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AbstractBackgroundDespite malnutrition being associated with increased mortality and morbidity, there continues to be great difficulty in defining criteria and implementing widespread screening. Tools used to diagnose decreased fat‐free mass (FFM [sarcopenia]) should be easy to use, relatively inexpensive, and safe. Bioelectrical impedance analysis (BIA) has the potential to meet these criteria, but reliability across body mass index (BMI) classes is a concern.MethodsA total of 176 healthy ambulatory participants (aged 18–65 years) were recruited equally (n = 44) in 4 BMI categories: (1) 18.5–24.9, (2) 25.0–29.9, (3) 30–34.9, and (4) ≥35.0. Participants were fasting overnight and had S‐MFBIA (InBody 770) measurements the next morning, with DXA being performed subsequently within 30 minutes.ResultsThe measurement (mean ± SD) for FFM with DXA was 52.8 ± 11.0, and BIA was 53.6 ± 11.0. Delta (S‐MFBIA vs DXA) was 0.8 ± 2.2 (5% limits of agreement −3.5 to +5.2), and concordance correlation coefficient (CCC) was 0.98 (95% CI, 0.97–0.98). The measurements (mean ± SD) for PBF with DXA was 37.5 ± 10.6% and S‐MFBIA was 36.6 ± 11.3%. Delta (S‐MFBIA vs DXA) was −0.9 ± 2.6 (5% limits of agreement 6.0 to +4.2), and CCC was 0.97 (95% CI, 0.96–0.98). The CCC according to the 4 BMI groups for FFM and PBF was between 0.96–0.98 and 0.90–0.94, respectively.ConclusionsFFM and PBF measured by S‐MFBIA had good agreement with DXA across all BMI categories measured in the current study of ambulatory participants.

Abstract Objective: Weight gain and vasomotor symptoms (VMS) are common complaints in midlife women going through the menopause transition. A selective serotonin 2C (5-HT2C) receptor agonist, lorcaserin, which was previously approved by the Food and Drug Administration for weight loss, has unreported observational evidence suggesting improvement in VMS with its use. The goal of this pilot study was to evaluate the efficacy of lorcaserin for weight loss and management of VMS in overweight midlife women. Methods: This was a 24-week open label pilot study of 20 overweight midlife women, aged 45-60 years, who were experiencing severe VMS. Participants received lorcaserin at the standard dose of 10 mg twice daily for 12 weeks, followed by 12 weeks of observation off the drug. The primary outcomes were changes in weight and subjectively reported VMS. Results: At the end of 12 weeks, mean change in weight was −2.4 kg (90% CI, −3.2 to −1.7, P < 0.001). However, the participants returned to the baseline weight at 24 weeks. Participants also reported significant subjective improvement in VMS, with a mean ± SD change in self-reported hot flash frequency from baseline to week 12 of −5.4 ± 3.9 (decrease of 1.4 standard deviations). There was a rapid increase in the frequency of VMS within 2 weeks of discontinuation of lorcaserin with a tendency to approach the baseline frequency of VMS. Conclusions: In addition to its weight loss-inducing effect, 5-HT2C receptor modulation may have an additional beneficial effect on VMS in midlife women. A treatment option that targets both weight and VMS in midlife women is attractive. Video Summary: http://links.lww.com/MENO/A622.

AbstractBackgroundBariatric surgery is by far the most effective treatment option available for successfully achieving and maintaining weight loss in the obese population, but it can also be associated with complications that lead to malnutrition. There is limited data on how enteral nutrition (EN) can be used to provide nutrition support in such cases.MethodsRetrospective review of our Home Enteral Nutrition (HEN) database was conducted from February 2013 to April 2018 to identify patients who received HEN because of bariatric surgery–related complication.ResultsDuring the study period, 72 patients (86% female, mean age 50.3 ± 11.6 years) initiated HEN because of bariatric surgical complication. Most common bariatric surgery was Roux‐en‐Y (74%) and most common indication for HEN was malnutrition/failure to thrive (33%). HEN was most commonly provided through nasojejunal feeds and resulted in an average increase in body weight and body mass index from 74.8 kg and 26.5, respectively, before HEN to 76.9 kg and 27.2, respectively, at the end of the HEN period. Through HEN, patients received 22.2 ± 7.9 kcal/kg/d and 1.0 ± 0.3 g/kg/d protein, meeting 94% ± 17% of their energy goals and 95% ± 29% of their protein goals. Vitamin deficiencies were noted in 69% of patients at the time of HEN initiation, which improved to 10% after enteral feeds and appropriate vitamin supplementation.ConclusionHEN is safe and effective in treating malnutrition and vitamin deficiencies that might occur as a complication of bariatric surgery, leading to avoidance of parenteral nutrition support in most cases.

