Background Although a risk score estimating postoperative mortality for patients undergoing gastric bypass exists, there is none predicting postoperative morbidity. Our objective was to develop a ...validated risk calculator for 30-day postoperative morbidity of bariatric surgery patients. Study Design We used the American College of Surgeons' 2007 National Surgical Quality Improvement Program (NSQIP) dataset. Patients undergoing bariatric surgery for morbid obesity were studied. Multiple logistic regression analysis was performed and a risk calculator was created. The 2008 NSQIP dataset was used for its validation. Results In 11,023 patients, mean age was 44.6 years, 20% were male, 77% were Caucasian, and mean body mass index (BMI; calculated as kg/m2 ) was 48.9. Thirty-day morbidity and mortality were 4.2% and 0.2%, respectively. Risk factors associated with increased risk of postoperative morbidity included recent MI/angina (odds ratio OR = 3.65; 95% CI 1.23 to 10.8), dependent functional status (OR = 3.48; 95% CI 1.78 to −6.80), stroke (OR = 2.89; 95% CI 1.09 to 7.67), bleeding disorder (OR = 2.23; 95% CI 1.47 to 3.38), hypertension (OR = 1.34; 95% CI 1.10 to 1.63), BMI, and type of bariatric surgery. Patients with BMI 35 to <45 and >60 had significantly higher adjusted OR compared with patients with BMI of 45 to 60 (p < 0.05 for all). These factors were used to create the risk calculator and subsequently validate it, with the model performance very similar between the 2007 training dataset and the 2008 validation dataset (c-statistics: 0.69 and 0.66, respectively). Conclusions NSQIP data can be used to develop and validate a risk calculator that predicts postoperative morbidity after various bariatric procedures. The risk calculator is anticipated to aid in surgical decision making, informed patient consent, and risk reduction.
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GEOZS, NUK, OILJ, SBJE, UL, UPUK
Background While the epidemic of obesity continues to plague America, bariatric surgery is underused due to concerns for surgical risk among patients and referring physicians. A risk score estimating ...postoperative mortality (OS-MRS) exists, however, is limited by consideration of only 12 preoperative variables, failure to separate open and laparoscopic cases, a lack of robust statistical analyses, risk factors not being weighted, and being applicable to only gastric bypass surgery. The objective of this study was to develop a validated risk calculator for 30-day postoperative mortality after bariatric surgery. Study Design The National Surgical Quality Improvement Program (NSQIP) dataset (2006 to 2008) was used. Patients undergoing bariatric surgery for morbid obesity (n = 32,889) were divided into training (n = 21,891) and validation (n = 10,998) datasets. Multiple logistic regression analysis was performed on the training dataset. The model fit from the training dataset was maintained and was used to estimate mortality probabilities for all patients in the validation dataset. Results Thirty-day mortality was 0.14%. Seven independent predictors of mortality were identified: peripheral vascular disease, dyspnea, previous percutaneous coronary intervention, age, body mass index, chronic corticosteroid use, and type of bariatric surgery. This risk model was subsequently validated. The model performance was very similar between the training and the validation datasets (c-statistics, 0.80 and 0.82, respectively). The high c-statistics indicate excellent predictive performance. The risk model was used to develop an interactive risk calculator. Conclusions This risk calculator has excellent predictive ability for mortality after bariatric procedures. It is anticipated that it will aid in surgical decision-making, informed patient consent, and in helping patients and referring physicians to assess the true bariatric surgical risk.
