Image-guided high-dose-rate brachytherapy as the method of choice in medically inoperable early-stage endometrial cancer patients.

PURPOSE: About 3-9% of patients with endometrial cancer are unable to undergo surgery due to medical comorbidities, including morbid obesity, or age-related frailty syndrome. An alternative curative option is irradiation. The aim of this prospective study was to evaluate clinical outcomes of high-dose-rate intracavitary brachytherapy (HDR-ICBT) treatment in such patients. MATERIALS AND METHODS: Seventy-eight patients with FIGO stage I-II endometrial cancer disqualified from surgery were treated with HDR-ICBT with 45-52,5 Gy prescribed to high-risk clinical target volume (HR-CTV) in 5-9 fractions given once a week. All fractions were planned using computed tomography (CT) scans. RESULTS: The median follow-up time was 67 months. Median age was 79 years (range: 42-93 years). Median body mass index (BMI) was 39,1 kg/m2 (range: 24,2-68 kg/m2). We observed no statistically significant impact of BMI ≥ 40 on overall survival (OS) or prgression free survival (PFS). The 3- and 5-year OS for the whole population were 69% and 55%, respectively. The impact of high risk features (FIGO II, grade 3 or type 2 cancer) on OS was significant (p = 0,049). The 5-year cumulative incidence of local failure, distant metastases and non-cancer death were 12,9% [95% CI: 5,4%-20,5%], 6,4% [95% CI: 0,9%-11,9%], 33,1% [95% CI: 22,3%-43,9%], respectively. The 5-year risk of cancer and non-cancer death were 9% (95% CI: 3%-16%) and 36% (95% CI: 25%-47%), respectively. We observed G1 vaginal apex stenosis only. CONCLUSIONS: CT-guided HDR-ICBT is a feasible and safe management of FIGO stage I endometrial cancer in obese and elderly patients. The survival outcome of the treated group is influenced more by associated comorbidities than by the progression of endometrial cancer.

Links between gut microbiome, metabolome, clinical variables and non-alcoholic fatty liver disease severity in bariatric patients.

BACKGROUND AND AIMS: Bacterial species and microbial pathways along with metabolites and clinical parameters may interact to contribute to non-alcoholic fatty liver disease (NAFLD) and disease severity. We used integrated machine learning models and a cross-validation approach to assess this interaction in bariatric patients. METHODS: 113 patients undergoing bariatric surgery had clinical and biochemical parameters, blood and stool metabolite measurements as well as faecal shotgun metagenome sequencing to profile the intestinal microbiome. Liver histology was classified as normal liver obese (NLO; n = 30), simple steatosis (SS; n = 41) or non-alcoholic steatohepatitis (NASH; n = 42); fibrosis was graded F0 to F4. RESULTS: We found that those with NASH versus NLO had an increase in potentially harmful E. coli, a reduction of potentially beneficial Alistipes putredinis and an increase in ALT and AST. There was higher serum glucose, faecal 3-(3-hydroxyphenyl)-3-hydroxypropionic acid and faecal cholic acid and lower serum glycerophospholipids. In NAFLD, those with severe fibrosis (F3-F4) versus F0 had lower abundance of anti-inflammatory species (Eubacterium ventriosum, Alistipes finegoldii and Bacteroides dorei) and higher AST, serum glucose, faecal acylcarnitines, serum isoleucine and homocysteine as well as lower serum glycerophospholipids. Pathways involved with amino acid biosynthesis and degradation were significantly more represented in those with NASH compared to NLO, with severe fibrosis having an overall stronger significant association with Superpathway of menaquinol-10 biosynthesis and Peptidoglycan biosynthesis IV. CONCLUSIONS: In bariatric patients, NASH and severe fibrosis were associated with specific bacterial species, metabolic pathways and metabolites that may contribute to NAFLD pathogenesis and disease severity.

Readability of American Society of Metabolic Surgery's Patient Information Publications.

