Obesity in the critically ill: a narrative review

Beyond body mass index: exploring the role of visceral adipose tissue in intensive care unit outcomes

Obesity is a worldwide health crisis and poses significant challenges in critical care. Many studies suggest an 'obesity paradox', in which obesity, defined by body mass index (BMI), is associated with better outcomes. However, the inability of BMI to discriminate between fat and muscle or between visceral adipose tissue and subcutaneous adipose tissue, limits its prediction of metabolic ill health. We suggest that the 'obesity paradox' may be more reflective of the limitations of BMI than the protective effect of obesity. We explore the biological processes leading to visceral fat accumulation, and the evidence linking it to outcomes in critical illness. In the 'spillover' hypothesis of adipose tissue expansion, caloric excess and impaired expansion of storage capacity in the subcutaneous adipose tissue lead to accumulation of visceral adipose tissue. This is associated with a chronic inflammatory state, which is integral to the link between visceral adiposity, type 2 diabetes mellitus, and ischaemic heart disease. We review the current evidence on visceral adiposity and critical illness outcomes. In COVID-19, increased visceral adipose tissue, irrespective of BMI, is associated with more severe disease. This is mirrored in acute pancreatitis, suggesting visceral adiposity is linked to poorer outcomes in some hyperinflammatory conditions. We suggest that visceral adiposity's chronic inflammatory state may potentiate acute inflammation in conditions such as COVID-19 and acute pancreatitis. Further work is required to investigate other critical illnesses, especially sepsis and acute respiratory distress syndrome, in which current evidence is scarce. This may give further insights into pathophysiology and inform tailored treatment and nutrition strategies based on body fat distribution.

Pronounced effects of the sepsis-obesity paradox in elderly and male individuals without septic shock and the role of immune-inflammatory status: an analysis of MIMIC-IV data

BACKGROUND

Obesity has been shown to reduce short-term mortality in sepsis patients, but the main subgroups and its role in immune-related inflammatory status require further research. The aim of this study was to identify the primary beneficiaries of the sepsis-obesity paradox and to investigate the involvement of immune-inflammatory status.

METHODS

In this study, we analyzed data from 6602 sepsis patients from the MIMIC-IV database. Body mass index (BMI) was divided into quartiles, and mortality rates were assessed for each interval. Logistic trend tests and subgroup and restricted cubic spline (RCS) analyses were performed. Blood biochemical indicators were compared across different BMI ranges and between survivors and non-survivors. The receiver operating characteristic (ROC) curve for 28-day mortality was also evaluated.

RESULTS

The 28-day mortality of sepsis patients followed a U-shaped pattern with increasing BMI. Trend analysis confirmed that BMI was a significant risk factor for 28-day mortality (p < 0.05). Subgroup analysis revealed an interactive effect of BMI on 28-day mortality in elderly (≥ 65 years old), male, and non-septic shock individuals (p < 0.05). A higher BMI was associated with an increased lymphocyte proportion and decreased neutrophil proportion, neutrophil-to-lymphocyte ratio (NLR), and systemic immune-inflammation index (SII) (p < 0.05). Compared with survivors, non-survivors had lower lymphocyte proportions and higher neutrophil proportions, NLRs, and SIIs. ROC analysis revealed that the lymphocyte and neutrophil proportions, NLR, and SII had predictive value for 28-day mortality. Subgroup and RCS analyses revealed that increased BMI was associated with reduced 28-day mortality in sepsis patients, mainly in elderly, male, and septic shock individuals, with protective BMIs ranging from 27.8 ~ 41.7 kg/cm2, 28.4 ~ 37.7 kg/cm2, and > 28.6 kg/cm2, respectively.

CONCLUSIONS

The sepsis-obesity paradox significantly affects elderly (≥ 65 years old), male, and non-septic shock individuals, displaying a U-shaped pattern for 28-day mortality. BMI may mediate this phenomenon by influencing the body's immune-inflammatory status.

Association of obesity on short- and long-term survival in patients with moderate to severe pneumonia-related ARDS: a retrospective cohort study

BACKGROUND

The incidence of obesity among patients admitted to the intensive care unit (ICU) is increasing, and pneumonia remains the leading cause of acute respiratory distress syndrome (ARDS). The association of obesity on both short- and long-term outcomes in patients with pneumonia-induced ARDS has been the subject of only limited research.

METHODS

We conducted a retrospective analysis of a prospective cohort consisting of ARDS patients who had microbiologically confirmed pneumonia and a PaO2/FiO2 ratio ≤ 150 mmHg. Patients were assessed for mortality at 28 days, 90 days, and at 1 year from the diagnosis of ARDS and compared between obese defined by a body mass index (BMI) ≥ 30 kg.m2 and non-obese patients. Models were adjusted for age, sex, COPD, coronary artery disease, immunodepression, severity score and acute kidney injury on admission to the ICU, severity of ARDS (PaO2/FiO2 ratio ≤ 100 mmHg), severe hypercapnia (PaCO2 ≥ 50 mmHg), ventilatory ratio and plateau pressure the first day of ARDS, influenza, COVID-19, pneumocystosis, and bacteria involved in pneumonia. We also investigated the continuous spectrum of BMI on the risk of mortality.

RESULTS

Of 603 patients, 227 patients (37.6%) were obese. Obesity was associated with female gender (p = 0.009), hypertension (p < 0.001), diabetes mellitus (p < 0.001), COVID-19 pneumonia (p = 0.008), and PaO2/FiO2 ratio ≤ 100 mmHg (p = 0.006). Obesity was independently associated with lower mortality at 28 days (adjusted Odds Ratio (OR) 0.55, 95% confident interval (CI) 0.33-0.90, p = 0.02) but not at 90 days (adjusted OR 0.70, 95% CI 0.45-1.09, p = 0.11) nor at 1 year from the diagnosis of ARDS (adjusted OR 0.73, 95% CI 0.47-1.13, p = 0.16). Mortality at 28 days was significantly lower in obese patients than in non-obese patients when propensity score matching was used (15.2% versus 22%, p = 0.04). BMI was also independently associated with lower mortality at 28 days (p = 0.038) but not with mortality at 90 days (p = 0.12) and 1 year (p = 0.12).

CONCLUSION

Our results suggest that in patients with pneumonia-related ARDS, obesity is independently associated with better survival at 28 days but not at 90 days and 1 year from the diagnosis of ARDS.

The Association Between Body Mass Index and 28-day Mortality in Patients With Sepsis: A Retrospective Cohort Study

BackgroundSepsis is a severe clinical syndrome with high morbidity and mortality in intensive care units (ICUs). Body Mass Index (BMI) shows a rising trend of obese patients being admitted to ICUs. The relationship between BMI and the clinical outcome of sepsis remains highly debated.MethodsThe data used in this study were sourced from the Intensive Care Information Center IV (MIMIC-IV) database. Baseline information extracted within 24 hours of ICU admission was categorized according to World Health Organization (WHO)'s BMI classifications. A multivariate Cox regression model and curve fitting assessed the independent correlation between BMI and the primary outcome.ResultsA total of 7836 patients were included in the study and categorized into five groups based on BMI. The overall 28-day mortality rate was 21.94% (1719/7836). Class I obesity (17.14%) and class II/III obesity (13.49%) individuals tended to be younger and male. Compared to patients with normal BMI (32.55%), those with low BMI (5.79%) had a 47% increased risk of 28-day mortality (HR 1.47, 95% CI 1.16-1.85, P = 0.0013), while class II/III obesity patients had a 17% lower 28-day mortality rate (HR 0.83, 95% CI 0.71-0.97, P = 0.0218). Curve fitting revealed a nonlinear relationship between BMI and 28-day mortality. The Kaplan-Meier survival analysis highlighted variations in survival rates across the five groups (P = 0.0123), with underweight patients exhibiting poorer survival outcomes.ConclusionIn sepsis patients, a low BMI is related to higher 28-day mortality compared to those with a normal BMI. Conversely, patients with a BMI≥35 kg/m2 have significantly reduced mortality risks.

Exploring dietitians' experiences caring for patients living with obesity in acute care: a qualitative study

BACKGROUND

Obesity is a modifiable risk factor associated with hospital-associated complications. Recent studies show there is a high prevalence of patients with obesity presenting to hospital and evidence indicates that people living with obesity should receive diet advice from a dietitian; however, patients often do not receive this care in acute settings.

AIM

The primary aim of this study was to explore the experiences of dietitians caring for patients living with obesity in acute hospital settings.

METHODS

A multi-site qualitative study was conducted from October 2021 to November 2023 in Melbourne, Australia. Constructivist grounded theory methodology informed sampling and data collection. Semi-structured interviews were undertaken with dietitians working in acute care. Data were analysed using open coding and constant comparison underpinned by Charmaz's framework.

RESULTS

Interviews were conducted with 25 dietitians working across four hospitals. The theory developed from the data describes an enculturated decision-making process whereby acute clinical dietitians are limiting acute nutrition care for people living with obesity in hospital. The theory includes five interdependent categories that influence clinical decision-making and practice: (1) culture of professional practice, (2) science and evidence, (3) acknowledgement of weight bias and stigma, (4) dietitian-led care and (5) hospital systems and environment.

CONCLUSION

The findings from this study provide new insights as to why dietitians may not be providing acute nutrition care for people living with obesity. Strategic leadership from clinical leaders and education providers together with the lived experience perspectives of people with obesity is needed to shift the culture of dietetic professional practice to consider all nutrition care needs of patients living with obesity who are accessing acute hospitals for health care.

Why One-Size-Fits-All Doesn't Work in Intensive Care Unit Nutrition?

