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Eason JA, Vandal A, Patel AU. Impact of body mass index on total cost of trauma and elective spine surgical procedures at a quaternary spinal referral centre. ANZ J Surg 2022; 92:2984-2989. [DOI: 10.1111/ans.18104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/30/2022] [Accepted: 09/29/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Josephine A. Eason
- Department of Surgery University of Otago Medical School Dunedin New Zealand
| | - Alain Vandal
- Department of Statistics University of Auckland Auckland New Zealand
- Ko Awatea Research and Evaluation Office Counties Manukau Health Auckland New Zealand
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2
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Tolley PD, McClellan JM, Butler D, Stewart BT, Pham TN, Sheckter CC. Burn Outcomes at Extremes of Body Mass Index- Underweight is as problematic as Morbid Obesity. J Burn Care Res 2022; 43:1180-1185. [PMID: 35106572 DOI: 10.1093/jbcr/irac014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Limited evidence suggests that obesity adversely affects burn outcomes. However, the impacts of body mass index (BMI) across the continuum has not been fully characterized. Therefore, we aimed to characterize outcomes after burn injury across the BMI continuum. We hypothesized that 'normal' BMI (18.5-24.9) would have the lowest mortality and complication rates. The US National Trauma Data Bank (NTDB) was queried for adult burn-injured patients from 2007-2015. Admission BMI was calculated and grouped according to World Health Organization (WHO) classification. The primary outcome was in-hospital mortality. Secondary outcomes of time to wound closure, length of stay (LOS), and inpatient complications were similarly assessed. Of the 116,008 burn patient encounters that were identified, 7,243 underwent at least one operation for wound closure. Mortality was lowest in the overweight (p=0.039) and obese I cohorts (BMI 25-29.9, 30.0-34.9) at 2.9% and increased in both directions of the BMI continuum to 4.1% in the underweight (p=0.032) and 5.1% in the morbidly obese (class III) group (p=0.042). Time to final wound closure was longest in the two BMI extremes. BMI >40 was associated with increased ICU days, ventilator days, renal and cardiac complications. BMI <18.5 had increased hospital days and rates of sepsis. Aberrations in metabolism associated with both increases and decreases of body weight may cause pathophysiologic changes that lead to worsened outcomes in burn-injured patients. In addition to morbidly obese patients, underweight patients also experience increased burn-related death and complications. In contrast, overweight BMI patients may have greater physiologic reserves without the burden of obesity or sarcopenia.
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Affiliation(s)
- Philip D Tolley
- UW Medicine Regional Burn Center, Harborview Medical Center, University of Washington.,Division of Plastic and Reconstructive Surgery, University of Washington
| | - John M McClellan
- UW Medicine Regional Burn Center, Harborview Medical Center, University of Washington
| | - Demsie Butler
- UW Medicine Regional Burn Center, Harborview Medical Center, University of Washington
| | - Barclay T Stewart
- UW Medicine Regional Burn Center, Harborview Medical Center, University of Washington.,Harborview Injury Prevention and Research Center
| | - Tam N Pham
- UW Medicine Regional Burn Center, Harborview Medical Center, University of Washington.,Harborview Injury Prevention and Research Center
| | - Clifford C Sheckter
- Department of Surgery, Stanford University.,Northern California Regional Burn Center, Santa Clara Valley Medical Center
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3
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Whitley J, Moore KJ, Louie M. The Association Between Resident Participation and Hysterectomy Outcomes in Morbidly Obese Patients. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julia Whitley
- Department of Obstetrics and Gynecology, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia, USA
| | - Kristin J. Moore
- Program in Health Disparities Research, School of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michelle Louie
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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4
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Halpern LR, Adams DR. The Dentoalveolar Surgical Patient: Perioperative Principles Based on Contemporary Controversies. Oral Maxillofac Surg Clin North Am 2020; 32:495-510. [PMID: 32912778 DOI: 10.1016/j.coms.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Dentoalveolar surgery comprises more than 50% of the practice of oral and maxillofacial surgeons worldwide and is the most commonly performed category of surgical procedure. Optimal strategies for management of many medical problems, however, remain unclear. Remaining current on medical and surgical perioperative strategies is a standard for best practice. This article provides contemporary approaches for the perioperative management of patients presenting for dentoalveolar surgery. Attention will be directed to the perioperative management of cardiovascular disease, diabetes, and obesity. These diseases are chosen owing to controversies with respect to good scientific evidence that supports a standard of perioperative care.