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Background Postoperative respiratory failure (PRF) (requiring mechanical ventilation > 48 h after surgery or unplanned intubation within 30 days of surgery) is associated with significant morbidity ...and mortality. The objective of this study was to identify preoperative factors associated with an increased risk of PRF and subsequently develop and validate a risk calculator. Methods The American College of Surgeons National Surgical Quality Improvement Program (NSQIP), a multicenter, prospective data set (2007-2008), was used. The 2007 data set (n = 211,410) served as the training set and the 2008 data set (n = 257,385) as the validation set. Results In the training set, 6,531 patients (3.1%) developed PRF. Patients who developed PRF had a significantly higher 30-day mortality (25.62% vs 0.98%, P < .0001). On multivariate logistic regression analysis, five preoperative predictors of PRF were identified: type of surgery, emergency case, dependent functional status, preoperative sepsis, and higher American Society of Anesthesiologists (ASA) class. The risk model based on the training data set was subsequently validated on the validation data set. The model performance was very similar between the training and the validation data sets (c-statistic, 0.894 and 0.897, respectively). The high c-statistics (area under the receiver operating characteristic curve) indicate excellent predictive performance. The risk model was used to develop an interactive risk calculator. Conclusions Preoperative variables associated with increased risk of PRF include type of surgery, emergency case, dependent functional status, sepsis, and higher ASA class. The validated risk calculator provides a risk estimate of PRF and is anticipated to aid in surgical decision making and informed patient consent.
Perioperative myocardial infarction or cardiac arrest is associated with significant morbidity and mortality. The Revised Cardiac Risk Index is currently the most commonly used cardiac risk ...stratification tool; however, it has several limitations, one of which is its relatively low discriminative ability. The objective of the present study was to develop and validate a predictive cardiac risk calculator.
Patients who underwent surgery were identified from the American College of Surgeons' 2007 National Surgical Quality Improvement Program database, a multicenter (>250 hospitals) prospective database. Of the 211 410 patients, 1371 (0.65%) developed perioperative myocardial infarction or cardiac arrest. On multivariate logistic regression analysis, 5 predictors of perioperative myocardial infarction or cardiac arrest were identified: type of surgery, dependent functional status, abnormal creatinine, American Society of Anesthesiologists' class, and increasing age. The risk model based on the 2007 data set was subsequently validated on the 2008 data set (n=257 385). The model performance was very similar between the 2007 and 2008 data sets, with C statistics (also known as area under the receiver operating characteristic curve) of 0.884 and 0.874, respectively. Application of the Revised Cardiac Risk Index to the 2008 National Surgical Quality Improvement Program data set yielded a relatively lower C statistic (0.747). The risk model was used to develop an interactive risk calculator.
The cardiac risk calculator provides a risk estimate of perioperative myocardial infarction or cardiac arrest and is anticipated to simplify the informed consent process. Its predictive performance surpasses that of the Revised Cardiac Risk Index.
Background This study was conducted to determine if team training using a federally sponsored team training program improves operating room (OR) performance and culture. Methods The TeamSTEPPS ...program, a team training program designed and tested for health care applications, was provided to the OR staff. The training occurred over 2 months to all members of the OR team, including scrub technicians, nurses, certified registered nurse anesthetists, anesthesiologists, surgeons, and all anesthesiology and surgical resident staff. Results After 9 months, there was a significant improvement in the OR staff team work (score 53.2 to 62.7; P < .05) and OR communications (score 47. 5 to 62.7; P < .05). There was significant improvement in OR first case starts (69% to 81%), Surgical Quality Improvement Program measures (antibiotic administration, 78% to 97% P < .05; venous thromboembolism administration, 74% to 91% P < .05; and beta blocker administration, 19.7% to 100%; P < .05) and patient satisfaction (willingness to recommend, 77% to 89.3% P < .05). NSQIP measured overall surgical morbidity and mortality, which were both significantly improved (mortality, 2.7% to 1% P < .05; morbidity, 20.2% to 11.0% P < .05), indicating a significant change in the overall OR culture. A year later, the data showed that factors linked to regulatory requirements, such as Surgical Quality Improvement Program measures linked to the time out remained improved while first case on time starts decreased (81% to 69%; P < .05), patient willingness to recommend decreased (89.3% to 80.8%; P < .05), surgical mortality increased (1% to 1.5%; P < .05), and surgical morbidity increased (11% to 13%; P < .05) reflecting a degree of culture deterioration which has persisted. Conclusion These data confirm that team training improves OR performance, but continued team training is required to provide sustained improved OR culture.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
