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1.
Ann R Coll Surg Engl ; 2024 Aug 14.
Artículo en Inglés | MEDLINE | ID: mdl-39141001

RESUMEN

INTRODUCTION: The aim of this study was to investigate the effect of body mass index (BMI, kg/m2) on outcomes of high-volume low-complexity (HVLC) general surgery procedures and to determine critical values for BMI when selecting patients into HVLC programmes. METHODS: A systematic review was conducted of studies looking at patients in different BMI categories undergoing HVLC general surgery procedures (laparoscopic cholecystectomy, inguinal hernia repair and umbilical or paraumbilical hernia repair), in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. A comparison meta-analysis model was constructed to compare the outcomes using random-effects modelling. The QUIPS (Quality In Prognosis Studies) tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) system were used to assess bias. RESULTS: A total of 26 studies including 486,392 patients were examined. In laparoscopic cholecystectomy, BMI ≥40 was associated with higher conversion to open surgery (odds ratio [OR]: 1.33, p=0.040) but did not affect complications (OR: 0.69, p=0.400) or length of hospital stay (mean difference [MD]: -0.01 days, p=0.900). In inguinal hernia repair, BMI ≥35 was associated with longer operative time (MD: 18.00 minutes, p<0.00001), and higher risk of wound complications (OR: 3.01, p<0.00001) and hospital readmission (OR: 1.46, p=0.0008). In umbilical or paraumbilical hernia repair, BMI ≥30 was associated with higher risk of wound complications (OR: 6.45, p<0.0001) and hospital readmission (OR: 5.56, p<0.00001), and longer operative time (MD: 4.01 minutes, p=0.030). CONCLUSIONS: Obesity was associated with longer operative time (up to 23 minutes) and higher risk of postoperative morbidity (up to 4-fold) in HVLC procedures. BMI <40 (moderate GRADE certainty - laparoscopic cholecystectomy) and BMI <35 (moderate GRADE certainty - inguinal hernia) appear to represent optimal critical values for perioperative safety metrics.

3.
BJS Open ; 5(4)2021 07 06.
Artículo en Inglés | MEDLINE | ID: mdl-34323917

RESUMEN

INTRODUCTION: Core surgical training programmes are associated with a high risk of burnout. This study aimed to assess the influence of a novel enhanced stress-resilience training (ESRT) course delivered at the start of core surgical training in a single UK statutory education body. METHOD: All newly appointed core surgical trainees (CSTs) were invited to participate in a 5-week ESRT course teaching mindfulness-based exercises to develop tools to deal with stress at work and burnout. The primary aim was to assess the feasibility of this course; secondary outcomes were to assess degree of burnout measured using Maslach Burnout Inventory (MBI) scoring. RESULTS: Of 43 boot camp attendees, 38 trainees completed questionnaires, with 24 choosing to participate in ESRT (63.2 per cent; male 13, female 11, median age 28 years). Qualitative data reflected challenges delivering ESRT because of arduous and inflexible clinical on-call rotas, time pressures related to academic curriculum demands and the concurrent COVID-19 pandemic (10 of 24 drop-out). Despite these challenges, 22 (91.7 per cent) considered the course valuable and there was unanimous support for programme development. Of the 14 trainees who completed the ESRT course, nine (64.3 per cent) continued to use the techniques in daily clinical work. Burnout was identified in 23 trainees (60.5 per cent) with no evident difference in baseline MBI scores between participants (median 4 (range 0-11) versus 5 (1-11), P = 0.770). High stress states were significantly less likely, and mindfulness significantly higher in the intervention group (P < 0.010); MBI scores were comparable before and after ESRT in the intervention cohort (P = 0.630, median 4 (range 0-11) versus 4 (1-10)). DISCUSSION: Despite arduous emergency COVID rotas ESRT was feasible and, combined with protected time for trainees to engage, deserves further research to determine medium-term efficacy.


Asunto(s)
Agotamiento Profesional/prevención & control , Curriculum , Cirugía General/educación , Resiliencia Psicológica , Estrés Psicológico/prevención & control , Cirujanos/psicología , Adulto , Ansiedad/prevención & control , COVID-19/epidemiología , Depresión/prevención & control , Estudios de Factibilidad , Femenino , Humanos , Masculino , Atención Plena , Pandemias , Encuestas y Cuestionarios , Reino Unido , Tolerancia al Trabajo Programado
5.
BJS Open ; 5(1)2021 01 08.
Artículo en Inglés | MEDLINE | ID: mdl-33609373