INTRODUCTION: Appropriate education and information are the keystones of patient autonomy. Surgical societies support this goal through online informational publications. Despite these recommendations, many of these sources do not provide the appropriate level of reading for the average patient. Multiple national organizations, including the AMA and NIH, have recommended that such materials be written at or below a 6th-grade level. We therefore aimed to evaluate the readability of patient information publications provided by the American Society of Metabolic and Bariatric Surgery (ASMBS). METHODS: Patient information publications were collected from the ASMBS webpage (https://asmbs.org/patients) and evaluated for readability. Microsoft Office was utilized to calculate Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) scores. Flesch Reading Ease (FRE) is a 0-100 score, with higher scores equating to easier reading (≥80 = 6th-grade reading level). Flesch-Kincaid Grade Level (FKGL) rates text on a US grade school level. Qualitative and univariate analyses were performed. RESULTS: Eleven patient information publications were evaluated. None of the publications achieved an FRE score of 80 or an FKGL of a 6th-grade reading level. The average FRE score was 35.8 (range 14.9-53.6). The average FKGL score was 13.1 (range 10.1-17.5). The publication with the highest FRE and lowest FKGL (best readability) was that for benefits of weight loss. The brochure with the lowest FRE and highest FKGL (worst readability) was that for Medical Tourism. CONCLUSIONS: Although the ASMBS patient information publications are a trusted source of patient literature, none of the 11 publications met the recommended criteria for patient readability. Further refinement of these will be needed to provide the appropriate reading level for the average patient.

Documentation of the Patient Characteristics Morbid Obesity and Bariatric Surgery in the Hospital Information System and the Influence on the Number of Medication-Related Problems.

BACKGROUND: As a result of pharmacokinetic changes, individuals with morbid obesity and/or with bariatric surgery may require dose adjustments, additional monitoring or medication should be avoided. Clinical decision support (CDS) may provide automated alerts enabling correct prescribing but requires documentation of these patient characteristics in the Hospital Information System (HIS) to prevent medication-related problems (MRPs). OBJECTIVE: The primary objective is to determine the proportion of patients with documentation of the patient characteristics morbid obesity and bariatric surgery in the HIS. The secondary objective is to compare the proportion of patients with an MRP in the group with versus without documentation. Also, the type and severity of MRPs and the medication involved are determined. METHODS: A prospective cohort study was performed. Patients admitted to the hospital were identified as morbidly obese and/or with bariatric surgery. In the identified patients, the proportion of patients with documentation of the patient characteristics in the HIS was evaluated as primary outcome. Subsequently, patient records were reviewed for MRPs, which were categorized and associated medication was registered. For the primary objective, descriptive statistics was used. For the secondary outcome, the Fisher's exact test was used. RESULTS: In 43 (21.4%, 95% confidence interval [CI]: 15.7%-27.1%) of 201 included patient (113 morbid obesity, 70 bariatric surgery and 18 both), the patient characteristics were documented. An MRP occurred in 2.3% versus 13.9% (P = 0.032) of patients with and without documentation, respectively. The most common MRP was underdosing in morbid obesity, while in patients with bariatric surgery it was prescription of contra-indicated medication. CONCLUSION AND RELEVANCE: The proportion of patients with documentation of the patient characteristics bariatric surgery and/or morbid obesity in the HIS is low, which appears to be associated with more MRPs. To improve medication safety, it is important to document these patient characteristics.

The association between obesity severity and food reward in adolescents with obesity: a one-stage individual participant data meta-analysis.

BACKGROUND: Food reward and cue reactivity have been linked prospectively to problematic eating behaviours and excess weight gain in adults and children. However, evidence to date in support of an association between degree of adiposity and food reward is tenuous. A non-linear relationship between reward sensitivity and obesity degree has been previously proposed, suggesting a peak is reached in mild obesity and decreases in more severe obesity in a quadratic fashion. OBJECTIVE: To investigate and characterise in detail the relationship between obesity severity, body composition, and explicit and implicit food reward in adolescents with obesity. METHODS: Data from seven clinical trials in adolescents with obesity were aggregated and analysed in an independent participant data meta-analysis. Linear and curvilinear relationships between the degree of obesity and explicit and implicit reward for sweet and high fat foods were tested in fasted and fed states with BMI-z score as a continuous and discrete predictor using clinically recognised partitions. RESULTS: Although positive associations between obesity severity and preference for high-fat (i.e. energy dense) foods were observed when fasted, none reached significance in either analysis. Conversely, adiposity was reliably associated with lower reward for sweet, particularly when measured as implicit wanting (p = 0.012, ηp2 = 0.06), independent of metabolic state. However, this significant association was only observed in the linear model. Fat distribution was consistently associated with explicit and implicit preference for high-fat foods. CONCLUSIONS: A limited relationship was demonstrated between obesity severity and food reward in adolescents, although a lower preference for sweet could be a signal of severe obesity in a linear trend. Obesity is likely a heterogenous condition associated with multiple potential phenotypes, which metrics of body composition may help define. CLINICAL TRIAL REGISTRATIONS: NCT02925572: https://classic. CLINICALTRIALS: gov/ct2/show/NCT02925572 . NCT03807609: https://classic. CLINICALTRIALS: gov/ct2/show/NCT03807609 . NCT03742622: https://classic. CLINICALTRIALS: gov/ct2/show/NCT03742622 . NCT03967782: https://classic. CLINICALTRIALS: gov/ct2/show/NCT03967782 . NCT03968458: https://classic. CLINICALTRIALS: gov/ct2/show/NCT03968458 . NCT04739189: https://classic. CLINICALTRIALS: gov/ct2/show/NCT04739189 . NCT05365685: https://www. CLINICALTRIALS: gov/study/NCT05365685?tab=history .

