Association of body mass index with 30-day outcomes following groin hernia repair.

PURPOSE: Although groin hernia repairs are relatively safe, efforts to identify factors associated with greater morbidity and resource utilization following these operations are warranted. An emphasis on obesity has limited studies from a comprehensive evaluation of the association between body mass index (BMI) and outcomes following groin hernia repair. Thus, we aimed to ascertain the association between BMI class with 30-day outcomes following these operations. METHODS: The 2014-2020 National Surgical Quality Improvement Program database was queried to identify adults undergoing non-recurrent groin hernia repair. Patient BMI was used to stratify patients into six groups: underweight, normal, overweight, and obesity classes I-III. Association of BMI with major adverse events (MAE), wound complication, and prolonged length of stay (pLOS) as well as 30-day readmission and reoperation were evaluated using multivariable regressions. RESULTS: Of the 163,373 adults who underwent groin hernia repair, the majority of patients were considered overweight (44.4%). Underweight patients more commonly underwent emergent operations and femoral hernia repair compared to others. After adjustment of intergoup differences, obesity class III was associated with greater odds of an MAE (AOR 1.50), wound complication (AOR 4.30), pLOS (AOR 1.40), and 30-day readmission (AOR 1.50) and reoperation (AOR 1.75, all p < 0.05). Underweight BMI portended greater odds of pLOS and unplanned readmission. CONCLUSION: Consideration of BMI in patients requiring groin hernia repair could help inform perioperative expectations. Preoperative optimization and deployment of a minimally invasive approach when feasible may further reduce morbidity in patients at the extremes of the BMI spectrum.

Platelet mapping as part of modified thromboelastography (TEG®) in patients undergoing cardiac surgery and cardiopulmonary bypass.

The platelet-mapping assay of the thromboelastograph was used to measure platelet aggregation and to examine the effect of cardiopulmonary bypass on multiple platelet receptors and the role of altered receptor activity in postoperative bleeding. The percentage platelet aggregation for collagen, adenosine diphosphate and arachidonic acid was measured in 40 patients divided post-hoc into high- or low-bleeding groups depending on postoperative 24-h chest tube output. Platelet aggregation was lower after cardiopulmonary bypass compared to before it using collagen (mean (SD) 45 (25) vs 19 (12)%, p<0.001), adenosine diphosphate (76 (23) vs 35 (24)%, p<0.001), and arachidonic acid (61 (33) vs 31 (35)%, p<0.001). Only platelet aggregation as measured using collagen pre- and post-cardiopulmonary bypass was significantly less in the high- compared to the low-bleeding group. This finding was significantly correlated with the 24-h chest tube drainage, and it predicted postoperative bleeding with a sensitivity of 83% and a specificity of 68%. Therefore, platelet aggregation is reduced following cardiopulmonary bypass, and this may play a role in predicting postoperative blood loss.

A survey of inhalational anaesthetic abuse in anaesthesia training programmes.

This study aims to assess the prevalence and outcomes of inhalational anaesthetic abuse among anaesthesia training programmes. Online surveys were completed by chairpersons of academic anaesthesia training programmes in the United States. The response rate was 84% (106/126 programmes). Twenty-two percent of the departments had had at least one incident of inhalational anaesthetic abuse. Forty-eight percent (15/31) of the persons abusing inhalational anaesthetics were sent for rehabilitation. Only 22% (7/31) of those found to be abusing inhalational anaesthetics were ultimately able to return successfully to anaesthesia practice with sustained recovery. The mortality rate among individuals found abusing inhalational anaesthetics was 26% (8/31). The majority of the anaesthesia departments (97/104, 93%) did not have any pharmacy accounting of inhalational anaesthetics. This is the first published survey of inhalational anaesthesia abuse. Inhalational anaesthetic abuse should be considered in at-risk individuals or those with a history of substance abuse. The concern about substance abuse is not unique to American anaesthetists. Countries around the world deal with similar substance abuse issues.

Surgical complications and long-term outcome of different biliary reconstructions in liver transplantation for primary sclerosing cholangitis-choledochoduodenostomy versus choledochojejunostomy.

