Pavia, Pavia, Italy
| | - M Sund-Levander
- Faculty of Health Sciences, University of Linköping, Linköping, Sweden
| | - L Valentini
- Section of Dietetics, Department of Agriculture and Food Sciences, University of Applied Sciences, Neubrandenburg, Germany
| | - K Schindler
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria
| | - J Törmä
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
| | - S Volpato
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - G Zuliani
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - M Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - K Lok
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - J M Kane
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA.,Hofstra North Shore LIJ School of Medicine, Hempstead, New York, USA.,The Feinstein Institute for Medical Research, Manhasset, New York, USA.,Albert Einstein College of Medicine, Bronx, New York, USA
| | - G Sergi
- Department of Medicine - DIMED, Geriatrics Section, University of Padova, Padova, Italy
| | - C U Correll
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA.,Hofstra North Shore LIJ School of Medicine, Hempstead, New York, USA.,The Feinstein Institute for Medical Research, Manhasset, New York, USA.,Albert Einstein College of Medicine, Bronx, New York, USA
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106
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Casaer MP, Ziegler TR. Nutritional support in critical illness and recovery. Lancet Diabetes Endocrinol 2015; 3:734-45. [PMID: 26071886 DOI: 10.1016/s2213-8587(15)00222-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 01/10/2023]
Abstract
An adequate nutritional status is crucial for optimum function of cells and organs, and for wound healing. Options for artificial nutrition have greatly expanded in the past few decades, but have concomitantly shown limitations and potential side-effects. Few rigorous randomised controlled trials (RCTs) have investigated enteral or parenteral nutritional support, and evidence-based clinical guidance is largely restricted to the first week of critical illness. In the early stages of critical illness, whether artificial feeding is better than no feeding intervention has been given little attention in existing RCTs. Expected beneficial effects of various forms of early feeding interventions on rates of morbidity or mortality have generally not been supported by results of recent high-quality RCTs. Thus, whether nutritional interventions early in an intensive care unit (ICU) stay improve outcomes remains unclear. Trials assessing feeding interventions that continue after the first week of critical illness and into the post-ICU and post-hospital settings are clearly needed. Although acute morbidity and mortality will remain important safety parameters in such trials, primary outcomes should perhaps, in view of the adjunctive nature of nutritional intervention in critical illness, be focused on physical function and assessed months or even years after patients are discharged from the ICU. This Series paper is based on results of high-quality RCTs and provides new perspectives on nutritional support during critical illness and recovery.
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Affiliation(s)
- Michael P Casaer
- Intensive Care Department and Laboratory of Intensive Care Medicine, Leuven University Hospitals, Leuven, Belgium.
| | - Thomas R Ziegler
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids and Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA, USA
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107
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Modification of the β-Adrenoceptor Stimulation Pathway in Zucker Obese and Obese Diabetic Rat Myocardium. Crit Care Med 2015; 43:e241-9. [PMID: 26079096 DOI: 10.1097/ccm.0000000000000999] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Although metabolic syndrome is associated with increased sympathetic activity that chronically stimulates β-adrenoceptors, the β-adrenoceptor signaling pathway has been poorly studied in this situation. We studied the β-adrenoceptor signaling pathway in Zucker lean, obese, and obese diabetic rats. DESIGN Experimental, prospective study. SETTING University medical research laboratory. SUBJECTS Adult male Zucker lean (control), obese, and obese diabetic rats. INTERVENTIONS The effects of β-adrenoceptor stimulation were investigated in vitro in isolated left ventricular papillary muscles in control, obese, and obese diabetic rats. β1-, β2-, and β3-adrenoceptors and multidrug resistance-associated protein 4 were quantified by Western Blotting. Triglyceride, cholesterol, leptin, adiponectin, and C-peptide plasma concentrations were measured. Data are mean ± SD. MEASUREMENTS AND MAIN RESULTS Hyperlipidemia, high leptin, and C-peptide concentrations were observed in obese and obese diabetic strains, whereas hyperglycemia occurred only in the diabetic strain. The positive inotropic effect of isoproterenol was slightly reduced in obese rats (183% ± 11% of baseline; p = 0.003; n = 7) and markedly reduced in obese diabetic rats (137% ± 18% of baseline; p < 0.001; n = 10) when compared with control rats (210% ± 17% of baseline; n = 9). β1-adrenoceptors were down-regulated in obese (-41%; p = 0.02) and diabetic (-54%; p = 0.003) when compared with control rats, whereas β3-adrenoceptors and multidrug resistance-associated protein expression remained unchanged. Direct stimulation of adenylate cyclase with forskolin or administration of 3',5'-cyclic adenosine monophosphate suggests that subtle impairments also occurred beside the down-regulation of β1-adrenoceptor. CONCLUSIONS The positive inotropic effect of β-adrenoceptor stimulation is slightly decreased in Zucker obese rats and was more markedly decreased in Zucker diabetic rats. These decreases are mainly related to β1-adrenoceptor down-regulation.
