Obesity-associated microbiomes instigate visceral adipose tissue inflammation by recruitment of distinct neutrophils.

Neutrophils are increasingly implicated in chronic inflammation and metabolic disorders. Here, we show that visceral adipose tissue (VAT) from individuals with obesity contains more neutrophils than in those without obesity and is associated with a distinct bacterial community. Exploring the mechanism, we gavaged microbiome-depleted mice with stool from patients with and without obesity during high-fat or normal diet administration. Only mice receiving high-fat diet and stool from subjects with obesity show enrichment of VAT neutrophils, suggesting donor microbiome and recipient diet determine VAT neutrophilia. A rise in pro-inflammatory CD4+ Th1 cells and a drop in immunoregulatory T cells in VAT only follows if there is a transient spike in neutrophils. Human VAT neutrophils exhibit a distinct gene expression pattern that is found in different human tissues, including tumors. VAT neutrophils and bacteria may be a novel therapeutic target for treating inflammatory-driven complications of obesity, including insulin resistance and colon cancer.

Obesity Is Associated with Improved Early Survival but Increased Late Mortality in Surgical Patients with Sepsis: A Propensity Matched Analysis.

INTRODUCTION: While obesity is a risk factor for post-operative complications, its impact following sepsis is unclear. The primary objective of this study was to evaluate the association between obesity and mortality following admission to the surgical ICU (SICU) with sepsis. METHODS: We conducted a single center retrospective review of SICU patients grouped into obese (n = 766, BMI ≥30 kg/m2) and non-obese (n = 574, BMI 18-29.9 kg/m2) cohorts. Applying 1:1 propensity matching for age, sex, comorbidities, SOFA, and transfer status, demographic data, comorbidities, and sepsis presentation were compared between groups. Primary outcomes included in-hospital and 90-day mortality, ICU length of stay (LOS), need for mechanical ventilation (IMV) and renal replacement therapy (RRT). P < 0.05 was considered significant. RESULTS: Obesity associates with higher median ICU LOS (8.2 vs 5.6, p < 0.001), need for IMV (76% vs 67%, p = 0.001), ventilator days (5 vs 4, p < 0.004), and RRT (23% vs 12%, p < 0.001). In-hospital (29% vs 18%, p < 0.0001) and 90-day mortality (34% vs 24%, p = 0.0006) was higher for obese compared to non-obese groups. Obesity independently predicted need for IMV (OR 1.6, 95th CI: 1.2-2.1), RRT (OR 2.2, 95th CI: 1.5-3.1), in-hospital (OR 2.1, 95th CI: 1.5-2.8) and 90-day mortality (HR: 1.4, 95TH CI: 1.1-1.8), after adjusting for SOFA, age, sex, and comorbidities. Comparative survival analyses demonstrate a paradoxical early survival benefit for obese patients followed by a rapid decline after 7 days (logrank p = 0.0009). CONCLUSIONS: Obesity is an independent risk factor for 90-day mortality for surgical patients with sepsis, but its impact appeared later in hospitalization. Understanding differences in systemic responses between these cohorts may be important for optimizing critical care management. LEVEL OF EVIDENCE: III.

Formal ultrasound curriculum for surgical critical care fellows leads to improvement in comfort and skills in the intensive care unit.

BACKGROUND: Despite its importance, there are no official guidelines for point of care ultrasound training during surgical critical care fellowship. The primary objective of this study was to evaluate the comfort and competency of fellows after implementation of a point of care ultrasound program. METHODS: Surgical critical care fellows (n = 7) participated in an ultrasound rotation (2021-2022), including dedicated lectures and training with interventional and echocardiography technicians. Pre and post self-assessments were administered evaluating comfort in point of care ultrasound for focused assessment with sonography for trauma, vascular access, drainage procedures, volume status, cardiac activity during arrest, and global cardiac function. Technicians assessed fellow skill in probe orientation, location, image manipulation, machine adjustment, and image quality. All questions were answered on a 7-point Likert scale (1, not-at-all; 7, yes/very much). Pre and post cohorts were compared using Wilcoxon signed-rank tests. RESULTS: After the rotation, fellows reported improvement in comfort level for ultrasound-guided technique for focused assessment with sonography for trauma, drainage procedures, volume status, and cardiac assessment. Technician evaluations demonstrated improvement in probe orientation (5 [4-6] vs 7 [7-7], P = .02) and location (5 [3-6] vs 7 [7-7], P = .02), image manipulation (5 [4-5] vs 7 [7-7], P = .02), machine adjustment (5 [4-5] vs 7 [7-7], P = .02), and overall image quality (4 [4-6] vs 7 [7-7], P = .02) after the rotation. All fellows reported the course significantly improved their skill, comfort level, and was worthwhile. CONCLUSION: All fellows exhibited significant improvement in skill and comfort with point of care ultrasound after this rotation. This is the first study to describe a dedicated ultrasound curriculum for surgical critical care with significant skill acquisition.

