Surgical management of obesity: is bariatric surgery as good as it’s made out to be?

Objectives: Estimates from the WHO indicate that the prevalence of obesity in the developed world is reaching epidemic proportions. In 2005 there were at least 400 million obese adults worldwide and this figure is predicted to rise to 700 million by 2015, with an additional 2.3 billion overweight adults. This review aims to examine evidence for the benefits and risks of bariatric surgery and whether this treatment achieves both long-term weight loss and alleviation of obesity-related diseases. Methods: An electronic PubMed (1980-2008) search using MeSH database search terms ‘obesity or overweight’ and ‘bariatric surgery’ was performed. The search continued up to August 24, 2008, and yielded 388 papers, of which 62 were considered eligible for inclusion. Manual reference checks of papers cited in recent review articles were examined for suitable studies and the Cochrane Library database was also searched. Results: Bariatric surgery using restrictive and malabsorptive procedures achieves long-term significant weight loss compared with medical treatment, resulting on average in a 25-44kg weight loss at up to two years, and a 20kg loss up to eight years later. Cardiovascular, respiratory and psychological complications of obesity are also improved after bariatric surgery, with almost complete resolution of type 2 diabetes. Operative death rates are 1% and complication rates are acceptably low. Conclusions: There is strong evidence supporting a role for bariatric surgery in the management of obesity.</p

Is stimulation a good thing? An overview of sacral nerve stimulation in faecal incontinence

Sacral nerve stimulation (SNS) is a new technique used in the treatment of faecal incontinence. It refers to chronic low frequency electrical pulse stimulation of the sacral nerves at their spinal origin. SNS was first used in the treatment of urinary retention and detrusor instability, but has since been used in the treatment of faecal incontinence in patients with a functionally deficient but morphologically intact anal sphincter. Although the exact neuroanatomical mechanism is unclear, both motor and sensory components are believed to be involved. The greater than 75% reduction in the frequency of incontinent episodes and an almost complete resolution of symptoms (75-100%)12 may make SNS one of the most revolutionary treatments in this field.</p

The impact of COVID-19 pandemic on clinical teaching: a clinical educator’s perspective

There is no doubt that the COVID-19 pandemic has had a drastic impact on medical students' clinical education. The inability to deliver face-to-face lectures, students’ absences due to illness and selfisolation due to close contact, reduced social interactions with classmates, and reduced clinical exposure are amongst the main challenges that will have a lasting impact. On a positive note, students have received more attention from clinical educators with increased one-on-one teaching, small group teaching and targeted simulation sessions. The challenges outlined above necessitated clinical educators to adapt and enhance innovative teaching methods to meet medical students' learning objectives while aligning with government and public health guidelines </p

Natural orifice transluminal endoscopic surgery (NOTES): the future of surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an exciting and rapidly evolving area of surgery that may eventually provide the previously unattainable goal of scarless, and potentially pain free, surgery. Although a patent detailing the prospective therapy was filed in 1994, it was not until 2004 that interest flourished in this area, progressing quickly from largely investigative techniques in porcine models to the first two human NOTES cholecystectomies, which were performed almost simultaneously in Europe and the USA in April 2007.</p

Cardiotoxicity monitoring guidelines in patients on anti-HER2 therapy

Introduction  Anti-HER2 therapies such as Trastuzumab carry warnings for cardiotoxicity, though cardiac assessment and monitoring remains an area of clinical debate. Utility of cardiotoxicity monitoring protocols in light of refined treatment regimens is unknown. The degree to which day-to-day clinical practice is informed by current guidelines is unclear.  Methods  A brief survey was designed to audit guideline awareness relating to cardiotoxicity prevalence and monitoring in breast cancer patients treated with HER2-targeted therapy amongst a representative cohort (n=10) of non-consultant hospital doctors (NCHDs) on the breast cancer surgical service in a large tertiary referral centre.  Results  Some lack of awareness of current guidelines across grades was evident, which likely reflects a disconnect between the theoretical guidelines and their clinical usefulness, as well as the relatively infrequent prevalence of cardiotoxicity. Although understanding of normal parameters was generally good (80% of NCHDs correctly recognising normal baseline LVEF as >55%), appropriate frequency of monitoring (12 weekly) was underestimated by 90% of this cohort (n=10). All respondents also underestimated the recommended frequency of monitoring in patients with cardiac impairment. Prevalence of cardiotoxicity was overestimated by all respondents. Although 90% of clinicians surveyed could suggest several assessment modalities, MUGA scans were not mentioned, despite being the method suggested in the Irish guidelines.  Conclusion  Cardiotoxicity is an infrequent but clinically important adverse event in the treatment of HER2-positive breast cancer patients. This small study suggests the timeliness of reviewing and potentially updating current guidelines to reflect imaging advances, as well as re-examining the criteria for scanning frequency in light of refined treatment protocols.</p

