Obesity in the critically ill: a narrative review

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.

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.

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

BACKGROUND

Intensive 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.

OBJECTIVE

to present the impact of implementing Walker View 3.0 SCX technology in post-intensive care unit rehabilitation of obese patient.

METHODS

A 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.

RESULTS

The 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.

CONCLUSIONS

Integrating 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.

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.

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.

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.

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.

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.

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

BACKGROUND

Sepsis 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.

METHODS

The 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.

RESULTS

A 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.

CONCLUSION

In 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.

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.

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.

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.

Preoperative Atelectasis in Patients with Obesity Undergoing Bariatric Surgery: A Cross-Sectional Study

BACKGROUND

Pulmonary atelectasis is present even before surgery in patients with obesity. We aimed to estimate the prevalence and extension of preoperative atelectasis in patients with obesity undergoing bariatric surgery and to determine if variation in preoperative Spo2 values in the seated position at room air is explained by the extent of atelectasis coverage in the supine position.

METHODS

This was a cross-sectional study in a single center specialized in laparoscopic bariatric surgery. Preoperative chest computed tomographies were reassessed by a senior radiologist to quantify the extent of atelectasis coverage as a percentage of total lung volume. Patients were classified as having atelectasis when the affection was ≥2.5%, to estimate the prevalence of atelectasis. Crude and adjusted prevalence ratios (aPRs) and odds ratios (aORs) were obtained to assess the relative prevalence of atelectasis and percentage coverage, respectively, with increasing obesity category. Inverse probability weighting was used to assess the total, direct (not mediated), and indirect (mediated through atelectasis) effects of body mass index (BMI) on preoperative Spo2, and to quantify the magnitude of mediation (proportion mediated). E-values were calculated, to represent the minimum magnitude of association that an unmeasured confounder with the same directionality of the effect should have to drive the observed point estimates or lower confidence intervals (CIs) to 1, respectively.

RESULTS

In 236 patients with a median BMI of 40.3 kg/m2 (interquartile range [IQR], 34.6-46.0, range: 30.0-77.3), the overall prevalence of atelectasis was 32.6% (95% CI, 27.0-38.9) and by BMI category: 30 to 35 kg/m2, 12.7% (95% CI, 6.1-24.4); 35 to 40 kg/m2, 28.3% (95% CI, 17.2-42.6); 40 to 45 kg/m2, 12.3% (95% CI, 5.5-24.3); 45 to 50 kg/m2, 48.4% (95% CI, 30.6-66.6); and ≥50 units, 100% (95% CI, 86.7-100). Compared to the 30 to 35 kg/m2 group, only the categories with BMI ≥45 kg/m2 had significantly higher relative prevalence of atelectasis-45 to 50 kg/m2, aPR = 3.52 (95% CI, 1.63-7.61, E-value lower bound: 2.64) and ≥50 kg/m2, aPR = 8.0 (95% CI, 4.22-15.2, E-value lower bound: 7.91)-and higher odds of greater atelectasis percentage coverage: 45-50 kg/m2, aOR = 7.5 (95% CI, 2.7-20.9) and ≥50 kg/m2, aOR = 91.5 (95% CI, 30.0-279.3). Atelectasis percent alone explained 70.2% of the variation in preoperative Spo2. The proportion of the effect of BMI on preoperative Spo2 values <96% mediated through atelectasis was 81.5% (95% CI, 56.0-100).

CONCLUSIONS

The prevalence and extension of atelectasis increased with higher BMI, being significantly higher at BMI ≥45 kg/m2. Preoperative atelectasis mediated the effect of BMI on Spo2 at room air in the seated position.

