The impact of duration and severity of obesity exposure on cardiometabolic health.

PURPOSE: Duration and severity of exposure to excess adipose tissue are important risk factors for complications, but are generally not examined in conjunction. We developed a metric considering both factors to examine the relationship between obesity-related complications and parameters of cardiometabolic health in patients undergoing a metabolic bariatric procedure (MBS). MATERIALS & METHODS: Data from patients screened for primary MBS between 2017 and 2021 were analyzed. The Obesity Exposure score (OBES), based on self-reported years of life with a BMI ≥ 25 kg/m2, was calculated with increased weighting applied for higher BMI categories. Multivariate logistic regression analysis was performed, adjusting for multiple potential confounders. RESULTS: In total, 2441 patients were included (76% female, age 42.1 ± 11.9 years, BMI 42.0 ± 4.9 kg/m2). OBES was positively related to myocardial infarction, atrial fibrillation and renal function loss (per 10 OBES-units: OR 1.31, 95%CI [1.11-1.52], p = 0.002; OR 1.23, 95% CI [1.06-1.44], p = 0.008; and OR 1.26, 95% CI [1.04-1.51], p = 0.02). OBES was negatively associated with obstructive sleep apnea syndrome (OSAS) (OR 0.90, 95% CI [0.83-0.98], p = 0.02). In patients without obesity-related complications, OBES was related to lower HbA1c and higher HDL-cholesterol levels (ß -0.5 95% CI [-0.08-.0.02] p < 0.001 and ß 0.02 [0.00-0.04] p = 0.01). CONCLUSION: OBES was related to myocardial infarction, atrial fibrillation and renal function loss in patients applying for MBS. OBES was negatively related to OSAS, possibly because undiagnosed years were not taken into account. In the absence of obesity-related complications, OBES was not related to metabolic blood markers. Our data may aid in improving perioperative risk assessments.

The usability of a digital diary from the perspectives of intensive care patients' relatives: A pilot study.

BACKGROUND: Diaries have been used regularly in international settings as an evidence-based and easily applicable intervention following a person-centred approach in the intensive care unit (ICU). In addition, a diary web application known as 'Post-ICU' has been implemented. AIM: To explore the usability of an innovative digital diary from the perspectives of intensive care patients' relatives. STUDY DESIGN: A cross-sectional online survey study was applied among a convenience sample of relatives in the ICUs of two hospitals in the Netherlands. The investigator-developed questionnaire included, among other things, items with the appreciation of the layout, user friendliness and functionality of the diary. Relevance and applicability were rated between 1 and 10. Data were analysed with SPSS© software, version 27, and reported as the means (±standard deviation [SD]) and percentages. RESULTS: Sixty-three relatives with an average age of 51 years (SD ± 14.3) participated in the study; there was a slight predominance of women (57%). All but one participant found using the digital diary easy and were able to upload photos to the diary. The participants had invited other relatives (75%) and nurses (61%) to write in the diary, which they viewed as easily feasible (89%). The relevance and applicability of the diary were rated with mean scores of 8.1 (SD ± 1.9) and 8.3 (SD ± 1.6), respectively. CONCLUSIONS: The participants found the Post-ICU diary web application highly valuable and easily feasible. Perceived ease of use, perceived usefulness and technophobia were not found to influence the usability of the digital diary. RELEVANCE TO CLINICAL PRACTICE: The implementation of this new digital tool supports a person-centred ICU policy because of its focus on the personal diary entries of the patient and the collaborative writing process featuring relatives and professionals.

Lessons Learned from Telemonitoring in an Outpatient Bariatric Surgery Pathway-Secondary Outcomes of a Patient Preference Clinical Trial.

BACKGROUND: Remote monitoring is increasingly used to support postoperative care. This study aimed to describe the lessons learned from the use of telemonitoring in an outpatient bariatric surgery pathway. MATERIALS AND METHODS: Patients were assigned based on their preference to an intervention cohort of same-day discharge after bariatric surgery. In total, 102 patients were monitored continuously for 7 days using a wearable monitoring device with a Continuous and Remote Early Warning Score-based notification protocol (CREWS). Outcome measures included missing data, course of postoperative heart and respiration rate, false positive notification and specificity analysis, and vital sign assessment during teleconsultation. RESULTS: In 14.7% of the patients, data for heart rate was missing for > 8 h. A day-night-rhythm of heart rate and respiration rate reappeared on average on postoperative day 2 with heart rate amplitude increasing after day 3. CREWS notification had a specificity of 98%. Of the 17 notifications, 70% was false positive. Half of them occurred between day 4 and 7 and were accompanied with surrounding reassuring values. Comparable postoperative complaints were encountered between patients with normal and deviated data. CONCLUSION: Telemonitoring after outpatient bariatric surgery is feasible. It supports clinical decisions, however does not replace nurse or physician care. Although infrequent, the false notification rate was high. We suggested additional contact may not be necessary when notifications occur after restoration of circadian rhythm or when surrounding reassuring vital signs are present. CREWS supports ruling out serious complications, what may reduce in-hospital re-evaluations. Following these lessons learned, increased patients' comfort and decreased clinical workload could be expected. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT04754893.

