Bariatric Space, Technology, and Design: A Round Table.

BACKGROUND: Planning and executing healthcare for the patient or resident living with obesity can be a challenging task that has implications to the occupational health professional. METHODS: Leading global experts in the areas of occupational health, ergonomics, bariatrics, technology, and patient care were identified and invited to participate in a round table discussion. Questions posed to experts were based on literature that addressed patient handling and mobility, architectural design recommendations, clinical care of the person with obesity, and ergonomic guidelines. FINDINGS: Experts agreed that special considerations must be in place to care for the person who is obese. These special considerations should address not only clinical care of the patient, but ways to protect workers from occupational injury associated with clinical care. Experts suggested that, in some situations, a bariatric training suit may be helpful in better understanding space and design challenges, as well as a better understanding of the physical limitations associated with a larger body habitus (although simulated). Further, experts agreed that insensitivities often stem from failure to have proper space, technology and design accommodations in place. Conclusions/Application to Practice: The occupational health professional is a key resource to teams charged with planning and executing healthcare for the patient or resident living with obesity. Interprofessional understanding and communication can lead to a more comprehensive approach to space, design and technology that not only addresses the patient, but the worker providing direct care.

Attitude Isn't the Only Thing, It's Everything: Humanistic Care of the Bariatric Patient Using Donabedian's Perspective on Quality of Care.

Comprehensive care of bariatric patients is challenging. Although structural knowledge exists about safe care given correct equipment and supplies, care processes also must be humane. The literature suggests morbidly obese patients may fear the health system because of past negative experiences. The purpose of this literature review was to examine quality issues in the care of bariatric patients in light of Donabedian's structure-process-outcomes model, emphasizing process components. Using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO; the criteria English language and years 2005 to 2017; and the search terms morbid obesity, obesity, bariatric, attitudes, health professionals, health clinicians, and patient care yielded 150 articles. Of those, 35 were pertinent to the review. A subsequent search using the terms Donabedian, care, and quality in MEDLINE and CINAHL resulted in 68 and 36 citations, respectively; 4 were used. When the searches were combined, no articles were identified. Findings show care providers generally understand structure aspects (knowledge or what to do) but need increased understanding of optimal care interventions (process issues or how to perform an intervention), including physical and psychological aspects. Organizations have a responsibility to ensure appropriate equipment and supportive services are available to achieve desired outcomes. Structure components will not overcome barriers or prevent complications if uncaring attitudes (processes) interfere with interpersonal interactions. Implications for clinical practice include requisite reflection on personal belief systems and empathetic understanding of precursors to morbid obesity development. Research needs to analyze what process issues are hampering quality care delivery and how to eradicate deficiencies. Health professionals can promote optimal bariatric patient outcomes by developing necessary insight and clinical wisdom. Obesity is a worldwide epidemic and those affected deserve improved care now.

Organization of future training in bariatric gastroenterology.

A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the long-term impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a long-term approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees' prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicated obesity.

Deficiencia clínica de vitamina A tras bypass gástrico. Descripción de un caso clínico y revisión de la literatura / Vitamin A deficiency after gastric bypass. Case report and review of the literature

La deficiencia de vitamina A es infrecuente en los países desarrollados. La cirugía bariátrica constituye un factor de riesgo de deficiencia de esta vitamina. Se han descrito varios casos en pacientes sometidos a técnicas con un importante componente malabsortivo, como la derivación biliopancreática. En este artículo se describe un caso de deficiencia clínica de vitamina A con manifestaciones oculares y cutáneas tras bypass gástrico y se revisan las publicaciones sobre este tema y las recomendaciones para la prevención de esta importante complicación (AU)

Vitamin A deficiency is uncommon in developed countries. Bariatric surgery emerges a an important risk factor for vitamin A defi ciency and some clinical cases have been described, specially associated with malabsorptive surgical techniques, such as biliopancreatic diversion. In this paper we report a clinical case of a patient who developed blindness, ophthalmological disease and cutaneous alterations secondary to vitamin A deficiency after gastric bypass. A review of other publications and recommendations on this important subject is also included (AU)

A History of Bariatric Surgery: The Maturation of a Medical Discipline.

This article examines the progression of bariatric surgery since its creation more than 60 years ago with a focus on the effect of surgery on weight loss, comorbidity reduction, and safety. The success has been remarkable. It is possible to cure severe obesity, type 2 diabetes, and hyperlipidemia in addition to the many other manifestations of the metabolic syndrome with remarkable safety. Equally important are the opportunities for research afforded by the surgery and its outcomes. Until better treatments become available, bariatric surgery is the therapy of choice for patients with morbid obesity for weight control and comorbidity improvement.