The safety and efficacy of nonvitamin K antagonist oral anticoagulants in morbidly obese patients with atrial fibrillation: a meta-analysis.

BACKGROUND AND AIM: Atrial fibrillation (AF) is the most frequently observed cardiac arrhythmia in clinical settings. Obesity can influence the efficacy of the treatment administered, which requires a larger dose and more time to accomplish therapeutic targets due to altered pathophysiology. Our study aimed to assess the overall efficacy and safety of nonvitamin K antagonist oral anticoagulants (NOACs) versus warfarin in AF patients with morbid obesity (BMI > 40 kg/m2 and/or weight > 120 kg) to prevent complications. METHODS: We conducted a literature search on PubMed, Web of Science, the Cochrane Library, and Scopus till October 2022 for articles addressing the efficacy and safety of NOACs versus warfarin for the treatment of AF in morbidly obese patients. We performed the meta-analysis with RevMan software version 5.4 and Open Meta Analyst. The main outcomes assessed were stroke, major bleeding, and minor bleeding after anticoagulation, as did the history of comorbidities and risk factors in morbidly obese patients. Quality assessment was performed using Cochrane's ROB-2 tool and the Newcastle-Ottawa scale. RESULTS: Regarding major bleeding events, pooled data showed that patients taking NOACs had a significantly lower risk than patients taking warfarin (OR = 0.54, 95% CI: [0.41-0.70]; p < 0.00001). However, for minor bleeding, there was a nonsignificant effect of NOACs on reducing the risk of bleeding (OR = 0.72, 95% CI = 0.47-1.09; p = 0.12), which became highly significant in favor of NOACs after sensitivity analysis (OR = 0.55, 95% CI = 0.49-0.61]; p < 0.00001). There was a significant difference in the incidence of stroke between the NOAC group and the warfarin group (OR = 0.69, 95% CI = 0.60-0.80]; p < 0.00001). According to the results of the single-arm study analysis, the overall effect of all the outcomes was associated with a high risk of disease development in patients receiving NOACs. CONCLUSION: Our meta-analysis showed a favorable effect of NOACs vs warfarin in morbidly obese patients. Some outcomes were not significantly different, which calls for future research to better assess their safety and efficacy in this particular weight group. TRIAL REGISTRATION: The study was registered with PROSPERO under registration number CRD42022362493 on October 2022.

Bariatric surgery: trends in utilization, complications, conversions and revisions.

