Weight Bias: Examining Achalasia Therapy in the Obese Patient.

We hypothesize that obesity is a common diagnosis in those with achalasia at our institution but time to diagnosis and treatment is longer compared to normal weight counterparts due to implicit bias. We retrospectively reviewed all adult patients between 1/1/2013 and 6/31/2020 with a diagnosis of achalasia. Demographics, comorbidities, Eckardt scores, interventions, complications, time to consult, duration of symptoms, and follow-up were evaluated. More than half of the patients were seen in the most recent 2 years following POEM introduction and 138 had available BMI data. 46 were obese (33%) and 92 were non-obese (67%). Obese patients reported a shorter duration of symptoms prior to seeking treatment 12 versus 24 months. There was no difference in time to intervention or procedure offered. There was a non-significant trend toward higher leak (11 vs 5%) and overall complication rate (19 vs 17%) in obese patients. In follow-up 98 patients had BMI data. There was a a significant difference in mean BMI change -1.2 +/- 4.2 kg/m2 in obese patients and +0.1 +/- 2.1 kg/m2 in normal weight patients. One year follow-up was available in 16 (47%) obese and 25 (33%) non-obese patients and showed a non-significant trend toward greater weight gain in the normal/overweight group (+3.2 +/- 1.1 kg/m2) compared to obese (+2.0 +/- 3.5 kg/m2). Obese patients with achalasia have unique considerations. Duration of symptoms may be shorter in the obese patient with esophageal dysphagia. We noted trends toward greater weight gain following interventions in non-obese patients with equivalent complication rates.

A Survey of Mechanical Ventilator Practices Across Burn Centers in North America.

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The χ, Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

Elevations in inflammatory cytokines are associated with poor outcomes in mechanically ventilated burn patients.

BACKGROUND: The treatment of burn patients who undergo mechanical ventilation is complicated by many factors; patient outcomes and mortality could potentially be improved with predictive biomarkers. Severe burn provokes a systemic inflammatory response characterized by the release of a host of cytokines. Recent studies evaluated the prognostic value of temporal changes in cytokine levels in several patient populations, but few have compared differences in the cytokine profiles of survivors and nonsurvivors following severe burn. We previously compared high-frequency percussive ventilation and low-tidal-volume ventilation and found no difference in mortality or cytokine levels between the two treatments. Since it is unknown whether cytokine levels are predictive of mortality in these patients, we performed a post hoc analysis comparing cytokine levels in survivors and nonsurvivors. METHODS: We evaluated plasma levels of several cytokines (interleukin 1ß [IL-1ß], IL-6, IL-8, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor α) for their prognostic biomarker potential related to mortality at 0, 3, and 7 days in survivors and nonsurvivors of burns. RESULTS: While the majority of values for IL-1ß, granulocyte-macrophage colony-stimulating factor, and tumor necrosis factor α fell below the limit of quantification, univariate analysis demonstrated higher plasma levels of IL-6 and IL-8 in nonsurvivors on Day 7. Logistic regression revealed that elevated plasma IL-8 was independently associated with an increased likelihood of the composite end point of death or ventilator-associated pneumonia with odds ratios of 7.9, 26, and 7.3 on Days 0, 3, and 7, respectively. CONCLUSION: Early increases in plasma IL-8 are associated with a multifold increase in death or ventilator-associated pneumonia in mechanically ventilated burn patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level IV.