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Affiliation(s)
- Leslie R Halpern
- Oral and Maxillofacial Surgery, University of Utah School of Dentistry, 530 South Wakara Way, Salt Lake City, UT 84108, USA.
| | - David R Adams
- Oral and Maxillofacial Surgery, University of Utah School of Dentistry, 530 South Wakara Way, Salt Lake City, UT 84108, USA
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Whitley J, Moore KJ, Carey ET, Louie M. The Effect of Bariatric Surgery on Perioperative Complications after Hysterectomy. J Minim Invasive Gynecol 2019; 27:1363-1369. [PMID: 31843695 DOI: 10.1016/j.jmig.2019.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE To compare intraoperative and 30-day posthysterectomy outcomes between patients who had bariatric surgery before hysterectomy and patients with a body mass index (BMI) >40 kg/m2 without a history of bariatric surgery. DESIGN A retrospective cohort study. SETTING A tertiary-care, academic medical center. PATIENTS Patients with a history of bariatric surgery and patients with BMI >40 kg/m2 and no previous bariatric surgery who underwent any route of hysterectomy between January 1, 2000, and March 1, 2018. INTERVENTIONS After exclusion of patients with gynecologic malignancy and bariatric surgery reversal, 223 patients with a history of bariatric surgery were matched at a 1:2 ratio by year of hysterectomy to 446 randomly selected patients with a BMI >40 kg/m2 and no bariatric surgery before hysterectomy. Demographics, medical comorbidities, and surgical characteristics were collected by a manual chart review. Chi-square or Fisher's exact tests were used to compare the incidence of intraoperative and 30-day postoperative complications. Polytomous logistic regression was used to estimate the odds of major and minor postoperative complications. Binary logistic regression was used to estimate the odds of any intra- or postoperative complications. MEASUREMENTS AND MAIN RESULTS The mean BMI in the bariatric surgery group was 35.2 ± 7.9 kg/m2, compared with 46.3 ± 5.6 kg/m2 in the control group (p <.01). Fewer patients in the bariatric surgery group had obesity-related comorbidities than the group with no previous bariatric surgery (p <.01). There were lower odds of any intraoperative complication in the bariatric surgery group than in the group with no bariatric surgery (adjusted odds ratio, 0.32; 95% confidence interval [CI], 0.13-0.77), after adjusting for relevant confounding factors between groups. However, there was no difference in overall postoperative complications between women who had bariatric surgery and those who did not (adjusted odds ratio, 1.25; 95% CI, 0.82-1.91). When analyzed individually, a higher proportion of patients in the bariatric surgery group had postoperative cuff separation or dehiscence (1.4% [3/223], p = .04) and urinary retention (5.8% [13/223], p <.01). Combining all perioperative complications, we found no significant difference in minor complications, defined as Clavien-Dindo Grade 1 or 2 (adjusted odds ratio, 1.04; 95% CI, 0.68-1.60), major complications, defined as Clavien-Dindo Grade 3 or higher (adjusted odds ratio, 1.25; 95% CI, 0.61-2.54), or combined major and minor perioperative complications (adjusted odds ratio, 0.96; 95% CI, 0.63-1.44) between patients with a history of bariatric surgery and morbidly obese patients with no bariatric surgery before hysterectomy, after adjusting for relevant confounding factors between groups. CONCLUSION Compared with women who had a BMI >40 kg/m2, patients with a history of bariatric surgery before hysterectomy had a lower odds of complications during hysterectomy. However, despite lower BMI and fewer obesity-related medical comorbidities, there was no significant difference in posthysterectomy complications and no significant differences in overall major and minor complications.