Choledochojejunostomy (CJS) is commonly used for biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC). We alternatively performed choledochoduodenostomy (CDS) and side-to-side choledochodocholedochstomy in a large cohort of patients. Fifty-one patients with PSC, transplanted between 1988 and 2000, were analyzed retrospectively. Biliary reconstruction was CDS in 25 (49%), CJS in 20 (39%) and CC in 6 transplantations (12%). Biliary leaks occurred in the early follow-up (< or =41 days) only in CDS patients (20%). However, in the late follow-up (>4 months), stricturing of anastomosis was found once in CDS (4%) and CJS (5%). Later (>9 months), intrahepatic bile duct strictures were diagnosed in four CDS (16%), one CJS (5%) and one CC (17%) patient(s). In 48% of CDS (12/25), 60% of CJS (12/20) and 17% of CC (1/6) at least one incidence of cholangitis was observed. Overall, biliary complication rates were significantly higher in CDS (40%) than CJS (10%) and CC (17%); of those none in CC and 12% in CDS were anastomosis-related. Graft/patient survival showed no significant differences among groups. Based on our results we consider CJS the standard method for biliary reconstruction in PSC; however, in selected cases where CJS is difficult to accomplish because of previous surgery or for retransplantation, CDS may present an alternative technique.

Aerobic exercise, lipids and lipoproteins in overweight and obese adults: a meta-analysis of randomized controlled trials.

OBJECTIVE: Use the meta-analytic approach to examine the effects of aerobic exercise on lipids and lipoproteins in overweight and obese adults. DATA SOURCES: (1) Computerized literature searches, (2) cross-referencing from review and original articles, (3) hand searching, and (4) expert review of reference list. STUDY SELECTION: (1) randomized controlled trials, (2) aerobic exercise > or =8 weeks, (3) adult humans > or =18 y of age, (4) all subjects overweight or obese (BMI > or =25 kg/m(2)), (5) studies published in journal, dissertation, or master's thesis format, (6) studies published in the English-language, (7) studies published between 1 January 1955 and 1 January 2003, (8) assessment of one or more of the following lipid and/or lipoprotein variables: total cholesterol (TC), high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), and triglycerides (TG). DATA ABSTRACTION: Dual-coding by the first two authors (inter-rater agreement=0.96). RESULTS: In total, 13 studies representing 31 groups (17 exercise, 14 control), 613 subjects (348 exercise, 265 control), and up to 17 outcomes were available for pooling. Across all categories, random-effects modeling resulted in statistically significant improvements for TC (X +/- s.e.m., - 3.4+/-1.7 mg/dl, 95% CI, - 6.7 to - 0.2 mg/dl) and TG (X +/-s.e.m., - 16.1+/-7.3 mg/dl, 95% CI, - 30.2 to - 2.1 mg/dl) but not HDL (X +/- s.e.m., 1.6+/-0.8 mg/dl, 95% CI, - 0.02 to 3.2 mg/dl) or LDL (X +/-s.e.m., - 0.5+/-1.3 mg/dl, 95% CI, - 3.0 to 2.0 mg/dl). Changes were equivalent to improvements of 2% (TC), 11% (TG), 3% (HDL), and 0.3% (LDL). After conducting sensitivity analyses (each study deleted from the model once), only decreases in TG remained statistically significant. Increases in HDL were associated with increases in maximum oxygen consumption (VO(2 max) in ml/kg/min, r=0.75, P=0.002) and decreases in body weight (r=0.77, P<0.001), while decreases in LDL were associated with decreases in body weight (r=0.75, P=0.009). CONCLUSIONS: Aerobic exercise decreases TG in overweight and obese adults. However, a need exists for additional randomized controlled trials in various overweight and/or obese populations above and beyond those included in our analysis.

Validation of the BodyGem hand-held calorimeter.

