Wanberg, Erik J.

Summary Bariatric surgery and glucagon-like peptide-1 receptor agonist medications (GLP-1RAs) are common and effective methods for treating obesity. Since bariatric surgery is associated with an increased risk of malnutrition, there are extensive post-operative dietary recommendations and nutritional monitoring guidelines. There is, however, less evidence regarding the risk of malnutrition with GLP-1RAs and little research on the use of GLP-1RAs in patients post-bariatric surgery. We present a clinical case in which a 39-year-old male on semaglutide therapy presented with severe weakness and inability to ambulate. His symptoms had developed over the prior 3 months following transoral outlet reduction surgery and worsened with an increase of his semaglutide dose to 1.7 mg/week. Physical examination demonstrated severe distal-predominant bilateral lower extremity weakness, loss of lower extremity reflexes, and impaired sensation distal to the T4 dermatome. Laboratory serum testing revealed thiamine and vitamin E deficiencies. Lumbar magnetic resonance imaging demonstrated mild homogeneous enhancement of the cauda equina nerve roots, neural foraminal narrowing, and disc protrusions without significant spinal canal stenosis. Given the absence of structural abnormalities, he was diagnosed with lumbosacral polyradiculopathy due to micronutrient deficiencies. Treatment included discontinuation of semaglutide and initiation of thiamine and vitamin E supplementation. He was admitted for inpatient rehabilitation therapy and demonstrated improvement of motor and sensory symptoms over the next month. With the increasing use of GLP-1RAs, it is crucial for clinicians, dietitians, and pharmacists to understand the risk and pathophysiologic processes of these medications when used in combination with other weight-loss therapies such as bariatric surgery. Learning points While there are robust pre- and post-operative micronutrient screening guidelines for patients undergoing bariatric surgery, nutritional monitoring guidelines are limited for patients on GLP-1 receptor agonist therapy or for patients with a history of bariatric surgery who are on GLP-1 receptor agonist therapy. The use of multiple weight-loss therapies that suppress appetite and nutrient intake may increase the risk of micronutrient deficiencies. Micronutrient deficiencies can have severe neurological manifestations, which may be correctable with nutritional supplementation. Avoid initiating GLP-1 receptor agonist therapy in close proximity to bariatric surgery. Further research is needed focusing on patients using multiple weight-loss therapies. This may contribute to the development of specific nutritional and micronutrient monitoring guidelines for this population. Endocrinologists, bariatric surgeons, and primary care providers must work together to care for patients undergoing weight-loss interventions.

Background While rapid response teams (RRT) are widely implemented to address clinical deterioration in hospitalized patients, their impact on goals of care (GOC) discussions remains underexplored. Aims We aimed to evaluate whether RRT activations were associated with subsequent goals of care discussions, code status changes, and clinical outcomes. Methods We conducted a retrospective single-center review of hospitalized adult patients admitted to medicine services who had RRT activations between January and December 2023. The primary outcome was GOC discussion within 72 h of RRT. GOC discussions were identified through EMR documentation of conversations, code status changes, and ACP notes. Secondary outcomes included code status change, transition to comfort care, and 30- and 90-day mortality. Analyses were adjusted using inverse probability of treatment weighting. Results 1823 RRTs among 1677 patients were analyzed; 47% of patients were female and 88% identified as white. Those transferred to the ICU had higher odds of goals of care discussions (OR 1.52, P < 0.001), code status change (OR 2.43, P < 0.001), and transition to comfort care (OR 1.47, P = 0.026) compared to those who remained on the floor. ICU transfer was also associated with increased 30- (OR 1.39, P = 0.006) and 90-day mortality (OR 1.30, P = 0.014). Conclusions ICU transfer following RRT activation is strongly associated with downstream goals of care discussions, changes in code status, comfort-focused care, and higher mortality. This demonstrates the importance of initiating goals of care discussions early and often, regardless of whether clinical decompensation is anticipated.

Abstract Rationale: The Deterioration Index (DTI) may serve as a crucial tool for predicting adverse patient outcomes; however, there is a paucity of literature attempting to externally validate this tool in specific clinical scenarios. In this study, we analyzed the relationship between DTI scores during rapid response team (RRT) activations and subsequent ICU transfer, initiation of goals of care (GOC) conversations, and 90-day mortality. Methods: This was a retrospective single-center review of adult patients who had an RRT activation while hospitalized between January 1, 2023 and December 31, 2023. This study was approved by our hospital institutional review board. Deterioration scores (0-100) were recorded every 15 minutes during the RRT event, and the highest score of each encounter was selected for analysis. The primary outcome was transfer to the ICU as a direct result of the RRT activation. Secondary outcomes included GOC discussions following RRT activation and 90-day mortality. GOC discussions, defined as physician-led conversations that specifically addressed code status, treatment priorities, or broader goals of care, met criteria only if initiated within 72 hours of the analyzed RRT activation. Logistic regression was used to assess the relationship between DTI scores during RRT activations and the aforementioned variables. Results: A total of 1643 patients were included in the analysis. For every 1-point increase in the deterioration score, the odds of ICU transfer increased by 2.7% (OR: 1.027, CI: 1.021-1.034, p&lt;0.0001), the odds of a goals of care discussion within 72 hours increased by 3.3% (OR: 1.033, CI: 1.025-1.040, p&lt;0.0001), and the likelihood of mortality within 90 days increased by 2.6% (OR: 1.026, CI: 1.019-1.033, p&lt;0.0001). Conclusion: Our findings contribute to external validation of DTI predictive value during RRT events. DTI scores were associated with key clinical outcomes, including ICU transfer and 90-day mortality. There was also an association between DTI scores and the likelihood of physician-led GOC discussions, suggesting that DTI may demonstrate predictive value not only of patient outcomes, but also the likelihood of specific non-medical physician actions. Further validation of these scores in prospective studies, specifically in the context of acute decompensation events, could help facilitate the integration of DTI-based RRT interventions into routine hospital practice.