Tonsillectomy Outcomes for Children With Severe Obesity.

OBJECTIVES/HYPOTHESIS: To determine the success of an adenotonsillectomy (T&A) in treating children with severe obesity utilizing a more accurate obesity scale. STUDY DESIGN: Retrospective cohort. METHODS: A retrospective cohort of children with obesity between 5 and 10 years of age who underwent a T&A at Children's Hospital of Colorado (CHCO) was used. This study also utilized publicly available data from the Childhood Adenotonsillectomy Trial (CHAT) study. The cohort was divided into three obesity classes using age- and sex-specific body mass index (BMI) expressed as a percentage of the 95th percentile (%BMIp95) and compared for operative success differences. RESULTS: There were 132 patients included in our primary analysis, with obesity distribution as follows: Class 1 to 53 patients (40%), Class 2 to 45 patients (34%), and Class 3 to 34 patients (26%). Overall, 52 patients (35.9%) experienced a cure (obstructive apnea/hypopnea index [OAHI] <1), with 27 (52%) patients in Class 1 obesity, 18 (35%) in Class 2, and 7 (13%) in Class 3. Class 3 had a significantly lower obstructive sleep apnea cure rate compared with Class 1 patients (P = .013), but after adjusting for covariates, this difference was no longer present (P > .05). There was no significant difference in the preoperative to postoperative percent change in mean oxygen saturation (P = .82 CHCO, P = .43 CHAT), oxygen nadir (P = .20 CHCO, P = .49 CHAT), or OAHI (P = .12 CHCO, P = .26 CHAT) between the obesity classes. CONCLUSION: After adjusting for covariates, children with Class 3 obesity are as likely to be cured with a T&A as those with Class 1 obesity. A T&A should be considered a first line treatment for all children with obesity. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:461-469, 2022.

Efficacy and Safety of Direct Oral Anticoagulants for Atrial Fibrillation Across Body Mass Index Categories.

Background Direct-acting oral anticoagulants are now the preferred method of anticoagulation in patients with atrial fibrillation. Limited data on efficacy and safety of these fixed-dose regimens are available in severe obesity where drug pharmacokinetics and pharmacodynamics may be altered. The objectives of this study were to evaluate efficacy and safety in patients with atrial fibrillation taking direct-acting oral anticoagulants across body mass index (BMI) categories in a contemporary, real-world population. Methods and Results We performed a retrospective study of patients with atrial fibrillation at an integrated multisite healthcare system. Patients receiving a direct-acting oral anticoagulant prescription and ≥12 months of follow-up between 2010 and 2017 were included. The primary efficacy and safety outcomes were ischemic stroke or systemic embolism and intracranial hemorrhage. We performed Cox proportional hazards modeling to compute hazard ratios (HRs) adjusted for CHA2DS2-VASc score to examine differences by excess BMI categories relative to normal BMI. Of 7642 patients, mean±SD age was 69±12 years with a median (interquartile range) follow-up of 3.8 (2.2-6.0) years. Approximately 22% had class 1 obesity and 19% had class 2 or 3 obesity. Stroke risks were similar in patients with and without obesity (HR, 1.2; 95% CI, 0.5-2.9; and HR, 0.68; 95% CI, 0.23-2.0 for class 1 and class 2 or 3 obesity compared with normal BMI, respectively). Risk of intracranial hemorrhage was also similar in class 1 and class 2 or 3 obesity compared with normal BMI (HR, 0.64; 95% CI, 0.35-1.2; and HR, 0.66; 95% CI, 0.35-1.2, respectively). Conclusions Direct-acting oral anticoagulants demonstrated similar efficacy and safety across all BMI categories, even at high weight values.