OBJECTIVE: To assess the validity and reliability of a hand-held indirect calorimeter. DESIGN: Resting metabolic rate (RMR) was measured on two separate mornings. SUBJECTS: A heterogeneous sample of 41 healthy adults. MEASUREMENTS: RMR using both a metabolic cart (Sensormedics 2900, SM-2900) and a hand-held indirect calorimeter (BodyGem, BG). RESULTS: There were no trial-to-trial differences in RMR measured by the BG (6756+/-163 vs 6697+/-163 kJ/day) or the SM-2900 (6400+/-163 vs 6396+/-167 kJ/day). RMR measured by the BG was significantly higher than that measured by the SM-2900 during both trials. In a sample of 10 subjects, the energy cost of holding the BG in position was determined to be (0.17+/-0.04 kJ/min, or 255+/-84 kJ/day). After applying this adjustment, the differences between systems were no longer significant during trial 1 (mean difference=101+/-67 kJ/day) or trial 2 (46+/-75 kJ/day). In overweight and obese individuals, RMR measured by the BodyGem was more accurate than that estimated by the Harris-Benedict equations. CONCLUSION: The BodyGem provides valid and reliable measurements of RMR. The BodyGem produces significantly higher values than the Sensor Medics 2900 indirect calorimeter, with the increase largely due to an increased energy demand required to hold the BG in position.

Walking and resting blood pressure in adults: a meta-analysis.

BACKGROUND: The purpose of this study was to examine the effects of walking on resting systolic and diastolic blood pressure in adults. METHODS: A total of 24 primary outcomes from 16 studies and 650 subjects (410 exercise, 240 control) met the criteria for inclusion: (1) randomized and nonrandomized controlled trials, (2) walking as the only intervention, (3) subjects apparently sedentary, (4) adult humans > or =18 years of age, (5) English-language studies published between January 1966 and December 1998, (6) resting blood pressure assessed, (7) training studies > or =4 weeks. RESULTS: Using a random effects model, statistically significant decreases of approximately 2% were found for both resting systolic and diastolic blood pressure (systolic, mean +/- SEM = -3 +/- 1 mm Hg, 95% confidence interval: -5 to -2 mm Hg; diastolic, mean +/- SEM = -2 +/- 1 mm Hg, 95% confidence interval: -3 to -1 mm Hg). CONCLUSION: Walking exercise programs reduce resting blood pressure in adults.

Progression of autosomal-dominant polycystic kidney disease in children.

BACKGROUND: Although many case reports describe manifestations of autosomal-dominant polycystic kidney disease (ADPKD) in children, no longitudinal studies have examined the natural progression or risk factors for more rapid progression in a large number of children from ADPKD families. METHODS: Since 1985, we have studied 312 children from 131 families with a history, a physical examination, blood and urine chemistries, an abdominal ultrasonography, and gene linkage analysis. One hundred fifteen of 185 affected children were studied multiple times for up to 15 years. Renal volumes were determined by ultrasound imaging. Graphs of mean renal volumes according to age were compared between affected and unaffected children, ADPKD children with and without early severe disease, and children with and without high blood pressure. RESULTS: Affected children had faster renal growth than unaffected children. ADPKD children with severe renal enlargement at a young age continued to experience faster renal growth than those with mild enlargement or normal kidney size for their age, and affected children with high blood pressure had faster renal growth than those with lower blood pressure. Glomerular filtration rate did not decrease in any children except for two with unusually severe early onset disease. CONCLUSIONS: The progression of ADPKD clearly occurs in childhood and manifests as an increase in cyst number and renal size. This study identifies children at risk for rapid renal enlargement who may benefit the most from future therapeutic interventions.

Resistance training and bone mineral density in women: a meta-analysis of controlled trials.

The purpose of this study was to use meta-analysis to examine the effects of resistance training on bone mineral density at the femur, lumbar spine, and radius in pre- and postmenopausal women. Resistance training had a positive effect on bone mineral density at the lumbar spine of all women and at the femur and radius sites for postmenopausal women. It was concluded that resistance training has a positive effect on bone mineral density in women.

Original metric vs. standardized effect sizes for meta-analysis of clinical data.

This study compared the use of the original metric effect size with the standardized effect size for clinical data in meta-analysis. The example data set included 17 controlled clinical trials dealing with the effects of progressive resistance exercise on resting diastolic blood pressure in adults. Original metric effect size showed a decrease in resting diastolic blood pressure of -2.07 mm Hg (95% confidence interval, -3.60 to -0.54). From a clinical standpoint, this is considered a "small" effect. The standardized approach showed an average effect of -0.21, 95% CI= -0.39 to -0.02. This is also considered a "smal" effect. When possible, use of the original metric is preferred because it can be more clinically meaningful and will enhance interpretation of blood pressure results for a wider range of readers. (c) 2001 by CHF, Inc

Aerobic exercise and resting blood pressure: a meta-analytic review of randomized, controlled trials.

