Diagnostic Value of C-Reactive Protein Levels in Postoperative Infectious Complications After Bariatric Surgery: a Systematic Review and Meta-Analysis

The association of bariatric surgery with myocardial infarction and coronary revascularization: a propensity score match analysis of National Inpatient Sample

BACKGROUND

Metabolic bariatric surgery (MBS) not only leads to a durable weight loss but also lowers mortality, and reduces cardiovascular risks.

OBJECTIVES

The current study aims to investigate the association of bariatric metabolic surgery (BMS) with admissions for acute myocardial infarction (AMI), including ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), as well as, coronary revascularization procedures, including percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and thrombolysis.

SETTING

The National Inpatient Sample (NIS) database.

METHODS

The NIS data from 2016 to 2020 were analyzed. A propensity score matching in a 1:1 ratio was performed to match patients with history of MBS with non-MBS group.

RESULTS

Two hundred thirty-three thousand seven hundred twenty-nine patients from the non-MBS group were matched with 233,729 patients with history of MBS. The MBS group had about 52% reduced odds of admission for AMI compared to the non-MBS group (adjusted odd ratio: .477, 95% confidence interval: .454-.502, P value <.001). In addition, the odds of STEMI and NSEMI were significantly lower in the MBS group in comparison to the non-MBS group. Also, the MBS group had significantly lower odds of CABG, PCI, and thrombolysis compared to the non-MBS group. In addition, in patients with AMI, MBS was associated with lower in-hospital mortality (adjusted odd ratio: .627, 95% confidence interval: .469-.839, P value = .004), length of hospital stays, and total charges.

CONCLUSIONS

History of MBS is significantly associated with reduced risk of admission for AMI including STEMI and NSTEMI, as well as the, need for coronary revascularization such as PCI and CABG.

Machine learning analysis of lab tests to predict bariatric readmissions

The purpose of this study was to develop a machine learning model for predicting 30-day readmission after bariatric surgery based on laboratory tests. Data were collected from patients who underwent bariatric surgery between 2018 and 2023. Laboratory test indicators from the preoperative stage, one day postoperatively, and three days postoperatively were analyzed. Least absolute shrinkage and selection operator regression was used to select the most relevant features. Models constructed included support vector machine (SVM), generalized linear model, multi-layer perceptron, random forest, and extreme gradient boosting. Model performance was evaluated and compared using the area under the receiver operating characteristic curve (AUROC). A total of 1262 patients were included, of which 7.69% of cases were readmitted. The SVM model achieved the highest AUROC (0.784; 95% CI 0.696-0.872), outperforming other models. This suggests that machine learning models based on laboratory test data can effectively identify patients at high risk of readmission after bariatric surgery.

Periprocedural Changes of Serum Biomarkers in Predicting Complications Following Bariatric Surgery for Obesity: Systematic Review and Meta-analysis

Bariatric surgery is an effective treatment for severe obesity, but complications and peri-operative monitoring are important considerations. We conducted a comprehensive review of studies assessing pre-operative biomarkers and complications in patients undergoing bariatric surgery. A total of 14 studies were included. Gastric leak, infections, bleeding, obstruction or stenosis, hypoglycemia, and hypoalbuminemia were the most common complications observed. Our analysis showed a significant association between lower pre-operative albumin levels and complications (SMD [95%CI] =  - 0.21 [- 0.38; - 0.04]). However, other biomarkers did not have a significant impact on complication occurrence. Changes in C-reactive protein, neutrophil-lymphocyte ratio, and white blood cell levels were observed in certain peri-operative time points and complication subgroups. These findings suggest the potential use of pre-operative biomarkers and peri-operative changes of biomarker's levels for predicting complications.

Is Routine Post-operative Biological Laboratory Assessment Necessary After Sleeve Gastrectomy?

BACKGROUND

Incidence of post-operative complications after sleeve gastrectomy (SG) is low. However, the early identification of these complications remains crucial. Here, we report the impact of routine laboratory monitoring for the early diagnosis of complications after SG.

MATERIAL AND METHODS

From January 2018 to December 2019, all consecutive patients who underwent primary SG (n = 457) were included. This was a comparative study of patients undergoing primary SG. Patients were divided into two groups: one group with routine laboratory monitoring performed at postoperative day (POD) 1 and 3 (LAB group) and another group without routine laboratory monitoring (control group). The study's primary endpoint was the overall impact of routine laboratory monitoring. The secondary endpoints were evaluation of patients with complications.

RESULTS

The population in the two groups were similar in term of demographic and intra-operative data. There was a statistical difference between the two groups in term of length of stay (5.7 days in the LAB group and 3.5 days in the control group (p < 0.001)). There were 19 complications (6.0%) in the LAB group and 5 complications in the control group (3.5%) (p = 0.25). A cut-off C-reactive protein level of 46.3 mg/l was found to be significant (p = 0.006). In the LAB group, 9 patients (2.9%) required readmission vs. three patients (2.0%) in the control group (p = 0.62).

