Is There Synergistic Effect Between Obesity and Hypoalbuminemia on Postoperative Outcomes Among Primary Total Shoulder Arthroplasty Recipients?

Background: Malnutrition and obesity are established predictors of complications following joint replacement surgery. However, the effect of obesity in the setting of albumin deficiency has not been explored in non-weight-bearing upper-extremity joint arthroplasty. Purpose: We sought to determine whether there is a synergistic effect between obesity and hypoalbuminemia among patients undergoing primary total shoulder arthroplasty (TSA) with respect to postoperative outcomes, including (1) mortality rates, (2) composite surgical complications, (3) length of hospitalization, and (4) hospital readmission. Methods: We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database to find patients who underwent primary TSA from January 1, 2006, to December 31, 2019. We grouped these patients as obese (body mass index [BMI] ≥ 30 kg/m2) or nonobese (BMI = 18.5-29.9 kg/m2) and by serum albumin level (hypoalbuminemia < 3.5 mg/dL or normoalbuminemia ≥ 3.5 mg/dL). We gathered data on readmission and mortality rates, and NSQIP complications were organized into 3 composite variables: wound infection, systemic infection, and cardiac/pulmonary complication. For each outcome, multivariate logistic regression analysis evaluated its association with obesity and hypoalbuminemia, as well as with the interaction of BMI and albumin, while adjusting for covariates. Results: Of 12,881 patients, 51.8% were obese and 7.0% had hypoalbuminemia; 7.6% of obese patients had hypoalbuminemia versus 6.3% of those who were not obese. Patients with hypoalbuminemia had the longest hospital stays and the highest rates of mortality and systemic infection of all subgroups. Multivariate logistic regression analysis did not show higher complication rates due to obesity or evidence of additive interaction between hypoalbuminemia and obesity. Conclusion: Unlike previous reports in weight-bearing arthroplasty, in this retrospective study of a cohort of patients who underwent TSA, we did not observe greater complications due to obesity alone, nor did we find evidence of additive interaction between obesity and hypoalbuminemia. This distinction may be due to the non-weight-bearing nature of TSA, in which excessive BMI may be less relevant for postoperative healing.

Association between Paravertebral Block and Pain Score at the Time of Hospital Discharge in Oncoplastic Breast Surgery: A Retrospective Cohort Study.

BACKGROUND: Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge. METHODS: The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression. RESULTS: Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001). CONCLUSION: Paravertebral blocks are associated with decreased pain score at the time of hospital discharge. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prevalence of the metabolic syndrome in children with psoriatic disease.

Adults with psoriasis have a greater risk of developing metabolic syndrome (MetS) and cardiovascular disease (CVD), but few studies have investigated the prevalence of MetS and other risk factors for CVD in children with psoriasis. In an assessor-blinded study, 20 children ages 9-17 years with a current or previously documented history of psoriasis involving 5% or more of their body surface area or psoriatic arthritis were compared with a cohort of age- and sex-matched controls with benign nevi, warts, or acne. MetS, our primary endpoint, was defined by the presence of abnormal values in at least three of the following measures: triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), waist circumference, and blood pressure. Secondary endpoints included high-sensitivity C-reactive protein (hs-CRP), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C). Thirty percent (6/20) of children with psoriasis met the criteria for MetS, compared with 5% (1/20) of the control group (p < 0.05). Subjects with psoriasis had higher mean FBG (91.1 mg/dL) than the control group (82.9 mg/dL) (p = 0.01). There were no statistically significant differences in the other four components of MetS, BMI, BMI percentile, hs-CRP, TC, or LDL-C. The results of this trial demonstrate that children with psoriasis have higher rates of MetS than age- and sex-matched controls. It may therefore be important to evaluate children with psoriasis for components of MetS to prevent future CVD morbidity and mortality.

Bone marrow changes in adolescent girls with anorexia nervosa.

Early osteoporosis is common among adolescent girls with anorexia nervosa (AN) and may result from premature conversion of red (RM) to yellow bone marrow. We performed right knee magnetic resonance imaging (MRI) on a 1.0 T extremity scanner in 20 patients and 20 healthy controls, aged 16.2 +/- 1.6 years (mean +/- SD). Coronal T(1)-weighted (T(1)W) images and T(1) maps were generated from T(1) relaxometry images. Blinded radiologists visually assessed RM in the distal femoral and proximal tibial metaphyses in T(1)W images using a scale of signal intensity from 0 (homogeneous hyperintensity, no RM) to 4 (all dark, complete RM). Subjects with AN exhibited nearly twofold lower metaphyseal RM scores in both the femur (0.64 versus 1.22, p = .03) and tibia (0.54 versus 0.96, p = .08). In relaxometric measurements of four selected regions (femur and tibia amd epiphysis and metaphysis), subjects with AN showed higher mean epiphyseal but lower metaphyseal T(1). The net AN-control difference between epiphysis and metaphysis was 70 ms in the femur (+31 versus -35 ms, p = .02) and of smaller magnitude in the tibia. In relaxometry data from the full width of the femur adjacent to the growth plate, AN subjects showed mean T(1) consistently lower than in controls by 30 to 50 ms in virtually every part of the sampling region. These findings suggest that adolescents with AN exhibit premature conversion of hematopoietic to fat cells in the marrow of the peripheral skeleton potentially owing to adipocyte over osteoblast differentiation in the mesenchymal stem cell pool.