In this study the authors used the meta-analytic approach to examine the effects of aerobic exercise on resting systolic and diastolic blood pressure in adults. Forty-seven clinical trials representing a total of 72 effect sizes in 2543 subjects (1653 exercise, 890 control) met the criteria for inclusion. Statistically significant exercise-minus-control decreases were found for changes in resting systolic and diastolic blood pressure in both hypertensive (systolic, -6 mm Hg, 95% CI, -8 to -3; diastolic, -5 mm Hg, 95% CI, -7 to -3) and normotensive (systolic, -2 mm Hg, 95% CI, -3 to -1; diastolic, -1 mm Hg, 95% CI, -2 to -1) groups. The differences between groups were statistically significant (systolic, p=0.008; diastolic, p=0.000). Relative decreases were approximately 4% (systolic) and 5% (diastolic) in hypertensives, and 2% (systolic) and 1% (diastolic) in normotensives. It was concluded that aerobic exercise reduces resting systolic and diastolic blood pressure in adults. (c) 2001 by CHF, Inc.

Age-related decreases in lymphocyte protein kinase C activity and translocation are reduced by aerobic fitness.

This study investigated the effects of advancing age and long-term aerobic fitness on lymphocyte protein kinase C (PKC) activity and translocation. Lymphocytes were obtained from young (20-36 years old) and older (61-78 years old) healthy men who were either aerobically conditioned or deconditioned. Both baseline PKC activity and the response of this enzyme to the direct PKC stimulating agent, phorbol 12-myristate, 13-acetate (PMA) or to the mitogen, phytohaemagglutinin (PHA), were measured in partially purified extracts of cytosolic and membranous fractions of lymphocytes. Basal PKC activity, PMA-induced redistribution of PKC, and PHA-induced enhancement of PKC activity were reduced among older subjects in both lymphocyte cytosolic and membranous fractions. However, the magnitudes of these reductions were smaller among the older subjects who were aerobically fit. Lymphocyte PKC activity and translocation may be biological markers of aging, and the maintenance of aerobic fitness into later life may serve to slow the rate at which activation of this enzyme declines during senescence.

Exercise and bone mineral density in men: a meta-analysis.

The purpose of this study was to use the meta-analytic approach to examine the effects of exercise on bone mineral density (BMD) in men. A total of 26 effect sizes (ES) representing 225 subjects from 8 studies met the criteria for inclusion. When BMD sites assessed were specific to the sites loaded during exercise, increases of approximately 2.6% (2.1% in the exercisers and -0.5% in the controls) were found. These results were statistically significant (ES = 0.213, 95% bootstrap confidence interval = 0.007-0.452). Statistically significant ES changes were found for older (>31 yr) but not younger (<31 yr) adults, with differences between groups statistically significant (P = 0.04). Statistically significant changes were also observed at the femur, lumbar, and os calcis sites. The results of this study suggest that site-specific exercise may help improve and maintain BMD at the femur, lumbar, and os calcis sites in older men. However, the biological importance of the small changes observed for most outcomes, quality of studies, and limited data pool prevent us from forming any firm conclusion regarding the use of exercise for maintaining and/or improving BMD in men. Clearly, a need exists for additional studies.

Reliability of a handgrip test for evaluating heart rate and pressor responses in multiple sclerosis.

PURPOSE: The purpose of this study was to determine the test-retest reliability of an isometric handgrip exercise protocol designed to evaluate heart rate and arterial pressure responses in individuals with multiple sclerosis (MS). METHODS Three males and eleven females, aged 24 through 51, performed isometric handgrip contractions at 30% of maximal voluntary contraction (MVC) to the point of fatigue (defined as inability to maintain the target force for three consecutive seconds). During this exercise, rate of perceived exertion (RPE) was recorded every 30 s. Heart rate and beat-to-beat systolic, diastolic, and mean arterial pressures were recorded continuously throughout the duration of exercise. Surface EMG was monitored continuously via loudspeaker to provide feedback on extraneous muscular activity. Each subject performed three trials. A repeated measures ANOVA was used to calculate interclass reliability estimates for each dependent variable. RESULTS: Reliability estimates for MVC and time to fatigue were 0.98 and 0.84, respectively. Reliability estimates for the following dependent variables at the point of fatigue were: RPE, 0.90; delta HR, 0.97; delta systolic pressure, 0.92; delta diastolic pressure, 0.87; and delta MAP, 0.88. CONCLUSIONS: We conclude that this isometric handgrip protocol is a reliable method for evaluating heart rate and blood pressure responses in MS patient.