Is Endoluminal Bariatric Therapy a New Paradigm of Treatment for Obesity?

The prevalence of obesity has steadily increased throughout recent decades, and along with it, the costs of caring for the associated comorbid conditions has increased as well. Traditional bariatric surgical procedures generally are safe and effective, but patient acceptance, the risk of minor and sometimes serious complications, costs, and insurance coverage have limited the application of these techniques to the treatment of a minority of patients. Endoluminal techniques represent newer approaches to weight loss that can be used independently or in concert with traditional medical and surgical treatments for obesity, with varying degrees of success. It is anticipated that less invasiveness will increase the appeal across a broader representation of patients, perhaps increasing the number of obese patients who choose an intervention over medical management and possibly resulting in a greater total loss of excess body weight across a population; this may reduce costs involved in treating the complications of weight-related comorbidities. Acceptance of endoluminal bariatric procedures and devices will hinge on proving safety, efficacy, and value.

Clinician challenges in providing health care for a morbidly obese family member: a bariatric case study.

Morbid obesity is a chronic disease affecting millions of Americans. The disorder is likely to increase in prevalence because currently one third of the American population is obese. Many factors are associated with morbid obesity, including psychological (eg, depression), physiological (eg, hypothyroidism) mechanisms, sleep disorders (eg, sleep apnea), drug therapy (antidepressants, antidiabetic agents, steroids), and genetics. Increasing numbers of morbidly obese patients are requiring critical care, presenting major challenges to professional staff across the disciplines. This manuscript presents a case study describing the experiences of a morbidly obese woman in the final years of her life from the perspective of her health professional relative. The patient typifies many of the major risk factors for morbid obesity; her story reveals many of the issues faced as she revolved in and out of the critical care and acute care system. Her substantive health problems affected multiple body systems and included hypothyroidism, congestive heart failure, hyperlipidemia, and subclinical Cushing's Syndrome, likely related to previous medical therapy (cortisone) for rheumatic fever in childhood. The case description addresses many integumentary system issues the patient experienced; skin injuries and infections that can pose serious life-threatening situations for the morbidly obese patient must be prevented or treated efficiently. Health professionals can learn a great deal and improve the care they provide by listening to morbidly obese patients.

Descripción de la asistencia en urgencias de pacientes intervenidos de cirugía bariátrica en un centro de referencia / Evaluation of bariatric surgery patients at the emergency department of a tertiary referral hospital

OBJETIVO: describir el perfil de consulta en el servicio de Urgencias de pacientes intervenidos de cirugía bariátrica (CB). MÉTODO: análisis retrospectivo de las consultas al servicio de Urgencias de pacientes intervenidos de CB. Se analizan las visitas realizadas en los primeros 30 días tras el alta. Se evalúan número y motivos de consulta/reconsulta, exploraciones complementarias realizadas, diagnóstico clínico establecido y destino de los pacientes. RESULTADOS: entre enero de 2010 y julio de 2012 se intervinieron de 320 pacientes de CB, 53 enfermos (16,6 %) consultaron al menos una vez en Urgencias. Se registraron 58 consultas (1,1 visitas/paciente). Los pacientes intervenidos de cruce duodenal y bypass gástrico representaron el 74 %. Los motivos de consulta más frecuentes fueron dolor abdominal (50 %) y problemas relacionados con la herida quirúrgica (22,4 %). La analítica sanguínea fue la exploración complementaria más solicitada (75,9 %). El diagnóstico más frecuente fue dolor abdominal inespecífico en 27 casos (46,6 %), y problemas de herida quirúrgica en 10 casos (17,2 %). Diecinueve pacientes (35,84 %) requirieron ingreso hospitalario desde Urgencias y 5 de ellos precisaron reintervención quirúrgica (9,4 %). El análisis multivariante muestra que la única variable en relación a las visitas a Urgencias es el tipo de cirugía. CONCLUSIONES: las visitas a Urgencias de pacientes intervenidos de cirugía bariátrica son poco frecuentes, menos de un tercio de ellos precisan ingreso hospitalario. Las exploraciones complementarias sólo mostraron resultados patológicos en un pequeño porcentaje de los casos. La tasa de reconsultas es baja. La técnica quirúrgica es el único predictor de consulta en Urgencias