BACKGROUND: Sleeve gastrectomy (SG) increased in popularity after 2010 but recent data suggest it has concerning rates of gastroesophageal reflux and need for conversions. This study aims to evaluate recent trends in the utilization of bariatric procedures, associated complications, and conversions using an administrative claims database in the United States. METHODS: We included adults who had bariatric procedures from 2000 to 2020 with continuous enrollment for at least 6 months in the MarketScan Commercial Claims and Encounters database. Index bariatric procedures and subsequent revisions or conversions were identified using CPT codes. Baseline comorbidities and postoperative complications were identified with ICD-9-CM and ICD-10 codes. Cumulative incidences of complications were estimated at 30-days, 6-months, and 1-year and compared with stabilized inverse probability of treatment weighted Kaplan-Meier analysis. RESULTS: We identified 349,411 bariatric procedures and 5521 conversions or revisions. The sampled SG volume appeared to begin declining in 2018 while Roux-en-Y gastric bypass (RYGB) remained steady. Compared to RYGB, SG was associated with lower 1-year incidence [aHR, (95% CIs)] for 30-days readmission [0.65, (0.64-0.68)], dehydration [0.75, (0.73-0.78)], nausea or vomiting [0.70, (0.69-0.72)], dysphagia [0.55, (0.53-0.57)], and gastrointestinal hemorrhage [0.43, (0.40-0.46)]. Compared to RYGB, SG was associated with higher 1-year incidence [aHR, (95% CIs)] of esophagogastroduodenoscopy [1.13, (1.11-1.15)], heartburn [1.38, (1.28-1.49)], gastritis [4.28, (4.14-4.44)], portal vein thrombosis [3.93, (2.82-5.48)], and hernias of all types [1.36, (1.34-1.39)]. There were more conversions from SG to RYGB than re-sleeving procedures. SG had a significantly lower 1-year incidence of other non-revisional surgical interventions when compared to RYGB. CONCLUSIONS: The overall volume of bariatric procedures within the claims database appeared to be declining over the last 10 years. The decreasing proportion of SG and the increasing proportion of RYGB suggest the specific complications of SG may be driving this trend. Clearly, RYGB should remain an important tool in the bariatric surgeon's armamentarium.

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study.

BACKGROUND: Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy. METHODS: In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n = 59 [gastric bypass surgery n = 26, sleeve gastrectomy n = 31, missing n = 2] and controls n = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17-20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5). RESULTS: The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p = 0.228) or development of gestational diabetes (n = 3 [5%] vs. n = 7 [5%], p = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p = 0.030). CONCLUSION: Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Muscle Strength of Lower Limbs as a Postoperative Predictor in Bariatric Surgery.

OBJECTIVE: The aim of our study was to assess postoperative lower limbs muscle strength (MS) as a predictor of late surgical success (36 months). METHODS: Body composition analyses and isokinetic dynamometry evaluation were performed before (T0: n=123), six months (T1: n=123) and 36 months (T2: n=79) after Roux-en-y gastric bypass (RYGB). Surgical success (SS) was defined as ≥ 50% excess weight loss (EWL) 36 months after surgery or ≤ 50% surgical failure (SF). RESULTS: There was no difference between relative MS extension (Ext) and flexion (Flex) in T1 and T2. There was also, no difference between relative MS Ext and Flex in T1 and T2 between patients with SS and SF. There was a difference in relative MS Ext (144.9 ± 39.8 Nm/kg x 125.5 ± 29.2 Nm/kg; p=0.04) and Flex (73.6 ± 21.8 Nm/kg x 60.4 ± 15.8 Nm/kg; p=0.02) between SS and SF patients only in T2. Patients with an increment in Ext and Flex MS ≥4 Nm/kg at T1 had approximately 76% of SS at 36 months. CONCLUSION: An increase of lower limbs MS ≥4 Nm/kg 6 months after RYGB predicts SS at 36 months. CLINICALTRIALS: gov ID: NCT04129801.

Dosing of 7 + 3 induction chemotherapy in a patient with acute myeloid leukemia (AML) and morbid obesity.

INTRODUCTION: Traditional chemotherapy dosing is based on body surface area (BSA) using standard formulas, which can pose challenges in dosing patients at body weight extremes. Studies suggest that chemotherapy dosing according to actual body weight does not increase toxicity in obese patients and current guidelines recommend full weight-based dosing of chemotherapy regardless of body mass index (BMI). However, the dosing of anthracyclines in obese patients can be challenging given limitations in maximum cumulative dosage, particularly in those at very extreme BMI. In this case, we highlight the difficulties of dosing anthracycline-based induction chemotherapy in a patient with newly diagnosed acute myeloid leukemia (AML) and BMI >90 kg/m2. CASE REPORT: A 40-year-old female with morbid obesity is diagnosed with AML (nucleophosmin 1 (NPMI) and isocitrate dehydrogenase-2 mutated, FMS-like tyrosine kinase 3-Internal tandem duplication negative). MANAGEMENT AND OUTCOME: The patient was initiated on induction therapy with 7 + 3 with dose capping of BSA at 2.75 m2 (cytarabine 200 mg/m2 continuous infusion over 24 h for 7 days, plus daunorubicin 60 mg/m2 slow intravenous push for 3 days), followed by two cycles of high-dose cytarabine consolidation therapy using actual BSA. The patient achieved morphologic complete remission; however, measurable residual disease testing for NPM1 remained positive after induction therapy. DISCUSSION: This case suggests that dose capping of anthracyclines in the treatment of newly diagnosed AML may be an effective and safe treatment alternative in those with extreme BMI elevations beyond what has been studied in the literature. Given the increasing incidence of morbid obesity, further studies are needed to confirm appropriate dosing of anthracycline-based regimens at upper BMI extremes (>60 kg/m2).