Postoperative delirium (POD) is common among surgical patients admitted to the intensive care unit (ICU) and is associated with increased resource utilization, morbidity, and death. Our primary aim was to compare rates of POD using administrative International Classification of Diseases, Ninth Revision, records and automated interrogation of electronic health records from Confusion Assessment Method for the ICU (CAM-ICU) screening. The secondary aim was to assess POD risk associated with patient and perioperative characteristics. Electronic health records of surgical patients admitted to the ICU during 2011 through 2014 were abstracted for POD assessment by CAM-ICU and by administrative codes, Charlson comorbidity index, surgical characteristics, and Acute Physiology, Age, Chronic Health Evaluation III scores. Of 6338 patients, CAM-ICU identified 606 (9.6%) and administrative records identified 55 (0.9%) POD cases, with agreement on 50 cases. In multivariable logistic regression based on POD identified with CAM-ICU, preexisting dementia had the strongest association with POD (odds ratio [95% confidence interval], 6.47 [3.68–11.37]; P < 0.001). Other associations found were older age, congestive heart failure, chronic pulmonary disease, increased surgical duration, emergency cases, blood transfusions, postoperative ventilation, and higher Acute Physiology, Age, Chronic Health Evaluation III scores (all P ≤ 0.01). POD cases had lengthier ICU and hospital stays and a higher mortality rate (all P < 0.001). CAM-ICU scores identified higher rates of POD than a search for POD based on administrative codes. Preoperative presence of dementia and major comorbidities were associated with POD. Delirium in surgical patients is associated with worse outcomes.

The Charlson Comorbidity Index (CCI) has not been assessed for elderly (95 years of age or older) surgical patients. We examined the association between the CCI and life-threatening complications and 30-day mortality rate. Medical records of patients 95 years old or older from 2004 through 2008 were reviewed for major postoperative morbidity or death. Logistic regression analyses of age, sex, the CCI, American College of Cardiology/American Heart Association Surgical Risk Stratification, and surgical urgency were performed to identify associations with poor surgical outcome. One hundred eighty-seven patients were identified (mean [standard deviation] age, 96.6 [1.9] years; median [interquartile range] CCI, 4 [2 to 6]). Ninety patients (48.1%) underwent moderate-risk and 20 (10.7%) underwent high-risk surgical procedures. Twenty patients (10.7%) died within 30 postoperative days and 20 others had major morbidity. Only moderate-risk ( P = 0.045) and high-risk surgical procedures ( P = 0.001) were associated with poor outcome. Patients of advanced age have high rates of morbidity and death after surgical procedures. These events are associated with surgical risk stratification and are independent of patient comorbidities. Risks, benefits, and alternatives must be considered carefully and discussed with patients and their families before deciding to proceed with high-risk surgery.