OBJECTIVE: To describe the profile of the bariatric surgery patients that were admitted to the Emergency Department (ED). METHOD: A retrospective review of the reasons why bariatric surgery patients go to our ED. We analyzed the first 30 days after the surgery. We evaluated the number and indications of admissions, the examinations ordered, and final diagnosis and destination of the patients. RESULTS: From January 2010 to July 2012, 320 patients underwent bariatric surgery at our Institution. Fifty three patients (16.6 %) were admitted to the ED at leas t once. We found 58 admissions (1.1 admissions by patient). Patients who had duodenal switch and Roux-en-Y gastric bypass were the most representative (74 %). The main indications for admission were abdominal pain (50 %), and problems related to the surgical wounds (22.4 %). Blood test was the most performed examination (75.9 %). The most frequent final diagnosis was unspecific abdominal pain in 27 cases (46.6 %), and complications of the surgical wound in 10 patients (17.2 %). Nineteen patients (35.84 %) were admitted to the surgical ward from the ED, and 5 of them required surgical revision (9.4 %). Multivariate analyses showed that the type of surgery was the only predictor variable for the ED admission. CONCLUSIONS: Attending ED after bariatric surgery is not common, and less than a third of the patients required hospital admission. Just a small percentage of the examinations showed any pathological value. Readmission rate is very low. Surgical procedure is the only predictor for ED admission

Efectividad de un programa de intervención sobre los estilos de vida en personas con obesidad atendidos en régimen de Hospital de día / Effectiveness of lifestyle intervention program in persons with obesity treated in a day hospital

Introducción. La obesidad es una enfermedad crónica que afecta aproximadamente al 25% de la población española, ocasionando una elevada morbimortalidad y costes sanitarios asociados. Objetivo. Evaluar la efectividad de un programa de intervención sobre los estilos de vida en pacientes obesos atendidos en régimen de hospital de día (HD). Métodos. Estudio de intervención prospectivo no controlado realizado en pacientes obesos atendidos en el HD de Endocrinología y Nutrición del Hospital Puerto Real, e incluidos en un programa de modificación de estilos de vida hasta alcanzar una pérdida de peso mínima >= 5%. Resultados. Se estudiaron 262 pacientes de 44,6 ± 16,0 años (71% mujeres) con un peso, índice de masa corporal y perímetro de cintura inicial de 110,4 ± 21,1 kg, 41,6 ± 6,6 kg/m2 y 120,5 ± 13,2 cm, respectivamente. Los pacientes que continuaron el seguimiento perdieron una media de 4,8 ± 4,8 kg (n = 165) y 7,0 ± 6,2 kg (n = 48) a los 3 y 6 meses respectivamente, alcanzando el objetivo de pérdida de peso >= 5% el 51,5% de los pacientes (n = 135). No se observaron diferencias significativas en la pérdida de peso en ninguna de las variables clínicas o de modalidad de seguimiento analizadas. El 43,5% de los pacientes abandonó voluntariamente el seguimiento sin cumplir el objetivo propuesto. Conclusión. La intervención sobre los estilos de vida en pacientes obesos atendidos en HD permite lograr pérdidas moderadas de peso a medio plazo, alcanzando una pérdida de peso >= 5% aproximadamente la mitad de los pacientes (AU)

Introduction: Obesity is a chronic disease that affects approximately 25% of the Spanish population, causing high morbidity and associated healthcare costs. Objective: To evaluate the effectiveness of an intervention program on lifestyles in obese patients treated in a day hospital scheme. Methods: A prospective non- controlled intervention study was conducted on obese patients treated in the Endocrinology and Nutrition day hospital, Puerto Real University Hospital, and included in program of lifestyle modification to achieve a weight loss of >= 5% minimum. Results: We studied 262 patients with a mean age of 44.6 ± 16.0 years (71% women) with an initial weight, body mass index and waist circumference of 110.4 ± 21.1 kg, 41.6 ± 6.6 Kg/m2 and 120.5 ± 13.2 cm, respectively. Patients who continued in the study lost an average of 4.8 ± 4.8 kg (n = 165) and 7.0 ± 6.2 kg (n = 48) at three and six months, respectively, with 51.5% (n = 135) patients reaching the weight loss goal of >= 5%. There were no statistically differences in weight loss between any clinical or follow-up variables analysed. 43.5% of patients voluntarily left the study without reaching the weight loss goal. Conclusion: The intervention on lifestyles in obese patients treated in a day hospital achieves moderate weight loss in the medium term, with half of patients achieving a weight loss >= 5% (AU)

