Obesity and 1-year outcomes in older Americans with severe sepsis

Association of Body Mass Index with Multiple Organ Failure in Hospitalized Patients with COVID-19: A Multicenter Retrospective Cohort Study

Purpose: This study examines whether excessive adipose tissue, as measured by the body mass index (BMI), is associated with higher systemic markers of inflammation and higher risk of severe acute organ failure among patients with coronavirus disease 2019 (COVID-19). Methods: This was a multicenter retrospective cohort study of 1370 hospitalized adults (18 years or older) with COVID-19 during the first wave of the pandemic. Patient-level variables were extracted from the electronic medical record. The primary predictor variable was the BMI at time of hospital admission, in accordance with the World Health Organization classification. Multivariable logistic regression analyses examined the association of BMI with the composite of acute respiratory distress syndrome (ARDS), as defined by the use of high-flow nasal canula, non-invasive ventilation, or mechanical ventilation, severe acute kidney injury (AKI), as defined by acute dialysis requirement, or in-hospital death. Results: After adjustment for important cofounders, the BMI stratum of > 40 kg/m2 (compared to the BMI < 25 kg/m2 reference group) was associated with higher odds for the composite of ARDS, severe AKI, or in-hospital death (adjusted odds ratio [ORadj] 1.69; 95% confidence interval [CI]1.03, 2.78). As a continuous variable, BMI (per 5-kg/m2 increase) remained independently associated with the composite outcome (ORadj 1.13; 95% CI 1.03, 1.23); patients in higher BMI categories exhibited significantly higher peak levels of C-reactive protein (CRP), a systemic marker of inflammation (P = .01). In a sub-cohort of 889 patients, the association of BMI with the composite outcome was no longer significant after adjustment for the peak level of CRP. Conclusions: Among hospitalized patients with COVID-19, a higher BMI is associated with higher risk of severe organ failure or in-hospital death, which dissipates after adjustment for CRP level. This supports the hypothesis that inflammation is a downstream mediator of adipose tissue on acute organ dysfunction.

Role of obesity in lower mortality risk in sepsis: a meta-analysis of observational studies

This meta-analysis aims to explore the correlation between obesity and mortality in patients with sepsis. Data were gathered from various sources, including PubMed, the Cochrane Library, and Embase (no language restrictions). Clinical studies, both retrospective and prospective ones, were selected to analyze mortality due to sepsis in patients with or without obesity. The Newcastle-Ottawa Scale was used to assess the quality of the studies included. In data synthesis, odds ratio (OR) and 95% confidence interval (CI) were meta-analyzed using the DerSimonian-Laird random-effects model, followed by sensitivity and heterogeneity analyses. Two cohort studies were included to investigate survival in inpatients with obesity and sepsis, with pooled analysis indicating a lowered mortality rate (OR=0.88; 95% CI: 0.81-0.95; I2=0.00%; P=0.000). This meta-analysis lends support to the obesity paradox, suggesting a reduced mortality from sepsis in obese patients. However, further prospective trials and research on mechanisms are needed to test this hypothesis.

Development and Validation of a Predictive Model for Acute Kidney Injury in Sepsis Patients Based on Recursive Partition Analysis

BACKGROUND

Sepsis-associated acute kidney injury (SA-AKI) is a critical condition with significant clinical implications, yet there is a need for a predictive model that can reliably assess the risk of its development. This study is undertaken to bridge a gap in healthcare by creating a predictive model for SA-AKI with the goal of empowering healthcare providers with a tool that can revolutionize patient care and ultimately lead to improved outcomes.

METHODS

A cohort of 615 patients afflicted with sepsis, who were admitted to the intensive care unit, underwent random stratification into 2 groups: a training set (n = 435) and a validation set (n = 180). Subsequently, a multivariate logistic regression model, imbued with nonzero coefficients via LASSO regression, was meticulously devised for the prognostication of SA-AKI. This model was thoughtfully rendered in the form of a nomogram. The salience of individual risk factors was assessed and ranked employing Shapley Additive Interpretation (SHAP). Recursive partition analysis was performed to stratify the risk of patients with sepsis.

RESULTS

Among the panoply of clinical variables examined, hypertension, diabetes mellitus, C-reactive protein, procalcitonin (PCT), activated partial thromboplastin time, and platelet count emerged as robust and independent determinants of SA-AKI. The receiver operating characteristic curve analysis for SA-AKI risk discrimination in both the training set and validation set yielded an area under the curve estimates of 0.843 (95% CI: 0.805 to 0.882) and 0.834 (95% CI: 0.775 to 0.893), respectively. Notably, PCT exhibited the most conspicuous influence on the model's predictive capacity. Furthermore, statistically significant disparities were observed in the incidence of SA-AKI and the 28-day survival rate across high-risk, medium-risk, and low-risk cohorts (P < .05).

CONCLUSION

The composite predictive model, amalgamating the quintet of SA-AKI predictors, holds significant promise in facilitating the identification of high-risk patient subsets.

Obesity and septic patient outcomes: Shaping the puzzle through age and sex perspectives

BACKGROUND & AIMS

While obesity has been reported as a protective factor in septic patients, little is known about the potential modifying effects of age and sex. The objective of this study is to investigate age and sex-specific associations between obesity and the prognosis of septic patients.

METHODS

A retrospective analysis was conducted on a cohort of 15,464 septic patients, categorized by body mass index (BMI) into four groups: underweight (<18.5 kg/m2, n = 483), normal (18.5-24.9 kg/m2, n = 4344), overweight (25-29.9 kg/m2, n = 4949) and obese (≥30 kg/m2, n = 5688). Multivariable logistic regression and inverse probability weighting were employed to robustly confirm the protective effect of a higher BMI on 28-day mortality, with normal weight serving as the reference category. Subgroup analyses based on age (young: 18-39, middle-aged: 40-64 and elderly: ≥65) and sex were performed.

RESULTS

The findings demonstrate that high BMI independently confers a protective effect against 28-day mortality in septic patients. However, the relationship between BMI and 28-day mortality exhibits a non-linear trend, with a BMI of 34.5 kg/m2 displaying the lowest odds ratio. Notably, the survival benefits associated with a high BMI were not observed in the young group. Moreover, being underweight emerges as an independent risk factor for middle-aged and elderly female patients, while in males it is only a risk factor in the elderly group. Interestingly, being overweight and obese were identified as independent protective factors in middle-aged and elderly male patients, but not in females.

CONCLUSIONS

The effect of BMI on mortality in septic patients varies according to age and sex. Elderly individuals with sepsis may derive more prognostic benefits from obesity.

Muscle Dysfunction and Functional Status in COVID-19 Patients during Illness and after Hospital Discharge

BACKGROUND

COVID-19 pneumonia is associated with SIRS and hypercatabolism. The aim of this study was to determine muscle loss during the acute phase of COVID-19 pneumonia and evaluate long-term sequelae in discharged patients.

METHODS

A total of 16 patients with COVID-19 pneumonia and respiratory insufficiency were included in the study. Selected parameters (weight, BMI, LBM = lean body mass, albumin, CRP, NLR = neutrophil-to-lymphocyte ratio, ultrasound measured thickness of rectus femoris muscle = US RF and rectus femoris + vastus intermedius = US RF + VI, handgrip strength, quality of life = EQ-5D questionnaire, and activities of daily living = Barthel's ADLs) were recorded on admission, discharge, and 1, 3, and 6 months after discharge.

RESULTS

The most significant changes were between hospital admission and discharge: US RF and RF + VI (-1.28 ± 1.97 mm, p = 0.046; -1.76 ± 2.94 mm, p = 0.05), EQ-5D score (14.6 ± 19.2, p = 0.02), and ADLs (17.1 ± 22.6; p = 0.02). There was a significant positive correlation between US RF + VI and handgrip strength (p = 0.014) and a negative correlation between weight and Barthel index (p = 0.012). There was an association between muscle function with an EQ-5D score and ADLs during outpatient check-ups, most noticeably between handgrip strength, US RF+VI, and ADLs (p = 0.08; p = 0.1, respectively). Conclusions: In patients with COVID-19 pneumonia, there is a significant reduction of health-related quality of life, impaired even 6 months after hospital discharge, influenced mainly by muscle loss. During the hospital stay, there was a significant muscle mass reduction. Ultrasound measurement of thigh muscle thickness may be a useful method to monitor muscle loss.

Early Sepsis-Associated Acute Kidney Injury and Obesity

Importance

The prevalence of obesity is increasing in the intensive care unit (ICU). Although obesity is a known risk factor for chronic kidney disease, its association with early sepsis-associated acute kidney injury (SA-AKI) and their combined association with patient outcomes warrant further investigation.

Objective

To explore the association between obesity, early SA-AKI incidence, and clinical outcomes in patients with sepsis.

Design, Setting, and Participants

This nationwide, prospective cohort study analyzed patients aged 19 years or older who had sepsis and were admitted to 20 tertiary hospital ICUs in Korea between September 1, 2019, and December 31, 2021. Patients with preexisting stage 3A to 5 chronic kidney disease and those with missing body mass index (BMI) values were excluded.

Exposures

Sepsis and hospitalization in the ICU.

Main Outcomes and Measures

The primary outcome was SA-AKI incidence within 48 hours of ICU admission, and secondary outcomes were mortality and clinical recovery (survival to discharge within 30 days). Patients were categorized by BMI (calculated as weight in kilograms divided by height in meters squared), and data were analyzed by logistic regression adjusted for key characteristics and clinical factors. Multivariable fractional polynomial regression models and restricted cubic spline models were used to analyze the clinical outcomes with BMI as a continuous variable.

