Six‐minute walking test and the assessment of cardiorespiratory responses during weight‐loss programmes in obese children

Purpose. We assessed the exercise tolerance and cardiorespiratory responses during 2‐month weight‐loss programmes using the 6‐minute walking test (6MWT) in obese children. Methods. Twenty‐eight male obese children were randomly assigned to either a control group (C), an energy restriction group (R), an exercise training at maximum lipid‐oxidation (LIPOXmax) group (E), or an energy restriction/training group (RE). The body composition, the submaximal incremental cycling exercise, and the 6MWT were performed before and after the 2‐month programme. Results. After the programme, RE group showed a significant improvement of body composition (body weight reduced by 6.3 ± 1.5 kg, p < 0.01), and an increase of 6‐minute walking distance (6MWD) (+13.7%, p < 0.01). Similarly, maximum oxygen uptake calculated according to the American College of Science Medicine guideline (VO_2maxACSM) and VO_2max predicted from 6MWD were respectively higher (+12.9% and +10.0%, p < 0.01) than the R or E groups. Bland‐Altman analysis highlighted an agreement of these two methods of VO_2max measurement. Moreover, in all participants the 6MWD was significantly correlated with VO_2maxACSM and LIPOXmax (r = 0.77, p < 0.001 and r = 0.67, p < 0.01; respectively) before the programme as well as their changes in percentage over the programme (r = 0.85 and r = 0.86, p < 0.0001; respectively). Conclusions. We concluded that a 2‐month weight‐loss programme including energy restriction and exercise training targeted at LIPOXmax improved body composition and cardiorespiratory tolerance in obese children. Furthermore, the 6MWT could be considered as a useful and reliable tool for the assessment and the follow‐up of cardiorespiratory responses during weight‐loss programme in obese children. Copyright © 2010 John Wiley & Sons, Ltd.     

Morbidity and mortality characteristics of morbidly obese patients admitted to hospital and intensive care units

Background

The purpose of this study is to evaluate the outcomes of hospitalized morbidly obese inpatients.

Methods

In this retrospective cohort study, we reviewed the records of all adult morbidly obese patients (defined as body mass index [BM]) >40 kg/m² upon admission) admitted to tertiary university hospital from 2000 to 2008. Primary outcome was hospital mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), need for and duration of mechanical ventilation (MV), and tracheostomy rates. We divided patients into quartiles based on their admission BMI. Baseline characteristics and outcomes were reported for each quartile.

Results

Over the 8-year period, we reviewed 897 admissions for 545 patients. The median number of admissions was 1 per patient (mean, 2.44 ± 2.9), with a range of 1 to 20. A total of 40.9% had more than one admission. Morbidly obese patients were more likely to be admitted to a medical service. Higher BMI quartiles had higher rates of ICU admission, MV, and rate of tracheostomy. Although the higher BMI quartiles had longer hospital LOS, hospital mortality did not significantly differ.

Conclusions

As BMI increases, utilization of medical resources also increases such as ICU admission, MV, longer hospital LOS, and tracheostomy. Although overall BMI interquartile mortality rates do not differ significantly in our study, utilization of valuable and costly hospital resources is a major challenge facing health care delivery. Our findings indicate the need for increased efforts and novel strategies for treatment, prevention, and resource allocation to deal with this emerging challenge.     

Laparoscopic obesity surgery in an Asian Institute: A 10‐year prospective study with review of literature