Medida de la satisfacción del paciente e identificación de oportunidades de mejora en la preparación de pacientes de cirugía bariátrica / Measuring patient satisfaction and identifying opportunities for improvement in the preparation of bariatric surgery patients

Objetivo. Evaluar la satisfacción de los pacientes candidatos a cirugía bariátrica con la realización de un programa de preparación grupal precirugía, detectar oportunidades de mejora en el programa y evaluar la satisfacción de los participantes tras su implantación. Material y métodos. Se ha utilizado una encuesta diseñada ad hoc dirigida a evaluar la opinión sobre diferentes aspectos del programa, la satisfacción con el mismo y la identificación de mejoras. Se administró a dos grupos de pacientes: al primero un año después del programa para identificar propuestas de mejora y al segundo un año después de la implementación de la mejora. Se evaluaron 112 pacientes, 66 en el primer pase de la encuesta y 46 en el segundo. Ambos grupos fueron homogéneos en las variables sociodemográficas. Resultados. La principal mejora detectada fue la participación de pacientes expertos en el programa de preparación. Tras su implantación se produjeron ligeros cambios en las valoraciones de las diferentes preguntas, que no fueron significativos. La satisfacción general pasó de un 9,5 a 9,74 sobre 10. Otras propuestas de mejora fueron mejorar la presentación audiovisual y adaptar el mobiliario de la sala a las características de los pacientes. Conclusiones. La elevada satisfacción encontrada es habitual en los trabajos sobre satisfacción hospitalaria, siendo los resultados obtenidos aquí aún mayores que los de los estudios consultados y estando en todos los casos en niveles de excelencia. Esto impide que se produzcan diferencias estadísticamente significativas. Tampoco se encontró una diferencia significativa en los resultados pre y postimplantación de la mejora. La evaluación continua permite constatar nuevas posibilidades de mejora(AU)

Objective. To evaluate the satisfaction of patients candidates for bariatric surgery with the performance of a group training program prior to surgery, identifying opportunities for improvement in the program and evaluating participants satisfaction following their implementation. Method. An "ad hoc" designed survey was used, addressed to assess opinions on different aspects of the program, overall satisfaction and identification of areas for improvement. The survey was administered to two groups of patients: the first after one year of implementation of the program to identify suggestions for improvement, and the second after one year of the implementation of the improvement. A total of 112 patients were assessed, 66 in the first pass of the questionnaire and 46 in the second. Both groups were homogeneous in demographic variables Results. The main improvement detected was expert patients in the preparation of the program. After implantation, slight changes in the ratings of the questions were produced, that were not significant. Overall satisfaction rose from 9.5 to 9.74 out of 10. The other proposals for improvement were to improve audiovisuals and to fit the room furniture to the characteristics of the patients. Conclusions. The very high satisfaction levels obtained are usual in studies on hospital satisfaction, our results still being above the studies consulted, as well as in levels of excellence. This prevents statistically significant differences being found. There were no significant differences in the results before and after implementation of improvement. Continuous assessment allows new possibilities for improvement(AU)

Estudio del sahos en candidatos a cirugía bariátrica / No disponible

No disponible

Bioimpedance analysis: should it be used in morbid obesity?

OBJECTIVES: Questions about reliability of bioimpedance analysis (BIA) in morbidly obese subjects have curtailed its use in this setting, but metabolic implications might reignite the debate. In a prospective study, it was aimed to analyze anthropometric and clinical associations. METHODS: Bariatric candidates (n = 94) with or without metabolic syndrome were consecutively investigated. Age was 34.9 ± 10.4 years (68.1% females), and BMI was 40.8 ± 4.6 kg m(-2) . Methods included single-frequency BIA, anthropometrics, inflammatory indices, and general biochemical profile. RESULTS: Body composition results (water, fat) in females, but not in males, were entirely consistent with the literature. In both genders good association was observed with anthropometrics (BMI, waist circumference), inflammatory indices (ferritin, C-reactive protein) and general biochemical variables. Anthropometric measurements also displayed comparable associations. Multivariate tests including the two sets of measurements indicated no predominance of one method over the other, one complementing the other as metabolic marker. CONCLUSIONS: BIA limitations were mostly relevant for males, not females. Despite such discrepancies, good associations with anthropometry were demonstrated for both genders. Correlations with liver enzymes, and indices of protein, carbohydrate, and lipid metabolism could be demonstrated. BIA deserves more investigations concerning liver steatosis and ongoing inflammation, and it could contribute as well, synergistically with anthropometry, to monitor weight loss, body fat shifts, and metabolic risk.