Nutrition therapy is a complex intervention with several underlying considerations that may influence effectiveness. Considerations include the mechanism of action of the intervention and the patient phenotype, including sex, ethnicity, body composition, and the patients' nutritional and inflammatory status. Energy and protein targets are elements of nutrition therapy that may be particularly influenced by individual patient factors. Biomarkers may provide a useful tool to monitor and individualize nutrition therapy in the future. The considerations mentioned, with many yet to be studied, highlight the rationale for more individualized interventions moving away from a 'one-size-fits-all' approach.

Obesity is associated with progressive brain structural changes

OBJECTIVE

The aim of this study was to investigate the relationship between obesity (OB) progression and brain structural changes.

METHODS

T1-weighted magnetic resonance images were acquired from 258 participants with overweight (OW) or OB and 74 participants with normal weight. Participants with OW or OB were divided into four groups according to BMI grades. Two-sample t tests compared disparities between the four subgroups and the participants with normal weight. We used causal structural covariance networks to examine the progressive impact of OB on brain structure.

RESULTS

With increasing BMI values, reductions in gray matter volume originated in the left caudate nucleus, medial orbitofrontal cortex, and left insula and expanded to the right hippocampus and left lateral orbitofrontal cortex and then to the right parahippocampal gyrus, left precuneus, and left dorsolateral prefrontal cortex (p < 0.05, false discovery rate corrected). The left caudate nucleus and medial orbitofrontal cortex are the primary hubs of the directional network, exhibiting positive causality to the right hippocampus and left dorsolateral prefrontal cortex. Moreover, the right hippocampus is identified as an important transition hub.

CONCLUSIONS

These findings suggest that changes in gray matter volume in individuals with OB may originate from reward/motivation processing regions, subsequently progressing to inhibitory control/learning memory regions, providing a new reference direction for clinical intervention and treatment of OB.

Exploring differential miRNA expression profiles in muscular and visceral adipose tissue of patients with severe obesity

BACKGROUND

This study aims to investigate the differential miRNA expression profile between the visceral white adipose tissue and the skeletal muscle of people with obesity undergoing bariatric surgery.

METHODS

Skeletal muscle and visceral adipose tissue samples of 10 controls and 38 people with obesity (50% also with type 2 diabetes) undergoing bariatric surgery were collected. miRNA expression profiles were analyzed using Next-Generation Sequencing and subsequently validated using RT-PCR.

RESULTS

Approximately 69% of miRNAs showed similar expression in both tissues, however, 55 miRNAs were preferentially expressed in visceral adipose tissue and 53 in skeletal muscle. miR-122b-5p was uniquely identified in skeletal muscle, while miR-1-3p and miR-206 were upregulated in skeletal muscle. Conversely, miR-224-5p and miR-335-3p exhibited upregulation in visceral adipose tissue. Notably, distinctions related to the presence of type 2 diabetes were observed solely in the expression of miR-1-3p and miR-206 in visceral adipose tissue.

CONCLUSIONS

This is the first study unveiling distinct miRNA expression profiles in paired samples of visceral adipose tissue and skeletal muscle in humans. The identification of obesity-specific miRNAs in these tissues opens up promising avenues for research into potential biomarkers for obesity diagnosis and treatment.

Mechanical power of ventilation and survival in critically ill obese patients

BACKGROUND

Obesity complicates mechanical ventilation due to altered respiratory mechanics, raising the risk of ventilator-induced lung injury (VILI). Mechanical power (MP) quantifies the energy transferred from the ventilator to the lungs per unit time, incorporating factors such as tidal volume, airway pressures, respiratory rate, and PEEP. The role of mechanical power as a predictor of outcomes in critically obese patients remains uncertain.

METHODS

This retrospective cohort study analyzed data from the MIMIC-IV database, including 1860 obese patients (BMI ≥ 30 kg/m2) on mechanical ventilation for at least 48 h. Mechanical power was calculated over the first and second 24-h intervals, with time-weighted averages considered. Logistic regression, propensity score matching, and inverse probability of treatment weighting were employed to assess the relationships between mechanical power and hospital mortality.

RESULTS

A total of 1860 patients were included in the final analysis, of whom 539 (29.0 %) experienced in-hospital mortality. The median mechanical power during the second 24 h of ventilation was 15.50 J/min [10.54, 21.45], while the time-weighted average mechanical power was 16.12 J/min [11.75, 20.94]. No significant association was found between mechanical power during the second 24 h of ventilation and hospital mortality (OR 0.99, 95 % CI 0.97-1.00). However, time-weighted average mechanical power was associated with hospital length of stay (OR 0.98, 95 % CI 0.96-1.00). Additionally, the duration of mechanical ventilation emerged as a significant predictor of hospital mortality, whereas mechanical power alone did not significantly impact ICU or 28-day mortality.

CONCLUSIONS

Mechanical power did not predict hospital mortality in critically ill obese patients, suggesting the need for tailored ventilatory strategies focusing on both mechanical power and exposure duration.

AI-powered model for predicting mortality risk in VA-ECMO patients: a multicenter cohort study

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a critical life support technology for severely ill patients. Despite its benefits, patients face high costs and significant mortality risks. To improve clinical decision-making, this study aims to develop a non-invasive, efficient artificial intelligence (AI)-enabled model to predict the risk of mortality within 28 days post-weaning from VA-ECMO. A multicenter, retrospective cohort study was conducted across five hospitals in China, including all the patients who received VA-ECMO support between January 2020 and January 2024. Based on the innovatively selected 25 easily obtainable patient examination features as potentially relevant, this study involved developing ten predictive models using both classical and advanced machine learning techniques. The model's performance is evaluated using various statistical metrics and the optimal predictive model are identified. Feature correlations are analyzed using Pearson correlation coefficients, and SHapley Additive exPlanations (SHAP) are employed to interpret feature importance. Decision curve analysis is used to evaluate the clinical utility of the predictive models. The study included 225 patients, with 66 patients from one hospital forming the training cohort. Three validation cohorts were used: internal validation with 16 patients from the training hospital and external validation with 30 and 60 patients from the other 4 hospitals. The random forest model emerged as the best predictor of 28-day mortality, achieving an AUROC of 1.00 in the training cohort and 1.00, 0.97, and 0.93 in the three validation cohorts, respectively. Despite the limited training data, the developed model, eCMoML, demonstrated high accuracy, generalizability and reliability. The model will be available online for immediate use by clinicians. The eCMoML model, validated in a multicenter cohort study, offers a rapid, stable, and accurate tool for predicting 28-day mortality post-VA-ECMO weaning. It has the potential to significantly enhance clinical decision-making, helping doctors better assess patient prognosis, optimize treatment plans, and improve survival rates.

Impact of Body Mass Index on Stroke in Extracorporeal Cardiopulmonary Resuscitation: Data from the Extracorporeal Life Support Organization Registry

Objective: We aimed to characterize the impact of body mass index (BMI) on stroke in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). Methods: We queried the Extracorporeal Life Support Organization registry for patients receiving ECPR (2020-2024). Patients were categorized into five BMI groups: underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), class 1 obesity (30-34.9 kg/m2), and class 2 obesity or above (≥35 kg/m2). A generalized additive model (GAM) analysis was used to identify the BMI range with the greatest stroke risk. Multivariable regression was used to compare odds of stroke between standard BMI groups and normal weight. Propensity score matching was used to compare stroke and mortality between normal weight and the BMI group with the highest predicted stroke risk. Results: Of 6390 patients (median age = 57.5, 68.6% male), 470 (7.4%) had a stroke during ECMO support (4.5% ischemic; 3.4% hemorrhagic). A total of 9.6% (n = 131) of class 1 obesity patients experienced stroke compared with 6.6% (n = 111) of normal weight, 6.9% (n = 79) of class 2 obesity or above, 6.9% (n = 143) of overweight, and 5.4% (n = 6) of underweight patients (p = 0.01). The GAM analysis showed a highest predicted stroke risk for class 1 obesity patients (n = 1366), which was confirmed by multivariable regression (adjusted odds ratio (aOR) = 1.63, 95%CI = 1.01-2.62, p = 0.045). After propensity matching (n = 357 each), class 1 obesity was associated with ischemic (aOR = 2.01, 95%CI = 1.02-4.08, p = 0.047) but not hemorrhagic stroke. Odds of hospital mortality were higher in both class 1 and 2 obesity patients compared with normal weight. Conclusions: Class 1 obesity was associated with increased odds of ischemic but not hemorrhagic stroke compared with normal weight patients.

The Japanese Critical Care Nutrition Guideline 2024

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

Why Do Total Joint Arthroplasties Get Canceled on the Day of Surgery?

BACKGROUND

Same-day cancellations of elective surgeries present challenges to patients, providers, and health-care institutions. This study aimed to investigate the frequency and predictors of same-day cancellations for elective total joint arthroplasty (TJA).

METHODS

A retrospective review was conducted on 13,744 scheduled primary, elective TJAs at an urban academic center from September 2017 to August 2023. Cases that experienced same-day cancellations were grouped based on the reasoning for cancellation into one of two categories - operative concern (e.g., acute health issues and medication noncompliance) or a nonoperative concern (e.g., financial clearance and transportation issues). Patient demographics were compared between the cancellation and surgery cohorts and between the categorical reasons for cancellation.

RESULTS

Out of the 38,849 scheduled TJAs, 362 cases (0.9%) were canceled on the day of surgery. Higher patient body mass index was the singular patient factor predictive of same-day cancellation across all TJAs. Non-White race, men, and higher Charlson comorbidity index were additional significant predictors for total hip arthroplasty, but not TKA cancellation. Operative concerns accounted for 74.9% of the cancellations, and nonoperative concerns accounted for 25.1%. Increased patient body mass index was predictive of TJAs canceled due to operative concerns, whereas younger patient age was predictive of TJAs canceled due to nonoperative concerns. Of all same-day cancellations, 81.8% were ultimately rescheduled, and rescheduled cases occurred at a median of 25 days (range, one to 425) after cancellation. There were no significant differences in rescheduling rates and time to reschedule cases between the reasons for cancellation.