Results

Of the 4041 patients (median age, 73 years [IQR, 63-81 years]; 2349 [58.1%] male) included in the study, 1367 (33.8%) developed early SA-AKI. Obesity was associated with a higher incidence of SA-AKI compared with normal weight (adjusted odds ratio [AOR], 1.40; 95% CI, 1.15-1.70), as was every increase in BMI of 10 (OR, 1.75; 95% CI, 1.47-2.08). While obesity was associated with lower in-hospital mortality in patients without SA-AKI compared with their counterparts without obesity (ie, underweight, normal weight, overweight) (AOR, 0.72; 95% CI, 0.54-0.94), no difference in mortality was observed in those with SA-AKI (AOR, 0.85; 95% CI, 0.65-1.12). Although patients with obesity without SA-AKI had a greater likelihood of clinical recovery than their counterparts without obesity, clinical recovery was less likely among those with both obesity and SA-AKI.

Conclusions and Relevance

In this cohort study of patients with sepsis, obesity was associated with a higher risk of early SA-AKI and the presence of SA-AKI modified the association of obesity with clinical outcomes.

Postdischarge Survival After Sepsis: A Cohort Study

BACKGROUND

After hospital discharge, patients who had sepsis have increased mortality. We sought to estimate factors associated with postdischarge mortality and how they vary with time after discharge.

METHODS

This was a retrospective study of hospital survivors of sepsis using time-varying Cox proportional hazard models, which produce a baseline hazard ratio (HR) and a second number (δHR) that reflects the amount by which the baseline HR changes with time.

RESULTS

Of the 32,244 patients who survived sepsis at hospital discharge, 13,565 patients (42%) died (mean ± standard deviation: 1.41 ± 1.87 years) after discharge from the index hospitalization, while 18,679 patients were still alive at follow-up (4.98 ± 2.86 years). The mortality rate decreased with time after discharge: approximately 8.7% of patients died during the first month after discharge, 1.1% of patients died during the 12th month after discharge, and 0.3%% died during the 60th month; after Kaplan-Meier analysis, survival was 91% (95% confidence interval [CI], 91%-92%) at 1 month, 76% (95% CI, 76%-77%) at 1 year, 57% (95% CI, 56%-58%) at 5 years, and 48% (95% CI, 47%-48%) at 10 years after discharge. Organ dysfunction at discharge was associated with worse survival. In particular, elevated urea nitrogen at discharge (HR, 1.10 per 10 mg/dL, 95% CI, 1.08-1.12, P < .001) was associated with increased mortality, but the HR decreased with time from discharge (δHR, 0.98 per 10 mg/dL per year, 95% CI, 0.98-0.99, P < .001). Higher hemoglobin levels were associated with lower mortality (HR, 0.92 per g/dL, 95% CI, 0.91-0.93, P < .001), but this association increased with increasing time after discharge (δHR, 1.02 per g/dL per year, 95% CI, 1.01-1.02, P < .001). Older age was associated with an increased risk of mortality (HR, 1.29 per decade of age, 95% CI, 1.27-1.31, P < .001) that grew with increasing time after discharge (δHR, 1.01 per year of follow-up per decade of age, 95% CI, 1.00-1.02, P < .001). Compared to private insurances Medicaid as primary insurance was associated with an increased risk of mortality (HR, 1.17, 95% CI, 1.10-1.25, P < .001) that did not change with time after discharge. In contrast, Medicare status was initially associated with a similar risk of mortality as private insurance at discharge (HR, 1), but was associated with greater risk as time after discharge increased (δHR, 1.04 per year of follow-up, 95% CI, 1.03-1.05, P < .001).

CONCLUSIONS

Acute physiologic derangements and organ dysfunction were associated with postdischarge mortality with the associations decreasing over time.

Obesity Alters cytokine signaling and gut microbiome in septic mice

Sepsis is a leading cause of mortality. Plasma cytokine levels may identify those at increased risk of mortality from sepsis. Our aim was to understand how obesity alters cytokine levels during early sepsis and its correlation with survival. Six-week-old C57BL/6 male mice were randomized to control (non-obese) or high fat diet (obese) for 5-7 weeks. Sepsis was induced by cecal ligation and perforation (CLP). Cytokine levels were measured from cheek bleeds 8 h after CLP, and mice were monitored for survival. Other cohorts were sacrificed 1 h after CLP for plasma and tissue. Septic obese mice had higher survival. At 8 h after sepsis, obese mice had higher adiponectin, leptin, and resistin but lower TNFα and IL-6 compared to non-obese mice. When stratified by 24-h survival, adipokines were not significantly different in obese and non-obese mice. TNFα and IL-6 were higher in non-obese, compared to obese, mice that died within 24 h of sepsis. Diet and to sepsis significantly impacted the cecal microbiome. IL-6 is a prognostic biomarker during early sepsis in non-obese and obese mice. A plausible mechanism for the survival difference in non-obese and obese mice may be the difference in gut microbiome and its evolution during sepsis.

Obesity Does Not Increase Risk for Mortality in Severe Sepsis Trauma Patients

INTRODUCTION

The prevalence of obesity in the United States is up to 40% in adults. Obese patients with severe sepsis have a lower mortality rate compared with normal body mass index (BMI) patients. We hypothesized that trauma patients with severe sepsis and obese BMI will have a decreased mortality risk in comparison with normal BMI patients.

METHODS

The Trauma Quality Improvement Program (2017) was queried for adult trauma patients with documented BMI and severe sepsis. Patients were grouped based on BMI: non-obese trauma patients (nOTP) BMI <30 kg/m2 and obese trauma patients (OTP) ≥30 kg/m2. A multivariable logistic regression model was used for analysis of mortality.

RESULTS

From 1246 trauma patients with severe sepsis, 566 (42.4%) were nOTP and 680 (57.6%) were OTP. OTP had increased length of stay (LOS) (19 vs 21 days, P < .001), intensive care unit (ICU) LOS (13 vs 18 days, P < .001) and ventilator days (10 vs 11 days, P < .001). After adjusting for covariates, when compared to normal BMI patients, patients who were overweight (OR 1.11 CI .875-1.41 P = .390), obese (OR .797 CI .59-1.06 P = .126), severely obese (OR .926 CI .63-1.36 P = .696) and morbidly obese (OR 1.448 CI 1.01-2.07 P = .04) all had a similar associated risk for mortality compared to patients with normal BMI.

CONCLUSION

In adult trauma patients with severe sepsis, this national analysis demonstrated OTP had increased LOS, ICU LOS, and ventilator days compared to nOTP. However, patients with increasing degrees of obesity had similar associated risk of mortality compared to trauma patients with severe sepsis and a normal BMI.

Does the "Obesity Paradox" Have an Expiration Date? A Retrospective Cohort Study

(1) Background: The "obesity paradox" refers to a protective effect of higher body mass index (BMI) on mortality in acute infectious disease patients. However, the long-term impact of this paradox remains uncertain. (2) Methods: A retrospective study of patients diagnosed with community-acquired acute infectious diseases at Shamir Medical Center, Israel (2010-2020) was conducted. Patients were grouped by BMI: underweight, normal weight, overweight, and obesity classes I-III. Short- and long-term mortality rates were compared across these groups. (3) Results: Of the 25,226 patients, diverse demographics and comorbidities were observed across BMI categories. Short-term (90-day) and long-term (one-year) mortality rates were notably higher in underweight and normal-weight groups compared to others. Specifically, 90-day mortality was 22% and 13.2% for underweight and normal weight respectively, versus 7-9% for others (p < 0.001). Multivariate time series analysis revealed underweight individuals had a significantly higher 5-year mortality risk (HR 1.41 (95% CI 1.27-1.58, p < 0.001)), while overweight and obese categories had a reduced risk (overweight-HR 0.76 (95% CI 0.72-0.80, p < 0.001), obesity class I-HR 0.71 (95% CI 0.66-0.76, p < 0.001), obesity class II-HR 0.77 (95% CI 0.70-0.85, p < 0.001), and obesity class III-HR 0.79 (95% CI 0.67-0.92, p = 0.003)). (4) Conclusions: In this comprehensive study, obesity was independently associated with decreased short- and long-term mortality. These unexpected results prompt further exploration of this counterintuitive phenomenon.

Examining Obesity and Its Association With Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation Study

INTRODUCTION

Literature examining the connection between obesity and burn injuries is limited. This study is a secondary analysis of a multicenter trial data set to investigate the association between burn outcomes and obesity following severe burn injury.

MATERIALS AND METHODS

Body mass index (BMI) was used to stratify patients as normal weight (NW; BMI 18.5-25), all obese (AO; any BMI>30), obese I (OI; BMI 30-34.9), obese II (OII; BMI 35-39.9), or obese III (OIII; BMI>40). The primary outcome examined was mortality. Secondary outcomes included hospital length of stay (LOS), number of transfusions, injury scores, infection occurrences, number of operations, ventilator days, intensive care unit LOS, and days to wound healing.