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108
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Karnell LH, Sperry SM, Anderson CM, Pagedar NA. Influence of body composition on survival in patients with head and neck cancer. Head Neck 2015; 38 Suppl 1:E261-7. [PMID: 25545073 DOI: 10.1002/hed.23983] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Recent evidence has suggested links between obesity and outcomes for various types of cancer. This study investigates the impact that body composition has on survival in patients with head and neck cancer. METHODS Data prospectively collected from 578 patients were analyzed using Cox regression models to determine independent associations that pretreatment body mass index (BMI) and 3-month weight change have on observed survival. RESULTS Higher BMIs were associated with better survival (p < .001). Five-year rates ranged from 33.8% for underweight to 75.3% for overweight/obese patients. Patients with stable weight had the highest 5-year rate (72.6%; p = .019), whereas patients who gained ≥5% had worse survival (45.8%) than those who lost ≥5% (65.8%). BMI independently predicted survival, whereas weight change was not an independent predictor. CONCLUSION This demonstrated association between BMI and survival provides useful information when offering prognoses and investigating optimal treatments © 2015 Wiley Periodicals, Inc. Head Neck 38: E261-E267, 2016.
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Affiliation(s)
- Lucy Hynds Karnell
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa College of Medicine, Iowa City, Iowa
| | - Steven M Sperry
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa College of Medicine, Iowa City, Iowa
| | - Carryn M Anderson
- Department of Radiation Oncology, University of Iowa College of Medicine, Iowa City, Iowa
| | - Nitin A Pagedar
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa College of Medicine, Iowa City, Iowa
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109
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Abstract
Obesity is highly prevalent in the United States and is becoming increasingly common worldwide. The anatomic and physiological changes that occur in obese individuals may have an impact across the spectrum of critical illness. Obese patients may be more susceptible to hypoxemia and hypercapnia. During mechanical ventilation, elevated end-expiratory pressures may be required to improve lung compliance and to prevent ventilation-perfusion mismatch due to distal airway collapse. Several studies have shown an increased risk of organ dysfunction such as the acute respiratory distress syndrome and acute kidney injury in obese patients. Predisposition to ventricular hypertrophy and increases in blood volume should be considered in fluid management decisions. Obese patients have accelerated muscle losses in critical illness, making nutrition essential, although the optimal predictive equation to estimate nutritional needs or formulation for obese patients is not well established. Many common intensive care unit medications are not well studied in obese patients, necessitating understanding of pharmacokinetic concepts and consultation with pharmacists. Obesity is associated with higher risk of deep venous thrombosis and catheter-associated bloodstream infections, likely related to greater average catheter dwell times. Logistical issues such as blood pressure cuff sizing, ultrasound assistance for procedures, diminished quality of some imaging modalities, and capabilities of hospital equipment such as beds and lifts are important considerations. Despite the physiological alterations and logistical challenges involved, it is not clear whether obesity has an effect on mortality or long-term outcomes from critical illness. Effects may vary by type of critical illness, obesity severity, and obesity-associated comorbidities.
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110
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Lee SH, Kim MJ, Jeong ES, Jo EJ, Eom JS, Mok JH, Kim MH, Kim KU, Park HK, Lee MK, Lee K. Outcomes and prognostic factors in patients with prolonged acute mechanical ventilation: A single-center study in Korea. J Crit Care 2015; 30:1016-20. [PMID: 26100582 DOI: 10.1016/j.jcrc.2015.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/01/2015] [Accepted: 05/27/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of the study is to evaluate outcomes and objective parameters related to poor prognosis in patients who were defined as prolonged acute mechanical ventilation (PAMV; ventilator care ≥96 hours) in the medical intensive care unit of a university-affiliated tertiary care hospital in Korea. MATERIAL AND METHODS We analyzed retrospectively clinical data gathered from the medical records on day 4 of MV between 2008 and 2013. In total, 311 were categorized as PAMV. RESULTS Their median age was 67 years (range, 18-93 years), and 71.7% were male. The 28-day mortality rate after intensive care unit admission was 34.7%. Four variables on day 4 of mechanical ventilation (need for neuromuscular blockers [hazard ratio {HR}, 2.432; 95% confidence interval, 1.337-4.422], need for vasopressors [HR, 2.312; 95% confidence interval, 1.258-4.248], need for hemodialyses [HR, 1.913; 95% confidence interval, 1.018-3.595], and body mass index ≤21 kg/m(2) [HR, 1.827; 95% confidence interval, 1.015-3.288]) were independent factors associated with mortality based on a Cox proportional hazards model. As the number of these prognostic factors increased, the survival rate decreased. CONCLUSIONS Four clinical factors (body mass index ≤21, requirement for neuromuscular blockers, vasopressors, and hemodialysis) on day 4 of mechanical ventilation were associated with 28-day mortality in PAMV patients.