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Affiliation(s)
- Julia Whitley
- Department of Obstetrics and Gynecology (Drs. Whitley, Carey, and Louie), School of Medicine.
| | - Kristin J Moore
- Department of Epidemiology, Gillings School of Global Public Health (Dr. Moore), University of North Carolina, Chapel Hill, NC
| | - Erin T Carey
- Department of Obstetrics and Gynecology (Drs. Whitley, Carey, and Louie), School of Medicine
| | - Michelle Louie
- Department of Obstetrics and Gynecology (Drs. Whitley, Carey, and Louie), School of Medicine
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Acharya P, Upadhyay L, Qavi A, Naaraayan A, Jesmajian S, Acharya S, Bharati R. The paradox prevails: Outcomes are better in critically ill obese patients regardless of the comorbidity burden. J Crit Care 2019; 53:25-31. [PMID: 31174173 DOI: 10.1016/j.jcrc.2019.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/12/2019] [Accepted: 05/06/2019] [Indexed: 12/31/2022]
Abstract
During critical illness, obese patients have better outcomes compared to patients with normal BMI, and this is known as the obesity paradox. The difference in comorbidity burden have been implied to be responsible for the paradox. We performed a retrospective review from 2001 to 2012 of critically ill patients from the Medical Information Mart for Intensive Care database. We included 11,433 patients and classified them according to body mass index (BMI) and comorbidity burden (Elixhauser comorbidity measure). The odds of inpatient mortality were lower in obese patients compared to patients with normal BMI; in group with the least comorbidity score (Elixhauser <0) [OR: 0.47, CI (0.28-0.80), p-value 0.006] and higher comorbidity scores, (Elixhauser 1-5) [(OR: 0.66, CI (0.46-0.95), p-value 0.02)] and (Elixhauser 6-13) [OR: 0.69, CI (0.53-0.92), p-value 0.01]. 30-day mortality was also significantly lower in obese patients, in groups with the lowest (Elixhauser <0) [OR:49, CI (0.31-0.77), p-value 0.002] as well as the highest comorbidity burden (Elixhauser >14) [OR:0.59, CI (0.45-0.77), p-value <.001]. Subgroup analysis in patients with various comorbidities showed better outcomes in obese patients. These findings show that the decreased odds of mortality in critically ill obese patients is independent of the comorbidity burden or type of comorbidity.
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Affiliation(s)
- Prakash Acharya
- Department of Medicine, Montefiore New Rochelle, Albert Einstein College of Medicine, New Rochelle, NY 10801, United States of America.
| | - Laxmi Upadhyay
- Department of Medicine, Montefiore New Rochelle, Albert Einstein College of Medicine, New Rochelle, NY 10801, United States of America
| | - Ahmed Qavi
- Department of Medicine, Montefiore New Rochelle, Albert Einstein College of Medicine, New Rochelle, NY 10801, United States of America
| | - Ashutossh Naaraayan
- Department of Medicine, Montefiore New Rochelle, Albert Einstein College of Medicine, New Rochelle, NY 10801, United States of America
| | - Stephen Jesmajian
- Department of Medicine, Montefiore New Rochelle, Albert Einstein College of Medicine, New Rochelle, NY 10801, United States of America
| | - Sabita Acharya
- Department of Computer Science, University of Illinois in Chicago, Chicago, IL 60607, United States of America
| | - Rajani Bharati
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY 10027, United States of America
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A comparison between inhalational (Desflurane) and total intravenous anaesthesia (Propofol and dexmedetomidine) in improving postoperative recovery for morbidly obese patients undergoing laparoscopic sleeve gastrectomy: A double-blinded randomised controlled trial. J Clin Anesth 2018; 45:6-11. [DOI: 10.1016/j.jclinane.2017.12.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/23/2017] [Accepted: 12/05/2017] [Indexed: 01/01/2023]
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Abstract
PURPOSE OF REVIEW The purpose is to review the key anatomical and physiological changes in obese patients and their effects on preoperative, intraoperative, and postoperative care and to highlight the best practices to safely extend minimally invasive approaches to obese patients and provide optimal surgical outcomes in this high-risk population. RECENT FINDINGS Minimally invasive surgery is safe, feasible, and cost-effective for obese patients. Obesity is associated with anatomical and physiological changes in almost all organ systems, which necessitates a multimodal approach and an experienced, multidisciplinary team. Preoperative counseling, evaluation, and optimization of medical comorbidities are critical. The optimal minimally invasive approach is primarily determined by the patient's anatomy and pathology. Specific intraoperative techniques and modifications exist to maximize surgical exposure and panniculus management. Postoperatively, comprehensive medical management can help prevent common complications in obese patients, including hypoxemia, venous thromboembolism, acute kidney injury, hyperglycemia, and prolonged hospitalization. SUMMARY Given significantly improved patient outcomes, minimally invasive approaches to gynecological surgery should be considered for all obese patients with particular attention given to specific perioperative considerations and appropriate referral to an experienced minimally invasive surgeon.