RESUMEN

BACKGROUND: Bibliometric and Altmetric analyses provide different perspectives regarding research impact. This study aimed to determine whether Altmetric score was associated with citation rate independent of established bibliometrics. METHODS: Citations related to a previous cohort of 100 most cited articles in surgery were collected and a 3-year interval citation gain calculated. Citation count, citation rate index, Altmetric score, 5-year impact factor, and Oxford Centre for Evidence-Based Medicine levels were used to estimate citation rate prospect. RESULTS: The median interval citation gain was 161 (i.q.r. 83-281); 74 and 62 articles had an increase in citation rate index (median increase 2.8 (i.q.r. -0.1 to 7.7)) and Altmetric score (median increase 3 (0-4)) respectively. Receiver operating characteristic (ROC) curve analysis revealed that citation rate index (area under the curve (AUC) 0.86, 95 per cent c.i. 0.79 to 0.93; P < 0.001) and Altmetric score (AUC 0.65, 0.55 to 0.76; P = 0.008) were associated with higher interval citation gain. An Altmetric score critical threshold of 2 or more was associated with a better interval citation gain when dichotomized at the interval citation gain median (odds ratio (OR) 4.94, 95 per cent c.i. 1.99 to 12.26; P = 0.001) or upper quartile (OR 4.13, 1.60 to 10.66; P = 0.003). Multivariable analysis revealed only citation rate index to be independently associated with interval citation gain when dichotomized at the median (OR 18.22, 6.70 to 49.55; P < 0.001) or upper quartile (OR 19.30, 4.23 to 88.15; P < 0.001). CONCLUSION: Citation rate index and Altmetric score appear to be important predictors of interval citation gain, and better at predicting future citations than the historical and established impact factor and Oxford Centre for Evidence-Based Medicine quality descriptors.


Asunto(s)
Bibliometría , Medicina Basada en la Evidencia , Cirugía General , Publicaciones Periódicas como Asunto , Humanos , Factor de Impacto de la Revista , Modelos Logísticos , Curva ROC
6.
BJS Open ; 4(5): 970-976, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32706526

RESUMEN

BACKGROUND: Entrants into UK surgical specialty training undertake a 2-year programme of core surgical training, rotating through specialties for varying lengths of time, at different hospitals, to gain breadth of experience. This study aimed to assess whether these variables influenced core surgical trainee (CST) work productivity. METHODS: Intercollegiate Surgical Curriculum Programme portfolios of consecutive CSTs between 2016 and 2019 were examined. Primary outcome measures were workplace-based assessment (WBA) completion, operative experience and academic outputs (presentations to learned societies, publications and audits). RESULTS: A total of 344 rotations by 111 CSTs were included. Incremental increases in attainment were observed related to the duration of core surgical training rotation. The median number of consultant-validated WBAs completed during core surgical training were 48 (range 0-189), 54 (10-120) and 75 (6-94) during rotations consisting of 4-, 6- and 12-month posts respectively (P < 0·001). Corresponding median operative caseloads (as primary surgeon) were 84 (range 3-357), 110 (44-394) and 134 (56-366) (P < 0·001) and presentations to learned societies 0 (0-12), 0 (0-14) and 1 (0-5) (P = 0·012) respectively. Hospital type and specialty training theme were unrelated to workplace productivity. Multivariable analysis identified length of hospital rotation as the only factor independently associated with total WBA count (P = 0·001), completion of audit (P = 0·015) and delivery of presentation (P = 0·001) targets. CONCLUSION: Longer rotations with a single educational supervisor, in one training centre, are associated with better workplace productivity. Consideration should be given to this when reconfiguring training programmes within the arena of workforce planning.