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Affiliation(s)
- Sang Hee Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Min Ji Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Eun Suk Jeong
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Eun-Jung Jo
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jung Seop Eom
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jeong Ha Mok
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Mi Hyun Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Ki Uk Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Min Ki Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea.
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Erstad BL. Designing drug regimens for special intensive care unit populations. World J Crit Care Med 2015; 4:139-151. [PMID: 25938029 PMCID: PMC4411565 DOI: 10.5492/wjccm.v4.i2.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/06/2014] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
This review is intended to help clinicians design drug regimens for special populations of critically ill patients with extremes of body size, habitus and composition that make drug choice or dosing particularly challenging due to the lack of high-level evidence on which to make well-informed clinical decisions. The data sources included a literature search of MEDLINE and EMBASE with reviews of reference lists of retrieved articles. Abstracts of original research investigations and review papers were reviewed for their relevance to drug choice or dosing in the following special critically ill populations: patients with more severe forms of bodyweight or height, patients with amputations or missing limbs, pregnant patients, and patients undergoing extracorporeal membrane oxygenation or plasma exchange. Relevant papers were retrieved and evaluated, and their associated reference lists were reviewed for citations that may have been missed through the electronic search strategy. Relevant original research investigations and review papers that could be used to formulate general principles for drug choice or dosing in special populations of critically ill patients were extracted. Randomized studies with clinically relevant endpoints were not available for performing quantitative analyses. Critically ill patients with changes in body size, habitus and composition require special consideration when designing medication regimens, but there is a paucity of literature on which to make drug-specific, high-level evidence-based recommendations. Based on the evidence that is available, general recommendations are provided for drug choice or dosing in special critically ill populations.
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113
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Schultze BS, Ridner SH. Death by Sugar: The Impact of Sugar on Acutely Ill Patients. J Nurse Pract 2015. [DOI: 10.1016/j.nurpra.2015.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aantaa R, Tonner P, Conti G, Longrois D, Mantz J, Mulier JP. Sedation options for the morbidly obese intensive care unit patient: a concise survey and an agenda for development. Multidiscip Respir Med 2015; 10:8. [PMID: 25883785 PMCID: PMC4399437 DOI: 10.1186/s40248-015-0007-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/17/2015] [Indexed: 12/13/2022] Open
Abstract
Background We offer some perspectives and commentary on the sedation of obese patients in the intensive care unit (ICU). Discussion Sedation in morbidly obese patients should conform to the same broad principles now current in ICU practice. These include a general presumption against benzodiazepines as first-line agents. Opioids should be avoided in any situation where spontaneous breathing is required. Remifentanil is the preferred agent where continuous stable opioid levels using an infusion are required, because of its lack of context-sensitive accumulation. Volatile anaesthetics may be an option for the same reason but there are no substantial, controlled demonstrations of effectiveness/safety in short-term use in the ICU setting. Propofol is a valuable resource in the morbidly obese patients but the duration of continuous sedation should not exceed 6 days, in order to avoid propofol infusion syndrome. Alpha-2 agonists offer a range of theoretically positive features for the sedation of morbidly obese patients, but at present there is a lack of pharmacokinetic data and a critical mass of high-grade clinical data. Dexmedetomidine has the attraction of not causing respiratory depression or obstructive breathing during sedation and its sympatholytic effects should help deliver stable blood pressure and heart rate. Ketamine has a poor tolerability profile in adults so its use in the ICU context is largely confined to paediatrics. Conclusion None of the agents currently available is ideal for every situation encountered in the management of morbidly obese patients. This article identifies additional research needed to place sedation practice of obese patients on a more systematic footing.