Cost-effectiveness of routine and group programs for treatment of obese children.

BACKGROUND: Cost-effectiveness analyses facilitate the allocation of health care resources. The aim of the study was to compare the cost-effectiveness of group treatment, already known to be more effective, with routine counseling in obese children. METHOD: A prospective 6-month intervention assessed family-based group treatment (15 separate sessions for parents and children) and routine counseling (two appointments for children). Children's weights and heights were measured at baseline, at the end of the intervention and at follow up 6 months later, and the changes in weight for height and body mass index standard deviations scores (BMI-SDS) were calculated and used as main outcome measures. The mean costs and effects of the programs were analyzed to produce the incremental cost-effectiveness ratio, which is an estimate of the additional costs per 1% decrease in weight for height or 0.1 decrease in BMI-SDS. Cost-effectiveness analysis was performed from the perspective of the service provider. RESULTS: At the end of the intervention, group treatment costs were 1.4-fold (non-calculable 6 months later) when counted per 1% weight for height decrease, and 3.5-fold (2.8-fold 6 months later) when counted per 0.1 BMI-SDS decrease. Incremental cost-effectiveness ratio estimates were euro 53 when calculated for 1% weight for height decrease, and euro 266 (euro 275 6 months later) when calculated for 0.1 BMI-SDS decrease. CONCLUSIONS: Family-based group treatment is more costly compared with individual routine counseling. Salaries form most of the total costs.

Equipping your facility for bariatric patients.

As the number of extremely obese people increases worldwide, all healthcare facilities-not just those with bariatric surgical programs-are treating patients who have special equipment and space requirements. Is your facility ready? This article will help you analyze your current capabilities and identify the steps you still need to take to accommodate this segment of the population.

Evaluation of bariatric Centers of Excellence Web sites for functionality and efficacy.

BACKGROUND: The Internet is a valuable method of information sharing and could have important applications for bariatric surgical practices. The purpose of this study was to devise criteria by which Centers of Excellence Web sites could be evaluated. By applying these criteria to the study sample, we hoped to identify specific content that could improve Web site functionality and, thereby, its efficacy. METHODS: We developed an original survey instrument that used specific criteria of Web site content to determine its functionality. The categories of content were Marketing, Interactivity, Education, and Support. Each of these categories was further divided into 3-7 subcategories for more in-depth analysis. From the Surgical Review Committee Web site page, 66 Centers of Excellence Web sites met our inclusion criteria of private, exclusively bariatric surgery practices. We then applied the survey instrument to evaluate their functionality. RESULTS: The survey revealed marketing and education content in all sites, and nearly all were interactive and provided patient support. However, all Web sites had deficiencies in >1 subcategory. CONCLUSION: Many Centers of Excellence have a Web presence. However, the opportunity exists to increase Web site functionality and efficacy by improving content in specific areas and using up-to-date technology.

Current issues and challenges in the management of bariatric patients.

Morbid obesity is an increasingly common healthcare problem, and providers and patients currently face numerous challenges in dealing with this problem effectively. Issues addressed in this article include the effect of stigma, the need for more evidence regarding effective management options, and the declining insurance coverage for bariatric surgery. The role of bariatric surgery in effective management of morbid obesity is discussed, along with the effect on and possible reasons for declining coverage. A comparison between benefits and coverage for bariatric surgery and angioplasty/stent placement is included.

Surgical treatment for obesity: ensuring success.

In the United States, obesity has reached epidemic proportions. Serious medical complications, impaired quality of life, and premature mortality are all associated with obesity. Medical conditions such as type 2 diabetes mellitus, hypertension, hyperlipidemia, or sleep apnea can improve or be cured with weight loss. Medical treatment programs focused on diet, behavior modification, and/or pharmacologic intervention have met with limited long-term success. Although surgical treatments for obesity have become popular in recent years, they should only be used as a last resort for weight loss. Not all patients can be considered appropriate candidates for surgery; therefore, guidelines based on criteria from the National Institutes of Health should be used preoperatively to help identify suitable persons. Most individuals who opt for weight-loss surgery have usually struggled for many years with losing weight and keeping it off, but surgery alone will not ensure successful weight loss. Patient education is imperative for long-term success. Moreover, any such educational regimen should include information on diet, vitamin and mineral supplementation, and lifestyle changes, as well as expected weight-loss results and improvements in comorbid conditions. Patients must be willing to commit to a long-term follow-up program intended to promote successful weight loss and weight maintenance and to prevent metabolic and nutritional complications.