Area Deprivation Index Predicts Mortality for Critically Ill Surgical Patients With Sepsis.

Background: The impact of socioeconomic status on outcomes after sepsis has been challenging to define, and no polysocial metric has been shown to predict mortality in sepsis. The primary objective of this study was to evaluate the association between the Area Deprivation Index (ADI) and mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. Patients and Methods: All patients admitted to the SICU with sepsis (Sequential Organ Failure Assessment [SOFA] score ≥2) were retrospectively reviewed. The ADI scores were obtained and classified as "high ADI" (≥85th percentile, n = 400, representative of high socioeconomic deprivation) and "control ADI" (ADI <85th percentile, n = 976). Baseline demographic and clinical characteristics were compared between groups. The primary outcome was 90-day mortality. Results: High ADI patients were younger (mean age 58.5 vs. 60.8; p = 0.01) and more likely to be non-white (23.7% vs. 10.0%; p < 0.0005) and to present with chronic obstructive pulmonary disease (26.5% vs. 19.0%; p = 0.002). High ADI patients had increased in-hospital (27.3% vs. 21.6%; p = 0.025) and 90-day mortality (35.0% vs. 28.9%; p = 0.03). High ADI patients also had increased rates of renal failure (20.3% vs. 15.3%; p = 0.02). Both cohorts had similar intensive care unit (ICU) lengths of stay and median hospital stay, Charlson comorbidity index, and rate of discharge to home. High ADI is an independent risk factor for 90-day mortality after admission for surgical sepsis (odds ratio [OR], 1.39 ± 0.24; p = 0.014). Conclusions: High ADI is an independent predictor of 90-day mortality in patients with surgical sepsis. Targeted community interventions are needed to reduce sepsis mortality for these at-risk patients.

Mid-term Outcomes of Nissen Fundoplication Versus Roux-en-y Gastric Bypass for Primary Management of Gastroesophageal Reflux Disease in Patients With Obesity.

INTRODUCTION: The efficacy and outcomes of laparoscopic Nissen fundoplication (LNF) in patients with obesity is controversial. Specifically, concerns regarding long-term outcomes and recurrence in the setting of obesity has led to interest in laparoscopic Roux-en-Y gastric bypass (RYGB). METHODS: In this retrospective cohort study, we studied patients with obesity who underwent either LNF or RYGB for gastroesophageal reflux disease. Baseline demographics, clinical variables, operative outcomes, and symptom severity scores were compared. RESULTS: Baseline demographics, operative outcomes, and quality-of-life scores were similar. Proton pump inhibitor usage, quality-of-life, symptom severity scores, and satisfaction with the operation were similar between groups at mid-term follow-up. DISCUSSION: RYGB and LNF produced similar improvements in disease-specific quality of life with similar rates of complications, side effects, and need for reoperation. This demonstrates that RYGB and LNF represent possible options for surgical management of gastroesophageal reflux disease in obese patients.

Characterization of Mortality by Sepsis Source in Patients Admitted to the Surgical Intensive Care Unit.