Cirugía bariátrica de conversión por fallo de la técnica inicial: 25 años de experiencia en una Unidad especializada de Cirugía de la Obesidad en España / Revisional bariatric surgery due to failure of the initial technique: 25 years of experience in a specialized Unit of Obesity Surgery in Spain

Objetivos: Valorar la eficacia de la cirugía de conversión en una unidad de cirugía bariátrica con 25 años de experiencia. Método: Estudio observacional retrospectivo de pacientes con obesidad tipo II o superior reintervenidos mediante cirugía de conversión por reganancia de peso, índice de masa corporal (IMC) residual > 35 kg/m2 o pérdida < 50% del exceso de peso. Se analizaron los datos demográficos y antropométricos, las comorbilidades y los datos perioperatorios en 5 periodos de tiempo: inicial, post-cirugía1, pre-cirugía2, post-cirugía2 y actualidad. Resultados: Se incluyeron un total de 112 pacientes con una media de edad de 40,2 años intervenidos inicialmente mediante gastroplastia vertical anillada (GVA) (32,1%), banda gástrica ajustable (BGA) (23,2%), bypass gástrico en Y de Roux (BGYR) (21,4%) y gastrectomía vertical (GV) (23,2%). Las técnicas de conversión, realizadas tras una mediana de 70 meses, incluyeron: BGYR (58,9%), GV (1,8%), bypass gástrico de una anastomosis (BAGUA) (11,6%), acortamiento de asa común (AAC) (24,1%) y derivación bilio-pancreática (DBP) (3,6%). Hubo una reducción del peso inicial de 144,2 ± 30,3 a 101,5 ± 21,8 kg tras la cirugía-1 y de 115,6 ± 24,0 a 91,5 ± 19,0 kg tras la cirugía-2. El peso en la actualidad es de 94,7 ± 16,4 kg tras una mediana de seguimiento de 27,5meses. Un grado de reducción similar ocurrió con el IMC. La mejoría de las comorbilidades se produjo sobre todo tras la primera intervención. Conclusiones: La cirugía de conversión provoca una reducción de peso que no supera a la pérdida alcanzada tras la primera cirugía, pero a diferencia de esta, logra estabilizar el peso a lo largo del tiempo. La tasa de morbilidad perioperatoria es aceptable y justificaría su aplicación, a pesar de que el impacto en las comorbilidades sea limitado

Objectives: To evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25 years of experience. Method: Retrospective observational study of patients with typeII obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI) > 35 kg/m2 or <5 0% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current. Results: A total of 112 patients were included, with a mean age of 40.2 years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2 ± 30.3 to 101.5 ± 21.8 kg after surgery-1; from 115.6 ± 24.0 to 91.5 ± 19.0 kg after surgery-2. The weight at present is 94.7 ± 16.4 kg, with a median follow-up of 27.5 months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention. Conclusions: Conversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities

Revisional bariatric surgery due to failure of the initial technique: 25 years of experience in a specialized Unit of Obesity Surgery in Spain. / Cirugía bariátrica de conversión por fallo de la técnica inicial: 25 años de experiencia en una Unidad especializada de Cirugía de la Obesidad en España.

OBJECTIVES: To evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25years of experience. METHOD: Retrospective observational study of patients with typeII obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI)>35kg/m2 or <50% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current. RESULTS: A total of 112 patients were included, with a mean age of 40.2years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2±30.3 to 101.5±21.8kg after surgery-1; from 115.6±24.0 to 91.5±19.0kg after surgery-2. The weight at present is 94.7±16.4kg, with a median follow-up of 27.5months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention. CONCLUSIONS: Conversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities.

Metabolically Healthy Obesity and Bariatric Surgery.

A peculiar category of persons with obesity lacking common metabolic disturbances has been depicted and termed as metabolically healthy obesity (MHO). Yet, although MHO patients are free of obesity-associated complications, they might not be entirely precluded from developing cardio-metabolic disorders. Among patients with morbid obesity (MO) who are referred to bariatric surgery, a subset of metabolically healthy MO (MHMO) has been identified and the question arises if these patients would benefit from surgery in terms of mitigating the peril of cardio-metabolic complications. We revisited the pathophysiological mechanisms that define MHO, the currently available data on the cardio-metabolic risk of these patients and finally we reviewed the benefits of bariatric surgery and the urge to better characterize MHMO before submission to surgery.

