Impact of major co-morbidities on mortality and complications after gastric bypass

BACKGROUND: We hypothesized that major co-morbidities affect survival and complications after gastric bypass. METHODS: A total of 1465 patients undergoing laparoscopic and open gastric bypass between 1995 and 2002 were studied. Patients with a body mass index >or= 35 kg/m(2) and major co-morbidities (group 1, n = 1045) were compared with patients with a body mass index >or= 40 kg/m(2) with minor/no co-morbidities (group 2, n = 420). RESULTS: Group 1 patients were older (43 versus 36 years, P < 0.001) and had a greater BMI (53 versus 50 kg/m(2), P < 0.001). Early postoperative complications were greater in group 1 than in group 2 and included leaks (4.1% versus 1.2%, P < 0.0032) and wound infections (3.9% versus 1.4%, P < 0.0133). Procedure-related mortality in the series was 1.7%. Mortality was 10-fold greater in group 1 (2.3% versus 0.2%, P < 0.0032). The incidence of small bowel obstruction, incisional hernia, and pulmonary embolism was similar in the two groups. Excess weight loss was significantly greater in group 2 (68% versus 62%, P < 0.001) at 1 year. Resolution of group 1 co-morbidities was great, including hypertension in 62%, diabetes in 75%, venous stasis disease in 96%, and pseudotumor cerebri in 98%. CONCLUSION: Outcomes analysis of obesity surgery requires risk stratification. The very low mortality rates in published studies are likely explained by surgical treatment of low-risk patients with minor co-morbidities, such as those seen in group 2. However, despite the increased perioperative risk, the group 1 patients (with major co-morbidities) demonstrated dramatic resolution of their co-morbid conditions, justifying the decision to go forward with surgery. The data support a radical change in treatment philosophy in which morbidly obese individuals should be offered bariatric surgery before major co-morbid conditions develop as a strategy to decrease the operative risk.     

Asthma and subjective sleep disordered breathing in a large cohort of urban adolescents

Objective: Sleep disordered breathing (SDB) has not been well studied in urban adolescents with asthma in community settings. Nor has the association of SDB symptoms and asthma severity been studied. We characterized self-reported symptoms suggesting SDB and investigated the association of SDB symptoms, probable asthma, and asthma severity. Methods: 9,565 adolescents from 21 inner-city high schools were screened for an asthma intervention study. Students reported on symptoms suggesting SDB using questions from the 2007 NHANES, if they were ever diagnosed with asthma, and on asthma symptoms. Using generalized linear mixed models with logit link with school as a random intercept and adjusting for age, gender, and race/ethnicity, we examined associations of SDB symptoms, and demographic characteristics, probable asthma, and asthma severity. Results: 12% reported SDB symptoms. Older and bi-racial participants (compared to Caucasian) had higher odds of symptoms suggesting SDB (p <.001). Compared to those without probable asthma, adolescents with probable asthma had 2.63 greater odds of reporting SDB symptoms (p <.001). Among those with probable asthma, the odds of reporting SDB symptoms increased with asthma severity. When exploring daytime severity and severity due to night wakening separately, results were similar. All results remained significant when controlling for age, gender, and ethnicity. Conclusions: In a large urban community cohort of predominately ethnic minority adolescents, self-reported SDB symptoms were associated with probable asthma and increased asthma severity. This study highlights the importance of SDB as a modifiable co-morbidity of asthma.     

Limitations in the inter-observer reliability of EuroSCORE: what should change in EuroSCORE II?

Objectives: To carry out an in-depth single-centre analysis of the inter-observer reliability of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) to propose changes for the EuroSCORE II. Methods: Data for the EuroSCORE additive and logistic models were prospectively collected by surgeons (computer-assisted calculation) (SurgAE and SurgLE) and perfusionists (on A4 data collection forms; PerfAE) for 1719 consecutive adult heart operations. The performance of the EuroSCORE was first analysed, then inter-observer discrepancies in the score were assessed globally and for any of its 17 risk factors. Results: Hospital mortality was 4.3% (SurgAE and SurgLE: 5.3 and 7.3, respectively). The predictive ability and the calibration of the score were acceptable (area under the receiver operating characteristics curve: 0.75 for SurgAE and 0.753 for SurgLE, p = 0.98, Hosmer and Lemeshow goodness-of-fit test). Overall inter-observer concordance was satisfactory (Kappa coefficient: 0.71) but SurgAE and PerfAE were different in 26.3% of cases (SurgAE > PerfAE in 18.6%, and PerfAE > SurgAE in 7.7%). Five of the 17 risk factors accounted for most of the variability: left-ventricular ejection fraction, extracardiac arteriopathy, surgery other than isolated coronary artery bypass graft, recent myocardial infarction and pulmonary hypertension (with discrepancies respectively noticed in 7.6%, 5.3%, 5%, 3.9% and 3% of cases). Encoding mismatches for EuroSCORE items have been either assigned to human errors related to interpretation or conflicting information in the charts. Both situations may reflect structural weaknesses of the EuroSCORE. Conclusions: The EuroSCORE is a widely used score, but its predictive power and reliability are declining due to changes in cardiac surgery case mix and outcomes in recent years. The present work highlights the fact that the encoding system in the EuroSCORE still gives room for interpretation. Along with other possible modifications described elsewhere, it is suggested that reliability and predicting ability of the score might be increased by changes in some definitions of risk factors and by the use of numeric values instead of intervals of values.     

