Impact of pretransplant recipient body mass index on post heart transplant mortality: A systematic review and meta‐analysis

The ISHLT's 2016 Guidelines on the selection of heart transplant (HT) candidates recommends weight loss prior to listing for persons with body mass (BMI) index greater than 35 kg/m². We conducted a systematic review to assess the impact of BMI on all‐cause mortality. We searched to identify eligible observational studies that followed HT recipients. We used the GRADE system to quantify absolute effects and quality of evidence, and meta‐analyzed survival curves to assess post‐transplant mortality across BMI categories. We found a significantly increased risk of mortality in patients with BMI > 30 kg/m² across all age categories, independently of transplant era and study source (BMI 30‐34.9: HR 1.10, 95% CI 1.04‐1.17; BMI ≥ 35: HR 1.24, 95% CI 1.12‐1.38). We also found an increased risk of death in underweight (BMI < 18.5 kg/m²) candidates over 39 years of age (Age 40‐65: HR 1.24, 95% CI 1.02‐1.53; Age > 65: HR 1.70, 95% 1.13‐2.57). We found obesity and underweight BMI to be associated with mortality post‐HT. The similar and overlapping increased risk of mortality in patients with BMI 30‐34.9 and BMI ≥ 35 does not support the recently updated ISHLT guidelines. Future evidence in the form of randomized controlled trials is required to assess effectiveness of interventions targeting obesity‐related comorbidities and weight management.     

Improvement of kidney function in patients with chronic kidney disease and severe obesity after bariatric surgery: A systematic review and meta-analysis

The general management for chronic kidney disease (CKD) includes treating reversible causes, including obesity, which may be both a driver and comorbidity for CKD. Bariatric surgery has been shown to reduce the likelihood of CKD progression and improve kidney function in observational studies. We performed a systematic review and meta-analysis of patients with at least stage 3 CKD and obesity receiving bariatric surgery. We searched Embase, MEDLINE, CENTRAL and identified eligible studies reporting on kidney function outcomes in included patients before and after bariatric surgery with comparison to a medical intervention control if available. Risk of bias was assessed with the Newcastle-Ottawa Risk of Bias score. Nineteen studies were included for synthesis. Bariatric surgery showed improved eGFR with a mean difference (MD) of 11.64 (95%CI: 5.84 to 17.45, I² = 66%) ml/min/1.73m² and reduced SCr with MD of ?0.24 (95%CI ?0.21 to ?0.39, I² = 0%) mg/dl after bariatric surgery. There was no significant difference in the relative risk (RR) of having CKD stage 3 after bariatric surgery, with a RR of ?1.13 (95%CI: ?0.83 to ?2.07, I² = 13%), but there was reduced likelihood of having uACR >30 mg/g or above with a RR of ?3.03 (95%CI: ?1.44 to ?6.40, I² = 91%). Bariatric surgery may be associated with improved kidney function with the reduction of BMI and may be a safe treatment option for patients with CKD. Future studies with more robust reporting are required to determine the feasibility of bariatric surgery for the treatment of CKD.     

An Appraisal of Biomarker-Based Risk-Scoring Models in Chronic Heart Failure: Which One Is Best?

Purpose of Review

While prediction models incorporating biomarkers are used in heart failure, these have shown wide-ranging discrimination and calibration. This review will discuss externally validated biomarker-based risk models in chronic heart failure patients assessing their quality and relevance to clinical practice.

Recent Findings

Biomarkers may help in determining prognosis in chronic heart failure patients as they reflect early pathologic processes, even before symptoms or worsening disease. We present the characteristics and describe the performance of 10 externally validated prediction models including at least one biomarker among their predictive factors. Very few models report adequate discrimination and calibration. Some studies evaluated the additional predictive value of adding a biomarker to a model. However, these have not been routinely assessed in subsequent validation studies.

Summary

New and existing prediction models should include biomarkers, which improve model performance. Ongoing research is needed to assess the performance of models in contemporary patients.