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Affiliation(s)
- Riku Aantaa
- Division of Perioperative Services, Intensive Care, Emergency Care and Pain Medicine, University of Turku, Turku, Finland
| | - Peter Tonner
- Department of Anaesthesiology and Intensive Care Medicine, Emergency Medicine Hospital Links der Weser GmbH, Bremen, Germany
| | - Giorgio Conti
- Department of Intensive Care and Anaesthesiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Dan Longrois
- Université Paris-Diderot, Hôpitaux Universitaires Paris Nord Val de Seine, Département d'Anesthésie Réanimation Chirurgicale, Hôpital Bichat-Claude Bernard, Paris, France
| | - Jean Mantz
- Anaesthesiology Department, Beaujon Hospital, AP-HP, Université Paris-Diderot, Paris, France
| | - Jan P Mulier
- Department of Anaesthesiology, Intensive and Emergency Care, Sint Jan Brugge-Oostende, Ruddershove 10, Brugge, 8000 Belgium
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Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Management of the Gastrointestinal Tract and Nutrition in the Geriatric Surgical Patient. Surg Clin North Am 2015; 95:85-101. [DOI: 10.1016/j.suc.2014.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Teitelbaum DH, Guenter P, Griebel D, Abrams SA, Bark S, Baker M, Berry KL, Bistrian BR, Brenna JT, Bonnot D, Carpentier YA, Deckelbaum RJ, Hise M, Koletzko B, Mirtallo JM, Mulberg AE, O'Reilly RC, Shaffer J, von Kleist E, Zaloga GP, Ziegler TR. Proceedings From FDA/A.S.P.E.N. Public Workshop: Clinical Trial Design for Intravenous Fat Emulsion Products, October 29, 2013. JPEN J Parenter Enteral Nutr 2014; 39:768-86. [PMID: 25475623 DOI: 10.1177/0148607114560825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/23/2014] [Indexed: 01/08/2023]
Abstract
The development of intravenous fat emulsion (IVFE) is the culmination of physiological, biochemical, nutritional, and medical scientific advancements. IVFEs have the ability to deliver critical nutritional substrates to the patient. Recent literature purports that they may also play roles in modulation of immune functionality and pulmonary physiology, but data supporting these potential benefits are limited. While soybean-based IVFEs have comprised the dominant fat in U.S. markets, a number of other novel IVFEs may prove to optimize the care of children and adults in both hospitalized and home settings. The October 2013 U.S. Food and Drug Administration (FDA)/American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Public Workshop brought together scientists, researchers, and clinical experts to present updated clinical perspectives of IVFEs, including historical development, current state of usage throughout the world, and considerations for the regulatory approval of new IVFEs in the United States.
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Affiliation(s)
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland
| | - Donna Griebel
- Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Steven A Abrams
- Department of Pediatrics, Sections of Neonatology and USDA/ARS Children's Nutrition Research Center, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Staffan Bark
- Department of Surgery, Karolinska Institute, Stockholm, Sweden, and Department of Surgery, Visby Hospital, Visby, Sweden
| | | | - Karyn L Berry
- Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Bruce R Bistrian
- Harvard Medical School, Clinical Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - J Thomas Brenna
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Denis Bonnot
- Scientific Affairs, Business Unit, Parenteral Nutrition & Colloids, Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany
| | - Yvon A Carpentier
- Free University of Brussels (Université Libre de Bruxelles) and Lipid Nutrition Center, Brussels, Belgium
| | - Richard J Deckelbaum
- Department of Pediatrics and Epidemiology, Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Mary Hise
- Baxter Healthcare, Deerfield, Illinois
| | - Berthold Koletzko
- Dr von Hauner Children's Hospital, University of Munich Medical Centre, Germany
| | - Jay M Mirtallo
- The Ohio State University, College of Pharmacy, Ohio State University, Columbus, Ohio
| | - Andrew E Mulberg
- Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | - Jonathan Shaffer
- Intestinal Failure Unit, Salford Royal Hospital, University of Manchester, United Kingdom
| | - Elke von Kleist
- Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | | | - Thomas R Ziegler
- Division of Endocrinology, Metabolism and Lipids and Emory Center for Clinical and Molecular Nutrition, Emory University Hospital, Atlanta, Georgia
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Abstract
BACKGROUND Obesity rates are increasing worldwide, particularly in North America. The impact of obesity on the outcome of critically ill patients is unclear. METHODS A prospective observational cohort study of consecutive patients admitted to a tertiary critical care unit in Canada between January 10, 2008 and March 31, 2009 was conducted. Exclusion criteria were age <18 years, admission <24 h, planned cardiac surgery, pregnancy, significant ascites, unclosed surgical abdomen and brain death on admission. Height, weight and abdominal circumference were measured at the time of intensive care unit (ICU) admission. Coprimary end points were ICU mortality and a composite of ICU mortality, reintubation, ventilator-associated pneumonia, line sepsis and ICU readmission. Subjects were stratified as obese or nonobese, using two separate metrics: body mass index (BMI) ≥ 30 kg/m(2) and a novel measurement of 75th percentile for waist-to-height ratio (WHR). RESULTS Among 449 subjects with a BMI ≥ 18.5 kg/m(2), both BMI and WHR were available for comparative analysis in 348 (77.5%). Neither measure of obesity was associated with the primary end points. BMI ≥ 3 0 kg/m(2) was associated with a lower odds of six-month mortality than the BMI <30 kg/m(2) group (adjusted OR 0.59 [95% CI 0.36 to 0.97]; P=0.04) but longer intubation times (adjusted RR 1.56 [95% CI 1.17 to 2.07]; P=0.003) and longer ICU length of stay (adjusted RR 1.67 [95% CI 1.21 to 2.31]; P=0.002). Conversely, measurement of 75th percentile for WHR was associated only with decreased ICU readmission (OR 0.23 [95% CI 0.07 to 0.79]; P=0.02). CONCLUSIONS Obesity was not necessarily associated with worse outcomes in critically ill patients.