Seven-Year Outcomes of Laproscopic Sleeve Gastectomy in Indian Patients with Different Classes of Obesity.

BACKGROUND: The aim of the study was to assess the long-term outcome in terms of weight loss and remission of comorbidities among the patients who had undergone LSG in an Indian setting. METHODS: This is a retrospective observational study of patients (BMI > 30 kg/m2) who underwent LSG having a minimum 6 months of follow-up data. Based on preoperative BMI, patients were grouped as class 1, 30 < BMI < 35 kg/m2; class 2, 35 < BMI < 40 kg/m2; and class 3, BMI > 40 kg/m2. Data on BMI and %EWL between three classes and among genders at different follow-up points for 7 years were compared. RESULT: Study included 95 patients (mean age of 33.7 ± 11 years), and the preoperative mean BMI was 40.2 ± 5.1 kg/m2. At one year of surgery, 85.5% patients achieved > 50%EWL. The highest mean %EWL was found in class 1 (66.19%), followed by class 2 (56.73%) and class 3 (46.59%) at the sixth month follow-up. At the seventh year, %EWLs were 85.11% (class 1), 76.69% (class 2), and 62.98% (class 3) and the mean BMIs were 25.13 ± 3.09 kg/m2 (class 1), 26.86 ± 2.12 kg/m2 (class 2), and 31.07 ± 3.39 kg/m2 (class 3) and were significantly different (p < 0.05). At the last follow-up, though, the males showed slight weight regain; however, there were no statistical differences between the genders (p = 0.065). CONCLUSION: Outcome from LSG was better in patients with BMI < 40 kg/m2 compared to the patients with BMI > 40 kg/m2. Remission of obesity-related comorbidities was observed with LSG in all groups and gender did not influence the outcome significantly.

Binational cohort study comparing the management and outcomes of pregnant women with a BMI >50-59.9 kg/m2 and those with a BMI ≥60 kg/m2.

OBJECTIVES: To compare the management, maternal and perinatal outcomes of women with a body mass index (BMI) ≥60 kg/m2 with women with a BMI >50-59.9 kg/m2. DESIGN: International collaborative cohort study. SETTING: Binational study in the UK and Australia. PARTICIPANTS: UK: all pregnant women, and Australia: women who gave birth (birth weight ≥400 g or gestation ≥20 weeks) METHODS: Data from the Australasian Maternity Outcomes Surveillance System and UK Obstetric Surveillance System. Management, maternal and infant outcomes were compared between women with a BMI ≥60 kg/m2 and women with a BMI >50-59.9 kg/m2, using unconditional logistic regression. RESULTS: The sociodemographic characteristics and previous medical histories were similar between the 111 women with a BMI ≥60 kg/m2 and the 821 women with a BMI >50-59.9 kg/m2. Women with a BMI ≥60 kg/m2 had higher odds of thromboprophylaxis usage in both the antenatal (24% vs. 12%; OR 2.25, 95% CI 1.39 to 3.64) and postpartum periods (78% vs. 66%; OR 1.68, 95% CI 1.04 to 2.70). Women with BMI ≥60 kg/m2 had nearly double the odds of pre-eclampsia/eclampsia (adjusted OR 1.83 (95% CI 1.01 to 3.30)). No other maternal or perinatal outcomes were statistically significantly different. Severe adverse outcomes such as perinatal death were uncommon in both groups thus limiting the power of these comparisons. The rate of perinatal deaths was 18 per 1000 births for those with BMI ≥60 kg/m2; 12 per 1000 births for those with BMI >50-59.9 kg/m2; those with BMI ≥60 kg/m2 had a non-significant increased odds of perinatal death (unadjusted OR 1.46, 95% CI 0.31 to 6.74). CONCLUSIONS: Women are managed differently on the basis of BMI even at this extreme as shown by thromboprophylaxis. The pre-eclampsia result suggests that future research should examine whether weight reduction of any amount prior to pregnancy could reduce poor outcomes even if women remain extremely obese.

Impact of Severe Obesity on Cardiovascular Risk Factors in Youth.