Modulatory Effects of Lactobacillus paracasei-Fermented Turmeric on Metabolic Dysregulation and Gut Microbiota in High-Fat Diet-Induced Obesity in Mice

Turmeric, derived from Curcuma longa, and Lactobacillus paracasei, a lactic acid bacteria, have been studied for their potential antiobesity effects. To date, the antiobesity effects of turmeric fermented with L. paracasei have not been sufficiently investigated. This study was conducted via oral administration of 5% L. paracasei-fermented (FT) and unfermented turmeric (UT) in diet over 16 weeks using high-fat diet (HFD)-induced obese C57BL/6J mice. Results showed that the curcuminoid content of turmeric decreased following fermentation. Furthermore, FT significantly suppressed weight gain and liver and visceral adipose tissue weight and reduced plasma metabolic parameters in both the UT and FT experimental groups. The effects of FT were more noticeable than those of the unfermented form. Moreover, FT downregulated the expression of adipogenesis, lipogenesis, and inflammatory-related protein, but upregulated liver β-oxidation protein SIRT 1, PPARα, and PGC-1α in perigonadal adipose tissue. Additionally, FT ameliorated insulin resistance by activating insulin receptor pathway protein expressions in visceral adipose tissues. FT also modulated gut microbiota composition, particularly in two beneficial bacteria, Akkermansia muciniphila and Desulfovibrio, as well as two short-chain fatty acid-producing bacteria: Muribaculum intestinale and Deltaproteobacteria. Our findings indicate that the modulation effect of FT may be an important pathway for its antiobesity mechanisms.

VV-ECMO in critical COVID-19 obese patients: a cohort study

BACKGROUND

Obesity causes significant difficulties in successful extracorporeal membrane oxygenation (ECMO) support and may interfere with patient outcomes. During the COVID-19 pandemic, we experienced an increased number of obese patients supported with ECMO in our intensive care unit due to severe illness in this population.

METHODS

We designed a single-center retrospective study to identify prognostic factors for 180-day survival in obese critical COVID-19 patients receiving venovenous ECMO (VV-ECMO). We included adult critical COVID-19 patients on VV-ECMO, who were obese and overweight (according to the World Health Organization) and admitted to a tertiary hospital's intensive care unit from April 1, 2020, to May 31, 2022. Univariate logistic regression analysis was performed to assess differences in 180-day mortality.

RESULTS

Forty-one patients were included. The median age was 55 (IQR 45-60) years, and 70.7% of the patients were male. The median body mass index (BMI) was 36 (IQR 31-42.5) kg/m2; 39% of patients had a BMI ≥ 40 kg/m2. The participants had 3 (IQR 1.5-4) days of mechanical ventilation prior to ECMO, and 63.4% were weaned from VV-ECMO support after a median of 19 (IQR 10-34) days. The median ICU length of stay was 31.9 (IQR 17.5-44.5) days. The duration of mechanical ventilation was 30 (IQR 19-49.5) days. The 180-day mortality rate was 41.5%. Univariate logistic regression analysis revealed that a higher BMI was associated with greater 180-day survival (OR 1.157 [1.038-1.291], p = 0.009). Younger age, female sex, less invasive ventilation time before ECMO, and fewer complications at the time of ECMO cannulation were associated with greater 180-day survival [OR 0.858 (0.774-0.953), p 0.004; OR 0.074 (0.008-0.650), p 0.019; OR 0.612 (0.401-0.933), p 0.022; OR 0.13 (0.03-0.740), p 0.022), respectively].

CONCLUSION

In this retrospective cohort of critical COVID-19 obese adult patients supported by VV-ECMO, a higher BMI, younger age, and female sex were associated with greater 180-day survival. A shorter invasive ventilation time before ECMO and fewer complications at ECMO cannulation were also associated with increased survival.