     

Long-term impact of bariatric surgery on glycemic control and glucose-lowering therapy for people with type 2 diabetes: population-based cohort study

BackgroundRandomized controlled trials (RCTs) have demonstrated that bariatric surgery improves glycemic control among people with diabetes. However, evidence from RCTs may not be generalizable to real-world clinical care with unselected patients in routine clinical practice.ObjectivesTo examine long-term glycemic control and glucose-lowering drug regimens following bariatric surgery for people with type 2 diabetes (T2D) in unselected patients in routine clinical practice.SettingPopulation-based cohort study using linked routinely collected real-world data from Ontario, Canada.MethodsIndividuals with T2D who were assessed for bariatric surgery at any referral center in the province between February 2010 and November 2016 were identified and divided into those who received surgery within 2 years of the initial assessment and those who did not.ResultsThere were 3674 people who had bariatric surgery and 1335 who did not. By 2 years, people who had undergone surgery had a significantly lower HbA1C (6.3 ± 1.2 % versus 7.8 ± 1.8 %, P < .0001), and this difference persisted at 3, 4, 5, and 6 years. Even by 6 years, half of those who had undergone surgery remained on no glucose-lowering drugs, and they were nearly 6 times less likely to be on insulin than those who had not undergone surgery.ConclusionsIn real-world clinical care, bariatric surgery was associated with large and sustained improvements in glycemic control.     

The Impact of Distance on Triage to Trauma Center Care in an Urban Trauma System

Abstract Background. Urban trauma systems are characterized by high population density, availability of trauma centers, and acceptable road transport times (within 30 minutes). In such systems, patients meeting field trauma triage (FTT) criteria should be transported directly to a trauma center, bypassing closer non-trauma centers. Objective. We evaluated emergency medical services (EMS) triage practices to identify opportunities for improving care delivery. Objective. Specifically, we evaluated the effect of the additional distance to a trauma center, compared with a closer non-trauma center, on the noncompliance with trauma destination criteria by EMS personnel in an urban environment. Methods. This was a retrospective cohort study of adults having at least one physiologic derangement and meeting Toronto EMS field trauma triage criteria from 2005 to 2010. Road travel distances between the site of injury, the closest non-trauma center, and the closest trauma center were estimated using geographic information systems. For patients who were transported to non-trauma centers, we estimated "differential distance": the additional travel distance required to transport directly to a trauma center. Logistic regression was used to analyze the effect of differential distance on triage decisions, adjusting for other patient characteristics. Results. Inclusion criteria identified 898 patients; 53% were transported directly to a trauma center. Falls, female gender, and age greater than 65?years were associated with transport to non-trauma centers. Differential distances greater than 1 mile were associated with a decreased likelihood of triage to a trauma center. Conclusion. Differential distance between the closest non-trauma center and the closest trauma center was associated with lower compliance with triage protocols, even in an urban setting where trauma centers can be accessed within approximately 30 minutes. Our findings suggest that there are opportunities for reducing the gap between ideal and actual application of field trauma triage guidelines through a process of education and feedback.     

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study

Background/PurposeAppendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system.MethodsUsing administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression.ResultsOver the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those > 125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31–4. 02, p = 0.001; and OR 2.55, 95%CI 1.35–4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates.ConclusionsIn this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada.Level of evidencePrognosis study, level II.     

The effect of pre–heart transplant body mass index on posttransplant outcomes: An analysis of the ISHLT Registry Data

We evaluated the effect of pre–heart transplant body mass index (BMI) on posttransplant outcomes using the International Society for Heart and Lung Transplantation Registry. Kaplan‐Meier analysis and a multivariable Cox proportional hazard regression model were used for all‐cause mortality, and cause‐specific hazard regression for cause‐specific mortality and morbidity. We assessed 38 498 recipients from 2000 to 2014 stratified by pretransplant BMI. Ten‐year survival was 56% in underweight, 59% in normal weight, 57% in overweight, 52% in obese class I, 54% in class II, and 47% in class III patients (P < 0.001). Mortality was increased in underweight (HR 1.29, 95% CI 1.24‐1.35), obese class I (HR 1.19, 95% CI 1.13‐1.26), class II (HR 1.20, 95% CI 1.08‐1.32), and class III patients (HR 1.45, 95% CI 1.15‐1.83). Obesity was independently associated with increased death from myocardial infarction, chronic rejection, infection, and renal dysfunction. An underweight BMI lead to increased death from infection, acute and chronic rejection, malignancy, and bleeding. Obese patients had a higher incidence of renal dysfunction, diabetes, stroke, acute rejection, cardiac allograft vasculopathy, and malignancy, and underweight recipients had increased acute rejection. We have shown that pretransplant obese and underweight patients have increased post–heart transplant mortality and morbidity. This has implications for candidate selection and posttransplant management.