This article discusses the role of carcinoembryonic antigen (CEA) as a facilitator of the inflammatory response and its effect on colorectal cancer hepatic metastasis. Colorectal cancer accounts for ...11% of all cancers in the United States and the majority of deaths are associated with liver metastasis. If left untreated, median survival is only six to 12 months. Resection of liver metastases offers the only chance for cure. Of the small number of patients who have operable cancer most will have further tumor recurrence. The molecular mechanisms associated with colorectal cancer metastasis to the liver are largely unknown. However CEA production has been shown both clinically and experimentally to be a factor in an increased metastatic potential of colorectal cancers to the liver. CEA also has a role in protecting tumor cells from the effects of anoikis and this affords a selective advantage for tumor cell survival in the circulation. CEA acts in the liver through its interaction with its receptor (CEAR), a protein that is related to the hnRNP M family of RNA binding proteins. In the liver CEA binds with hnRNP M on Kupffer cells and causes activation and production of pro- and anti-inflammatory cytokines including IL-1, IL-10, IL-6 and TNF-α. These cytokines affect the up-regulation of adhesion molecules on the hepatic sinusoidal endothelium and protect the tumor cells against cytotoxicity by nitric oxide (NO) and other reactive oxygen radicals. HnRNP M signaling in Kupffer cells appears to be controlled by beta-adrenergic receptor activation. The cells will respond to the β-adrenergic receptor agonist terbutaline resulting in reduced TNF-α and increased IL-10 and IL-6 production following CEA activation. This has implications for the control of tumor cell implantation and survival in the liver.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Fat Depot–Specific Characteristics Are Retained in Strains Derived From Single Human Preadipocytes
Tamara Tchkonia 1 ,
Nino Giorgadze 1 ,
Tamar Pirtskhalava 1 ,
Thomas Thomou 1 ,
Matthew DePonte 2 ,
...Ada Koo 2 ,
R. Armour Forse 3 ,
Dharmaraj Chinnappan 1 ,
Carmen Martin-Ruiz 4 ,
Thomas von Zglinicki 4 and
James L. Kirkland 1 5
1 Department of Medicine, Boston University, Boston, Massachusetts
2 AdipoGenix, Boston, Massachusetts
3 Department of Surgery, Creighton University, Omaha, Nebraska
4 Henry Wellcome Biogerontology Laboratory, Institute for Ageing and Health, University of Newcastle, Newcastle, U.K
5 Department of Biochemistry, Boston University, Boston, Massachusetts
Address correspondence and reprint requests to James L. Kirkland, MD, PhD, Boston University, 88 East Newton St., Robinson
2, Boston, MA 02118. E-mail: kirkland{at}bu.edu
Abstract
Fat depots vary in size, function, and potential contribution to disease. Since fat tissue turns over throughout life, preadipocyte
characteristics could contribute to this regional variation. To address whether preadipocytes from different depots are distinct,
we produced preadipocyte strains from single abdominal subcutaneous, mesenteric, and omental human preadipocytes by stably
expressing human telomere reverse transcriptase (hTERT). These strains could be subcultured repeatedly and retained capacity
for differentiation, while primary preadipocyte adipogenesis and replication declined with subculturing. Primary omental preadipocytes,
in which telomeres were longest, replicated more slowly than mesenteric or abdominal subcutaneous preadipocytes. Even after
40 population doublings, replication, abundance of the rapidly replicating preadipocyte subtype, and resistance to tumor necrosis
factor α–induced apoptosis were highest in subcutaneous, intermediate in mesenteric, and lowest in omental hTERT-expressing
strains, as in primary preadipocytes. Subcutaneous hTERT-expressing strains accumulated more lipid and expressed more adipocyte
fatty acid–binding protein (aP2), peroxisome proliferator–activated receptor γ2, and CCAAT/enhancer-binding protein α than
omental cells, as in primary preadipocytes, while hTERT abundance was similar. Thus, despite dividing 40 population doublings,
hTERT strains derived from single preadipocytes retained fat depot–specific cell dynamic characteristics, consistent with
heritable processes contributing to regional variation in fat tissue function.