Objective: Obesity surgery is the most effective treatment for morbid obesity and leads to dramatic improvement in related co‐morbidities. The aim of this study was to present the long‐term results of a prospective trial studying the efficacy of laparoscopic obesity surgery in a group of oriental patients. Method: From April 1998 to March 2009, 2385 patients who underwent obesity surgery in a single bariatric center in Asia were recruited. Various procedures have been adopted so far, including laparoscopic vertical banded gastric partition in 652 patients (27.3%), laparoscopic gastric bypass (LGB) in 1228 patients (51.5%), laparoscopic adjustable gastric banding in 226 patients (9.5%), laparoscopic sleeve gastrectomy in 128 patients (5.4%), gastric balloon in 68 patients (2.8%) and laparoscopic revision surgery in 83 patients (3.5%). We evaluated the clinical data and effect of obesity surgery on different procedures. Results: Overall, the major complication rate and mortality were 1.5% and 0.12%. There was an increase of surgical risk in laparoscopic sleeve gastrectomy and laparoscopic revision surgery patients. The mean total weight loss for the population was 28.1%, 33.9%, 21.3% 18.7% and 17.4% at 1, 3, 5, 7 and 9 years after surgery, respectively. LGB had a better weight loss (30.1%) than that of the restrictive‐type procedures (20.9%) at 5 years after surgery. After surgery, most of the obesity‐associated co‐morbidities were resolved or improved in these patients. Conclusion: Laparoscopic obesity surgery resulted in significant and sustained weight loss in morbidly obese Asian patients with resolution of associated co‐morbidities. LGB had a better result in weight reduction than other restrictive procedures.     

Maximal explosive muscle power in obese and non‐obese prepubertal children

Objective: The objectives of the present study was to compare the maximal explosive muscle power developed by the lower limbs in obese and non‐obese prepubertal children. Design: Twenty‐five obese [mean body mass index (BMI) z‐score: 2·4] and 30 non‐obese (mean BMI z‐score: 0) children aged 8–12 years, participated in this study. Body composition was measured by bioelectrical impedance analysis and the maximal explosive power of the lower limbs was assessed by the Exercise‐Ergometer (a sledge dynamometer). Results: Absolute peak force (F_peak) was higher in obese than in non‐obese children by 18·2% (P<0·001). Peak speed (v_peak) was not significantly different between groups (P = 0·504). Consequently, absolute peak power (W′_peak) was higher in obese than in non‐obese children (+19·3%, P = 0·021). Considering gender differences, absolute F_peak and v_peak were higher in boys than in girls by +12·3 and +17·4% (P<0·05), respectively, thus yielding higher absolute W′_peak values in boys as compared to girls (+26·1%, P<0·001). Finally, W′_peak normalized for fat‐free mass (FFM) was not different between obese and non‐obese children but higher in boys than in girls (+24·5%, P<0·001). Conclusions: Power generation capability per unit of FFM was similar between obese and non‐obese children but was significantly higher in boys than girls. On the clinical practice it seems important to devote supplementary care to sustain and improve the motor function of obese and non‐obese girls.     

Emergency department management of hip fractures: Development of an evidence‐based clinical guideline by literature review and consensus

The Emergency Department at Dandenong Hospital has recently developed an evidence‐based clinical guideline for the emergency department management of hip fractures. This paper will comment on the role of clinical guidelines in the emergency department, discuss the process of the development of evidence‐based guidelines for the care of hip fractures and present the evidence found during the development process. Evidence‐based recommendations for practice are made regarding pulse oximetry and supplemental oxygen, preoperative use of skin traction, thromboembolism prophylaxis, pain management including the use of nerve blocks, pressure area care, the use of indwelling urinary catheters and time to surgical repair.     

The safety of dosing dalteparin based on actual body weight for the treatment of acute venous thromboembolism in obese patients.

Data evaluating the safety of using weight-based low-molecular-weight heparin in the treatment of obese patients with acute venous thromboembolism are limited. The product monograph of dalteparin suggests the maximum dose should be limited to 18,000 U subcutaneously once daily. There are no specific data regarding the risk of recurrence or bleeding in patients given dalteparin in a weight-based dose of 200 IU kg(-1). We report a retrospective chart review of 193 obese patients who weighed more than 90 kg and who received dalteparin at or near to 200 IU kg(-1) actual body weight for 5-7 days for acute venous thromboembolism with 90 day follow-up information. Of the patients, 77% had idiopathic venous thromboembolism, 16% had an underlying malignancy, and 7% had a transient risk factor. Warfarin was initiated within 2 days with a target International Normalized Ratio range of 2.0-3.0. All patients were followed for 12 weeks post diagnosis. Only two patients had a major hemorrhage, 4 and 8 weeks from diagnosis. This study supports the safety of dosing dalteparin based on actual body weight in obese patients.     