Health Status and COVID-19 Epidemiology in an Inland Region of Portugal: A Retrospective Study

Multiple factors, from socioeconomic development to genetic background, can affect the regional impact of some diseases, and this has also been seen during the COVID-19 pandemic. The objective of this retrospective study was to characterize a population in the interior of Portugal regarding health status and COVID-19 epidemiology. Between October 2021 and January 2023, 1553 subjects residing in Beira Baixa, Portugal, were included. Using a self-report approach, demographic and clinical data were obtained. Blood group, blood pressure, peripheral oxygen saturation and anti-spike protein immunoglobulin concentration were also analyzed. Statistical analysis was performed using IBM SPSS Statistics. The average age of the participants was 48.95 (±14.43) years, with 64% being male and 36% being female. The most prevalent comorbidities were hypertension (19.2%), dyslipidemia (12.6%) and diabetes mellitus (6.6%). Half of the population was overweight, and more than half of the subjects had no history of tobacco consumption. Among the participants, 33% were infected with SARS-CoV-2: 70.1% had mild disease, 14.1% moderate disease and 1.4% severe disease. There was a very significant adherence to vaccination (97%). Previously infected or vaccinated people had higher anti-spike protein immunoglobulin values; this value depended on the vaccine administered (p < 0.001). Patients with autoimmune diseases and smokers had lower levels of anti-S IgG antibodies (p = 0.030 and p = 0.024, respectively). The severity of COVID-19 did not affect the concentration of anti-S IgG (p = 0.430). This study highlights the general health statuses and the impact of COVID-19 on a population in the Portuguese interior. Knowledge of the circulation and impact of the virus in this specific population can alert and assist in better interventions being conducted by health authorities.

BMI and mortality in critically ill patients with COVID-19: another brick in the wall of the obesity paradox

OBJECTIVE

The objective of this study was to assess the existence of the obesity paradox in patients with COVID-19 admitted to the intensive care unit.

METHODS

This was a multicentric retrospective cohort study including individuals aged 18 years or older admitted to the intensive care unit with SARS-CoV-2. Data were obtained from electronic medical records. The primary outcome was in-hospital mortality. Multiple logistic regression and restricted cubic splines analyses were conducted to assess the association between BMI and mortality.

RESULTS

From March 2020 to December 2021, 977 patients met the inclusion criteria, and 868 were included in the analysis. Obesity was identified in 382 patients (44%). Patients with obesity more often underwent prone positioning (42% vs. 28%; p < 0.001), although they used less vasoactive medications (57% vs. 68%; p < 0.001). The overall in-hospital mortality was 48%, with 44% observed in the subgroup of individuals with obesity and 50% in those without obesity (p = 0.06). Patients with BMI < 25 kg/m2 had the highest mortality.

CONCLUSIONS

Obesity was not associated with higher mortality rates in critically ill patients with COVID-19. Moreover, patients with BMI < 25 kg/m2 had a higher mortality rate compared with those in higher BMI categories.

Should Obesity Be an Exclusion Criterion for Extracorporeal Membrane Oxygenation Support? A Scoping Review

Obesity is often considered a contraindication to extracorporeal membrane oxygenation (ECMO) candidacy due to technical challenges with vascular access, higher cardiac output requirements, and known associations between obesity and overall increased morbidity and mortality due to chronic health conditions. However, a growing body of literature suggests that ECMO may be as safe and efficacious in both obese and nonobese patients. This scoping review provides a synthesis of the available literature on the outcomes of obese patients supported with (1) venovenous (VV)-ECMO in acute respiratory distress syndrome (ARDS) not due to coronavirus disease 2019 (COVID-19), (2) VV-ECMO in ARDS due to COVID-19, (3) venoarterial (VA)-ECMO for all indications, and (4) studies combining data of patients supported with VA- and VV-ECMO. A librarian-assisted search was performed using 4 primary electronic medical databases (PubMed, Web of Science, Excerpta Medica database [Embase], and Cochrane Library) from January 2003 to March 2023. Articles that reported outcomes of obese patients requiring ECMO support were included. Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. A total of 354 publications were imported for screening on titles and abstracts, and 30 studies were selected for full-text review. A total of 26 publications met the inclusion criteria: 7 on VV-ECMO support in non-COVID-19 ARDS patients, 6 on ECMO in COVID-19 ARDS patients, 8 in patients supported with VA-ECMO, and 5 combining both VA- and VV-ECMO data. Although the included studies are limited to retrospective analyses and display a heterogeneity in definitions of obesity and comparison groups, the currently available literature suggests that outcomes and complications of ECMO therapy are equivalent in obese patients as compared to nonobese patients. Hence, obesity as measured by body mass index alone should not be considered an exclusion criterion in the decision to initiate ECMO.