Mortality profile after 2 years of hip fractures in elderly patients treated with early surgery

BackgroundIn geriatric age group, hip fractures tend to become a major public health hazard. Due to this high occurrence, there is a need to develop standardized, effective, and multidisciplinary management for treatment. These elderly patients have excessive mortality that can extend ahead of the time of recovery. Early surgery after hip fractures has lead to a notable reduction in mortality rates. Still, it is considerably high as compared to other fractures.Methods266 patients of >65 years who were operated within 72 h hours in a tertiary level health care centre for hip fractures were included. They were evaluated with X-rays and grade of Singh’s index was noted. Mortality rates and the factors associated with it such as age, sex, co morbidities (using Charlson’s co morbidity Index/CCI) were evaluated after 2 year follow up.ResultsThe overall 2-year mortality reported in our study population was 11.2%. It was broadly lower as compared to most of the other studies. It was 6.3% in females as compared to 18.1% in males. While it was reported to be only 6% in 65–74 years of age, it was 25% in patients who were 85 years and above. 76.6% of the patients had Singh’s index of ≤ grade 3 showing osteoporosis. The patients with Low Charlson’s score showed only 4.2% mortality while those with high Charlson’s score showed 25.5% mortality.ConclusionIt was concluded that Mortality among elderly patients after early surgery after osteoporotic hip fractures is quite significant. The factors for improvement in long term survival post-hip fracture may include changing treatment patterns, increasing life expectancy and early surgery. Increase in age, female sex, and high CCI Scores were major risk factors of mortality after hip fractures in a 2-year follow-up period.     

Comparison of the ACC/AHA and Framingham algorithms to assess cardiovascular risk in HIV-infected patients

The aim of this study was to compare the predictions of Framingham cardiovascular (CV) risk score (FRS) and the American College of Cardiology/American Heart Association (ACC/AHA) risk score in an HIV outpatient clinic in the city of Vitoria, Espirito Santo, Brazil. In a cross-sectional study 341 HIV infected patients over 40 years old consecutively recruited were interviewed. Cohen's kappa coefficient was used to assess agreement between the two algorithms. 61.3% were stratified as low risk by Framingham score, compared with 54% by ACC/AHA score (Spearman correlation 0.845; p < 0.000). Only 26.1% were classified as cardiovascular high risk by Framingham compared to 46% by ACC/AHA score (Kappa = 0.745; p < 0.039). Only one out of eight patients had cardiovascular high risk by Framingham at the time of a myocardial infarction event registered up to five years before the study period. Both cardiovascular risk scores but especially Framingham underestimated high-risk patients in this HIV-infected population.     

Major comorbid disease processes associated with increased incidence of acute kidney injury

Acute kidney injury (AKI) is commonly seen amongst critically ill and hospitalized patients. Individuals with certain co-morbid diseases have an increased risk of developing AKI. Thus, recognizing the co-morbidities that predispose patients to AKI is important in AKI prevention and treatment. Some of the most common co-morbid disease processes that increase the risk of AKI are diabetes, cancer, cardiac surgery and human immunodeficiency virus (HIV) acquired immune deficiency syndrome (AIDS). This review article identifies the increased risk of acquiring AKI with given co-morbid diseases. Furthermore, the pathophysiological mechanisms underlying AKI in relation to co-morbid diseases are discussed to understand how the risk of acquiring AKI is increased. This paper reviews the effects of various co-morbid diseases including: Diabetes, cancer, cardiovascular disease and HIV AIDS, which all exhibit a significant increased risk of developing AKI. Amongst these co-morbid diseases, inflammation, the use of nephrotoxic agents, and hypoperfusion to the kidneys have been shown to be major pathological processes that predisposes individuals to AKI. The pathogenesis of kidney injury is complex, however, effective treatment of the co-morbid disease processes may reduce its risk. Therefore, improved management of co-morbid diseases may prevent some of the underlying pathology that contributes to the increased risk of developing AKI.     

COPD Recent Findings: Impact on Clinical Practice

ABSTRACT

Chronic obstructive pulmonary disease is now considered as a systemic disease originating in the lungs. The natural history of this disease reveals numerous extrapulmonary manifestations and co-morbidity factors that complicate the evolution of COPD. Recent publications have documented these systemic manifestations and co-morbidities and clarified somewhat the role of muscle dysfunction, nutritional anomalies, endocrine dysfunction, anaemia, osteoporosis and cardiovascular and metabolic disorders as well as lung cancer and psychological elements in this complex disease. Importantly, recent studies have shown that effort intolerance, exertional desaturation, loss of autonomy and reduced physical activity, loss of muscle mass and quadriceps strength as well as dyspnoea and impaired quality of life can be considered as independent predictive factors for survival in COPD. Use of these data may advance understanding of mechanisms; improve evaluation and thereby patient management in COPD.     

Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?

Background

Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity.