Covid 19:Anesthesia, Weight Loss Surgery and Malnutrition
October 30, 2021 8:52 am
As the COVID-19 pandemic is charting its course into 2022, as health care providers, we have had to adapt and adjust to the transient and shifting environment. Testing for COVID-19 has been in place, and is now part of the standard for preoperative work-up. In addition, covid testing will likely be part of screening any surgical procedure for the foreseeable future.
The challenge of pandemic control is the large pockets of populations in the US and worldwide that do not have protection against the virus and are not vaccinated. Vaccination provides the only proven long-term protection against COVID-19 infection and its long-term persistent health effect. In addition, the complication rate reported in scientific journals is negligible compared to the complication and death rate from the COVID-19 infection.
There are implications of covid infection and general anesthesia published in peer-reviewed journals. The increased risk of general anesthesia after covid infection is related to the severity of the initial infection and the extent of the treatment required, and the persistence of the post covid symptoms, including shortness of breath, fatigue, and laboratory finding elevated inflammatory markers. Long after resolution of the acute COVID-19 symptoms, the most common persistent complaints are fatigue, shortness of breath, Joint and chest pain; and all these increase the risk of post-operative complications (Carfì et al., 2020)
The required delay for surgery may be as short as 2-4 weeks to as long as six months or longer if the persistent symptoms are present. Surgery may not be avoidable in a critical life-threatening situation and may be necessary even with a much-increased risk of complication (Collaborative, 2020). Recovery post-COVID-19 may not be complete with the resolution of the initial symptoms (Dexter et al., 2020)
Recent publications and scientific presentations have also shown the protection that weight loss surgery and maintained weight loss provide in those who come down with the COVID-19 infection (Aminian et al., 2021). However, the rate of weight gain, lack of weight loss is worse for weight loss surgical patients post COVID-19 disorder (Bullard et al., 2021; Conceição et al., 2021). Furthermore, patients with COVID-19 infection post weight loss are at a higher risk of malnutrition (di Filippo et al., 2021; Kikutani et al., 2021). Up to 40% of patients have malnutrition if hospitalized with COVID (Anker et al., 2021).
To summarize, Weight loss and weight loss surgery reduce the severity of the initial COVID-19 infection. However, it increases malnutrition risk, requiring nutritional support and surgical interventions in non-responsive cases.
REFERENCES:
Aminian, A., Fathalizadeh, A., Tu, C., Butsch, W. S., Pantalone, K. M., Griebeler, M. L., Kashyap, S. R., Rosenthal, R. J., Burguera, B., & Nissen, S. E. (2021). Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity. Surgery for Obesity and Related Diseases, 17(1). https://doi.org/10.1016/j.soard.2020.10.026
Bullard, T., Medcalf, A., Rethorst, C., & Foster, G. D. (2021). Impact of the COVID-19 pandemic on initial weight loss in a digital weight management program: A natural experiment. Obesity, 29(9). https://doi.org/10.1002/oby.23233
Conceição, E., de Lourdes, M., Ramalho, S., Félix, S., Pinto-Bastos, A., & Vaz, A. R. (2021). Eating behaviors and weight outcomes in bariatric surgery patients amidst COVID-19. Surgery for Obesity and Related Diseases, 17(6).
Di Filippo, L., De Lorenzo, R., D’Amico, M., Sofia, V., Roveri, L., Mele, R., Saibene, A., Rovere-Querini, P., & Conte, C. (2021). COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: A post-hoc analysis of a prospective cohort study. Clinical Nutrition, 40(4). https://doi.org/10.1016/j.clnu.2020.10.043
Kikutani, T., Ichikawa, Y., Kitazume, E., Mizukoshi, A., Tohara, T., Takahashi, N., Tamura, F., Matsutani, M., Onishi, J., & Makino, E. (2021). COVID-19 infection-related weight loss decreases eating/swallowing function in schizophrenic patients. Nutrients, 13(4). https://doi.org/10.3390/nu13041113
What does efficiency in healthcare delivery mean? Examples of two market failures
October 08, 2021 3:41 pm
Introduction:
Economic efficiency measures system performance (Enrique & Marta, 2020); the Healthcare delivery system (HCDS) is no different. In non-biologic systems, the efficiency can be measured and optimized since all variables are predictable. However, efficiency becomes a complex and possibly unachievable task in a biological environment such as HCDS. The summary report will define the efficiency and examine the limitation of achieving efficiency in the healthcare delivery system.