RESULTS

Of 335 patients included for study, 130 were obese. Median total body surface area (TBSA) was 31%, 77 patients (23%) had inhalation injury and 41 patients died. Inhalation injury was higher in OIII than NW (42.1% versus 20%, P = 0.03). Blood stream infections (BSI) were higher in OI versus NW (0.72 versus 0.33, P = 0.03). Total operations, ventilator days, days to wound healing, multiorgan dysfunction score, Acute Physiology and Chronic Health Evaluationscore, hospital LOS, and intensive care unit LOS were not significantly affected by BMI classification. Mortality was not significantly different between obesity groups. Kaplan-Meier survival curves did not significantly differ between the groups (χ2 = 0.025, P = 0.87). Multiple logistic regression identified age, TBSA, and full thickness burn as significant independent predictors (P < 0.05) of mortality; however, BMI classification itself was not predictive of mortality.

CONCLUSIONS

No significant association between obesity and mortality was seen after burn injury. Age, TBSA, and percent full- thickness burn were independent predictors of mortality after burn injury, while BMI classification was not.

Pneumosepsis survival in the setting of obesity leads to persistent steatohepatitis and metabolic dysfunction

BACKGROUND

As critical care practice evolves, the sepsis survivor population continues to expand, often with lingering inflammation in many organs, including the liver. Given the concurrently increasing population of patients with NAFLD, in this study, we aimed to understand the long-term effect of sepsis on pre-existing NAFLD and hyperglycemia.

METHODS

Male mice were randomized to a high-fat diet or a control diet (CD). After 24 weeks on diet, mice were inoculated with Klebsiella pneumoniae (Kpa). Serial glucose tolerance tests, and insulin and pyruvate challenge tests were performed 1 week before infection and at 2 and 6 weeks after infection. Whole tissue RNA sequencing and histological evaluation of the liver were performed. To test whether persistent inflammation could be reproduced in other abnormal liver environments, mice were also challenged with Kpa after exposure to a methionine-choline-deficient high-fat diet. Finally, a retrospective cohort of 65,139 patients was analyzed to evaluate whether obesity was associated with liver injury after sepsis.

RESULTS

After Kpa inoculation, high-fat diet mice had normalized fasting blood glucose without a change in insulin sensitivity but with a notable decrease in pyruvate utilization. Liver examination revealed focal macrophage collections and a unique inflammatory gene signature on RNA analysis. In the clinical cohort, preobesity, and class 1 and class 2 obesity were associated with increased odds of elevated aminotransferase levels 1-2 years after sepsis.

CONCLUSIONS

The combination of diet-induced obesity and pneumosepsis survival in a murine model resulted in unique changes in gluconeogenesis and liver inflammation, consistent with the progression of benign steatosis to steatohepatitis. In a cohort study, obese patients had an increased risk of elevated aminotransferase levels 1-2 years following sepsis.

Association of obesity and mortality in sepsis patients: A meta-analysis from observational evidence

The project aims to investigate the correlation between obesity, overweight, or low body weight and the risk of mortality in sepsis patients. We performed a rigorous and thorough search of major electronic databases, including PubMed, Web of Science, EMBASE, and Cochrane Library, from the inception of these databases up to March 28, 2023. The data were analyzed with Stata software (version 16.0). Twelve studies incorporating 521,207 individuals were enrolled. The results demonstrated that obesity (OR = 0.82; 95% CI: 0.69-0.97; P < 0.001) or overweight (OR = 0.83; 95% CI: 0.73-0.94; P < 0.001) decreased the risk of mortality in sepsis patients. Instead, the reverse phenomena existed in patients with a low weight (OR = 1.43; 95%CI: 1.16-1.76; P = 0.038). There is an "obesity paradox" phenomenon in the mortality of obese and overweight patients with sepsis, but low body weight is an independent risk factor for the mortality of sepsis patients. This study demonstrated that the mortality in sepsis patients and obesity or overweight were negatively correlated, but displayed a significant positive relation to low weight.

Association of body mass index with mortality of sepsis or septic shock: an updated meta-analysis

BACKGROUND

The effects of body mass index (BMI) on mortality of sepsis remain unknown, since previous meta-analyses have reported conflicting results. Several observational studies published recently have provided new evidence. Thus, we performed this updated meta-analysis.

METHODS

PubMed, Embase, Web of Science, and Cochran Library were searched for articles published before February 10, 2023. Observational studies that assessed the association of BMIs with mortality of sepsis patients aged > 18 years were selected. We excluded studies of which data were unavailable for quantitative synthesis. Odds ratios (OR) with 95% confidence interval (CI) were the effect measure, which were combined using fixed-effect or random-effect models. The Newcastle-Ottawa Scale was applied for quality assessment. Subgroups analyses were conducted according to potential confounders.

RESULTS

Fifteen studies (105,159 patients) were included in the overall analysis, which indicated that overweight and obese BMIs were associated with lower mortality (OR: 0.79, 95% CI 0.70-0.88 and OR: 0.74, 95% CI 0.67-0.82, respectively). The association was not significant in patients aged ≤ 50 years (OR: 0.89, 95% CI 0.68-1.14 and OR: 0.77, 95% CI 0.50-1.18, respectively). In addition, the relationship between morbidly obesity and mortality was not significant (OR: 0.91, 95% CI 0.62-1.32).

CONCLUSIONS

Overweight and obese BMIs (25.0-39.9 kg/m²) are associated with reduced mortality of patients with sepsis or septic shock, although such survival advantage was not found in all crowds. Trial registration The protocol of this study was registered in PROSPERO (registration number CRD42023399559).

The Relationship between Body Mass Index and In-Hospital Mortality in Bacteremic Sepsis

BACKGROUND

The association between Body Mass Index (BMI) and clinical outcomes following sepsis continues to be debated. We aimed to investigate the relationship between BMI and in-hospital clinical course and mortality in patients hospitalized with bacteremic sepsis using real-world data.

METHODS

A sampled cohort of patients hospitalized with bacteremic sepsis between October 2015 and December 2016 was identified in the National Inpatient Sample (NIS) database. In-hospital mortality and length of stay were defined as the relevant outcomes. Patients were divided into 6 BMI (kg/m²) subgroups; (1) underweight ≤ 19, (2) normal-weight 20-25, (3) over-weight 26-30, (4) obese I 31-35, (5) obese II 36-39, and (6) obese stage III ≥ 40. A multivariable logistic regression model was used to find predictors of mortality, and a linear regression model was used to find predictors of an extended length of stay (LOS).

RESULTS

An estimated total of 90,760 hospitalizations for bacteremic sepsis across the U.S. were analyzed. The data showed a reverse-J-shaped relationship between BMI and study population outcomes, with the underweight patients (BMI ≤ 19 kg/m²) suffering from higher mortality and longer LOS as did the normal-weight patients (BMI 20-25 kg/m²) when compared to the higher BMI groups. The seemingly protective effect of a higher BMI diminished in the highest BMI group (BMI ≥ 40 kg/m²). In the multivariable regression model, BMI subgroups of ≤19 kg/m² and ≥40 kg/m² were found to be independent predictors of mortality.

CONCLUSIONS

A reverse-J-shaped relationship between BMI and mortality was documented, confirming the "obesity paradox" in the real-world setting in patients hospitalized for sepsis and bacteremia.

SEX-DEPENDENT EFFECTS OF ADIPOCYTE STAT3 INHIBITION ON THE INFLAMMATORY RESPONSE DURING SEVERE SEPSIS

ABSTRACT

Introduction: Sepsis is a dysregulated host response to infection that can lead to life-threatening organ dysfunction. Clinical and animal studies consistently demonstrate that female subjects are less susceptible to the adverse effects of sepsis, demonstrating the importance of understanding how sex influences sepsis outcomes. The signal transducer and activator of transcription 3 (STAT3) pathway are a major signaling pathway that facilitates inflammation during sepsis. STAT3 is abundantly expressed in white adipose tissue; however, little is known about the contribution of white adipose tissue STAT3 activation during sepsis. We hypothesize that adipocyte STAT3 inhibition during severe sepsis will exaggerate the inflammatory response and impact organ injury, in a sex-dependent manner. Methods: We generated STAT3 flox/flox (wild-type [WT]) and adipocyte STAT3 knock out (A-STAT3 KO) mice using Cre-lox technology. Studies were done in 12- to 16-week-old male and female mice. Polymicrobial sepsis was induced by cecal ligation and puncture (CLP). Control nonseptic mice did not undergo CLP (0 h CLP). Tissues were harvested 18 h after CLP. Body composition was determined by echo magnetic resonance imaging. Energy metabolism was determined by indirect calorimetry. White adipose tissue morphology was determined by hematoxylin and eosin staining, while STAT3 activation in the white adipose tissue was determined by western blot analysis and immunohistochemistry staining of STAT3 activation/phosphorylation at tyrosine 705. Plasma cytokines (TNF-α, IL-6, and leptin) were determined by luminex assay. Neutrophil infiltration of the lung and liver was assessed by myeloperoxidase activity assay. Histological signs of organ injury on lung and liver tissue were assessed by hematoxylin and eosin staining. Liver injury was further assessed by measuring plasma alanine and aspartate aminotransferase. In a separate cohort of mice, sepsis was induced by CLP and mice were monitored every 6-12 h over a 7-day period to assess survival rate. Results: We demonstrate that neither body composition nor energy metabolism is altered with adipocyte STAT3 inhibition in male or female mice, under nonseptic conditions. Sepsis was associated with reduced adipocyte size in female WT and A-STAT3 KO mice, suggesting that this event is STAT3 independent. Sepsis did not alter adipocyte size in male WT and A-STAT3 KO mice, suggesting that this event is also sex dependent. Although STAT3 phosphorylation at tyrosine 705 expression is negligible in male and female A-STAT3 KO mice, septic female WT and A-STAT3 KO mice have higher white adipose tissue STAT3 activation than male WT and A-STAT3 KO mice. Adipocyte STAT3 inhibition did not alter the proinflammatory cytokine response during sepsis in male or female mice, as measured by plasma TNF-α, IL-6, and leptin levels. Adipocyte STAT3 inhibition reduced lung neutrophil infiltration and histological signs of lung injury during sepsis in male mice. On the contrary, adipocyte STAT3 inhibition had no effect on lung neutrophil infiltration or lung injury in female mice. We further demonstrate that neither liver neutrophil infiltration nor histological signs of liver injury are altered by adipocyte STAT3 inhibition during sepsis, in male or female mice. Lastly, adipocyte STAT3 inhibition did not affect survival rate of male or female mice during sepsis. Conclusions: Our study demonstrates that sex influences white adipose tissue STAT3 activation and morphology during sepsis, which is not dependent on the presence of functional STAT3 in mature adipocytes. Furthermore, genetic inhibition of adipocyte STAT3 activation in male, but not female mice, results in reduced lung neutrophil infiltration and lung injury during sepsis. The results from our study demonstrate the importance of considering biological sex and the white adipose tissue as potential sources and targets of inflammation during sepsis.