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The "obesity-mortality paradox" in severely traumatic patients in intensive care unit. Injury 2014; 45:1799. [PMID: 24231076 DOI: 10.1016/j.injury.2013.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 10/11/2013] [Indexed: 02/02/2023]
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Abstract
This article discusses obesity, its contribution to clinical outcomes, and the current literature on nutrition. More than one third of Americans are obese. Literature suggests that, among critically ill patients, the relationship between obesity and outcomes is complex. Obese patients may be at greater risk of developing acute respiratory distress syndrome (ARDS) than normal weight patients. Although obesity may confer greater morbidity in intensive care, it seems to decrease mortality. ARDS is a catabolic state; patients demonstrate a profound inflammatory response, multiple organ dysfunction, and hypermetabolism, often with malnutrition. The concept of pharmaconutrition has emerged.
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Affiliation(s)
- Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont, 149 Beaumont Avenue, Burlington, VT 05405, USA.
| | - Benjamin T Suratt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont, 149 Beaumont Avenue, Burlington, VT 05405, USA
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Felizardo RJF, Silva MBD, Aguiar CF, Câmara NOS. Obesity in kidney disease: A heavyweight opponent. World J Nephrol 2014; 3:50-63. [PMID: 25332896 PMCID: PMC4202492 DOI: 10.5527/wjn.v3.i3.50] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/18/2014] [Accepted: 06/11/2014] [Indexed: 02/05/2023] Open
Abstract
Obesity is an important worldwide challenge that must be faced in most developed and developing countries because of unhealthy nutritional habits. The consequences of obesity and being overweight are observed in different organs, but the kidney is one of the most affected. Excess adipose tissue causes hemodynamic alterations in the kidney that can result in renal disease. However, obesity is also commonly associated with other comorbidities such as chronic inflammation, hypertension and diabetes. This association of several aggravating factors is still a matter of concern in clinical and basic research because the pathophysiologic mechanisms surrounding chronic kidney disease development in obese patients remain unclear. This review will discuss the consequences of obesity in the context of renal injury.
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Adler D, Dupuis-Lozeron E, Richard JC, Janssens JP, Brochard L. Does Inspiratory Muscle Dysfunction Predict Readmission after Intensive Care Unit Discharge? Am J Respir Crit Care Med 2014; 190:347-50. [DOI: 10.1164/rccm.201404-0655le] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Prince NJ, Brown KL, Mebrahtu TF, Parslow RC, Peters MJ. Weight-for-age distribution and case-mix adjusted outcomes of 14,307 paediatric intensive care admissions. Intensive Care Med 2014; 40:1132-9. [PMID: 25034475 PMCID: PMC4107282 DOI: 10.1007/s00134-014-3381-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 06/19/2014] [Indexed: 11/29/2022]
Abstract
Aims To determine whether the paediatric intensive care (PIC) population weight distribution differs from the UK reference population and whether weight-for-age at admission is an independent risk factor for mortality. Methods Admission weight-for-age standard deviation scores (SDS) were calculated for all PIC admissions (March 2003–December 2011) to Great Ormond Street Hospital: this is the number of standard deviations (SD) between a child’s weight and the UK mean weight-for-age. Categorised into nine SDS groups, standardised mortality ratios (SMR) and logistic regression were used to assess the relationship between weight-for-age at admission and risk-adjusted mortality. Results Out of 12,458 admissions, mean weight-for-age was 1.04 SD below the UK reference population mean (p < 0.0001). Based on 942 deaths, risk-adjusted mortality was lowest in those with mild-to-moderately raised weight-for-age (SDS 0.5–2.5) and highest in children with extreme under- or overweight (SDS < −3.5 and SDS > +3.5). Logistic regression indicated that age, gender, ethnicity and weight-for-age are independent risk factors for mortality. South Asian and ‘other’ ethnicities had significantly increased risk of death compared to children of white