OBJECTIVE: To compare cardiovascular risk factor clustering (CVRFC) in severely obese youth with those with lower degrees of obesity. STUDY DESIGN: We divided a childhood obesity clinic derived cohort into the degrees of obesity (class I, II, and III) and added a "class IV" category corresponding to >160% of the 95th centile of body mass index (BMI) for age and sex. In a cross-sectional analysis, we investigated the presence of CVRFC in 2244 participants; in 621 who were followed longitudinally, we investigated the determinants of endpoint CVRFC. RESULTS: Class IV obesity was associated with increased risk for CVRFC compared with overweight (OR = 17.26, P < .001) at a similar magnitude to class III obesity (OR = 17.26, P < .001). Male children were at greater risk for presence of CVRFC (OR = 1.57, P = .03) compared with female children. Adiponectin (OR = 0.90, P < .001) and leptin levels (OR = 0.98, P = .008) were protective, independent of degree of obesity. Baseline class IV obesity was associated with increased risk compared with overweight of having CVRFC at follow-up (OR = 5.76, P = .001), to a similar extent as class III obesity (OR = 5.36, P = .001). Changes in the degree of obesity were significant predictors of CVRFC on follow-up (OR = 1.04, P < .01 per percent BMI change). CONCLUSIONS: The metabolic risk associated with obesity in childhood is conferred prior to reaching class IV obesity. An individualized risk stratification approach in children with severe obesity should be based on presence of complications rather than simple BMI cutoffs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01967849.

Preoperative Assessment of Patients Undergoing Elective Gastrointestinal Surgery: Does Body Mass Index Matter?

BACKGROUND: At Queen Elizabeth Hospital Birmingham (QEHB), no specific protocol to stratify patients by body mass index (BMI) exists. This study sought to evaluate outcomes following gastrointestinal surgery. METHODS: Patients undergoing gastrointestinal surgery attending preassessment screening clinic (PAS) from August to September 2016 at the QEHB were identified. Primary outcome was postoperative complications. Secondary outcomes were major complications and 30-day readmission rates. RESULTS: Of 368 patients preassessed, 31% (116/368) were overweight and 35% (130/368) were obese. Median age was 57 (range: 17-93). There was no difference of BMI between the low risk and high risk clinics. Patients in high risk clinic had significantly higher rates of comorbidities, major surgical grades, and malignancy as the indication for surgery. Overall complication rates were 14% (52/368), with 3% (10/368) having major complications (Clavien-Dindo Grades III-IV). Whilst BMI was associated with comorbidity (p = 0.03) and ASA grade (p < 0.001), it was not associated with worse outcomes. Patients attending high risk clinic had significantly higher rates of complications. CONCLUSIONS: Surgery grade was found to be an independent risk factor of complication rates. Use of BMI as an independent factor for preassessment level is not justified from our cohort.

[The way from cost approval to bariatric surgery : Analysis of resource utilization in a maximum care hospital]. / Vom Antrag auf Kostengutsprache bis zur bariatrischen Operation : Personelle Ressourcenanalyse an einem Zentrum der Maximalversorgung.