Continuous remote monitoring in post-bariatric surgery patients: development of an early warning protocol.

BACKGROUND: Continuous monitoring of vital parameters after bariatric surgery can detect postoperative bleeding or anastomotic leakage. OBJECTIVES: This report describes the development of a continuous remote early warning score (CREWS). This is an EWS-based notification protocol for deterioration detection in bariatric patients. SETTING: Catharina Hospital, the Netherlands. METHODS: Several CREWS protocols were developed by combining thresholds indicative of tachycardia and tachypnea using literature insights and expert sessions. These protocols were tested retrospectively using continuously measured vital signs in a cohort of 185 patients who underwent primary bariatric surgery. A wearable remote monitoring device (Healthdot, Philips) was used in hospital and at home up to 14 days after surgery. The outcomes included were demographics, use of beta-blockers, and complications necessitating reintervention. RESULTS: Thresholds of 110 beats per minute (bpm) and 20 breaths per minute (rpm) for heart rate and respiration rate, respectively, detected postoperative bleeding and anastomotic leakage with 75% (3/4 patients) sensitivity. The protocol was silent (no alarms/day) in 69.5% of patients and produced more than 1 alarm/day in 1.6% of patients. The average postoperative heart rate was unaffected by the use of beta-blockers. CONCLUSIONS: A description of the steps in the development of an EWS protocol in bariatric patients based on continuous vital sign monitoring is useful. The most sensitive and silent protocol measured heart rate and respiratory rate with thresholds of 110 bpm and 20 rpm and appeared to be feasible for clinical use. There seemed to be no clinically relevant impact of beta-blockers. This CREWS protocol could be a starting point for future studies.

Screening for Mild Cognitive Impairment in the Preoperative Setting: A Narrative Review.

Cognitive impairment predisposes patients to the development of delirium and postoperative cognitive dysfunction. In particular, in older patients, the adverse sequelae of cognitive decline in the perioperative period may contribute to adverse outcomes after surgical procedures. Subtle signs of cognitive impairment are often not previously diagnosed. Therefore, the aim of this review is to describe the available cognitive screeners suitable for preoperative screening and their psychometric properties for identifying mild cognitive impairment, as preoperative workup may improve perioperative care for patients at risk for postoperative cognitive dysfunction. Electronic systematic and snowball searches of PubMed, PsycInfo, ClinicalKey, and ScienceDirect were conducted for the period 2015-2020. Major inclusion criteria for articles included those that discussed a screener that included the cognitive domain 'memory', that had a duration time of less than 15 min, and that reported sensitivity and specificity to detect mild cognitive impairment. Studies about informant-based screeners were excluded. We provided an overview of the characteristics of the cognitive screener, such as interrater and test-retest reliability correlations, sensitivity and specificity for mild cognitive impairment and cognitive impairment, and duration of the screener and cutoff points. Of the 4775 identified titles, 3222 were excluded from further analysis because they were published prior to 2015. One thousand four hundred and forty-eight titles did not fulfill the inclusion criteria. All abstracts of 52 studies on 45 screeners were examined of which 10 met the inclusion criteria. For these 10 screeners, a further snowball search was performed to obtain related studies, resulting in 20 articles. Screeners included in this review were the Mini-Cog, MoCA, O3DY, AD8, SAGE, SLUMS, TICS(-M), QMCI, MMSE2, and Mini-ACE. The sensitivity and specificity range to detect MCI in an older population is the highest for the MoCA, with a sensitivity range of 81-93% and a specificity range of 74-89%. The MoCA, with the highest combination of sensitivity and specificity, is a feasible and valid routine screening of pre-surgical cognitive function. This warrants further implementation and validation studies in surgical pathways with a large proportion of older patients.

Postbariatric EArly discharge Controlled by Healthdot (PEACH) trial: study protocol for a preference-based randomized trial.