INTRODUCTION: The impact of infectious source on sepsis outcomes for surgical patients is unclear. The objective of this study was to evaluate the association between sepsis sources and cumulative 90-d mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. METHODS: All patients admitted to the SICU at an academic institution who met sepsis criteria (2014-2019, n = 1296) were retrospectively reviewed. Classification of source was accomplished through a chart review and included respiratory (RT, n = 144), intra-abdominal (IA, n = 859), skin and soft tissue (SST, n = 215), and urologic (UR, n = 78). Demographics, comorbidities, and clinical presentation were compared. Outcomes included 90-d mortality, respiratory and renal failure, length of stay, and discharge disposition. Cox-proportional regression was used to model predictors of mortality; P < 0.05 was significant. RESULTS: Patients with SST were younger, more likely to be diabetic and obese, but had the lowest total comorbidities. Median admission sequential organ failure assessment scores were highest for IA and STT and lowest in urologic infections. Cumulative 90-d mortality was highest for IA and RT (35% and 33%, respectively) and lowest for SST (20%) and UR (8%) (P < 0.005). Compared to the other categories, UR infections had the lowest SICU length of stay and the highest discharge-to-home (57%, P < 0.0005). Urologic infections remained an independent negative predictor of 90-d mortality (odds ratio 0.14, 95% confidence interval: 0.1-0.4), after controlling for sequential organ failure assessment. CONCLUSIONS: Urologic infections remained an independent negative predictor of 90-d mortality when compared to other sources of sepsis. Characterization of sepsis source revealed distinct populations and clinical courses, highlighting the importance of understanding different sepsis phenotypes.

Presence of refractory GERD-like symptoms following laparoscopic fundoplication is rarely indicative of true recurrent GERD.

BACKGROUND: Laparoscopic fundoplication (LF) is the gold standard for gastroesophageal reflux disease (GERD). Recurrent GERD is a known complication; however, the incidence of recurrent GERD-like symptoms and long-term fundoplication failure is rarely reported. Our objective was to identify the rate of recurrent pathologic GERD in patients with GERD-like symptoms following fundoplication. We hypothesized that patients with recurrent GERD-like symptoms refractory to medical management do not have evidence of fundoplication failure as indicated by a positive ambulatory pH study. METHODS: This is a retrospective cohort study of 353 consecutive patients undergoing LF for GERD between 2011 and 2017. Baseline demographics, objective testing, GERD-HRQL scores, and follow-up data were collected in a prospective database. Patients with return visits to clinic following routine post-operative visits were identified (n = 136, 38.5%), and those with a primary complaint of GERD-like symptoms (n = 56, 16%) were included. The primary outcome was the proportion of patients with a positive post-operative ambulatory pH study. Secondary outcomes included proportion of patients with symptoms managed with acid-reducing medications, time to return to clinic, and need for reoperation. P values < 0.05 were considered significant. RESULTS: Fifty-six (16%) patients returned during the study period for an evaluation of recurrent GERD-like symptoms with a median interval of 51.2 (26.2-74.7) months. Twenty-four patients (42.9%) were successfully managed expectantly or with acid-reducing medications. Thirty two (57.1%) presented with GERD-like symptoms and failure of management with medical acid suppression and underwent repeat ambulatory pH testing. Of these, only 5 (9%) were found to have a DeMeester score of > 14.7, and three (5%) underwent recurrent fundoplication. CONCLUSION: Following LF, the incidence of GERD-like symptoms refractory to PPI therapy is much higher than the incidence of recurrent pathologic acid reflux. Few patients with recurrent GI symptoms require surgical revision. Evaluation, including objective reflux testing, is critical to evaluating these symptoms.

Distressed Communities Index Is Not Associated with Mortality for Critically Ill Surgical Patients with Sepsis.

Background: The impact of socioeconomic metrics on outcomes after sepsis is unclear. The Distressed Communities Index (DCI) is a composite score quantifying socioeconomic well-being by zip code. The primary objective of this study was to evaluate the association between DCI and mortality in patients with sepsis admitted to the surgical intensive care unit (SICU). Patients and Methods: All patients with sepsis admitted to the SICU (Sequential Organ Failure Assessment [SOFA] score ≥2) were reviewed retrospectively. Composite DCI scores were obtained for each patient and classified into high-distress (DCI ≥75th percentile; n = 331) and control distress (DCI <50th percentile; n = 666) groups. Baseline demographic and clinical characteristics were compared between groups. The primary outcomes were in-hospital and 90-day mortality. Results: The high-distress cohort was younger and more likely to be African American (19.6% vs. 6.2%), transferred from an outside facility (52% vs. 42%), have chronic obstructive pulmonary disease (25.1% vs. 18.8%), and baseline liver disease (8.2% vs. 4.2%). Sepsis presentation was comparable between groups. Compared with the control cohort, high-distress patients had similar in-house (23% vs. 24%) and 90-day mortality (30% vs. 28%) but were associated with longer hospital stay (23 vs. 19 days). High DCI failed to predict in-hospital or 90-day mortality but was an independent risk factor for longer hospital length of stay (odds ratio [OR], 2.83 ± 1.42; p = 0.047). Conclusions: High DCI was not associated with mortality but did independently predict longer length of stay. This may reflect limitations of DCI score in evaluating mortality for patients with sepsis. Future studies should elucidate its association with length of stay, re-admissions, and follow-up.