Preventing healthcare-associated infection through education: have surgeons been overlooked?

BACKGROUND/AIMS: Some 20-30% of HCAI are considered to be preventable through an extensive infection prevention and control programme. Through an extensive literature review we aim to critically appraise studies which have utilised education initiatives to decrease HCAI. METHODS: An extensive review of the literature was carried out in both online medical journals and through the Royal College of Surgeons in Ireland library. FINDINGS: Many studies over the last 10 years have demonstrated success in educating nursing staff, critical care healthcare workers as well as medical students and junior doctors in the infection prevention and control of infection. Comparatively few have focussed on surgical trainees. A blended learning approach, with particular focus on the small group format is important. Interventions involving web-based learning in combination with established education formats are proving successful in changing behaviour. CONCLUSIONS: The development of an educational strategy for surgical trainees focussing on infection prevention and control is overdue. Such a programme would have far reaching benefits for individual patients, contribute to significant economic savings within health services and enhance the quality and safety of patient care.</p

Pregnancy after breast cancer - prognostic safety and pregnancy outcomes according to oestrogen receptor status: a systematic review

Purpose: Breast cancer is the primary cause of cancer-related death in women. Women diagnosed with estrogen receptor (ER)-positive breast cancer have prolonged treatment durations. Owing to the paucity of research and lack of consensus regarding conception planning and pregnancy for patients with ER-positive breast cancer, we aimed to assess pregnancy and survival outcomes in women with ER-positive breast cancer during and after treatment. Methods: We conducted a systematic review of the available studies on pregnancy after ER-positive breast cancer. The assessed outcomes included overall survival (OS), disease-free survival (DFS), hormonal therapy duration, and pregnancy outcomes. Results: Ultimately, 2,669 patients from five studies were included in this study. When all breast cancer receptor subtypes were included in the analysis, pregnancy after breast cancer was associated with a time-dependent protective effect on both DFS and OS. This protective effect was not evident when examining ER-positive patients with subsequent pregnancies, and no significant differences in DFS were observed. ER-positive patients who became pregnant received significantly lower rates of hormonal therapy. Hormonal treatment at the time of pregnancy was correlated with increased rates of termination owing to concerns about teratogenic effects. Conclusions: Pregnancy after breast cancer did not significantly affect DFS in ER-positive patients over a follow-up period of 5-10 years from diagnosis, although did significantly affect hormonal treatment duration in the reviewed studies. Further analysis and in-depth studies are required to assess the effects of altered hormonal treatment times, as well as patient management related to pregnancy planning after breast cancer.</p

Introducing the physician associate role in Ireland: Evaluation of a hospital based pilot project

Objective: Ireland has medical workforce challenges and a growing demand for services. One strategy is to include Physician Associates (PAs) in healthcare settings. A pilot study was undertaken with PAs recruited from North America and the United Kingdom to work in a large Dublin teaching hospital. Methods: Four PAs were deployed on surgical services. Communication with the hospital staff preceded their employment. A series of interviews were undertaken at the beginning [2015] and end [2017] of the project. Data collection included surveys and interviews with staff and PAs. Results: Despite a series of communications about the employment of PAs a lack of awareness among hospital staff prevailed. This presented a challenge for the PAs to assume their role and for staff to bring them on board. Once on board those staff who worked with the PAs found their role beneficial in terms of continuity of care and skillset. Recommendations for inclusion of PAs in any new employment should include a more robust stakeholder engagement and promulgation throughout the wider healthcare system. Conclusion: Attitudes about the adoption of the PA have come slowly when first introduced in a country and Ireland seems no exception. At the same time communication lessons were learned about introducing a new health provider role in Irish society.</p