Association of body mass index and hypoglycemia with mortality rates among sepsis patients: A retrospective sub-analysis of the FORECAST study

Aim

Hypoglycemia at admission is associated with high mortality in sepsis patients. However, the influence of body mass index (BMI) on this association remains unknown. Therefore, this study assesses the association of hypoglycemia at admission with mortality in patients with sepsis according to BMI.

Methods

This was a secondary analysis of a multicenter, prospective cohort study of 59 intensive care units in Japan. We included 1184 patients (age ≥16 years) with severe sepsis and excluded those with missing data on glucose level, BMI, or survival at discharge. The initial blood glucose level of <70 mg/dL was defined as hypoglycemia. Patients were assigned to the hypoglycemia or non-hypoglycemia group as per BMI category (<18.5 [low], 18.5-24.9 [normal], and ≥25 [high] kg/m²). The main outcome was in-hospital mortality. Multivariate logistic regression models were used to evaluate BMI category-by-hypoglycemia interactions.

Results

Overall, 1103 patients, including 65 with hypoglycemia, were analyzed. In the normal BMI group, patients with hypoglycemia had a higher in-hospital mortality rate (18/38, 47.4%) than those without (119/584, 20.4%). There was a significant interaction between normal BMI and hypoglycemia affecting in-hospital mortality; however, this effect was not observed for other BMI categories (odds ratio, 2.32; 95% confidence interval, 1.05-5.07; p-value for interaction = 0.0476).

Conclusion

The relationship between patients with sepsis and hypoglycemia on admission may differ according to BMI. Hypoglycemia on admission may be associated with high mortality in patients with normal BMI, but not in those with low or high BMI.

A nomogram to predict prolonged stay of obesity patients with sepsis in ICU: Relevancy for predictive, personalized, preventive, and participatory healthcare strategies

Objective

In an era of increasingly expensive intensive care costs, it is essential to evaluate early whether the length of stay (LOS) in the intensive care unit (ICU) of obesity patients with sepsis will be prolonged. On the one hand, it can reduce costs; on the other hand, it can reduce nosocomial infection. Therefore, this study aimed to verify whether ICU prolonged LOS was significantly associated with poor prognosis poor in obesity patients with sepsis and develop a simple prediction model to personalize the risk of ICU prolonged LOS for obesity patients with sepsis.

Method

In total, 14,483 patients from the eICU Collaborative Research Database were randomized to the training set (3,606 patients) and validation set (1,600 patients). The potential predictors of ICU prolonged LOS among various factors were identified using logistic regression analysis. For internal and external validation, a nomogram was developed and performed.

Results

ICU prolonged LOS was defined as the third quartile of ICU LOS or more for all sepsis patients and demonstrated to be significantly associated with the mortality in ICU by logistic regression analysis. When entering the ICU, seven independent risk factors were identified: maximum white blood cell, minimum white blood cell, use of ventilation, Glasgow Coma Scale, minimum albumin, maximum respiratory rate, and minimum red blood cell distribution width. In the internal validation set, the area under the curve was 0.73, while in the external validation set, it was 0.78. The calibration curves showed that this model predicted probability due to actually observed probability. Furthermore, the decision curve analysis and clinical impact curve showed that the nomogram had a high clinical net benefit.

Conclusion

In obesity patients with sepsis, we created a novel nomogram to predict the risk of ICU prolonged LOS. This prediction model is accurate and reliable, and it can assist patients and clinicians in determining prognosis and making clinical decisions.

Hypothesis: Enhanced glucose availability and insulin resistance enhances an activated immune system and accounts for the obesity paradox

Many studies have demonstrated an 'obesity paradox' where people with obesity have reduced mortality in the context of acute critical illnesses compared to people of normal weight. In contrast, obesity is associated with reduced life expectancy in the population in general and is associated with an increased risk for type 2 diabetes, cardiovascular disease and other health problems. However, the absence of the metabolic syndrome is associated a lower mortality than when the metabolic syndrome is present regardless of body mass index status and the obesity paradox appears to only occur in association with the metabolic syndrome, but cardiorespiratory fitness modifies these outcomes. Enhanced glucose availability is important when the immune system is activated not only because it has an acute onset, a high consumption of glucose and is substantially an obligate glucose utilizer but also because it has priority over most other tissues and cells for the available glucose. Thus, for vulnerable populations, such as children with severe infections, this increases the risk of hypoglycaemia and death. The obesity paradox may be substantially a consequence of two features associated with obesity. One is endogenous glucose production (EGP). Obesity is associated with an increased capacity for EGP and thus is associated with enhanced glucose availability. Second is insulin resistance that reduces the amount of glucose metabolized by cells that are not obligate glucose utilizers and increases the release of fatty acids and glycerol from adipose stores that are alternative fuels for tissues and cells.

Survival and Outcomes After Cardiac Arrest With VA-ECMO Rescue Therapy

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) use in patients with cardiac arrest is increasing. Utilization remains variable between centers using ECMO as a rescue therapy or early protocolized extracorporeal cardiopulmonary resuscitation.

METHODS

Single-center, retrospective evaluation of cardiac arrest with cardiopulmonary resuscitation and rescue ECMO support from 2011 through 2019. Study objectives included survival, non-neurologic, and neurologic outcomes; validation of the SAVE and modified SAVE (mSAVE) scores for survival and favorable neurologic outcome; and predictive factor identification in cardiac arrest with ECMO rescue therapy.

RESULTS

Eighty-nine patients were included. In-hospital survival was 38.2% and median CPC score was 2. Survivors had lower BMI (27.9 ± 4.2 kg/m2 vs. 32.3 ± 7.5 kg/m2, P = 0.003), less obesity (BMI ≥ 30 kg/m2) (26.5% vs. 49.1%, P = 0.035), shorter CPR duration (35.5 ± 31.7 m vs. 58.0 ± 49.5 m, P = 0.019), more tracheostomy (38.2% vs. 7.3%, P < 0.001), and less renal replacement therapy (RRT) (17.6% vs. 38.2%, P = 0.031). Patients with a favorable neurologic outcome had lower body weight (86.2 ± 17.9 kg vs. 98.1 ± 19.4 kg, P = 0.010), lower BMI (28.1 ± 4.5 kg/m2 vs. 33.9 ± 7.9 kg/m2, P < 0.001), and less obesity (29.7% vs. 56.3%, P = 0.026). mSAVE score predicted in-hospital survival (OR 1.11; 95%CI 1.03-1.19; P = 0.004) and favorable neurologic outcome (OR 1.11; 1.03-1.20; P = 0.009). Multivariate analysis for in-hospital survival included mSAVE, BMI, CPR-time, tracheostomy, and RRT (c-statistic: 0.864). Favorable neurologic outcome included mSAVE and BMI (c-statistic: 0.805).

CONCLUSIONS

mSAVE, BMI, RRT, and tracheostomy are predictors of in-hospital survival and mSAVE and BMI are predictors of favorable neurologic outcome in cardiac arrest with ECMO rescue therapy.

Early supplemental parenteral nutrition is associated with reduced mortality in critically ill surgical patients with high nutritional risk

BACKGROUND & AIMS

Adequate nutritional provision is important for critically ill patients to improve clinical outcomes. Starting enteral nutrition (EN) as early as possible is recommended and preferred to parenteral nutrition (PN). However, patients who undergo emergency abdominal operations may have alterations in their intra-abdominal environment and gastrointestinal motility leading to limitation in starting an enteral diet. Therefore, our study was designed to evaluate the benefit of early supplemental PN to achieve adequate calorie and protein supply in critically ill patients undergoing surgery who are not eligible for early EN.

METHODS

We reviewed the medical records of 317 patients who underwent emergency abdominal surgery for complicated intra-abdominal infection (cIAI) between January 2013 and December 2018. The nutritional data of the patients were collected for 7 days in maximum, starting on the day of intensive care unit (ICU) admission. The patients were divided by low or high malnutrition risk using the modified Nutrition Risk in Critically ill (mNUTRIC) score and body mass index. The low- and high-risk groups were subdivided into the following two categories: those who received PN within 48 h ("early") and those who did not ("usual"). Data regarding the baseline characteristics, initial severity of illness, morbidity, and mortality rates were also obtained. The average calorie and protein supply per day were calculated in these groups.

RESULTS

Patients in all groups showed no significant differences in baseline characteristics, initial status, and infectious complications. In terms of outcomes, patients with low malnutrition risk had no significant difference in mortality. However, among patients with high malnutrition risk, the "Early" group had lower rates of 30-day mortality (7.6% vs. 26.7%, p = 0.006) and in-hospital mortality (13.6% vs. 28.9%, p = 0.048) than those of the "Usual" group. Kaplan-Meier survival curves for 30-day mortality in these groups also showed a statistically significant difference (p = 0.001). The caloric adequacy of the "Early" group and the "Usual" group were 0.88 ± 0.34 and 0.6 ± 0.29, respectively. Amounts of protein received were 0.94 ± 0.39 g/kg in the "Early" group and 0.47 ± 0.34 g/kg in the "Usual" group, respectively. There was no significant difference in infectious complications between both groups.

CONCLUSIONS

Mortality in patients with high malnutrition risk who received early PN supply within 48 h after emergency surgery for cIAI was lower than those who did not receive PN earlier. PN may be necessary to fulfill the caloric and protein requirements for critically ill patients who cannot achieve their nutritional requirements to the fullest with EN alone.

The Impact of Obesity on Critical Illnesses

ABSTRACT

In the last few decades, obesity became one of the world's greatest health challenges reaching a size of global epidemic in virtually all socioeconomic statuses and all age groups. Obesity is a risk factor for many health problems and as its prevalence gradually increases is becoming a significant economic and health burden. In this manuscript we describe how normal respiratory and cardiovascular physiology is altered by obesity. We review past and current literature to describe how obesity affects outcomes of patients facing critical illnesses and discuss some controversies related to this topic.

Underweight but not overweight is associated with excess mortality in septic ICU patients

Background

Higher survival has been shown for overweight septic patients compared with normal or underweight patients in the past. This study aimed at investigating the management and outcome of septic ICU patients in different body mass index (BMI) categories in a large multicenter database.

Methods

In total, 16,612 patients of the eICU collaborative research database were included. Baseline characteristics and data on organ support were documented. Multilevel logistic regression analysis was performed to fit three sequential regression models for the binary primary outcome (ICU mortality) to evaluate the impact of the BMI categories: underweight (<18.5 kg/m²), normal weight (18.5 to < 25 kg/m²), overweight (25 to < 30 kg/m²) and obesity (≥ 30 kg/m²). Data were adjusted for patient level characteristics (model 2) as well as management strategies (model 3).

Results

Management strategies were similar across BMI categories. Underweight patients evidenced higher rates of ICU mortality. This finding persisted after adjusting in model 2 (aOR 1.54, 95% CI 1.15–2.06; p = 0.004) and model 3 (aOR 1.57, 95%CI 1.16–2.12; p = 0.003). No differences were found regarding ICU mortality between normal and overweight patients (aOR 0.93, 95%CI 0.81–1.06; p = 0.29). Obese patients evidenced a lower risk of ICU mortality compared to normal weight, a finding which persisted across all models (model 2: aOR 0.83, 95%CI 0.69–0.99; p = 0.04; model 3: aOR 0.82, 95%CI 0.68–0.98; p = 0.03). The protective effect of obesity and the negative effect of underweight were significant in individuals > 65 years only.

Conclusion

In this cohort, underweight was associated with a worse outcome, whereas obese patients evidenced lower mortality. Our analysis thus supports the thesis of the obesity paradox.

Obesity protects against sepsis-induced and norepinephrine-induced white adipose tissue browning

Sepsis is a dysregulated systemic response to infection and can lead to organ damage and death. Obesity is a significant problem worldwide and affects outcomes from sepsis. Our laboratory demonstrated that white adipose tissue (WAT) undergoes browning during sepsis, a process whereby WAT adopts a brown adipose tissue phenotype. However, this browning process was not observed in obese mice during sepsis. White adipose tissue browning is detrimental in patients with burn injury and cancer. We hypothesize that norepinephrine (NE) induces WAT browning in nonobese mice but not in obese mice similarly to sepsis-induced WAT browning. Six-week-old C57BL/6 male mice were randomized to a high-fat diet or normal diet. After 6-7 wk of feeding, polymicrobial sepsis was induced by cecal ligation and puncture (CLP). Norepinephrine was administered intraperitoneally via osmotic minipumps for 18 h or 72 h (no CLP) at which time tissue and plasma were harvested. Controls were mice that underwent CLP (no NE) with 18-h harvest. A separate group of mice underwent pretreatment with NE or vehicle infusion for 72 h, CLP was performed, and at 18 h had tissue and plasma harvested. Sepsis resulted in significant weight loss in both nonobese and obese mice. NE treatment alone caused weight loss in obese mice. Septic nonobese mice had higher uncoupling protein-1 (UCP1) expression compared with control and obese septic mice. NE treatment increased UCP1 expression in nonobese, but not obese mice. NE-treated obese septic mice had lower lung myeloperoxidase (MPO) activity, alanine aminotransferase (ALT), aspartate aminotransferase (AST), TNFα, and IL-6 levels compared with NE-treated nonobese septic mice. Obesity protects mice from septic-induced and NE-induced WAT browning.NEW & NOTEWORTHY White adipose tissue browning is detrimental in patients with burn injury and cancer. WAT browning occurs in nonobese mice and can be induced by β receptor norepinephrine infusion, but obese mice are resistant to sepsis-induced and norepinephrine-induced WAT browning. We propose that the lack of WAT browning and unchanged inflammatory cytokine response may contribute to the protection of obese mice from sepsis.

Effect of obesity on mortality among hospitalized paediatric patients with severe sepsis

INTRODUCTION

Severe sepsis is one of the leading causes of mortality among children. Studies in adults have suggested a protective effect of obesity on mortality among patients hospitalized with sepsis. Paediatric studies evaluating similar relationship is lacking.

METHODS

We analysed non-overlapping years of the Kids Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2014 of all paediatric patients with severe sepsis (PSS) up to 20 years of age. PSS was defined using specific International Classification of Diseases (ICD) codes and modified Angus criteria. Using ICD-9 diagnosis codes, patients were divided into three mutually exclusive groups (obesity, morbid obesity and control groups), and these groups were compared for outcomes measures including in-hospital mortality and healthcare resource utilization using the length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analysed 109 026 hospitalizations due to PSS. The prevalence rate of obesity was 1.5% (n = 1643), and morbid obesity was 1.05% (n = 1147). Multivariate regression models showed obesity was associated with 63% (OR 0.37, CI: 0.29-0.47, p < 0.001) and 54% reduction in mortality among PSS patients and patients with septic shock respectively. Contrastingly, morbid obesity was not associated with mortality among PSS patients and but was associated with 1.37 times (CI: 1.06-1.78, p = 0.01) increased risk of mortality among paediatric patients with septic shock.

CONCLUSIONS

Paediatric obesity is associated with reduced mortality among patients with PSS, with the exception of morbid obesity. Further prospective studies are needed to better understand the relationship between obesity and outcomes in PSS.

Metabolic Pathways Involved in Formation of Spontaneous and Lipopolysaccharide-Induced Neutrophil Extracellular Traps (NETs) Differ in Obesity and Systemic Inflammation

Obesity manifests itself with low-grade chronic inflammation that shapes immune responses during infection. Albeit obese individuals are at risk of higher mortality due to comorbidities, they are better protected from systemic inflammation. Recently, we showed that in the vasculature of obese mice kept on high-fat diet (HFD), neutrophils produce less neutrophil extracellular traps (NETs) than in lean controls (normal diet, ND). NETs are used by neutrophils to counteract severe infection, but they also cause collateral damage. Hardly anything is known about metabolic requirements for their formation, especially in the context of obesity and/or sepsis. Thus, we aimed to study the immunometabolism of NET formation by application of ex vivo neutrophil analyses (Seahorse analyzer, selective inhibitors, confocal imaging) and intravital microscopy. The obtained data show that glycolysis and/or pentose phosphate pathway are involved in NETs release by ND neutrophils in both physiological and inflammatory conditions. In contrast, such cells of septic HFD mice utilize these routes only to spontaneously cast NETs, while after secondary ex vivo activation they exhibit so called "exhausted phenotype", which manifests itself in diminished NET release despite high glycolytic potential and flexibility to oxidize fatty acids. Moreover, impact of ATP synthase inhibition on NET formation is revealed. Overall, the study shows that the neutrophil potential to cast NETs depends on both the metabolic and inflammatory state of the individual.

Impact of Body Mass Index on the Survival of Patients with Sepsis with Different Modified NUTRIC Scores

Nutritional status affects the survival of patients with sepsis. This retrospective study analyzed the impact of body mass index (BMI) and modified nutrition risk in critically ill (mNUTRIC) scores on survival of these patients. Data of 1291 patients with sepsis admitted to the intensive care unit (ICU) were extracted. The outcomes were mortality, duration of stay, ICU stay, and survival curve for 90-day mortality. Logistic regression analysis was performed to examine the risk factors for mortality. Cytokine and biomarker levels were analyzed in 165 patients. The 90-day survival of underweight patients with low mNUTRIC scores was significantly better than that of normal-weight patients with low mNUTRIC scores (70.8% vs. 58.3%, respectively; p = 0.048). Regression model analysis revealed that underweight patients with low mNUTRIC scores had a lower risk of mortality (odds ratio = 0.557; p = 0.082). Moreover, normal-weight patients with low mNUTRIC scores had the lowest human leukocyte antigen DR (HLA-DR) level on days 1 (underweight vs. normal weight vs. overweight: 94.3 vs. 82.1 vs. 94.3, respectively; p = 0.007) and 3 (91.8 vs. 91.0 vs. 93.2, respectively; p = 0.047). Thus, being underweight may not always be harmful if patients have optimal clinical nutritional status. Additionally, HLA-DR levels were the lowest in patients with low survival.

