Faculty Bibliography

INTRODUCTION/BACKGROUND:Coronavirus disease 2019 (COVID-19) has been shown to affect outcomes among surgical patients. We hypothesized that COVID-19 would be linked to higher mortality and longer length of stay of trauma patients regardless of the injury severity score (ISS). METHODS:We performed a retrospective analysis of trauma registries from two level 1 trauma centers (suburban and urban) from March 1, 2019, to June 30, 2019, and March 1, 2020, to June 30, 2020, comparing baseline characteristics and cumulative adverse events. Data collected included ISS, demographics, and comorbidities. The primary outcome was time from hospitalization to in-hospital death. Outcomes during the height of the first New York COVID-19 wave were also compared with the same time frame in the prior year. Kaplan-Meier method with log-rank test and Cox proportional hazard models were used to compare outcomes. RESULTS:There were 1180 trauma patients admitted during the study period from March 2020 to June 2020. Of these, 596 were never tested for COVID-19 and were excluded from the analysis. A total of 148 COVID+ patients and 436 COVID- patients composed the 2020 cohort for analysis. Compared with the 2019 cohort, the 2020 cohort was older with more associated comorbidities, more adverse events, but lower ISS. Higher rates of historical hypertension, diabetes, neurologic events, and coagulopathy were found among COVID+ patients compared with COVID- patients. D-dimer and ferritin were unreliable indicators of COVID-19 severity; however, C-reactive protein levels were higher in COVID+ relative to COVID- patients. Patients who were COVID+ had a lower median ISS compared with COVID- patients, and COVID+ patients had higher rates of mortality and longer length of stay. CONCLUSIONS:COVID+ trauma patients admitted to our two level 1 trauma centers had increased morbidity and mortality compared with admitted COVID- trauma patients despite age and lower ISS. C-reactive protein may play a role in monitoring COVID-19 activity in trauma patients. A better understanding of the physiological impact of COVID-19 on injured patients warrants further investigation.

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

OBJECTIVE:To evaluate the effects of surgical weight loss on fatty liver disease in severely obese patients. SUMMARY BACKGROUND DATA/BACKGROUND:Nonalcoholic fatty liver disease (NAFLD), a spectrum that extends to liver fibrosis and cirrhosis, is rising at an alarming rate. This increase is occurring in conjunction with the rise of severe obesity and is probably mediated in part by metabolic syndrome (MS). Surgical weight loss operations, probably by reversing MS, have been shown to result in improvement in liver histology. METHODS:Patients who underwent laparoscopic surgical weight loss operations from March 1999 through August 2004, and who agreed to have an intraoperative liver biopsy followed by at least one postoperative liver biopsy, were included. RESULTS:There were 70 patients who were eligible. All patients underwent laparoscopic operations, the majority being laparoscopic Roux-en-Y gastric bypass. The mean excess body weight loss at time of second biopsy was 59% +/- 22% and the time interval between biopsies was 15 +/- 9 months. There was a reduction in prevalence of metabolic syndrome, from 70% to 14% (P < 0.001), and a marked improvement in liver steatosis (from 88% to 8%), inflammation (from 23% to 2%), and fibrosis (from 31% to 13%; all P < 0.001). Inflammation and fibrosis resolved in 37% and 20% of patients, respectively, corresponding to improvement of 82% (P < 0.001) in grade and 39% (P < 0.001) in stage of liver disease. CONCLUSION/CONCLUSIONS:Surgical weight loss results in significant improvement of liver morphology in severely obese patients. These beneficial changes may be associated with a significant reduction in the prevalence of the metabolic syndrome.

BACKGROUND:Obesity can have a tremendous impact on the psychosocial, physical, and economic health of those afflicted by it. We hypothesized that if surgery results in significant weight loss and improves quality of life, those unemployed and disabled as a result of their morbid obesity might be more likely to become gainfully employed after Roux-en-Y gastric bypass (RYGBP). METHODS:We reviewed the medical charts of all patients who underwent RYGBP from April 1998 to December 1999. Demographics and employment status were obtained, along with preoperative weight, body mass index, Short Form 36 Health Survey and Beck Depression Inventory-II scores. For those employed, the recuperation time was also analyzed. Statistical analysis was performed using Student's t test and analysis of variance. RESULTS:Fifty-seven patients underwent RYGBP. Of the 57 patients, 41 were selected for analysis, 34% of whom were employed, with a mean recuperation time of 3.5 weeks. Their mean age was 32.4 years. The mean body mass index was 53.4 kg/m(2) preoperatively and 31.2 kg/m(2) at 5 years. Of the 41 patients, 27 (66%) were receiving disability and 25 (61%) attributed their disability to their morbidly obese state. At 5 years, 4 (16%) of the 25 were gainfully employed and no longer receiving public assistance. CONCLUSION/CONCLUSIONS:Despite successful long-term weight loss and improvement in quality of life, many morbid obesity patients do not return to gainful employment in the workforce after RYGBP. The mean body mass index was greater in the unemployed group at both 1 and 5 years, but the difference was not statistically significant. The socioeconomic impact of morbid obesity persists long after a reduction in weight and improvement in quality of life.

