Pre-operative cardiopulmonary, metabolic, abdominal, and somatic variations by race in men with obesity resolve after Laparoscopic Roux-en-Y gastric bypass (LRYGB): Dyslipidemia and psychologicals by race persist.

BACKGROUND: Whether/how LRYGB men vary by race in clinical characteristics/post-operative outcomes is unknown. OBJECTIVE: Identify male pre-/post LRYGB clinical/outcomes variations by race. METHODS: Data from 17,734 LYRGB BOLD database men were analyzed in five groups: African American (AA, n = 1310), Caucasian (C, n = 14,168), Asian (A, n = 53), Hispanic (H, n = 1519), and Other (O, Pacific Islander, Native American, or more than one race, n = 684). DATA: demographics, BMI, and 28 weight-related conditions. RESULTS: Pre-LRYGB age, health insurance, unemployment, BMI, and 24/28 obesity related comorbidities varied by race (p < 0.01). Highest pre-LRYGB: AA 4, C 14, A 5, H none, O 1 comorbidity. 12 month BMI and 14 comorbidities varied by race (p < 0.05). 24 months only dyslipidemia, depression, and psychological impairment varied by race (p < 0.05). CONCLUSION: Demographics, BMI and 24 obesity comorbidities vary by race in LRYGB men, but only 3 at 24 months. Caucasians have the greatest cardiopulmonary related comorbidities. This advanced knowledge may facilitate peri-operative management.

Factors influencing resilience and burnout among resident physicians - a National Survey.

BACKGROUND: Residency training exposes young physicians to a challenging and high-stress environment, making them vulnerable to burnout. Burnout syndrome not only compromises the health and wellness of resident physicians but has also been linked to prescription errors, reduction in the quality of medical care, and decreased professionalism. This study explored burnout and factors influencing resilience among U.S. resident physicians. METHODS: A cross-sectional study was conducted through an online survey, which was distributed to all accredited residency programs by Accreditation Council of Graduate Medical Education (ACGME). The survey included the Connor-Davidson Resilience Scale (CD-RISC 25), Abbreviated Maslach Burnout Inventory, and socio-demographic characteristics questions. The association between burnout, resilience, and socio-demographic characteristics were examined. RESULTS: The 682 respondents had a mean CD-RISC score of 72.41 (Standard Deviation = 12.1), which was equivalent to the bottom 25th percentile of the general population. Males and upper-level trainees were more resilient than females and junior residents. No significant differences in resilience were found associated with age, race, marital status, or training program type. Resilience positively correlated with personal achievement, family, and institutional support (p <  0.001) and negatively associated with emotional exhaustion and depersonalization (p <  0.001). CONCLUSIONS: High resilience, family, and institutional support were associated with a lower risk of burnout, supporting the need for developing a resilience training program to promote a lifetime of mental wellness for future physicians.

Outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB) vary by sex: Analysis of 83,059 women and men with morbid obesity.

BACKGROUND: Previously we have reported variation in pre-operative clinical characteristics between women and men undergoing laparoscopic roux-en-Y gastric bypass (LRYGB). However, variation by sex in post-operative outcomes following LRYGB has not been investigated. METHODS: Pre-operative data was compared to follow-up data at 12 months after surgery on 83,059 patients from the Surgical Review Corporation's BOLD database. Data included age, weight, BMI, and 31 obesity-related medical conditions. RESULTS: Men had increased weight, actual weight lost, and BMI. Women had higher rates of gastrointestinal and mental health disorders. Men failed to resolve cardiopulmonary/vascular and metabolic derangements, abdominal hernia, and were more functionally impaired than women. CONCLUSIONS: Overall, women may benefit more from LRYG than men, as their pre-operative conditions showed greater improvement at 12 months post-op. This advance knowledge may aid LRYGB planning and improve outcomes.

Variation in Clinical Characteristics of Women versus Men Preoperative for Laparoscopic Roux-en-Y Gastric Bypass: Analysis of 83,059 Patients.