Pregnancy following assisted reproductive technology in morbidly obese patients: assessment of feto-maternal outcomes.

PURPOSE: To examine feto-maternal characteristics and outcomes of morbidly obese pregnant patients who conceived with assisted reproductive technology (ART). METHODS: This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 48,365 patients with ART pregnancy from January 2012 to September 2015, including non-obesity (n = 45,125, 93.3%), class I-II obesity (n = 2445, 5.1%), and class III obesity (n = 795, 1.6%). Severe maternal morbidity at delivery per the Centers for Disease and Control Prevention definition was assessed with multivariable binary logistic regression model. RESULTS: Patients in the class III obesity group were more likely to have a hypertensive disorder (adjusted-odds ratio (aOR) 3.03, 95% confidence interval (CI) 2.61-3.52), diabetes mellitus (aOR 3.08, 95%CI 2.64-3.60), large for gestational age neonate (aOR 3.57, 95%CI 2.77-4.60), and intrauterine fetal demise (aOR 2.03, 95%CI 1.05-3.94) compared to those in the non-obesity group. Increased risks of hypertensive disease (aOR 1.35, 95%CI 1.14-1.60) and diabetes mellitus (aOR 1.39, 95%CI 1.17-1.66) in the class III obesity group remained robust even compared to the class I-II obesity group. After controlling for priori selected clinical, pregnancy, and delivery factors, patients with class III obesity were 70% more likely to have severe maternal morbidity at delivery compared to non-obese patients (8.2% vs 4.4%, aOR 1.70, 95%CI 1.30-2.22) whereas those with class I-II obesity were not (4.1% vs 4.4%, aOR 0.87, 95%CI 0.70-1.08). CONCLUSIONS: The results of this national-level analysis in the United States suggested that morbidly obese pregnant patients conceived with ART have increased risks of adverse fetal and maternal outcomes.

The evaluation of bariatric surgery effect on cardiac structure and function using transthoracic echocardiography: a cohort study.

BACKGROUND: Obesity is a pathology and a leading cause of death worldwide. Obesity can harm multiple organs, including the heart. In this study, we aim to investigate the effect of bariatric surgery and following weight loss on cardiac structure and functions using echocardiography parameters in patients with morbid obesity. METHODS: In this cohort study, 30 patients older than 18 with BMI > 40 or BMI > 35 and comorbidity between March 2020 to March 2021 were studied. The patients underwent transthoracic echocardiography before and after six months of the bariatric surgery. RESULTS: In total, 30 patients (28 women, 93.3%) with a mean age of 38.70 ± 9.19 were studied. Nine (30%) were diabetic, and 9 (30%) had hypertension. After six months of bariatric surgery, all physical measurements, including weight, Body mass index, and Body surface area, decreased significantly (p < 0.001). After bariatric surgery, all parameters regarding left ventricular morphology, including left ventricular mass, interventricular septal thickness, left ventricular posterior wall thickness, left ventricular end-systolic diameter, and left ventricular end-diastolic diameter, improved significantly (p < 0.001). Also, LVEF rose post-bariatric surgery (p < 0.001). TAPSE parameter indicating right ventricular function also improved (p < 0.001). Right ventricular diameter, left atrium volume, and mitral inflow E/e' decreased significantly (p < 0.001). CONCLUSION: Systolic and diastolic parameters refine significantly after bariatric surgery in patients with obesity. Bariatric surgery lead to significant cardiac structure and function improvement.

Computed tomography-based gastric volumetry for morbid obesity to assess weight loss and fatty liver change.

