Clinical outcomes among morbidly obese patients hospitalized with diabetic foot complications

The relationship between lower extremity amputation and body mass index

OBJECTIVES

Non-traumatic lower extremity amputation (LEA) is associated with significant morbidity and mortality. Diabetes mellitus (DM) and peripheral vascular disease (PVD) are associated with increased risk for LEA. As such, DM and PVD account for 54% of all LEA's, performed in the United States annually. As obesity is highly associated with both DM and PVD, our study sought to explore the relationship between LEA and obesity defined by BMI.

METHODS

Using the National Inpatient Sample (NIS) database, a retrospective review of patients who underwent non-traumatic LEA (LEA) between 2008 and 2014 was performed. The International Classification of Diseases 9th edition (ICD-9) codes were utilized to determine the diagnoses, comorbidities, and procedures. Patient BMIs were classified as follows: Non-obese [BMI <30], Obesity class I [BMI 30-34.9], Obesity class II [BMI 35-39.9], and Obesity class III [BMI ≥40]. Predictors for LEA were compared between groups using chi-square test and binary logistic regression to identify possible underlying factors associated with LEA. We also conducted a multivariate analysis to measure the effect of multiple variables on LEA.

RESULTS

We identified 16,259 patients with non-traumatic LEA and a mean age of 59.9 years. Rate of amputation in females was lower than males at 0.35% vs 0.87% respectively (p < 0.001). Of patients that underwent amputation there was a V-shape trend based on BMI, with 30.4% in non-obese patients, 18.2% in obesity class I, 17.3% in obesity class II, and 34.1% in obesity class III. The incidence of diabetes increased with obesity class, while the incidence of PVD decreased. Interestingly, of those with DM there was an inverse relationship between amputation rate and BMI class, with LEA rates in non-obese versus obesity class III patients were 1.63% vs 0.98% respectively (p < 0.001). Similarly, patients who had both diabetes and PVD showed a downward trend in LEA rate as obesity class increased; non-obese patients had a LEA rate of 8.01%, while obesity class III had 4.65% (p < 0.001). Patients in higher income bracket have lower odds of LEA (OR 0.77, p < 0.001) compared to the lowest income patients. Also, patients with comorbidities such as PVD (OR 10.78), diabetes (OR 5.02), renal failure (OR 1.41), and hypertension (OR 1.36) had higher odds to get an LEA (p < 0.001). Individuals with obesity class III are almost at half the odds (OR 0.52) to get an LEA compared to non-obese (p < 0.001).

CONCLUSIONS

Higher BMI and female gender are protective factors against lower extremity amputation. Factors that predisposing to LEA include lower household income and certain comorbidities such as PVD, diabetes, renal failure, and hypertension. These findings warrant further research to identify patients at high risk for LEA and help develop management guidelines for targeted populations.

The micronutrient content of the diet is correlated with serum glucose biomarkers and lipid profile and is associated with the odds of being overweight/obese-a case-control study

Background

A low micronutrient intake has been reported to contribute to the double-burden of obesity, increasing the risk for chronic diseases such as cardiovascular disease, diabetes, cancer, and mental disorders. This case-control study compared micronutrient intake profiles in overweight/obese vs. normal-weight individuals. We hypothesized that a low intake of certain micronutrients would increase the odds of being overweight/obese.

Methods

The case group (n = 812 adults) consisted of individuals with a BMI of ≥25  kg/m², and the control group (n = 793) had BMIs of 17.9-24.9  kg/m². A validated 124-item food frequency questionnaire was used to determine micronutrient-related dietary-quality, using the index of nutritional quality (INQ), calculated as the fraction of a micronutrient consumed vs. its dietary requirement. In addition, body surface area (BSA) was calculated according to the Mosteller formula.

Results

The control group had significantly higher INQ-scores of vitamin A, vitamin C, calcium, magnesium, and selenium compared to the case group. Furthermore, individuals with normal BSA (≤1.91 m² for men; ≤1.71  m² for women) had significantly higher INQ scores of vitamin C, calcium, magnesium, and zinc compared to participants with high BSA. In multivariable adjustment regression models, INQs of vitamin C (OR_BMI = 0.79, 95%CI: 0.64-0.97; OR_BSA = 0.81, 95%CI, 0.68-0.97) and magnesium (OR_BMI = 0.69, 95%CI: 0.47-0.99; OR_BSA = 0.71, 95%CI: 0.52-0.97) were significantly associated with the odds of obesity/overweight (in both BMI and BSA categories).

Conclusion

The significant association between micronutrient levels of the diet, especially of vitamin C and magnesium, with both obesity criteria, emphasized the importance of certain micronutrients in the obesity/overweight causal network.

