BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.
Only four early years postgraduate surgical training posts in the UK meet nationally approved minimum quality standards. Specific recommendations are made to improve training in this cohort and to bolster recruitment and retention into Higher Surgical Training.
Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.
IntroductionEarly exposure to practical skills in surgical training is essential in order to master technically demanding procedures such as the design and execution of local skin flaps. Changes in working patterns, increasing subspecializations, centralization of surgical services, and the publication of surgeon-specific outcomes have all made hands-on-training in a clinical environment increasingly difficult to achieve for the junior surgeon. This has been further compounded by the COVID-19 pandemic. This necessitates alternative methods of surgical skills training. To date, there are no standardized or ideal simulation models for local skin flap teaching.AimThis systematic review aims to summarize and evaluate local skin flap simulation and teaching models published in the literature.Materials and MethodsA systematic review protocol was developed and undertaken in accordance with PRISMA guidelines. Key search terms encompassed both “local skin flaps” and “models” or “surgical simulation”. These were combined using Boolean logic and used to search Embase, Medline, and the Cochrane Library. Studies were collected and screened according to the inclusion criteria. The final included articles were graded for their level of evidence and recommendation based on a modified educational Oxford Center for evidence-based medicine classification system and assessed according to the CRe-DEPTH tool for articles describing training interventions in healthcare professionals.ResultsA total of 549 articles were identified, resulting in the inclusion of 16 full-text papers. Four articles used 3D simulators for local flap teaching and training, while two articles described computer simulation as an alternative method for local flap practicing. Four models were silicone based, while gelatin, Allevyn dressings, foam rubber, and ethylene-vinyl acetate-based local flap simulators were also described. Animal models such as pigs head, porcine skin, chicken leg, and rat, as well as a training model based on fresh human skin excised from body-contouring procedures, were described. Each simulation and teaching method was assessed by a group of candidates via a questionnaire or evaluation survey grading system. Most of the studies were graded as level of evidence 3 or 4.ConclusionMany methods of simulation for the design and execution of local skin flaps have been described. However, most of these have been assessed only in small cohort numbers, and, therefore, larger candidate sizes and a standardized method for assessment are required. Moreover, some proposed simulators, although promising, are in a very preliminary stage of development. Further development and evaluation of promising high-fidelity models is required in order to improve training in such a complex area of surgery.
Earl Scruggs joined the Grand Ole Opry, the high-profile country-music radio show, in December 1945. Although some were skeptical that he’d fit in, Scruggs turned out to be a necessary counterpoint to the approach of mandolinist and singer Bill Monroe, already a star of the show. Also in the band was singer-songwriter Lester Flatt, Scruggs’s eventual co-bandleader for many years. Another prominent figure of the day, singer Mac Wiseman, recalled that Monroe didn’t have a definite sound in mind when assembling the elements of bluegrass but was experimenting with different sounds. In later years, Monroe was to say that Scruggs has benefited more from his work with Monroe than the other way around. But most observers believe that Scruggs was the key element that brought bluegrass together as a style between 1945 and 1948.
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