Microvesicle-Mediated Transfer of DNA Methyltransferase Proteins Results in Recipient Cell Immunosuppression.

INTRODUCTION: Patients with sepsis exhibit significant, persistent immunologic dysfunction. Evidence supports the hypothesis that epigenetic regulation of key cytokines plays an important role in this dysfunction. In sepsis, circulating microvesicles (MVs) containing elevated levels of DNA methyltransferase (DNMT) mRNA cause gene methylation and silencing in recipient cells. We sought to examine the functional role of MV DNMT proteins in this immunologic dysfunction. METHODS: In total, 33 patients were enrolled within 24 h of sepsis diagnosis (23 sepsis, 10 critically ill controls). Blood and MVs were collected on days 1, 3, and 5 of sepsis, and protein was isolated from the MVs. Levels of DNMT protein and activity were quantified. MVs were produced in vitro by stimulating naïve monocytes with lipopolysaccharide. Methylation was assessed using bisulfate site-specific qualitative real-time polymerase chain reaction. RESULTS: The size of MVs in the patients with sepsis decreased from days 1 to 5 compared to the control group. Circulating MVs contained significantly higher levels of DNMT 1 and 3A, protein. We recapitulated the production of these DNMT-containing MVs in vitro by treating monocytes with lipopolysaccharide. We found that exposing naïve monocytes to these MVs resulted in increased promoter methylation of tumor necrosis factor alpha. CONCLUSIONS: An analysis of the isolated MVs revealed higher levels of DNMT proteins in septic patients than those in nonseptic patients. Exposing naïve monocytes to DNMT-containing MVs produced in vitro resulted in hypermethylation of tumor necrosis factor alpha, a key cytokine implicated in postsepsis immunosuppression. These results suggest that DNMT-containing MVs cause epigenetic changes in recipient cells. This study highlights a novel role for MVs in the immune dysfunction of patients with sepsis.

Comorbidities Matter as Distressed Communities Index Fails to Predict Mortality in Necrotizing Soft Tissue Infection.

Background: Necrotizing soft tissue infections (NSTIs) are life-threatening infections requiring prompt intervention. The Distressed Communities Index (DCI) is a comprehensive ranking of socioeconomic well-being based on zip code. We sought to identify the role of DCI in predicting mortality in NSTI, because it remains unknown. Patients and Methods: A retrospective, single-institution analysis of patients diagnosed with NSTI (2011-2020) requiring surgical intervention. The DCI is a composite score based on community-level factors: unemployment, education level, poverty rate, median income, business growth, and housing vacancies. The DCI scores were matched to the patient's zip code and stratification was performed using quintiles. Parametric and non-parametric analyses were performed to evaluate both the demographic and clinical characteristics. Multivariable regression analyses were performed to identify independent variables associated with outcomes. Results: Six hundred twenty patients met inclusion criteria. Ninety-day mortality was 12.4% (n = 77). Patients who died were more likely to be female (58.4%), older (median age 60.5 ± 11.3 years), have a body mass index (BMI) ≥30 (61.5%), have a higher Charlson Comorbidity Index (3; interquartile range [IQR], 2-7). After regression analysis, neither the composite DCI by quintile, nor the individual component scores, were found to correlate with mortality. Interestingly, underlying heart disease, hepatic dysfunction, and renal disease at baseline were found to significantly correlate with mortality from NSTI with p values <0.05. Conclusions: Socioeconomic status and insurance payer are championed for inclusion when constructing risk models, evaluating resource utilization, comparing hospitals, and determining patient management. The severity of community distress measured by DCI did not correlate with mortality for NSTI, despite contrasting evidence in other diseases. This finding is likely caused by a combination of both individual and community-level resources. This is highlighted by the recognition that comorbidities did correlate with mortality. The absence of DCI-related associations observed in this study warrants further investigation, as do mechanisms for the prevention of further organ dysfunction.