BACKGROUND: Morbid obesity is a medical and economic challenge. Patients who have the indications for bariatric surgery face a long way from the first visit until surgery and a high utilization of resources is required. OBJECTIVES: The present study aimed to evaluate labor costs and labor time required to supervise obese patients from their first visit until preparation of a bariatric report to ask for cost acceptance of bariatric surgery from their health insurance. In addition, the reasons for not receiving bariatric surgery after receiving cost acceptance from the health insurance were evaluated. MATERIAL AND METHODS: Patients who had indications for bariatric surgery according to the S3 guidelines between 2012 and 2013, were evaluated regarding labor costs and labor time of the process from the first visit until receiving cost acceptance from their health insurance. Furthermore, body mass index (BMI), age, sex, Edmonton Obesity Staging System (EOSS) stage and comorbidities were evaluated. Patients who had not received surgery up to December 2015 were contacted via telephone to ask for the reasons. RESULTS: In the present study 176 patients were evaluated (110 females, 62.5%). Until preparation of a bariatric report the patients required an average of 2.7 combined visits in the department of surgery with the department of nutrition, 1.7 visits in the department of psychosomatic medicine, 1.5 separate visits in the department of nutrition and 1.4 visits in the department of internal medicine. Average labor costs from the first visit until the bariatric survey were 404.90 ± 117.00 euros and 130 out of 176 bariatric reports were accepted by the health insurance (73.8%). For another 40 patients a second bariatric survey was made and 20 of these (50%) were accepted, which results in a total acceptance rate of 85.2% (150 out of 176). After a mean follow-up of 2.8 ± 1.1 years only 93 out of 176 patients had received bariatric surgery (53.8%). Of these 16 had received acceptance of surgery by their health insurance only after a second bariatric survey. CONCLUSION: A large amount of labor and financial resources are required for treatment of obese patients from first presentation up to bariatric surgery. The cost-benefit calculation of an obesity center needs to include that approximately one half of the patients do not receive surgery within more than 2.5 years.

Perfil farmacoterapêutico de pacientes obesos no pós-operatório de cirurgia bariátrica / Pharmacotherapeutic profile of obese patients during the postoperative period after bariatric surgery

Resumo Contexto A obesidade pode estar relacionada a doenças como diabetes, hipertensão arterial e dislipidemia. A cirurgia bariátrica é um dos tratamentos mais eficazes, levando à diminuição de peso e comorbidades. Objetivo Avaliar o perfil metabólico e farmacoterapêutico de pacientes obesos após cirurgia bariátrica. Métodos Trata-se de um estudo observacional transversal retrospectivo, realizado em um hospital localizado na cidade de Porto Alegre, RS, Brasil. Foram avaliados 70 prontuários de pacientes que realizaram cirurgia bariátrica, nos períodos de antes de 2 meses e mais de 6 meses após a cirurgia bariátrica. A análise estatística foi realizada no programa SPSS 17.0®. Resultados A pressão arterial inicial foi de 130/85 mmHg, passando para 120/80 mmHg (p < 0,01). Com relação ao perfil metabólico antes de dois meses, o HDL foi de 34 mg/dL, o colesterol total foi de 195,07 ± 40,17 mg/dL, o LDL foi de 118,22 ± 41,28 mg/dL, os triglicerídeos foram de 141,09 ± 43,39 mg/dL, e a glicemia de jejum foi de 90 mg/dL. Após 6 meses de cirurgia, os valores passaram para 43 mg/dL, 133,67 ± 28,14 mg/dL, 65,53 ± 24,3 mg/dL, 104,41 ± 29,6 mg/dL, e 77 mg/dL, respectivamente (p < 0,01). Com relação ao uso de medicamentos, 41% utilizaram anti-hipertensivos, 39% utilizaram hipolipemiantes, 10% utilizaram hipoglicemiantes orais e 97% utilizaram suplementos antes dos 2 meses de cirurgia. Após os 6 meses, os percentuais foram alterados para 21%, 19%, 9% e 99%, respectivamente. Conclusões O estudo mostra o sucesso da cirurgia bariátrica em pacientes obesos com comorbidades, revelando melhora no perfil metabólico e redução na utilização de medicamentos para tratamento de comorbidades.

Abstract Background Obesity can be associated with diseases such as diabetes, arterial hypertension and dyslipidemia. Bariatric surgery is one of the most effective treatments available, reducing both weight and comorbidities. Objective To evaluate the metabolic and pharmacotherapeutic profile of obese patients after bariatric surgery. Methods This is a retrospective, cross-sectional, observational study conducted at a hospital located in the city of Porto Alegre, RS, Brazil, based on analysis of the medical records for 70 patients who underwent bariatric surgery covering periods spanning from 2 months prior to more than 6 months after their bariatric surgery. Statistical analysis was conducted using SPSS 17.0®. Results Initial arterial blood pressure was 130/85 mmHg, 6 months after surgery it was 120/80 mmHg (p < 0.01). The metabolic profile 2 months before surgery was as follows: HDL was 34 mg/dL, total cholesterol was 195.07 ± 40.17 mg/dL, LDL was 118.22 ± 41.28 mg/dL, triglycerides were 141.09 ± 43.39 mg/dL, and fasting glycemia was 90 mg/dL. The same figures 6 months after surgery were 43 mg/dL, 133.67 ± 28.14 mg/dL, 65.53 ± 24.3 mg/dL, 104.41 ± 29.6 mg/dL, and 77 mg/dL, respectively (p < 0.01). Use of medications 2 months before surgery was as follows: 41% were on antihypertensives, 39% on hypolipidemics, 10% on oral hypoglycemics, and 97% were on nutritional supplements. These percentages 6 months after surgery had changed to 21%, 19%, 9% and 99%, respectively. Conclusions This study illustrates that bariatric surgery for obese patients with comorbidities was successful, demonstrating improvements in their metabolic profile and reductions in use of medications used to treat comorbidities.

Cesarean delivery complications in women with morbid obesity.

OBJECTIVE: To compare cesarean complication rates between women with body mass index (BMI) 40-49.9 kg/m(2) and BMI ≥ 50 kg/m(2) and associations with surgical techniques. METHODS: This retrospective cohort study from 2009 to 2014 included women who underwent cesarean with delivery BMI ≥ 50 and an equal number with BMI 40-49.9. Wound infections and/or separations were compared. We also examined wound complication rates between skin closure techniques and self-retaining retractor use. RESULTS: Among 498 patients (249 with BMI ≥ 50 and 249 with BMI 40-49.9) there were no differences in estimated blood loss >1000 mL, blood transfusion, deep vein thrombosis or endometritis. Among those with outpatient follow-up (144 with BMI ≥ 50 and 162 with BMI 40-49.9), those with BMI ≥ 50 had a significantly higher rate of wound separations (p = 0.01) but not infections. There were no differences in wound complication rates between skin closure techniques or self-retaining retractor use, though the study was not powered for these comparisons. CONCLUSION: Wound complications, particularly separations, increase with BMI ≥ 50 compared to a lesser degree of morbid obesity. Skin closure techniques and self-retaining retractor use were not associated with cesarean wound complications in patients with morbid obesity.

Analgesia en el politraumatizado obeso. Utilidad de la ketamina intravenosa fuera de quirófano / Analgesia options for the morbidity obese with multiple trauma. Role of intravenous ketamine outside the operating theatre

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Class III Obesity is Not a Contraindication to Venovenous Extracorporeal Membrane Oxygenation Support.

BACKGROUND: The use of venovenous extracorporeal membrane oxygenation (ECMO) has increased as a bridge to recovery for acute respiratory distress syndrome (ARDS) refractory to conventional support. Morbid obesity can pose a significant challenge to obtaining indexed flows, and outcomes in this population are not well described. METHODS: Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed. Demographics, ECMO variables, and outcomes were assessed. Morbid obesity and super obesity were defined as a body mass index (BMI) greater than 40 kg/m(2) and greater than 50 kg/m(2), respectively. RESULTS: Fifty-five patients with ARDS were placed on ECMO during the study period. Twelve were morbidly obese with a BMI of 49.0 kg/m(2) (interquartile range [IQR]: 45.4-57.3 kg/m(2)). Pre-ECMO mechanical ventilatory support and indices of disease severity were similar between the 2 groups, as were cannulation strategy and duration of ECMO support. Nine (75%) morbidly obese patients and 27 (63%) non-morbidly obese patients were successfully weaned from ECMO support, and patient survival to time of discharge was 67% and 58%, respectively. In the subset of super obese patients (n = 6; BMI, 57.3 kg/m(2) [IQR: 51.3-66.5 kg/m(2)]), recovery and midterm survival was 100%. CONCLUSIONS: In this review, class III obesity was not associated with poorer outcomes, and based on these data, ECMO support should not be withheld from this patient population.

Limitations of administrative databases in spine research: a study in obesity.

