Association between neighborhood food environments and bariatric surgery outcomes

BackgroundIndividual characteristics associated with weight loss after bariatric surgery are well established, but the neighborhood characteristics that influence outcomes are unknown.ObjectivesThe objective of this study was to determine if neighborhood characteristics, including social determinants and lifestyle characteristics, were associated with weight loss after bariatric surgery.SettingSingle university healthcare system, United States.MethodsIn this retrospective cohort study, all patients who underwent primary bariatric surgery from 2008 to 2017 and had at least 1 year of follow-up data were included. Patient-level demographics and neighborhood-level social determinants (area deprivation index, urbanicity, and walkability) and lifestyle factors (organic food use, fresh fruit/vegetable consumption, diet to maintain weight, soda consumption, and exercise) were analyzed. Median regression with percent total body weight (%TBW) loss as the outcome was applied to examine factors associated with weight loss after surgery.ResultsOf the 647 patients who met inclusion criteria, the average follow-up period was 3.1 years, and the mean %TBW loss at the follow-up was 22%. In adjusted median regression analyses, Roux-en-Y gastric bypass was associated with greater %TBW loss (11.22%, 95% confidence interval [8.96, 13.48]) compared to sleeve, while longer follow-up time (?2.42% TBW loss per year, 95% confidence interval [?4.63, ?0.20]) and a preoperative diagnosis of diabetes (?1.00% TBW loss, 95% confidence interval [?1.55, ?0.44]) were associated with less. None of the 8 neighborhood level characteristics was associated with weight loss.ConclusionsPatient characteristics rather than neighborhood-level social determinants and lifestyle factors were associated with weight loss after bariatric surgery in our cohort of bariatric surgery patients. Patients from socioeconomically deprived neighborhoods can achieve excellent weight loss after bariatric surgery.     

The role of food and activity environment in a bariatric surgery population: impact on postoperative weight loss

BackgroundFood and activity factors may have an impact on weight in the general population, but little is known about how this affects postbariatric surgery weight loss.ObjectivesTo understand the impact of environmental food and activity factors on weight loss after bariatric surgery.SettingA multidisciplinary integrated health system with an accredited bariatric surgery program.MethodsAn institutional review board–approved retrospective review of patients who underwent bariatric surgery from 2001–2018 was completed. Food security, food retailers, and activity factors associated with postoperative percentage of total body weight loss (TBWL) at short-term (1–2 yr), medium-term (3–5 yr), and long-term (≥6 yr) follow-up were evaluated.ResultsOverall, 1673 patients were included; 90% experienced ≥20% TBWL in the short term and 65% in the long term. No differences in mean TBWL were observed for food deserts or areas with high versus low food insecurity. Mean TBWL was significantly different for low versus high healthy food density (32.5% versus 33.4%, P = .024) and low versus high fitness facility density (32.6% versus 33.4%, P = .048) at short-term follow-up. Increased mean TBWL was observed for counties with more versus less exercise opportunities at short and medium-term follow-up (33.4% versus 32.5%, P = .025; 31.2% versus 29.7%, P = .019).ConclusionPatients experienced significant TBWL after bariatric surgery. Living in a food desert or area with high food insecurity did not significantly impact mean TBWL. Healthy food density, fitness facility density, and exercise opportunities had a short- to medium-term impact on TBWL. These data can be used to support patients to maximize the benefits of bariatric surgery.     

Non-Hispanic Blacks undergoing distal pancreatectomy have higher risk-adjusted rates of morbidity and are more likely to be high-cost outliers

BackgroundFew studies evaluate racial disparities in costs and clinical outcomes for patients undergoing distal pancreatectomy (DP).MethodsWe queried the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing DP. Multivariable regression (MVR) was used to evaluate the association between race and postoperative outcomes.Results2,493 patients underwent DP; 265 (10%) were black, and 221 (8%) were of Hispanic ethnicity. On MVR, black and Hispanic patients were less likely than whites to undergo surgery in high volume centers (OR 0.53, 95% CI [0.40, 0.71]; OR 0.45, 95% CI [0.32, 0.62]). Black patients had a greater risk of postoperative complication (OR 1.40, 95% CI [1.07, 1.83]), 90-day readmission (OR 1.53, 95% CI [1.15, 2.02]), prolonged length of stay (OR 1.74, 95% CI [1.25–2.44]), and of being a high cost outliers (OR 1.40, 95% CI [1.02, 1.91]) compared to white patients.ConclusionBlack patients have increased risk of having a postoperative complication, prolonged hospitalization, and of being a high-cost outlier than non-Hispanic whites.     