PURPOSE/OBJECTIVE:Many women with polycystic ovarian syndrome (PCOS) are overweight. This study investigated the impact of weight loss surgery on the clinical manifestations of this disorder in morbidly obese women with PCOS-a major risk factor for the development of heart disease, stroke, and type II diabetes. METHODS:We reviewed the outcomes of women diagnosed with PCOS who had undergone weight loss surgery at the University of Pittsburgh between July 1997 and November 2001. We evaluated the changes in menstrual cycles, hirsutism, infertility, and type II diabetes. RESULTS:A total of 24 women with PCOS were included in the study. Their mean age was 34 +/- 9.7 years. The mean preoperative body weight was 306 +/- 44 lb, with a body mass index of 50 +/- 7.5. All patients were oligomenorrheic. Of the 24 patients, 23 were hirsute. All women underwent elective laparoscopic gastric bypass surgery. The mean follow-up period was 27.5 +/- 16 months. The mean excess weight loss at 1 year of follow-up was 56.7% +/- 21.2%. All women resumed normal menstrual cycles after a mean of 3.4 +/- 2.1 months postoperatively. Of the 23 women with hirsutism, 12 (52%) had complete resolution at a mean follow-up of 8 +/- 2.3 months, 6 (25%) had moderate resolution at a mean of 21 +/- 18 months, and 3 had minimal resolution at 34 +/- 14 months. Two women reported no change in their hirsutism at 32 +/- 7 months. Five women were able to conceive after surgery without the use of clomiphene. CONCLUSION/CONCLUSIONS:Gastric bypass surgery and its consequent weight loss results in significant improvement of multiple clinical problems related to PCOS.

BACKGROUND:Recent evidence suggests that morbid obesity is a chronic inflammatory condition that may be associated with immune dysfunction. To test this hypothesis, we investigated several leukocyte cell surface markers of chronic inflammation and followed their response to surgically-induced weight loss. METHODS:26 patients having Roux-en-Y gastric bypass (RYGBP) for morbid obesity (BMI > 40) were compared to 10 normal controls (BMI < 25). Relative monocyte and neutrophil frequencies and expression of the activation antigens CD11b (adhesion molecule), CD16 (Fc receptor), and CD62L (L-selectin), were evaluated by flow cytometry preoperatively and at 1, 3, 6 and 12 months after RYGBP. Cases served as their own controls but were also compared to non-obese controls. The results were statistically analyzed using Student's t-test and ANOVA for parametric values and Mann-Whitney along with Kruskal-Wallis ANOVA for nonparametric values. RESULTS:The control group had mean age 37 +/- 7.6 with mean 23 +/- 2.5 and no comorbidities. The mean age of the sample group was 40.36 +/- 13.7 with mean BMI 52 +/- 8.2. The neutrophil and monocyte relative frequencies of CD11b (monocytes and neutrophils), and CD16 (neutrophils only) were comparable to controls at baseline and did not change significantly with weight loss throughout the study period. However, a significant reduction of CD62L (L-selectin) expression was noted in monocytes and neutrophils at baseline (neutrophils 103 vs 240 gmf, p < 0.001) (monocytes 104 vs 246 gmf, P < 0.001) when compared to normal controls. Levels of L-selectin normalized by 6 months in both monocytes and neutrophils, and by 12 months had become abnormally elevated in monocytes (monocytes 391 gmf, P = 0.007); in neutrophils, there was an upward trend that did not reach significance. The expression of the LPS receptor CD14 in the study group was elevated significantly compared to controls at baseline (1129 vs 719 gmf, P = 0.004); this marker appeared to return to normal by 3 months. Monocyte CD14+/CD16+ subset percentage were also elevated significantly at baseline (14.3% vs 5.25%, P < 0.001), declined throughout the time period but was still significant at 1 year (8.8%, P < 0.001). Eosinophil percentages were elevated at baseline (3.3% obese vs 1.8% controls, P = 0.003) and remained so throughout the time period. CONCLUSION/CONCLUSIONS:Deficiencies in the immune system of morbidly obese individuals include elevated levels of eosinophils, monocyte CD14, and monocyte CD14+/CD16+ subsets, with depression of monocyte and neutrophil CD62L. These abnormal levels reverse rapidly with surgically-induced weight loss. RYGBP is not only a weight loss operation but also appears to be an immune restorative procedure.