and black ethnic origin. Conclusion The PIC population mean weight-for-age is significantly lower than the UK reference mean. The extremes of weight-for-age are over-represented, especially underweight. Weight-for-age at admission is an independent risk factor for mortality. A U-shaped association between weight and risk-adjusted mortality exists, with the lowest risk of death in children who are mild-to-moderately overweight. Future studies should determine the impact of malnutrition on risk-adjusted mortality and investigate the aetiology of risk disparities with ethnicity. Electronic supplementary material The online version of this article (doi:10.1007/s00134-014-3381-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicholas J Prince
- Respiratory Critical Care and Anaesthesia Unit, Institute of Child Health, University College London, London, WC1N 1EH, UK,
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Development of a murine model of early sepsis in diet-induced obesity. BIOMED RESEARCH INTERNATIONAL 2014; 2014:719853. [PMID: 24967393 PMCID: PMC4054609 DOI: 10.1155/2014/719853] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/25/2014] [Indexed: 12/15/2022]
Abstract
Sepsis, a global health issue, is the most common cause of mortality in the intensive care unit. The aim of this study was to develop a new model of sepsis that investigates the impact of prolonged western diet (WD) induced obesity on the response to early sepsis. Male C57BL/6 mice were fed either a high fat WD or normal chow diet (NCD) for 6, 15, or 27 weeks. Septic obese mice at 15 and 27 weeks had significantly lower levels of lung myeloperoxidase (26.3 ± 3.80 U/mg tissue) compared to age matched ad lib (44.1 ± 2.86 U/mg tissue) and diet restricted (63.2 ± 5.60 U/mg tissue) controls. Low levels of lung inflammation were not associated with changes in hepatic cytokines and oxidative stress levels. Obese mice had significantly (P < 0.0001) larger livers compared to controls. Histological examination of the livers demonstrated that WD fed mice had increased inflammation with pronounced fat infiltration, steatosis, and hepatocyte ballooning. Using this model of prolonged exposure to high fat diet we have data that agree with recent clinical observations suggesting obese individuals are protected from sepsis-induced lung injury. This model will allow us to investigate the links between damage to the hepatic microcirculation, immune response, and lung injury.
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Buck DL, Møller MH. Influence of body mass index on mortality after surgery for perforated peptic ulcer. Br J Surg 2014; 101:993-9. [PMID: 24828155 DOI: 10.1002/bjs.9529] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 12/03/2013] [Accepted: 03/11/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Body mass index (BMI) is a strong predictor of mortality in the general population. In spite of the medical hazards of obesity, a protective effect on mortality has been suggested in surgical patients: the obesity paradox. The aim of the present nationwide cohort study was to examine the association between BMI and mortality in patients treated surgically for perforated peptic ulcer (PPU). METHODS This was a national prospective cohort study of all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009, for whom BMI was registered. Non-surgically treated patients and those with malignant ulcers were excluded. The primary outcome measure was 90-day mortality. The association between BMI and mortality was calculated as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.). RESULTS Of 2668 patients who underwent surgical treatment for PPU, 1699 (63.7 per cent) had BMI recorded. Median age was 69.4 (range 17.6-100.9) years and 53.7 per cent of the patients were women. Some 1126 patients (66.3 per cent) had at least one of six co-morbid diseases; 728 (42.8 per cent) had an American Society of Anesthesiologists grade of III or more. A total of 471 patients (27.7 per cent) died within 90 days of surgery. Being underweight was associated with a more than twofold increased risk of death following surgery for PPU (adjusted RR 2.26, 95 per cent c.i. 1.37 to 3.71). No statistically significant association was found between obesity and mortality. CONCLUSION Being underweight was associated with increased mortality in patients with PPU, whereas being overweight or obese was neither protective nor an adverse prognostic factor.
