How to train surgical residents to perform laparoscopic roux-en-Y gastric bypass safely

Background As a result of increasing numbers of patients with morbid obesity there is a worldwide demand for bariatric surgeons. The Roux-en-Y gastric bypass, nowadays performed mostly laparoscopically (LRYGB), has been proven to be a highly effective surgical treatment for morbid obesity. This procedure is technically demanding and requires a long learning curve. Little is known about implementing these demanding techniques in the training of the surgical resident. The aim of this study was to evaluate the safety and feasibility of the introduction of LRYGB into the training of surgical residents. Methods All patients who underwent LRYGB between March 2006 and July 2010 were retrospectively analyzed. The procedure was performed by a surgical resident under strict supervision of a bariatric surgeon (group I) or by a bariatric surgeon (group II). The primary end point was the occurrence of complications. Secondary end points included operative time, days of hospitalization, rate of readmission, and reappearance in the emergency department (ED) within 30 days. Results A total of 409 patients were found eligible for inclusion in the study: 83 patients in group I and 326 in group II. There was a significant difference in operating time (129 min in group I vs. 116 min in group II; p<0.001) and days of hospitalization. Postoperative complication rate, reappearance in the ED, and rate of readmission did not differ between the two groups. Conclusions Our data suggest that under stringent supervision and with sufficient laparoscopic practice, implementation of LRYGB as part of surgical training is safe and results in only a slightly longer operating time. Complication rates, days of hospitalization, and the rates of readmission and reappearance in the ED within 30 days were similar between the both groups. These results should be interpreted by remembering that all procedures in group I were performed in a training environment so occasional intervention by a bariatric surgeon, when necessary, was inevitable

On cycling risk and discomfort: urban safety mapping and bike route recommendations

Bike usage in Smart Cities is paramount for sustainable urban development: cycling promotes healthier lifestyles, lowers energy consumption, lowers carbon emissions, and reduces urban traffic. However, the expansion and increased use of bike infrastructure has been accompanied by a glut of bike accidents, a trend jeopardizing the urban bike movement. This paper leverages data from a diverse spectrum of sources to characterise geolocated bike accident severity and, ultimately, study cycling risk and discomfort. Kernel density estimation generates a continuous, empirical, spatial risk estimate which is mapped in a case study of Zürich city. The roles of weather, time, accident type, and severity are illustrated. A predominance of self-caused accidents motivates an open-source software artifact for personalized route recommendations. This software is used to collect open baseline route data that are compared with alternative routes minimizing risk and discomfort. These contributions have the potential to provide invaluable infrastructure improvement insights to urban planners, and may also improve the awareness of risk in the urban environment among experienced and novice cyclists alike

Sudden Death of a Young Wrestler During Competition

Sudden death of healthy athletes during and because of their sport activities, are relatively very rare but cause anxiety among athletes, technical and administrative personnel, sport fans and, above all, consternation and grief to the family, while being given lavish coverage by the press. Negative effects of such sport injuries do not seem to last long, but compel Sports Science in general and Sports Medicine in particular, which is concerned with the athlete's well-being, to study such incidents thoroughly so that they may be prevented. Mechanical forces are mainly responsible for sudden death in healthy children and adolescents during sport activities. Although accidental death can occur in any sport, at any age, sports involving body contact and collisions present the greatest potential for fatal injury, because of their high inherent risk for sport-related sudden death. Head and neck injuries seem to account for the majority of deaths (80%) among athletes in collision or contact sports, as in American football (Blyth et aI., 1969), rugby football (Bruce et aI., 1982), soccer (Zakopoulos, 1973), basketball (Bruce et al., 1982), boxing (Ryan, 1987), etc., as well as in non-contact sports. Regarding wrestling, a contact and collision sport, there appears to be no other case of fatal injury other than the one which occurred recently in Greece in the course of a wrestling match, and which is the subject of this study

Achieving a Preoperative Target HbA1c of < 69 mmol/mol in Elective Vascular and Orthopedic Surgery: A Retrospective Single Center Observational Study