CONCLUSION

The interest of routine laboratory monitoring after SG seems limited. Routine laboratory monitoring alone is not associated with earlier diagnosis of complications. This routine monitoring is associated with an increase of stay in hospital.

Berry Consumption in Relation to Allostatic Load in US Adults: The National Health and Nutrition Examination Survey, 2003-2010

INTRODUCTION

Berries are a rich source of antioxidant polyphenols and other nutrients that are associated with good health. Allostatic load (AL) is an aggregate measure of chronic stress-induced physiological dysregulations across cardiovascular, metabolic, autonomic, and immune systems; the extent of these dysregulations, collectively or in each system, can be characterized by a composite score or a domain score assessed by integrated biomarkers. It was hypothesized that the anti-inflammatory and other effects of berries lower AL. The association was determined between berry consumption and AL composite and domain scores in the 2003-2010 National Health and Nutrition Examination Survey (NHANES).

METHODS

Berry intake was measured using two 24 h dietary recalls collected from US adults in the 2003-2010 NHANES (n = 7684). The association with AL and its specific domains was examined using population weight-adjusted multivariable linear regression.

RESULTS

The mean AL composite scores for consumers of any berries (11.9), strawberries (11.6), and blueberries (11.6), respectively, were significantly lower than nonconsumers (12.3), after fully adjusting for sociodemographic, lifestyle, and dietary confounders. A significant dose-response relationship was determined between greater consumption of total berries, strawberries, and blueberries and lower mean AL composite scores (p-trend < 0.05, for all). Consistently, mean cardiovascular and metabolic domain scores remained significantly lower in the consumers of total berries (mean cardiovascular domain score: 4.73 versus 4.97 for nonconsumers; mean metabolic domain score: 2.97 versus 3.1), strawberries (4.73 versus 4.95; 2.99 versus 3.1), and blueberries (4.6 versus 4.95; 2.92 versus 3.11). Berry consumers also had significantly lower mean AL immune scores (1.52 versus 1.56) and lower mean AL autonomic scores (2.49 versus 2.57) than nonconsumers (initial sample: n = 15,620).

CONCLUSIONS

The current study indicates that consumption of berries lowers the AL composite scores and potentially reduces stress-related disease risks in the US adult population.

Diagnostic efficacy of serum presepsin for postoperative infectious complications: a meta-analysis

Background

Postoperative infectious complications (PICs) are major concerns. Early and accurate diagnosis is critical for timely treatment and improved outcomes. Presepsin is an emerging biomarker for bacterial infections. However, its diagnostic efficacy for PICs across surgical specialties remains unclear.

Methods

In this study, a systematic search on MEDLINE, Embase, Google Scholar, and Cochrane Library was performed on September 30, 2023, to identify studies that evaluated presepsin for diagnosing PICs. PIC is defined as the development of surgical site infection or remote infection. Pooled sensitivity, specificity, and hierarchical summary receiver operating characteristic (HSROC) curves were calculated. The primary outcome was the assessment of the efficacy of presepsin for PIC diagnosis, and the secondary outcome was the investigation of the reliability of procalcitonin or C-reactive protein (CRP) in the diagnosis of PICs.

Results

This meta-analysis included eight studies (n = 984) and revealed that the pooled sensitivity and specificity of presepsin for PIC diagnosis were 76% (95% confidence interval [CI] 68%-82%) and 83% (95% CI 75%-89%), respectively. The HSROC curve yielded an area under the curve (AUC) of 0.77 (95% CI 0.73-0.81). Analysis of six studies on procalcitonin showed a combined sensitivity of 78% and specificity of 77%, with an AUC of 0.83 derived from the HSROC. Meanwhile, data from five studies on CRP indicated pooled sensitivity of 84% and specificity of 79%, with the HSROC curve yielding an AUC of 0.89.

Conclusion

Presepsin exhibits moderate diagnostic accuracy for PIC across surgical disciplines. Based on the HSROC-derived AUC, CRP has the highest diagnostic efficacy for PICs, followed by procalcitonin and presepsin. Nonetheless, presepsin demonstrated greater specificity than the other biomarkers. Further study is warranted to validate the utility of and optimize the cutoff values for presepsin.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023468358.