Familial hypocalciuric hypercalcaemia type 1 caused by a novel heterozygous missense variant in the CaSR gene, p(His41Arg): two case reports

Background: Familial hypocalciuric hypercalcaemia (FHH) is a rare, inherited disorder of extracellular calcium sensing. It is clinically characterised by mild to moderate parathyroid hormone dependent hypercalcaemia, an autosomal dominant pattern of inheritance, and a normal to reduced urinary calcium excretion in spite of high serum calcium. Case presentation: We report two cases of FHH in a family caused by a novel pathogenic missense variant in the CaSR gene, p. His41Arg. Case 1, describes a 17 year old female with no significant past medical history, admitted with acute appendicitis requiring laparoscopic appendectomy and reporting a six month history of polydipsia. Routine investigations were significant for hypercalcaemia, corrected calcium 3.19 mmol/L (2.21-2.52mmol/L), elevated parathyroid hormone of 84pg/ml (15-65pg/ml) and a low 24-hour urine calcium of 0.75mmol/24 (2.50-7.50mmol/24). She was initially managed with intravenous fluids and Zolendronic acid with temporary normalisation of calcium though ultimately required commencement of Cinacalcet 30 mg daily for persistent symptomatic hypercalcaemia. Genetic analysis was subsequently positive for the above variant. Case 2, a 50-year-old female, was referred to the endocrine outpatient clinic for the management of type 2 diabetes and reported a longstanding history of asymptomatic hypercalcaemia which had not been investigated previously. Investigation revealed hypercalcaemia; corrected calcium of 2.6 mmol/L (reference range: 2.21-2.52 mmol/L); PTH of 53.7ng/L (reference range: 15-65 ng/L) and an elevated 24-hour urine calcium of 10 mmol/24 (2.50-7.50 mmol/24hr) with positive genetic analysis and is managed conservatively. Despite sharing this novel mutation, these cases have different phenotypes and their natural history is yet to be determined. Two further relatives are currently undergoing investigation for hypercalcaemia and the family have been referred for genetic counselling. Conclusion: Accurate diagnosis of FHH and differentiation from classic primary hyperparathyroidism can be challenging, however it is essential to avoid unnecessary investigations and parathyroid surgery. Genetic analysis may be helpful in establishing a diagnosis of FHH in light of the biochemical heterogeneity in this population and overlap with other causes of hypercalcaemia.</p

Patient Willingness to be Seen by a Physician Associate in Ireland

Background: The physician associate (PA) role was piloted in Dublin, Ireland between 2015 and 2017. However, the concept of a PA and the acceptance of their role in Ireland had not been previously explored. Objective: To investigate the willingness of Irish citizens to be seen by a PA based on medical scenarios in a typical clinical setting. Design: A mixed methods study was undertaken. A preference survey, with three medical scenarios, gave participants a choice to be treated by a PA or a doctor, with two time trade-off options offered. Responses were supported with qualitative text. Four hundred people were invited to participate as surrogate patients. Setting and participants: In 2017 a total of 270 respondents took part in the study (67.5%) in two hospitals (one private and one public) in Dublin. The mean age was 60; male (n=142) and female (n=128) respondents. Findings: In total, 95% of the respondents chose to see a PA over a doctor based on the scenarios presented and a wait time of 30 minutes. Waiting time, trust, competency and the severity or seriousness of the medical condition were categorized into three themes for choosing the PA over the doctor. The ‘surrogate patient’ decisions made by this sample were influenced by knowing that the PA is supervised and can check decisions with their supervizing physician. Conclusion: These findings are consistent with studies carried out in other countries where willingness to be seen by a PA is neither age nor gender specific. Patient preference seems to concur around the importance of trust and confidence in the medical provider.</p