Interferon gamma mediates the reduction of adipose tissue regulatory T cells in human obesity.

Decreased adipose tissue regulatory T cells contribute to insulin resistance in obese mice, however, little is known about the mechanisms regulating adipose tissue regulatory T cells numbers in humans. Here we obtain adipose tissue from obese and lean volunteers. Regulatory T cell abundance is lower in obese vs. lean visceral and subcutaneous adipose tissue and associates with reduced insulin sensitivity and altered adipocyte metabolic gene expression. Regulatory T cells numbers decline following high-fat diet induction in lean volunteers. We see alteration in major histocompatibility complex II pathway in adipocytes from obese patients and after high fat ingestion, which increases T helper 1 cell numbers and decreases regulatory T cell differentiation. We also observe increased expression of inhibitory co-receptors including programmed cell death protein 1 and OX40 in visceral adipose tissue regulatory T cells from patients with obesity. In human obesity, these global effects of interferon gamma to reduce regulatory T cells and diminish their function appear to instigate adipose inflammation and suppress adipocyte metabolism, leading to insulin resistance.

Characterization of Necrotizing Soft Tissue Infections in Obese and Non-Obese Patients.

Background: The impact of obesity on the pathogenesis and prognosis of necrotizing soft tissue infections (NSTIs) is unclear. The goal of this study was to characterize differences in NSTI presentation and outcomes by obesity status. Patients and Methods: A retrospective analysis of institutional data for patients diagnosed with NSTIs were identified (n = 619; 2011-2020). Patients were divided based on obesity (body mass index [BMI] ≥ 30 kg/m2) and non-obese (BMI <30 kg/m2). Primary outcomes included NSTI location, micro-organisms, and index hospitalization data. Multiple logistic regression was used to model predictors of in-hospital and 90-day mortality. Results: The obese cohort (n = 390; 63%) had higher rates of congestive heart failure and type 2 diabetes mellitus. There were no differences in length of stay, mortality, or discharge disposition between groups. A higher rate of respiratory failure was observed in the obese versus non-obese group (36.7% vs. 20.9%; p < 0.0005). The obese cohort was associated with perineal (40.8% vs. 27.0%) and torso NSTIs (20.9% vs. 15.8%; p < 0.005) but reduced staphylococcal (19.2% vs. 27.4%; p = 0.02) and group A streptococcal (2.6% vs. 6.5%; p = 0.03) infections, and increased polymicrobial infections. Class 2 obesity was a negative predictor for in-hospital mortality (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.03-0.5) and 90-day mortality (OR, 0.3; 95% CI, 0.1-0.8), when adjusting for demographic data, type of infection, and baseline comorbidities. Conclusions: Necrotizing soft tissue infections in obesity may present with unique distributions and microbial characteristics. Class 2 obesity may exhibit a survival benefit compared with non-obese patients, suggestive of an obesity paradox.

Outcomes of Patients with Necrotizing Soft Tissue Infections: A Propensity-Matched Analysis Using the National Inpatient Sample.

Background: Necrotizing soft tissue infections (NSTIs) are severe, rapidly spreading infections with high morbidity and mortality. Attempts to identify risk factors for mortality and morbidity have produced variable results. We hope to determine which factors across the NSTI population impact mortality, morbidities, and discharge disposition. Patients and Methods: Retrospective data from the National Inpatient Sample from 2012-2018 of patients with primary diagnosis of NSTI (gas gangrene, necrotizing faciitis, cutaneous gangrene, or Fournier gangrene) were identified for analysis. A 1:4 greedy match was performed and risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using t-tests and Wilcoxon rank sum tests. Categorical variables were assessed using χ2 and Fisher exact tests. Statistical significance was defined as p < 0.05. Results: A total of 6,608 patients were identified. Weighted, this represents 33,040 patients; 32,390 are in the no-mortality cohort and 650 in the mortality cohort. Advanced age group was a risk factor for both in-hospital mortality and morbidity, but not for discharge to a skilled nursing or rehabilitation facility. Having two or more comorbidities was a risk factor for mortality, morbidity, and discharge to skilled nursing or rehabilitation facility. Cancer, liver disease, and kidney disease were predictors of in-hospital mortality. Diabetes mellitus and kidney disease were predictors of experiencing an in-hospital complication. Diabetes mellitus, heart disease, and kidney disease were predictors for discharge to skilled nursing or rehabilitation facility. Conclusions: Necrotizing soft tissue infections are associated with substantial morbidity and mortality. Identifying patients at higher risk for mortality, morbidity, and higher level of care at discharge can help providers properly allocate resources to improve patient outcomes and reduce the financial burden on patients and healthcare facilities. Special attention should be paid to those with existing or acute kidney dysfunction because this was the only comorbidity associated with increased risk mortality, morbidity, and discharge to higher level of care.