CONCLUSIONS

Approximately, 1% of patients experienced a same-day cancellation of their elective TJA, most of which occurred due to operative concerns. These findings may guide the development of preoperative optimization strategies aimed at reducing the occurrence of same-day cancellations for high-risk patients, thereby maximizing the utilization of operative resources and enhancing care for TJA patients.

Relationship between weight-to-waist index and post-stroke depression

BACKGROUND

The weight-to-waist index (WWI) serves as an innovative metric specifically designed to assess central obesity. However, the relationship between WWI and the prevalence of post-stroke depression (PSD) remains inadequately explored in the literature.

AIM

To elucidate the relationship between WWI and PSD.

METHODS

Data from the National Health and Nutrition Examination Survey 2005 to 2018 were analyzed. Multivariable logistic regression models and propensity score matching were utilized to investigate the association between WWI and PSD, with adjustments for potential confounders. The restricted cubic spline statistical method was applied to explore non-linear associations.

RESULTS

Participants with elevated WWI values had a significantly greater risk of developing PSD. Specifically, individuals in the higher WWI range exhibited more than twice the likelihood of developing PSD compared to those with lower WWI values (odds ratio = 2.21, 95% confidence interval: 1.84-2.66, P < 0.0001). After propensity score matching, the risk of PSD remained significantly elevated (odds ratio = 1.43, 95%confidence interval: 1.09-1.88, P = 0.01). Tertile analysis revealed that participants in the highest WWI tertile faced a significantly higher risk of PSD compared to those in the lowest tertile. Restricted cubic spline analysis further revealed a non-linear association, with the risk of PSD plateauing at higher WWI values.

CONCLUSION

There is a significant association between elevated WWI and increased risk of PSD. Thus, regular depression screening should be implemented in stroke patients with elevated WWI to enhance patient outcomes.

Obesity Class and Severity of Metabolic Emergencies: A Single-Center Retrospective Five-Year Study

Background/Objectives: This study aims to investigate the impact of obesity severity on the prevalence and outcomes of acute metabolic emergencies in the emergency department (ED) setting, with a specific focus on obesity class stratification and associated metabolic complications. Methods: This retrospective, single-center study analyzed data from 433 patients admitted to the ED of the Timisoara Municipal Emergency Hospital between January 2019 and March 2024. Patients were classified according to WHO obesity grades (Class I: BMI 30.0-34.9 kg/m2, Class II: 35.0-39.9 kg/m2, Class III: ≥ 40.0 kg/m2). The prevalence and severity of metabolic emergencies, including hyperglycemic crises, acute kidney injury (AKI), and severe electrolyte imbalances, were compared across obesity classes. Results: Obese patients (37.2%) exhibited a significantly higher prevalence of metabolic emergencies than non-obese individuals (p < 0.001). Hyperglycemia was present in 27.9% of obese patients vs. 11.0% of non-obese patients (p < 0.001). AKI incidence nearly doubled in obese patients (12.4% vs. 5.5%, p = 0.01). Logistic regression identified Class III obesity as an independent risk factor for metabolic emergencies (adjusted OR = 3.2, 95% CI: 2.1-4.9, p < 0.001). Conclusions: The severity of metabolic emergencies increases with increasing obesity class, emphasizing the need for obesity-specific risk stratification in ED settings. Routine monitoring of metabolic markers and early intervention strategies should be prioritized for high-risk obese patients.

Mechanistic insights into GLP-1 receptor agonist-induced weight loss through ceRNA network analysis

BACKGROUND

GLP-1 receptor agonists (GLP-1RA) have been extensively utilized in the management of body weight in individuals with obesity. Circular RNA (circRNA), a class of covalently closed RNA molecules, has garnered increasing attention for its potential role in the pathogenesis of obesity. However, the specific mechanisms through which circRNA contributes to GLP-1RA-induced weight loss remains elusive.

METHODS

High-throughput sequencing analyzed epididymal adipose tissue from obese mice under high-fat, and GLP-1RA intervention (600 μg/kg/d). The functions of differentially expressed (DE) genes were enriched and analyzed. The circRNA-miRNA-mRNA interaction network was constructed in Cytoscape, and KEGG pathway gene enrichment was validated via western blotting.

RESULTS

A total of 644 DEcircRNAs, 186 DEmiRNAs, and 3474 DEmRNAs were identified. Based on ceRNA score calculations, network diagrams were constructed. Gene Ontology (GO) analysis revealed that DERNAs were linked to lipid and fatty acid metabolism. DE genes within ceRNA pairs were enriched in lipid metabolism pathways, especially the PI3K-Akt and AMPK signaling pathways. GLP-1RA induced the phosphorylation of AKT and AMPK, which subsequently led to a reduction of SREBP-1, ACC, and FAS.

CONCLUSION

GLP-1RA might activate PI3K-Akt and AMPK signaling pathways to combat obesity through the ceRNA network of circRNAs.

Task-oriented robotic rehabilitation for back mobility and functioning in a post-intensive care unit obese patient: A case report

BackgroundIntensive care unit (ICU) acquired weakness is a detrimental condition characterized by muscle weakness, difficulty in weaning from mechanical ventilation, impaired mobility, and functional limitations, severely affecting overall quality of life. Obese patients face additional challenges due to obesity-related factors that exacerbate the negative effects of immobilization. Rehabilitation interventions have emerged as a crucial component of post-ICU care, but the rehabilitation management of obese patients remains challenging.Objectiveto present the impact of implementing Walker View 3.0 SCX technology in post-intensive care unit rehabilitation of obese patient.MethodsA 69-year-old Caucasian man with a BMI of 44.8 kg/m2 was referred to the Cardiopulmonary Rehabilitation Unit at Alessandria Hospital, Italy, following an ICU admission for pneumonia. After a comprehensive multidisciplinary evaluation, the patient underwent an intensive rehabilitation program including physical exercises and a personalized dietary plan. A task-oriented robotic rehabilitation was added, utilizing the Walker View 3.0 SCX, for 30 min/day, 5 days/week. The robotic rehabilitation program focused on sit-to-stand mobility with weight support initially and progressed to a weight-supported robotic treadmill.ResultsThe patient showed clear improvements in physical function, muscle strength, and independence in activity of daily living (Barthel Index improved from 15 to 70, De Morton Mobility Index improved from 8 to 39, Medical Research Council Strength improved from 17 to 40, Functional Ambulation Classification score improved from 0 to 3, Handgrip Strength Test improved from 8.8 kg to 39.4 kg). Managed by a single physiotherapist, this approach showed positive results in enhancing functional outcomes, with potential benefits in reducing operator time and assistance costs.ConclusionsIntegrating task-oriented robotic rehabilitation with Walker View 3.0 SCX showed promising outcomes for obese patients post-ICU. Personalized interventions with weight-bearing capabilities and real-time feedback optimized post-ICU care, enhancing functional outcomes, and potentially reducing operator time and assistance costs. Further research with larger samples is needed to validate the broader applicability and cost-effectiveness of robotic rehabilitation technologies in obese patients with ICU-acquired weakness.

Impact of obesity on outcomes in patients receiving extracorporeal membrane oxygenation: A systematic review and meta-analysis

Given the growing obesity pandemic, the impact of obesity on outcomes of Extracorporeal Membrane Oxygenation (ECMO) would be increasingly relevant to our daily practise. This meta-analysis aims to evaluate the impact of obesity on ECMO outcomes, integrating the latest evidence. Systematic literature search was conducted from inception until December 2024 on MEDLINE, Embase and the Cochrane Library using the terms 'ECMO', 'obesity', and their related terms. Twenty-eight studies were included from 2013 to 2024, including a total of 74,330 ECMO patients (Mean age 52.84 ± 13.55 years). Obese patients had a similar risk of in-hospital or 30-day mortality when compared to non-obese patients (Risk difference -2%, 95%CI -5% to -1%, I2 = 85%, p = 0.25). Subgroup analysis of patients on V-V-ECMO showed a trend towards lower mortality in obese patients which did not reach statistical significance (risk difference -6%, 95%CI -13% to 0%, I2 = 53%, p = 0.06). Subgroup analysis of patients on V-A-ECMO showed significantly higher mortality in obese patients (risk difference 5%, 95%CI 1% to 9%, I2 = 54%, p = 0.007). Regarding secondary outcomes, obesity had no significant association with major bleeding or thrombotic complications (Risk difference 0%, 95%CI -1% to 2%, I2 = 15%, p = 0.63). Obesity was associated with significantly shorter hospital length-of-stay (Mean difference -2.92 days, 95% CI -5.03 to -0.80, I2 = 74%, p = 0.007), but had no impact on ECMO duration (Mean difference 0.35 days, 95%CI -0.03 to 0.74, I2 = 41%, p = 0.07). In summary, our meta-analysis showed that obesity was a favourable prognostic factor in V-V-ECMO. However, obesity increased mortality in V-A-ECMO patients. The modality of ECMO support should be taken into consideration when evaluating ECMO candidacy in individual obese patients.

A descriptive, retrospective single-centre study of air-leak syndrome in intensive care unit patients with COVID-19

BACKGROUND

Acute respiratory failure is the predominant presentation of intensive care unit (ICU) patients with COVID-19, and lung protective strategies are recommended to mitigate additional respiratory complications such as air-leak syndrome. The aim of this study is to investigate the prevalence, type, and timing of air-leak syndrome with regards to associated factors and patient outcome in patients with COVID-19 in ICUs at a large Swedish emergency hospital.

METHODS

This retrospective study included all adult patients admitted to an ICU for COVID-19-related respiratory failure at Södersjukhuset between March 6, 2020, and June 6, 2021. Primary outcomes were proportion of patients diagnosed with air-leak syndrome and its different types of manifestations, and timing of diagnoses in relation to ICU admission and initiation of invasive ventilation. Secondary outcomes included the highest level of respiratory support prior to the diagnosis of air-leak syndrome, patient characteristics and treatment variables associated with air-leak syndrome, and 90-day mortality for patients with air-leak syndrome compared to those without.