Low doses of acetyl trihexyl citrate plasticizer promote adipogenesis in hepatocytes and mice

Accumulating epidemiological evidence underscores the association between pervasive environmental factors and an increased risk of metabolic diseases. Environmental chemicals, recognized disruptors of endocrine and metabolic processes, may contribute to the global prevalence of metabolic disorders, including obesity. Acetyl tributyl citrate (ATHC), categorized as a citric acid ester plasticizer, serves as a substitute for di-(2-ethylhexyl) phthalate (DEHP) in various everyday products. Despite its widespread use and the increasing risk of exposure in humans and animals due to its high leakage rates, information regarding the safety of exposure to environmentally relevant doses of ATHC remains limited. This study aimed to investigate the potential impact of ATHC exposure on metabolic homeostasis. Both in vivo and in vitro exposure models were used to characterize the effects induced by ATHC exposure. C57BL/6 J male mice were subjected to a diet containing ATHC for 12 weeks, and metabolism-related parameters were monitored and analyzed throughout and after the exposure period. Results indicated that sub-chronic dietary exposure to ATHC induced an increase in body fat percentage, elevated serum lipid levels, and increased lipid content in the liver tissue of mice. Furthermore, the effect of ATHC exposure on murine hepatocytes were examined and results indicated that ATHC significantly augmented lipid levels in AML12 hepatocytes, disrupting energy homeostasis and altering the expression of genes associated with fatty acid synthesis, uptake, oxidation, and secretion pathways. Conclusively, both in vivo and in vitro results suggest that exposure to low levels of ATHC may be linked to an elevated risk of obesity and fatty liver in mice. The potential implications of ATHC on human health warrant comprehensive evaluation in future studies.

Intravenous calcitriol administration improves the liver redox status and attenuates ferroptosis in mice with high-fat diet-induced obesity complicated with sepsis

Obesity aggravates ferroptosis, and vitamin D (VD) may inhibit ferroptosis. We hypothesized that weight reduction and/or calcitriol administration have benefits against the sepsis-induced liver redox imbalance and ferroptosis in obese mice. Mice were fed a high-fat diet for 11 weeks, then half of the mice continued to consume the diet, while the other half were transferred to a low-energy diet for 5 weeks. After feeding the respective diets for 16 weeks, sepsis was induced by cecal ligation and puncture (CLP). Septic mice were divided into four experimental groups: OS group, obese mice injected with saline; OD group, obese mice with calcitriol; WS group, weight-reduction mice with saline; and WD group, weight-reduction mice with calcitriol. Mice in the respective groups were euthanized at 12 or 24 h after CLP. Results showed that the OS group had the highest inflammatory mediators and lipid peroxide levels in the liver. Calcitriol treatment reduced iron content, enhanced the reduced glutathione/oxidized glutathione ratio, upregulated nuclear factor erythroid 2-related factor 2, ferroptosis-suppressing protein 1, and solute carrier family 7 member 11 expression levels. Also, mitochondrion-associated nicotinamide adenine dinucleotide phosphate oxidase 1, peroxisome proliferator-activated receptor-γ coactivator 1, hypoxia-inducible factor-1α, and heme oxidase-1 expression levels increased in the late phase of sepsis. These results were not noted in the WS group. These findings suggest that calcitriol treatment elicits a more-balanced glutathione redox status, alleviates liver ferroptosis, and enhances mitochondrial biogenesis-associated gene expressions. Weight reduction alone had minimal influences on liver ferroptosis and mitochondrial biogenesis in obese mice with sepsis.

The obesity paradox and 90 day mortality in chronic critically ill patients: a cohort study using a large clinical database

BACKGROUND

This study investigates the obesity paradox, where obesity is linked to lower mortality in certain patient groups, focusing on its impact on long-term mortality in chronic critically ill (CCI) patients.