S148: Long-term patient-reported outcomes of laparoscopic magnetic sphincter augmentation versus Nissen fundoplication: a 5-year follow-up study.

BACKGROUND: Laparoscopic magnetic sphincter augmentation (MSA) has emerged as an alternative to laparoscopic Nissen fundoplication (LNF) for the management of symptomatic gastroesophageal reflux disease (GERD). While short-term outcomes of MSA compare favorably to those of LNF, direct comparisons of long-term outcomes are lacking. We hypothesized that the long-term patient-reported outcomes of MSA would be similar to those achieved with LNF. METHODS: We tested this hypothesis in a retrospective cohort undergoing primary LNF or MSA between March 2013 and July 2015. The primary outcome was GERD-Health Related Quality of Life (GERD-HRQL) score at long-term follow-up relative to baseline. Secondary outcomes included dysphagia and bloating scores, proton-pump inhibitor (PPI) cessation, reoperations, and overall satisfaction with surgery. RESULTS: 70 patients (25 MSA, 45 LNF) met criteria for study inclusion. MSA patients had lower baseline BMI (median: 27.1 [IQR: 22.7-29.9] versus 30.4 [26.4-32.8], p = 0.02), lower total GERD-HRQL (26 [19-32] versus 34 [25-40], p = 0.02), and dysphagia (2 [0-3] versus 3 [1-4], p = 0.02) scores. Median follow-up interval exceeded 5 years (MSA: 68 [65-74]; LNF: 65 months [62-69]). Total GERD-HRQL improved from 26 to 9 after MSA (p < 0.001) and from 34 to 7.5 after LNF (p < 0.01); these scores did not differ between groups (p = 0.68). Dysphagia (MSA: 1 [0-2]; LNF: 0 [0-2], p = 0.96) and bloating (MSA: 1.5 [0.5-3.0]; LNF: 3.0 [1.0-4.0], p = 0.08) scores did not show any statistically significant differences. Device removal was performed in 4 (16%) MSA patients and reoperation in 3 (7%) LNF patients. Eighty-nine percent of LNF patients reported satisfaction with the procedure, compared to 70% of MSA patients (p = 0.09). CONCLUSIONS: MSA appears to offer similar long-term improvement in disease-specific quality of life as LNF. For MSA, there was a trend toward reduced long-term bloating compared to LNF, but need for reoperation and device removal may be associated with patient dissatisfaction.

Facilitating Success of the Early Stage Surgeon Scientist Trainee: Growing the Surgeon Scientist Pipeline.

OBJECTIVE: Surgeon scientists bring to bear highly specialized talent and innovative and impactful solutions for complicated clinical problems. Our objective is to inform and provide framework for early stage surgeon scientist training and support. SUMMARY OF BACKGROUND DATA: Undergraduate, medical student, and residency experiences impact the career trajectory of surgeon scientists. To combat the attrition of the surgeon scientist pipeline, interventions are needed to engage trainees and to increase the likelihood of success of future surgeon scientists. METHODS: A surgery resident writing group at an academic medical center, with guidance from faculty, prepared this guidance document for early stage surgeon scientist trainees with integration of the published literature to provide context. The publicly available National Institutes of Health RePORTER tool was queried to provide data salient to early stage surgeon scientist training. RESULTS: The educational path of surgeons and the potential research career entry points are outlined. Challenges and critical supportive elements needed to inspire and sustain progress along the surgeon scientist training path are detailed. Funding mechanisms available to support formal scientific training of early stage surgeon scientists are identified and obstacles specific to surgical careers are discussed. CONCLUSIONS: This guidance enhances awareness of essential education, communication, infrastructure, resources, and advocacy by surgery leaders and other stakeholders to promote quality research training in residency and to re-invigorate the surgeon scientist pipeline.