Expression and prognostic value of C-reactive protein in adult immune thrombocytopenia (ITP) patients

The aim of this study was to investigate the effect of C-reactive protein (CRP) on the prognosis of adult patients with Immune thrombocytopenia purpura (ITP). A retrospective study of 628 adult ITP patients, as well as 100 healthy and 100 infected patients, attending the Affiliated Hospital of Xuzhou Medical University from January 2017 to June 2022 was performed. The ITP patients were grouped according to their CRP levels, and the differences in clinical characteristics of each group and the influencing factors of efficacy in newly diagnosed ITP patients were analyzed. CRP levels were significantly higher in the ITP and infected groups compared with healthy controls (P < 0.001), and platelet counts were significantly lower in the ITP group (P < 0.001). Between the CRP normal and elevated group, their age, white blood cell count, neutrophil count, lymphocyte count, red blood cell count, hemoglobin, platelet count, complement C3 and C4, PAIgG, bleeding score, proportion of severe ITP, and proportion of refractory ITP were significantly different (P < 0.05). Patients of severe ITP (P < 0.001), refractory ITP (P = 0.002), and with active bleeding (P < 0.001) had significantly higher CRP levels. Patients with no response after treatment had significantly higher CRP levels than those who achieved CR or R (P < 0.001). Platelet counts (r = - 0.261, P < 0.001) in newly diagnosed ITP patients and treatment outcomes (r = - 0.221, P < 0.001) were negatively correlated with CRP levels, and bleeding score was positively correlated with CRP levels (r = 0.207, P < 0.001). Treatment outcome was positively correlated with decrease in CRP levels (r = 0.313, P = 0.027). A multifactorial regression analysis of the influencing factors of treatment outcomes on newly diagnosed patients found that CRP was an independent risk factor of the prognosis (P = 0.011). In conclusion, CRP can help assess the severity and predict the prognosis of ITP patients.

Suggested Flowchart Through Integrated C-Reactive Protein and White Blood Cell Count Analysis for Screening for Early Complications After Gastric Bypass: a Single-Center Retrospective Study

INTRODUCTION

Early leakage detection following bariatric procedures is crucial, but a standardized evaluation method is lacking. The aim was to validate the potential benefits of postoperative day 1 (POD1) C-reactive protein (CRP) levels and white blood cell (WBC) counts in distinguishing at-risk patients following Roux-en-Y gastric bypass (RYGB) while considering the impact of obesity-related chronic inflammation.

METHODS

Retrospective analysis of 261 consecutive patients aged 18-65 years with a body mass index (BMI) of 32.5-50 kg/m2 who underwent primary RYGB between 2017 and 2022. Sequential changes in CRP levels and WBC counts measured 48 h preoperatively and on POD1 morning were collected and compared between patients with/without complications and in patients without complications stratified by preoperative CRP levels.

RESULTS

Female patients and those with a higher BMI tended to have higher baseline CRP levels, which were positively related to postoperative CRP. Patients experiencing complications had higher WBC counts and a higher prevalence of WBC counts >14,000/μl (77.8% vs. 25.4%; p<0.001) than those without complications. Baseline CRP ≥ 0.3 mg/dl, a longer operative time, and blood loss >10 ml were significantly more common with WBC counts above 14,000/μl; a reasonable range of change in WBC count (∆WBC) derived from its positive correlation to postoperative WBC count (r=0.6695) may serve as a useful complementary indicator.

CONCLUSION

An individualized CRP threshold setting and integrated interpretation of the WBC count can be more appropriate than using static criteria for differentiating at-risk patients after RYGB. Further studies are needed to validate these findings and determine their generalizability.

The Effects of Pilates Exercise Training Combined with Walking on Cardiorespiratory Fitness, Functional Capacity, and Disease Activity in Patients with Non-Radiologically Confirmed Axial Spondylitis

The objective of the study was to examine the effects of Pilates exercise training combined with walking on cardiorespiratory fitness, functional capacity, and disease activity in patients with non-radiologically confirmed axial spondylitis (nr-axSpA). Thirty patients with nr-axSpA (seven women (90%), with a mean age of 46.07 ± 10.48 years old and C-reactive protein (CRP) 2.26 ± 2.14 mg/L) were randomly divided into two groups: A (n1 = 15 patients) and B (n2 = 15 patients). Group A followed a 6-month home-based Pilates exercise training program, while Group B remained untrained until the end of the study. A cardiopulmonary exercise test (CPET), timed up and go test (TUG), five times sit-to-stand test (5×STS), sit-and-reach test (SR), back scratch test for the right (BSR) and the left arm (BSL), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Ankylosing Spondylitis Disease Activity Score (ASDAS) were applied to all patients, both at the beginning and at the end of the study. After 6 months, Group A showed higher values in exercise time by 37.41% (p = 0.001), higher peak oxygen uptake (VO2peak) by 25.41% (p = 0.01), a higher ratio between oxygen uptake and maximum heart rate (VO2/HRmax) by 14.83% (p = 0.04), and higher SR by 18.70% (p = 0.007), while lower values were observed in TUG by 24.32% (p = 0.001), 5×STS by 12.13% (p = 0.001), BASDAI score by 20.00% (p = 0.04) and ASDAS score by 23.41% (p = 0.03), compared to Group B. Furthermore, linear regression analysis showed a positive correlation in Group A between BASDAI and 5×STS (r = 0.584, p = 0.02), BASDAI and TUG (r = 0.538, p = 0.03), and ASDAS and 5×STS (r = 0.538, p = 0.03), while a negative correlation was found between BASDAI and VO2peak (r = -0.782, p < 0.001), ASDAS and SR (r = -0.548, p = 0.03), and ASDAS and VO2peak (r = -0.659, p = 0.008). To sum up, cardiorespiratory fitness, functional capacity, and disease activity improved after a long-term Pilates exercise training program in patients with nr-axSpA.