RESULTS

Out of a total of 669 patients, 81 (12%) were diagnosed with air-leak syndrome. Air-leak syndrome manifested as pneumomediastinum (PMD) (n = 58, 72%), pneumothorax (PTX) (n = 43, 53%), subcutaneous emphysema (SCE) (n = 28, 35%) and pneumatocele (PC) (n = 4, 4.9%). Air-leak syndrome was diagnosed at a median of 14 days (IQR 6-22) after ICU admission and 12 days (IQR 6-19) following the initiation of invasive ventilation. The highest respiratory support prior to diagnosis was invasive ventilation (IV) in 64 patients (79%), non-invasive ventilation in two patients (2.5%), and low- or high-flow oxygen in 15 patients (19%). Multiple logistic regression showed that pulmonary disease at baseline (OR 1.87, 95% CI 1.07-3.25), a lower body mass index (OR 0.95, 95% CI 0.9-0.99), admission later compared with earlier in the pandemic (OR 3.89, 95% CI 2.14-7.08), and IV (OR 3.92, 95% CI 2.07-7.44) were associated with an increased risk of air-leak syndrome. Compared with patients not diagnosed with air-leak syndrome, patients with air-leaks had a higher mortality at 90 days after ICU admission, 46% versus 26% (p <.001). However, the mortality rate differed with different air-leak manifestations, 47% for PMD, 47% for PTX, 50% for the combination of both PMD and PTX and 0% in patients with only SCE and/or PC, respectively.

CONCLUSION

In 669 ICU patients with COVID-19, 12% had one or more manifestations of air-leak syndrome. Notably, PMD, rather than PTX, was the most common manifestation, suggesting a potentially distinctive feature of COVID-19-related air-leak syndrome. Further research is needed to determine whether COVID-19 involves different pathophysiological or iatrogenic mechanisms compared with other critical respiratory conditions.

REGISTRATION OF CLINICAL TRIAL

Clinicaltrials.gov, identifying number, NCT05877443.

EDITORIAL COMMENT

This single-centre cohort study of air leakage into soft tissue in ventilated COVID cases presents findings for associated factors and clinical manifestations, including with different COVID-19 periods and treatments.

Sex-based outcomes of obesity in critically ill patients: a retrospective cohort study

BACKGROUND

Obesity is increasingly prevalent among critically ill patients, generally more common among females than males. Whether the patient's sex influences the outcome in these patients is unclear.

OBJECTIVE

Evaluate the outcomes of critically ill-patients with obesity admitted to the intensive care unit (ICU).

DESIGN

A retrospective cohort study.

SETTING

ICU of King Abdulaziz Medical City, Riyadh, Saudi Arabia.

PATIENTS AND METHODS

All obese patients aged more than 18 years admitted to ICU between 2002 to 2017 were included.

MAIN OUTCOME MEASURES

The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay, mechanical ventilation duration, renal replacement therapy, vasopressor use, and tracheostomy. A multivariable analysis was conducted to evaluate the association of sex differences with hospital mortality.

SAMPLE SIZE

7277 patients.

RESULTS

Of the included patients with obesity, 3965 were females, and 3312 were males. The females were older, more likely to be admitted for medical reasons and less likely for trauma than males. The crude hospital mortality rate was significantly higher in females than males (1056 [26.7%] vs. 744 [22.5%], P<.0001). Multivariable analysis demonstrated no association between sex and hospital mortality (OR: 1.05, 95% CI: 0.94, 1.19, P=.52). However, age (OR: 1.04; 95% CI: 1.01-1.02; P<.0001), chronic liver disease (OR: 5.04; 95% CI: 4.19-6.06; P<.0001), and chronic renal disease (OR: 2.19; 95% CI: 1.86-2.57;P<.0001) were found to be associated with higher mortality while admission due to trauma showed lower mortality (OR: 0.69; 95% CI: 0.53-0.90; P=.007).

CONCLUSION

Obese females admitted to ICU have a higher hospital crude mortality rate than obese males. This difference does not appear to be related to sex, but rather to older age, higher comorbid conditions, and more frequent admissions related to non-trauma reasons among females.

LIMITATIONS

A single-center retrospective study.

Managing Refractory Hypoxemia in Acute Respiratory Distress Syndrome Obese Patients with Veno-Venous Extra-Corporeal Membrane Oxygenation: A Narrative Review

Veno-venous extracorporeal membrane oxygenation (vvECMO) is a life-saving intervention for severe respiratory failure unresponsive to conventional therapies. However, managing refractory hypoxemia in morbidly obese patients poses significant challenges due to the unique physiological characteristics of this population, including hyperdynamic circulation, elevated cardiac output, and increased oxygen consumption. These factors can limit the effectiveness of vvECMO by diluting arterial oxygen content and complicating oxygen delivery. Refractory hypoxemia in obese patients supported by vvECMO often stems from an imbalance between ECMO blood flow and cardiac output. Hyperdynamic circulation exacerbates the recirculation of oxygenated blood and impairs the efficiency of oxygen transfer. To address these challenges, a stepwise, individualized approach is essential. Strategies to reduce oxygen consumption include deep sedation, neuromuscular blockade, and temperature control. Cardiac output modulation can be achieved through beta-blockers and cautious therapeutic hypothermia. Optimizing oxygen delivery involves improving residual lung function; high positive end-expiratory pressure ventilation guided by esophageal pressure monitoring; prone positioning; and adjustments to the ECMO circuit, such as using dual oxygenators, larger membranes, or additional drainage cannulas. This review highlights the interplay of physiological adaptations and technical innovations required to overcome the challenges of managing refractory hypoxemia in obese patients during vvECMO. By addressing the complexities of high cardiac output and obesity, clinicians can enhance the effectiveness of vvECMO and improve outcomes for this high-risk population.

Exploring the Nutrition Care Journey of People Living With Obesity in Acute Care

BACKGROUND

Recent studies show a high prevalence in hospital populations and best practice evidence indicates that people living with obesity should receive dietetic advice. However, patients often do not receive this care in acute settings. Understanding the experiences of people living with obesity is crucial to designing successful strategies for management.

OBJECTIVE

This qualitative study aimed to understand the experience of nutrition care for patients living with obesity in the acute hospital setting and to redesign an optimised patient journey using a design approach. Using patient journey mapping, nutrition care across the inpatient admission was explored. A lived experience perspective was applied to reflect on the patient journey and interactions of patients with dietetic services in the acute setting. A co-creation session was conducted with dietitians and consumers to redesign the patient journey.

RESULTS

The patient journey revealed that for patients living with obesity, discussions about weight were absent from the journey from all healthcare professionals. For patients receiving dietetic care, the Nutrition Care Process was followed; nutrition intervention focused on acute nutrition issues with increased energy and protein prescription: a lack of goal setting and absence of discharge planning. The redesign of the nutrition care journey identified pivot points in the pathway to support engagement in obesity-related care.

CONCLUSION

The findings from this study provide new insights into current nutrition care for people living with obesity in the acute setting. These findings can inform future education, research and advocacy for practice changes to improve dietetic care for people living with obesity.

Sex-Specific Obesity Paradox in Critically Ill Patients With Severe Acute Kidney Injury: A Retrospective Analysis

OBJECTIVES

Although obesity is typically correlated with adverse outcomes in various diseases, certain acute critical illnesses exhibit a phenomenon known as the obesity paradox. This study evaluated sex-specific differences in the prognostic implications of the body mass index (BMI) of patients with severe acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT).

DESIGN

A multicenter retrospective cohort study.

SETTING

Data from eight tertiary hospitals in Korea.

PATIENTS

A total of 3805 critically ill patients receiving CRRT. Patients were categorized into four BMI groups: underweight, normal weight, overweight, and obese.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 2308 male and 1497 female patients. The 90-day mortality risk significantly differed among BMI groups in the overall patient population and the male subpopulation but not the female subpopulation. Following adjustment for confounding variables, the 90-day mortality risk was higher in the underweight group than in the obese group (hazard ratio [HR], 1.20; 95% CI, 1.05-1.36; p = 0.006). Among male patients, the 90-day mortality risk was higher in both the underweight and normal weight groups than in the obese group (underweight: HR, 1.30; 95% CI, 1.10-1.53; p = 0.002 and normal weight: HR, 1.18; 95% CI, 1.04-1.35; p = 0.010); however, no such association was observed among female patients. Subgroup analysis demonstrated the obesity paradox in male patients of old age, with septic AKI, or with low albumin levels.

CONCLUSIONS

There were sex differences in the association between BMI and mortality in critically ill patients with severe AKI. Although the precise distribution of fat mass and muscle mass was not identified, obese male patients had a more favorable prognosis, which was not evident among female patients. These findings highlight the importance of considering sex-specific factors in understanding the complex relationship between obesity and mortality in critically ill patients with AKI.

Comparative effectiveness of massage combined with lifestyle intervention and lifestyle intervention alone for simple obesity: A systematic review and meta-analysis

BACKGROUND

This study aimed to assess the comparative effectiveness of massage combined with lifestyle intervention and lifestyle intervention alone in patients with simple obesity.

METHODS

The PubMed, Embase, Cochrane Library, CNKI, VIP Database, and Wanfang Data were searched. Meta-analysis was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Primary outcomes were body weight (BW) and body mass index (BMI). Secondary outcomes were waist circumference (WC), hip circumference (HC), total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), fasting insulin (FINS), and homeostasis model assessment-insulin resistance (HOMA-IR) and adverse events.

