Surgeon Involvement in Pre-Clinical Medical Education: Attitudes of Directors of Education

Background: Application rates to surgical residencies have shown a downward trend recently. Introducing students to surgeons early in medical school can increase interest in surgery as a career and enhance the instruction of important surgical topics. Directors of undergraduate medical education have unique insight and influence regarding the participation of surgeons in pre-clinical education. Methods: To understand the attitudes of these educators towards surgeons as teachers in pre-clinical programs, a survey was administered to the directors of undergraduate medical education at each of the English-language medical schools in Canada. Results: Educators estimate the participation of surgeons in all categories of pre-clinical education to be low, despite being valuable, and think that it should be increased. The most significant barrier to participation identified was a lack of surgeons’ time. Conclusions: Despite the value of surgeons participating in pre-clinical education, their rate of participation is low. Steps should be taken to facilitate the involvement of surgeons in this phase of education, which may lead to improved education for students and increased student interest in surgery residencies.

A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery

Background. The utility of bariatric surgery in type 1 diabetes remains controversial. The aim of the present study is to evaluate glycemic control outcomes in obese patients with type 1 diabetes after bariatric surgery. Methods. A comprehensive search of electronic databases was completed. Inclusion criteria included human adult subjects with BMI ≥35 kg/m2 and a confirmed diagnosis of type 1 diabetes who underwent a bariatric surgical procedure. Results. Thirteen primary studies (86 patients) were included. Subjects had a mean age of 41.16±6.76 years with a mean BMI of 42.50±2.65 kg/m2. There was a marked reduction in BMI postoperatively at 12 months and at study endpoint to 29.55±1.76 kg/m2 (P<0.00001) and 30.63±2.09 kg/m2 (P<0.00001), respectively. Preoperative weighted mean total daily insulin requirement was 98±26 IU/d, which decreased significantly to 36±15 IU/d (P<0.00001) and 42±11 IU/d (P<0.00001) at 12 months and at study endpoint, respectively. An improvement in HbA1c was also seen from 8.46±0.78% preoperatively to 7.95±0.55% (P=0.01) and 8.13±0.86% (P=0.03) at 12 months and at study endpoint, respectively. Conclusion. Bariatric surgery in patients with type 1 diabetes leads to significant reductions in BMI and improvements in glycemic control

The Economic Impact of Weight Regain

Background. Obesity is well known for being associated with significant economic repercussions. Bariatric surgery is the only evidence-based solution to this problem as well as a cost-effective method of addressing the concern. Numerous authors have calculated the cost effectiveness and cost savings of bariatric surgery; however, to date the economic impact of weight regain as a component of overall cost has not been addressed. Methods. The literature search was conducted to elucidate the direct costs of obesity and primary bariatric surgery, the rate of weight recidivism and surgical revision, and any costs therein. Results. The quoted cost of obesity in Canada was $2.0 billion-$6.7 billion in 2013 CAD. The median percentage of bariatric procedures that fail due to weight gain or insufficient weight loss is 20% (average: 21.1% ± 10.1%, range: 5.2-39, = 10). Revision of primary surgeries on average ranges from 2.5% to 18.4%, and depending on the procedure accounts for an additional cost between $14,000 and$50,000 USD per patient. Discussion. There was a significant deficit of the literature pertaining to the cost of revision surgery as compared with primary bariatric surgery. As such, the cycle of weight recidivism and bariatric revisions has not as of yet been introduced into any previous cost analysis of bariatric surgery

The Economic Impact of Weight Regain

Background. Obesity is well known for being associated with significant economic repercussions. Bariatric surgery is the only evidence-based solution to this problem as well as a cost-effective method of addressing the concern. Numerous authors have calculated the cost effectiveness and cost savings of bariatric surgery; however, to date the economic impact of weight regain as a component of overall cost has not been addressed. Methods. The literature search was conducted to elucidate the direct costs of obesity and primary bariatric surgery, the rate of weight recidivism and surgical revision, and any costs therein. Results. The quoted cost of obesity in Canada was $2.0 billion–$6.7 billion in 2013 CAD. The median percentage of bariatric procedures that fail due to weight gain or insufficient weight loss is 20% (average: 21.1%±10.1%, range: 5.2–39, n=10). Revision of primary surgeries on average ranges from 2.5% to 18.4%, and depending on the procedure accounts for an additional cost between $14,000 and$50,000 USD per patient. Discussion. There was a significant deficit of the literature pertaining to the cost of revision surgery as compared with primary bariatric surgery. As such, the cycle of weight recidivism and bariatric revisions has not as of yet been introduced into any previous cost analysis of bariatric surgery