INTRODUCTION: Performing bariatric surgery in a daycare setting has a potential reduction in hospital costs and increase in patients' satisfaction. Although the feasibility and safety of such care pathway has already been proven, its implementation is hampered by concerns about timely detection of short-term complications. This study is designed to evaluate a combined outcome measurement in outpatient bariatric surgery supplemented by a novel wireless remote monitoring system versus current standard of care. METHODS AND ANALYSIS: A total of 200 patients with multidisciplinary team approval for primary bariatric surgery will be assigned based on their preference to one of two postoperative trajectories: (1) standard of in-hospital care with discharge on the first postoperative day or (2) same day discharge with ongoing telemonitoring up to 7 days after surgery. The device (Healthdot R Philips) transfers heart rate, respiration rate, activity, and body posture of the patient continuously by LoRaWan network to our hospital's dashboard (Philips Guardian). The primary outcome is a composite outcome measure within 30 days postoperative based on mortality, mild and severe complications, readmission, and prolonged length-of-stay. Secondary outcomes include patients' satisfaction and data handling dimensions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04754893 , Registered on 12 February 2021.

Experiences of nurses with an innovative digital diary intervention in the intensive care unit: A qualitative exploration.

INTRODUCTION: Diaries have been used regularly in various intensive care units (ICUs) in international settings. Hard copy diaries written by relatives became impractical during the COVID-19 pandemic due to ICU visiting restrictions and infection control considerations. The implementation of a web based application, named the "Post-ICU" diary, offered relatives the ability to collaboratively write in a digital diary, to easily upload photos, video and audio clips and to feel engaged with the patient at a safe distance. In addition it allowed nurses to easily provide up-to-date information. The aim of this pilot study was to explore the experiences of ICU nurses with the implementation process and application of the Post-ICU diary. METHODS: A multicentre qualitative design with focus group interviews was used with ICU nurses in November 2020. Interview data were audiotaped and transcribed verbatim, and then a thematic analysis was performed to categorize the data. RESULTS: Participants from three hospitals (n = 14), 57% of whom were women, with a mean age of 40.6 years, described their experiences with the Post-ICU diary. The following themes emerged: implementation process, COVID-19, integration, and motivation. The results showed that ICU nurses perceived the Post-ICU diary to be applicable in daily care and endorsed the added value of the digital Post-ICU diary as a new opportunity to improve interhuman connectedness. However, the nurses also experienced barriers such as non-user-friendly access, lack of time and hesitance to write short messages. CONCLUSION: ICU nurses reported that the Post-ICU diary had added value for patients and their relatives. However, in the beginning they also experienced barriers such as lack of time, insufficient integration with their own work processes, and challenges regarding writing short messages themselves. For structural embedding of the intervention, tailored strategies are needed to support ICU nurses in using this innovative Post-ICU diary.

The effects of glucagon like peptide-1 (GLP-1) on cardiac remodeling: exploring the role of medication and physiological modulation after metabolic surgery.

Obesity and associated comorbidities reach epidemic proportions nowadays. Several treatment strategies exist, but bariatric surgery has the only longstanding effects. Since a few years, there is increasing interest in the effects of gastro-intestinal hormones, in particular Glucagon-Like Peptide-1 (GLP-1) on the remission of Type 2 Diabetes (T2DM) and its effects on cardiac cardiovascular morbidity, cardiac remodeling, and mortality. In the past years several high quality multicenter randomized controlled trials were developed to assess the effects of GLP-1 receptor agonist therapy on cardiovascular morbidity and mortality. Most of the trials were designed and powered as non-inferiority trials to demonstrate cardiovascular safety. Most of these trials show a reduction in cardiovascular morbidity in patients with T2DM. Some follow-up studies indicate potential beneficial effects of GLP-1 receptor agonists on cardiovascular function in patients with heart failure, however the results are contradictory, and we need long-term studies to make firm conclusions about the pleiotropic properties of incretin-based therapies. However, it seems that GLP-1 receptor agonists have different effects than the increased GLP-1 production after bariatric surgery on cardiovascular remodeling. One of the hypotheses is that the blood concentrations of GLP-1 receptor agonists are three times higher compared to GLP-1 increase after bariatric and metabolic surgery. The purpose of this narrative review is to summarize the effects of GLP-1 on cardiovascular morbidity, mortality and remodeling due to medication but also due to bariatric and metabolic surgery. The second objective is to explain the possible differences in effects of GLP-1 agonists and bariatric and metabolic surgery.

Effects of Bariatric Surgery on Heart Rhythm Disorders: a Systematic Review and Meta-Analysis.