Predictive value of C-reactive protein levels for the early and later detection of postoperative complications after cytoreductive surgery and HIPEC

Synopsis

C-reactive protein (CRP), white blood cells and procalcitonin (PCT) participate in the systemic response to inflammation and increase after postoperative infective complications. Postoperative complications after CRS and HIPEC could be predicted using the CRP cut-off value (169 mg/L at PODs 3-5 and 62 mg/L at PODs 7-10).

Background

Postoperative elevation of C-reactive protein (CRP) can be used in order to predict the postoperative complications in many indications. Cytoreduction surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with high morbidity.

Objectives

The aim of the study was to demonstrate the CRP predictive value for the occurrence of complications.

Methods

All patients who had CRS and HIPEC, regardless of the origin of peritoneal metastasis, were included in this retrospective study. Postoperative complications and CRP and white blood cell (WBC) counts were recorded from postoperative day (POD) 1 through 10.

Results

Among the 127 patients included, 58 (45.7%) had no complications (NCs), 53 (41.7%) had infective complications (ICs), and 16 (12.6%) had non-infective complications (NICs). The IC group had a higher CRP value than the NC group, which was statistically significant from POD7 to POD10 (41.1 versus 107.5 p = 0.023 and 77.8 versus 140 p = 0.047, respectively). A cut-off CRP value was 169 mg/L at PODs 3-5 and 62 mg/L at PODs 7-10. The area under the curve (AUC) at POD5 was 0.56 versus 0.76 at POD7, p=0.007. The sensibility, specificity, positive and negative predictive values of these cut-offs were 55%, 83%, 74% and 67%, respectively. Moreover, 17 patients (32%) with ICs had a CRP value higher than these cut-offs before the diagnosis was made by the medical team.

Conclusion

This study suggested that postoperative complications could be predicted using the CRP cut-off value on PODs 3-5 (169 mg/l) and PODs 7-10 (62 mg/l) after CRS and HIPEC.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (&gt; 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Dendrobium officinale Xianhu 2 polysaccharide helps forming a healthy gut microbiota and improving host immune system: An in vitro and in vivo study

Dendrobium officinale is widely consumed owing to its numerous beneficial effects. We aimed to characterize polysaccharides of Dendrobium officinale (DOP) from the stems of Dendrobium officinale Xianhu 2 and clarify whether it benefit the intestinal microbiota and the immune system. The DOP weighed 291 kDa and comprised mannose, glucose, galactose, and rhamnose at 59.31:33.31:1.00:0.51 M ratio. In in vitro/vivo studies, DOP significantly increased benign intestinal microbe proportion (Lactobacillus, etc.), but reduced harmful bacteria (Escherichia_Shigella) (P < 0.05), and significantly increased butyric acid production (P < 0.05). Concentrations of 2 g/L DOP for in vitro fermentation and 100 mg/kg body weight for the mouse model were effective. In mice, DOP significantly reduced CRP, CD3, CD4, and TNF-α levels and increased C4 levels (P < 0.05). DOP might influence the immune system indirectly through regulation of the gut microbiota. Its possible regulation mechanism was that DOP reduced CD4+ Th cells proliferation so that reduced the secretion of TNF-α.

Diagnostic accuracy of procalcitonin and interleukin-6 for postoperative infection in major gastrointestinal surgery: a systematic review and meta-analysis

BACKGROUND

We aim to assess the diagnostic accuracy of procalcitonin (PCT) and interleukin-6 (IL-6) as diagnostic biomarkers for postoperative infection/sepsis following major abdominal surgery. Postoperative infection is an important cause for morbidity and mortality in major surgery. Early diagnosis and antimicrobial treatment improves outcomes, and high-performing biomarkers could guide clinical decision making.