METHODS

We retrospectively analyzed CCI patients from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database's Intensive Care Unit, categorizing them into six groups based on Body Mass Index (BMI). Using stepwise multivariable Cox regression and restricted cubic spline models, we examined the association between BMI and 90 day mortality, accounting for confounding variables through subgroup analyses.

RESULTS

The study included 1996 CCI patients, revealing a 90 day mortality of 34.12%. Overweight and obese patients exhibited significantly lower mortality compared to normal-weight individuals. Adjusted analysis showed lower mortality risks in overweight and obese groups (HRs 0.60 to 0.72, p < 0.001). The cubic spline model indicated a negative correlation between BMI and 90 day mortality, with subgroup analyses highlighting interactions with age.

CONCLUSION

Our findings confirm the obesity paradox in CCI patients, especially among the elderly (65-85 years) and very elderly (≥ 85 years). The results suggest a beneficial association of higher BMI in older CCI patients, though caution is advised for those under 45.

Association of visceral adiposity index with phenotypic age acceleration: insight from NHANES 1999-2010

BACKGROUND

Obesity correlates with accelerated aging. This study aims to investigate the association between the visceral adiposity index (VAI) and accelerated aging.

METHODS

Biological aging was evaluated by phenotypic age acceleration (PhenoAgeAccel). Utilizing data from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2010, we employed weighted multivariable logistic regression models, along with subgroup analysis, to examine the association between VAI and PhenoAgeAccel. Moreover, smooth curve fitting was utilized to identify potential nonlinear association, complemented by a two-piece linear regression model to investigate threshold effects.

RESULTS

Of the included 11,340 participants aged 20 years and older, the mean (95% CI) age was 46.569 (45.946, 47.191) years, and 49.189% were male. The mean (95% CI) VAI for all participants was 2.176 (2.114, 2.238), and the mean (95% CI) PhenoAgeAccel was -6.306 (-6.618, -5.994) years. In the fully adjusted model, each incremental unit increase of VAI was associated with a 0.312-year increase in PhenoAgeAccel (β = 0.312, 95% CI: 0.217, 0.408). This positive association was more statistically significant among individuals with cancer. Furthermore, a segmented association was observed between VAI and PhenoAgeAccel, with a turning point identified at 10.543. Below this threshold, VAI exhibited a positive correlation with PhenoAgeAccel (β = 0.617, 95% CI: 0.499, 0.735), while beyond it, the association became nonsignificant.

CONCLUSION

This study demonstrated a positive association between VAI and accelerated aging within a nationally representative population. The findings suggest that controlling adiposity may exert anti-aging effects and help prevent aging-related diseases.

Metabolic Syndrome and Menopause: The Impact of Menopause Duration on Risk Factors and Components

Purpose

This study was undertaken to investigate the impact of menopause duration on the risk factors and components of metabolic syndrome (MetS).

Patients and Methods

Women aged between 45 and 60 years participated in the study. Participants were split into two groups based on the duration of menopause. Women who had been menopausal for 1 to ≤5 years constituted Group 1, while women with 6-10 years of menopause duration formed Group 2.

Results

Significant differences were observed between the two groups for various factors associated with MetS, including anthropometric measurements, biochemical markers, and blood pressure. The conicity index, weight-to-hip ratio, waist-to-height ratio, visceral adiposity index (VAI), and menopause duration were associated with increased risk of MetS. Our multivariate logistic regression model showed that women with elevated VAI had a 2.073-fold (95% CI: 1.73-2.48, p<0.001) increased risk of MetS, while women with menopause duration more than 5 years had a 6.44-fold (95% CI: 3.336-12.45, p<0.001) increased risk of MetS.

Conclusion

The duration of menopause was found to be linked to a higher risk of MetS. Our results emphasize the importance of monitoring and managing metabolic health in women during the menopausal period, particularly those with extended menopause duration.