Sepsis and the Obesity Paradox: Size Matters in More Than One Way

OBJECTIVES

Multiple studies have demonstrated an obesity paradox such that obese ICU patients have lower mortality and better outcomes. We conducted this study to determine if the mortality benefit conferred by obesity is affected by baseline serum lactate and mean arterial pressure.

DESIGN

Retrospective analysis of prospectively collected clinical data.

SETTING

Five community-based and one academic medical center in the Omaha, NE.

PATIENTS

7,967 adults hospitalized with sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were categorized by body mass index as underweight, normal weight, overweight, or obese. Multivariable logistic regression models were used to estimate the odds of in-hospital death by body mass index category; two-way interactions between body mass index and each covariate were also evaluated. Subgroup and sensitivity analyses were conducted using an ICU cohort and Acute Physiology and Chronic Health Evaluation III scores, respectively. The overall unadjusted mortality rate was 12.1% and was consistently lower in higher body mass index categories (all comparisons, p < 0.007). The adjusted mortality benefit observed in patients with higher body mass index was smaller in patients with higher lactate levels with no mortality benefit in higher body mass index categories observed at lactate greater than 5 mmol/L. By contrast, the association between lower MAP and higher mortality was constant across body mass index categories. Similar results were observed in the ICU cohort. Finally, the obesity paradox was not observed after including Acute Physiology and Chronic Health Evaluation III scores as a covariate.

CONCLUSIONS

Our retrospective analysis suggests that although patient size (i.e., body mass index) is a predictor of in-hospital death among all-comers with sepsis-providing further evidence to the obesity paradox-it adds that illness severity is critically important whether quantified as higher lactate or by Acute Physiology and Chronic Health Evaluation III score. Our results highlight that the obesity paradox is more than a simple association between body mass index and mortality and reinforces the importance of illness severity.

Impact of obesity on outcome of severe bacterial infections

Introduction

Obesity is a rapidly growing global health concern with considerable negative impact on life-time expectancy. It has yet not been clarified if and how obesity impacts outcomes of severe bacterial infections. The aim of this study was to determine how body mass index impacts outcome of severe bacterial infections in a well-defined population-based cohort.

Methods

This study is based on a cohort of 2196 patients included in a Swedish prospective, population-based, consecutive observational study of the incidence of community-onset severe sepsis and septic shock in adults. All patients with weight and height documented in the medical records on admission were included.

Results

The case fatality rate (CFR) was negatively correlating with increasing BMI. Outcomes included 28-day CFR (p-value = 0.002), hospital CFR (p-value = 0.039) and 1-year CFR (p-value<0.001). When BMI was applied as continuous variable in a multiple logistic regression together with other possible covariates, we still could discern that BMI was associated with decreasing 28-day CFR (OR = 0.93, 95% CI 0.88–0.98, p-value = 0.009) and 1-year CFR (OR = 0.94, 95% CI 0.91–0.97, p-value<0.001).

Conclusion

The hypothesis and paradox of obesity being associated with higher survival rates in severe bacterial infections was confirmed in this prospective, population-based observational study.

Serum leptin level as a diagnostic and prognostic marker in infectious diseases and sepsis: A comprehensive literature review

BACKGROUND

Infections and sepsis are common causes of morbidity and mortality, with an increasing incidence worldwide. Leptin is involved in the inflammatory process and may modulate the cytokine production, immune cell proliferation and endothelial function. There are conflicting results regarding alterations of leptin levels in infectious diseases and the outcome from sepsis.The aim of the current article is to provide an overview of the medical literature on the correlations between variations of leptin levels and infectious diseases and sepsis.

METHODS

We performed an extensive literature search in PubMed and Google Scholar databases, using keywords to identify articles related to leptin in infectious diseases and sepsis. Searches were referenced using medical subject headings that included "leptin," "adipokines," "sepsis," "infectious diseases," "leptin deficiency," "leptin resistance" or "hyperleptinemia." The language of publication, journal, or country were not included as limitation criteria.Articles or abstracts containing adequate information, such as age, sex, anthropometric indices, clinical presentation, comorbidities, and management were included in the study, whereas articles with insufficient clinical and demographic data were excluded. We assessed the quality of the studies selected.The final review of all databases was conducted on June 18, 2020.

RESULTS

We find the results from the current review to be of great importance due to the possible therapeutic role of leptin analogs in states of leptin deficiency associated with infectious diseases or sepsis.In hyperleptinemia, a therapeutic plan for obtaining leptin neutralization also needs further investigations. This could lead to the reduction of proinflammatory responses.There is a need for further studies to demonstrate the specificity and sensitivity of leptin in the early diagnosis of sepsis and the need to measure serum leptin levels in routine evaluation of the critical patient.

CONCLUSION

The multiple effects of leptin are of growing interest, but further studies are needed to elucidate the role of leptin signalling in infectious diseases and sepsis. Because very few human studies are reported, we recommend the need for further research.Better understanding of the pathophysiology of sepsis and the implication of circulating total leptin in this process could help physicians in managing this life-threatening condition.

Body mass index and risk of dying from a bloodstream infection: A Mendelian randomization study

BACKGROUND

In observational studies of the general population, higher body mass index (BMI) has been associated with increased incidence of and mortality from bloodstream infection (BSI) and sepsis. On the other hand, higher BMI has been observed to be apparently protective among patients with infection and sepsis. We aimed to evaluate the causal association of BMI with risk of and mortality from BSI.

METHODS AND FINDINGS

We used a population-based cohort in Norway followed from 1995 to 2017 (the Trøndelag Health Study [HUNT]), and carried out linear and nonlinear Mendelian randomization analyses. Among 55,908 participants, the mean age at enrollment was 48.3 years, 26,324 (47.1%) were men, and mean BMI was 26.3 kg/m2. During a median 21 years of follow-up, 2,547 (4.6%) participants experienced a BSI, and 451 (0.8%) died from BSI. Compared with a genetically predicted BMI of 25 kg/m2, a genetically predicted BMI of 30 kg/m2 was associated with a hazard ratio for BSI incidence of 1.78 (95% CI: 1.40 to 2.27; p < 0.001) and for BSI mortality of 2.56 (95% CI: 1.31 to 4.99; p = 0.006) in the general population, and a hazard ratio for BSI mortality of 2.34 (95% CI: 1.11 to 4.94; p = 0.025) in an inverse-probability-weighted analysis of patients with BSI. Limitations of this study include a risk of pleiotropic effects that may affect causal inference, and that only participants of European ancestry were considered.

CONCLUSIONS

Supportive of a causal relationship, genetically predicted BMI was positively associated with BSI incidence and mortality in this cohort. Our findings contradict the "obesity paradox," where previous traditional epidemiological studies have found increased BMI to be apparently protective in terms of mortality for patients with BSI or sepsis.

The Collision of Meta-Inflammation and SARS-CoV-2 Pandemic Infection

The coronavirus disease 2019 (COVID-19) pandemic has forced us to consider the physiologic role of obesity in the response to infectious disease. There are significant disparities in morbidity and mortality by sex, weight, and diabetes status. Numerous endocrine changes might drive these varied responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including hormone and immune mediators, hyperglycemia, leukocyte responses, cytokine secretion, and tissue dysfunction. Studies of patients with severe COVID-19 disease have revealed the importance of innate immune responses in driving immunopathology and tissue injury. In this review we will describe the impact of the metabolically induced inflammation (meta-inflammation) that characterizes obesity on innate immunity. We consider that obesity-driven dysregulation of innate immune responses may drive organ injury in the development of severe COVID-19 and impair viral clearance.

The Association Between Body Mass Index and the Risk of Hospitalization and Mortality due to Infection: A Prospective Cohort Study

Background

We aim to determine whether obesity increases the risk of various infections using a large prospective population-based cohort.

Methods

A total of 120 864 adults were recruited from the New Taipei City health screening program from 2005 to 2008. Statistics for hospitalization and mortality due to infection were obtained from the National Health Insurance Database and the National Death Registry in Taiwan.

Results

During a mean follow-up period of 7.61 years, there were 438, 7582, 5298, and 1480 first hospitalizations due to infection in the underweight, normal, overweight, and obese groups, respectively. Obesity significantly increases the risk of hospitalization for intra-abdominal infections (adjusted hazard ratio [aHR], 1.19; 95% CI, 1.00–1.40), including diverticulitis, liver abscess, acute cholecystitis and anal and rectal abscess, reproductive and urinary tract infection (aHR, 1.38; 95% CI, 1.26–1.50), skin and soft tissue infection (aHR, 2.46; 95% CI, 2.15–2.81), osteomyelitis (aHR, 1.70; 95% CI, 1.14–2.54), and necrotizing fasciitis (aHR, 3.54; 95% CI,1.87–6.67), and this relationship is dose-dependent. This study shows that there is a U-shaped association between body mass index (BMI) and hospitalization for lower respiratory tract infection, septicemia, and the summation of all infections and that underweight people are at the greatest risk, followed by obese people. There is a clear negative relationship between BMI and infection-related mortality.

Conclusions

The pattern that BMI affects the risk of hospitalization and mortality due to infection varies widely across infection sites. It is necessary to tailor preventive and therapeutic measures against different infections in hosts with different BMIs.

