Article

Impact of Obesity in the Critically Ill Trauma Patient: A Prospective Study

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Obesity has risen at an epidemic rate over the past 20 years in the US. To our knowledge, there is an absence of data evaluating the impact of obesity in the critically ill trauma patient. Prospective data were collected on 1,167 patients admitted to the ICU over a 2-year period. Obesity was defined as a body mass index (calculated as weight [kg]/height [m(2)]) of 30 or higher. Outcomes analyzed included infection rate, hospital and ICU length of stay, and mortality. Multiple logistic regression was used to evaluate outcomes between obese and nonobese patients for infection (infection versus noninfection) and mortality (deceased versus not deceased). Continuous outcomes such as hospital and ICU lengths of stay were evaluated using multiple linear regression analyses. Sixty-two of 1,167 (5.3%) patients were obese. The majority (71%) of injuries in the study cohort were blunt. Although the majority of patients were men (76%), women (10% versus 4%) were more likely to be obese (p < 0.001). Obese patients had a more than twofold increase in risk of acquiring a bloodstream, urinary tract, or respiratory infection, or being admitted to the ICU (p < 0.001), after statistically controlling for age and Injury Severity Score. When controlling for diabetes, gender, obesity, age, COPD, and Injury Severity Score, obese patients were 7.1 times (95% CI, 2.06-8.9) more likely to die in the hospital. Obesity is associated with a substantial increase in morbidity and mortality in the critically ill trauma patient. Future studies are warranted in both the prevention of infection and intensive care management of the obese trauma patient.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... With the pandemic of obesity, the number of obese patients admitted to the intensive care unit (ICU) has increased [8,9]. Whether the phenomenon of obesity paradox exists in the population with critical illness has received widespread attention and has been investigated in a series of studies [10][11][12][13][14][15][16][17][18][19][20][21]. It should be noted that the proportion of diabetic patients recruited in the above studies was limited and that only one study [13] reported the relationship between obesity and hospital mortality in diabetic patients, despite in the context that diabetes mellitus (DM) has become another major global health issue and common comorbidity in the ICU [22,23]. ...
... According to the WHO definition of obesity, the prevalence of obesity in the present study was 46.1%, which was higher than that in the previous studies [10][11][12][13][14][15][16][17][18][19][20][21]. It was probably due to the only inclusion of diabetic patients in our study. ...
... 6 Journal of Diabetes Research electively more often because of the concerns regarding airway management and earlier aggressive care. Additionally, unlike some previous findings [9,16,17,34], our study showed that the ventilation duration in the obesity group was not longer than that in the normal weight group. This observation was unusual, as obese patients always have reduced compliance of the respiratory system and increased work of breathing and abdominal pressure, resulting in increased risks of atelectasis, aspiration, and pneumonia, and would therefore be expected to have longer ventilation duration [8,35]. ...
Article
Full-text available
Background: The relationship between obesity and the outcomes of critically ill diabetic patients is not completely clear. We aimed to assess the effects of obesity and overweight on the outcomes among diabetic patients in the intensive care unit (ICU). Methods: Critically ill diabetic patients in the ICU were classified into three groups according to their body mass index. The primary outcomes were 30-day and 90-day mortality. ICU and hospital length of stay (LOS) and incidence and duration of mechanical ventilation were also assessed. Cox regression models were developed to evaluate the relationship between obesity and overweight and mortality. Results: A total of 6108 eligible patients were included. The 30-day and 90-day mortality in the normal weight group were approximately 1.8 times and 1.5 times higher than in the obesity group and overweight group, respectively (P < 0.001, respectively). Meanwhile, the ICU (median (IQ): 2.9 (1.7, 5.3) vs. 2.7 (1.6, 4.8) vs. 2.8 (1.8, 5.0)) and hospital (median (IQ): 8.3 (5.4, 14.0) vs. 7.9 (5.1, 13.0) vs. 8.3 (5.3, 13.6)) LOS in the obesity group and overweight group were not longer than in the normal weight group. Compared with normal weight patients, obese patients had significantly higher incidence of mechanical ventilation (58.8% vs. 64.7%, P < 0.001) but no longer ventilation duration (median (IQ): 19.3 (7.0, 73.1) vs. 19.0 (6.0, 93.7), P = 1). Multivariate Cox regression showed that obese and overweight patients had lower 30-day (HR (95% CI): 0.62 (0.51, 0.75); 0.76 (0.62, 0.92), respectively) and 90-day (HR (95% CI): 0.60 (0.51, 0.70); 0.79 (0.67, 0.93), respectively) mortality risks than normal weight patients. Conclusions: Obesity and overweight were independently associated with greater survival in critically ill diabetic patients, without increasing the ICU and hospital LOS. Large multicenter prospective studies are needed to confirm our findings and the underlying mechanisms warrant further investigation.
... 114,116,132 Obese patients have twofold higher rates of catheter and bloodstream infections. 155 Bochicchio et al. showed that obese patients had more than double the risk of catheter-associated infections and nosocomial pneumonia. Moreover, such patients also had much longer durations of central lines and urinary catheters. ...
... Moreover, such patients also had much longer durations of central lines and urinary catheters. 155 Additionally, obesity and OSA increase the risk for venous thromboembolism because of decreased mobility and increased blood coagulability. [156][157][158][159][160] Therefore, special attention should be paid to prophylactic measures. ...
Chapter
Obesity hypoventilation syndrome (OHS) is a severe complication of obesity. OHS patients may present with acute hypercapnic respiratory failure (AHRF), necessitating intensive care unit (ICU) admission for monitoring and treatment. Unfortunately, OHS remains under-recognized as a cause of AHRF. Prompt treatment of these patients with noninvasive ventilation (NIV) improves blood gases and lung mechanics, decreases the need for invasive mechanical ventilation, and may reduce hospital stay and morbidity. The management of mechanical ventilation in obese patients with respiratory failure is one of the most challenging problems facing the treating physician. In this chapter, we address the issues surrounding OHS in the ICU setting, including the pathophysiology, clinical characteristics, and contemporary management of this serious medical problem.
... for poor outcomes in trauma [8][9][10][11][12][13][14][15] whereas others have not demonstrated any such association [16][17][18][19][20][21][22][23]. However, a meta-analysis of these studies with nearly 7800 obese trauma patients found an association between obesity and higher risk of mortality and in-hospital complications such as acute respiratory distress syndrome (ARDS) [24]. ...
... The rising prevalence of obesity in the United States has drastically increased the likelihood that a significant portion of the trauma population will be comprised of individuals with higher BMI levels [1]. As a result, many studies have been conducted to investigate the impact of obesity on outcomes in trauma [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26], however, its impact in trauma patients undergoing laparotomy continues to remain unclear [31][32][33]. Using seven years of data derived from the TQIP database, we found the likelihood of mortality in morbidly obese trauma patients to increase by 2.6 times. ...
Article
Full-text available
Background Patient-related risk factors for the development of postoperative pulmonary complications (PPCs) include age ≥ 60-years, congestive heart failure, hypoalbuminemia and smoking. The effect of obesity is unclear and has not been shown to independently increase the likelihood of PPCs in trauma patients undergoing trauma laparotomy. We hypothesized the likelihood of mortality and PPCs would increase as body mass index (BMI) increases in trauma patients undergoing trauma laparotomy.Methods The Trauma Quality Improvement Program (2010–2016) was queried to identify trauma patients ≥ 18-years-old undergoing trauma laparotomy within 6-h of presentation. A multivariable logistic regression analysis was used to determine the likelihood of PPCs and mortality when stratified by BMI.ResultsFrom 8,330 patients, 2,810 (33.7%) were overweight (25–29.9 kg/m2), 1444 (17.3%) obese (30–34.9 kg/m2), 580 (7.0%) severely obese (35–39.9 kg/m2), and 401 (4.8%) morbidly obese (≥ 40 kg/m2). After adjusting for covariates including age, injury severity score, chronic obstructive pulmonary disease, smoking, and rib/lung injury, the likelihood of PPCs increased with increasing BMI: overweight (OR = 1.37, CI 1.07–1.74, p = 0.012), obese (OR = 1.44, CI 1.08–1.92, p = 0.014), severely obese (OR = 2.20, CI 1.55–3.14, p < 0.001), morbidly obese (OR = 2.42, CI 1.67–3.51, p < 0.001), compared to those with normal BMI. In addition, the adjusted likelihood of mortality increased for the morbidly obese (OR = 2.60, CI 1.78–3.80, p < 0.001) compared to those with normal BMI.Conclusion Obese trauma patients undergoing emergent trauma laparotomy have a high likelihood for both PPCs and mortality, with morbidly obese trauma patients having the highest likelihood for both. This suggests obesity should be accounted for in risk prediction models of trauma patients undergoing laparotomy.
... Signifi cant medical comorbidities have been associated with obesity and increased Body Mass Index (BMI); these include hypertension, dyslipidemia, coronary artery disease, stroke, sleep apnea, type II diabetes mellitus and certain types of cancer. Trauma patients with higher BMIs are more likely to have increased complication rates, develop multiple system organ failure, acute respiratory distress syndrome and infections [3][4][5]. Additionally, obesity is an independent risk factor for increased morbidity and mortality following high-impact blunt force trauma and has been associated with signifi cantly longer Intensive Care Unit (ICU) lengths of stay with greater anticipated hospital costs [6,7]. ...
... Previous work has demonstrated that obese patients have higher odds of sustaining medicallytreated injuries [8,19]. Although the effect of obesity on traumatically injured patients has produced inconsistent results in the literature [5,[20][21][22][23], the present study contributes to a growing body of work reporting that obese trauma patients have signifi cantly higher mortality, increased complications and worse outcomes compared to their nonobese counterparts [3,6,12,13,24]. ...
Article
Full-text available
p>The rising trend of obesity in the United States has been a growing concern within the healthcare system for decades. Since the early 1960s, the prevalence of obesity has more than doubled among U.S. adults, and one out of every three Americans is now considered obese according to the National Health and Nutrition Examination Survey [1,2]. Significant medical comorbidities have been associated with obesity and increased Body Mass Index (BMI); these include hypertension, dyslipidemia, coronary artery disease, stroke, sleep apnea, type II diabetes mellitus and certain types of cancer. </p
... The interplay between immune and metabolic pathways regulates inflammatory cascades typically initiated by pathogen-and danger-associated molecular patterns (PAMPs and DAMPs) and obesity is now well recognised to perturb a diverse range of inflammatory cascades through effects on these pathways. This is best evidenced by infection complications and increased risk of vaccine failure [36,37]. Examples include a higher risk for viral and bacterial infections along with secondary infections such as sepsis (women only) and community-acquired pneumonia [38,39]. ...
... Studies of the maternal contribution to the obesity-related milieu in pregnancy also tend to focus on the placenta and to a lesser extent AT, and seldom consider the role of or effect on the peripheral, circulating immune system herein represented by monocytes (see Fig. 3 for summary of all three). This is important because obesity has serious effects on the immune system outside of pregnancy with down-regulated immune responsiveness best evidenced by infection complications and increased risk of vaccine failure [36,37]. Specific examples include a higher risk for viral and bacterial infections along with secondary infections such as sepsis (women only) and community-acquired pneumonia [38,39]. ...
Article
Mandatory maternal metabolic and immunological changes are essential to pregnancy success. Parallel changes in metabolism and immune function make immunometabolism an attractive mechanism to enable dynamic immune adaptation during pregnancy. Immunometabolism is a burgeoning field with the underlying principle being that cellular metabolism underpins immune cell function. With whole body changes to the metabolism of carbohydrates, protein and lipids well recognised to occur in pregnancy and our growing understanding of immunometabolism as a determinant of immunoinflammatory effector responses, it would seem reasonable to expect immune plasticity during pregnancy to be linked to changes in the availability and handling of multiple nutrient energy sources by immune cells. While studies of immunometabolism in pregnancy are only just beginning, the recognised bi-directional interaction between metabolism and immune function in the metabolic disorder obesity might provide some of the earliest insights into the role of immunometabolism in immune plasticity in pregnancy. Characterised by chronic low-grade inflammation including in pregnant women, obesity is associated with numerous adverse outcomes during pregnancy and beyond for both mother and child. Concurrent changes in metabolism and immunoinflammation are consistently described but any causative link is not well established. Here we provide an overview of the metabolic and immunological changes that occur in pregnancy and how these might contribute to healthy versus adverse pregnancy outcomes with special consideration of possible interactions with obesity.
... By examining data on the incidence and prognosis of the most common infections in subjects with obesity, in regard to the flu, several meta-analyses and epidemiological studies disclosed an association between obesity and more severe prognosis, increased risk of admission to the intensive care unit (ICU) and death in subjects with H1N1 (Table 1); however, a higher incidence of infection in subjects with obesity has not been demonstrated [2][3][4][5][6]. Several other recent studies have shown an association between obesity and an increased risk of urinary tract infection (UTI), especially posttraumatic, ICU-acquired, pregnancy-related and postpartum [7][8][9][10]. Different cohort studies reported a close relation between obesity and the risk of nosocomial infections [11,12], skin and surgical site infections (SSIs) [13][14][15][16], longer hospitalization and higher incidence rates of sepsis [17,18]. ...
... Some studies have shown that obesity can be a risk factor for UTIs in specific conditions, such as admission to intensive care, moderate or major surgery, or after traumatic injury [3,4,98]. In a prospective study on 1105 patients admitted to the ICU over a 2-year period, mostly due to trauma, a twofold increase in the relative risk of acquiring a UTI was observed in patients with obesity [7]. Furthermore, a high BMI was independently associated with a higher rate of ICU-acquired UTIs (P = 0.02) in a retrospective study on 301 patients affected by septic shock [8]. ...