Definitions:
Efficiency measures the adeptness of a system allowing identification of the inadequacies and opportunities for improvement. Economic efficiency minimizes cost and maximizes production for profit (Petrou, 2014).
Healthcare is a commodity (Mills & Gilson, 2009). Increased need and limited resources, environment, illnesses are forces on an equilibrium of efficiency that requires flexibility. These are why economically competitive markets fail to achieve healthcare efficiency (Johansen & van den Bosch, 2017).
The concept of efficiency in health care has been described as Technical, Productive, and Allocative (Palmer & Torgerson, 1999). Extensive work has looked at special measures and populations for optimizing efficiency (Cylus & Papanicolas, 2016).
Efficient systems require predictable input, components, processes, and output, unlike efficiency in HCDS. The differences include:
- Biologic environments introduce variability in the system. Therefore, the HCDS efficiency will need to be flexible to diversity. Unfortunately, flexibility and efficiency counteract each other at industrial levels (Adler et al., 1999; AHRENS & CHAPMAN, 2004), and thus inefficiency is to be expected.
- Efficiency can be measured at two points:
- Efficiency of delivery
- Efficiency of outcome
Efficiency in HCDS means providing the most cost-efficient healthcare to those in need. As equity is a pillar of the HCDS, efficiency and equity are opposing forces (Guinness et al., 2011). Therefore, it is critical to have the broader determinants of health into consideration on HCDS. This broad spectrum of variables, individual level, and upstream factors (Dahlgren G & Whitehead M, 1991) will affect efficiency models applicable in one setting for a given population and inefficient in another (Hussey et al., 2009).
Healthcare Market:
The principle of maximizing profits applies to the four market types[1][2]. However, healthcare markets achieve Social Efficiency[3] and not economic efficiency (Folland & Goodman, 2013). This is due to Asymmetry of the information, Adverse selection, Moral hazard, Independent supply and demand stresses, and Externalities (Mwachofi & Al-Assaf, 2011).
Examples of Market Failure
At the onset of the pandemic, most governments, WHO assumed the costs of COVID-19 vaccination as they became available. Social media has disseminated incorrect information on vaccines (Lin et al., 2020; Wajahat Hussain, 2020). The Asymmetry of the information (AOI) has resulted in a sizable portion of the eligible population not being vaccinated (Coe et al., 2021; Malik et al., 2020). HCDS’s failure is a public relations problem and a breakdown in the trust of institutions (Soares et al., 2021).
Adverse selection (AS) compounds the AOI. There have been pockets of efficiency in vaccination with no equity for the world population (Mathieu et al., 2021).
This is due to the AOI and the structural inequities in HCDS (Hyder et al., 2021). Few countries are offering vaccine boosters, where most of the world’s population has not received any.
References:
Adler, P. S., Goldoftas, B., & Levine, D. I. (1999). Flexibility Versus Efficiency? A Case Study of Model Changeovers in the Toyota Production System. Organization Science, 10(1), 43–68. https://doi.org/10.1287/orsc.10.1.43
Adler, P. S., Goldoftas, B., & Levine, D. I. (1999). Flexibility Versus Efficiency? A Case Study of Model Changeovers in the Toyota Production System. Organization Science, 10(1), 43–68. https://doi.org/10.1287/orsc.10.1.43
AHRENS, T., & CHAPMAN, C. S. (2004). Accounting for Flexibility and Efficiency: A Field Study of Management Control Systems in a Restaurant Chain*. Contemporary Accounting Research, 21(2), 271–301. https://doi.org/https://doi.org/10.1506/VJR6-RP75-7GUX-XH0X
Coe, A. B., Elliott, M. H., Gatewood, S. B. S., Goode, J. V. R., & Moczygemba, L. R. (2021). Perceptions and predictors of intention to receive the COVID-19 vaccine. Research in Social and Administrative Pharmacy. https://doi.org/10.1016/j.sapharm.2021.04.023
Cylus, J., & Papanicolas, I. (2016). Health System Efficiency 46 How to make measurement matter for policy and management. London.
Dahlgren G, & Whitehead M. (1991). Dahlgren and Whitehead (1991) – Policies and strategies to promote social equity in health. Stockholm: Institute for future studies. Dahlgren G, Whitehead M. Retrieved from https://core.ac.uk/display/6472456
Enrique, B., & Marta, B. (2020). Efficacy, Effectiveness and Efficiency in the Health Care: The Need for an Agreement to Clarify its Meaning. International Archives of Public Health and Community Medicine, 4(1). https://doi.org/10.23937/2643-4512/1710035
Folland, S., & Goodman, A. (2013). The Economics of Health and Health Care. Oakland: Pearson.