RESULTS

Thirteen randomized controlled trials were included. The meta-analysis showed that massage combined with lifestyle intervention significantly decreased BW (mean difference [MD]: -4.85; 95% confidence interval [CI]: -8.25 to -1.46; P = .005), BMI (MD: -2.65; 95% CI: -4.05 to -1.24; P = .0002), WC (MD: -3.63; 95% CI: -6.28 to -0.98; P = .007), TC (MD: -0.52; 95% CI: -0.84 to -0.20; P = .001), TG (MD: -0.23; 95% CI: -0.45 to -0.02; P = .003), LDL-C (MD: -0.48; 95% CI: -0.54 to -0.42; P < .00001), HDL-C (MD: -0.11; 95% CI: -0.17 to -0.05; P = .0004), FINS (MD: -1.64; 95% CI: -3.16 to -0.12; P = .03), and HOMA-IR (MD: -0.42; 95% CI: -0.65 to -0.18; P = .0005) compared with lifestyle intervention alone. In subgroup analyses, more obvious reduction in BMI (P = .02, I2 = 80.3%) for the children and adolescents subgroup, more obvious reduction in HC (P = .04, I2 = 76.1%) for the adults subgroup, more significant reduction in TC (P < .00001, I2 = 98.3%), LDL-C (P < .00001, I2 = 95.6%), and HDL-C (P < .0001, I2 = 94.1%) for intermittent treatment subgroup and more significant reduction in TC (P < .00001, I2 = 95.9%) and HDL-C (P < .0001, I2 = 94.1%) for treatment times ≤30 subgroup were detected.

CONCLUSIONS

Compared with lifestyle intervention alone, massage combined with lifestyle intervention significantly decreased BW, BMI, WC, TC, TG, LDL-C, FINS, and HOMA-IR, but produced less effect in increasing HDL-C. And different ages, treatment intervals, and treatment times can all affect treatment outcomes.

Casual correlation between overweight, obesity, and severe COVID-19 infection with respiratory failure: A two-sample Mendelian randomization

This study aimed to detect the causal association of overweight and obesity on severe COVID-19 infection with respiratory failure through a two-sample Mendelian randomization (MR) method based on the genome-wide association studies datasets. All genome-wide association studies summary data of exposures and outcome used in this study were obtained from the IEU database derived from Europeans. The study mainly used the inverse variance weighted method to test causal relationship. Simultaneously, MR-PRESSO and MR-EGGER were used to detect the pleiotropy, and sensitivity analysis was performed using leave-one-out analysis. In the inverse variance weighted analyses, we found no causal association between obesity (e.g., OR = 1.15, 95% CIs = 0.96-1.37, P = .13 for obesity-ebi-a-GCST90000255), obesity subtypes (e.g., OR = 1.93, 95% CIs = 0.90-4.14, P = .10 for obesity and other hyperalimentation) as well as overweight (OR = 0.90, 95% CIs = 0.64-1.27, P = .54) and severe COVID-19 infection with respiratory failure. The findings showed no causal association between obesity or overweight and severe COVID-19 infection with respiratory failure. Further validation is needed regarding whether obesity or overweight is a risk factor for it.

Incidence, Risk Factors, and Long-Term Outcomes for Extubation Failure in ICU in Patients With Obesity: A Retrospective Analysis of a Multicenter Prospective Observational Study

BACKGROUND

To our knowledge, no large observational study has compared the incidence and risk factors for extubation failure within 48 h and during ICU stay in the same cohort of unselected critically ill patients with and without obesity.

RESEARCH QUESTION

What are the incidence and risk factors of extubation failure in patients with and without obesity?

STUDY DESIGN AND METHODS

In the prospective multicenter observational Practices and Risk Factors for Weaning and Extubation Airway Failure in Adult Intensive Care Unit: A Multicenter Trial (FREEREA) study in 26 ICUs, the primary objective was to compare the incidence of extubation failure within 48 h in patients with and without obesity. Secondary objectives were to describe and to identify the independent specific risk factors for extubation failure using first a logistic regression model and second a decision tree analysis.

RESULTS

Of 1,370 extubation procedures analyzed, 288 (21%) were performed in patients with obesity and 1,082 (79%) in patients without obesity. The incidence of extubation failure within 48 h among patients with or without obesity was 23 of 288 (8.0%) vs 118 of 1,082 (11%), respectively (unadjusted OR, 0.71; 95% CI, 0.45-1.13; P = .15); alongside patients with obesity receiving significantly more noninvasive ventilation [87 of 288 (30%) vs 233 of 1,082 (22%); P = .002] and physiotherapy [165 of 288 (57%) vs 527 of 1,082 (49%); P = .02] than patients without obesity. Risk factors for extubation failure also differed according to obesity status: female sex (adjusted OR, 4.88; 95% CI, 1.61-13.9; P = .002) and agitation before extubation (adjusted OR, 6.39; 95% CI, 1.91-19.8; P = .001) in patients with obesity, and absence of strong cough before extubation (adjusted OR, 2.38; 95% CI, 1.53-3.84; P = .0002) and duration of invasive mechanical ventilation before extubation (adjusted OR, 1.03/d; 95% CI, 1.01-1.06; P = .01) in patients without obesity. The decision tree analysis found similar risk factors.

INTERPRETATION

Our findings indicate that anticipation and application of preventive measures for patients with obesity before and after extubation led to similar rates of extubation failure among patients with and without obesity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02450669; URL: www.

CLINICALTRIALS

gov.

Dapagliflozin treatment decreases visceral and subcutaneous adipose tissue: a systematic review and meta-analysis

Aims

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) have been shown to reduce visceral (VAT) and subcutaneous (SAT) adipose tissue. Although many systematic reviews have examined SGLT2i's effect on VAT and SAT, a focus analysis of dapagliflozin, one of the more commonly prescribe SGLT2i, has yet to been done. This study aims to determine the effect of dapagliflozin on reducing VAT and SAT in patients with chronic disease.

Methods

SCOPUS, PubMed, EBSCO, and LILACS databases were searched until December 26, 2023. Heterogeneity was determined using Cochran's Q test and quantified using the inconsistency index. The random-effects model was used to calculate the pooled standardize difference in means (SDM) and 95% confidence intervals (95% CI). Duval and Tweedie trim and fill (DT), Egger's test, and Beggs-Muzamar's test were used to assess publication bias. PROSPERO: CRD42023426208.

Results

Twelve reports were included (treated = 299 and controls = 301). Overall, dapagliflozin treatment reduced VAT (SDM = - 0.406, 95% CI: - 0.526 to - 0.286, p < 0.001) and SAT (SDM = - 0.439, 95% CI: - 0.601 to - 0.278, p < 0.001). These results were stable as determined with a sensitivity analysis; however, there was potential publication bias. Two and three imputed studies were determined by the DT method for VAT and SAT, respectively. When stratified by pathology (obesity, T2D, and T2D/NAFLD), dapagliflozin treatment decreased VAT and SAT for all conditions. However, for specifically SAT, only when compared between T2D and T2D/NAFLD, T2D/NAFLD was associated with a twofold decrease (p = 0.003).

Conclusion

Treatment with dapagliflozin resulted in a significant reduction in VAT and SAT in patients with obesity, T2D, or T2D/NAFLD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-024-00765-y.

Noninvasive respiratory support following extubation in critically ill adults with obesity: a systematic review and network meta-analysis

Background

Patients with obesity are at high-risk of extubation failure. Discrepancies were found in the results of recent randomized controlled trials (RCTs) regarding the roles of noninvasive ventilation (NIV), high flow nasal cannula (HFNC) and conventional oxygen therapy (COT) to prevent extubation failure in critically ill patients with obesity.

Methods

In this systematic review and network meta-analysis, we searched MEDLINE, Cochrane Center Register of Controlled Trials and Web of Science from 1 January 1998 to 1 July 2024 for RCTs evaluating noninvasive respiratory support therapies (NIV, HFNC, COT, NIV + HFNC) after extubation in critically ill adults with obesity. Primary outcome was reintubation at day 7. Secondary outcome was 28-day mortality. We generated pooled risk ratios (RR) and numbers needed to treat (NNT). We rated risk of bias using the Cochrane risk-of-bias 2.0 tool. The study was registered with PROSPERO (CRD 42022308995).

Findings

In seven RCTs including 1933 patients, NIV + HFNC (RR 0.36 [95% confidence interval (CI) 0.16-0.82], NNT = 10 [95% CI 7-33]) and NIV (RR 0.45 [95% CI 0.23-0.88], NNT = 11 [95% CI 8-50]) but not HFNC (RR 0.79 [95% CI 0.40-1.59]) reduced reintubation at day 7, compared to COT. Compared to HFNC, NIV + HFNC (RR 0.46 [95% CI 0.23-0.90], NNT = 14 [95% CI 10-77]) but not NIV (RR 0.57 [95% CI 0.32-1.02]) reduced reintubation at day 7. Compared to HFNC, both NIV (RR 0.31 [95% CI 0.13-0.74], NNT = 15 [95% CI 12-40]) and NIV + HFNC (RR 0.30 [95% CI 0.10-0.89], NNT = 15 [95% CI 11-90]) reduced 28-day mortality.

Interpretation

The results suggest that compared to COT and HFNC, NIV alone or with HFNC reduces reintubation in critically ill patients with obesity after extubation. Compared to HFNC, NIV alone or with HFNC reduces mortality. The number needed to treat with NIV or NIV + HFNC to avoid one death was 15. These findings support the application of NIV to mitigate extubation failure in critically ill adults with obesity.

Funding

None.

[Translated article] Drug dosing in obese critically ill patients, a literature review

INTRODUCTION

Obesity constitutes a global public health problem, and knowledge about drug dosing in obese patients is limited. Clinical trials in critically ill patients rarely include obese individuals, resulting in a lack of specific dosing information in product data sheets. The aim of this literature review is to provide clinicians with efficient and safe guidelines for this group of patients.