Resident participation and postoperative outcomes in adrenal surgery

Background

The changing paradigm of surgical residency training has raised concerns about the effects on the quality of training. The purpose of this study is to identify if resident participation in laparoscopic adrenalectomy (LA) and open adrenalectomy (OA) cases is associated with deleterious outcomes.

Materials and methods

This is a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. Data from patients undergoing LA and OA from 2005 to 2010 were queried. Preoperative variables as well as intra- and post-operative outcomes for each procedure were evaluated. Multivariate logistic regression was used to analyze if resident participation was associated with significant differences in outcomes, compared with no resident participation. Subset analysis was done to determine possible differences in outcomes based on the level of resident participating, divided into junior (Post Graduate Year [PGY]1–3), senior (PGY4–5), or fellow (≥PGY6) levels.

Results

A total of 3219 adrenalectomies were performed. Of these, 735 (22.8%) were OAs and 2484 (77.2%) were LAs. Residents were involved in 2582 (80.2%) surgeries, which comprised 1985 (76.9%) LAs and 597 (23.1%) OAs. Senior residents or fellows performed majority of the cases (85.2%). Mean operative time was significantly higher with resident participation in LA (P < 0.0001) and OA group (P < 0.0001). On multivariate analysis, resident participation was not associated with significant differences in the operative outcomes of 30-d mortality or postoperative complications after laparoscopic or OA.

Conclusions

Although resident participation does increase operative time in LA and OA, this does not appear to be clinically significant and does not result in adverse patient outcomes.     

右美托咪定对甲状腺手术患者呛咳反应的影响

目的探讨右美托咪定对甲状腺手术患者呛咳反应的影响。方法择期全麻下甲状腺肿瘤手术患者118例,男43例,女75例,年龄18~65岁,BMI 18~30kg/m2,ASAⅠ或Ⅱ级,采用随机数字表法分为两组,每组59例。D组在手术开始时持续静脉泵注右美托咪定0.4μg·kg~(-1)·h~(-1)至手术结束,C组在手术开始时持续静脉泵注等容量生理盐水至手术结束。观察患者全麻恢复期间呛咳发生情况,记录患者术后24、48h引流量,以及心动过速、低血压、高血压、心动过缓等不良反应的发生情况。结果 D组全麻恢复期间呛咳发生率明显低于C组(10.1%vs 30.5%,P0.05),D组术后第1个24h[(62.3±26.8)ml vs(78.6±30.1)ml,P0.05]、第2个24h[(28.0±12.5)ml vs(37.5±18.6)ml,P0.05]引流量明显少于C组;D组围术期心动过速发生率明显低于C组(3.4%vs 23.7%,P0.05)。结论术中持续输注右美托咪定0.4μg·kg-1·h-1能够有效减轻甲状腺手术患者全麻恢复期间的呛咳反应,降低患者术后出血的风险。     

The BARI-hoods Project: neighborhood social determinants of health and postoperative weight loss using integrated electronic health record,census, and county data