Deficiency of Energy and Nutrient and Gender Differences among Chinese Adults: China Nutrition and Health Survey (2015-2017)

Half of Chinese adults face the double burden of overweight/obesity and micronutrient deficiencies, and nearly 40% of them are severely overweight/obese or have micronutrient deficiencies. This study used the data from China Nutrition and Health Survey (CNHS) from 2015 to 2017 to estimate the prevalence of inadequate dietary micronutrient intake (including vitamin A, vitamin B1, vitamin B2, vitamin C, cCalcium, iron and sodium) in Chinese adults and further determine the differences in micronutrient intake by gender, age and BMI. A total of 61,768 subjects were included in this study, of which 33,262 (54%) were female. The intake of energy and all macronutrients decreased with age, and the intake was higher in men than in women. Inadequate energy intake occurs in adults of all ages. In terms of nutrient intake, women had a higher rate of insufficient carbohydrate intake than men in all age groups. Inadequate protein intake was more common in women aged 18-49 years (60.9%) than in men. Compared with women, men had a higher rate of vitamin B2 intake. Insufficient vitamin B3 intake was more common in women aged 18-49 years (35.6%), men aged 65-79 years (39.7%) and men aged 80 years and above (47.9%). In all age groups, insufficient vitamin C intake is higher in women than in men-up to 85.8 percent in women aged 80 years old and above. Compared with men in the same age group, insufficient intake of calcium and iron is more obvious in women. Women have significantly higher rates of inadequate intake of calcium, iron and sodium than men. In the analysis of correlations between BMI or demographic data and micronutrient intakes, the likelihood of micronutrient intakes being insufficient was higher in the central and western regions in all age groups compared to the eastern regions. The risk of insufficient micronutrient intake was higher in obese men and women aged 18-49 years and 50-64 years. Underweight and overweight women in the 65-79 age group were more likely to have inadequate micronutrient intake. Obese women over 80 years of age were less likely to have inadequate micronutrient intake. No significant difference was found between urban and rural areas for each age group.

Comparative effects of high-intensity interval training and moderate-intensity continuous training on weight and metabolic health in college students with obesity

The purpose of this study was to compare the effects of High-Intensity Interval Training (HIIT) and Moderate-Intensity Continuous Training (MICT) on weight, body composition, blood lipid indicators, and metabolic status in college students living with obesity. The study focused on a sample of 40 college students living with obesity, including 20 males and 20 females, aged between 18 and 25. Participants were randomly assigned to either the HIIT group or the MICT group. Both groups underwent an 8-week intervention, consisting of three sessions per week with alternate-day training. The MICT group's training consisted of continuous aerobic exercise for 35 min at 60-70% of maximum heart rate. The HIIT group engaged in 28 min of alternating high-intensity and low-intensity exercise, where the high-intensity phase was at 85-90% of maximum heart rate for 4 min, followed by a 3-min recovery period at 50-60% of maximum heart rate, repeated four times. Both groups underwent heart rate monitoring before and after the training sessions to ensure the accuracy of the training intensity. Within each group, further distinctions were made based on gender, resulting in the following subgroups: Male HIIT group (n = 10), Female HIIT group (n = 10), Male MICT group (n = 10), and Female MICT group (n = 10). Differences in anthropometric and biochemical indicators among the groups were analyzed, and the different effects of the two intervention strategies on the obese college student population were comprehensively evaluated. Compared to the baseline assessment, the HIIT group showed a more favorable declining trend than the MICT group in terms of body morphology and body composition, particularly in the aspect of body fat percentage (BF%). The male HIIT group, female HIIT group, male MICT group, and female MICT group respectively reduced by - 23.71%, - 26.76%, - 9.81%, - 7.16%. Male and female HIIT group experienced a more pronounced decrease compared to the MICT group, with the female HIIT group reducing an additional 3.75% more than the male HIIT group. Regarding intergroup differences, BF% significant differences were shown between male MICT group and the HIIT group (P < 0.05), and female MICT group and the HIIT group (P < 0.01). In terms of biochemical indicators, the HIIT group also presented a more favorable declining trend compared to the MICT group, with male HIIT participants showing more reduction than female HIIT participants, especially in total cholesterol (TC) (10.64%), low-density lipoprotein cholesterol (LDL-C) (11.73%), alanine aminotransferase (ALT) (11.99%), and uric acid (UA) (11.76%). Regarding triglycerides (TG), significant intergroup differences were observed between male MICT and HIIT groups (P < 0.01) and female MICT and HIIT groups (P < 0.01). Concerning ALT, a significant difference was shown between female MICT and HIIT groups (P < 0.01), while no significant difference was observed among male participants. Overall, for college students living with obesity, both HIIT and MICT have shown positive effects. Among these, HIIT demonstrates greater effectiveness compared to MICT in BF% and biochemical markers.