METHODS

A multidisciplinary group composed of pharmacists specialised in hospital pharmacy and physicians specialised in intensive care medicine was formed. The therapeutic groups and, in depth, the most commonly used active ingredients in the intensive care unit were identified and reviewed. The bibliographic review was carried out using terms such as: "obese", "overweight", "critical illness", "drug dosification", and "therapeutic dose monitoring". All the information was evaluated by the working group, which reached a consensus on dosing recommendations for each drug in obese critically ill patients.

RESULTS

Eighty three drugs belonging to the following therapeutic groups were identified: antivirals, antibacterials, antifungals, immunosuppressants, antiepileptics, vasopressors, anticoagulants, neuromuscular blocking agents, and sedatives. A table with the consensus dosing recommendation for each of these was produced after review.

CONCLUSIONS

Drug dosing in obese patients, both in critical and non-critical settings, remains an area with significant uncertainties. This review provides updated and exhaustive information on the dosing of the main therapeutic groups in obese critically ill patients, and is a useful tool for both physicians in critical care units and clinical pharmacists in their practice in this setting.

The association between the metabolic score for insulin resistance and mortality in patients with cardiovascular disease: a national cohort study

Background

The metabolic score for insulin resistance (METS-IR) is a novel index for evaluating insulin resistance and identifying high-risk cardiovascular disease (CVD) patients. This study aims to assess the prognostic value of METS-IR in predicting mortality risk in CVD patients.

Methods

We analyzed data from 2,515 CVD patients in the National Health and Nutrition Examination Survey (NHANES). Associations between METS-IR and all-cause mortality and cardiovascular mortality were evaluated using multivariable Cox proportional hazards models and restricted cubic splines (RCS). Threshold effects and sensitivity analyses were conducted to ensure robustness.

Results

Over a median follow-up of 91.4 months, 1,090 patients died, including 447 from cardiovascular causes. A U-shaped relationship was identified between lnMETS-IR and all-cause and cardiovascular mortality, with thresholds at 3.70 and 3.67. Below thresholds, an increase of lnMETS-IR was associated with a 75% reduction in the risk of all-cause mortality (HR: 0.25, 95% CI: 0.14-0.46) and a 79% reduction in the risk of cardiovascular mortality (HR: 0.21, 95% CI: 0.07-0.56). While above thresholds, an increase of lnMETS-IR was associated with a 180% increase in the risk of all-cause mortality (HR: 2.80, 95% CI: 1.61-4.88) and a 233% increase in the risk of cardiovascular mortality (HR: 3.33, 95% CI: 1.43-7.75).

Conclusions

This study identified a U-shaped association between lnMETS-IR and mortality among CVD patients, underscoring the potential of METS-IR as a valuable prognostic marker for mortality risk in patients with CVD.

Safety of Percutaneous Dilatational Tracheostomy in Critically Ill Adults With Obesity: A Retrospective Cohort Study

OBJECTIVE

This study aimed to assess the safety and efficacy of endoscopic percutaneous dilatational tracheostomy (PDT) in obese and nonobese critically ill adults.

METHODS

A retrospective study of all cases of PDT performed at two academic health centers between 2016 and 2023 was conducted. Primary outcomes included peri- and postoperative complications stratified by both timing and severity. body mass index (BMI) data were stratified according to the World Health Organization classification (class I obesity defined as BMI ≥ 30, class II obesity ≥35 and <40, class 3 obesity ≥40).

RESULTS

Totally 336 patients underwent a PDT, 279 of whom had available BMI data: 193 (69.2%) patients had a normal BMI, 56 (20.1%) had class I obesity, 15 (5.4%) class II obesity, and 15 (5.4%) class III obesity. The overall complication rates for the class I, II, and III obesity were 8.9%, 13.3%, and 13.3%, respectively. All procedures were successfully completed at the bedside (no conversions to an open approach), and there was no procedure-related mortality. The only accidental decannulation event was in a patient with class III obesity. There was no difference in overall complication rates between patients without obesity and patients with obesity (7.3% vs. 10.5%, respectively, p = 0.370).

CONCLUSION

This study significantly expands the current literature and represents one of the largest studies to date reporting on PDT in patients with obesity.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:5015-5020, 2024.

The Obesity Paradox Revisited: Is Obesity Still a Protective Factor for Patients With High Comorbidity Burden or High-Complexity Procedures?

Objective

To investigate the relationship between obesity and postoperative mortality in the context of high procedural complexity and comorbidity burden.

Background

The "obesity paradox" suggests better postoperative outcomes in patients with higher body mass index (BMI), despite obesity's associated health risks. Research remains scarce on the influence of procedural complexity and comorbidities on the obesity-postoperative mortality relationship.

Methods

We performed an observational study of adult patients undergoing major surgery using the 2016 to 2019 National Surgical Quality Improvement Program database. The outcome was 30-day mortality. We first estimated the risk-adjusted effects of BMI on mortality across the full cohort via multivariable regression and restricted cubic spline models. Then, we investigated the subgroups stratified by procedural complexity and comorbidity burden using a modified Charlson Comorbidity Index (mCCI) and mortality probability.

Results

Among 3,085,582 patients, 47% had obesity. There was a reverse J-shaped relationship between BMI and mortality in the full cohort, consistent with the obesity paradox. However, no difference in odds of mortality was observed in patients with obesity who underwent high-complexity procedures compared with normal BMI counterparts (BMI 30-34.9: odds ratio, 0.93 [95% confidence interval: 0.86-1.01]; BMI 35-39.9: 0.92 [0.83-1.03]; BMI ≥ 40: 0.94 [0.83-1.07]), and in patients with obesity with high comorbidity burden (mCCI ≥ 8 [BMI 30-34.9: 0.95 (0.77-1.16); BMI 35-39.9: 0.78, (0.60-1.02); BMI ≥ 40: 0.84 (0.63-1.12)] and top 3% mortality probability [BMI 30-34.9: 0.96 (0.90-1.02); BMI ≥ 40: 0.94 (0.86-1.01)]).

Conclusion

Our findings suggest the existence of an obesity paradox in most adult surgical patients, yet the trend dissipates with high procedural complexity and comorbidity burden.

Association between the triglyceride glucose index and short-term mortality in septic patients with or without obesity: a retrospective cohort study

BACKGROUND

Sepsis is a significant contributor to both intensive care unit (ICU) admissions and mortality among patients in ICU, with a rising prevalence of obesity. There is a lack of extensive research on the correlation between TyGI and findings in patients with sepsis, especially in obese patients.

METHODS

This study used a retrospective cohort design and included patients with sepsis (≥18 years) from the Medical Information Mart for Intensive Care IV database. The association between TyGI and outcome was examined using multivariable logistic regression analysis.

RESULTS

8,840 patients with sepsis were included in the analysis. The in-ICU mortality rate was 9.7%. Non-survivors exhibited significantly greater TyGI levels than survivors [9.19(8.76-9.71) vs. 9.10(8.67-9.54), p < 0.001]. The adjusted multivariate regression model showed that elevated TyGI values were linked to a greater likelihood of death in ICU (odds ratio [OR] range 1.072-1.793, p < 0.001) and hospital (OR range 1.068-1.445, p = 0.005). Restricted Cubic Spline analysis revealed a nonlinear association between TyGI and in-ICU and in-hospital mortality risks within specified ranges. Subgroup analysis revealed interaction effects in the general obesity, abdominal obesity, and impaired fasting glucose subgroups (p = 0.014, 0.016, and < 0.001, respectively).

CONCLUSION

TyGI was associated with an increased sepsis-related short-term mortality risk and adverse outcomes after ICU admission.

Nutritional assessment and medical dietary therapy for management of obesity in patients with non-dialysis chronic kidney disease: a practical guide for endocrinologist, nutritionists and nephrologists. A consensus statement from the Italian society of endocrinology (SIE), working group of the club nutrition-hormones and metabolism; the Italian society of nutraceuticals (SINut), club ketodiets and nutraceuticals "KetoNut-SINut"; and the Italian society of nephrology (SIN)

PURPOSE

Chronic kidney disease (CKD) is a serious health concern with an estimated prevalence of about 13.4% worldwide. It is cause and consequence of various comorbidities, including cardiovascular diseases. In parallel, common pathological conditions closely related to ageing and unhealthy dietary habits increase the risk of CKD development and progression, including type 2 diabetes and obesity. Among these, obesity is either independent risk factor for new onset kidney disease or accelerates the rate of decline of kidney function by multiple mechanisms. Therefore, the role of diets aimed at attaining weight loss in patients with obesity is clearly essential to prevent CKD as to slow disease progression. Various dietary approaches have been licensed for the medical dietary therapy in CKD, including low-protein diet and Mediterranean diet. Interestingly, emerging evidence also support the use of low-carbohydrate/ketogenic diet (LCD/KD) in these patients. More specifically, LCD/KDs may efficiently promote weight loss, improve metabolic parameters, and reduce inflammation and oxidative stress, resulting in a dietary strategy that act globally in managing collateral conditions that are directly and indirectly related to the kidney function.

CONCLUSION

This consensus statement from the Italian Society of Endocrinology (SIE), working group of the Club Nutrition - Hormones and Metabolism; the Italian Society of Nutraceuticals (SINut), Club Ketodiets and Nutraceuticals "KetoNut-SINut"; and the Italian Society of Nephrology (SIN) is intended to be a guide for Endocrinologist, Nutritionists and Nephrologist who deal with the management of patients with obesity with non-dialysis CKD providing a practical guidance on assessing nutritional status and prescribing the optimal diet in order to best manage obesity to prevent CKD and its progression to dialysis.

Minimally-invasive tracheostomy (MIT): A care bundle for safety improvement in high-risk critically ill patients

BACKGROUND

Detailed reports are scarce on minimally-invasive tracheostomy (MIT) techniques for critically ill patients with challenging anatomy or complex coagulopathies. In such high-risk patients, conventional percutaneous dilatational tracheostomy (PDT) may lead to severe complications.