Variation by sex in preoperative clinical characteristics of female and male laparoscopic Roux-en-Y gastric bypass (LRYGB) patients has not been evaluated comprehensively. The objective of our study was to identify clinical differences between morbidly obese women and men seeking LRYGB. Data from 83,059 patients in the Surgical Review Corporation's Bariatric Outcomes Longitudinal Database who were about to undergo LRYGB was analyzed in two groups: women (n = 65,325) and men (n = 17,734). Statistics were evaluated with analysis of variance and the χ2 equation. Cardiopulmonary comorbidities affected more men than women (P ≤ 0.0002) except for female asthma (P < 0.0001). Diabetes, gout, dyslipidemia, abdominal hernia, liver disease, alcohol and tobacco use, and substance abuse were higher for men (P < 0.0001). Women had gastroesophageal reflux disease, cholelithiasis, abdominal panniculitis, back pain, musculoskeletal pain, mental health disorders, depression, and impaired psychological status more often (P < 0.0001). Among LRYGB patients, men are older, smoke, and drink more, and have increased cardiopulmonary, metabolic, and liver disease versus women. Female somatic pain, gallstones, and mental health diagnoses are higher. This advance knowledge may aid management of LRYGB patients. By raising the index of suspicion for weight-related comorbidities, management of nonbariatric surgical patients may be facilitated.

Prospectively validated preoperative prediction of weight and co-morbidity resolution in individual patients comparing five bariatric operations.

BACKGROUND: No method preoperatively predicts the postoperative bariatric surgery outcomes in individual patients. Decisions for or against surgery and operation choice remain subjective. Only 1% of qualifying patients embrace bariatric surgery. OBJECTIVE: To predict preoperatively and validate prospectively the weight and co-morbidity resolution in individual patients after open Roux-en-Y gastric bypass (RYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (SG), and biliopancreatic diversion/duodenal switch (BPD/DS). SETTING: Surgical Review Corporation BOLD database, 2007-2010. METHODS: A total of 166,601 patients who had undergone RYGB (n = 5389), LRYGB (n = 83,059), LAGB (n = 67,514), SG (n = 8966), or BPD/DS (n = 1673) were randomized into modeling (n = 124,053) and validation (n = 42,548) groups. From preoperative data, multivariate linear and logistic regression predicted weight and co-morbidities at 2, 6, 12, 18, and 24 months postoperatively. Model fit was examined by R2 and receiver operating characteristic/area under the curve and predicted versus observed results via Pearson correlation coefficient and sensitivity/specificity. RESULTS: Follow-up at 2/24 months was 120,909/11,014 for the modeling group and 41,528/3703 for validation. Weight models' R2 was .910, .813, .725, .638, and .613 at 2, 6, 12, 18, and 24 months, respectively. The categorical receiver operating characteristic/area under the curve was .617 to .949 for 24-month predictions. Pearson continuous coefficients were .969 and .811 at 2 and 24 months, respectively. The median 24-month sensitivity and specificity of co-morbidity resolution were 79.2% and 97.42%, respectively. CONCLUSIONS: Prospectively validated preoperative models predict, in individual patients, weight and obesity co-morbidities 2 years in advance for RYGB, LRYGB, LAGB, SG, and BPD/DS. This advance knowledge facilitates choosing the operation that is best for each individual and may encourage more patients to choose bariatric surgery.

In the superobese, weight loss and resolution of obesity comorbidities after biliopancreatic bypass and/or duodenal switch vary according to health insurance carrier: Medicaid vs Medicare vs Private insurance vs Self-Pay in 1681 Bariatric Outcomes Longitudinal Database patients.

BACKGROUND: Differences in Medicaid vs Medicare vs Private vs Self-Pay duodenal switch (DS) results are unknown. This study identified DS outcomes variations by health insurance. METHODS: Data from 1,681 DS patients were analyzed retrospectively: Medicaid (n = 138), Medicare (n = 313), Private insurance (n = 1,171), and Self-Pay (n = 59). General linear models included baseline and postoperative data and were modified for dichotomous variables. RESULTS: Hypertension, obstructive sleep apnea, abdominal hernia, diabetes, and 9 other hepatobiliary, and somatic conditions were lowest in Private (P < .05). Self-Pay cholelithiasis, gastroesophageal reflux disease, back and/or musculoskeletal pain, and 3 others were lowest; asthma, angina, congestive heart failure, alcohol use, liver disease, and 3 others were highest (P < .05). Medicare had highest abdominal hernia and musculoskeletal pain, pseudotumor cerebri; lowest asthma, and polycystic ovarian syndrome (P < .05). Medicaid hypertension, sleep apnea, cholelithiasis, gastroesophageal reflux disease, diabetes, back pain, and 5 others were highest (P < .05); dyslipidemia and alcohol use were lowest. CONCLUSIONS: Outcomes after DS vary by health insurance. These findings may facilitate management of DS patients.