BACKGROUND/PURPOSE: Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for patients with morbid obesity, but the optimal gastric volume (GV) for resection remains unclear. Accordingly, we aimed to determine the optimal percentage of excised stomach that could engender significant weight loss and improve fatty liver. METHODS: This prospective study included 63 patients. Computed tomography (CT) scans were performed before and 1 year after LSG to evaluate the gastric lumen (GL) and GV. Specifically, the stomach was distended with effervescent powder, following water-contrast mixture (20:1) and assessed by three-dimensional reconstruction. The correlations of reduced gastric lumen/volume (RGL/RGV) with total body weight (BW) loss and liver-spleen density ratio (LSDR) changes were analyzed, and optimal RGL/RGV associated with significant BW and fatty liver changes were determined. RESULTS: We noted a positive correlation between the percentage of RGV/RGL (%RGV/%RGL) and percentage of total weight loss (%TWL; r = 0.359, p = 0.004 and r = 0.271, p = 0.032). Furthermore, a %RGL value of >78.2% and %RGV value of >75.3% were associated with more significant BW loss than did limited excision (both p < 0.01). On the other hand, LSDR values increased significantly after LSG, corresponding to the improvement of fatty liver disease at %RGL and %RGV values of >59.1% and >56.4% (both p < 0.01), respectively. CONCLUSION: %RGV and %RGL were determined to be factors affecting LSG outcomes. LSG engendered significantly more BW loss when %RGV was >75.3% and resulted in fatty liver disease improvement when %RGV was >56.4%.

Is Morbid Obesity a Modifiable Risk Factor in Patients Who Have Severe Knee Osteoarthritis and do Not Have a Formal Perioperative Optimization Program?

BACKGROUND: Obesity is considered a modifiable risk factor prior to total knee arthroplasty (TKA); however, little data support this hypothesis. Our purpose was to evaluate patients who have a body mass index (BMI) >40 presenting for TKA to determine the incidence of: (1) patients who achieved successful weight loss through nutritional modification or bariatric surgery and (2) patients who underwent TKA over the study period without the presence of a formal optimization program. METHODS: This was a retrospective, single-center analysis. Inclusion criteria included: Kellgren and Lawrence grade 3 or 4 knee osteoarthritis, BMI >40 at presentation, and minimum 1-year follow-up (mean 45 months) (N = 624 patients). Demographics, weight loss interventions, pursuit of TKA, maximum BMI change, and Patient-Reported Outcomes Measurement Information System scores were collected. Multivariable logistic and linear regressions evaluated associations of underlying demographic and treatment characteristics with outcomes. RESULTS: There were 11% of patients who ended up pursuing TKA over the study period. Bariatric surgery was 3.7 times more likely to decrease BMI by minimum 10 compared to nonsurgical intervention (95% confidence interval [CI] [1.7, 8.1]; P = .001). Bariatric surgery resulted in mean BMI change of -3.3 (range, 0 to 22) compared to nonsurgical interventions (-2.6 [range, 0 to 12]) and no intervention (0.4 [range, 0 to 15]; P < .0001). Bariatric surgery patients were 3.1 times more likely to undergo TKA (95% CI [1.3, 7.1]; P = .008), and nonsurgical interventions were 2.4 times more likely to undergo TKA (95% CI [1.3, 4.5]; P = .006) compared to no intervention. Non-White patients across all interventions were less likely to experience loss >5 BMI compared to White patients (95% CI [0.2, 0.9]; P = .018). CONCLUSIONS: Most patients were unable to reduce BMI more than 5 to 10 over a mean 4-year period without a formal weight optimization program. Utilization of bariatric surgery was most successful compared to nonsurgical interventions, although ultimate pursuit of TKA remained low in all cohorts.

Obesity and Primary Total Hip Arthroplasty: The Absolute versus Relative Risk of Periprosthetic Joint Infection at 15 Years.