Effects of 14 d of covert substitution of olestra for conventional fat on spontaneous food intake.

We conducted a double-blind, placebo-controlled, within-subject crossover study to investigate the effects of covert substitution of olestra, a non-energy-containing fat replacer, for conventional fat on food selection and energy intake in lean and obese men and women. Fifty-one subjects [BMI (kg/m2): 19-36; age: 25-63 y] were studied during two 14-d treatment periods (olestra and placebo), with a 7-d washout between feeding periods. During the intervention periods all foods were provided to the subjects. The aim was to produce a 10% dilution of total energy intake by replacing conventional triacylglycerol with olestra. To accomplish this, subjects were required to consume core foods providing 20-35 g olestra (depending on estimated energy needs) or the same foods containing placebo triacylglycerol. Additional items could be selected from foods that varied in macronutrient composition. When the two treatment periods were compared, total energy intake was 8% lower and fat intake 11% lower during the olestra period than during the placebo treatment period (P < 0.0001). Overall, subjects compensated for 15% of the fat and 20% of the total energy replaced by olestra. In absolute terms, subjects consumed 32% of total energy from fat during the placebo period and 27% of total energy from fat during the olestra period. Neither carbohydrate nor protein intake (g/d) differed between periods. The results did not differ as a function of BMI (lean compared with obese) or sex. Over a 2-wk period, covert substitution of olestra for conventional fat led to reductions in dietary fat intake and total energy intake in all subjects.

Age-related declines in maximal aerobic capacity in regularly exercising vs. sedentary women: a meta-analysis.

Our purpose was to determine the relationship between habitual aerobic exercise status and the rate of decline in maximal aerobic capacity across the adult age range in women. A meta-analytic approach was used in which mean maximal oxygen consumption (VO2 max) values from female subject groups (ages 18-89 yr) were obtained from the published literature. A total of 239 subject groups from 109 studies involving 4,884 subjects met the inclusion criteria and were arbitrarily separated into sedentary (groups = 107; subjects = 2,256), active (groups = 69; subjects = 1, 717), and endurance-trained (groups = 63; subjects = 911) populations. VO2 max averaged 29.7 +/- 7.8, 38.7 +/- 9.2, and 52.0 +/- 10.5 ml . kg-1 . min-1, respectively, and was inversely related to age within each population (r = -0.82 to -0.87, all P < 0.0001). The rate of decline in VO2 max with increasing subject group age was lowest in sedentary women (-3.5 ml . kg-1 . min-1 . decade-1), greater in active women (-4.4 ml . kg-1 . min-1 . decade-1), and greatest in endurance-trained women (-6.2 ml . kg-1 . min-1 . decade-1) (all P < 0.001 vs. each other). When expressed as percent decrease from mean levels at age approximately 25 yr, the rates of decline in VO2 max were similar in the three populations (-10.0 to -10.9%/decade). There was no obvious relationship between aerobic exercise status and the rate of decline in maximal heart rate with age. The results of this cross-sectional study support the hypothesis that, in contrast to the prevailing view, the rate of decline in maximal aerobic capacity with age is greater, not smaller, in endurance-trained vs. sedentary women. The greater rate of decline in VO2 max in endurance-trained populations may be related to their higher values as young adults (baseline effect) and/or to greater age-related reductions in exercise volume; however, it does not appear to be related to a greater rate of decline in maximal heart rate with age.

Pressor response to isometric exercise in patients with multiple sclerosis.