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Affiliation(s)
- D L Buck
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Herlev
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Gonzalez MC, Pastore CA, Orlandi SP, Heymsfield SB. Obesity paradox in cancer: new insights provided by body composition. Am J Clin Nutr 2014; 99:999-1005. [PMID: 24572565 DOI: 10.3945/ajcn.113.071399] [Citation(s) in RCA: 218] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Obesity, defined by body mass index (BMI), appears to have a paradoxical protective effect in several chronic diseases. OBJECTIVE We investigated the obesity paradox in cancer patients by using body composition. DESIGN The study was an observational study of 175 cancer patients assessed before chemotherapy. Obesity was defined as BMI (in kg/m(2)) ≥30 or fat mass index (FMI; fat mass divided by the square of height) ≥5.2 (men) and ≥8.2 (women) measured by using a bioelectrical impedance analysis. Low muscle mass (sarcopenia) was defined as fat-free mass index (fat-free mass divided by the square of height) <17.5 (men) and <15.1 (women). RESULTS Most patients were women (65.7%) and had a mean (±SD) age of 56.9 ± 12.8 y. According to BMI criteria, 60% of patients were overweight or obese. The median survival time for overweight (2.64 y; range: 0.23-3.16 y) and obese (2.61 y; range: 0.26-3.20 y) patients was significantly higher than for patients with a normal (2.04 y; range: 0.06-3.05 y) or low (0.52 y; range: 0.19-0.98 y) BMI (P < 0.001). Sarcopenic patients had shorter survival, regardless of their FMI. Obesity predicted higher survival rates only when sarcopenia was absent. In a multivariate Cox regression model, sarcopenia was an independent predictor of higher mortality (HR: 5.19; 95% CI: 2.58, 10.43) after we controlled for BMI, age, and tumor stage. CONCLUSIONS The obesity paradox is present in cancer patients only when obesity is defined by BMI. Patients with sarcopenic obesity had the poorest prognosis. Cancer patients with high mortality risk can be identified by a body-composition assessment.
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Affiliation(s)
- Maria Cristina Gonzalez
- Postgraduation Program on Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil (MCG); the Nutrition College of Nutrition, Federal University of Pelotas, Pelotas, Brazil (CAP and SPO); the Pennington Biomedical Research Center, Baton Rouge, LA (SBH and MCG); and the Study Group on Body Composition and Nutrition, COCONUT (MCG, CAP, and SPO)
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SWOL J, BUCHWALD D, DUDDA M, STRAUCH J, SCHILDHAUER TA. Veno-venous extracorporeal membrane oxygenation in obese surgical patients with hypercapnic lung failure. Acta Anaesthesiol Scand 2014; 58:534-8. [PMID: 24588415 DOI: 10.1111/aas.12297] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND In patients with a body mass index (BMI) > 35 kg/m(2) , or in extreme cases weighting > 250 kg, we are faced with special challenges in therapy and logistics. The aim was to analyze the feasibility of the extracorporeal membrane oxygenation (ECMO) in these patients. METHODS We report 12 adult patients [10 male, 2 female; mean age 56.7 (34-74) years; mean BMI 47.9 (35-88.6) kg/m(2) ] with acute lung failure treated with veno-venous ECMO from 1 January 2009 to 30 June 2013. All patients were cannulated percutaneously into the right internal jugular vein and one of the femoral veins at the bedside. RESULTS The mean time to ECMO after admission to the intensive care unit (ICU) was 2 days (0-10), and the mean ECMO run time was 9 days (4 h-20 days). Lung failure occurred in the contexts of wound infection (two patients), anaphylactic shock (one patient), major trauma (one patients) and pneumonia after surgery (four patients), and respiratory failure in abdominal sepsis (four patients). The mean time in the ICU was 31 days (0-89), and the mean time at the hospital was 38 days (0-101). Three patients died on the system because of multiorgan failure; nine patients were weaned from ECMO (75%); and six were patients discharged from the ICU and from the hospital (survival rate 50%). CONCLUSIONS ECMO in obese patients is feasible and life saving. Therefore, a percutaneous cannulation remains feasible. The goals of the ECMO therapy include early spontaneous breathing, tracheotomy, rapid reduction of sedation and adequate analgesia. Rehabilitation includes nutritional therapy, as well as psychiatric therapy and bariatric surgery, as perspectives for the future.