BackgroundWhile social determinants of health (SDoH) have gained attention for their role in weight loss following bariatric surgery, electronic health record (EHR) data provide limited information beyond demographics associated with disparities in weight loss.ObjectiveTo integrate EHR, census, and county data to explore disparities in SDoH and weight loss among patients in the largest populous county of Ohio.SettingSeven hundred seventy-two patients (82.1% female; 37.0% Black) who had primary bariatric surgery (48.7% gastric bypass) from 2015 to 2019 at Ohio State University.MethodsEHR variables included race, insurance, procedure, and percent total weight lost (%TWL) at 2/3, 6, 12, and 24 months. Census variables included poverty and unemployment rates. County variables included food stores, fitness/recreational facilities, and open area within a 5- and 10-minute walk from home. Two mixed multilevel models were conducted with %TWL over 24 months, with visits as the between-subjects factor; race, census, county, insurance, and procedure variables were covariates. Two additional sets of models determined within-group differences for Black and White patients.ResultsAccess to more food stores within a 10-minute walk was associated with greater %TWL over 24 months (P = .029). Black patients with access to more food stores within a 10-minute (P = .017) and White patients with more access within a 5-minute walk (P = .015) had greater %TWL over 24 months. Black patients who lived in areas with higher poverty rates (P = .036) experienced greater %TWL over 24 months. No significant differences were found for unemployment rate or proximity to fitness/recreational facilities and open areas.ConclusionsClose proximity to food stores is associated with better weight loss 2 years after bariatric surgery. Lower poverty levels did not negatively affect weight loss in Black patients.     

听力减退与全麻腹部手术患者术后谵妄的相关性

目的探讨听力减退与全麻腹部手术患者术后谵妄(POD)的相关性,同时评价听力减退对POD的早期预测价值。方法本研究设计为单中心、前瞻性、观察性队列研究。选择2019年1—6月择期行全麻腹部手术患者119例,男80例,女39例,年龄65～86岁,BMI 14～32 kg/m~2,ASAⅠ—Ⅲ级。术前1 d采用纯音测听进行听阈测试。术后2 h及术后1～3 d每天2次(上午和下午各1次,2次间隔时间6 h)采用意识模糊评估量表(CAM)评估POD的发生情况。根据术后3 d内POD发生与否分为两组:谵妄组(POD组)和非谵妄组(NPOD组)。记录患者一般临床资料、手术麻醉相关资料、听阈测试结果和POD的发生情况。结果共29例(24.4%)患者发生POD。与NPOD组比较,POD组听阈明显升高(P0.001)。多因素Logistic回归分析结果显示,听阈每增高1 dB,POD发生风险明显增高(OR=1.072,95%CI 1.022～1.124,P=0.004)。听阈预测POD的ROC曲线下面积为0.771,临界值为27 dB,敏感性为89.7%,特异性为57.8%(P0.001)。结论听力减退是全麻腹部手术患者POD发生的独立危险因素之一,听阈27 dB对POD可能具有一定的预测价值。     

衰弱量表与衰弱表型评估对老年髋部骨折患者术后转归的预测作用

目的 比较衰弱量表与衰弱表型评估对老年髋部骨折患者术后转归的预测作用。
方法 2019年9月至2020年1月髋部骨折患者120例,男65例,女55例,年龄≥65岁,术前1 d分别采用衰弱量表和衰弱表型完成衰弱评估,依据两个量表各自评估的结果将患者分为：非衰弱期、衰弱前期和衰弱期,通过κ检验比较两种方法的一致性,并通过χ2检验确定衰弱与术后转归各项指标之间的关系。
结果 采用衰弱量表和衰弱表型检出老年髋部骨折患者术前衰弱期的比例分别为15.0%、22.5%,一致性检验κ值为0.55（95%CI 0.42～0.67）。根据衰弱量表评估结果,衰弱期患者术后总并发症（RR=4.5,95%CI 0.9～21.5）、术后住院时间超过5 d（RR=3.5,95%CI 1.0～12.2）和PACU停留时间超过60 min（RR=6.9,95%CI 1.2～40.1）的发生风险明显高于非衰弱期患者,衰弱前期患者术后住院时间超过5 d的发生风险明显高于非衰弱期患者（RR=2.7,95%CI 1.0～7.0）。根据衰弱表型评估结果,衰弱前期患者术后总并发症的发生风险明显高于非衰弱期患者（RR=4.7,95%CI 1.0～22.9）,衰弱期患者PACU停留时间超过60 min的发生风险明显高于非衰弱期患者（RR=5.3,95%CI 1.0～28.6）。
结论 衰弱量表和衰弱表型作为老年髋部骨折术前衰弱评估工具,两者评估一致性中等,其中衰弱量表在预测术后转归方面更具优势。     