Introduction Diabetes mellitus (DM) is present in 10–15% of the surgical population. It is a known risk factor for adverse postoperative outcomes. UK perioperative guidance recommends optimizing glycemic control preoperatively, aiming for a target glycated hemoglobin (HbA1c) of < 69 mmol/mol. However, real-world compliance with this guidance remains unknown. The aim of our study was to determine how many patients with DM undergoing elective orthopedic and vascular surgery had a preoperative HbA1c of < 69 mmol/mol. We also reviewed the surgical reasons for non-concordance with the recommended preoperative HbA1c target. Methods This was a retrospective observational study of 1000 consecutive patients who had been referred for elective vascular and orthopedic surgery at a large tertiary center. Data were collected on these patients, both those with and without DM, between January 2016 and February 2017. Electronic databases were used to collect information on the patients’ preoperative HbA1c concentration and to determine whether there was a resulting delay in surgery when the preoperative HbA1c target of < 69 mmol/mol was exceeded. Results Of the 1000 patients referred for surgery (500 orthopedic and 500 vascular patients) included in the study, 201 (20%) had diabetes. Among these 201 people with DM, 155 (77%) had a preoperative HbA1c < 69 mmol/mol. Among the 46 people with DM whose HbA1c exceeded the recommended target, 41 were operated on despite the high HbA1c level, and only five had their surgery deferred or canceled due to suboptimal preoperative glycemic control. Conclusions Our data shows that the majority (77% ) of people undergoing elective vascular and orthopedic surgery were able to achieve a target HbA1c of < 69 mmol/mol. The current preoperative guidance is therefore achievable in a real-life setting. However, as is stated in the national guidance, this target should only be used where it is safe to do so and a degree of clinical discretion is necessary

Beyond BMI: Practical Guide for Clinicians to Integrate the Lancet Commission's Obesity Framework and King's Obesity Staging System

Body mass index (BMI) on its own is a poor diagnostic and staging tool for obesity because it does not measure health status. The newly published Lancet Clinical Obesity Criteria (LCOC) for defining clinical obesity distinguish preclinical and clinical obesity based on organ or tissue dysfunction. The King's Obesity Staging System (KOSS) goes further and incorporates biomedical, psychosocial, and economic factors while offering a practical, holistic, and health domain-specific assessment of obesity's impact. This paper compares and maps the LCOC against the KOSS to highlight their complementary aspects, strengths, and potential for integration. By combining the LCOC philosophical framework with the practical patient-centred approach of the KOSS, we propose a unified model that enhances diagnostic ability and allows the clinician to track the impact of any obesity treatment. This integrated framework advances obesity management, addressing both medical, functional, and broader psychosocial challenges

Diabetic retinopathy: current and future methods for early screening from a retinal hemodynamic and geometric approach

Diabetic retinopathy (DR) is a major disease and is the number one cause of blindness in the UK. In England alone, 4200 new cases appear every year and 1280 lead to blindness. DR is a result of diabetes mellitus, which affects the retina of the eye and specifically the vessel structure. Elevated levels of glucose cause a malfunction in the cell structure, which affects the vessel wall and, in severe conditions, leads to their breakage. Much research has been carried out on detecting the different stages of DR but not enough versatile research has been carried out on the detection of early DR before the appearance of any lesions. In this review, the authors approach the topic from the functional side of the human eye and how hemodynamic factors that are impaired by diabetes affect the vascular structur

How value-sensitive design can empower sustainable consumption

In a so-called overpopulated world, sustainable consumption is of existential importance. However, the expanding spectrum of product choices and their production complexity challenge consumers to make informed and value-sensitive decisions. Recent approaches based on (personalized) psychological manipulation are often intransparent, potentially privacy-invasive and inconsistent with (informational) self-determination. By contrast, responsible consumption based on informed choices currently requires reasoning to an extent that tends to overwhelm human cognitive capacity. As a result, a collective shift towards sustainable consumption remains a grand challenge. Here, we demonstrate a novel personal shopping assistant implemented as a smart phone app that supports a value-sensitive design and leverages sustainability awareness, using experts’ knowledge and ‘wisdom of the crowd’ for transparent product information and explainable product ratings. Real-world field experiments in two supermarkets confirm higher sustainability awareness and a bottom-up behavioural shift towards more sustainable consumption. These results encourage novel business models for retailers and producers, ethically aligned with consumer preferences and with higher sustainability