Vancomycin dosing in an obese patient with acute renal failure: A case report and review of literature

BACKGROUNDVancomycin is the most commonly used drug for methicillin-resistant Staphylococcus aureus. The empirical clinical doses of vancomycin based on non-obese patients may not be optimal for obese ones.CASE SUMMARYThis study reports a case of vancomycin dosing adjustment in an obese patient (body mass index 78.4 kg/m²) with necrotizing fasciitis of the scrotum and left lower extremity accompanied with acute renal failure. Dosing adjustment was performed based on literature review and factors that influence pharmacokinetic parameters are analyzed. The results of the blood drug concentration monitoring confirmed the successful application of our dosing adjustment strategy in this obese patient. Total body weight is an important consideration for vancomycin administration in obese patients, which affects the volume of distribution and clearance of vancomycin. The alterations of pharmacokinetic parameters dictate that vancomycin should be dose-adjusted when applied to obese patients. At the same time, the pathophysiological status of patients, such as renal function, which also affects the dose adjustment of the patient, should be considered. CONCLUSIONMonitoring vancomycin blood levels in obese patients is critical to help adjust the dosing regimen to ensure that vancomycin concentrations are within the effective therapeutic range and to reduce the incidence of renal injury.     

Gastric cancer after mini‐gastric bypass surgery: A case report and literature review

Gastric cancer in the stomach after Roux‐en‐Y gastric bypass or mini‐gastric bypass is rare, but a few cases have been reported since 1991, when the first case emerged. According to the literature, the interval between bypass surgery and the diagnosis of cancer ranged from 1 to 22 years. Given the difficulty of monitoring a bypassed stomach, the potential for gastric cancer must be considered, especially in countries with high incidence of this cancer. The literature reported the first case in the Asia–Pacific region – a woman developed advanced gastric cancer in her stomach 9 years after laparoscopic mini‐gastric bypass for morbid obesity.     

Impact of physical activity and body composition on heart function and morphology in middle‐aged,abdominally obese women

Several studies have shown training induced morphological changes in the heart. Our aim was to assess how frequent, low‐intensity exercise (walking and cycling) influences heart function and morphology in abdominally obese women. Fifty women with abdominal obesity (mean age 47·0 ± 7·5 years, waist circumference (WC) 103·2 ± 7·8 cm), free of cardiovascular problems were recruited. They were equipped with a bicycle and pedometers and instructed to start commuting in a physically active way for 6 months. Evaluation of cardiac function and morphology was performed using echocardiography (ECHO) before and after 6 months of training. The subjects increased significantly their daily physical activity. After 6 months, there was a significant decrease in WC (from 103·3 ± 7·9 to 100·8 ± 8·4 cm, P = 0·0003), in systolic and diastolic blood pressure (126·8 ± 15·2 to 120·4 ± 14·5 mmHg, P = 0·0001, and 79·8 ± 7·8 to 77·8 ± 8·4 mmHg, P = 0·0006, respectively). ECHO showed an increase in the right ventricular (RV) systolic longitudinal function expressed as tricuspid annular motion from 22·00 ± 3·30 to 23·05 ± 3·59 mm, P = 0·015; and a similar trend in left ventricular (LV) mitral annular motion, which increased from 13·09 ± 1·53 to 13·39 ± 1·47 mm, P = 0·070. Cycling was associated with reductions in LV systolic and RV diastolic dimensions, whereas walking was not associated with any changes in the ECHO‐variables. A reduction in WC by frequent, low‐intensity exercise in abdominally obese women is associated with decrease in blood pressure and improved longitudinal RV systolic function.     

Effect of laparoscopic sleeve gastrectomy on elevated C-reactive protein and atherogenic dyslipidemia in morbidly obese patients

Objectives

To examine the effect of weight loss by laparoscopic sleeve gastrectomy (LSG) on plasma hs-CRP and lipid profiles in morbidly obese patients.

Design and methods

A mean follow-up of 9 months in 37 patients.

Results

A mean weight loss of 35 kg decreased plasma hs-CRP, glucose, HbA1c, triglycerides, cholesterol, non-HDL-cholesterol, and increased HDL-cholesterol. The percentage reduction of BMI was significantly associated with changes in plasma hs-CRP.

Conclusions

Weight loss by LSG improves inflammation and dyslipidemia.