Halving the usage of rigid-soled postoperative shoes does not affect outcomes in forefoot reconstruction surgery

BackgroundPostoperative shoes are commonly used after forefoot surgery. This study’s aim was to demonstrate that reducing rigid-soled shoe time to 3 weeks neither compromises functional outcomes nor does it produce complications.MethodsProspective cohort study: 6 weeks versus 3 weeks of rigid postoperative shoe (100 and 96 patients respectively), after forefoot surgery with stable osteotomies. Manchester-Oxford Foot Questionnaire (MOXFQ) and pain Visual Analog Scale (VAS) were studied preoperative and one year postoperative. Radiological angles were also assessed after removing the rigid shoe and at 6 months.ResultsThe MOXFQ index and pain VAS depicted similar results in each group (group A: 29.8 and 25.7; group B: 32.7 and 23.7) with no differences between them (p = .43 Vs. p = .58). Moreover, no differences were reported in their differential angles (HV differential-angle p = .44, IM differential-angle p = .18) or in their complication rate.ConclusionIn forefoot surgery with stable osteotomies, shortening the postoperative shoe time to 3 weeks, neither impairs clinical results nor the initial correction angle.     

The emergency surgery score (ESS) and outcomes in elderly patients undergoing emergency laparotomy: A post-hoc analysis of an EAST multicenter study

IntroductionWe sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL).MethodsThis is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65–74, 75–84, ≥85 years old).Results715 patients were included, of which 52% were 65–74, 34% were 75–84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%–60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65–74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively).ConclusionESS is an accurate predictor of outcome in the elderly EL patient 65–85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.     

围术期电针刺激对妇科腹腔镜手术患者术后早期恢复质量的影响

目的 探讨围术期电针刺激对妇科腹腔镜手术患者术后早期恢复质量的影响。方法选择择期行妇科腹腔镜手术的患者49例,年龄20～60岁,BMI 18～32 kg/m²,ASAⅠ或Ⅱ级。将患者随机分为两组：电针刺激组(EA组,n=25)和假电针刺激组(C组,n=24)。入室后EA组电针针刺中脘穴(CV12)、双侧内关穴(PC6)和合谷穴(LI4);C组电针针刺相应穴位旁2 cm处。电针预刺激20 min后开始麻醉诱导,手术野消毒前撤去两组CV12穴位电针,保留双侧PC6、LI4穴位电针持续电刺激至麻醉苏醒。记录术前1 d、术后1 d的40项恢复质量评分(QoR-40)、空腹血糖(FBG)、胰岛素(INS)浓度,并计算胰岛素抵抗指数(HOMA2-IRI),记录术后1 d疼痛视觉模拟评分(VAS)最高分、术后恶心呕吐(PONV)评分、补救镇痛和止吐治疗例数。结果 与术前1 d比较,术后1 d C组QoR-40量表中情绪状态、身体舒适度、自理能力、疼痛评分及总评分均明显降低,FBG、INS和HOMA2-IRI均明显升高,术后1 d EA组QoR-40量表中身体舒适度、自理能力、疼...     

Patient-reported allergies predict postoperative outcomes and psychosomatic markers after spine surgery

Background Context

Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes.

The “weekend effect” in pediatric surgery — increased mortality for children undergoing urgent surgery during the weekend

Background

For a number of pediatric and adult conditions, morbidity and mortality are increased when patients present to the hospital on a weekend compared to weekdays. The objective of this study was to compare pediatric surgical outcomes following weekend versus weekday procedures.

Methods

Using the Nationwide Inpatient Sample and the Kids’ Inpatient Database, we identified 439,457 pediatric (< 18 years old) admissions from 1988 to 2010 that required a selected index surgical procedure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were compared using logistic regression models that adjusted for patient and hospital characteristics as well as procedure performed.

