The impact of duration and severity of obesity exposure on cardiometabolic health.

PURPOSE: Duration and severity of exposure to excess adipose tissue are important risk factors for complications, but are generally not examined in conjunction. We developed a metric considering both factors to examine the relationship between obesity-related complications and parameters of cardiometabolic health in patients undergoing a metabolic bariatric procedure (MBS). MATERIALS & METHODS: Data from patients screened for primary MBS between 2017 and 2021 were analyzed. The Obesity Exposure score (OBES), based on self-reported years of life with a BMI ≥ 25 kg/m2, was calculated with increased weighting applied for higher BMI categories. Multivariate logistic regression analysis was performed, adjusting for multiple potential confounders. RESULTS: In total, 2441 patients were included (76% female, age 42.1 ± 11.9 years, BMI 42.0 ± 4.9 kg/m2). OBES was positively related to myocardial infarction, atrial fibrillation and renal function loss (per 10 OBES-units: OR 1.31, 95%CI [1.11-1.52], p = 0.002; OR 1.23, 95% CI [1.06-1.44], p = 0.008; and OR 1.26, 95% CI [1.04-1.51], p = 0.02). OBES was negatively associated with obstructive sleep apnea syndrome (OSAS) (OR 0.90, 95% CI [0.83-0.98], p = 0.02). In patients without obesity-related complications, OBES was related to lower HbA1c and higher HDL-cholesterol levels (ß -0.5 95% CI [-0.08-.0.02] p < 0.001 and ß 0.02 [0.00-0.04] p = 0.01). CONCLUSION: OBES was related to myocardial infarction, atrial fibrillation and renal function loss in patients applying for MBS. OBES was negatively related to OSAS, possibly because undiagnosed years were not taken into account. In the absence of obesity-related complications, OBES was not related to metabolic blood markers. Our data may aid in improving perioperative risk assessments.

Lessons Learned from Telemonitoring in an Outpatient Bariatric Surgery Pathway-Secondary Outcomes of a Patient Preference Clinical Trial.

BACKGROUND: Remote monitoring is increasingly used to support postoperative care. This study aimed to describe the lessons learned from the use of telemonitoring in an outpatient bariatric surgery pathway. MATERIALS AND METHODS: Patients were assigned based on their preference to an intervention cohort of same-day discharge after bariatric surgery. In total, 102 patients were monitored continuously for 7 days using a wearable monitoring device with a Continuous and Remote Early Warning Score-based notification protocol (CREWS). Outcome measures included missing data, course of postoperative heart and respiration rate, false positive notification and specificity analysis, and vital sign assessment during teleconsultation. RESULTS: In 14.7% of the patients, data for heart rate was missing for > 8 h. A day-night-rhythm of heart rate and respiration rate reappeared on average on postoperative day 2 with heart rate amplitude increasing after day 3. CREWS notification had a specificity of 98%. Of the 17 notifications, 70% was false positive. Half of them occurred between day 4 and 7 and were accompanied with surrounding reassuring values. Comparable postoperative complaints were encountered between patients with normal and deviated data. CONCLUSION: Telemonitoring after outpatient bariatric surgery is feasible. It supports clinical decisions, however does not replace nurse or physician care. Although infrequent, the false notification rate was high. We suggested additional contact may not be necessary when notifications occur after restoration of circadian rhythm or when surrounding reassuring vital signs are present. CREWS supports ruling out serious complications, what may reduce in-hospital re-evaluations. Following these lessons learned, increased patients' comfort and decreased clinical workload could be expected. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT04754893.

Heparin-resistance in AL amyloidosis: a case report.

BACKGROUND: Non-AT-III mediated heparin-resistance during CPB occurs by complex-forming with heparin-binding proteins. Currently, there are no specific recommendations for non-AT-III mediated heparin-resistance. CASE PRESENTATION: We present a fatal case of a 70-yr-old male-patient undergoing cardiac-surgery in which refractory heparin-resistance was observed. The massive AL amyloidosis found at autopsy is thought to be responsible and illustrates that awareness and knowledge of the etiology and perioperative strategies of non-AT-III mediated heparin-resistance is important. CONCLUSION: For anticoagulation during cardiopulmonary bypass surgery in case of a non-AT-III medicated heparin resistance, we refer to the decision tree added to this manuscript and if necessary to consider direct thrombin inhibitors, such as bivalirudin or argatroban, as it bypasses the complexing pathway.

Continuous remote monitoring in post-bariatric surgery patients: development of an early warning protocol.

BACKGROUND: Continuous monitoring of vital parameters after bariatric surgery can detect postoperative bleeding or anastomotic leakage. OBJECTIVES: This report describes the development of a continuous remote early warning score (CREWS). This is an EWS-based notification protocol for deterioration detection in bariatric patients. SETTING: Catharina Hospital, the Netherlands. METHODS: Several CREWS protocols were developed by combining thresholds indicative of tachycardia and tachypnea using literature insights and expert sessions. These protocols were tested retrospectively using continuously measured vital signs in a cohort of 185 patients who underwent primary bariatric surgery. A wearable remote monitoring device (Healthdot, Philips) was used in hospital and at home up to 14 days after surgery. The outcomes included were demographics, use of beta-blockers, and complications necessitating reintervention. RESULTS: Thresholds of 110 beats per minute (bpm) and 20 breaths per minute (rpm) for heart rate and respiration rate, respectively, detected postoperative bleeding and anastomotic leakage with 75% (3/4 patients) sensitivity. The protocol was silent (no alarms/day) in 69.5% of patients and produced more than 1 alarm/day in 1.6% of patients. The average postoperative heart rate was unaffected by the use of beta-blockers. CONCLUSIONS: A description of the steps in the development of an EWS protocol in bariatric patients based on continuous vital sign monitoring is useful. The most sensitive and silent protocol measured heart rate and respiratory rate with thresholds of 110 bpm and 20 rpm and appeared to be feasible for clinical use. There seemed to be no clinically relevant impact of beta-blockers. This CREWS protocol could be a starting point for future studies.