BACKGROUND CONTEXT: The use of national inpatient databases for spine surgery research has been increasing. Unfortunately, without firsthand knowledge of each specific database, it can be difficult to judge the validity of such studies. Large databases that rely on administrative data, such as International Classification of Diseases, Ninth Revision (ICD-9) codes, may misrepresent patient information and could thus affect the results of studies that use these data. PURPOSE: The present study uses obesity, an easily quantified and objective variable, as an example comorbidity to assess the accuracy of ICD-9 codes in the setting of their continued use in spine database studies. STUDY DESIGN/SETTING: A cross-sectional study at a large academic medical center. PATIENT SAMPLE: All patients spending at least one night in the hospital as an inpatient between April 1, 2013 and April 16, 2013. Obstetrics and gynecology, psychiatry, and pediatric patients were excluded. OUTCOME MEASURES: Proportion of patients for whom ICD-9 obesity diagnosis codes assigned at hospital discharge match chart-documented body mass index (BMI). METHODS: The medical record was reviewed for each patient, and obesity ICD-9 codes were directly compared with documented BMI. RESULTS: The study included 2,075 patients. Of 573 "obese" patients (calculated BMI 30-39.9), only 109 received the correct code (278.00), giving this ICD-9 code a sensitivity of 0.19. Of 174 "morbidly obese" patients (calculated BMI >40), only 84 received the correct code (278.01), giving this ICD-9 code a sensitivity of 0.48. CONCLUSIONS: Using obesity as an example, this study highlights the potential errors inherent to using ICD-9-coded databases for spine surgery research. Should a study based on such data use "obesity" as a variable in any analyses, the reader should interpret these results with caution. We further suggest that obesity is likely not the only comorbidity to which these results apply. As database research continues to represent an increasing proportion of publications in the field of spine surgery, it is important to realize that study outcomes can be skewed by data accuracy, and, thus, should not be blindly accepted simply by virtue of large sample sizes.

Desordens no comportamento alimentar antes e após a cirurgia de bypass gástrico em um hospital público / Disorders in eating behavior before and after gastric bypass surgery in a public hospital

A cohort study with 25 patients was carried out in a public hospital unit aiming to identify the prevalence of eating disorders before bariatric surgery; verify their persistence at 6 months postoperatively; and analyze how such disorders influenced the ponderal weight loss in bariatric patients. Through anthropometric comparative analysis and the applica-tion of questionnaires regarding eating behavior, patients were classified as ?presenting? or ?free from? eating disorders before and 6 months after surgery. Significant reduction was observed in the prevalence of nocturnal eating and binge eating among patients at 6 months postoperatively. Lower loss of excess weight was verified among patients classified as ?presenting? eating disorders in the preoperative phase. Patients affected by eating disorders require monitoring by expert staff, which contributes to achieve satisfactory results.

Con el objetivo de determinar la prevalencia de trastornos alimentarios antes de la cirugía bariátrica, de comprobar si éstos persistieron 6 meses después de la intervención y de analizar cómo tales trastornos influyeron en la pérdida de peso de los pacientes bariátricos, se realizó un estudio de cohorte con 25 pacientes en unidad de hospital público, con medición antropométrica y aplicación de un cuestionario relacionado con el comportamiento alimentario, siendo clasificados, los pacientes, como portadores o libres de trastornos alimentarios, antes de la cirugía y 6 meses después. Se encontró una reducción significativa en la prevalencia de comedores compulsivos y nocturnos entre aquellos pacientes evaluados 6 meses después de la intervención. Se evidenció una menor pérdida del exceso de peso entre los pacientes clasificados como portadores de trastornos alimentarios en la fase preoperatoria. Pacientes que sufren de trastornos alimentarios requieren un seguimiento con personal especializado, contribuyendo, así, al logro de resultados satisfactorios.