Article
The current pandemic due to widespread SARS-CoV-19 infection has again highlighted the role of obesity, whose global prevalence increased up to 13%, as a risk factor for both susceptibility to infections and the occurrence of a more severe disease course. To date, this association has not been sufficiently explored. Obesity-related susceptibility to infectious diseases is mostly thought to be due to an impairment of both innate and adaptive immune responses and vitamin D deficiency. Several cofactors can indirectly favour the onset and/or worsening of infectious diseases, such as impairment of respiratory mechanics, skin and subcutaneous tissue homoeostasis, obesity-related comorbidities and inappropriate antimicrobial therapy. Subjects with obesity have a higher incidence of cutaneous infections, probably due to changes in skin barrier functions and wound healing. Excess weight is also associated with an increased risk of urinary tract infection and its recurrence, as well as with a higher prevalence of both lower and higher respiratory tract infections. Moreover, patients with obesity appear to have an increased risk of surgical site infections when undergoing general, orthopaedic, gynaecological, and bariatric surgery. Data concerning the different infectious diseases related to obesity are rather limited since anthropometric parameters are usually poorly recorded. Furthermore, specific therapeutic protocols in subjects with obesity are lacking, especially regarding antibiotic therapy and further supplements. This review summarizes etiopathogenetic and epidemiological evidence and highlights areas of uncertainty in the field of infectious diseases and obesity, which require further research. It is important to raise public awareness of this additional risk related to obesity and to raise awareness among the scientific community to develop specific clinical protocols for subjects with obesity.
... Studies have pointed out a strong link between obesity and worse clinical outcomes for trauma patients in recent years. For example, obese trauma patients showed increased mortality, morbidity and higher complication rates [26][27][28]. Furthermore, an adverse pro-inflammatory state was also seen in obese patients compared to regular weight ...
... Studies have pointed out a strong link between obesity and worse clinical outcomes for trauma patients in recent years. For example, obese trauma patients showed increased mortality, morbidity and higher complication rates [26][27][28]. Furthermore, an adverse proinflammatory state was also seen in obese patients compared to regular weight counterparts suffering trauma; in this study, the researchers found a positive relationship between higher BMI and lower max SIRS during hospitalization [10]. ...
Article
Full-text available
Objectives In recent years; increasing evidence pointed out the clinical importance of adipose tissue (AT) distribution in various patient populations. In particular, visceral adipose tissue (VAT), when compared to subcutaneous adipose tissue (SAT), was found to play a pivotal role in the development of inflammatory reaction. The aim of the present study was to examine whether body fat distribution has an impact on the development of systemic inflammatory response syndrome (SIRS) in patients with polytrauma. Methods In our retrospective study; we filtered our institution records of the German Trauma Registry (Trauma Register DGU) from November 2018 to April 2021 and included 132 adult polytrauma patients with injury severity score (ISS) >16. Subsequently; we measured the visceral and subcutaneous adipose tissue area based on whole-body CT scan and calculated the ratio of VAT to SAT (VSr). Thereafter, the patient population was evenly divided into three groups; respectively VSr value less than 0.4 for the first group (low ratio), 0.4–0.84 for the second group (intermediate ratio), and greater than 0.84 for the third group (high ratio). Considering the other influencing factors; the groups were further divided into subgroups in the respective analysis according to gender (male/female), BMI (
... Although the ICU length of stay was similar among BMI categories, the hospital length of stay was longer in overweight and obese than in normal BMI patients. Several studies have also shown a strong association between obesity and prolonged ICU and hospital lengths of stay (5,(19)(20)(21), findings that have been attributed to greater dependence on mechanical ventilation (4) or to increased risk of acquiring infection (5,(21)(22)(23)(24)(25). Indeed, several studies have reported that obese patients may be at higher risk of infection (13, [24][25][26], but, in our study, none of the BMI categories was associated with an increased hazard of developing new infection during the ICU stay. ...
... Several studies have also shown a strong association between obesity and prolonged ICU and hospital lengths of stay (5,(19)(20)(21), findings that have been attributed to greater dependence on mechanical ventilation (4) or to increased risk of acquiring infection (5,(21)(22)(23)(24)(25). Indeed, several studies have reported that obese patients may be at higher risk of infection (13, [24][25][26], but, in our study, none of the BMI categories was associated with an increased hazard of developing new infection during the ICU stay. We previously reported in a large multicenter cohort study of 3,147 patients that the overall prevalence of sepsis during the ICU stay was similar between BMI groups, despite an increased risk of ICU-acquired infection in overweight and obese patients (12). ...
... While the obesity paradox has been established in numerous clinical areas, the effect of BMI class on trauma mortality remains unclear. Several studies have demonstrated no association between obesity and mortality [13][14][15][16][17][18], while others have found increased mortality in obese trauma patients [19][20][21][22][23][24][25]. A lack of uniform BMI categorization among previous studies renders meta-analysis difficult. ...
... While overweight and Class I obesity was associated with decreased odds of mortality, increasing BMI categories above normal had a linear relationship with the secondary outcomes of LOS, ICU LOS and ventilator days, as seen by sequential increases in IRR for those categories with each successive BMI category. The association between increased BMI and increased LOS, ICU LOS and ventilator days is congruent with other publications examining the impact of obesity on trauma [16,21,22,24]. Obesity is associated with reduced lung volumes, decreased lung compliance and reduced gas exchange, leading to difficulty weaning from mechanical ventilation [31]. ...
Article
Full-text available
Objective The obesity paradox is the association of increased survival for overweight and obese patients compared to normal and underweight patients, despite an increased risk of morbidity. The obesity paradox has been demonstrated in many disease states but has yet to be studied in trauma. The objective of this study is to elucidate the presence of the obesity paradox in trauma patients by evaluating the association between BMI and outcomes.Methods Using the 2014–2015 National Trauma Database (NTDB), adults were categorized by WHO BMI category. Logistic regression was used to assess the odds of mortality associated with each category, adjusting for statistically significant covariables. Length of stay (LOS), ICU LOS and ventilator days were also analyzed, adjusting for statistically significant covariables.ResultsA total of 415,807 patients were identified. Underweight patients had increased odds of mortality (OR 1.378, p < 0.001 95% CI 1.252–1.514), while being overweight had a protective effect (OR 0.916, p = 0.002 95% CI 0.867–0.968). Class I obesity was not associated with increased mortality compared to normal weight (OR 1.013, p = 0.707 95% CI 0.946–1.085). Class II and Class III obesity were associated with increased mortality risk (Class II OR 1.178, p = 0.001 95% CI 1.069–1.299; Class III OR 1.515, p < 0.001 95% CI 1.368–1.677). Hospital and ICU LOS increased with each successive increase in BMI category above normal weight. Obesity was associated with increased ventilator days; Class I obese patients had a 22% increase in ventilator days (IRR 1.217 95% CI 1.171–1.263), and Class III obese patients had a 54% increase (IRR 1.536 95% CI 1.450–1.627).Conclusion The obesity paradox exists in trauma patients. Further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance patient care.Level of evidenceLevel III, prognostic study
... While some data suggest obese critically ill patients do not exhibit worse outcomes when placed on mechanical ventilation (MV), apart from patients with a body mass index (BMI) greater than 40 kg/m 2 , other research indicates that obese patients with a BMI greater than 31 have significantly more cases of pulmonary complications and mortality throughout the intensive care unit (ICU) stay. 4,5 Similarly, obese patients with blunt force trauma have significantly greater incidence of rib fractures, pulmonary contusions and pelvic fractures relative to non-obese patients. 6 These differences in incidence of injuries may be attributable to the use of standard size crash test dummies that may not reflect the needs of populations who are obese. ...
Article
Objective To examine whether BMI impacts the outcomes of mechanically ventilated patients. Methods Data was collected retrospectively among patients involved in motor vehicle accidents in intensive care at a major trauma center in Atlanta, GA. Patients were categorized into five BMI groups: underweight (BMI < 18.5), normal weight (BMI of 18.5-24.9), overweight (BMI of 25-29.9), obese (BMI of 30-39.9), and morbidly obese (BMI of >40). Results Among all patients (n=2,802), 3% of patients were underweight, 34% were of normal weight, 30% were overweight, 27% were obese, and 6% were morbidly obese. The mean number of ventilator days for normal weight patients was 4.6, whereas the mean number of ventilator days for underweight and morbidly obese patients were higher (10.3 and 7.4, respectively). Conclusions Underweight and morbidly obese populations may require additional interventions during their ICU stays to address the challenges presented by having an unhealthy BMI.
... Results of linear analysis for 7 29,30,34,37,[50][51][52] studies showed a 0.6% decrease in the risk of mortality per unit increase of BMI, from 14.5 to 47.6 kg/m 2 (odds ratio: 0.994; 95% CI, 0.989-0.998). We assessed nonlinear association in 24 studies between BMI and the risk of mortality in the ICU. ...
Article
Full-text available
Introduction: Both low and high body mass index (BMI) are associated with mortality in the intensive care unit (ICU). Although many studies have been done to determine the relationship between BMI and risk of mortality in the ICU, their results were inconsistent. This study aimed to conduct a dose-response meta-analysis of published observational studies to assess the effect of BMI on the risk of mortality in patients admitted to the ICU. Methods: PubMed, Scopus, and Google Scholar were searched to identify articles up to May 2019. A total of 31 relevant articles, with 238,961 patients and a follow-up period of 1 month to 11 years, were analyzed. Results: Linear analysis showed a 0.6% decrease in mortality rate per unit (kg/m2 ) increase in BMI (odds ratio: 0.99; 95% CI, 0.98-0.99). In addition, nonlinear analysis showed a decrease in risk of mortality for a BMI of 35 (P < .001) and then increased the risk of mortality with a BMI > 35 (P < .001). Conclusion: This dose-response meta-analysis revealed that a BMI ≤ 35 can be a protective agent against mortality, but a BMI > 35 is a life-threatening factor in patients admitted to the ICU.
... For example, one study published in the Journal of the American College of Surgeons showed that trauma patients with a BMI greater than or equal to 30 were 7.1 times more likely to die in the hospital compared to their non-obese counterparts. This was after they controlled for diabetes, gender, obesity, age, chronic obstructive pulmonary disease (COPD), and Injury Severity Score (ISS) [3]. Furthermore, studies investigating race showed that black trauma patients had worse outcomes than their white counterparts [1,4]. ...
... Likewise, Childs et al. (9) reported that obese polytrauma patients with orthopaedic trauma had longer ICU days compared to nonobese (mean 7.06 vs. 5.25 days; P = 0.05). Similar findings are observed in critically ill trauma patients, where Bochicchio et al. (16) reported that obesity resulted in 7.7 times the odds for ICU prolonged length of stay (P<0.001). In a meta-analysis evaluating 7,751 trauma patients, obesity had significantly increased ICU stay (17). ...
Article
Full-text available
Objectives The objective of this study was to evaluate the effect of obesity on outcomes following operative treatment of fractures in obese polytrauma patients. Design A prospective cohort study. Setting Academic level 1 trauma center. Patients: This study was prospectively performed from January 2014 until December 2017. The eligibility criteria were adult (age >= 18 years) polytrauma patients who presented to our institution with at least one orthopaedic fracture that required operative fixation. Polytrauma was defined as any patient with an Injury Severity Score (ISS) >= 16. Out of 891 patients, a total of 337 matched the eligibility criteria with 252 nonobese and 85 obese patients. Main Outcome Measurement The primary outcome variable was the total hospital length of stay in days. The secondary outcome variables were the number of patients who had an intensive care unit (ICU) admission, the ICU length of stay in days, the number of patients who had mechanical ventilation, the duration of mechanical ventilation in days, perioperative complications, and mortality. Results Obesity was associated with increased total hospital stay (36 vs. 27 days; P<0.001), increased ICU stay (13 vs. 8 days; P=0.04), increased ICU admissions (83.5% vs. 68.6%; P=0.008) and increased incidence of mechanical ventilation (64.7% vs. 43.7%; P=0.001). These findings remained statistically significant following adjusted regression models for age, gender, ISS, and injuries sustained. However, the mechanical ventilation duration was not significantly different between both groups on adjusted and unadjusted analyses. However, an increase per unit BMI significantly increases the duration of mechanical ventilation (P=0.02). In terms of complications, obesity was only associated with an increase in acute renal failure (ARF) on unadjusted analyses (P=0.004). Whereas, adjusted logistic regression demonstrated that an increase per BMI unit led to a significant increase in the odds ratio for wound infection (P=0.03) and ARF (P=0.024). Conclusions This study displayed that obesity was detrimental to polytrauma patients with operatively treated fractures leading to prolonged hospital and ICU length of stay. This highlights the importance of optimizing trauma care for obese polytraumatized patients to reduce morbidity. With 41.1% of our population being obese, obesity presents a unique challenge in the care of polytrauma patients which mandates further research in improving health care for this population group. Introduction The objective of this study was to evaluate the effect of obesity on outcomes following operative treatment of fractures in obese polytrauma patients. Methods This was a prospective cohort study at a level I trauma center from January 2014 until December 2017. The eligibility criteria were adult (age >= 18 years) polytrauma patients who presented with at least one orthopaedic fracture that required operative fixation. Polytrauma was defined as having an Injury Severity Score (ISS) >= 16. Out of 891 patients, a total of 337 were included with 85 being obese. The primary outcome variable was the total hospital length of stay in days. The secondary outcome variables were the number of patients who had an intensive care unit (ICU) admission, the ICU length of stay in days, the number of patients who had mechanical ventilation, the duration of mechanical ventilation in days, perioperative complications, and mortality. Results Obesity was associated with increased total hospital stay (36 vs. 27 days; P<0.001), increased ICU stay (13 vs. 8 days; P=0.04), increased ICU admissions (83.5% vs. 68.6%; P=0.008) and increased incidence of mechanical ventilation (64.7% vs. 43.7%; P=0.001). These findings remained statistically significant following adjusted regression models for age, gender, ISS, and injuries sustained. However, the mechanical ventilation duration was not significantly different between both groups on adjusted and unadjusted analyses. However, an increase per unit BMI significantly increases the duration of mechanical ventilation (P=0.02). In terms of complications, obesity was only associated with an increase in acute renal failure (ARF) on unadjusted analyses (P=0.004). Whereas, adjusted logistic regression demonstrated that an increase per BMI unit led to a significant increase in the odds ratio for wound infection (P=0.03) and ARF (P=0.024). Conclusions This study displayed that obesity was detrimental to polytrauma patients with operatively treated fractures leading to prolonged hospital and ICU length of stay. This highlights the importance of optimizing trauma care for obese polytraumatized patients to reduce morbidity. With 41.1% of our population being obese, obesity presents a unique challenge in the care of polytrauma patients which mandates further research in improving health care for this population group.