METHODS

Aiming to broaden the scope of MIT for patients previously excluded due to high risks, we developed a new care bundle (MIT technique), specifically designed for intensive care specialists. Our study examined the outcomes of MIT in 32 high-risk patients treated in an ICU of a University Hospital with specific focus on gastrointestinal and liver diseases.

RESULTS

We have modified the conventional PDT technique by incorporating an initial skin incision, blunt dissection, diaphanoscopy-guided probe puncture, and continuous bronchoscopic monitoring. Our care bundle also introduces an anterolateral approach for tracheal entry, a significant advancement for patients with complex neck anatomy or dense vasculature, where an anterolateral trajectory avoids midline blood vessels. This enhanced method has proven to be safer than traditional PDT, with a notable absence of post-procedural hemorrhages, cannula misplacements, or infections.

CONCLUSION

The use of our refined care bundle enabled swift minimally-invasive tracheostomy in high-risk patients without the occurrence of serious complications.

Assessment of bidirectional relationships between frailty and acute respiratory distress syndrome: a bidirectional Mendelian Randomization study

BACKGROUND

While previous observational studies have suggested a link between frailty and acute respiratory distress syndrome (ARDS), the causality of this connection remains unclear. The objective of this study was to explore the potential bidirectional causal links between frailty and ARDS.

METHODS

A two-sample univariable Mendelian randomization (MR) was performed to assess the causal relationship between frailty, as defined by frailty index (FI, n = 175,226) and fried frailty score (FFS, n = 386,565), and ARDS. The genome-wide association study (GWAS) data of frailty was from the UK Biobank and the ARDS data was from the FinnGen Database. Univariable MR analyses were conducted using inverse-variance weighted (IVW), weighted median, MR-Egger regression, and robust adjusted profile score (MR. RAPS). We also performed multivariable Mendelian randomization (MVMR) analysis including smoking initiation, alcohol consumption, body mass index (BMI), and cognitive performance.

RESULTS

This bidirectional MR analysis demonstrated no causal effect of FI (OR = 0.96, 95% CI 0.14-6.88) and FFS (OR = 1.95, 95%CI 0.14-28.16) on increased susceptibility of ARDS. Also, no evidence was found for an effect of ARDS on the risk of frailty. The MVMR analysis indicated higher BMI and poorer cognitive performance were associated with increased risk of ARDS.

CONCLUSIONS

The outcomes of our analysis imply a probable absence of a direct causal relationship between frailty and susceptibility to ARDS. To reinforce and expand upon these preliminary findings, it is imperative to conduct larger-scale genome-wide association studies.

Hyperactive browning and hypermetabolism: potentially dangerous element in critical illness

Brown/beige adipose tissue has attracted much attention in previous studies because it can improve metabolism and combat obesity through non-shivering thermogenesis. However, recent studies have also indicated that especially in critical illness, overactivated brown adipose tissue or extensive browning of white adipose tissue may bring damage to individuals mainly by exacerbating hypermetabolism. In this review, the phenomenon of fat browning in critical illness will be discussed, along with the potential harm, possible regulatory mechanism and corresponding clinical treatment options of the induction of fat browning. The current research on fat browning in critical illness will offer more comprehensive understanding of its biological characteristics, and inspire researchers to develop new complementary treatments for the hypermetabolic state that occurs in critically ill patients.

46-kg abdominal tumor misdiagnosed as obesity: Unveiling healthcare bias due to obesity stigma

Key Clinical Message

Obesity results in higher risk of some cancers while obesity stigma affect patient's quality of care. In this case report, a 46 kg ovary mass was misdiagnosed as severe obesity. Obesity stigma awareness and a sustained effort from healthcare professionals are required to deliver adequate patient care to patients with obesity.

Abstract

Obesity is a disease associated with an increased risk of cardiovascular diseases, diabetes, musculoskeletal disorders, and some cancers. Obesity stigma affect patients and healthcare professionals leading to mistrust, poor adherence, noncompliance to screening, and misdiagnosis. We reported a case report of a patient sent to our referral center for surgical evaluation of long-standing severe obesity (BMI 59). Physical examination was significant for abdominal obesity with a hard consistency, but no cushingoid dysmorphism or lipodystrophy. No abdominal pain, pelvic pain, vaginal bleeding, or change in bowel movements were present. Tumor markers were normal except for an elevated Ca 19.9. Imaging showed a large, intraperitoneal abdominal mass with no metastatic disease. The patient underwent surgery to remove a 46-kg complex ovarian cystic mass (circumference: 160 cm, diameter: 67 cm), full of liquid and with six nodular areas. The mass was entirely extracted with an intact capsule. The cystic mass resulted in a well-differentiated intestinal-type adenocarcinoma with microinvasive foci, an endophytic borderline area (sec. WHO 2014), and mucinous-cystic areas with no atypia. The patient had postoperative bilateral basal pleural effusion resolved with conservative treatment and was discharged at home on postoperative day 12 with an uneventful 90-day postoperative follow-up. In the present case report, a 46 kg ovary mass was misdiagnosed as severe obesity, and the patient was referred for bariatric evaluation. Unveiling biases related to obesity stigma is the first step to ensuring better patient care. Obesity stigma awareness and a sustained effort from healthcare professionals are required to deliver adequate patient care to patients with obesity.

Drug dosing in obese critically ill patients, a literature review

INTRODUCTION

The prevalence of obesity represents a significant global public health challenge, and the available evidence concerning the appropriate dosing of pharmaceutical in patients with obesity is limited. It is uncommon for clinical trials in critically ill patients to include obese individuals, which results in a lack of specific dosing information in product data sheets. The objective of this literature review is to provide clinicians with efficacious and secure guidelines for this cohort of patients.

METHODS

A multidisciplinary team comprising pharmacists specialized in hospital pharmacy and physicians with expertise in intensive care medicine was established. The therapeutic groups and, in particular, the most commonly used active ingredients within the Intensive Care Unit were identified and subjected to detailed analysis. The following terms were included in the search: "obese", "overweight", "critical illness", "drug dosification", and "therapeutic dose monitoring". All the information was then evaluated by the working group, which reached a consensus on the dosing recommendations for each drug in obese critically ill patients.

RESULTS

A total of 83 drugs belonging to the following therapeutic groups were identified: antivirals, antibacterials, antifungals, immunosuppressants, antiepileptics, vasopressors, anticoagulants, neuromuscular blocking agents and sedatives. A table was produced containing the consensus dosing recommendations for each of the aforementioned drugs following a review of the available evidence.

CONCLUSIONS

Drug dosing in obese patients, both in critical and noncritical settings, remains an area with significant uncertainty. This review provides comprehensive and up-to-date information on the dosing of the main therapeutic groups in obese critically ill patients, offering a valuable resource physicians in critical care units and clinical pharmacists in their practice in this setting.

Body composition as a potential imaging biomarker for predicting the progression risk of chronic kidney disease

PURPOSE

To investigate whether the body composition parameters can be employed as potential biomarkers for predicting the progression risk of chronic kidney disease (CKD).

MATERIALS AND METHODS

Four hundred sixteen patients diagnosed with CKD were included in this retrospective study. Patients with a greater than 50% decline in estimated glomerular filtration rate or progression to end-stage kidney disease were in the high-risk group, otherwise, they were in a low-risk group. Body composition area, the index, and radiodensities in the Hounsfield unit (HU), which reflect the degree of X-ray absorption, were measured on abdominal CT images. Risk factors in body composition and clinical parameters of CKD were identified by Cox regression and utilized to construct the nomogram. The performance of the nomogram was assessed using time receiver operating characteristics curves, calibration curves, and decision curve analysis.

RESULTS

There were 254 patients in low-risk group and 162 in high-risk group (268 males, 148 females, mean age: 55.89 years). Urea, diabetes, 24 h-urinary protein, mean arterial pressure, and subcutaneous adipose tissue radiodensity (SATd) were valuable indicators for predicting the high-risk group. The area under curve values for the nomogram of training/validation set at 1 year, 2 years, and 3 years were 0.805/0.753, 0.784/0.783, and 0.846/0.754, respectively. For diabetic CKD patients, extra attention needs to be paid to visceral to subcutaneous fat ratio and renal sinus fat radiodensity.

CONCLUSION

SATd was the most valuable noninvasive indicator of all body composition parameters for predicting high-risk populations with CKD. The nomogram we constructed has generalization with easily obtainable indicators, good performance, differentiation, and clinical practicability.

CRITICAL RELEVANCE STATEMENT

Radiodensity rather than an area of adipose tissue can be used as a new biomarker of prognosis for CKD patients, providing new insights into risk assessment, stratified management, and treatment for CKD patients.

KEY POINTS

Obesity is an independent risk factor for the development and prognosis of CKD. Adipose tissue radiodensity is more valuable than fat area in prognosticating for kidney disease. Parameters that prognosticate in diabetic CKD patients are different from those in other CKD patients.

Association of serum Metrnl levels and high-density lipoprotein cholesterol in patients with type 2 diabetes mellitus: a cross-sectional study

Purpose

Meteorin-like (Metrnl) is a novel adipokine which is highly expressed in adipose tissue and has a beneficial effect on glucose and lipid metabolism. High density lipoprotein cholesterol (HDL-C) is well recognized to be inversely associated with cardiovascular events. However, the relationship between serum Metrnl levels and HDL-C in the type 2 diabetes mellitus (T2DM) remains unclear. Therefore, the present study aimed to evaluate the association of serum Metrnl with HDL-C levels in T2DM.

Materials and Methods

Eighty participants with T2DM were included in this cross-sectional study. They were divided into two groups according to HDL-C levels: Group1 (lower HDL-C group): HDL-C < 1.04 mmol/L; Group2 (higher HDL-C group): HDL-C ≥ 1.04 mmol/L. Serum Metrnl levels were measured by enzyme-linked immunosorbent assay (ELISA).