A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery

Background. The utility of bariatric surgery in type 1 diabetes remains controversial. The aim of the present study is to evaluate glycemic control outcomes in obese patients with type 1 diabetes after bariatric surgery. Methods. A comprehensive search of electronic databases was completed. Inclusion criteria included human adult subjects with BMI ≥35 kg/m 2 and a confirmed diagnosis of type 1 diabetes who underwent a bariatric surgical procedure. Results. Thirteen primary studies (86 patients) were included. Subjects had a mean age of 41.16 ± 6.76 years with a mean BMI of 42.50 ± 2.65 kg/m 2 . There was a marked reduction in BMI postoperatively at 12 months and at study endpoint to 29.55 ± 1.76 kg/m 2 ( &lt; 0.00001) and 30.63 ± 2.09 kg/m 2 ( &lt; 0.00001), respectively. Preoperative weighted mean total daily insulin requirement was 98 ± 26 IU/d, which decreased significantly to 36 ± 15 IU/d ( &lt; 0.00001) and 42 ± 11 IU/d ( &lt; 0.00001) at 12 months and at study endpoint, respectively. An improvement in HbA1c was also seen from 8.46 ± 0.78% preoperatively to 7.95 ± 0.55% ( = 0.01) and 8.13 ± 0.86% ( = 0.03) at 12 months and at study endpoint, respectively. Conclusion. Bariatric surgery in patients with type 1 diabetes leads to significant reductions in BMI and improvements in glycemic control

Effectiveness of cricoid pressure in preventing gastric aspiration during rapid sequence intubation in the emergency department: study protocol for a randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>Cricoid pressure is considered to be the gold standard means of preventing aspiration of gastric content during Rapid Sequence Intubation (RSI). Its effectiveness has only been demonstrated in cadaveric studies and case reports. No randomised controlled trials comparing the incidence of gastric aspiration following emergent RSI, with or without cricoid pressure, have been performed. If improperly applied, cricoid pressure increases risk to the patient. The clinical significance of aspiration in the emergency department is unknown. This randomised controlled trial aims to; 1. Compare the application of the 'ideal" amount of force (30 - 40 newtons) to standard, unmeasured cricoid pressure and 2. Determine the incidence of clinically defined aspiration syndromes following RSI using a fibrinogen degradation assay previously described.</p> <p>Methods/design</p> <p>212 patients requiring emergency intubation will be randomly allocated to either control (unmeasured cricoid pressure) or intervention groups (30 - 40 newtons cricoid pressure). The primary outcome is the rate of aspiration of gastric contents (determined by pepsin detection in the oropharyngeal/tracheal aspirates or treatment for aspiration pneumonitis up to 28 days post-intubation). Secondary outcomes are; correlation between aspiration and lowest pre-intubation Glasgow Coma Score, the relationship between detection of pepsin in trachea and development of aspiration syndromes, complications associated with intubation and grade of the view on direct largyngoscopy.</p> <p>Discussion</p> <p>The benefits and risks of cricoid pressure application will be scrutinised by comparison of the incidence of aspiration and difficult or failed intubations in each group. The role of cricoid pressure in RSI in the emergency department and the use of a pepsin detection as a predictor of clinical aspiration will be evaluated.</p> <p>Trial registration</p> <p>Australian New Zealand Clinical Trials Registry (ANZCTR): <a href="http://www.anzctr.org.au/ACTRN12611000587909.aspx">ACTRN12611000587909</a></p

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Biliopancreatic Diversion: The Effectiveness of Duodenal Switch and Its Limitations

The prevalence of morbidly obese individuals is rising rapidly. Being overweight predisposes patients to multiple serious medical comorbidities including type two diabetes (T2DM), hypertension, dyslipidemia, and obstructive sleep apnea. Lifestyle modifications including diet and exercise produce modest weight reduction and bariatric surgery is the only evidence-based intervention with sustainable results. Biliopancreatic diversion (BPD) produces the most significant weight loss with amelioration of many obesity-related comorbidities compared to other bariatric surgeries; however perioperative morbidity and mortality associated with this surgery are not insignificant; additionally long-term complications including undesirable gastrointestinal side effects and metabolic derangements cannot be ignored. The overall quality of evidence in the literature is low with a lack of randomized control trials, a preponderance of uncontrolled series, and small sample sizes in the studies available. Additionally, when assessing remission of comorbidities, definitions are unclear and variable. In this review we explore the pros and cons of BPD, a less well known and perhaps underutilized bariatric procedure

Biliopancreatic Diversion: The Effectiveness of Duodenal Switch and Its Limitations

The prevalence of morbidly obese individuals is rising rapidly. Being overweight predisposes patients to multiple serious medical comorbidities including type two diabetes (T2DM), hypertension, dyslipidemia, and obstructive sleep apnea. Lifestyle modifications including diet and exercise produce modest weight reduction and bariatric surgery is the only evidence-based intervention with sustainable results. Biliopancreatic diversion (BPD) produces the most significant weight loss with amelioration of many obesity-related comorbidities compared to other bariatric surgeries; however perioperative morbidity and mortality associated with this surgery are not insignificant; additionally long-term complications including undesirable gastrointestinal side effects and metabolic derangements cannot be ignored. The overall quality of evidence in the literature is low with a lack of randomized control trials, a preponderance of uncontrolled series, and small sample sizes in the studies available. Additionally, when assessing remission of comorbidities, definitions are unclear and variable. In this review we explore the pros and cons of BPD, a less well known and perhaps underutilized bariatric procedure