... Body Mass Index (BMI) is often used to define high body weight, with a BMI of 25.0 or greater indicating overweight status, and a BMI of 30.0 or greater indicating obesity 8 . Several studies have also found that obesity may have implications for both the types of injuries that patients suffer when exposed to trauma 9,10 , and the outcomes of their treatment following injury 11,12 . Following falls and motor vehicle crashes, individuals with obesity are less likely to suffer from head injuries 10 , but more likely to suffer from injuries to the lower extremities 9 , likely because of physical differences in body structure. ...
Article
Full-text available
Traumatic injury is a leading cause of death and disability worldwide. Obesity may put trauma patients at risk for complications leading to negative clinical outcomes. Data on all hospital admissions due to traumatic injury in the Detroit metropolitan area between 2006 and 2014 were obtained from the Michigan State Inpatient Database. Generalized linear modelling was used to compare patients with and without obesity on three outcomes: mortality, length of hospital stay and total charges for care. Adjusting for demographics, patients with obesity had 26% longer hospitalization. Adjusting for demographics and length of stay, charges were 8% higher. Obesity was unrelated to mortality. Obesity had greater impact on length of stay among younger adults; its relationship with charges emerged only among older adults. Obesity has significant clinical implications for trauma care. Demands for trauma care resources, and the charges associated with providing care, are likely to increase as obesity rates rise.
... Many studies proved the negative impact of obesity on mortality and morbidity in critically ill patients after surgery, as well as trauma patients. 18,19 Our study focuses on the impact of BMI on mortality and morbidity after burn injuries. Several independent risk factors are known to affect the survival of severely burned patients. ...
Article
Full-text available
Although obesity appears to be an important predictor of mortality and morbidity, little data about the impact of body mass index (BMI) on the outcome of severely burned patients are available. Patients admitted to the General Hospital Vienna between 1994 and 2014, who underwent surgery because of burn injuries, were enrolled in this study. BMI was used to divide patients into five groups: BMI 18.5 to 24.9, 25 to 29.9, 30 to 34.9, 35 to 39.9, and > 40. The groups were compared in terms of difference of mortality and morbidity. Of 460 patients, 34.3% (n = 158) died. Mortality rates were the lowest in patients with obesity class III and the highest in patients with BMI 35 to 39.9 (BMI 18.5‐24.9: 30.5%, BMI 25‐29.9: 31.5%, BMI 30‐34.9: 41.3%, BMI 35‐39.9: 55.5%, BMI > 40: 30%; P = .031). BMI was not found to be an independent risk factor when corrected with age, percent total body surface area burned, full‐thickness burns, and inhalation injury. No significant differences in length of stay, inhalation trauma, pneumonia, wound infection, sepsis, and invasive ventilation were observed. BMI as an independent risk factor for severely burned patients could not be confirmed via multivariate analysis.
... Some have focused on ICU and polytrauma patients in particular, noting that obesity poses an increased risk for late mortality in critically ill patients following a course of ICU care. 21,22 Similarly, a 2014 National Trauma Data Bank study of blunt trauma patients has demonstrated longer ICU stays and a higher likelihood of in-hospital complications among obese patients. Of note, the BMI threshold used in that study was 40, limiting the exposure group to morbidly obese patients. ...
Article
Background: With rising obesity rates in the United States, knowledge of obesity's impact on trauma outcomes is essential to providing high-quality care. The interaction between body mass and outcomes is unclear, with existing literature demonstrating conflicting results. We hypothesized that in a broad cohort of trauma patients, obesity would be associated with in-hospital mortality. Materials and methods: We conducted a retrospective cohort study using the 2014-2015 Pennsylvania Trauma Outcomes Study (PTOS) registry, a state-wide registry to which all accredited Pennsylvania trauma centers are required to report. We included nonburn adult trauma patients admitted to level I and II centers. Because PTOS lacks height data, weight thresholds of 111.75 kg for men and 95.05 kg for women were used, which correspond to BMI = 30 kg/m2 at the 99th height percentile in the United States. We tested the association of obesity with in-hospital mortality using logistic regression to adjust for confounders. Results: We included 46,329 patients in a complete case analysis. In univariate logistic regression analysis, injury mechanism, presence of a complication, age, sex, need for blood transfusion, Revised Trauma Score, and Injury Severity Score were associated with mortality. On multivariate analysis, including these factors, obesity was significantly associated with mortality (odds ratio 1.36, 95% confidence interval 1.10-1.69). Respiratory, thromboembolic, and infectious complications, as defined by PTOS, were more common in obese patients. Conclusions: After adjusting for patient and injury characteristics, obesity is associated with increased mortality following trauma. This information may help resolve previous conflicting evidence and guide providers in caring for the obese patient.
... Упродовж останнього часу темпи ожиріння продовжують зростати, що пов'язують із зменшенням фізичної активності населення [1]. Специфічні фізіологічні процеси ожиріння формують підґрунтя для тяжчих пошкоджень внаслідок отриманої травми, зокрема скелетної, а також високих ступенів ризику розвитку ускладнень, часто аж до летальних наслідків [2,3]. ...
... Unfortunately, obesity has been shown to be an independent risk factor for difficult IV access. [51][52][53] The causes of difficult IV access in the obese patient are likely multifactorial and include increased adipose tissue, increased tissue edema, and smaller vein caliber. Alternatives to peripheral IV access include the intraosseous route and central venous access. ...
Article
Full-text available
Emergency physicians (EP) frequently resuscitate and manage critically ill patients. Resuscitation of the crashing obese patient presents a unique challenge for even the most skilled physician. Changes in anatomy, metabolic demand, cardiopulmonary reserve, ventilation, circulation, and pharmacokinetics require special consideration. This article focuses on critical components in the resuscitation of the crashing obese patient in the emergency department, namely intubation, mechanical ventilation, circulatory resuscitation, and pharmacotherapy. To minimize morbidity and mortality, it is imperative that the EP be familiar with the pearls and pitfalls discussed within this article.
... These results have since been further validated and expanded in several additional studies, 3,4,[8][9][10] including studies of patients presenting to the ICU. 5,11 Multiple authors indicate increased mortality in obese trauma patients, possibly up to 4-fold greater than the nonobese population. Ciesla et al. 12 also found that obese patients are at increased risk for multiple organ system failure (OR 1.8, 95% CI 1.2-2.7). ...
Article
The incidence of obesity has been increasing in the United States, and the medical care of obese patients after injury is complex. Obesity has been linked to increased morbidity after blunt trauma. Whether increased girth protects abdominal organs from penetrating injury or complicates management from obesity-associated medical comorbidities after penetrating injury has not been well defined. All patients admitted with penetrating injury between January 1, 2010, and December 31, 2013, at a university-affiliated Level I center trauma center were reviewed. Primary endpoints for analysis were the presence of significant injuries requiring operative intervention and outcomes, including inpatient complications. Logistic regression, chi-squared tests, and the Kruskal-Wallis test were used to compare groups. Five hundred patients were included in the study; 225 with stabs and 275 with gunshot wounds (GSWs). In each group, there was no major difference between obese and nonobese patients in regard to injury location, operative approach, or postoperative outcomes. Unadjusted odds ratios comparing both overweight and obese individuals to normal BMI patients did not suggest a decreased rate of therapeutic operations for either population after stabs or GSWs. In obese or overweight patients, there is no difference in the rate of operative intervention for significant injuries after penetrating axial trauma compared with a normal BMI population. On the other hand, obesity was not associated with prolonged length of stay, increased complications, or death after penetrating injuries.
... They do not heal well, are slow to mobilize, and are generally a greater surgical risk. 3 As previously shown, for obese patients with a BMI greater than 40, there is a 14 per cent mortality and 29 per cent amputation rate (P < 0.05) after lower extremity revascularization compared with 1.5 and 6 per cent (respectively) for nonobese patients. 4 The amount of force required to dislocate the human knee has been measured at 650 to 800 psi. ...
... Because of its high prevalence and negative impact on quality of life and longevity, overweight in childhood and adolescence is a major public health concern. 1 A study performed by the Imperial College London in partnership with the World Health Organization (WHO), published in 2017, estimated a 10-fold increase over a period of 40 years in the prevalence of overweight in children older than 5 years. 2 Studies evaluating nutrition status have usually focused on underweight as predictor of risk; a more recent trend, however, is the investigation of overweight in hospitalized children. 3 Around the year 2000, the first studies focusing on overweight and obese children and adolescents in hospital settings were published. [4][5][6][7] According to the latest Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient, issued by the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition (ASPEN), z-scores for body mass index for age (BMI/A; weight for length < 2 years) should be used to screen patients at extremes of these values on pediatric intensive care unit (PICU) admission. Thus, overweight patients are included in the risk range together with underweight/low-height individuals. ...
Article
Background Because of its high prevalence and negative impact on quality of life and longevity, overweight in childhood and adolescence is a major public health concern. The objective of the present study was to determine whether excess weight is associated with clinical outcomes in critically ill children and adolescents admitted to the pediatric intensive care unit (PICU). Method This retrospective cohort study was performed with children and adolescents admitted to a PICU over 3 years. Nutrition status was classified based on the body mass index z‐ score for age, following World Health Organization (WHO) criteria. The following outcomes were assessed: mortality, need for mechanical ventilation, length of admission, and multiple organ dysfunction syndrome. Results Of 1468 patients admitted during the study period, 1407 were included in the study: 956 (68.0%) had adequate weight, 228 (16.2%) were overweight, and 223 (15.8%) were underweight. Associations were detected between most variables and all nutrition categories (underweight, adequate weight, and overweight). In the descriptive analysis, mortality was more prevalent in nutrition status extremes (extremely underweight or overweight). An independent association between nutrition status and mortality was not detected in any category. Conclusion Nutrition status was not independently associated with poor outcomes. However, overweight should be considered a potential risk factor for adverse clinical outcomes in PICU admissions.
... Some trauma investigators have shown that increased BMI or obesity is associated with mortality [1][2][3], whereas others have demonstrated that there is no relationship [4][5][6][7][8][9][10]. Similarly, certain trauma experts have shown that increased BMI or obesity is linked to the duration of mechanical ventilation following blunt trauma [5,[7][8][9][10], yet others have failed to establish a connection [1,4,11]. ...
Article
Introduction: There is controversy regarding obesity or body mass index (BMI) effects on postinjury mortality and mechanical ventilation. The aim was to assess outcome associations with BMI and postinjury blood glucose and cholesterol. Method: Adult blunt traumatic brain injury patients admitted to a level I trauma center and requiring ≥ 3 days of intensive care were investigated. Admission blood glucose and day-4 total cholesterol were captured from the medical records. Cholesterol ratio was calculated by dividing day-4 values by published national normative levels according to sex, age, and injury date. Results: The parent cohort included 588 patients. The ventilator days ≥ 10 or died group, when compared to the ventilator days < 10 and lived group, had higher Injury Severity Score (ISS) (29.2±9.9 versus [vs.] 23.7±9.7, P < 0.0001), BMI (27.9±6.8 vs. 26.0±5.5, P = 0.0002), and admission glucose (182.6±79 vs. 155.4±59 mg/dl, P < 0.0001, n = 476) and lower emergency department Glasgow Coma Scale score (ED GCS) (6.9±4.7 vs. 10.3±5.0, P < 0.0001) and cholesterol ratio (0.64±0.2 vs. 0.70±0.2, P = 0.0018, n = 364). The ventilator days ≥ 10 or died group had independent associations with increased ISS (P = 0.0709), decreased ED GCS (P = 0.0078), and increased BMI÷cholesterol ratio (P = 0.0003). The ventilator days ≥ 10 or died group had independent associations with increased ISS (P = 0.0013), decreased ED GCS (P < 0.0001), and increased BMI × glucose (P < 0.0001). Ventilator days were increased with higher ISS (P < 0.0001), BMI (P = 0.0014) and glucose (P = 0.0031) and with lower ED GCS (P < 0.0001) and cholesterol ratio (P = 0.0004). Ventilator days had independent associations with increased ISS (P < 0.0001), decreased ED GCS (P = 0.0041), and increased BMI÷cholesterol ratio (P = 0.0010). Ventilator days had independent associations with increased ISS (P < 0.0001), decreased ED GCS (P < 0.0001), and increased BMI × glucose (P = 0.0041). Conclusion: For TBI patients, valid risk assessment measurements include ISS (anatomic injury burden), ED GCS (brain function), BMI (preinjury weight status), admission glucose (postinjury metabolism), and day-4 cholesterol ratio (postinjury inflammation).