Preoperative simultaneous fractionated cisplatin and radiation therapy in the treatment of advanced operable stage III and IV squamous cell carcinoma of the head and neck.

BACKGROUND: In Stage III/IV head and neck squamous cell carcinoma of the head and neck, multidisciplinary treatment is not standardized. This study evaluated preoperative simultaneous radiation therapy and Cisplatin 20 mg/M(2)/4 days during weeks 1, 4, and 7 of irradiation (CTRT). METHODS: Records of 143 CTRT and 48 patients treated with other surgery/radiation/chemotherapy regimens (CONTROL) were reviewed. Chi-square, analysis of variance, and Kaplan-Meier statistical analysis were performed. RESULTS: CTRT improved outcomes in Grade 2 to 5 toxicity (76% CONTROL vs 45% CTRT, P < .0001), complete clinical response (68% CTRT vs 36% CONTROL, P < .003), histologic complete response (67% in CTRT vs 28% in CONTROL, P = .0002), recurrence (33% in CTRT vs 66% in CONTROL, P = .0007), and distant metastases (2% CTRT vs 37% CONTROL, P = .0003); Kaplan-Meier disease-free survival was 65% CTRT versus 34% CONTROL. CONCLUSIONS: CTRT increases complete clinical response, histologic complete response, organ preservation, and survival, with lower recurrence and reduced toxicity and rare recurrence. CTRT may be the first treatment for Stage III/IV head and neck squamous cell carcinoma of the head and neck.

Operative Nd:YAG laser plus postoperative hyperbaric oxygen reduces surgical morbidity after radical head and neck cancer surgery and complex reconstruction.

UNLABELLED: Complications after radical head and neck cancer surgery in irradiated patients are frequent and life-threatening. Hemorrhage, salivary fistulas, wound infections that expose the carotid sheath, among others, make these patients difficult management challenges in the ICU. We studied the effects of Nd:YAG laser surgery plus hyperbaric oxygen (HBO2) therapy on radical head and neck resections and complex reconstruction as a means of reducing postoperative morbidity and mortality. METHODS: 43 head and neck cancer patients were reviewed. Eight (STD) had standard surgery; 35 (YAG:HBO2) had Nd:YAG laser and postoperative HBO2. RESULTS: Age, staging, primary tumor site, sex, reconstruction procedure and transfusion did not differ between STD and YAG/HBO2. All STD and Nd:YAG/HBO2 patients were irradiated, median dosages 5,000 centi-Gray (cGy) and 7,000 cGy, respectively (p = 0.073). Median blood loss was 1,000 ml STD and 700 ml YAG/HBO2 (p = 0.046). There were no postoperative deaths. Major surgical site complications developed in 63% of the STD and 17% of the YAG/HBO2 patients (p = 0.017). All STD and 62% of YAG/HBO2 cancers recurred within 28 months of surgery (p = 0.152). Within the STD and YAG/HBO2 groups, 100% and 77% of deaths, respectively, were due to cancer. CONCLUSIONS: Combined Nd:YAG laser surgery and HBO2 reduces morbidity in radical head and neck cancer surgery. Recurrent disease and poor cancer survival remain common in this high-risk population.

Gastric bypass: a family affair--41 families in which multiple members underwent bariatric surgery.