The correlation of BMI and insulin resistance in moderately burned patients

<b>Introduction:</b> Obesity is strongly related to serious comorbidities that might affect the healing process. Elevated Body Mass Index (BMI) and insulin resistance have a significant impact on the development of the metabolic syndrome often leading to lethal cardiovascular complications.<b>Aim:</b> The aim of the study was to verify the correlation of BMI and insulin resistance with clinical parameters of moderately burned patients.<b>Materials and methods:</b> There were 149 patients enrolled in the study and their clinical data was retrospectively analyzed. The laboratory tests, insulin demand, BMI, and surgical procedures were evaluated on admission and discharge.<b>Results:</b> Burned patients who required insulin were characterized by worse laboratory results on admission to the burn unit, they had lower hemoglobin (HGB) levels (P = 0.0001), higher creatinine levels by 0.323 units (P = 0.009), higher C-reactive protein (CRP) by approximately 94 units (P = 0.0001), as higher procalcitonin (PCT) by approximately 0.5 units (P = 0.001) as compared to non-insulin-treated patients. Moreover, burned patients who required insulin stayed in the hospital for an average of 10 days longer. All patients from the insulin-demand subgroup had elevated triglycerides (Tg) levels on admission with increased indexes of insulin resistance.<b>Discussion:</b> Our study suggests that the protective effect of a higher BMI in burned patients, known as the 'obesity paradox' may be compromised by insulin resistance.<b>Conclusions and significance of the study:</b> The results show that elevated Tg on admission to the burn unit coexisting with a BMI over 25 kg/m² may be used as an important prognostic factor and may help with prediction of insulin demand and worse outcome in moderately burned patients.

Joint association of weight-adjusted-waist index and physical activity with insulin resistance in adolescents: a cross-sectional study

BACKGROUND

The weight-adjusted waist index (WWI) is a recently developed obesity metric, and the aim of this study was to investigate the relationship between physical activity (PA) and WWI and the homeostasis model assessment of insulin resistance (HOMA-IR) in adolescents, as well as the joint association of HOMA-IR.

METHODS

This study was based on the National Health and Nutrition Survey conducted between 2013 and 2016 and included 1024 adolescents whose median age was 15.4. Multivariate linear regression was used to examine the associations between HOMA-IR and PA and WWI. Using generalized additive models, a potential nonlinear link between WWI and HOMA-IR was evaluated. Subgroup analysis was also carried out.

RESULTS

The fully adjusted model revealed a positive association (β: 0.48, 95% CI: 0.43, 0.53) between the WWI and HOMA-IR. The HOMA-IR was lower in physically active (β: -0.16, 95% CI: -0.26, -0.05) participants versus inactive participants. Participants who had higher WWI and were not physically active (β: 0.69; 95% CI: 0.56, 0.82) had the highest levels of HOMA-IR compared to participants who had lower WWI and were physically active. Subgroup analysis revealed that these correlations were similar in males and females.

CONCLUSION

Our results demonstrated that higher WWI and PA were associated with a lower HOMA-IR and that WWI and PA had a combined association with HOMA-IR. The findings of this study are informative for the preventing insulin resistance in adolescents.