METHODS

A systematic database search was conducted for studies reporting diagnostic performance of biomarkers (including PCT and IL-6) for infection/sepsis following major abdominal surgery. Studies were assessed for reporting of diagnostic accuracy, relevance and quality. Data were extracted for meta-analysis.

RESULTS

Ten studies with 1,611 participants reported the diagnostic accuracy of PCT, with pooled sensitivity, specificity and summary receiver operator curve of 72% (95% CI 66-78), 62% (95% CI 59-64) and 0.766, respectively. Four studies with 175 participants reported the diagnostic accuracy of IL-6, with pooled sensitivity, specificity and summary receiver operator curve of 84% (95% CI 72-92), 76% (95% CI 68-84) and 0.878, respectively There was variability in the timing of sampling and cut-off values and significant heterogeneity and inconsistency between studies (I2 diagnostic odds ratio (DOR)= 43.2% for PCT, I2 DOR=0% for IL-6).

CONCLUSIONS

PCT performs only moderately well as a diagnostic test for postoperative infection/sepsis in major abdominal surgery, demonstrating limited sensitivity and specificity. Heterogeneity between studies is a limitation of the meta-analysis. There is an ongoing need for a rapid, accurate biomarker for postoperative infection or sepsis.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Biomarkers Predictive of Metabolic Syndrome and Cardiovascular Disease in Childhood Cancer Survivors

The improvement in childhood cancer treatments resulted in a marked improvement in the survival of pediatric cancer patients. However, as survival increased, it was also possible to observe the long-term side effects of cancer therapies. Among these, metabolic syndrome is one of the most frequent long-term side effects, and causes high mortality and morbidity. Consequently, it is necessary to identify strategies that allow for early diagnosis. In this review, the pathogenetic mechanisms of metabolic syndrome and the potential new biomarkers that can facilitate its diagnosis in survivors of pediatric tumors are analyzed.

Waiting time for surgery influences the outcome in idiopathic normal pressure hydrocephalus - a population-based study

INTRODUCTION

Idiopathic normal pressure hydrocephalus (iNPH) is a disease that comes with a great impact on the patient's life. The only treatment for iNPH, which is a progressive disease, is shunt surgery. It is previously indicated that early intervention might be of importance for the outcome.

AIM

To investigate if a longer waiting time for surgery, negatively influences the clinical outcome.

METHODS

Eligible for this study were all iNPH patients (n = 3007) registered in the Swedish Hydrocephalus Quality Registry (SHQR) during 1^st of January 2004-12^th of June 2019. Waiting time, defined as time between the decision to accept a patient for surgery and shunt surgery, was divided into the intervals ≤ 3, 3.1-5.9 and ≥ 6 months. Clinical outcome was assessed 3 and 12 months after surgery using the modified iNPH scale, the Timed Up and Go (TUG) test and the mini mental state examination (MMSE).

RESULTS

Three months after surgery, 57% of the patients with ≤ 3 months waiting time showed an improvement in modified iNPH scale (≥ 5 points) whereas 52% and 46% of patients with 3.1-5.9 and ≥ 6 months waiting time respectively improved (p = 0.0115). At 12 months of follow-up, the corresponding numbers were 61%, 52% and 51% respectively (p = 0.0536).

CONCLUSIONS

This population-based study showed that in patients with iNPH, shunt surgery should be performed within 3 months of decision to surgery, to attain the best outcome.

Effects of Milk or Soy Milk Combined with Mild Resistance Exercise on the Muscle Mass and Muscle Strength in Very Old Nursing Home Residents with Sarcopenia

Background and aims: Sarcopenia is recognized as a major public health issue, because it is prevalent in the elderly, especially those who live in long-term care facilities. The purpose of this study was to investigate the beneficial effects of milk or soy milk combined with resistance exercise on the muscle mass and muscle strength of individual elderly nursing home residents with sarcopenia. Methods: This study was a randomized controlled trial (clincaltrials.gov as NCT05035121) that recruited very old (>75 years) subjects with sarcopenia in a nursing home (Su-Ao and Yuanshan Branches, Taipei Veterans General Hospital) from June to December 2017. Thirty-five elderly (84.9 ± 6.1 years old) subjects were recruited and divided into three groups: control (n = 12), milk supplemented (n = 12), and soy milk supplemented (n = 11). All participants joined a mild resistance exercise training program three times a week (30 min/time). Moreover, elderly subjects in the milk and soy milk groups drank 200 mL of milk or soy milk for breakfast and as a snack after exercise. Results: After 12 weeks, compared to the baseline, calf circumferences had significantly increased in the control and soy milk groups (p = 0.0362 and p = 0.0197, respectively). Hand grip strength had significantly improved in the milk and soy milk groups (p = 0.0407 and p = 0.0096, respectively). In addition, there was no difference among the three groups. Conclusions: Mild resistance exercise combined with milk or soy milk improved the calf circumference and hand grip strength in very old nursing home residents with sarcopenia.