BACKGROUND: The effects of multiple family members undergoing Roux-en-Y gastric bypass (RYGB) are unknown. The objective of our study was to evaluate RYGB in multiple-patient families compared with case-matched controls. METHODS: A total of 91 RYGB patients (family group) from 41 families with ≥ 2 bariatric surgeries were compared with 91 other RYGB patients (controls), case-matched by gender, age (± 5 yr), and body mass index (± 5 kg/m(2)). RESULTS: Of the 91 patients in the family group, 16 (18%) were men and 75 (82%) were women. The family groups included siblings (n = 20), father/adult offspring (n = 2), mother/adult offspring (n = 17), aunt or uncle/niece or nephew (n = 7), spouses (n = 12), cousins (n = 2), grandmother/granddaughter (n = 1), and in-laws (n = 3). Six families had 3 RYGB patients, and one family had 5. Incisional hernia occurred in 17% of the family group and 24% of the control group. The office follow-up duration was 6 months for 89% and 83% and 1 year for 83.5% and 58% of the family and control groups, respectively (P < .01). The percentage of excess weight lost (%EWL) was 58% ± 18% and 49% ± 15% at 6 months and 76% ± 18% and 62% ± 19% at 1 year in the family and control groups, respectively (P < .001). The %EWL was >80% in 45% of the family group versus in 19% of the controls (P < .01). The body mass index at 1 year was 31 ± 7 kg/m(2) in the family group and 35 ± 8 kg/m(2) in the controls (P < .05). Among the family group siblings, the 1-year %EWL was 81% ± 18% versus 60% ± 17% in the matched control patients (P < .0001). CONCLUSION: The post-RYGB weight loss and follow-up were increased among the family patients versus the case-matched control patients. The %EWL was greatest among the family siblings. The results linked family ties and follow-up compliance with the %EWL.

The systemic mediator-associated response test identifies patients in failed sepsis clinical trials among whom novel drugs reduce mortality.

BACKGROUND: Clinical trials using American College of Chest Physicians/Society of Critical Care Medicine Consensus sepsis definitions as entry criteria fail to reduce septic mortality. We hypothesized that the systemic mediator-associated response test (SMART) methodology could match sepsis therapies biologically to individual patients by relating baseline data statistically to outcomes and treatment effects. This article reports the SMART analyses of four failed sepsis investigations. METHODS: Databases from the E5 antiendotoxin antibody, North American Sepsis Trial (NORASEPT) and NORASEPT II anti-tumor necrosis factor antibody (TNFMAb), interleukin (IL)-1ra, and platelet-activation factor acetylhydrolase (PAF-AH) sepsis clinical trials were evaluated with SMART using multivariate logistic regression. From baseline data, within each study, mortality prediction models were built separately for the placebo and active drug populations. Subjects among whom each drug's effects were greatest were then identified by excluding from efficacy analysis subjects predicted by SMART to survive on placebo or to expire on active drug. Finally, prerandomization data from patients in each study were entered into SMART models, and placebo or active drug treatment effects were evaluated for parent populations and SMART cohorts. RESULTS: E5-consensus mortality: 27.4% placebo, 26.2% E5; SMART mortality: 17.1% placebo, 8.0% E5 (p < 0.01). NORASEPT-consensus mortality; 33.4% placebo, 29.5% TNFMAb; SMART mortality: 47.2% placebo, 34.7% TNFMAb (p = 0.03). IL-1ra-consensus mortality: 33.9% placebo, 29.8% IL-1ra; SMART mortality: 55.6% placebo, 34.9% IL-1ra (p < 0.001). PAF-AH-consensus mortality: 22.4% placebo, 23.9% PAF-AH; SMART mortality: 17.7% placebo, 28.9% PAF-AH (p = 0.039). CONCLUSIONS: Using prerandomization clinical trial data, SMART identifies septic patients whose host-inflammatory responses can benefit from specific drugs. SMART also predicts ineffective drugs and patients whom they might harm.

Non-transectional open gastric bypass as the definitive bariatric procedure for 61 patients with BMI of 70 and higher.