Inflammatory and metabolic markers and comorbidities remission following sleeve gastrectomy: A single center one-year cohort study

BACKGROUND AND AIM

Obesity is a global concern with several health-related complications. Bariatric surgeries are major treatment options in patients with obesity and other comorbidities. This study aims to investigate the effects of sleeve gastrectomy on metabolic indexes, hyperechogenic liver changes, inflammatory state, diabetes, and other obesity-related comorbidities remission after the sleeve gastrectomy.

METHODS

This prospective study was conducted on patients with obesity candidates for laparoscopic sleeve gastrectomy. Patients were followed for one year after the surgery. Comorbidities, metabolic and inflammatory parameters were assessed before and one- year after the surgery.

RESULTS

137 patients (16 males, 44 in the DM group) underwent sleeve gastrectomy. One year after the study, obesity-related comorbidities improved significantly; diabetes had complete remission in 22.7% and partial remission in 63.6% of patients. Hyper-cholesterolemia, hyper-triglyceridemia, and hyper-uricemia also improved in 45.6%, 91.2%, and 69% of the patients. Metabolic syndrome indexes improved in 17.5% of the patients. Also, the prevalence of hyperechogenic changes in the liver has declined from 21% before the surgery to 1.5% after that. Based on logistic regression analysis, increased levels of HbA1C reduced the chance of diabetes remission by 0.9%. In comparison, every unit of increased BMI before the surgery improved the case of diabetes remission by 16%.

CONCLUSION

Laparoscopic sleeve gastrectomy is a safe and effective treatment option in patients with obesity and diabetes. Laparoscopic sleeve gastrectomy alleviates BMI and insulin resistance and effectively improves other obesity-related comorbidities such as Hypercholesterolemia, hyper-triglyceridemia, hyper-uricemia, and hyperechogenic changes of the liver. HbA1C and BMI before the surgery are notable predictors of diabetes remission within the first year after the surgery.

Inpatient outcomes comparing White and Black patients with obesity hospitalized for COVID-19 infection

OBJECTIVE

Comparisons between Black and White patients with obesity hospitalized with COVID-19 have not been fully studied. We sought to determine outcomes differences between these two groups.

METHODS

National Inpatient Sample database year 2020 was studied using multivariable regression to compare Black and White patients with obesity and COVID-19 infection. Outcomes were in-hospital mortality, length of stay, and hospital charges.

RESULTS

205,365 Black and White patients with obesity were hospitalized for COVID-19. 141,010 (68.6%) were White and 64,355 (31.3%) were Black. Black patients were younger (mean age [± standard error] 55.5 ± 0.14 vs. 62.1± 0.11; p < 0.01), more likely female (63.2% vs 50.9%; p < 0.01), and had lower mean comorbidity (Elixhauser score means [± standard error] 4.4 ± 0.02 vs. 4.6 ± 0.01; p < 0.01) than White patients. Black patients had lower odds of in-hospital mortality (adjusted Odds Ratio {aOR}=0.86 CI [0.77-0.97]; p = 0.01), longer hospital stays (adjusted Mean Difference {aMD}=0.32 days CI [0.14-0.51]; p < 0.01) and incurred higher, though non-significant hospital charges (aMD = $2,144 CI [-2270-+6560]; p = 0.34) than White patients.

CONCLUSION

During the first year of the pandemic, Black patients with obesity and COVID-19 were less likely to die during the incident hospitalization but used greater hospital resources compared to White patients.

Holistic care of patients with diabetic foot ulcers during the COVID-19 era: integration of Henderson's Need Theory

The COVID-19 pandemic has inhibited the practice of diabetic foot ulcer care, particularly in the community. Comprehensive theory-based nursing care is needed to prevent further complications. Unfortunately, a study combining theory with nursing care in diabetic foot ulcer care has not been explored. When caring for patients with diabetic foot ulcers, who are also at increased risk of severe complications from COVID-19, it is important to take a holistic view of the patient and consider all of their needs and the factors affecting them. Henderson's Need Theory and the 14 basic needs contained within it was chosen to be integrated in the care of patients with diabetic foot ulcers during the pandemic, with the hope that the findings will help nurses to optimise care in both hospital-based and community practice.

Obesity as a mortality risk factor in the medical ward: a case control study

BACKGROUND

Research regarding the association between severe obesity and in-hospital mortality is inconsistent. We evaluated the impact of body mass index (BMI) levels on mortality in the medical wards. The analysis was performed separately before and during the COVID-19 pandemic.

METHODS

We retrospectively retrieved data of adult patients admitted to the medical wards at the Mount Sinai Health System in New York City. The study was conducted between January 1, 2011, to March 23, 2021. Patients were divided into two sub-cohorts: pre-COVID-19 and during-COVID-19. Patients were then clustered into groups based on BMI ranges. A multivariate logistic regression analysis compared the mortality rate among the BMI groups, before and during the pandemic.