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Affiliation(s)
- J. SWOL
- Department of Surgery; University Hospital Bergmannsheil; Bochum Germany
| | - D. BUCHWALD
- Department of Cardiac and Thoracic Surgery; University Hospital Bergmannsheil; Bochum Germany
| | - M. DUDDA
- Department of Surgery; University Hospital Bergmannsheil; Bochum Germany
| | - J. STRAUCH
- Department of Cardiac and Thoracic Surgery; University Hospital Bergmannsheil; Bochum Germany
| | - T. A. SCHILDHAUER
- Department of Surgery; University Hospital Bergmannsheil; Bochum Germany
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Yang YM, Shao XH, Zhu J, Zhang H, Liu Y, Gao X, Liu LS, Yu LT, Zhao L, Yu PF, Zhang H, He Q, Gu XD. Risk factors and incidence of stroke and MACE in Chinese atrial fibrillation patients presenting to emergency departments: A national wide database analysis. Int J Cardiol 2014; 173:242-7. [DOI: 10.1016/j.ijcard.2014.02.040] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 02/15/2014] [Accepted: 02/22/2014] [Indexed: 11/27/2022]
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The authors reply. Crit Care Med 2014; 42:e253. [PMID: 24534993 DOI: 10.1097/ccm.0000000000000182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The authors reply. Crit Care Med 2014; 42:e254-5. [PMID: 24534995 DOI: 10.1097/ccm.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The authors reply. Crit Care Med 2014; 42:e81-2. [PMID: 24346549 DOI: 10.1097/ccm.0000000000000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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135
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Does the association between a high body mass index and hospital mortality weigh "heavily" on the association between a low body mass index and hospital mortality? Crit Care Med 2014; 42:e79. [PMID: 24346546 DOI: 10.1097/ccm.0000000000000011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The "obesity-mortality paradox" phenomenon in critically ill patients: one size does not fit all. Crit Care Med 2014; 42:e80-1. [PMID: 24346548 DOI: 10.1097/ccm.0000000000000019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Particularités de la ventilation chez le patient obèse. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0832-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Soh S, Park JH, Kim JM, Lee MJ, Koh SO, Paik HC, Park MS, Na S. Predicting Delayed Ventilator Weaning after Lung Transplantation: The Role of Body Mass Index. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.4.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Ha Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Min Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Jung Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Ok Koh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Chae Paik
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moo Suk Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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140
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Hafner S, Hillenbrand A, Knippschild U, Radermacher P. The obesity paradox and acute kidney injury: beneficial effects of hyper-inflammation? Crit Care 2013; 17:1023. [PMID: 24326122 PMCID: PMC4059416 DOI: 10.1186/cc13152] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In the general population, obesity is associated with an increased mortality risk, whereas several epidemiological studies demonstrated a protective effect of obesity in critically ill patients. In this context, Sleeman and colleagues investigated the effects of obesity on kidney function in a well-established porcine model of cardiopulmonary bypass. The authors confirm literature data that obesity per se is associated with a chronic hyper-inflammatory status. Nevertheless, obese swine undergoing the surgical procedure presented with attenuated kidney dysfunction and tissue apoptosis. The authors suggest that the chronic inflammation causes pre-conditioning against excessive acute hyper-inflammation. The authors have to be commended for using a long-term, clinically relevant model that, moreover, addresses a variety of putative mechanisms. The study is discussed in the context of the controversial findings that, in contrast to the existing literature on improved survival, most studies available suggest a higher incidence and severity of acute kidney injury in obese patients when compared with lean controls.
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Affiliation(s)
- Sebastian Hafner
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Klinik für Anästhesiologie, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany
| | - Andreas Hillenbrand
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Uwe Knippschild
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Peter Radermacher
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Klinik für Anästhesiologie, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany
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141
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Orloff MS, Dokus MK. It is more than just size: obesity and transplantation. Liver Transpl 2013; 19:790-5. [PMID: 23840031 DOI: 10.1002/lt.23705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 06/27/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Mark S. Orloff
- Division of Solid Organ Transplant; University of Rochester Medical Center; Rochester NY
| | - M. Katherine Dokus
- Division of Solid Organ Transplant; University of Rochester Medical Center; Rochester NY
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Sekine H. [An immunohistochemical study of various breast tissues using CA15-3 (MAb 115D8 and MAb DF3)]. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 1987; 18:R12. [PMID: 24410863 PMCID: PMC4028783 DOI: 10.1186/cc13189] [Citation(s) in RCA: 285] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 01/03/2014] [Indexed: 12/18/2022]
Abstract
A CA15-3 RIA KIT, composed with two different monoclonal antibodies (115D 8 and DF 3), has been seen to react with the sera of breast cancer patients. Although the subclass of both antibodies is different, the antigen that reacted with them seems to be same, with a range from 300-450 kd. To reveal the reacting pattern of both antibodies, an immunohistochemical study was performed involving various breast tissues. In general, normal and benign breast tumors exhibited an apical stain by 115D8 and an apical and focal cytosol stain by DF 3. Breast carcinomas displayed not only an apical stain but a strong cytosol stain. However, the staining patterns showed little difference.
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