The purpose of this study was to determine whether patients with multiple sclerosis (MS) would show attenuated heart rate and/or pressor responses to isometric handgrip exercise. Patients with MS (30 males, 74 females, aged 23-61 yr) and control subjects (9 males, 16 females, aged 25-47 yr) performed isometric handgrip exercise at 30% of maximal voluntary contraction (MVC) to fatigue. Systolic, diastolic, and mean arterial pressure (MAP) increased linearly in both groups, but were significantly lower (P < 0.05) in patients with MS at 20%, 40%, 60%, 80%, and 100% of exercise duration. Mean change in MAP at fatigue was +47.9 mm Hg for controls and +28.2 mm Hg for patients with MS, with 18 patients with MS between -6 mm Hg and +15 mm Hg. Heart rate increased normally in patients with MS. To predict change in MAP at fatigue in patients with MS, stepwise regression analysis using six variables yielded an R2 of 0.26. These data suggest that in some patients MS lesions exist in areas of autonomic cardiovascular control that result in attenuated pressor responses to exercise. In 17% of patients tested, attenuation was profound. Data also suggest an abnormal dissociation between the heart rate and pressor response to static work in patients with MS.

Nutrition and physical activity program to attenuate obesity and promote physical and metabolic fitness in elementary school children.

Obesity and low levels of physical and metabolic fitness are risk factors for cardiovascular disease and diabetes. The purpose of this investigation was to attenuate obesity and improve physical and metabolic fitness in elementary school children. Schools have the opportunity, mechanisms, and personnel in place to deliver nutrition education, fitness activities, and a school food service that is nutritious and healthy. Cohorts from grades 3 to 5 in two school districts in rural Nebraska (Intervention/Control) participated in a 2-year study of physical activity and modified school lunch program. Data collection for aerobic capacity, body composition, blood chemistry, nutrition knowledge, energy intake, and physical activity was at the beginning and end of each year. Int received enhanced physical activity, grade specific nutrition education, and a lower fat and sodium school lunch program. Con continued with a regular school lunch and team sports activity program. At year 2, Int lunches had significantly less energy (9%), fat (25%), sodium (21%), and more fiber (17%). However, measures of 24-hour energy intake for Int and Con showed significant differences for sodium only. Physical activity in the classroom was 6% greater for Int compared to Con (p < 0.05) but physical activity outside of school was approximately 16% less for Int compared to Con (p < 0.05). Body weight and body fat were not different between schools for normal weight or obese children. No differences were found for cholesterol, insulin, and glucose; however, HDL cholesterol was significantly greater and cholesterol/HDL was significantly less for Int compared to Con (p < 0.05). It appears that compensation in both energy intake and physical activity outside of school may be responsible for the lack of differences between Int and Con.

Aerobic exercise and normotensive adults: a meta-analysis.

Using the meta-analytic approach, the purpose of this study was to examine the effects of aerobic exercise on resting systolic (SYS) and diastolic (DIA) blood pressure in normotensive adults: The results of 35 human clinical training studies published in English-language journals between 1963 and 1992 and representing 1,076 subjects (800 exercise, 276 control) met criteria for inclusion. Across all categories and designs, statistically significant post-exercise reductions were found for both SYS and DIA blood pressure (mean +/- SD, SYS: -4.4 +/- 6.6 mm Hg, 95% CI, -6.2 to -2.6 mm Hg; DIA: -3.2 +/- 3.2 mm Hg, 95% CI, -4.0 to -2.2 mm Hg). When partitioned according to type of study: 1) (randomized controlled trials (RCT), 2) controlled trials (CT), and 3) no controls (NC), the following changes were noted: RCT, SYS: -4.5 +/- 7.2 mm Hg, 95% CI, -7.1 to -1.2 mm Hg; DIA: -3.8 +/- 2.9 mm Hg, 95% CI, -5.0 to -2.6 mm Hg; CT, SYS: -2.8 +/- 6.9 mm Hg, 95% CI, -10.0 to 4.4 mm Hg; DIA: -5.0 +/- 3.7 mm Hg, 95% CI, -8.9 to -1.1 mm Hg; NC, SYS: -4.7 +/- 6.1 mm Hg, 95% CI, -7.5 to 1.9 mm Hg; DIA: -1.7 +/- 3.0 mm Hg, 95% CI, -3.2 to -0.36 mm Hg. We concluded that aerobic exercise results in small reductions in resting SYS and DIA blood pressure among normotensive adults.