Objetivando identificar a prevalência de desordens alimentares antes da cirurgia bariátrica, verificar se persistiram aos 6 meses do pós-operatório e analisar como tais desordens influenciaram na perda ponderal de pacientes bariátricos, realizou-se um estudo de coorte com 25 pacientes em unidade pública hospitalar, com aferição antropométrica e aplicação de questionário referente ao comportamento alimentar, sendo classificados como portadores ou livres de desordens alimentares antes e 6 meses após a realização da cirurgia. Foi verificada uma redução significativa na prevalência de comedores compulsivos e comedores noturnos entre os pacientes aos 6 meses do pós-operatório. Foi evidenciada menor perda do excesso de peso entre os pacientes classificados como portadores de desordens alimentares na fase pré-operatória. Pacientes acometidos por desordens alimentares necessitam de acompanhamento com equipe especializada, contribuindo para o alcance de resultados satisfatórios.

Defining morbid obesity in children based on BMI 40 at age 18 using the extended international (IOTF) cut-offs.

BACKGROUND: Studies have reported that children who are obese are becoming more severely obese. OBJECTIVE: We aimed to classify obese children based on age- and gender-specific centile curves passing through body mass index (BMI) 30, 35 and 40 at age 18 as 'class I', 'class II' or severe, and 'class III' or morbid obesity. METHODS: In addition to the International Obesity Task Force BMI cut-offs corresponding to BMI 30 and 35, we calculated the BMI cut-offs corresponding to BMI 40 using the LMS method proposed by Cole and Lobstein. We classified 217 obese children according to these criteria. RESULTS: Fifty-six (25.8%) children had class III obesity, 73 (33.6%) class II obesity and 88 (40.6%) class I obesity. Class III obese children had a higher waist circumference, systolic blood pressure and fasting insulinaemia compared with less obese children. CONCLUSION: It is clinically important to classify obese children in different classes of obesity severity.

Bariatric surgery in morbidly obese patients improves the atherogenic qualitative properties of the plasma lipoproteins.

OBJECTIVE: The purpose of this study was to evaluate the effect of weight loss induced in morbidly obese subjects by Roux-en-Y gastric bypass bariatric surgery on the atherogenic features of their plasma lipoproteins. METHODS: Twenty-one morbidly obese subjects undergoing bariatric surgery were followed up for up to 1 year after surgery. Plasma and lipoproteins were assayed for chemical composition and lipoprotein-associated phospholipase A2 (Lp-PLA2) activity. Lipoprotein size was assessed by non-denaturing polyacrylamide gradient gel electrophoresis, and oxidised LDL by ELISA. Liver samples were assayed for mRNA abundance of oxidative markers. RESULTS: Lipid profile analysis revealed a reduction in the plasma concentrations of cholesterol and triglycerides, which were mainly associated with a significant reduction in the plasma concentration of circulating apoB-containing lipoproteins rather than with changes in their relative chemical composition. All patients displayed a pattern A phenotype of LDL subfractions and a relative increase in the antiatherogenic plasma HDL-2 subfraction (>2-fold; P < 0.001). The switch towards predominantly larger HDL particles was due to an increase in their relative cholesteryl ester content. Excess weight loss also led to a significant decrease in the plasma concentration of oxidised LDL (∼-25%; P < 0.01) and in the total Lp-PLA2 activity. Interestingly, the decrease in plasma Lp-PLA2 was mainly attributed to a decrease in the apoB-containing lipoprotein-bound Lp-PLA2. CONCLUSION: Our data indicate that the weight loss induced by bariatric surgery ameliorates the atherogenicity of plasma lipoproteins by reducing the apoB-containing Lp-PLA2 activity and oxidised LDL, as well as increasing the HDL-2 subfraction.

Clinical tracking of severely obese children: a new growth chart.

The 2000 Centers for Disease Control and Prevention growth charts are unable to accurately define and display BMI percentiles beyond the 97th percentile. At Children's Hospital Colorado, we created new growth charts that allow clinicians to track and visualize BMI values in severely obese children. This growth chart defines a child's BMI as a "percentage of the 95th percentile." It has the potential to allow clinicians to define subgroups of severe obesity, monitor trends in obese children, and measure treatment success or failure.