Guinness, L., Wiseman, V., & Wonderling, D. (2011). Introduction to health economics. (2nd ed. /). Maidenhead: McGraw-Hill/Open University Press.
Hussey, P. S., de Vries, H., Romley, J., Wang, M. C., Chen, S. S., Shekelle, P. G., & McGlynn, E. A. (2009). A systematic review of health care efficiency measures. Health Services Research, 44(3), 784–805. https://doi.org/10.1111/j.1475-6773.2008.00942.x
Hyder, A. A., Hyder, M. A., Nasir, K., & Ndebele, P. (2021). Inequitable COVID-19 vaccine distribution and its effects. Bulletin of the World Health Organization, 99(6), 406-406A. https://doi.org/10.2471/BLT.21.285616
Johansen, F., & van den Bosch, S. (2017). The scaling-up of Neighbourhood Care: From experiment towards a transformative movement in healthcare. Futures, 89, 60–73. https://doi.org/https://doi.org/10.1016/j.futures.2017.04.004
Lin, C. Y., Broström, A., Griffiths, M. D., & Pakpour, A. H. (2020). Investigating mediated effects of fear of COVID-19 and COVID-19 misunderstanding in the association between problematic social media use, psychological distress, and insomnia. Internet Interventions, 21. https://doi.org/10.1016/j.invent.2020.100345
Malik, A. A., McFadden, S. A. M., Elharake, J., & Omer, S. B. (2020). Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine, 26. https://doi.org/10.1016/j.eclinm.2020.100495
Mathieu, E., Ritchie, H., Ortiz-Ospina, E., Roser, M., Hasell, J., Appel, C., … Rodés-Guirao, L. (2021). A global database of COVID-19 vaccinations. Nature Human Behaviour, 5(7), 947–953. https://doi.org/10.1038/s41562-021-01122-8
Mills, A., & Gilson, L. (2009). Health Economics for Developing Countries: A Survival Kit. Esocialsciences.Com, Working Papers.
Mwachofi, A., & Al-Assaf, A. F. (2011). Health care market deviations from the ideal market. Sultan Qaboos University Medical Journal, 11(3), 328–337. Retrieved from https://pubmed.ncbi.nlm.nih.gov/22087373
Palmer, S., & Torgerson, D. J. (1999). Economic notes: definitions of efficiency. BMJ (Clinical Research Ed.), 318(7191), 1136. https://doi.org/10.1136/bmj.318.7191.1136
Petrou, A. (2014). Economic Efficiency. In A. C. Michalos (Ed.), Encyclopedia of Quality of Life and Well-Being Research (pp. 1793–1794). Dordrecht: Springer Netherlands. https://doi.org/10.1007/978-94-007-0753-5_818
Soares, P., Rocha, J. V., Moniz, M., Gama, A., Laires, P. A., Pedro, A. R., … Nunes, C. (2021). Factors associated with COVID-19 vaccine hesitancy. Vaccines, 9(3). https://doi.org/10.3390/vaccines9030300
Wajahat Hussain. (2020). Role of Social Media in COVID-19 Pandemic. The International Journal of Frontier Sciences, 4(2), 59–60. https://doi.org/10.37978/tijfs.v4i2.144
[1] Perfect competition, Monopoly, Oligopoly, Monopolistic competition
[2] Control of Total revenue (TR) and Cost (TC) to maximize profit
[3] An equilibrium point (Pareto Optimality) where Social Marginal Benefit (SMB) and the Cost (SMC) are equal
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COVID Vaccines
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There are no known contraindications from a weight-loss surgical perspective to prevent a post-surgical patient from getting the COVID vaccines.
A patient who has had a Duodenal Switch, Lap Sleeve Gastrectomy, RNY Gastric Bypass, or revisions to Weight Loss Surgery should have the COVID vaccine. The vaccination should be avoided for a few weeks after surgery. For other possible contraindications, please consult your PCP.
Here is a summary of the vaccines and the details of each one approved as of the publication date.
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Nyctalopia (Night Blindness) An Early Sign of Vitamin A Deficiency with VideoA recent article discusses the types and function of vitamin A. As with the pandemic of COVID-19 continuous to stress our body and mind, we must stay vigilant with our nutritional status. Therefore, Vitamin supplements are critical in maintaining a robust immune system. For some, oral supplements are adequate; others may require injectable forms. If the oral supplements do not correct the vitamin A levels, please contact your primary care or our office to available vitamin A injections.