Postprandial plasma bile acid responses in normal weight and obese subjects

Background Bile acids can act as signalling molecules via various receptors including the nuclear farnesoid X receptor (FXR) and pregnane X receptor (PXR), and the cell surface G-protein-coupled receptor TGR5. The signalling has been implicated in the release of peptide YY (PYY) and glucagon-like peptide 1 (GLP-1), which improves glycaemic control and energy expenditure. We investigated whether morbidly obese subjects have altered postprandial bile acid responses in comparison to normal weight subjects. Method Blood samples were taken every 30 min from 0 to 180 min following a 400 kcal test meal. Samples were taken from 12 normal weight subjects with a body mass index (BMI) of 23.2 (2.8) kg/m2 (median [interquartile range (IQR)]) and seven obese patients with a BMI of 47.2 (7.2) kg/m2. Fractionated bile acids were measured on these samples using high-performance liquid chromatography tandem mass spectrometry. Results The obese subjects showed a lower postprandial response in total bile acids compared with the normal weight subjects. An increase of 6.4 (5.0) and 2.6 (3.3) μmol/L (median [IQR]) in normal weight and obese subjects was observed, respectively ( P = 0.02). The difference was predominantly due to the glycine-conjugated fraction ( P = 0.03). There was no difference in the increase of the unconjugated or taurine-conjugated fractions. Conclusions The decreased postprandial bile acid response in obese subjects compared with normal weight subjects may partly explain the suboptimal GLP-1 and PYY responses and could affect appetite, glycaemic control and energy expenditure. </jats:sec

Sensing and Mining Urban Qualities in Smart Cities

The emergence of the Internet of Things in Smart Cities questions how the future citizens will perceive their predominant living and working environments and what quality of living they can experience within it, for instance the level of everyday stress. However, perception and experienced stress levels are challenging metrics to measure and are even more challenging to correlate with an underlying causal-effectual relationship in such stimulus abundant environments. The Internet of Things, enabled by several pervasive and ubiquitous devices such as smart phones and smart sensors, can provide real-time contextual information that can be used by advanced data science methodologies to generate new insights about urban qualities in Smart Cities and how they can be improved. The goal of this study is to show the predominant factors, which influence perceptual qualities of inhabitants in a Smart City equipped with sensing capabilities by the Internet of Things. To serve this goal, a novel data collection process for Smart Cities is introduced that involves (i) environmental data, such noise, dust, illuminance, temperature, relative humidity, (ii) location/mobility data, such as GNSS and citizens density detected via WiFi, and (iii) perceptual social data collected by citizens' responses in smart phones. These fine-grained real-time data can provide invaluable insights about the spatial correlations of the sensor measurements as well as the spatial and citizens' similarity illustrated. The data analysis illustrated reveals significant links between stress level and environmental changes observed

Metabolic adaptation following gastric bypass surgery: results from a 2-year observational study

Background/ObjectivesMetabolic adaptation is the lowering of basal metabolic rate (BMR) beyond what is predicted from changes in fat mass (FM) and fat-free mass (FFM) and may hamper weight-loss progression. It is unclear whether metabolic adaptation occurs following gastric bypass surgery (GBP) and if it persists. The aim of this study was to evaluate the reduction in BMR that is not explained by changes in body composition in patients following GBP compared to a weight-stable comparator group.SubjectsThirty-one patients [77.4% female; mean BMI 45.5(SD 7.0) kg/m2; age 47.4(11.6)y] who underwent GBP, and 32 time-matched comparators [50% female; BMI 27.2(4.6) kg/m2; age 41.8(13.6)y) were evaluated at 1-month pre-surgery, 3-, 12- and 24-months post-surgery.MethodsBMR was measured under standardised residential conditions using indirect calorimetry and body composition using DXA. Linear regression analyses assessed metabolic adaptation post-surgery.ResultsAfter surgery, patients lost a quarter of their body weight [−25.6%(1.8%); p &lt; 0.0001] consisting mainly of FM (4:1 FM to FFM loss ratio) at 24-months post-surgery. Absolute BMR (MJ/d) reduced by 25.7% at 24-months post-surgery with values becoming similar to the comparator group from 3-months post-surgery. Positive associations were observed between changes in BMR and changes in FFM and FM (P &lt; 0.03). Metabolic adaptation was present in patients during the 1) rapid weight loss phase (6.9 kg/month at 3-months post-surgery) (p = 0.011), 2) slower weight loss phase (1.6 kg/month from 3 to 12-months post-surgery) (p &lt; 0.0001), and, 3) weight maintenance phase (24-months post-surgery) (p = 0.00073). However, the degree of metabolic adaptation observed in GBP patients was similar to the weight-stable comparator group (no metabolic adaptation) from 12-months post-surgery onwards (3-months; p = 0.01, 12-months; p = 0.26, 24-months post-surgery; p = 0.70).ConclusionThese results suggest that there is a potential biological mechanism of surgery that attenuates the expected postoperative downregulation in BMR thus helping GBP patients maintain weight loss