... Impact on public health is major, as obesity is associated with an increased risk of all-cause mortality [2]. Moreover, obesity increased the susceptibility to community-acquired and nosocomial infections, especially in the ICU setting [3][4][5][6][7][8]. For example, obesity has a pathophysiological effect on the respiratory system in terms of respiratory mechanics [9]. ...
Article
PurposeObesity increases the risk of nosocomial infection, but data regarding the role of body mass index (BMI) in catheter related infections are scarce. We used the data gathered from four randomized, controlled trials (RCTs) to investigate the association between body mass index (BMI) and intravascular catheter infections in critically ill obese patients.Methods Adult obese patients who required short-term central venous, arterial or dialysis catheter insertion in the intensive care unit (ICU) were analyzed. The association between BMI and major catheter-related infection (MCRI), catheter-related bloodstream infection (CRBSI) and catheter tip colonization was estimated using univariate and multivariate marginal Cox models. Exploratory analysis using dressing disruptions was added.ResultsA total of 2282 obese patients and 4275 catheters from 32 centers were included in this post-hoc analysis. Overall, 66 (1.5%) MCRI, 43 (1%) CRBSI and 399 (9.3%) catheter colonizations were identified. The hazard ratio (HR) for MCRI, CRBSI and colonization increased with BMI. After adjustment for well-known infection risk factors, the BMI ≥ 40 group had an increased risk for MCRI (HR 1.88, 95% CI 1.13–3.12, p = 0.015), CRBSI (HR 2.19, 95% CI 1.19–4.04, p = 0.012) and colonization (HR 1.44, 95% CI 1.12–1.84, p = 0.0038) compared to the BMI < 40 group. The mean dressing disruption per catheter was increased in the BMI ≥ 40 group (2.03 versus 1.68 in the BMI < 40 group, p = 0.05).Conclusions Using the largest dataset ever collected from large multicentric RCTs, we showed that patients with BMI ≥ 40 had an increased risk for intravascular catheter infections. Targeted prevention measures should focus on this population with a particular attention to catheter care and dressing disruption.
... The BEFORE and AFTER cable tie practice pattern change cohorts were similar demographically, suggesting comparison is rational [11][12][13]. We did not extrapolate the noted racial distinctions for potential socioeconomic disparities some of which may have been associated with differing outcomes [14,15]. ...
Article
Full-text available
Objectives Thoracostomy tube (TT) connection to drainage device (DD) may be unintentionally disconnected, potentiating complications. Tape may strengthen this connection despite minimal data informing optimal practice. Our goal was to analyze the utility of cable ties for TT to DD connection. Methods On April 1, 2015, our trauma center supplanted use of tape or nothing with cable ties for securing TT to DD connection. We abstracted trauma registry patients with TTs placed from March 1, 2014 to May 31, 2016 and dichotomized as prior (“BEFORE”) and subsequent (“AFTER”) to the cable tie practice pattern change. We analyzed demographics, TT-specific details and outcomes. Primary outcome was TT to DD disconnection. Secondary outcomes included TT dislodgement from the chest, complications, length of stay (LOS), mortality, number of TTs placed and TT days. Results 121 (83.4% of abstracted) patients were analyzed. Demographics, indications for TT and operative rate were similar for BEFORE and AFTER cohorts. ISS was lower BEFORE (14.12 ± 2.35 vs 18.21 ± 2.71, p = 0.022); however, RTS and AIS for chest were similar (p = 0.155 and 0.409, respectively). TT to DD disconnections per TT days were significantly higher in the BEFORE cohort [6 (2.8%) vs. 1 (0.19%), p = 0.003], and dislodgements were statistically similar [0 vs 3 (0.57%), p = 0.36]. LOS, initial TTs placed and days per TT were similar, and median and mode of days per TT were the same. Conclusions Cable ties secure connections between TT and DDs with higher fidelity compared to tape or nothing but may increase rates of TT dislodgement from the chest.
... This is consistent with previous work highlighting a greater risk of developing VAP in obese and very obese patients. 33,34 Overall, our findings suggest that patients with a BMI !40 should be monitored more closely to minimise the risk of developing VAP. ...
Article
Background Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation in the intensive care unit. The incidence, patient characteristics, and outcomes have not been described in a regional Australian setting. Objectives Τhe primary objective was to establish the incidence of VAP in a regional intensive care unit using predetermined diagnostic criteria. The secondary objective was to compare the agreement between criteria-based and physician-based diagnostic processes. The tertiary objectives were to compare patient characteristics and clinical outcomes of cases with and without VAP. Methods A retrospective clinical audit was performed of adult patients admitted to Rockhampton Intensive Care Unit, Australia, between 2013 and 2016. We included all patients ventilated for ≥72 h and not diagnosed with a pneumonia before or during the first 72 h of ventilation. Results A total of 170 cases met the inclusion criteria. The incidence of VAP as per the criteria-based diagnosis was 27.3 cases per 1000 ventilator days (95% confidence interval [CI]: 18.4–36.2) and as per the physician-based diagnosis was 25.8 cases per 1000 ventilator days (95% CI: 17.1–34.4). There was a moderate chance-corrected agreement between the criteria- and physician-based diagnosis. Very obese cases (body mass index [BMI] ≥40) were nearly four times more likely to develop VAP than cases with normal BMI (BMI <30) (odds ratio: 3.664; 95% CI: 1.394–9.634; p = 0.008). After controlling for sex, BMI category, comorbidities, and Acute Physiology and Chronic Health Evaluation II scores, there was a trend (p = 0.283) for higher adjusted mortality rate for cases with VAP (10.1%, 95% CI: 4.8–21.5) than for those without VAP (6.1%, 95% CI: 3.0–12.4). Cases with VAP had a higher total hospital cost ($123,223 AUD vs $66,425 AUD, p < 0.001), than cases without VAP. Conclusions This is the first study reporting incidence of VAP in an Australian regional intensive care unit setting. An increased length of stay and significantly higher hospital costs warrant research investigating reliable and valid clinical prediction rules to forecast those at risk of VAP.
... Obesity may be a risk factor for bloodstream infections, pneumonia, and soft tissue infections in hospitalized and critically ill patients. 73,74 Potential contributors include altered cellular immunity, 75 Incorrect blood pressure cuff size may affect accuracy of blood pressure measurement and lead to inappropriate care in the ICU. Physicians should confirm that the appropriate cuff is being used in patients with obesity. ...
Article
The prevalence of obesity is rising worldwide. Adipose tissue exerts anatomic and physiologic effects with significant implications for critical illness. Changes in respiratory mechanics cause expiratory flow limitation, atelectasis, and ventilation/perfusion mismatch with resultant hypoxemia. Altered work of breathing and obesity hypoventilation syndrome may cause hypercapnia. Challenging mask ventilation and peri-intubation hypoxemia may complicate intubation. Patients with obesity are at increased risk of acute respiratory distress syndrome and should receive lung-protective ventilation based on predicted body weight. Increased positive end expiratory pressure (PEEP), coupled with appropriate patient positioning, may overcome the alveolar decruitment and intrinsic PEEP caused by elevated baseline pleural pressure, though evidence is insufficient regarding the impact of high PEEP strategies on outcomes. Venovenous extracorporeal membrane oxygenation may be safely performed in patients with obesity. Fluid management should account for increased prevalence of chronic heart and kidney disease, expanded blood volume, and elevated acute kidney injury risk. Medication pharmacodynamics and pharmacokinetics may be altered by hydrophobic drug distribution to adipose depots and comorbid liver or kidney disease. Obesity is associated with increased risk of venous thromboembolism and infection; appropriate dosing of prophylactic anti-coagulation and early removal of indwelling catheters may decrease these risks. Obesity is associated with improved critical illness survival in some studies. It is unclear whether this reflects a protective effect or limitations inherent to observational research. Obesity is associated with increased risk of intubation and death in SARS-CoV-2 infection. Ongoing molecular studies of adipose tissue may deepen understanding of how obesity impacts critical illness pathophysiology.
... People experiencing obesity are more prone to acquiring skin infections, postoperative infections, and other nosocomial infections and experience more severe illness and/or serious complications with common infections [12][13][14]. In one study, critically ill trauma patients with obesity (basal metabolic index [BMI] ≥ 30) exhibited an increased risk of acquiring severe forms of urinary tract infections (UTIs), respiratory tract infections (RTIs), and bloodstream infections able to progress to sepsis, with increased morbidity and mortality than patients with a BMI of less than 30 [15]. ...
Article
Full-text available
Obesity is characterized by low-grade, chronic inflammation, which promotes insulin resistance and diabetes. Obesity can lead to the development and progression of many autoimmune diseases, including inflammatory bowel disease, psoriasis, psoriatic arthritis, rheumatoid arthritis, thyroid autoimmunity, and type 1 diabetes mellitus (T1DM). These diseases result from an alteration of self-tolerance by promoting pro-inflammatory immune response by lowering numbers of regulatory T cells (Tregs), increasing Th1 and Th17 immune responses, and inflammatory cytokine production. Therefore, understanding the immunological changes that lead to this low-grade inflammatory milieu becomes crucial for the development of therapies that suppress the risk of autoimmune diseases and other immunological conditions. Cells generate extracellular vesicles (EVs) to eliminate cellular waste as well as communicating the adjacent and distant cells through exchanging the components (genetic material [DNA or RNA], lipids, and proteins) between them. Immune cells and adipocytes from individuals with obesity and a high basal metabolic index (BMI) produce also release exosomes (EXOs) and microvesicles (MVs), which are collectively called EVs. These EVs play a crucial role in the development of autoimmune diseases. The current review discusses the immunological dysregulation that leads to inflammation, inflammatory diseases associated with obesity, and the role played by EXOs and MVs in the induction and progression of this devastating conditi8on.
... The interaction between body mass and outcome has been incompletely explored, and the evidence of literature is contradictory. Obesity has been associated with increased mortality after motor vehicle collisions, despite comparable or reduced injury severity among obese patients [46][47][48][49][50]. Some have suggested that this demonstrates a "cushion" effect in automobile accidents, and the increased mortality is secondary to other systemic factors. ...
Article
Full-text available
Obesity is associated to an increased risk of morbidity and mortality due to respiratory, cardiovascular, metabolic, and neoplastic diseases. The aim of this narrative review is to assess the physio-pathological characteristics of obese patients and how they influence the clinical approach during different emergency settings, including cardiopulmonary resuscitation. A literature search for published manuscripts regarding emergency and obesity across MEDLINE, EMBASE, and Cochrane Central was performed including records till January 1, 2021. Increasing incidence of obesity causes growth in emergency maneuvers dealing with airway management, vascular accesses, and drug treatment due to both pharmacokinetic and pharmacodynamic alterations. Furthermore, instrumental diagnostics and in/out-hospital transport may represent further pitfalls. Therefore, people with severe obesity may be seriously disadvantaged in emergency health care settings, and this condition is enhanced during the COVID-19 pandemic, when obesity was stated as one of the most frequent comorbidity. Emergency in critical obese patients turns out to be an intellectual, procedural, and technical challenge. Organization and anticipation based on the understanding of the physiopathology related to obesity are very important for the physician to be mentally and physically ready to face the associated issues.
... In this study, the severely overweight patients experienced more complications, mainly pulmonary in nature. In a prospective study of trauma patients, Bochicchio et al. 20 found that, when controlling for other factors, obese patients were 7.1 times more likely to die in the hospital. Meroz and Gozal 21 found that obese trauma patients are far more likely to develop in-hospital complications, especially pulmonary, renal, and thromboembolic complications than are their normal-weight counterparts. ...
Article
Full-text available
Introduction This retrospective cohort study was designed to investigate the association between body mass index (BMI) and the functional progress of 327 consecutive patients with amputation admitted to the amputee unit of a freestanding acute care rehabilitation hospital between January 2000 and April 2006. Methods Data were analyzed during the period of January 2000 to April 2006 from all previously amputated patients admitted and discharged from an acute freestanding rehabilitation hospital. Data were retrieved from the medical record including diagnosis, height, and weight measured before amputation, functional independence measurements (FIMs) scored on admission and discharge, and the length of rehabilitation hospitalization. Results After adjusting for age, sex, and length of stay, the FIM gain per day was the highest among those in the obese class I, followed by those in obese class III and the underweight group. Conclusions In patients undergoing rehabilitation after amputation, FIM gain per day is not significantly associated with BMI. Thus, obese patients can expect to have functional gains that are similar to patients with normal BMI after amputation. Copyright
Article
Critical illness is a hypercatabolic state. It has been hypothesized that timely and adequate nutrition support may optimize the host response and thereby minimize nutritionally related complications while improving overall outcome. Any illness in due course can lead to a malnourished state—critical illness can worsen this state as patients may become immunocompromised and unable to mount an adequate inflammatory response and therefore susceptible to poor outcomes. Data indicate that prevalence of malnutrition in the ICU ranges from 38% to 78% and is independently associated with poor outcomes. Hence, exploring the role of nutrition as a way to mitigate critical illness is important. In this review, the basic pathophysiology of critical illness and how it alters carbohydrate, protein, and fat metabolism are discussed. This is followed by a discussion of malnutrition and how it affects patient and hospital outcomes. Finally, a summary of the available evidence regarding nutrition support and its impact on outcomes are provided. This review is not intended to provide practice‐based guidelines; instead, it intends to highlight available data on the role of nutrition support in critically ill patients.