Longitudinal Changes of Cytokines and Appetite in Older Hospitalized Patients

There are few data on the longitudinal association of cytokine and appetite among older hospitalized patients. We aimed to investigate the impact of the changes of inflammatory cytokines on appetite in older hospitalized patients. A total of 191 patients (mean age 81.3 ± 6.6 years, 64% women) participated in this prospective longitudinal observational study. Appetite was evaluated using the Edmonton Symptom Assessment System on admission and after seven days. Serum cytokines such as IL-1β, IL-6, IL-8, IL-10, IL-12p70, IL-17, IL-18, IL-23 and IL-33, IFN-α2, IFN-γ, TNF-α and MCP-1 were measured both times. No significant differences in the mean serum levels of all the cytokines could be detected overtime in relation to appetite changes, except for IL-18. Appetite significantly deteriorated overtime in patients with increasing IL-18 levels and improved in those without significant changes in IL-18 levels. In a stepwise regression analysis, changes of IL-18 levels were the major independent predictor for the changes of patients' appetite and explained 4% of the variance, whereas other cytokines and variables, such as age, sex, infection and disease, did not show any impact on appetite changes. We conclude that IL-18 seems to exert a significant impact on appetite in acutely ill older hospitalized patients and should, therefore, be considered as a potential target in the diagnosis, prevention and treatment of malnutrition.

Inflammatory cytokines and appetite in older hospitalized patients

It has already been confirmed that the decline in appetite during disease is a common issue and the biologic players of inflammation such as cytokines may serve as mediators of this effect. This study aimed to investigate the association of appetite with individual cytokines that could be involved in the inflammation-associated loss of appetite in acutely ill older hospitalized patients. 191 patients (mean age 81.3 ± 6.6 years, 64% women) participated in this prospective observational study. Risk of malnutrition and patient's appetite were evaluated using the Mini Nutritional Assessment Short Form and the Simplified Nutritional Appetite Questionnaire on admission, respectively. Serum C-reactive protein (CRP) and serum cytokines such as Interleukin 1 beta (IL-1β), IL-6, IL-8, IL-10, IL-12p70, IL-17, IL-18, IL-23 and IL-33, interferon alpha-2, interferon gamma, tumor necrosis factor alpha and monocyte chemoattractant protein-1 (MCP-1) were measured. Of total population, 30% had CRP>3.0 (mg/dL), 31% were malnourished and 31% demonstrated poor and very poor appetite. There were significant differences in the mean concentrations of a number of cytokines including IL-1β, MCP-1, IL-6, IL-10, IL-12p70, IL-18 and IL-23 across the appetite scores. In a regression analysis, an increased IL-18 level (P = 0.049) was the most prominent biomarker for poor appetite. No other significant associations between appetite and circulating levels of other cytokines were found in the regression analysis, except for IL-6 and IL-33, which were only significantly associated in the unadjusted model. The association of IL-18 with decreased appetite was independent from the severity of CRP-level and infections. In this study, certain cytokines, in particular IL-18 were associated with poor appetite in acutely diseased patients and should therefore be considered as a potential target of the prevention and treatment of malnutrition.

Associations between Pre-Bariatric High-Sensitivity C-Reactive Protein and Post-Surgery Outcomes

Background: Obesity is a chronic inflammatory condition associated with increased circulating levels of C-reactive protein (CRP). Bariatric surgery has been reported to be effective in improving both inflammatory and liver status. Our aims were to elucidate the relationships between pre-surgery high sensitivity-CRP (hs-CRP) values and post-surgery weight loss and liver steatosis and fibrosis in patients with severe obesity undergoing Roux-en-Y gastric bypass. Methods: We conducted an observational prospective study on 90 individuals with morbid obesity, who underwent gastric bypass. Anthropometric indices, laboratory assessment (lipid panel, glycemic status, liver enzymes, and hs-CRP), liver stiffness and steatosis were evaluated at baseline and 6-months after surgery. Results: There was a significant post-surgery reduction in all the anthropometric variables, with an average weight loss of 33.93 ± 11.79 kg; the mean percentage of total weight loss (TWL) was 27.96 ± 6.43%. Liver elasticity was significantly reduced (from 6.1 ± 1.25 to 5.42 ± 1.52 kPa; p = 0.002), as well as liver aminotransferases, nonalcoholic fatty liver disease fibrosis score (NFS) and the grade of steatosis. Serum hs-CRP levels significantly reduced (from 9.26 ± 8.45 to 3.29 ± 4.41 mg/L; p < 0.001). The correlations between hs-CRP levels and liver fibrosis (elastography), steatosis (ultrasonography), fibrosis-4 index, NFS, and surgery success rate were not significant. Regression analyses showed that serum hs-CRP levels were not predictive of liver status and success rate after surgery in both unadjusted and adjusted models. Conclusions: In patients with morbid obesity, bariatric surgery caused a significant decrease in hs-CRP levels, liver stiffness and steatosis. Baseline hs-CRP values did not predict the weight-loss success rate and post-surgery liver status.