BACKGROUND: To make an informed decision about total hip arthroplasty (THA), surgeons and patients need to understand the absolute and relative risks of periprosthetic joint infection (PJI). We sought to evaluate the long-term risk of PJI following primary THA stratified by body mass index (BMI) and PJI-related risk factors. METHODS: We identified 21,550 primary THAs performed from 2000 to 2021 at a single institution. Patients were stratified as having 0, 1, or ≥ 2 PJI risk factors (diabetes, chronic kidney disease, nonprimary osteoarthritis, immunosuppression, or active smoking) and into BMI categories. The 15-year cumulative risk of PJI was evaluated by BMI and PJI risk factors. RESULTS: For the entire cohort, the 15-year absolute risk of PJI was 2%. For patients who did not have PJI risk factors, the absolute risk of PJI at 15 years was 1% in normal weight, 2% in class III obesity, and 4% in class IV obesity. Patients who had class III and IV obesity had a 3-times and 9-times higher relative risk of PJI, respectively (P = .03, P < .001). Among patients who had ≥ 2 PJI risk factors, the absolute risk of PJI at 15 years was 2% in normal weight, 4% in class III obesity, and 18% in class IV obesity. CONCLUSIONS: Healthy patients who had class III and IV obesity had a 3-times and 9-times increased risk of PJI at 15 years relative to normal weight patients. However, the absolute risk of PJI at 15 years was 2 and 4%, respectively. Given emerging data questioning whether BMI modification decreases PJI risk, surgeons and patients must consider both a 3-times to 9-times increased relative risk of PJI and a 2 to 4% absolute risk of PJI at 15 years for healthy patients who had a BMI ≥ 40. LEVEL OF EVIDENCE: IV.

The Impact of Obesity on Total Hip Arthroplasty Outcomes When Performed by High-Volume Surgeons-A Propensity Matched Analysis From a High-Volume Urban Center.

BACKGROUND: Previous data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons. METHODS: A retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases. RESULTS: The MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056). CONCLUSIONS: Clinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons. LEVEL OF EVIDENCE: III.

The Use of Aspirin for Venous Thromboembolism Prophylaxis in Patients Who Have Morbid Obesity Undergoing Primary and Revision Total Joint Arthroplasty.

BACKGROUND: Venous thromboembolism (VTE) poses a major clinical concern due to its life-threatening nature, and obese and morbidly obese patients are thought to be at an increased risk for VTE. The aims of this study were twofold; first, to explore VTE rates in patients who have a body mass index (BMI) > 40 undergoing primary and revision total joint arthroplasty, and second, to investigate aspirin (ASA) efficacy and safety. METHODS: We identified all patients (n = 4,672) who had a BMI > 40 who underwent primary and revision total joint arthroplasty from 2016 to 2022 at a single academic tertiary care center. Patients were stratified by BMI groups: 40 to 44.9 (n = 3,462), 45 to 49.9 (n = 935), and 50+ (n = 275). The primary outcome was any VTE event within 90 days postoperatively. The secondary outcome consisted of wound complications within 90 days postoperatively. RESULTS: The total VTE rate was 0.4% (n = 21) and did not differ statistically between the BMI groups (0.4 versus 0.4 versus 0.7%, P = .669). The VTEs consisted of 6 deep venous thromboses (DVTs), 14 pulmonary embolisms, and one concomitant deep venous thrombosis and pulmonary embolism. The VTE rates were not statistically different between patients who received aspirin 325 mg 0.5% (n = 9), aspirin 81 mg 0.2% (n = 1), aspirin + anticoagulant (AC) 0.5% (n = 6), and AC alone 0.4% (n = 5) (P = .954). In addition, wound complications did not differ significantly between patients who received ASA 325 mg, ASA 81mg, ASA + AC, or AC alone (1.6 versus 1.0 versus 1.8 versus 1.1%, P = .351). CONCLUSIONS: The use of aspirin 325 and 81 mg was found to have similar VTE rates as aspirin + ACs and ACs alone, with no significant increase in wound complications. In patients who have a BMI > 40, the use of aspirin is a safe option for VTE prophylaxis and should be prescribed in the context of the patient who has other risk factors for VTE.

Does experience with total knee arthroplasty in morbidly obese patients effect surgical outcomes.