Article
During critical illness, obese patients have better outcomes compared to patients with normal BMI, and this is known as the obesity paradox. The difference in comorbidity burden have been implied to be responsible for the paradox. We performed a retrospective review from 2001 to 2012 of critically ill patients from the Medical Information Mart for Intensive Care database. We included 11,433 patients and classified them according to body mass index (BMI) and comorbidity burden (Elixhauser comorbidity measure). The odds of inpatient mortality were lower in obese patients compared to patients with normal BMI; in group with the least comorbidity score (Elixhauser <0) [OR: 0.47, CI (0.28–0.80), p-value 0.006] and higher comorbidity scores, (Elixhauser 1–5) [(OR: 0.66, CI (0.46–0.95), p-value 0.02)] and (Elixhauser 6–13) [OR: 0.69, CI (0.53–0.92), p-value 0.01]. 30-day mortality was also significantly lower in obese patients, in groups with the lowest (Elixhauser <0) [OR:49, CI (0.31–0.77), p-value 0.002] as well as the highest comorbidity burden (Elixhauser >14) [OR:0.59, CI (0.45–0.77), p-value <.001]. Subgroup analysis in patients with various comorbidities showed better outcomes in obese patients. These findings show that the decreased odds of mortality in critically ill obese patients is independent of the comorbidity burden or type of comorbidity.
Article
Blunt trauma is poorly tolerated in the elderly, and the degree to which obesity, a known risk factor for suboptimal outcomes in trauma affects this population remains to be determined. The incidence, prevalence, and mortality rates of blunt trauma by demographics, year, and geography were found using datasets from both the Global Burden of Disease database, and a Regional Level II trauma registry. Global Burden of Disease data were extracted from 284 country-year and 976 subnational-year combinations from 27 countries for the period 1990 to 2015. The regional trauma registry was interrogated for patients ≥70 years admitted with blunt trauma between 2014 and 2016. The incidence of elderly blunt trauma from falls increased at a global, national (United States), and state (WV) level from 1990 to 2015 by 78.3 per cent, 54.7 per cent, and 42.7 per cent, respectively with concomitant increases in mortality rates of 5.7 per cent, 102.6 per cent, and 89.3 per cent (P < 0.05). The regional cohort had a statistically similar mortality (obese, n = 320 vs nonobese, n = 926 of 4.8% vs 4.4%, respectively, P > 0.05). The hospital length-of-stay, Glasgow Coma Scale score, and systolic blood pressure on presentation were similar (P > 0.05) as was the Injury Severity Score. Major medical comorbidities were identified in 280 (87.5%) and 783 (84.6%) patients in the obese and nonobese groups, respectively. Blunt trauma, secondary to falls, has increased in elderly patients at a global, national, and state level with a concomitant increase in mortality rates. Although a similar increase in the incidence of blunt trauma in the elderly was noted at a regional center, its mortality has not been increased by obesity, possibly because of similar comorbidity rates.
Article
Introducción: No hay acuerdo en los reportes de la literatura sobre si un índice de masa corporal por arriba de 25 kg/m⁽²⁾ incrementa, no modifica o disminuye la mortalidad en pacientes en estado crítico. Objetivo: Comparar la mortalidad, morbilidad y consumo de recursos entre individuos con peso normal o bajo (índice de masa corporal IMC < 25 kg/m⁽²⁾) versus sujetos con sobrepeso u obesidad (IMC > 25 kg/m⁽²⁾). Diseño: Estudio de cohorte prolectiva en una unidad de terapia intensiva. Pacientes: Se incluyeron 159 personas en el estudio. Método: Se colectaron variables demográficas y clínicas, incluyendo peso y talla para calcular el índice de masa corporal. Se registraron datos de escalas de gravedad de la enfermedad SAPS-3, de falla orgánica Bruselas y de intervención terapéutica NEMS (como subrogado de consumo de recursos). El análisis estadístico fue multivariado; fue considerada significativa una p < 0.05. Resultados: Al comparar individuos con IMC < 25 kg/m⁽²⁾ con aquellos con un IMC mayor no hubo diferencia estadísticamente significativa en mortalidad y consumo de recursos. Sin embargo, al replantear el estudio y comparar sujetos con IMC < a 30 kg/m⁽²⁾ con aquellos con un IMC mayor, se encontró diferencia significativa en mortalidad entre ambos grupos y un tamaño del efecto considerable en cuanto a consumo de recursos en personas con un IMC > 30 kg/m⁽²⁾. Conclusiones: En México debemos cambiar el punto de corte del índice de masa corporal a 30 kg/m⁽²⁾ cuando comparemos mortalidad y consumo de recursos en los enfermos internados en la UTI. Este estudio abre la posibilidad de realizar un estudio multicéntrico para confirmar estos resultados.
Article
Introduction Chest trauma and obesity are both associated with increased risks for respiratory complications (e.g. hypoxia, hypercarbia, pneumonia), which are frequent causes of posttraumatic morbidity and mortality. However, as there is only limited and inconsistent evidence, the aim of our study was to analyse the effect of body mass index (BMI) on patient outcomes after thoracic trauma. Patients and Methods We screened 50.519 patients entered in TraumaRegister DGU®, between 2004–2009, when the BMI was part of the standardized dataset. After matching for injury patterns and severity of trauma we performed a matched tripled analysis with regard to the BMI (group 1: <25.0 kg/m²; group 2: 25.0–29.9 kg/m²; group 3: >30.0 kg/m²). Data are shown as percentages and mean values with standard deviation. Results The matching process yielded a cohort of 828 patients with serious blunt thoracic trauma, evenly distributed over the 3 BMI groups (276 triplets). BMI did not have an impact on the need for prehospital or emergency department interventions. There was a trend towards more liberal use of whole-body-CT scanning with increasing BMI (group 1: 68.8%; group 2: 73.2%; group 3: 75.0%). Additional abdominal injuries were more common in normal weight patients (Group 1: 28.3%; Group 2: 14.9%; Group 3: 17.8%). Obesity (BMI > 30.0 kg/m²) had a significant impact on the duration of mechanical ventilation (in days; group 1: 6.5 (9.4); group 2: 6.4 (8.9); group 3: 9.1 (14.4); p = 0.002), ICU days (in days; group 1: 11.5 (11.5); group 2: 10.9 (9.6); group 3: 14.1 (16.7); p = 0.005) and hospital length of stay (in days; group 1: 27.8 (19.3); group 2: 27.4 (19.2); group 3: 32.2 (25.9); p = 0.009). There were no significant differences regarding overall mortality (group 1: 3.6%; group 2: 1.8%; group 3: 4.0%; p = 0.26). Conclusions Obesity has a negative impact on outcomes after blunt chest trauma, as it is associated with prolonged duration of mechanical ventilation, ICU and hospital length of stay. Mortality did not seem to be affected, yet, further research is required to confirm these results in a larger cohort.
Article
Full-text available
Obesity represents a serious health problem as it is rapidly increasing worldwide. Obesity is associated with reduced health span and life span, decreased responses to infections and vaccination and increased frequency of inflammatory conditions. In this review, we summarize published data showing that obesity increases the risk of different types of infections, with a special focus on skin infections. Obesity also induces skin changes and conditions (inflammation-based and hypertrophic) which are often associated with fungi or bacteria overgrowth. The association of obesity with the skin microbiome has been established in both mice and humans. Balance of commensal microbes controls skin homeostasis and the host immune response, while changes in normal physiologic skin microbiome composition and pathologic bacteria contribute to skin diseases. We also summarize the major steps in wound healing and how obesity affects each of them. The role that immune cells have in this process is also described. Although the studies summarized in this review clearly demonstrate the deleterious effects of obesity on wound healing, additional studies are needed to better characterize the cellular and molecular mechanisms involved and identify specific targets of intervention.
Article
Background Although obesity is considered an epidemic in the United States, there is mixed evidence regarding the impact of obesity on outcomes after traumatic injury and major surgery. We hypothesized that obese patients undergoing trauma laparotomy would be at increased risk of failure to rescue (FTR), defined as death after a complication. Methods We analyzed trauma registry data for adult patients who underwent abdominal exploration for trauma at all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used competing risks regression to identify significant risk factors for complications. We used multivariable logistic regression to identify significant risk factors for FTR. Results Of 95,806 admitted patients, 15,253 (15.9%) were categorized as obese. Overall, 3228 (3.4%) underwent laparotomy, including 2681 (83.1%) nonobese and 547 (17.0%) obese patients. Among obese patients, 47.2% had at least one complication and 28.7% had two or more complications, compared with 33.5% and 18.7% of nonobese patients, respectively. The most common complication was pneumonia (15.0% of obese and 10.5% of nonobese patients; P = 0.003), followed by sepsis (8.8% versus 4.2%; P < 0.001) and deep vein thrombosis (8.4% versus 5.9%; P < 0.001). Obesity was independently associated with complications (hazard ratio, 1.4; 95% confidence interval, 1.2-1.6). In multivariable analysis, obesity was not associated with FTR (odds ratio, 1.3; 95% confidence interval, 0.9-2.0). Conclusions Obesity is a risk factor for complications after traumatic injury but not for FTR. The increased risk of complications may reflect processes of care that are not attuned to the needs of this population, offering opportunities for improvement in care.
Chapter
It is becoming more common for surgeons to manage obese patients in the acute setting with non-bariatric surgical emergencies. Obesity presents a diagnostic challenge for the acute care surgeon. Given the emergent need for intervention and the subsequently minimized opportunity for preoperative selection and optimization, obese patients requiring emergency surgery represent a complex patient population at high risk for perioperative morbidity. There is nothing unique about perforations of the upper gastrointestinal tract in the obese population versus other patients but there are specific additional considerations that the acute care surgeon should be aware of. It is particularly important that obese patients requiring emergency surgery are managed by an anesthetist experienced in the care of the obese along with an experienced surgeon in order to minimize the operative time and the risk of complications. Bariatric surgical expertise seems to favorably impact hospital length of stay and the application of more minimally invasive approaches in cases not routinely done laparoscopically.
Chapter
Obesity is associated with increased all-cause mortality in the general population but the mortality rate of obese patients after elective surgery is lower in comparison to normal-weight patients. The reasons for this “obesity paradox” remain unexplained because of the different parameters used to define obesity and the heterogeneity of the obese population, which includes metabolically healthy, unhealthy and complicated patients. Moreover, the obesity paradox was not confirmed after emergency surgery and trauma, when a large number of factors are involved in the pathogenesis of complications and death. Infection, sepsis, septic shock, cardiac and respiratory comorbidities are the main causes of death related to obesity: they should be considered when predicting surgical risk before surgery.
Chapter
Trauma and burns affect obese patients with typical clinical features. A high body mass index (BMI) and body habitus make burns more extended and involvement of the ribs and pelvic ring after trauma more frequent. There are also more difficulties in the care of the patients because they may be affected by cardiovascular and pulmonary complications. They show a high catabolic condition and have a high risk of pulmonary embolism. Careful evaluation of the complications and appropriate pharmacological treatment could contribute to the best results, but surgical site infections and mortality rates are higher than in the normal-weight population.
Article
Traumatic injuries account for 10% of all mortalities in the United States. Globally, it is estimated that by the year 2030, 2.2 billion people will be overweight (BMI ≥ 25) and 1.1 billion people will be obese (BMI ≥ 30). Obesity is a known risk factor for suboptimal outcomes in trauma; however, the extent of this impact after blunt trauma remains to be determined. The incidence, prevalence, and mortality rates from blunt trauma by age, gender, cause, BMI, year, and geography were abstracted using datasets from 1) the Global Burden of Disease group 2) the United States Nationwide Inpatient Sample databank 3) two regional Level II trauma centers. Statistical analyses, correlations, and comparisons were made on a global, national, and state level using these databases to determine the impact of BMI on blunt trauma. The incidence of blunt trauma secondary to falls increased at global, national, and state levels during our study period from 1990 to 2015, with a corresponding increase in BMI at all levels (P < 0.05). Mortality due to fall injuries was higher in obese patients at all levels (P < 0.05). Analysis from Nationwide Inpatient Sample database demonstrated higher mortality rates for obese patients nationally, both after motor vehicle collisions and mechanical falls (P < 0.05). In obese and nonobese patients, regional data demonstrated a higher blunt trauma mortality rate of 2.4% versus 1.2%, respectively (P < 0.05) and a longer hospital length of stay of 4.13 versus 3.26 days, respectively (P = 0.018). The obesity rate and incidence of blunt trauma secondary to falls are increasing, with a higher mortality rate and longer length of stay in obese blunt trauma patients.
Chapter
Over one third of the US population is considered obese, but the health issue of obesity is rapidly extending to a global epidemic. Thus, it is inevitable that acute care clinicians are to be involved in the metabolic management of hospitalized patients with obesity. Obesity compounds the metabolic and inflammatory response to critical illness and increases the risk of complications of overfeeding such as hyperglycemia, hypercapnia, and hepatic steatosis. The metabolic management of surgical patients with obesity is uniquely different from that of the nonobese patient. The scientific evidence for the use of hypocaloric, high-protein parenteral or enteral nutrition as well as practical techniques for delivering, managing, and monitoring this therapy is reviewed.
Article
Introduction Previous studies have identified obesity as a risk factor for difficult IV access, but this has not been studied in the acute trauma setting. The primary objective was to determine if obesity is associated with increased difficulty placing peripheral IVs in trauma patients. Secondary analysis evaluated IV difficulty and associations with nursing self-competence ratings, trauma experience, and patient demographics. Methods Prospective, observational study at academic level I trauma center with 58,000 annual visits. Trauma activation patients between January and October of 2016 were included. Each nurse who attempted IV placement, completed anonymous 7 question survey, including trauma experience (years), self-competence and IV difficulty (Likert scales 1–5), and attempts. Demographic and clinical information was retrospectively collected from the EMR and nursing surveys. Descriptive statistics, chi-square tests, and spearman correlations were used. Results 200 patients included in the study with 185 BMI calculations. 110 overweight (BMI > 25) and 48 obese (BMI > 30). 70 (35%) female, 149 (75%) white, average age 48. Increased BMI and IV difficulty displayed spearman correlation (ρ) of 0.026 (P = 0.72) suggesting against significant association. Increased trauma experience and self-competence ratings significantly correlated with decreased IV difficulty, ρ = −0.173 and −0.162 (P = 0.010 and 0.014). There was no statistically significant association with IV difficulty in regards to patient race, age, sex, or location of IV placement. Conclusion Obesity was not associated with increased difficulty in placing peripheral IVs in trauma activation patients. Nurses with greater trauma experience and higher self-competence ratings, had less difficulty inserting IVs.
Article
The obesity pandemic now affects hundreds of millions of people worldwide. As obesity rates continue to increase, emergency physicians are called on with increasing frequency to resuscitate obese patients. This article discusses important anatomic, physiologic, and practical challenges imposed by obesity on resuscitative care. Impacts on hemodynamic monitoring, airway and ventilator management, and pharmacologic therapy are discussed. Finally, several important clinical scenarios (trauma, cardiac arrest, and sepsis), in which alterations to standard treatments may benefit obese patients, are highlighted.
Chapter
The prevalence of obesity continues to rise in both the developed and developing countries and is associated with an increased incidence of a wide spectrum of medical and surgical ailments. This chapter provides an overview of the physiologic changes reported in respiratory and metabolic systems and the clinical implications for the management of respiratory failure and circulatory derangements. Alterations in pharmacokinetics and pharmacodynamics often require adjustment in dosing for common therapeutic agents. Proper equipment may be needed to ensure adequate and safe provision of care. Prior to ordering a diagnostic imaging, a review of scanner specification is recommended. Despite higher morbidity associated with the critically ill obese, a paradoxical lower intensive care unit (ICU) mortality (“obesity paradox”) is demonstrated in comparison to nonobese ICU patients.
Article
In the last few decades, obesity became one of the world's greatest health challenges reaching a size of global epidemic in virtually all socioeconomic statuses and all age groups. Obesity is a risk factor for many health problems and as its prevalence gradually increases is becoming a significant economic and health burden. In this manuscript we describe how normal respiratory and cardiovascular physiology is altered by obesity. We review past and current literature to describe how obesity affects outcomes of patients facing critical illnesses and discuss some controversies related to this topic.
Article
The prevalence of obesity continues to rise and is caused by many factors. Obesity places patients at risk for high blood pressure, diabetes, heart disease, and cancer. Although obesity in the normal population is associated with increased morbidity and mortality, obesity in critically ill patients has lower mortality. This is referred to as the obesity paradox, and although not fully understood, involves several mechanisms that demonstrate a protective factor in critically ill obese patients. However, despite the benefit, the management of critically ill obese patients faces many challenges.
Chapter
The severely injured trauma patient, defined as an Injury Severity Score (ISS) > 15, requiring resuscitation and admission to the Intensive Care Unit (ICU) is the population at risk for developing post-injury multiple organ failure (MOF). There have been several predictors for the development of MOF described over the last four decades; these include age, severity of injury, resuscitation and blood transfusion to name a few. Some MOF risk factors have changed over time due to demographic changes and with refinement of shock management and improved critical care management. Identifying the modifiable versus non-modifiable risk factors is the key factor to guiding research and therapeutic strategies to reduce the incidence and impact of post-injury MOF. This chapter will review the statistically proven clinical independent predictors including patient factors, injury factors and treatment factors affecting the population at risk and the predictors for developing MOF.
Article
Background: We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). Study design: Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30). Results: Of the 4192 patients identified, 3821 met the inclusion criteria; 3019 patients had a BMI <30, and 802 had a BMI ≥30. There was a statistically significant difference between the 2 groups with respect to gender (females: 57% vs 47%, P < .0001) and age (median: 80 [IQR: 63-88] vs 69 [IQR: 55-81], P < .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use. Conclusions: Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.
Article
Full-text available
Background Recently, about 2.35% of the world populations are estimated to be chronically infected with hepatitis C virus (HCV). Previous cohort studies indicated that obesity increases risk of hepatic steatosis and fibrosis in non-diabetic patients with chronic hepatitis C infection due to diminished response to anti-viral therapy and as a result obesity is considered as an important factor in the progression of chronic HCV. However, there is a strong association between BMI and the human immune system among HCV patients. Objective This study aimed to examine effects of weight reduction program on selected immune parameters among HCV Saudi patients. Material and methods One-hundred obese Saudi patients with chronic HCV infection participated in this study, their age ranged from 50–58 years and their body mass index (BMI) ranged from 30–35 kg/m². All Subjects were included in two groups: The first group received weight reduction program in the form of treadmill aerobic exercises in addition to diet control whereas, the second group received no therapeutic intervention. Parameters of CD3, CD4 and CD8 were quantified; Leukocyte, differential counts and BMI were measured before and after 3 months, at the end of the study. Results The mean values of BMI, white blood cells, total neutrophil count, monocytes, CD3, CD4 and CD8 were significantly decreased in the training group as a result of weight loss program; however the results of the control group were not significant. Also, there were significant differences between both groups at the end of the study. Conclusion Weight loss modulates immune system parameters of patients with HCV.
Article
Full-text available
Context The prevalence of obesity and overweight increased in the United States between 1978 and 1991. More recent reports have suggested continued increases but are based on self-reported data.Objective To examine trends and prevalences of overweight (body mass index [BMI] ≥25) and obesity (BMI ≥30), using measured height and weight data.Design, Setting, and Participants Survey of 4115 adult men and women conducted in 1999 and 2000 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population.Main Outcome Measure Age-adjusted prevalence of overweight, obesity, and extreme obesity compared with prior surveys, and sex-, age-, and race/ethnicity–specific estimates.Results The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared with 22.9% in NHANES III (1988-1994; P<.001). The prevalence of overweight also increased during this period from 55.9% to 64.5% (P<.001). Extreme obesity (BMI ≥40) also increased significantly in the population, from 2.9% to 4.7% (P = .002). Although not all changes were statistically significant, increases occurred for both men and women in all age groups and for non-Hispanic whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did not differ significantly in the prevalence of obesity or overweight for men. Among women, obesity and overweight prevalences were highest among non-Hispanic black women. More than half of non-Hispanic black women aged 40 years or older were obese and more than 80% were overweight.Conclusions The increases in the prevalences of obesity and overweight previously observed continued in 1999-2000. The potential health benefits from reduction in overweight and obesity are of considerable public health importance.
Article
Full-text available
The prevalence of obesity increased in the United States between 1976-1980 and 1988-1994 and again between 1988-1994 and 1999-2000. To examine trends in obesity from 1999 through 2008 and the current prevalence of obesity and overweight for 2007-2008. Analysis of height and weight measurements from 5555 adult men and women aged 20 years or older obtained in 2007-2008 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population. Data from the NHANES obtained in 2007-2008 were compared with results obtained from 1999 through 2006. Estimates of the prevalence of overweight and obesity in adults. Overweight was defined as a body mass index (BMI) of 25.0 to 29.9. Obesity was defined as a BMI of 30.0 or higher. In 2007-2008, the age-adjusted prevalence of obesity was 33.8% (95% confidence interval [CI], 31.6%-36.0%) overall, 32.2% (95% CI, 29.5%-35.0%) among men, and 35.5% (95% CI, 33.2%-37.7%) among women. The corresponding prevalence estimates for overweight and obesity combined (BMI > or = 25) were 68.0% (95% CI, 66.3%-69.8%), 72.3% (95% CI, 70.4%-74.1%), and 64.1% (95% CI, 61.3%-66.9%). Obesity prevalence varied by age group and by racial and ethnic group for both men and women. Over the 10-year period, obesity showed no significant trend among women (adjusted odds ratio [AOR] for 2007-2008 vs 1999-2000, 1.12 [95% CI, 0.89-1.32]). For men, there was a significant linear trend (AOR for 2007-2008 vs 1999-2000, 1.32 [95% CI, 1.12-1.58]); however, the 3 most recent data points did not differ significantly from each other. In 2007-2008, the prevalence of obesity was 32.2% among adult men and 35.5% among adult women. The increases in the prevalence of obesity previously observed do not appear to be continuing at the same rate over the past 10 years, particularly for women and possibly for men.
Article
Full-text available
To describe the prevalence of, and trends in, overweight and obesity in the US population using standardized international definitions. Successive cross-sectional nationally representative surveys, including the National Health Examination Survey (NHES I; 1960-62) and the National Health and Nutrition Examination Surveys (NHANES I: 1971-1974; NHANES II: 1976-1980; NHANES III: 1988-94). Body mass index (BMI:kg/m2) was calculated from measured weight and height. Overweight and obesity were defined as follows: Overweight (BMI > or = 25.0); pre-obese (BMI 25.0-29.9), class I obesity (BMI 30.0-34.9), class II obesity (BMI 35.0-39.9), and class III obesity (BMI > or = 40.0). For men and women aged 20-74 y, the age-adjusted prevalence of BMI 25.0-29.9 showed little or no increase over time (NHES I: 30.5%, NHANES I: 32.0%, NHANES II: 31.5% and NHANES III: 32.0%) but the prevalence of obesity (BMI > or = 30.0) showed a large increase between NHANES II and NHANES III (NHES I: 12.8%; NHANES I, 14.1%; NHANES II, 14.5% and NHANES III, 22.5%). Trends were generally similar for all age, gender and race-ethnic groups. The crude prevalence of overweight and obesity (BMI > 25.0) for age > or = 20 y was 59.4% for men, 50.7% for women and 54.9% overall. The prevalence of class III obesity (BMI > or = 40.0) exceeded 10% for non-Hispanic black women aged 40-59 y. Between 1976-80 and 1988-94, the prevalence of obesity (BMI > or= 30.0) increased markedly in the US. These findings are in agreement with trends seen elsewhere in the world. Use of standardized definitions facilitates international comparisons.
Article
Full-text available
Overweight and obesity are increasing dramatically in the United States and most likely contribute substantially to the burden of chronic health conditions. To describe the relationship between weight status and prevalence of health conditions by severity of overweight and obesity in the US population. Nationally representative cross-sectional survey using data from the Third National Health and Nutrition Examination Survey (NHANES III), which was conducted in 2 phases from 1988 to 1994. A total of 16884 adults, 25 years and older, classified as overweight and obese (body mass index [BMI] > or =25 kg/m2) based on National Institutes of Health recommended guidelines. Prevalence of type 2 diabetes mellitus, gallbladder disease, coronary heart disease, high blood cholesterol level, high blood pressure, or osteoarthritis. Sixty-three percent of men and 55% of women had a body mass index of 25 kg/m2 or greater. A graded increase in the prevalence ratio (PR) was observed with increasing severity of overweight and obesity for all of the health outcomes except for coronary heart disease in men and high blood cholesterol level in both men and women. With normal-weight individuals as the reference, for individuals with BMIs of at least 40 kg/m2 and who were younger than 55 years, PRs were highest for type 2 diabetes for men (PR, 18.1; 95% confidence interval [CI], 6.7-46.8) and women (PR, 12.9; 95% CI, 5.7-28.1) and gallbladder disease for men (PR, 21.1; 95% CI, 4.1-84.2) and women (PR, 5.2; 95% CI, 2.9-8.9). Prevalence ratios generally were greater in younger than in older adults. The prevalence of having 2 or more health conditions increased with weight status category across all racial and ethnic subgroups. Based on these results, more than half of all US adults are considered overweight or obese. The prevalence of obesity-related comorbidities emphasizes the need for concerted efforts to prevent and treat obesity rather than just its associated comorbidities.
Article
Full-text available
The prevalence of obesity and overweight increased in the United States between 1978 and 1991. More recent reports have suggested continued increases but are based on self-reported data. To examine trends and prevalences of overweight (body mass index [BMI] > or = 25) and obesity (BMI > or = 30), using measured height and weight data. Survey of 4115 adult men and women conducted in 1999 and 2000 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population. Age-adjusted prevalence of overweight, obesity, and extreme obesity compared with prior surveys, and sex-, age-, and race/ethnicity-specific estimates. The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared with 22.9% in NHANES III (1988-1994; P<.001). The prevalence of overweight also increased during this period from 55.9% to 64.5% (P<.001). Extreme obesity (BMI > or = 40) also increased significantly in the population, from 2.9% to 4.7% (P =.002). Although not all changes were statistically significant, increases occurred for both men and women in all age groups and for non-Hispanic whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did not differ significantly in the prevalence of obesity or overweight for men. Among women, obesity and overweight prevalences were highest among non-Hispanic black women. More than half of non-Hispanic black women aged 40 years or older were obese and more than 80% were overweight. The increases in the prevalences of obesity and overweight previously observed continued in 1999-2000. The potential health benefits from reduction in overweight and obesity are of considerable public health importance.
Article
Full-text available
Obesity is often perceived to be a risk factor for adverse outcomes following coronary artery bypass graft (CABG) surgery. Several studies have been unclear about the relationship between obesity and the risk of adverse outcomes. The aim of this study was to examine the relationship between obesity and in-hospital outcomes following CABG, while adjusting for confounding factors. A total of 4713 consecutive patients undergoing isolated CABG between April 1997 and September 2001 were retrospectively analyzed. Body mass index (BMI) was used as the measure of obesity and was grouped as non-obese (BMI <30), obese (BMI 30-35), and severely obese (BMI > or =35). Associations between obesity and in-hospital outcomes were assessed by use of logistic regression to adjust for differences in patient characteristics. A total of 3429 patients were defined as non-obese, compared to 1041 obese and 243 severely obese. There was no association between obesity and in-hospital mortality, stroke, myocardial infarction, re-exploration for bleeding and renal failure. Obesity was significantly associated with atrial arrhythmia (adjusted odds ratio (OR) 1.19, P = 0.037 for the obese; adjusted OR 1.52, P = 0.008 for the severely obese) and sternal wound infections (adjusted OR 1.82, P = 0.002 for the obese; adjusted OR 2.10, P = 0.038 for the severely obese). The severely obese patients were 4.17 (P < 0.001) times more likely to develop harvest site infections. Severely obese patients were also more likely to have prolonged mechanical ventilation and post-operative stays, compared to non-obese patients. Obese patients are not associated with an increased risk of in-hospital mortality following coronary artery bypass surgery. In contrast, there is a significant increased risk of morbidities and post-operative length of stay in obese patients compared to non-obese patients.
Article
BACKGROUND:Women usually have lower mortality rates than men do at any age. This pattern is observed for most causes of death from chronic diseases. Significant controversy still exists about gender differences in outcomes in trauma. We previously reported no differences in in-hospital mortality based on gender in a large single-institution study (n = 18,892) that had a significant limitation in that it was not population based. This current study was performed to validate our earlier findings in a separate, statewide, population-based dataset of trauma victims.STUDY DESIGN:Prospective data were collected on 22,332 trauma patients (18,432 blunt, 3,900 penetrating) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in in-hospital mortality were determined for the entire dataset and for the subsets of blunt and penetrating injury patients. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay of less than 24 hours, eliminating patients who expired soon after admission. The null hypothesis was that female gender is protective in trauma outcomes.RESULTS:Multiple logistic regression analysis identified age (odds ratio [OR] 1.03, confidence interval [CI] 1.02 to 1.03), Injury Severity Score (OR 1.06, CI 1.05 to 1.06), non-Caucasian race (OR 1.72, CI 1.39 to 2.15), blunt injury type (OR 0.327, CI 0.26 to 0.41), and Revised Trauma Score (OR 0.44, CI 0.41 to 0.47) as independent predictors of in-hospital mortality in trauma. Preexisting diseases, including cardiac disease (OR 1.53, CI 1.12 to 2.09) and malignancy (OR 4.08, CI 1.64 to 10.17), were also identified as independent predictors of in-hospital mortality in trauma. Female gender was not associated with decreased mortality (OR 0.83, CI 0.67 to 1.03, p = 0.093). A second multiple regression analysis in blunt trauma patients admitted for longer than 24 hours (which eliminated early deaths and patients with minor injuries) determined that in-hospital mortality was not significantly different in male or female blunt trauma patients stratified by Injury Severity Score and age. The same factors that were predictive of in-hospital mortality in the total dataset were also significant in this secondary analysis.CONCLUSIONS:These population-based data confirm that female gender does not adversely affect in-hospital mortality in trauma when patients are appropriately stratified for other variables, including Injury Severity Score and age, that do significantly affect outcomes.
Article
To determine the effect of admission body weight on blunt trauma victims, a chart review of all patients >12 years of age admitted to Sentara Norfolk General Hospital between January 1 and July 31, 1987 was undertaken. The charts of 351 patients were reviewed; 184 records contained admission height and weight. These 184 patients made up the study group and age, gender, injuries, Injury Severity Score (ISS), ventilator days (VD), complications, length of stay (LOS), and outcome were noted. Body Mass Index (BMI) (weight (kg)/(height (m))2, was calculated for each patient. The average ISS was 21.87 (range, 1-66) and the average BMI was 25.15 kg/m2 (range, 16-46 kg/m2). The overall mortality for the population was 9%. The population was grouped according to BMI: average (<27 kg/m2), overweight (27-31 kg/m2), and severely overweight (>31 kg/m2). The mortality of 5.0% and 8.0% in the average and overweight groups was not different. The severely overweight group had a higher mortality at 42.1% compared with the other two groups (p < 0.0001). The groups did not differ in age, ISS, LOS, nor VD. Age, BMI, and ISS were subjected to regression analysis. By this method BMI and ISS were independent determinants of outcome (p < 0.0001). There was an increase in complications, mainly pulmonary problems, in the SO group (p < 0.05). The three groups were subdivided into survivors and nonsurvivors. The nonsurvivors had a longer average LOS at 26.6 days compared with nonsurvivors in the overweight (5.0 days) or severely overweight (8.62 days) groups (p < 0.007). The severely overweight group was characterized by a rapid deterioration and demise that was unresponsive to intervention. ISS did not differ among nonsurvivors. Among survivors the severely overweight group had a lower ISS, 9.73. This was different from the overweight group (21.57) and from the average group (20.21) (p < 0.04). (C) Williams & Wilkins 1991. All Rights Reserved.
Article
Objective: To determine if body mass Index (BMI = weight [kg]/height [m]2), predictive of mortality in longitudinal epidemiologic studies, was also predictive of mortality in a sample of seriously ill hospitalized subjects. Design: Prospective, multicenter study. Setting: Five tertiary care medical centers in the United States. Patients: Patients >or=to18 yrs of age who had one of nine illnesses of sufficient severity to anticipate a 6-month mortality rate of 50% were enrolled at five participating sites in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Interventions: None. Measurements and Main Results: Patients were asked their current height and weight as part of the demographic data. Stratifying body mass index by percentile rank (<or=to15, 15 to 85, and >or=to85th percentiles), risk ratios for mortality were calculated by Cox Proportional Hazards using the 15th to 85th percentile of body mass index as the reference group while controlling for multiple variables such as prior weight loss, albumin, and Acute Physiology Score. A body mass index in the <or=to15th percentile was associated with an excess risk of mortality (risk ratio = 1.23; p < .001) within 6 months. High body mass index (>or=to85th percentile) was not significantly related to risk of mortality. Conclusions: Body mass index, a simple anthropometric measure of nutrition employed in community epidemiologic studies, has now been demonstrated to be a predictor of mortality in an acutely ill population of adults at five different tertiary centers. Even when controlling for multiple disease states and physiologic variables and removing from the analysis all patients with significant prior weight loss, a body mass index below the 15th percentile remained a significant and independent predictor of mortality. Examination of patient vs. proxy data did not change the results. Future studies examining variables predictive of mortality should include body mass index, even in acutely ill populations with a poor probability of survival. (Crit Care Med 1997; 25:1962-1968)
Article
The records of obese and nonobese victims of blunt trauma were compared to determine if obese individuals are predisposed to a specific injury pattern. Prospectively collected data on 6368 adults admitted to a level I trauma center over a 4-year period were analyzed. Twelve percent (743 patients) met Body Mass Index (weight/height2) criteria for obesity (greater than or equal to 30 kg/m2). The obese group was older (p less than 0.01) and had lower ISSs (p less than 0.05) and higher GCS scores (p less than 0.01). More obese patients were injured in vehicular crashes (62.7% vs. 54.1% [p less than 0.01]). The obese victims were more likely to have rib fractures, pulmonary contusions, pelvic fractures, and extremity fractures and less likely to have incurred head trauma and liver injuries (p less than 0.05). Obese people injured in vehicular crashes had a similar injury pattern with no difference in seating position, direction of impact, seat belt use, and ejection.
Article
To determine the effect of admission body weight on blunt trauma victims, a chart review of all patients greater than 12 years of age admitted to Sentara Norfolk General Hospital between January 1 and July 31, 1987 was undertaken. The charts of 351 patients were reviewed; 184 records contained admission height and weight. These 184 patients made up the study group and age, gender, injuries, Injury Severity Score (ISS), ventilator days (VD), complications, length of stay (LOS), and outcome were noted. Body Mass Index (BMI) (weight (kg)/(height(m))2, was calculated for each patient. The average ISS was 21.87 (range, 1-66) and the average BMI was 25.15 kg/m2 (range, 16-46 kg/m2). The overall mortality for the population was 9%. The population was grouped according to BMI: average (less than 27 kg/m2), overweight (27-31 kg/m2), and severely overweight (greater than 31 kg/m2). The mortality of 5.0% and 8.0% in the average and overweight groups was not different. The severely overweight group had a higher mortality at 42.1% compared with the other two groups (p less than 0.0001). The groups did not differ in age, ISS, LOS, nor VD. Age, BMI, and ISS were subjected to regression analysis. By this method BMI and ISS were independent determinants of outcome (p less than 0.0001). There was an increase in complications, mainly pulmonary problems, in the SO group (p less than 0.05). The three groups were subdivided into survivors and nonsurvivors. The nonsurvivors had a longer average LOS at 26.6 days compared with nonsurvivors in the overweight (5.0 days) or severely overweight (8.62 days) groups (p less than 0.007). The severely group was characterized by a rapid deterioration and demise that was unresponsive to intervention. ISS did not differ among nonsuvivors. Among survivors the severely overweight group had a lower ISS, 9.73. This was different from the overweight group (21.57) and from the average group (20.21) (p less than 0.04).
Article
To determine the utility of an audio-guided Doppler ultrasound device in improving success and decreasing complications in cannulation of the internal jugular vein in high-risk patients. Prospective, randomized, crossover clinical study. Two major university medical centers in critical care environments. Seventy-six consecutive, consenting adult patients with preexisting obesity or coagulopathy requiring central venous access. Subjects enrolled in the study were randomized to receive either the traditional "blind" (control) technique or the ultrasonic technique. A maximum of three cannulation attempts were allowed before crossover to three attempts with the alternative technique. All cannulations were attempted via the internal jugular vein through a high/central approach. Patient and operator characteristics were similar between groups. The initial use of an audio-guided ultrasound device was associated with increased success of cannulation (84.4% vs. 61.4%; p < .05) and decreased need to crossover to the alternative technique. Success on the first needle pass was more likely with the ultrasound technique (56.3% vs. 29.5%; p < .05). Significant complications were greater with the control technique (carotid artery puncture 16.3% vs. 2.0% [p < .02]; any significant complication 26.5% vs. 6.1% [p < .01]). The use of an audio-guided Doppler ultrasound vascular access device was associated with increased success of cannulation and a decreased frequency of significant complications in a population of high-risk patients with obesity or coagulopathy.
Article
The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the incidence and circumstances of problems with endotracheal intubation; 85 (4%) indicated difficulties with intubation. One third of these were emergency cases, one third involved an initially unassisted trainee and one fifth were outside normal working hours. Failure to predict a difficult intubation was reported in one third of the cases, with another quarter presenting serious difficulty despite preoperative prediction. Difficulties with ventilation were experienced in 1 in 7 of the 85 reports; there was one cardiac arrest, but no death. Endotracheal intubation was not achieved in one fifth of the cases. The commonest complications reported amongst the 85 incidents were oesophageal intubation (18 cases), arterial desaturation (15 cases), and reflux of gastric contents (7 cases). Emergency trans-tracheal airways were required in 5 cases. Obesity, limited neck mobility and mouth opening, and inadequate assistance together accounted for two thirds of all the contributing factors. The most successful intubation aid in this series was a gum elastic bougie. A capnograph contributed to management in 28% and a pulse oximeter in 12% of the cases in which they were used. The most serious desaturations were associated with accidental oesophageal intubation. These data suggest a lack of reliable preoperative assessment techniques and skills for the prediction of difficult intubations. They also suggest the need for a greater emphasis on ensuring that the necessary equipment is available, and on teaching and learning drills for difficult intubation and any associated difficulty with ventilation.
Article
Given that overweight is clearly associated with increased risk of many major chronic diseases, the United States could have saved approximately $45.8 billion or 6.8% of health care expenditures in 1990 alone if obesity were prevented. The question then arises, economically and socially, what is a healthy body weight? Using a prevalence-based approach to cost of illness, we estimated the economic costs (1993 dollars) associated with illness at different strata of body mass indexes (BMIs, in kg/m2) and varying increments of weight gain to address the questions: At what body weight do we initiate preventive services? What are the direct costs associated with weight gain? Second, using the 1988 National Health Interview Survey (NHIS), we evaluated the marginal increase in certain social indexes reflective of functional impairment and morbidity (ie, restricted-activity days, bed days, and work-loss days) as well as physician visits associated with different strata of BMI. With respect to economic and social indexes, a healthy body weight appears to be a BMI < 25, and weight gain should be kept to < 5 kg throughout a lifetime.
Article
To review recent advances in the pathophysiology and potential clinical applications of leptin, an adipose tissue-derived hormone. A MEDLINE search of the literature on leptin and the bibliographies of relevant papers. All 1320 publications on leptin. All identified articles were reviewed. Cited publications were selected on the basis of study quality and relevance to human obesity and disease. Leptin is a 16-kilodalton adipocyte-derived hormone that circulates in the serum in the free and bound form. Serum levels of leptin reflect the amount of energy stored in adipose tissue. Short-term energy imbalance as well as serum levels of several cytokines and hormones influence circulating leptin levels. Leptin acts by binding to specific receptors in the hypothalamus to alter the expression of several neuropeptides that regulate neuroendocrine function and energy intake and expenditure. Thus, leptin plays an important role in the pathogenesis of obesity and eating disorders and is thought to mediate the neuroendocrine response to food deprivation. Phase I and II trials recently showed that leptin administration to humans is safe, and ongoing phase III trials are assessing the efficacy of leptin as a treatment for obesity and related disorders. Availability of leptin or smaller and more soluble leptin analogues for clinical studies in humans is expected to significantly advance understanding of the mechanisms underlying energy homeostasis in humans. Leptin is significantly broadening our understanding of the mechanisms underlying neuroendocrine function, body weight, and energy homeostasis. Elucidation of these mechanisms is expected to result in the development of novel therapeutic approaches for obesity and eating disorders.
Article
Body mass index (weight in kilograms divided by the square of the height in meters [BMI]) is known to be associated with overall mortality. However, the effect of age on excess mortality from all causes associated with obesity is controversial. The aim of the present study is to determine the effect of age on the relationship between BMI and mortality. We analyzed data from a large collaborative observational study group, the Italian Group of Pharmacoepidemiology in the Elderly (GIFA), that collected data on hospitalized patients. A total of 18,316 patients consecutively admitted to 79 clinical centers during 5 different surveys in 1998, 1991, 1993, 1995, and 1997 were enrolled in the present study. The main outcome measure was the relative hazard ratio of death for different levels of BMI. Mortality rate was lowest among men and women with BMIs from 25.0 through 27.4 kg/m(2) (relative risk, 0.24; 95% confidence interval, 0.15-0.38). The graphed relationship between BMI and mortality in younger patients was hyperbolic, with increased death rates at the lowest and highest BMI rankings. On the contrary, the older patients showed an increased death rate at the lowest BMIs with only a slight elevation at the highest BMIs (>35 kg/m(2)). Our results suggest that BMI, a simple anthropometric measure of nutritional status, is an important predictor of mortality among young and old hospitalized patients. Even when controlling for clinical and functional variables, a low BMI remained a significant and independent predictor of shortened survival. Furthermore, the finding of the high BMI associated with minimum hazard in elderly subjects supports some past findings and opposes others and, if confirmed, has important implications for geriatric clinical guidelines.
Article
Obesity can profoundly alter pulmonary function and diminish exercise capacity by its adverse effects on respiratory mechanics, resistance within the respiratory system, respiratory muscle function, lung volumes, work and energy cost of breathing, control of breathing, and gas exchange. Weight loss can reverse many of the alterations of pulmonary function produced by obesity. Obesity places the patient at risk of aspiration pneumonia, pulmonary thromboembolism, and respiratory failure. It is the most common precipitating factor for obstructive sleep apnea and is a requirement for the obesity hypoventilation syndrome, both of which are associated with substantial morbidity and increased mortality. There are numerous medical and surgical therapies for obstructive sleep apnea and obesity hypoventilation. Weight reduction in the obese is among the most effective of these measures.
Article
Study objective: To describe the clinical course, complications, and prognostic factors of morbidly obese patients admitted to the ICU compared to a control group of nonobese patients. A retrospective study. Two university-affiliated hospitals. We reviewed the medical records of 117 morbidly obese patients (body mass index >/= 40 kg/m(2)) admitted to the medical ICU between January 1994 and June 2000. Data collected included demographic information, comorbid condition, APACHE (acute physiology and chronic health evaluation) II score, invasive procedures, organ failure, and in-hospital mortality. Obstructive airway disease, pneumonia, and sepsis were the main reasons for admission to the ICU in the morbidly obese group. Sixty-one percent of the morbidly obese patients and 46% of the nonobese group required mechanical ventilation (p = 0.02). The mean lengths of mechanical ventilation and ICU stay were significantly longer for the morbidly obese group (7.7 +/- 9.6 days and 9.3 +/- 10.5 days vs 4.6 +/- 7.1 days and 5.8 +/- 8.2 days, respectively; p < 0.001). APACHE II scores were not significantly different in the two groups (19.1 +/- 7.6 and 20.6 +/- 12.2; p = 0.6). Overall mortality was 30% for the morbidly obese patients and 17% for the nonobese group (p = 0.019). By multivariate analysis, multiorgan failure (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.1 to 16.6), PaO(2)/fraction of inspired oxygen < 200 for > 48 h (OR, 2.3; 95% CI, 1.2 to 7.8), and depressed left ventricular ejection fraction < 40% (OR, 1.4; 95% CI, 1.03 to 13.8) were independently associated with ICU mortality in the morbidly obese group. We conclude that critically ill morbidly obese patients are at increased risk of morbidity and mortality compared to the nonobese patients.
Article
We have recently shown that human monocytic cells express functional leptin receptors and that leptin is capable of inducing the expression and secretion of the IL-1 receptor antagonist (IL-1Ra). Although IL-1Ra has anti-inflammatory and possibly anti-atherogenic properties, it has also been shown to antagonize the action of leptin at the hypothalamic level in rodents, thereby inducing leptin resistance. We have therefore examined whether IL-1Ra levels are increased in human hyperleptinemic conditions, such as obesity. To this end, we measured serum IL-1Ra levels in 20 morbidly obese nondiabetic subjects [body mass index (BMI), 45 +/- 6 kg/m(2); serum leptin, 52 +/- 20 ng/ml] as well as in 10 age- and sex-matched lean controls (BMI, 22 +/- 2 kg/m(2); serum leptin, 7 +/- 4 ng/ml). Serum IL-1Ra concentrations proved to be elevated 6.5-fold in the obese subjects, and they were positively correlated in a linear manner with the leptin levels (r(2) = 0.34; P = 0.01), although lean body mass (LBM) and the insulin resistance index were even better predictors of IL-1Ra levels (r(2) = 0.45 and 0.58, respectively; P < 0.01). Six months after 15 of the 20 obese subjects had undergone bypass surgery for their morbid obesity, their mean BMI and leptin levels decreased to 33 +/- 7 kg/m(2) and 18 plus minus 12 ng/ml, respectively. This change in leptin concentrations was associated with a significant reduction in IL-1Ra levels (P < 0.02). However, there was a better correlation between the decrease in IL-1Ra level and the change in LBM than with the reduction in leptin levels, indicating that leptin is not the sole determinant of circulating IL-1Ra in obesity. In summary, we demonstrate that IL-1Ra levels are highly elevated in human obesity and that its concentrations decrease after weight loss from bypass surgery. However, LBM and insulin resistance are better predictors of serum IL-1Ra concentrations than are leptin levels, suggesting that additional metabolic factors control the secretion of this cytokine antagonist. Although the immunological consequences of this alteration remain unknown, it is tempting to speculate that the obesity-related increase in IL-1Ra might contribute to the central resistance to leptin in obese patients, similar to the inhibition of the hypothalamic signaling of leptin by IL-1Ra in rodents.
Article
Background: There is a large body of epidemiological data associating obesity with a wide variety of clinical disease processes, including cancer and wound infections. However, defining the specific defects of neutrophils has proved difficult and often contradictory. Methods: 27 patients having gastric bypass surgery for obesity (BMI > 40) were compared with 10 normal controls (BMI < 26). Relative neutrophil frequencies and expression of the activation antigens CD11b (integrin adhesion molecule), CD16 (Fc receptor), and CD62L (L-selectin), were evaluated by flow cytometry. Results: The study control group had a mean age of 37 +/- 7.6 yrs (range 30 to 57) with no significant health problems. Their mean BMI was 23 +/- 2.5 kg/m2 (range 21-26). The mean age of the sample group was 40.36 +/- 13.7 yrs (range 18 to 60) with a mean BMI of 52 +/- 8.2 kg/m2 (range 41 to 72). These patients had a large spectrum of diseases that afflict the morbidly obese, including hypertension (14), arthritis (10), exertional dyspnea (13), venous stasis (7), hypothyroidism (2), NIDDM (3), heart murmur (1), along with 8 smokers. The neutrophil frequency in the obese patients was comparable to the controls (control 49% vs obese 51%). Additionally, there was no apparent difference between obese and controls regarding CD11b or CD16 expression (424 vs 498 gmf) (267 vs 262 gmf). However, there was a significant reduction of CD62L (L-selectin) expression noted in the morbidly obese with respect to controls (102 vs 303 gmf, p < 0.001). An increased percentage of eosinophils when compared to controls (6.7% vs 1.73%, p < 0.001) was also observed. Conclusion: Discordant CD11b/CD62L levels, depressed levels of CD62L, and elevated eosinophil percentages support the hypothesis that a chronic inflammatory state exists in morbid obesity. Decreased levels of CD62L in the morbidly obese neutrophil pool possibly affect the neutrophil's ability to activate and migrate to sites of inflammation. This may play a role in the higher incidence of infectious complications seen in morbidly obese individuals.
Article
Previous studies have examined the independent effects of occupant height, obesity, and body mass index in motor vehicle collisions and identified related injury patterns. The hypothesis of this study was that as the driver's body habitus diverges from the 50% percentile male Hybrid III Crash Dummy (H3CD), the frequency of injury changes. The 1995 to 1999 National Automotive Sampling System Crashworthiness Data System was used. Study entry was limited to restrained drivers who were then subdivided into height and weight categories. Incidence rates were calculated for injuries to selected body regions as defined by the Abbreviated Injury Scale for overall, frontal, and driver's side collisions. When grouped according to height and weight as descriptors of body habitus, injury rates for restrained drivers were increased as well as decreased in several subgroups. This association was seen in overall, frontal, and driver's side collisions. The H3CD plays a major role in vehicular cabin interior design and crash testing. For drivers with a body habitus different from that of the H3CD, the vehicle cabin/body fit changes and the safety features may perform differently, which could account for these observations.
Article
Women usually have lower mortality rates than men do at any age. This pattern is observed for most causes of death from chronic diseases. Significant controversy still exists about gender differences in outcomes in trauma. We previously reported no differences in in-hospital mortality based on gender in a large single-institution study (n= 18,892) that had a significant limitation in that it was not population based. This current study was performed to validate our earlier findings in a separate, statewide, population-based dataset of trauma victims. Prospective data were collected on 22,332 trauma patients (18,432 blunt, 3,900 penetrating) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in in-hospital mortality were determined for the entire dataset and for the subsets of blunt and penetrating injury patients. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay of less than 24 hours, eliminating patients who expired soon after admission. The null hypothesis was that female gender is protective in trauma outcomes. Multiple logistic regression analysis identified age (odds ratio [OR] 1.03, confidence interval [CI] 1.02 to 1.03), Injury Severity Score (OR 1.06, CI 1.05 to 1.06), non-Caucasian race (OR 1.72, CI 1.39 to 2.15), blunt injury type (OR 0.327, CI 0.26 to 0.41), and Revised Trauma Score (OR 0.44, CI 0.41 to 0.47) as independent predictors of in-hospital mortality in trauma. Preexisting diseases, including cardiac disease (OR 1.53, CI 1.12 to 2.09) and malignancy (OR 4.08, CI 1.64 to 10.17), were also identified as independent predictors of in-hospital mortality in trauma. Female gender was not associated with decreased mortality (OR 0.83, CI 0.67 to 1.03, p = 0.093). A second multiple regression analysis in blunt trauma patients admitted for longer than 24 hours (which eliminated early deaths and patients with minor injuries) determined that in-hospital mortality was not significantly different in male or female blunt trauma patients stratified by Injury Severity Score and age. The same factors that were predictive of in-hospital mortality in the total dataset were also significant in this secondary analysis. These population-based data confirm that female gender does not adversely affect in-hospital mortality in trauma when patients are appropriately stratified for other variables, including Injury Severity Score and age, that do significantly affect outcomes.
Article
There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.
Article
Objectives This study sought to quantify the effect of body mass index (BMI) on early clinical outcomes following coronary artery bypass grafting (CABG).Background Obesity is considered a risk factor for postoperative morbidity and mortality after cardiac surgery, although existing evidence is contradictory.MethodsA concurrent cohort study of consecutive patients undergoing CABG from April 1996 to September 2001 was carried out. Main outcomes were early death; perioperative myocardial infarction; infective, respiratory, renal, and neurological complications; transfusion; duration of ventilation, intensive care unit, and hospital stay. Multivariable analyses compared the risk of outcomes between five different BMI groups after adjusting for case-mix.ResultsOut of 4,372 patients, 3.0% were underweight (BMI <20 kg/m2), 26.7% had a normal weight (BMI ≥20 and <25 kg/m2), 49.7% were overweight (BMI ≥25 and <30 kg/m2), 17.1% obese (BMI ≥30 and <35 kg/m2) and 3.6% severely obese (BMI ≥35 kg/m2). Compared with the normal weight group, the overweight and obese groups included more women, diabetics, and hypertensives, but fewer patients with severe ischemic heart disease and poor ventricular function. Underweight patients were more likely than normal weight patients to die in hospital (odds ratio [OR] = 4.0, 95% CI 1.4 to 11.1), have a renal complication (OR = 1.9, 95% confidence interval [CI] 1.0 to 3.7), or stay in hospital longer (>7 days) (OR = 1.7, 95% CI 1.1 to 2.5). Overweight, obese, and severely obese patients were not at higher risk of adverse outcomes than normal weight patients, and were less likely than normal weight patients to require transfusion (ORs from 0.42 to 0.86).Conclusions Underweight patients undergoing CABG have a higher risk of death or complications than normal weight patients. Obesity does not affect the risk of perioperative death and other adverse outcomes compared to normal weight, yet obese patients appear less likely to be selected for surgery than normal weight patients.