Characterization of inflammatory changes in the breast cancer associated adipose tissue and comparison to the unaffected contralateral breast.

BACKGROUND: Adipose tissue has emerged as an important window into cancer pathophysiology, revealing potential targets for novel therapeutic interventions. The goal of this study was to compare the breast adipose tissue (BrAT) immune milieu surrounding breast carcinoma and contralateral unaffected breast tissue obtained from the same patient. MATERIALS AND METHODS: Patients undergoing bilateral mastectomy for unilateral breast cancer were enrolled for bilateral BrAT collection at the time of operation. After BrAT was processed, adipocyte and stromal vascular fraction (SVF) gene expression was quantified by PCR. SVF cells were also processed for flow cytometric immune cell characterization. RESULTS: Twelve patients underwent bilateral mastectomy for unilateral ductal carcinoma. BrAT adipocyte CXCL2 gene expression trended higher in the tumor-affected breast as compared to the unaffected breast. Macrophage MCP-1 and PPARγ gene expression also tended to be higher in the tumor-affected breasts. T cell gene expression of FOXP3 (p = 0.0370) were significantly greater in tumor-affected breasts than unaffected breasts. Affected BrAT contained higher numbers of Th2 CD4+ cells (p = 0.0165) and eosinophils (p = 0.0095) while trending towards increased macrophage and lower Th1 CD4+ cells infiltration than tumor-affected BrAT. CONCLUSION: This preliminary study aimed to identify the immunologic environment present within BrAT and is the first to directly compare this in individual patients' tumor-associated and unaffected BrAT. These findings suggest that cancer-affected BrAT had increased levels of T cell specific FOXP3 and higher levels of anti-inflammatory/regulatory cells compared to the contralateral BrAT.

Transfer Status and 90-Day Mortality in Intensive Care Unit Patients With Sepsis: A Propensity Matched Analysis.

BACKGROUND: Timely identification and management of sepsis in surgical patients is crucial, and transfer status may delay optimal treatment of these patients. The objective of this study was to compare in-house and 90-day mortality between patients primarily admitted or transferred into the surgical ICU (SICU) at a tertiary referral center. MATERIAL AND METHODS: All patients admitted to the SICU with a diagnosis of sepsis (Sepsis III) were reviewed at a single institution between 2014 to 2019 (n = 1489). Demographics, comorbidities, and sepsis presentation were compared between transferred (n = 696) and primary patients (n = 793). Primary outcomes evaluated were in-house and 90 day mortality in an unmatched and propensity score matched cohorts. A P value < 0.05 was considered statistically significant. RESULTS: Transfer patients were more likely to have obesity (60% versus 49%, P < 0.005), a higher median SOFA (6 (4-8) versus 5 (3-8), P = 0.007), and require vasopressors on admission (42% versus 35%, P = 0.004). Compared to primary patients, transfer patients exhibited higher rates of respiratory failure (76% versus 69%, P = 0.003), in-house (30% versus 17%, P < 0.005), and 90 day mortality (36% versus 24%, P < 0.005). After matching, transferred patients were associated with 75% and 83% increased odds of in-house and 90 day mortality after controlling for age, sex, race, comorbidities, BMI, and sepsis severity. CONCLUSIONS: Transfer status is associated with an over 80% increase in the odds of 90 day mortality for patients admitted to the SICU with sepsis. Aggressive patient identification and earlier transfer of those at higher risk of death may reduce this effect.

Adipocytes, Innate Immunity and Obesity: A Mini-Review.

The role of adipose tissue (AT) inflammation in obesity and its multiple related-complications is a rapidly expanding area of scientific interest. Within the last 30 years, the role of the adipocyte as an endocrine and immunologic cell has been progressively established. Like the macrophage, the adipocyte is capable of linking the innate and adaptive immune system through the secretion of adipokines and cytokines; exosome release of lipids, hormones, and microRNAs; and contact interaction with other immune cells. Key innate immune cells in AT include adipocytes, macrophages, neutrophils, and innate lymphoid cells type 2 (ILC2s). The role of the innate immune system in promoting adipose tissue inflammation in obesity will be highlighted in this review. T cells and B cells also play important roles in contributing to AT inflammation and are discussed in this series in the chapter on adaptive immunity.