C/EBPα, CCAAT/enhancer-binding protein α
FBS, fetal bovine serum
G3PD, glycerol-3-phosphate dehydrogenase
hTERT, human telomere reverse transcriptase
mRNA, messenger RNA
PPAR, peroxisome proliferator–activated receptor
TNF, tumor necrosis factor
Footnotes
Additional information on this article can be found in an online appendix at http://diabetes.diabetesjournals.org .
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore
be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
Accepted June 8, 2006.
Received April 20, 2006.
DIABETES
Groin Hernias in Adults Fitzgibbons, Robert J; Forse, R. Armour
The New England journal of medicine,
02/2015, Volume:
372, Issue:
8
Journal Article
Peer reviewed
Watchful waiting is safe for men with asymptomatic inguinal hernias, but data from randomized trials suggest that most men will ultimately undergo surgery, primarily because of pain. Watchful waiting ...is not recommended in women, given their higher prevalence of femoral hernias.
This
Journal
feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.
A 67-year-old man presents with a bulge in his right groin, which he recently noticed while in the shower. He is easily able to push it back completely, but it reappears intermittently. He says it is not painful and that he has not altered his activity level because of it. Physical examination confirms the presence of a right inguinal hernia. How should . . .
Existing literature has shown racial/ethnic disparities between white and black surgical populations, however, surgical outcomes for Hispanic patients are limited in both scope and quantity.
Data ...from the American College of Surgeons National Surgical Quality Improvement Program from 2007 to 2015 was used to analyze surgical outcomes in approximately 3.5 million patients.
Overall, Hispanics experienced lower odds of mortality compared to non-Hispanic White, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native patients (all P < 0.0001). No difference was found in mortality odds between Hispanics and non-Hispanic Asian or Native Hawaiian patients. Hispanics experienced minimal disparities in complications as compared to non-Hispanic White and non-Hispanic Black but had a higher rate of select complications when compared to Non-Hispanic Asian, Native Hawaiian, or Pacific Islander.
Hispanics, in general, had lower odds of 30-day postoperative mortality and major morbidity compared to most of the races/ethnicities included in the ACS NSQIP database.
•Postoperative mortality lower in Hispanics than Whites, Blacks, and American Indians.•Surgical complications lower in Hispanics than Whites, Blacks, and American Indians.•Higher rate of select postoperative complications in Hispanics compared to Asians.•Provides evidence for the Hispanic Epidemiological Paradox in surgical outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
1 Obesity Research Center, 2 Department of Medicine and Department of Genetics and Genomics, Boston University, Boston, Massachusetts; 3 Department of Surgery, Creighton University, Omaha, Nebraska; ...4 Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston Massachusetts; and 5 Mayo Clinic Foundation, Rochester, Minnesota
Submitted 26 April 2006
; accepted in final form 6 September 2006
Anatomically separate fat depots differ in size, function, and contribution to pathological states, such as the metabolic syndrome. We isolated preadipocytes from different human fat depots to determine whether the basis for this variation is partly attributable to differences in inherent properties of fat cell progenitors. We found that genome-wide expression profiles of primary preadipocytes cultured in parallel from abdominal subcutaneous, mesenteric, and omental fat depots were distinct. Interestingly, visceral fat was not homogeneous. Preadipocytes from one of the two main visceral depots, mesenteric fat, had an expression profile closer to that of subcutaneous than omental preadipocytes, the other main visceral depot. Expression of genes that regulate early development, including homeotic genes, differed extensively among undifferentiated preadipocytes isolated from different fat depots. These profiles were confirmed by real-time PCR analysis of preadipocytes from additional lean and obese male and female subjects. We made preadipocyte strains from single abdominal subcutaneous and omental preadipocytes by expressing telomerase. Depot-specific developmental gene expression profiles persisted for 40 population doublings in these strains. Thus, human fat cell progenitors from different regions are effectively distinct, consistent with different fat depots being separate mini-organs.
visceral fat; homeotic genes; telomerase; metabolic syndrome
Address for reprint requests and other correspondence: J. L. Kirkland, Boston University Medical Center, 88 East Newton St., Boston, MA 02118
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