INTRODUCTION: Literature examining the risks, benefits, and potential complications of TKA in morbidly obese patients is conflicting. Surgeons with more experience performing TKA on morbidly obese patients may generate superior outcomes. This study sought to assess whether complication rates and implant survivorship in morbidly obese TKA patients varies between high (HV) and low (LV) volume surgeons. METHODS: A retrospective review was performed to include all morbidly obese (BMI ≥ 40) patients that underwent primary TKA between January 2016 and July 2021 at our high-volume center. Demographics and clinical outcomes were collected and compared between surgeons with a higher morbidly obese TKA volume (> 10 annual cases) and surgeons with a lower morbidly obese TKA volume. RESULTS: A total of 964 patients (HV 91 [9.4%], LV 873 [90.6%]) were identified. The HV surgeon and LV surgeons had an average annual volume of 15.3 and 5.2 cases, respectively. The average BMI for the HV and LV cohorts were 44.5 ± 3.7 and 44.0 ± 3.6, respectively (p = 0.160). The HV surgeon had significantly lower operative times (105.7 ± 17.4 vs. 110.7 ± 29.6 min, p = 0.018), and a lower 90-day minor complication rate (0.0% vs. 4.7%, p = 0.035). For patients with at least 2-year follow-up, all-cause revision (3.4% vs. 12.5%, p = 0.149) and revision due to PJI (0.0% vs. 5.8%, 0.193) rates were numerically lower in the HV cohort. Improvements in KOOS, JR and VR-12 scores were similar at 3-month and 1-year follow-up. Freedom from all-cause revision (HV: 96.6% vs. LV: 80.4%, p = 0.175) and revision due to PJI (HV: 100.0% vs. LV: 93.6%, p = 0.190, p = 0.190) at latest follow-up did not statistically differ between groups. CONCLUSION: The HV surgeon had significantly lower operative time and 90-day minor complication rates and numerically lower all-cause revision and revision due to PJI rates when performing TKA in morbidly obese patients. Surgeon's experience may affect surgical outcomes after TKA in morbidly obese patients. LEVEL OF EVIDENCE: III.

Decreased Hepatic and Serum Levels of IL-10 Concur with Increased Lobular Inflammation in Morbidly Obese Patients.

Background and Objectives: Non-alcoholic fatty liver disease (NAFLD) is associated with obesity and ranges from simple steatosis to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular carcinoma. Accumulating evidence in animal models suggests that loss of interleukin-10 (IL-10) anti-inflammatory actions might contribute to lobular inflammation, considered one of the first steps toward NASH development. However, the role of IL-10 in lobular inflammation remains poorly explored in humans. We examined mRNA and protein levels of IL-10 in liver biopsies and serum samples from morbidly obese patients, investigating the relationship between IL-10 and lobular inflammation degree. Materials and Methods: We prospectively enrolled morbidly obese patients of both sexes, assessing the lobular inflammation grade by the Brunt scoring system to categorize participants into mild (n = 7), moderate (n = 19), or severe (n = 13) lobular inflammation groups. We quantified the hepatic mRNA expression of IL-10 by quantitative polymerase chain reaction and protein IL-10 levels in liver and serum samples by Luminex Assay. We estimated statistical differences by one-way analysis of variance (ANOVA) and Tukey's multiple comparison test. Results: The hepatic expression of IL-10 significantly diminished in patients with severe lobular inflammation compared with the moderate lobular inflammation group (p = 0.01). The hepatic IL-10 protein levels decreased in patients with moderate or severe lobular inflammation compared with the mild lobular inflammation group (p = 0.008 and p = 0.0008, respectively). In circulation, IL-10 also significantly decreased in subjects with moderate or severe lobular inflammation compared with the mild lobular inflammation group (p = 0.005 and p < 0.0001, respectively). Conclusions: In liver biopsies and serum samples of morbidly obese patients, the protein levels of IL-10 progressively decrease as lobular inflammation increases, supporting the hypothesis that lobular inflammation develops because of the loss of the IL-10-mediated anti-inflammatory counterbalance.

Acanthosis nigricans - a potentially useful clue to the presence of significant occult disease at autopsy.

A 19-year-old male was found dead in his apartment. At autopsy he was morbidly obese (Body mass index; BMI - 40.5) with multiple areas of velvety pigmented thickening of the skin in folds around the neck, in the axillae, in the inframammary regions, over the anterior waistline and groin regions and over the dorsal aspects of the feet. These had the typical appearance of acanthosis nigricans. Internal examination revealed aspiration of gastric contents into the airways. Vitreous humour biochemistry showed markedly elevated levels of both glucose (62.9 mmol/L) and ß-hydroxybutyrate (13.54 mmol/L). Death was, therefore, due to aspiration pneumonia complicating diabetic ketoacidosis on a background of morbid obesity. The initial indicator of underlying diabetes, in conjunction with obesity had been acanthosis nigricans.