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Ludwig N, Hurt RT, Miller KR. The obesity paradox: validity and clinical implications. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0167-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Solsky I, Edelstein A, Brodman M, Kaleya R, Rosenblatt M, Santana C, Feldman DL, Kischak P, Somerville D, Mudiraj S, Leitman IM, Shamamian P. Perioperative care map improves compliance with best practices for the morbidly obese. Surgery 2016; 160:1682-1688. [PMID: 27622571 DOI: 10.1016/j.surg.2016.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/19/2016] [Accepted: 07/23/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. METHODS A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. RESULTS In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. CONCLUSION After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.
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Affiliation(s)
- Ian Solsky
- Montefiore Medical Center/Albert Einstein College of Medicine, Surgery, Bronx, NY
| | - Alex Edelstein
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - Michael Brodman
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - Ronald Kaleya
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Meg Rosenblatt
- Icahn School of Medicine at Mount Sinai, Surgery, New York, NY
| | - Calie Santana
- Montefiore Medical Center/Albert Einstein College of Medicine, Surgery, Bronx, NY
| | | | | | | | | | | | - Peter Shamamian
- Montefiore Medical Center/Albert Einstein College of Medicine, Surgery, Bronx, NY.
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Patel JJ, Rosenthal MD, Miller KR, Codner P, Kiraly L, Martindale RG. The Critical Care Obesity Paradox and Implications for Nutrition Support. Curr Gastroenterol Rep 2016; 18:45. [PMID: 27422122 DOI: 10.1007/s11894-016-0519-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Obesity is a leading cause of preventable death worldwide. The prevalence of obesity has been increasing and is associated with an increased risk for other co-morbidities. In the critical care setting, nearly one third of patients are obese. Obese critically ill patients pose significant physical and on-physical challenges to providers, including optimization of nutrition therapy. Intuitively, obese patients would have worse critical care-related outcome. On the contrary, emerging data suggests that critically ill obese patients have improved outcomes, and this phenomenon has been coined "the obesity paradox." The purposes of this review will be to outline the historical views and pathophysiology of obesity and epidemiology of obesity, describe the challenges associated with obesity in the intensive care unit setting, review critical care outcomes in the obese, define the obesity-critical care paradox, and identify the challenges and role of nutrition support in the critically ill obese patient.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Suite E5200 Pulmonary & Critical Care Medicine, Milwaukee, WI, 53226, USA.
| | | | - Keith R Miller
- Division of Trauma Surgery, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Panna Codner
- Division of Trauma Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Laszlo Kiraly
- Division of Trauma Surgery, Department of Surgery, Oregon Health Science University, Portland, OR, USA
| | - Robert G Martindale
- Division of General Surgery, Department of Surgery, Oregon Health Science University, Portland, OR, USA
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Boehm O, Baumgarten G, Hoeft A. Preoperative patient assessment: Identifying patients at high risk. Best Pract Res Clin Anaesthesiol 2016; 30:131-43. [DOI: 10.1016/j.bpa.2016.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/19/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
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