Bariatric Surgery and Cardiovascular Outcomes in Patients With Obesity and Cardiovascular Disease:: A Population-Based Retrospective Cohort Study

BACKGROUND

Bariatric surgery has been shown to significantly reduce cardiovascular risk factors. However, whether surgery can reduce major adverse cardiovascular events (MACE), especially in patients with established cardiovascular disease, remains poorly understood. The present study aims to determine the association between bariatric surgery and MACE among patients with cardiovascular disease and severe obesity.

METHODS

This was a propensity score-matched cohort study using province-wide multiple-linked administrative databases in Ontario, Canada. Patients with previous ischemic heart disease or heart failure who received bariatric surgery were matched on age, sex, heart failure history, and a propensity score to similar controls from a primary care medical record database in a 1:1 ratio. The primary outcome was the incidence of extended MACE (first occurrence of all-cause mortality, myocardial infarction, coronary revascularization, cerebrovascular events, and heart failure hospitalization). Secondary outcome included 3-component MACE (myocardial infarction, ischemic stroke, and all-cause mortality). Outcomes were evaluated through a combination of matching via propensity score and subsequent multivariable adjustment.

RESULTS

A total of 2638 patients (n=1319 in each group) were included, with a median follow-up time of 4.6 years. The primary outcome occurred in 11.5% (151/1319) of the surgery group and 19.6% (259/1319) of the controls (adjusted hazard ratio [HR], 0.58 [95% CI, 0.48-0.71]; P<0.001). The association was notable for those with heart failure (HR, 0.44 [95% CI, 0.31-0.62]; P<0.001; absolute risk difference, 19.3% [95% CI, 12.0%-26.7%]) and in those with ischemic heart disease (HR, 0.60 [95% CI, 0.48-0.74]; P<0.001; absolute risk difference, 7.5% [95% CI, 4.7%-10.5%]). Surgery was also associated with a lower incidence of the secondary outcome (HR, 0.66 [95% CI, 0.52-0.84]; P=0.001) and cardiovascular mortality (HR, 0.35 [95% CI, 0.15-0.80]; P=0.001).

CONCLUSIONS

Bariatric surgery was associated with a lower incidence of MACE in patients with cardiovascular disease and obesity. These findings require confirmation by a large-scale randomized trial.

Iron deficiency, fatigue and muscle strength and function in older hospitalized patients

BACKGROUND/OBJECTIVES

Iron deficiency is common in older patients. We investigated whether iron deficiency is an independent risk factor for functional impairment, low muscle function, fatigue, and rehabilitation progress in older hospitalized patients.

SUBJECTS/METHODS

Two hundred twenty-four patients (age range 65-95 years; 67% females) who were consecutively admitted to a geriatric acute care ward participated in this prospective longitudinal observational study. Ferritin, iron, transferrin in serum, and blood hemoglobin were measured and current iron supplementation was recorded. Fatigue and comorbidity were measured using the fatigue severity scale and Charlson Comorbidity Index, respectively. Barthel Index, handgrip strength, and isometric knee extension strength were conducted at the time of hospital admission and before discharge.

RESULTS

Ninety-one (41%) patients had iron deficiency in which the majority had functional iron deficiency (78/91, 86%). Absolute iron deficiency with and without anemia was diagnosed in 12 (13%) and one patients, respectively. Barthel Index and handgrip and knee extension strength significantly improved during hospitalization in iron deficiency and non-iron deficiency groups. Knee extension strength showed better improvement in iron-deficient patients receiving iron supplementation and iron supplementation during hospital stay was the main predictor for improvement in knee extension strength. Comorbidity, iron deficiency, and changes in handgrip strength were the major independent risk factors for poor improvement in Barthel Index during hospitalization. There were significant associations between patients' fatigue and iron deficiency, comorbidity, and female gender.

CONCLUSION

Iron deficiency is an independent risk factor for fatigue and poor functional recovery among older hospitalized patients. Iron supplementation seems to be capable of improving functional performance.

Management of Leak after Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy

The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been introduced in the past few years for the treatment of morbid obesity. SADI-S has shown good results in terms of long-term results and short-term complications. However, the management of patients undergoing SADI-S and suffering from a leak is a great challenge for surgeons. We present an extensive review of the currently available literature on the management of leak after SADI in morbid obese (MO) patients. We aim at providing objective information regarding the optimal management, including diagnosis, technical options for the different strategies that have been proposed, to facilitate the selection of the best individual approach for each MO patient.