Characterization of urgent versus nonurgent early readmissions (<30 days) following primary bariatric surgery: a single-institution experience.

BACKGROUND: Studies on early postoperative readmissions after bariatric surgery (BS) have examined readmissions as a single entity, regardless of urgency. Strategies to lower nonurgent readmissions would reduce unnecessary hospital utilization. OBJECTIVES: To identify predictors of urgent readmissions (UR) versus nonurgent readmissions (NUR) at 30 days post-BS. SETTING: Single academic institution. METHODS: Patients undergoing primary BS over 2 years (n = 589) were retrospectively reviewed. Baseline demographic, medical, and hospitalization data were compared between readmitted patients, stratified by urgency, and nonreadmitted patients. Multivariate regression models of UR and NUR were created using variables with a P value ≤ .2 on univariate analyses. A P value ≤ .05 was considered statistically significant. RESULTS: There were 39 documented instances of 30-day readmissions, of which 44% (n = 17) were NUR; NUR patients were more likely to be female (100% versus 78.2% male; P = .03) and trended toward being younger, experiencing ≥2 perioperative complications, and having a longer index hospital length of stay (LOS). Patients with URs had a higher baseline BMI (52.5 ± 11.4 kg/m2 versus 48.7 ± 8.3 kg/m2, respectively; P = .04), were more likely to have sleep apnea (77.3% versus 56.1%, respectively; P = .05), had a longer LOS (3 versus 2 d, respectively; P = .007), and were more likely to have ≥2 postoperative complications (46% versus 17.0%, respectively; P = .003) compared with those with an NUR. Independent predictors of NUR included public insurance (odds ratio [OR] = 3.7; 95% confidence interval [CI], 1.17-11.67; P = .03), younger age (OR = 1.05; 95% CI, 1-1.01; P = .04), and female sex, while URs were independently predicted by LOS (OR = 1.3; 95% CI, 1.04-1.5; P = .02). CONCLUSIONS: Public insurance appears to be associated with NURs, while LOS predicts URs after BS. This suggests an important dichotomy within readmissions based on urgency, which has important implications for targeted quality initiatives.

Influence of sociodemographic variables on weight loss outcomes up to 3-years following primary bariatric surgery.

BACKGROUND: Our group has previously demonstrated that low socioeconomic status (SES) independently predicts ≤ 25th percentile weight-loss following bariatric surgery (BS). Given that sociodemographic metrics can be separated into income, education, and race, we sought to investigate how each metric independently impacted weight loss following BS. METHODS: Patients from a single academic institution who underwent bariatric surgery from 2014 to 2016 were retrospectively reviewed. Patients were stratified by income (low/high), education (≤ high school/ ≥ college), and race (black/white) then compared using univariate analysis. Variables significant on univariate analyses were subsequently used for a greedy 1:3 propensity score match with a caliper of 0.2. After matching, groups were balanced on demographics, social/medical/psychological history, and surgery type. Percent excess body weight loss for each post-operative time point was compared using appropriate univariate analyses. A p-value ≤ 0.05 was considered statistically significant. RESULTS: 571 patients were included. Unmatched race analysis demonstrated black patients were significantly younger (p = 0.05), single (p < 0.0001), in a lower income bracket (p < 0.0001), and experienced less weight loss at 2- (p = 0.01), 6- (p = 0.007), 12- (p = 0.008) and 24- (p = 0.007) months post-op. After matching, black patients continued to experience less weight loss at 2- (p = 0.01) and 6- (p = 0.03) months, which trended at 1 year (p = 0.06). Initial income analysis demonstrated patients in the low-income group (LIG) were more likely to be black (p < 0.0001), have ≤ high school education (p = 0.004), a higher preoperative BMI (p = 0.008), and lower postoperative weight loss at 2- (p = 0.001), 6- (p = 0.01), and 12- (p = 0.04) months after surgery. After matching, no differences were observed up to 3-years post-op. Analysis of education demonstrated no effect on weight loss in both unmatched and matched analyses. CONCLUSION: Unmatched analysis demonstrated that low income and race impact short-term weight loss after BS. After matching, however, race, not socioeconomic status, predicted weight loss outcomes up to 1-year.