The aim of this systematic review is to provide an overview of the literature on the effects of bariatric surgery on obesity-associated electrocardiogram (ECG) abnormalities and cardiac arrhythmias. Fourteen studies were included with a methodological quality ranging from poor to good. Majority of the studies showed a significant decrease of QT interval and related measures after bariatric surgery. Seven studies were included in the meta-analysis on effects of bariatric surgery on QTc interval and a significant decrease in QTc interval of - 33.6 ms, 95%CI [- 49.8 to - 17.4] was seen. Bariatric surgery results in significant decrease in QTc interval and P-wave dispersion, i.e., a normalization of initial pathology. The effects on atrial fibrillation are conflicting and not yet fully understood.

Prolonged Unconsciousness Following Severe COVID-19.

OBJECTIVE: We report a case series of patients with prolonged but reversible unconsciousness after coronavirus disease 2019 (COVID-19)-related severe respiratory failure. METHODS: A case series of patients who were admitted to the intensive care unit due to COVID-19-related acute respiratory failure is described. RESULTS: After cessation of sedatives, the described cases all showed a prolonged comatose state. Diagnostic neurologic workup did not show signs of devastating brain injury. The clinical pattern of awakening started with early eye opening without obeying commands and persistent flaccid weakness in all cases. Time between cessation of sedatives to the first moment of being fully responsive with obeying commands ranged from 8 to 31 days. CONCLUSION: Prolonged unconsciousness in patients with severe respiratory failure due to COVID-19 can be fully reversible, warranting a cautious approach for prognostication based on a prolonged state of unconsciousness.

User Experience of a Chatbot Questionnaire Versus a Regular Computer Questionnaire: Prospective Comparative Study.

BACKGROUND: Respondent engagement of questionnaires in health care is fundamental to ensure adequate response rates for the evaluation of services and quality of care. Conventional survey designs are often perceived as dull and unengaging, resulting in negative respondent behavior. It is necessary to make completing a questionnaire attractive and motivating. OBJECTIVE: The aim of this study is to compare the user experience of a chatbot questionnaire, which mimics intelligent conversation, with a regular computer questionnaire. METHODS: The research took place at the preoperative outpatient clinic. Patients completed both the standard computer questionnaire and the new chatbot questionnaire. Afterward, patients gave their feedback on both questionnaires by the User Experience Questionnaire, which consists of 26 terms to score. RESULTS: The mean age of the 40 included patients (25 [63%] women) was 49 (SD 18-79) years; 46.73% (486/1040) of all terms were scored positive for the chatbot. Patients preferred the computer for 7.98% (83/1040) of the terms and for 47.88% (498/1040) of the terms there were no differences. Completion (mean time) of the computer questionnaire took 9.00 minutes by men (SD 2.72) and 7.72 minutes by women (SD 2.60; P=.148). For the chatbot, completion by men took 8.33 minutes (SD 2.99) and by women 7.36 minutes (SD 2.61; P=.287). CONCLUSIONS: Patients preferred the chatbot questionnaire over the computer questionnaire. Time to completion of both questionnaires did not differ, though the chatbot questionnaire on a tablet felt more rapid compared to the computer questionnaire. This is an important finding because it could lead to higher response rates and to qualitatively better responses in future questionnaires.

Severe arterial thromboembolism in patients with Covid-19.

INTRODUCTION: The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has emerged early December 2019 and was recently confirmed by the World Health Organization (WHO) to be a public health emergency of international concern. Earlier reports have shown coagulopathy in patients with severe coronavirus disease 2019 (Covid-19). MAIN SYMPTOMS AND IMPORTANT CLINICAL FINDINGS: We present four critically ill Covid-19 patients, who were admitted to our hospital. They were treated with supportive care, oral chloroquine, and standard 2500 or 5000 International Units (IU) of dalteparine subcutaneously once daily. Two patients died during the course of their stay as a consequence of severe large vessel arterial thromboembolism. The other two patients survived but symptoms of paralysis and aphasia persisted after cerebral ischemia due to large vessel arterial thromboembolism. Patients showed no signs of overt disseminated intravascular coagulation (DIC) in their laboratory analysis. CONCLUSION: This case series suggest that even in absence of overt DIC, arterial thromboembolic complications occur in critically ill patients with Covid-19. Further studies are needed to determine which parameters are useful in monitoring coagulopathy and which dose of anti-thrombotic therapy in Covid-19 patients is adequate, even when overt DIC is not present.

The usefulness of preoperative exercise therapy in patients scheduled for lung cancer surgery; a survey among Dutch pulmonologists and cardiothoracic surgeons.