RESULTS

Overall, 179,288 patients were admitted to the medical wards and had a recorded BMI measurement. 149,098 were admitted before the COVID-19 pandemic and 30,190 during the pandemic. Pre-pandemic, multivariate analysis showed a "J curve" between BMI and mortality. Severe obesity (BMI > 40) had an aOR of 0.8 (95% CI:0.7-1.0, p = 0.018) compared to the normal BMI group. In contrast, during the pandemic, the analysis showed a "U curve" between BMI and mortality. Severe obesity had an aOR of 1.7 (95% CI:1.3-2.4, p < 0.001) compared to the normal BMI group.

CONCLUSIONS

Medical ward patients with severe obesity have a lower risk for mortality compared to patients with normal BMI. However, this does not apply during COVID-19, where obesity was a leading risk factor for mortality in the medical wards. It is important for the internal medicine physician to understand the intricacies of the association between obesity and medical ward mortality.

The Impact of Morbid Obesity on the Health Outcomes of Hospital Inpatients: An Observational Study

Morbid obesity poses a significant burden on the health-care system. This study determined whether morbid obesity leads to worse health-outcomes in hospitalised patients. This retrospective-study examined nutritional data of all inpatients aged 18-79 years, with a body-mass-index (BMI) ≥ 18.5 kg/m² admitted over a period of 4 years at two major hospitals in Australia. Patients were divided into 3 groups for comparison: normal/overweight (BMI 18.5-29.9 kg/m²), obese (BMI 30-39.9 kg/m²) and morbidly-obese (BMI ≥ 40 kg/m²). Outcome measures included length-of-hospital-stay (LOS), in-hospital mortality, and 30-day readmissions. Multilevel-mixed-effects regression was used to compare clinical outcomes between the groups after adjustment for potential confounders. Of 16,579 patients, 1004 (6.1%) were classified as morbidly-obese. Morbidly-obese patients had a significantly longer median (IQR) LOS than normal/overweight patients (5 (2, 12) vs. 5 (2, 11) days, p value = 0.012) and obese-patients (5 (2, 12) vs. 5 (2, 10) days, p value = 0.036). After adjusted-analysis, morbidly-obese patients had a higher incidence of a longer LOS than normal/overweight patients (IRR 1.04; 95% CI 1.02-1.07; p value < 0.001) and obese-patients (IRR 1.13; 95% CI 1.11-1.16; p value < 0.001). Other clinical outcomes were similar between the different groups. Morbid obesity leads to a longer LOS in hospitalised patients but does not adversely affect other clinical outcomes.

Clinical outcomes among patients with chronic kidney disease hospitalized with diabetic foot disorders: A nationwide retrospective study

INTRODUCTION

Diabetic foot ulcerations or infections (DFUs/DFIs) are common complications of patients with diabetes. This study aimed to explore the impact of non-dialysis and dialysis CKD on hospitalized patients with DFUs/DFIs.

METHODS

A retrospective cohort study was conducted using the National Inpatient Sample database for the years 2017 and 2018. Patients hospitalized for DFUs/DFIs were included in the study. The primary outcome was lower limb amputations. The secondary outcomes were inpatient mortality, sepsis, length of stay (LOS), total hospitalization charges (THC) and disposition.

RESULTS

A total of 121,815 hospitalizations were included (26.1% non-dialysis CKD; 8.4% dialysis CKD). There was no significant difference in amputation rates between those on non-dialysis CKD (adjusted odds ratio [aOR]: 0.96; 95% confidence interval [CI]: 0.87-1.06) and dialysis CKD (aOR: 1.04, [95% CI: 0.91-1.12]) when compared to non-CKD group. Dialysis CKD group had increased odds of undergoing major amputation (aOR: 1.74, [95% CI: 1.32-2.29]), in-hospital mortality (aOR: 3.77 [95% CI: 1.94-7.31]), sepsis (aOR: 1.83 [95% CI: 1.27-2.62]), longer LOS (adjusted mean difference [aMD]: 1.46 [95 CI: 1.12-1.80) and higher THC (adjusted mean difference [aMD]: $20,148 [95% CI: $15,968-$24,327]). Non-dialysis CKD group had increased odds of sepsis (aOR: 1.36 [95% CI: 1.02-1.82]), less likely to be discharged home (aOR: 0.87 [95% CI: 0.80-0.95]), longer LOS (aMD: 0.91 [95% CI 0.69-1.13]) and higher THC (aMD: $20,148 [95% CI: $15,968-$24,327]).

CONCLUSION

Patients with CKD on dialysis had higher odds of undergoing major amputation. CKD increased the odds of in-hospital morbidity and resource utilization, with the most significant is for those on dialysis.

Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN study

BACKGROUND

Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. This study was undertaken to determine factors that predict mortality in patients hospitalized for DFU in Nigeria.

METHODS

The current study was part of Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN), an observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented to participate were recruited and subjected to relevant clinical, biochemical, and radiological assessments and multidisciplinary care until discharge or death. Data for type 1 diabetes mellitus (DM) patients were expunged from current mortality analysis due to their small number.

RESULTS

Three hundred and twenty-three type 2 DM subjects with mean age and mean duration of DM of 57.2 ± 11.4 years and 8.7 ± 5.8 years respectively participated in this study. The median duration of ulcers was 39 days with a range of 28 to 54 days and the majority (79.9%) presented with advanced ulcers of at least Wagner grade 3. Mortality of 21.4% was recorded in the study, with the highest mortality observed among subjects with Wagner grade 5. Variables significantly associated with mortality with their respective p values were DM duration more than 120 months (p 0.005), ulcer duration > 1 month (p 0.020), ulcer severity of Wagner grade 3 and above (p 0.001), peripheral arterial disease (p 0.005), proteinuria (p < 0.001), positive blood cultures (p < 0.001), low HDL (p < 0.001), shock at presentation (p < 0.001), cardiac failure (p 0.027), and renal impairment (p < 0.001). On Multivariate regression analysis, presence of bacteraemia (OR 5.053; 95% CI 2.572-9.428) and renal impairment (OR 2.838; 95% CI 1.349-5.971) were significantly predictive of mortality independent of other variables.

CONCLUSIONS

This study showed high intra-hospital mortality among patients with DFU, with the majority of deaths occurring among those with advanced ulcers, bacteraemia, cardiac failure, and renal impairment. Prompt attention to these factors might help improve survival from DFU in Nigeria.

Nurses' Perspective of Treating Patients With an Amputation Due to Diabetic Foot Syndrome

BACKGROUND

Expert nurses must provide both physical and emotional care to patients with diabetic foot syndrome (DFS) who require an amputation. This includes helping patients and families to cope with this situation, while ensuring the maximum level of comfort.

PURPOSE

The aim of this study was to explore the perspective of expert nurses on the needs and hospital care of people requiring an amputation due to DFS.

METHOD

This was a qualitative multicenter study involving 8 hospitals in Spain and Portugal. In-depth interviews with expert nurses were transcribed verbatim to enable content analysis.

RESULTS

Twenty-four expert nurses were interviewed about their knowledge and experience of treating patients with diabetic foot disease. Two themes emerged from the qualitative analysis: (1) poor self-care and the disease trajectory, and (2) effective hospital care.

CONCLUSIONS

The results of this study highlight the key role that expert nurses play in the care of patients with DFS. Expert nurses considered that amputation leaves the individual physically and psychologically vulnerable, especially upon discharge from hospital. It is therefore essential to provide these patients with comprehensive and multidisciplinary care that includes emotional support.

Obesity as a Risk Factor Among Hospitalized Patients with Infective Endocarditis

Objective

Obesity contributes to diagnostic and management challenges for many hospitalized patients. The impact of obesity on in-hospital outcomes in patients with infective endocarditis has not been studied and was the focus of this investigation.

Method

We used the 2013 and 2014 Nationwide Inpatient Sample to identify adults ≥18 years of age with a principle diagnosis of endocarditis. We divided the sample into 2 groups based on presence of absence of obesity. Multivariate linear and logistic regression analysis was used to compare in-hospital mortality, valvular replacement, length of stay (LOS), and hospitalization charges.

Results

A total of 24 494 adults 18 years and older were hospitalized with infective endocarditis, of which 2625 were classified as obese. Patients with obesity were older (mean age, 57.8 ± 0.3 vs 54.3 ± 0.6 years; P < .01), more likely to be female (50.1% vs 36.1%; P < .01), and had more comorbidities (Charlson comorbidity score ≥ 3, 50.6% vs 28.8%; P < .01). Multivariate regression analysis found no differences between the 2 groups for mortality or repairs or replacements for any valve. On evaluation of resource utilization, patients with obesity had longer average LOS (13.9 days; confidence interval [CI], 12.7–15.1 vs 12.4 days; CI, 12.0–12.8; P = .016) and higher total hospital charges (US $160 789.90; CI, $140.922.40–$180 657.50 vs US $130 627.20; CI, $123 916.70–$137 337.70; P <.01). After adjustment for LOS for total hospital charges, there was no observed difference $11436.26 (CI, -$6649.07–$29521.6; P = .22).

Conclusions

. Obesity does not significantly impact in-hospital mortality or surgical valvular interventions among patients hospitalized with infective endocarditis, but obesity is associated with increased utilization of hospital resources.