Pruritus: Is there a grain of salty truth?

Hemodialysis patients characteristically suffer from a range of unpleasant symptoms. Uremic pruritus effects close to half of the chronic kidney disease population, reducing quality of life and associated with increased mortality. Its pathophysiology though is poorly understood; currently deployed therapeutic approaches are ineffective. Excessive levels of skin and soft tissue sodium accumulate in dialysis patients, producing a range of biological consequences, including inflammation. We report an index case of a hemodialysis patient with debilitating pruritus and extreme levels of tissue sodium, measured with Sodium-23 magnetic resonance imaging. Both the tissue sodium loading and pruritus responded fully to initiation of expanded hemodialysis therapy with a recently introduced medium cutoff dialysis membrane-based dialyzer.

The impact of acute changes of inflammation on appetite and food intake among older hospitalised patients

The present study aimed to investigate the effect of acute changes in serum C-reactive protein (CRP) on appetite and food intake among older hospitalised patients. A total of 200 patients (age range 65-94 years, 62·5 % women) participated in this prospective longitudinal observational study. Risk of malnutrition was measured according to the Mini Nutritional Assessment Short Form. The Simplified Nutritional Appetite Questionnaire (SNAQ) and Edmonton Symptom Assessment System (ESAS) were used to evaluate patients' appetite at the time of hospital admission (baseline) and after 7 d (follow-up). Food intake was measured according to the plate diagram and serum CRP was analysed at baseline and follow-up. At baseline, 30·5 % of the patients had moderate to severe inflammation, 31·0 % were malnourished and 48·0 % had food intake <75 % of the meals offered. Also, 32·5 and 23·5 % reported poor and very poor appetite or severe loss of appetite according to the SNAQ and ESAS, respectively. Of the patients, 40 % displayed a pronounced reduction in median CRP levels by -1·2 mg/dl and 19 % demonstrated an increase in median CRP levels by +1·2 mg/dl. Appetite significantly improved (P = 0·006) in patients with a decrease in CRP level and deteriorated in those with an increase in CRP level (P = 0·032). Changes in CRP levels did not show any significant impact on food intake. In a regression analysis, changes of inflammation were the major independent predictor for changes of patients' appetite. We conclude that inflammation has a significant impact on appetite and should therefore be considered in the diagnosis and treatment of malnutrition.

Inflammation, Appetite and Food Intake in Older Hospitalized Patients

The effect of inflammation on appetite and food intake has been rarely studied in humans. In this study, we examined the association of C-reactive protein (CRP), as an inflammatory marker, with appetite and food intake among older hospitalized patients. A total of 200 older individuals, who were consecutively admitted to a geriatric acute care ward, participated in this prospective observational study. Appetite was evaluated using the Edmonton Symptom Assessment System (ESAS) and the Simplified Nutritional Appetite Questionnaire (SNAQ), respectively. Food intake was measured according to plate diagram method and participants were categorized as having food intake <75% and ≥75% of meals served. Nutritional status was evaluated using the Mini Nutritional Assessment Short Form (MNA-SF). In addition, serum CRP was analyzed and the levels >3.0 (mg/dL) were considered as moderate to severe inflammation. Of total population with mean age 81.4 ± 6.6 years (62.5% females), 51 (25.5%) had no inflammation and 88 (44.0%) and 61 (30.5%) had mild and moderate to severe inflammation, respectively. According to MNA-SF, 9.0% and 60.0% had normal nutritional status or a risk of malnutrition, respectively, whereas 31.0% were malnourished. Based on the SNAQ-appetite-question, 32.5% of the patients demonstrated poor and very poor appetite whereas 23.5% reported severe loss of appetite according to ESAS. Ninety-five (48.0%) of the participants had food intake <75% of the meals offered. Significant associations between SNAQ-appetite (p = 0.003) and ESAS-appetite (p = 0.013) scores and CRP levels were observed. In addition, significant differences were observed in CRP levels between intake ≥75% and <75% of meals served (p < 0.001). Furthermore, there were significant associations between appetite and nutritional status whereas malnourished older patients demonstrated a decreased appetite compared to those with normal nutritional status (p = 0.011). In a regression analysis, inflammation was the major independent risk factor for patients' appetite (p = 0.003) and food intake (p = 0.011) whereas other variables such as infection (p = 0.960), chronic inflammatory diseases (p = 0.371), age (p = 0.679) and gender (p = 0.447) do not show any impact on appetite. Our findings confirm that poor appetite and low food intake are associated with inflammation in older hospitalized patients, suggesting that inflammation may contribute an important aspect to the development of malnutrition in these patients.