Exploring the pathophysiology of post-sepsis syndrome to identify therapeutic opportunities

Sepsis is a major health problem worldwide. As the number of sepsis cases increases, so does the number of sepsis survivors who suffer from “post-sepsis syndrome” after hospital discharge. This syndrome involves deficits in multiple systems, including the immune, cognitive, psychiatric, cardiovascular, and renal systems. Combined, these detrimental consequences lead to rehospitalizations, poorer quality of life, and increased mortality. Understanding the pathophysiology of these issues is crucial to develop new therapeutic opportunities to improve survival rate and quality of life of sepsis survivors. Such novel strategies include modulating the immune system and addressing mitochondrial dysfunction. A sepsis follow-up clinic may be useful to identify long-term health issues associated with post-sepsis syndrome and evaluate existing and novel strategies to improve the lives of sepsis survivors.

Weight as a Risk Factor for Mortality in Critically Ill Patients

OBJECTIVES

To explore the hypothesis that obesity is associated with increased mortality and worse outcomes in children who are critically ill.

METHODS

Secondary analysis of the Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology study, a prospective, multinational observational study. Patients between 3 months and 25 years across Asia, Australia, Europe, and North America were recruited for 3 consecutive months. Patients were divided into 4 groups (underweight, normal weight, overweight, and obese) on the basis of their BMI percentile for age and sex.

RESULTS

A total of 3719 patients were evaluated, of whom 542 (14%) had a primary diagnosis of sepsis. One thousand fifty-nine patients (29%) were underweight, 1649 (44%) were normal weight, 423 (11%) were overweight, and 588 (16%) were obese. The 28-day mortality rate was 3.6% for the overall cohort and 9.1% for the sepsis subcohort and differed significantly by weight status (5.8%, 3.1%, 2.2%, and 1.8% for subjects with underweight, normal weight, overweight, and obesity, respectively, in the overall cohort [P < .001] and 15.4%, 6.6%, 3.6%, and 4.7% in the sepsis subcohort, respectively [P = .003]). In a fully adjusted model, 28-day mortality risk was 1.8-fold higher in the underweight group versus the normal weight group in the overall cohort and 2.9-fold higher in the sepsis subcohort. Patients who were overweight and obese did not demonstrate increased risk in their respective cohorts. Patients who were underweight had a longer ICU length of stay, increased need for mechanical ventilation support, and a higher frequency of fluid overload.

CONCLUSIONS

Patients who are underweight make up a significant proportion of all patients in the PICU, have a higher short-term mortality rate, and have a more complicated ICU course.

Phagocytosis-Inflammation Crosstalk in Sepsis: New Avenues for Therapeutic Intervention

Phagocytosis is a complex process by which cells within most organ systems remove pathogens and cell debris. Phagocytosis is usually followed by inflammatory pathway activation, which promotes pathogen elimination and inhibits pathogen growth. Delayed pathogen elimination is the first step in sepsis development and a key factor in sepsis resolution. Phagocytosis thus has an important role during sepsis and likely contributes to all of its clinical stages. However, only a few studies have specifically explored and characterized phagocytic activity during sepsis. Here, we describe the phagocytic processes that occur as part of the immune response preceding sepsis onset and identify the elements of phagocytosis that might constitute a predictive marker of sepsis outcomes. First, we detail the key features of phagocytosis, including the main receptors and signaling hallmarks associated with different phagocytic processes. We then discuss how the initial events of phagosome formation and cytoskeletal remodeling might be associated with known sepsis features, such as a cytokine-driven hyperinflammatory response and immunosuppression. Finally, we highlight the unresolved mechanisms of sepsis development and progression and the need for cross-disciplinary approaches to link the clinical complexity of the disease with basic cellular and molecular mechanisms.

Obesity prolongs the hospital stay in patients affected by COVID-19, and may impact on SARS-COV-2 shedding

•

Subjects with obesity affected by COVID-19 require longer hospitalization compared to subjects without obesity.

•

Subjects with obesity require more time to clear from SARS-COV-2 shedding compared to subjects without obesity.

•

Subjects with obesity affected by COVID-19 have higher inflammatory markers compared to subjects without obesity.

Introduction

On the last three months the new SARS-COV-2 coronavirus has created a pandemic, rapidly spreading all around the world. The aim of the study is to investigate whether obesity impacts on COVID-19 morbidity.

Methods

One hundred consecutive patients with COVID-19 pneumonia admitted in our Medical Unit were evaluated. Anthropometric parameters and past medical history were registered. Nasopharyngeal swab samples and biochemical analysis were obtained at admission and during hospital stay.

Results

Patients with (OB, 29) and without obesity (N-OB, 71) were similar in age, gender and comorbidities, with the exception of hypertension that was more frequent in OB group. At admission, inflammatory markers were higher in OB than N-OB group. OB group showed a worse pulmonary clinical picture, with lower PaO2 (57 ± 15 vs. 68 ± 14 mmHg, p = 0.042), and SaO2 (88 ± 6 vs. 92 ± 5%, p = 0.049) at admission consequently requiring higher volumes of oxygen (Fi02: 38 ± 15 vs. 29 ± 19%, p = 0.047) and a longer period to achieve oxygen weaning (10 ± 6 vs. 15 ± 7 days, p = 0.03). OB group also had positive swabs for longer time (19 ± 8 vs. 13 ± 7, days, p = 0.002), and required longer hospital stay (21 ± 8 vs. 13 ± 8, days, p = 0.0008). Partial least square regression analysis showed that BMI, age and CRP at admission were related to longer length of hospital stay, and time for negative swab. On the contrary, in this cohort, obesity did not predict higher mortality.

Conclusions

Subjects with obesity affected by COVID-19 require longer hospitalization, more intensive and longer oxygen treatment, and they may have longer SARS-COV-2 shedding.

Catalase is required for peroxisome maintenance during adipogenesis

Although obesity contributes to the onset and pathogenesis of metabolic diseases, it has been repeatedly demonstrated that being overweight or mildly obese carries a survival advantage compared with being thin or normal-weight. This relationship is called the obesity paradox. Hence, it is necessary to clarify the underlying mechanism of obesity onset for the prevention and treatment of these diseases. Catalase is distributed in peroxisomes under normal redox conditions and catalase activity is increased during the differentiation of 3T3-L1 preadipocytes to adipocytes. Although peroxisomes are responsible for lipid metabolism, the role of peroxisomal catalase in the process of lipid accumulation remains unclear. The present study aimed to investigate the relationships among catalase activity, peroxisome content, and lipid accumulation during the differentiation of 3T3-L1 preadipocytes to adipocytes. Increased catalase activity and lipid accumulation were observed during the differentiation of preadipocytes. Silencing of catalase by small interfering RNA or treatment with 3-amino-1,2,4-triazole (3-AT), a catalase inhibitor, resulted in reduced lipid accumulation. Inhibition of catalase activity in peroxisomes increases hydrogen peroxide (H₂O₂) levels, which results in a reduction of peroxisome content. Extracellular H₂O₂ had no influence on lipid accumulation during differentiation. The occurrence of autophagy was clearly enhanced in cells treated with 3-AT. Spautin-1, an inhibitor of autophagy flux, protected against a reduction in lipid accumulation by treatment with 3-AT. Our data provide evidence that catalase protects against the degradation of peroxisomes via the occurrence of autophagy triggered by the generation of H₂O₂ in peroxisomes. These results suggest that catalase in peroxisomes is crucial to adipogenesis.

Does Obesity Protect Against Death in Sepsis? A Retrospective Cohort Study of 55,038 Adult Patients

OBJECTIVES

Observational studies suggest obesity is associated with sepsis survival, but these studies are small, fail to adjust for key confounders, measure body mass index at inconsistent time points, and/or use administrative data to define sepsis. To estimate the relationship between body mass index and sepsis mortality using detailed clinical data for case detection and risk adjustment.

DESIGN

Retrospective cohort analysis of a large clinical data repository.

SETTING

One-hundred thirty-nine hospitals in the United States.

PATIENTS

Adult inpatients with sepsis meeting Sepsis-3 criteria.

EXPOSURE

Body mass index in six categories: underweight (body mass index < 18.5 kg/m), normal weight (body mass index = 18.5-24.9 kg/m), overweight (body mass index = 25.0-29.9 kg/m), obese class I (body mass index = 30.0-34.9 kg/m), obese class II (body mass index = 35.0-39.9 kg/m), and obese class III (body mass index ≥ 40 kg/m).

MEASUREMENTS

Multivariate logistic regression with generalized estimating equations to estimate the effect of body mass index category on short-term mortality (in-hospital death or discharge to hospice) adjusting for patient, infection, and hospital-level factors. Sensitivity analyses were conducted in subgroups of age, gender, Elixhauser comorbidity index, Sequential Organ Failure Assessment quartiles, bacteremic sepsis, and ICU admission.

MAIN RESULTS

From 2009 to 2015, we identified 55,038 adults with sepsis and assessable body mass index measurements: 6% underweight, 33% normal weight, 28% overweight, and 33% obese. Crude mortality was inversely proportional to body mass index category: underweight (31%), normal weight (24%), overweight (19%), obese class I (16%), obese class II (16%), and obese class III (14%). Compared with normal weight, the adjusted odds ratio (95% CI) of mortality was 1.62 (1.50-1.74) for underweight, 0.73 (0.70-0.77) for overweight, 0.61 (0.57-0.66) for obese class I, 0.61 (0.55-0.67) for obese class II, and 0.65 (0.59-0.71) for obese class III. Results were consistent in sensitivity analyses.