Results

As compared with lower HDL-C levels groups, serum Metrnl levels were significantly higher in the group with higher HDL-C. Binary logistic regression analysis showed serum Metrnl levels were positively associated with HDL-C group after adjustment with sex, age, body mass index (BMI), mean arterial pressure (MAP), fasting blood glucose (FPG), triglyceride (TG). Furthermore, serum Metrnl levels were inversely correlated with insulin resistance index (HOMA-IR). HDL-C levels were lowest in the group with the lowest Metrnl levels group and remained positively associated with Metrnl after adjustment for sex, age, BMI, TG, and HOMA-IR by using multivariate logistic regression analysis.

Conclusion

Serum Metrnl levels were positively associated with HDL-C levels in patients with T2DM.This suggests that increasing serum Metrnl levels maybe a candidate for improving lipid metabolism and preventing cardiovascular events in T2DM.

Registry and the Registration No of the Study/Trial

The study was registered in the Chinese clinical trial registry (ChiCTR- 2100047148).

Correlation between body mass index and gender-specific 28-day mortality in patients with sepsis: a retrospective cohort study

Objective

To investigate the potential correlation between body mass index (BMI) and the 28-day mortality rate among sepsis patients and the gender difference in this association.

Design

The current research was a retrospective cohort study.

Participants

A total of 14,883 male and female cohorts of sepsis patients were included in the Medical Information Mart for Intensive Care IV (MIMIC-IV V2.2) database. Patients in each gender cohort were further classified as underweight, normal weight, overweight, or obese according to BMI and the World Health Organization (WHO) BMI categories.

Outcomes

The 28-day mortality from the date of ICU hospitalization was the primary outcome measure.

Results

The BMI and 28-day mortality exhibited an L-shaped relationship (p for nonlinearity <0.001) with significant gender-specific differences. Subgroup analysis revealed different association patterns between the male and female cohorts. Specifically, BMI and mortality exhibited a U-shaped curve relationship among the males (p for nonlinearity <0.001) and an L-shaped relationship among the females (p for nonlinearity = 0.045).

Conclusion

This study proposes a link between extreme BMI and 28-day mortality in patients with sepsis. Underweight patients have an increased risk of mortality; however, this risk decreases in overweight and obese patients. Upon stratifying by sex, a U-shaped pattern was observed, indicating an association between BMI and 28-day mortality in males, while an L-shaped pattern emerged in females.

Acute-on-chronic liver failure in metabolic dysfunction-associated fatty liver disease patients: a disease multiplier

Acute-on-chronic liver failure (ACLF) is a syndrome of liver failure due to an acute hepatic insult leading to liver failure with or without extra-hepatic organ failure in a patient of chronic liver disease (CLD) with or without cirrhosis presenting for the first time. The definition is still with controversy; hence, homogeneity and clarity of the case is an unmet need. There is a paradigm shift noted as far as the etiology of CLD is concerned with rise in metabolic dysfunction-associated fatty liver disease (MAFLD) and ethanol as the dominant cause even in developing countries. MAFLD is the change in nomenclature from NAFLD to justify the metabolic derangement in these group of patients. The shift from an exclusion-based criteria to one that has evolved to a diagnosis that requires positive criteria has profound significance. Clearly there is a difference in terms of its prevalence, disease progression, and liver-related events, as well as management of metabolic risk factors and MAFLD itself which requires further understanding. In tandem with the global rise in MAFLD, the incidence of MAFLD-ACLF is increasing. Excessive alcohol consumption causes metabolic and toxic injury to the liver resulting in nearly similar pathway of fatty liver, hepatitis, and cirrhosis. The interaction of MAFLD as an additional underlying chronic liver injury in ACLF patients is complex due to the presence of metabolic risk factors that are unique to MAFLD. There is lack of clarity on how MAFLD affects the clinical course of ACLF due to scarcity of this specific data. This narrative review aims to understand the unique effects, consequences, and management of MAFLD as the chronic liver injury component in ACLF.

Metabolic homeostasis in fungal infections from the perspective of pathogens, immune cells, and whole-body systems

SUMMARYThe ability to overcome metabolic stress is a major determinant of outcomes during infections. Pathogens face nutrient and oxygen deprivation in host niches and during their encounter with immune cells. Immune cells require metabolic adaptations for producing antimicrobial compounds and mounting antifungal inflammation. Infection also triggers systemic changes in organ metabolism and energy expenditure that range from an enhanced metabolism to produce energy for a robust immune response to reduced metabolism as infection progresses, which coincides with immune and organ dysfunction. Competition for energy and nutrients between hosts and pathogens means that successful survival and recovery from an infection require a balance between elimination of the pathogen by the immune systems (resistance), and doing so with minimal damage to host tissues and organs (tolerance). Here, we discuss our current knowledge of pathogen, immune cell and systemic metabolism in fungal infections, and the impact of metabolic disorders, such as obesity and diabetes. We put forward the idea that, while our knowledge of the use of metabolic regulation for fungal proliferation and antifungal immune responses (i.e., resistance) has been growing over the years, we also need to study the metabolic mechanisms that control tolerance of fungal pathogens. A comprehensive understanding of how to balance resistance and tolerance by metabolic interventions may provide insights into therapeutic strategies that could be used adjunctly with antifungal drugs to improve patient outcomes.

Barriers and Strategies to Effective Serious Illness Communication for Patients with End-Stage Liver Disease in the Intensive Care Setting

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review

PURPOSE OF REVIEW

Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear.

RECENT FINDINGS

The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.

Comparing long-term prognosis following different surgical methods in patients with early stage breast cancer and obesity: a retrospective cohort study in China

OBJECTIVE

Breast-conserving therapy (BCT) includes breast-conserving surgery (BCS) combined with radiation therapy (RT). RT plays a crucial role in improving the prognosis of patients who undergo BCS. However, obesity is a potential risk factor for resistance to radiation. The aim of this study was to evaluate any difference in the long-term prognosis of patients with early stage breast cancer and obesity treated with BCT or total mastectomy (TM).

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective cohort study involving 1125 patients diagnosed with early stage breast cancer and obesity at the Shanghai Cancer Center of Fudan University from 2013 to 2016.

OUTCOME MEASURES

Obesity in the Chinese population was defined as a body mass index ≥28 kg/m2. Surgical options included BCT and TM. The primary survival outcomes were overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS). Inverse probability of treatment weighting (IPTW) was used to control for the impact of confounding factors on prognosis.

RESULTS

The median follow-up times in the BCT group and TM group without postoperative RT were 51.1 months (IQR of 40.6-68.1 months) and 61.8 months (IQR of 46.5-76.7 months), respectively. After IPTW, the baseline data were balanced. Compared with those in the TM cohort, patients in the whole IPTW cohort in the BCT cohort had worse DFS (HR 4.280, 95% CI 2.180 to 8.400; p<0.001), RFS (HR 4.380, 95% CI 2.370 to 8.120; p<0.001) and OS (HR 3.590, 95% CI 1.620 to 7.950; p=0.002).

CONCLUSION

In patients with early stage breast cancer and obesity, TM is associated with better survival outcomes than BCT.

Predictive biomarkers of mortality in patients with severe COVID-19 hospitalized in intensive care unit

Objectives

This study was performed to identify predictive markers of worse outcomes in patients with severe COVID-19 in an intensive care unit.

Methods

Sixty patients with severe COVID-19, hospitalized in the Intensive Care Unit (ICU) between March and July 2021, were stratified into two groups according to the outcome survivors and non-survivors. After admission to the ICU, blood samples were collected directly for biomarker analysis. Routine hematological and biochemical biomarkers, as well as serum levels of cytokines, chemokines, and immunoglobulins, were investigated.

Results

Lymphopenia, neutrophilia, and thrombocytopenia were more pronounced in non-surviving patients, while the levels of CRP, AST, creatinine, ferritin, AST, troponin I, urea, magnesium, and potassium were higher in the non-surviving group than the survival group. In addition, serum levels of IL-10, CCL2, CXCL9, and CXCL10 were significantly increased in patients who did not survive. These changes in the biomarkers evaluated were associated with increased mortality in patients with severe COVID-19.

Conclusion

The present study confirmed and expanded the validity of laboratory biomarkers as indicators of mortality in severe COVID-19.

Unlocking the Secrets of Adipose Tissue: How an Obesity-Associated Secretome Promotes Osteoblast Dedifferentiation via TGF-β1 Signaling, Paving the Path to an Adipogenic Phenotype

BACKGROUND

Obesity poses a significant global health challenge, given its association with the excessive accumulation of adipose tissue (AT) and various systemic disruptions. Within the adipose microenvironment, expansion and enrichment with immune cells trigger the release of inflammatory mediators and growth factors, which can disrupt tissues, including bones. While obesity's contribution to bone loss is well established, the direct impact of obese AT on osteoblast maturation remains uncertain. This study aimed to explore the influence of the secretomes from obese and lean AT on osteoblast differentiation and activity.

METHODS

SAOS-2 cells were exposed to the secretomes obtained by culturing human subcutaneous AT from individuals with obesity (OATS) or lean patients, and their effects on osteoblasts were evaluated.

RESULTS

In the presence of the OATS, mature osteoblasts underwent dedifferentiation, showing an increased proliferation accompanied by a morphological shift towards a mesenchymal phenotype, with detrimental effects on osteogenic markers and the calcification capacity. Concurrently, the OATS promoted the expression of mesenchymal and adipogenic markers, inducing the formation of cytoplasmic lipid droplets in SAOS-2 cells exposed to an adipogenic differentiation medium. Additionally, TGF-β1 emerged as a key mediator of these effects, as the OATS was enriched with this growth factor.

CONCLUSIONS

Our findings demonstrate that obese subcutaneous AT promotes the dedifferentiation of osteoblasts and increases the adipogenic profile in these cells.