BACKGROUND: Preoperative exercise training (PET) studies show promising results in various patient populations. However, the lack of standardised programmes and uniformity in practice guidelines are barriers for implementation. Aim of this study was to assess the current opinions of pulmonologists and cardiothoracic surgeons on the clinical applicability of PET in patients scheduled for lung cancer surgery. METHODS: Dutch pulmonologists and cardiothoracic surgeons were asked to complete a 29-question survey regarding PET as an additional option to further optimise the health status of patients scheduled for lung cancer surgery. RESULTS: In total, 47 respondents (63% response rate), including 30 pulmonologists and 11 cardiothoracic surgeons and 6 residents in training completed the survey. A vast majority of the respondents had a positive attitude towards PET. Home-based exercise was considered less useful, as well as unsupervised exercise. Patient's motivation, improvements in physical capacity and quality of life, and lifestyle adjustments are important factors for the success of PET. The programme should at least contain inspiratory muscle training (95.7%), lifestyle interventions (95.7%), and supervised exercise training (91.5%). Cardiac and pulmonary risk assessment and medication assessment and optimisation were found less important. CONCLUSION: Among pulmonologists and cardiothoracic surgeons, there is a tendency that PET can be a valuable addition to the perioperative care of lung surgery patients. Points of discussion are the contents of PET programmes, and there seems to be a lack of awareness among chest physicians.

Cardiac remodeling in obesity and after bariatric and metabolic surgery; is there a role for gastro-intestinal hormones?

Introduction: Obesity is associated with various diseases such as type 2 diabetes, hypertension, obstructive sleep apnea syndrome (OSAS), metabolic syndrome, and cardiovascular diseases. It affects several organ systems, including the pulmonary and cardiac systems. Furthermore, it induces pulmonary and cardiac changes that can result in right and/or left heart failure.Areas covered: In this review, authors provide an overview of obesity and cardiovascular remodeling, the individual actions of the gut hormones (like GLP-1 and PYY), the effects after bariatric/metabolic surgery and its influence on cardiac remodeling. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date until April 2019), regarding cardiac function changes before and after bariatric surgery and literature regarding changes in gastrointestinal hormones.Expert opinion: Regarding the surgical treatment of obesity and metabolic diseases there is recognition of the importance of both weight loss (bariatric surgery) and improvement in metabolic milieu (metabolic surgery). A growing body of evidence further suggests that bariatric surgical procedures [like the Sleeve Gastrectomy (SG), Roux-en Y Gastric Bypass (RYGB), or One Anastomosis Gastric Bypass (OAGB)] have can improve outcomes of patients suffering from a number of cardiovascular diseases, including heart failure.

Proper volume management during anesthesia for esophageal resection.

Esophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. Proper fluid management is essential to reduce postoperative pulmonary complications. Restrictive management is advocated in ERAS based protocols and recent guidelines for esophagectomy, however Goal Directed treatment may be useful. Perioperative fluid management must always be seen in light of a multi modal approach and must be balanced at the needs of the patient and the surgical approach chosen.

Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology.

The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the "metabolic syndrome." The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.

Clinical use of electrical stimulation with the Veinplicity® device and its effect on the first attempt success rate of peripheral intravenous cannulation: A non-randomized clinical trial.

BACKGROUND: Peripheral intravenous cannulation is one of the most frequently performed medical procedures. Venodilation, which can be achieved with different techniques, is an important factor for first attempt success. The objective of this study was to compare the first attempt success rates upon peripheral intravenous cannulation after applying a tourniquet, with venous dilation by electrical stimulation using the Veinplicity® device, or a combination of both techniques, in participants at moderate risk of a difficult peripheral intravenous access. METHODS: This non-randomized clinical trial was carried out in adult patients divided into three parallel study groups, consisting of cannulation with a tourniquet (control group), cannulation after electrical stimulation without using a tourniquet (intervention group 1), and cannulation after applying electrical stimulation followed by the application of a tourniquet on the selected upper extremity (intervention group 2). The primary outcome was the first attempt success rate of peripheral intravenous catheter placement. RESULTS: In all, 141 participants were included in this study, with an overall success rate of 86%. Success rates of 78%, 88%, and 92% were observed in the control group, intervention group 1, and intervention group 2, respectively (p = 0.25, χ2 = 2.771, df = 2). A higher first attempt success rate was detected in participants in intervention group 2, when compared to the control group (p = 0.04, χ2 = 4.63, df = 1). CONCLUSION: Increase in first attempt success was clinically relevant when electrical stimulation with the Veinplicity® device was combined with the application of a tourniquet in participants at moderate risk of a difficult peripheral intravenous access.