CONCLUSIONS

In adults with clinically defined sepsis, we demonstrate lower short-term mortality in patients with higher body mass indices compared with those with normal body mass indices (both unadjusted and adjusted analyses) and higher short-term mortality in those with low body mass indices. Understanding how obesity improves survival in sepsis would inform prognostic and therapeutic strategies.

Sepsis Patients in Critical Care Units with Obesity: Is Obesity Protective?

Obesity is becoming a global health issue and its prevalence is increasing. It is associated with an increased incidence of illness and sepsis. While obesity is associated with increased morbidity and mortality, obesity has been found to be associated with improvement in mortality outcomes in sepsis when compared to leaner patients, a phenomenon described as an obesity paradox. However, the effect of obesity on mortality in adults requiring treatment for sepsis is unclear. Studies evaluating this effect are inconsistent and there is an increased morbidity still associated with obesity. As well, there are many limitations to these studies confounding interpretation. Future prospective studies minimizing bias and confounding factors are suggested to address this important clinical issue.

Favorable 90-Day Mortality in Obese Caucasian Patients with Septic Shock According to the Sepsis-3 Definition

Septic shock is a frequent life-threatening condition and a leading cause of mortality in intensive care units (ICUs). Previous investigations have reported a potentially protective effect of obesity in septic shock patients. However, prior results have been inconsistent, focused on short-term in-hospital mortality and inadequately adjusted for confounders, and they have rarely applied the currently valid Sepsis-3 definition criteria for septic shock. This investigation examined the effect of obesity on 90-day mortality in patients with septic shock selected from a prospectively enrolled cohort of septic patients. A total of 352 patients who met the Sepsis-3 criteria for septic shock were enrolled in this study. Body-mass index (BMI) was used to divide the cohort into 24% obese (BMI ≥ 30 kg/m²) and 76% non-obese (BMI < 30 kg/m²) patients. Kaplan-Meier survival analysis revealed a significantly lower 90-day mortality (31% vs. 43%; p = 0.0436) in obese patients compared to non-obese patients. Additional analyses of baseline characteristics, disease severity, and microbiological findings outlined further statistically significant differences among the groups. Multivariate Cox regression analysis estimated a significant protective effect of obesity on 90-day mortality after adjustment for confounders. An understanding of the underlying physiologic mechanisms may improve therapeutic strategies and patient prognosis.

The Role of Adipose Tissue and Adipokines in Sepsis: Inflammatory and Metabolic Considerations, and the Obesity Paradox

PURPOSE

Sepsis has become a global health problem with rising incidence and high mortality, creating a substantial social and economic burden. Early diagnosis and treatment can improve outcome, but reliable sepsis biomarkers are lacking. This review summarizes current evidence of the pathophysiological mechanisms linking adipose tissue to sepsis and presents experimental and clinical data on adipokines and sepsis along with important insights into the obesity paradox in sepsis survival.

RECENT FINDINGS

Sepsis is characterized by significant alterations in circulating cytokines and adipokines, biologically active molecules produced by the adipose tissue, being implicated in metabolic and inflammatory processes. Although data are inconclusive regarding classic adipokines such as leptin and adiponectin, recent evidence have highlighted the striking elevation of resistin and visfatin in critical illness and sepsis as well as their association with sepsis severity and outcomes. Given that inflammatory and metabolic pathways are involved in sepsis, studying adipokines presents an attractive, innovative, and promising research field that may provide more powerful diagnostic and prognostic biomarkers as well as novel therapeutic targets, empowering the therapeutic armamentarium for sepsis management in order to improve survival.

Progressive loss of muscle mass could be an adverse prognostic factor of 28-day mortality in septic shock patients

A decrease in skeletal muscle mass has been shown to increase hospital mortality. Nevertheless, little is known about the association between progressive muscle loss over time and clinical outcomes. We aimed to evaluate whether progressive loss of muscle mass in septic shock patients was associated with mortality. We reviewed prospectively enrolled registry of septic shock which had 817 consecutive patients. Of these, 175 patients who had computed tomography (CT) at a time of admission as well as 3-6 months prior to admission were included. Between these two CTs, the change in total abdominal muscle area index (TAMAI) was evaluated for progressive muscle loss. The change in TAMAI was higher in the non-survivors (-7.6 cm²/m², 19.0% decrease) than the survivors (-4.0 cm²/m², 10.5% decrease) with statistical significance (p = 0.002). Multiple logistic regression showed that the patients who had more than a 6.4 cm²/m² (16.7%) reduction of TAMAI had a 4.42-fold higher risk for mortality at 28 days (OR, 4.42; 95% CI, 1.41-13.81, p = 0.011). Our study suggested that progressive loss of muscle mass might be a useful prognostic factor for septic shock patients. This implication will need to be further explored in future prospective studies.

Sepsis Induces Adipose Tissue Browning in Nonobese Mice But Not in Obese Mice

Severe sepsis and septic shock are the biggest cause of mortality in critically ill patients. Obesity today is one of the world's greatest health challenges. Little is known about the extent of involvement of the white adipose tissue (WAT) in sepsis and how it is being modified by obesity. We sought to explore the involvement of the WAT in sepsis. We hypothesize that sepsis induces browning of the WAT and that obesity alters the response of WAT to sepsis. Six-week-old C57BL/6 mice were randomized to a high-fat diet to induce obesity (obese group) or control diet (nonobese group). After 6 to 11 weeks of feeding, polymicrobial sepsis was induced by cecal ligation and puncture (CLP). Mice were sacrificed at 0, 18, and 72 h after CLP and epididymal WAT (eWAT), inguinal WAT, and brown adipose tissue (BAT) harvested. Both types of WAT were processed for light microscopy and transmission electron microscopy to assess for morphological changes in both obese and nonobese mice. Tissues were processed for immunohistochemistry, image analyses, and molecular analyses. BATs were used as a positive control. Nonobese mice have an extensive breakdown of the unilocular lipid droplet and smaller adipocytes in WAT compared with obese mice after sepsis. Neutrophil infiltration increases in eWAT in nonobese mice after sepsis but not in obese mice. Nonobese septic mice have an increase in mitochondrial density compared with obese septic mice. Furthermore, nonobese septic mice have an increase in uncoupling protein-1 expression. Although the WAT of nonobese mice have multiple changes characteristic of browning during sepsis, these changes are markedly blunted in obesity.

Obesity and 1-Year Mortality in Adults After Sepsis: A Systematic Review

PURPOSE

In recent years, researchers have noted an "obesity paradox," where individuals with obesity survive sepsis at higher rates than their nonobese counterparts. This systematic review summarizes the literature on studies examining the association between obesity and 1-year mortality among patients admitted with sepsis, severe sepsis, or septic shock.

MATERIALS AND METHODS

Using a comprehensive search strategy, a systematic review was conducted to identify studies examining the association of obesity and sepsis mortality. PubMed, Cumulative Index of Nursing and Allied Health Literature, and Elton B. Stephens Company host databases were searched for the terms sepsis, obesity, mortality, and adult.

RESULTS

The initial search identified 189 studies, 9 of which met inclusion criteria. Of these, four provided evidence that obese or very obese patients with sepsis have lower mortality than nonobese patients. Methodologic differences in the remaining five studies, which reported conflicting results, limit generalizability.

CONCLUSION

This systematic review on the association of obesity and sepsis mortality found three studies that demonstrated lower sepsis mortality among obese patients in the first 30 days and one showing that this protective effect extends up to 1 year. Given the increased number of patients surviving sepsis, it is important to consider long-term mortality and further describe the variables associated with increased survival.

Medical Versus Surgical ICU Obese Patient Outcome: A Propensity-Matched Analysis to Resolve Clinical Trial Controversies

OBJECTIVES

To determine the short- and long-term mortality of obese ICU patients following medical as opposed to surgical admission and the relation between obesity and mortality.

DESIGN

Retrospective analysis of prospectively collected data, using a propensity score-matched analysis of patients with medical or surgical admission.

SETTING

One French mixed medical-surgical ICU.

PATIENTS

Critically ill obese patients (body mass index ≥ 30 kg/m) and nonobese patients admitted during a 14-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Seven-hundred ninety-one obese patients and 4,644 nonobese patients were included, 338 (43%) and 2,367 (51%) medical and 453 (57%) and 2,277 (49%) surgical obese and nonobese patients, respectively. Mortality was significantly higher in medical than in surgical obese patients in ICU (25% vs 12%; p < 0.001) and up to 365 days (36% vs 18%; p < 0.001) post ICU admission. One-to-one propensity score matching generated 260 pairs with well-balanced baseline characteristics. After matching on propensity score, mortality was still significantly higher in medical patients both in the ICU (21% vs 13%; p = 0.03) and up to 365 days (30% vs 20%; p = 0.01) post ICU admission. Obesity was not significantly associated with mortality both in univariate analysis (140 obese patients [15%] in the dead group vs 651 [14%] in the alive group; p = 0.72) and multivariate analysis (odds ratio, 1.09 [95% CI, 0.86-1.38]; p = 0.49) after adjustment for Simplified Acute Physiology Score II, age, category of admission, history of cardiac disease, and history of respiratory disease.

CONCLUSIONS

After careful matching, the data suggest that ICU mortality in obese population was higher in the medical group than in the surgical group and remains significantly higher 365 days post ICU admission.