Results

Patient characteristics of those admitted on the weekend (n = 112,064) and weekday (n = 327,393) were similar, though patients admitted on the weekend were more likely to be coded as emergent (61% versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were more likely to die (OR 1.63, 95% CI 1.21–2.20), receive a blood transfusion despite similar rates of intraoperative hemorrhage (OR 1.15, 95% CI 1.01–1.26), and suffer from procedural complications (OR 1.40, 95% CI 1.14–1.74).

Conclusion

Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of systems-based deficiencies that may be detrimental to pediatric surgical care.     

小儿和成人整形外科手术后早期低氧血症

７００例施择期整形外科手术的病人，在麻醉恢复室用脉搏氧饱和度仪持续监测ＳｐＯ２，以观察年龄对术后早期低氧血症的影响。根据年龄将病人分成四组：Ⅰ组为年龄小于１岁的婴儿；Ⅱ组为年龄１～３岁的幼儿；Ⅲ组为年龄大于３岁的儿童；Ⅳ组为年龄１８～５８岁的成人。结果发现年龄愈小，手术后早期的ＳｐＯ２愈低，低氧血症的发生率愈高。到达麻醉恢复室后，Ⅰ、Ⅱ、Ⅲ、Ⅳ组病人的低氧血症发生率分别为４４．４％、３１．７％、１７．３％和８．３％。婴儿的低氧血症主要发生在术后４０分钟内，而１岁以上小儿和成人则主要发生在术后１５分钟内。     

Transdermal scopolamine patch in addition to ondansetron for postoperative nausea and vomiting prophylaxis in patients undergoing ambulatory cosmetic surgery

Study ObjectiveTo determine the efficacy of transdermal scopolamine in addition to ondansetron in decreasing the incidence of postoperative nausea and vomiting (PONV).DesignRandomized controlled trial.SettingAcademic hospital.Patients126 ASA physical status I and II patients undergoing outpatient plastic surgery with three or more risk factors for PONV.InterventionsPatients were randomly assigned to one of two groups to receive (Group 1) a transdermal scopolamine (TDS) patch or (Group 2), a placebo patch two hours before surgery.MeasurementsOccurrence of vomiting, severity of nausea using a visual analog scale (VAS), rescue medication, pain intensity and pain medications, and side effects were recorded every hour until discharge from hospital, then every 4 hours thereafter for a total of 24 hours.Main ResultsA statistically significant reduction in postoperative nausea between 8 and 24 hours in patients receiving TDS was noted.ConclusionsTransdermal scopolamine in addition to ondansetron benefits patients at high risk for PONV undergoing outpatient plastic surgery for up to 20 hours after surgery.     

不同剂量羟考酮对妇科腹腔镜术后疼痛及应激反应的影响

目的观察不同剂量羟考酮对妇科腹腔镜术后疼痛及应激反应的影响。方法择期行妇科腹腔镜手术患者60例,年龄18~50岁,随机均分为三组,每组20例。手术结束前15 min,C组静脉注射生理盐水5 ml,L组静脉注射羟考酮0.05 mg/kg,H组静脉注射羟考酮0.1 mg/kg。采用VAS评分和改良镇静-躁动评分(RASS)评价患者术后1、6、12、24 h的疼痛和镇静程度。于麻醉前、术后6、12、24 h测定血清中血糖和皮质醇水平。记录追加哌替啶及不良反应情况。结果 L组和H组在术后1 h的VAS评分明显低于C组(P0.05);H组在术后6 h的VAS评分明显低于C组和L组(P0.05)。L组和H组在术后1 h的RASS评分明显低于C组(P0.05)。与麻醉前比较,术后6、12、24 h三组血糖和血清皮质醇水平明显升高(P0.05)。L组和H组术后6、12 h血糖和血清皮质醇水平明显低于C组(P0.05)。三组无一例躁动、瘙痒和呼吸抑制,但均有1例(5%)恶心呕吐和头晕,组间差异无统计学意义。L组和H组术后均有2例(10%)追加哌替啶,明显少于C组的8例(40%)(P0.05)。结论术毕前静脉注射羟考酮0.1 mg/kg,可有效缓解妇科腹腔镜术后疼痛,术后应激反应较轻。