Background Maintaining baroreflex sensitivity is integral to ensuring blood pressure maintenance and end‐organ perfusion during hemorrhage. This is especially true under conditions of hypoxemia, where decreased tolerance to central hypovolemia is commonly observed. Hypoxia activates peripheral chemoreceptors and reduces baroreceptor‐vascular resistance reflex sensitivity. However, a direct role for the peripheral chemoreceptors in the hemodynamic response to hemorrhage in hypoxia remains unclear. Objective We tested the hypothesis that attenuation of peripheral chemoreceptor activity (low‐dose dopamine; 1–2 μg/kg/min) during acute hypoxia would promote maintenance of mean arterial pressure, pulse pressure, and other hemodynamic markers [heart rate (HR), stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR)] during simulated hemorrhage. Methods Ten healthy men (35±3 years, BMI 25±1 kg/m 2 ) participated in a randomized, double‐blind, placebo controlled study. Participants completed two experimental visits (saline and low‐dose dopamine) at which lower body negative pressure (LBNP) was conducted during hypoxia (SpO 2 ~85%; PaO2 ~52 mmHg) delivered via a non‐rebreather mask. Ventilation [V̇ (turbine transducer)], arterial blood pressure (brachial artery catheter), HR (ECG), and central venous pressure (peripherally inserted central catheter) were measured continuously and SV, CO, and TPR were calculated. Following a 5‐min rest, participants underwent LBNP for 5‐min at 3 intervals (−15, −30, and −45 mmHg). Outcome values were analyzed and compared using a mixed linear model (SAS PROC MIXED) with a direct product AR(1) covariance structure using indicator variables for saline vs. dopamine. Data from the mixed linear model are reported as an estimated change per 15 mmHg of LBNP. Results Dopamine had no effect on hypoxia P a O 2 , P a CO 2 , V̇ or respiratory rate (all P >0.05) and this relationship persisted throughout all LBNP stages. The mixed linear model showed no effect of dopamine vs. saline on changes in: central venous pressure (−1.1±0.4 vs −1.3±0.3 mmHg, P =0.15), mean arterial pressure (−4.7±2.3 vs −5.3±1.4 mmHg, P =0.25), pulse pressure (−6.7±1.5 vs −8.3±1.4 mmHg, P =0.50), HR (7.8±1.5 vs 6.1±1.5 bpm, P =0.41), SV (−10.9±1.9 vs −11.6±3.3 mL, P =0.41), CO (−0.3±0.2 vs −0.4±0.4 L · min −1 , P =0.31) or TPR (0.2±0.4 vs 0.7±0.6 mmHg · L · min −1 P =0.27). Discussion Intravenous infusion of low‐dose dopamine designed to attenuate peripheral chemoreflex activity during acute hypoxia did not alter the integrated hemodynamic response to simulated hemorrhage. Our data suggests that peripheral chemoreceptors have a limited role during hypoxic central hypovolemia. More research is needed to understand the sensitivity and cross‐talk between chemoreceptors and baroreceptors during hemorrhage. Support or Funding Information Funding: W81XWH‐13‐2‐0038 (DOD), DK90541 (NIH), UL1 TR000135 (NIH).

Background Frailty increases risk for complications after total joint arthroplasty (TJA). Whether this association is influenced by anesthetic administered is unknown. We hypothesized that use of neuraxial (spinal or epidural) anesthesia is associated with better outcomes compared with general anesthesia, and that the effect of anesthesia type on outcomes differs by frailty status. Methods This single-institution cohort study included all patients (≥50 years) from January 2005 through December 2016 undergoing unilateral, primary and revision TJA. Using multivariable Cox regression, we assessed relationships between anesthesia type, a preoperative frailty deficit index (FI) categorized as non-frail (FI <0.11), vulnerable (FI 0.11 to 0.20), and frail (FI >0.20), and complications (mortality, infection, wound complications/hematoma, reoperation, dislocation, and periprosthetic fracture) within 1 year after surgery. Interactions between anesthesia type and frailty were tested, and stratified models were presented when an interaction (p<0.1) was observed. Results Among 18 458 patients undergoing TJA, more patients were classified as frail (21.5%) and vulnerable (36.2%) than non-frail (42.3%). Anesthesia type was not associated with complications after adjusting for age, joint, and revision type. However, in analyzes stratified by frailty, vulnerable patients under neuraxial block had less mortality (HR=0.49; 95% CI 0.27 to 0.89) and wound complications/hematoma (HR=0.71; 95% CI 0.55 to 0.90), whereas no difference in risk by anesthesia type was observed among patients found non-frail or frail. Conclusions Neuraxial anesthesia use among vulnerable patients was associated with improved survival and less wound complications. Calculating preoperative frailty prior to TJA informs perioperative risk and enhances shared-decision making for selection of anesthesia type.