BACKGROUND: Technical difficulties in laparoscopic gastric bypass for severely obese patients have led to sleeve gastrectomy first and then laparoscopic gastric bypass as a second stage after significant weight loss. Rather than commit these fragile patients to two operations, we have done open gastric bypass as a definitive surgical treatment for extreme obesity. METHODS: Office records of 61 patients with body mass index (BMI) of 70 and higher were reviewed. All underwent non-transectional open gastric bypass with a 150 cm Roux limb. Data included age, sex, weight, BMI, co-morbidities, operative information, length of stay (LOS), surgical morbidity, and percent excess weight loss (%XSWL). Data are in median (range). RESULTS: There were 21 (34%) men and 40 (66%) women: age, 37 years (19-53); pre-operative weight, 468 lb (300-650); and pre-operative BMI, 77 (70-95). Co-morbidities were diabetes mellitus, 26 (46%); hypertension, 26 (43%); sleep apnea, 61 (100%); gastroesophageal reflux disease, 20 (33%); and hypothyroid nine (15%). Incision length was 15 cm (12-20), abdominal wall fat thickness was 8 cm (5-13), operative time was 150 min (100-210), and estimated blood loss was 100 ml (25-750); post-op intensive care unit: yes 16 (26%) and no 44 (74%). LOS was 3 days for 44 patients (74%), 4 days for 11 (18%), 5 days for five (8%), and 7 days for one (1.6%). Post-operative morbidity was as follows: zero mortality, splenectomy, stoma leak, deep venous thrombosis, pulmonary embolus, GI bleeding, stomal ulcer, intestinal obstruction, fascial dehiscence, or 30-day readmission; wound infections in one (1.6%); skin wound separation in six (10%); pneumonia in one (1.6%); anemia in nine (14.8%); vitamin B(12) deficiency in six (10%); incisional hernia in 17 (28%); and gastric staple line disruption in two (3.3%). %XSWL were 51% in 1 year (28-84) and 60% in 2 years (27-97). CONCLUSIONS: Non-transectional open gastric bypass for patients with BMI of 70 and higher is safe and effective as a one-stage operation for severe obesity.

Prospectively validated prediction of physiologic variables and organ failure in septic patients: The Systemic Mediator Associated Response Test (SMART).

OBJECTIVE: Conventional outcomes research provides only percentage risk of such end points as mortality rate, utilization of resources, and/or broad groupings of multiple organ system dysfunction. These prognostications generally are not applicable to individual patients. The purpose of the present study was to determine whether the Systemic Mediator Associated Response Test (SMART) methodology could identify interactions among demographics, physiologic variables, standard hospital laboratory tests, and circulating cytokine concentrations that predicted continuous and dichotomous dependent clinical variables, in advance, in individual patients with severe sepsis and septic shock, and whether these independent variables could be integrated into prospectively validated predictive models. DESIGN: Data review and multivariate stepwise logistic regression. SETTING: University research laboratory. PATIENTS: Three hundred three patients with severe sepsis or septic shock who comprised the placebo arm of a multiple-institution clinical trial, who were randomly separated into a model building training cohort (n = 200) and a predictive cohort (n = 103). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From baseline data and baseline plus serial input, including patient demographics, hospital laboratory tests, and plasma concentrations of interleukin-6, interleukin-8, and granulocyte colony stimulating factor, multiple regression models were developed that predicted clinically important continuous dependent variables quantitatively, in individual patients. Multivariate stepwise logistic regression was used to develop models that prognosticated dichotomous dependent end points. Data from individual patients in the predictive cohort were inserted into each predictive model for each day, with prospective validation accomplished by simple linear regression of individual predicted vs. observed values for continuous dependent variables, and by establishing the receiver operator characteristics area under the curve for logistic regression models that predicted dichotomous end points. Of SMART models for continuous dependent variables, 100 of 143 (70%) were validated at r values >.7 through day 3, and 184 of 259 (71%) above r =.5 through day 5. SMART predictions of dichotomous end points achieved receiver operator characteristics areas under the curve >.7 for up to 84% of the equations in the first week. Many SMART models for both continuous and dichotomous dependent variables were validated at clinically useful levels of accuracy as far as 28 days after baseline. CONCLUSIONS: SMART integration of demographics, bedside physiology, hospital laboratory tests, and circulating cytokines predicts organ failure and physiologic function indicators in individual patients with severe sepsis and septic shock.