ANTECEDENTES: Los residentes de especialidades quirúrgicas del Reino Unido realizan un período troncal de formación quirúrgica de 2 años, en el que rotan por diversas especialidades durante periodos de tiempo variables y en diversos hospitales, a fin de conseguir una experiencia amplia. Este estudio tuvo como objetivo evaluar si estas variables influyeron en la productividad de los residentes durante el período troncal (core surgical trainee, CST). MÉTODOS: Se examinaron los inventarios de los programas del Intercollegiate Surgical Curriculum Programme (ISCP) de CST consecutivos entre 2016 y 2019. Las variables principales fueron la puntuación final del Workplace-Based Assessment (WBA), y la actividad quirúrgica y académica (presentaciones a sociedades académicas, publicaciones y auditorías) realizadas. RESULTADOS: Se incluyeron 344 rotaciones de 111 CST. Se constataron mejores resultados en relación con la duración de la rotación de CST. La mediana (rango) de la puntuación de los supervisores en las WBA fue de 48 (0'189), 54 (10'120) y 75 (6'94) (P < 0,001) en las rotaciones a los 4, 6 y 12 meses, respectivamente. El número de intervenciones (como cirujano principal) fue de 84 (3'357), 110 (44'394) y 134 (56'366) (P < 0,001) y de presentaciones a sociedades científicas fue de 0 (0-12), 0 (0- 14) y 1 (0-5) (P = 0,012). No hubo relación entre el tipo de hospital o la especialidad y la productividad en el lugar de trabajo. El análisis multivariable identificó la duración de la rotación como único factor independientemente relacionado con la puntuación de la WBA (P = 0,001), la finalización de la auditoría (P = 0,015) y el número de presentaciones realizadas (P = 0,001). CONCLUSIÓN: Las rotaciones de periodos de tiempo largos con un solo supervisor y en un solo centro se asocian con una mejor productividad en el lugar de trabajo. Debería tenerse en cuenta este factor al reconfigurar los programas de capacitación desde el punto de vista laboral.


Asunto(s)
Competencia Clínica , Consultores/estadística & datos numéricos , Educación Médica Continua/organización & administración , Especialidades Quirúrgicas/educación , Lugar de Trabajo/organización & administración , Curriculum , Femenino , Hospitales , Humanos , Modelos Logísticos , Masculino , Análisis Multivariante , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Reino Unido
7.
BJS Open ; 3(6): 852-856, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31832592

RESUMEN

Background: This study aimed to analyse the degree of relative variation in specialty-specific competencies required for certification of completion of training (CCT) by the UK Joint Committee on Surgical Training. Methods: Regulatory body guidance relating to operative and non-operative surgical skill competencies required for CCT were analysed and compared. Results: Wide interspecialty variation was demonstrated in the required minimum number of logbook cases (median 1201 (range 60-2100)), indexed operations (13 (5-55)), procedure-based assessments (18 (7-60)), publications (2 (0-4)), communications to learned associations (0 (0-6)) and audits (4 (1-6)). Mandatory courses across multiple specialties included: Training the Trainers (10 of 10 specialties), Advanced Trauma Life Support (6 of 10), Good Clinical Practice (9 of 10) and Research Methodologies (8 of 10), although no common accord was evident. Discussion: Certification guidelines for completion of surgical training were inconsistent, with metrics related to minimum operative caseload and academic reach having wide variation.


Antecedentes: Este estudio se propuso analizar el grado de variación relativa en las competencias específicas de la especialidad que se requieren para obtener el certificado de haber completado la formación (Certification of Completion of Training, CCT) por el Joint Committee for Surgical Training (JCST) del Reino Unido. Métodos: Se analizaron y compararon las guías del organismo regulador relacionadas con las competencias en habilidades quirúrgicas, tanto operatorias como no operatorias, requeridas para el CCT. Resultados: Se demostró una amplia variación entre especialidades en el número mínimo requerido del cuaderno de casos (mediana 1.201; rango 60­2.100), operaciones índices (13; 5­55), evaluaciones basadas en procedimientos (18; 7­60), publicaciones (2; 0­4), comunicaciones para determinar asociaciones (0; 0­6) y auditorias (4; 1­6). Los cursos obligatorios entre las distintas especialidades incluían: formación de los formadores (10 de 10 especialidades), apoyo vital avanzado en traumas (6/10), buena práctica clínica (9/10) y metodologías clínicas (8/10), aunque era evidente que no existía un acuerdo común. Conclusión: Las directrices sobre la certificación para completar la formación quirúrgica eran inconsistentes, con una amplia variación en los números relativos a los mínimos casos operados y objetivos académicos alcanzados.


Asunto(s)
Certificación/normas , Competencia Clínica/normas , Educación de Postgrado en Medicina/normas , Especialidades Quirúrgicas/educación , Comités Consultivos/normas , Guías como Asunto , Especialidades Quirúrgicas/normas , Reino Unido
8.
Br J Surg ; 106(11): 1495-1503, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31424578

RESUMEN

BACKGROUND: This study investigated the indications, procedures and outcomes for adrenal surgery from the UK Registry of Endocrine and Thyroid Surgery database from 2005 to 2017, and compared outcomes between benign and malignant disease. METHODS: Data on adrenalectomies were extracted from a national surgeon-reported registry. Preoperative diagnosis, surgical technique, length of hospital stay, morbidity and in-hospital mortality were examined. RESULTS: Some 3994 adrenalectomies were registered among patients with a median age of 54 (i.q.r. 43-65) years (55·9 per cent female). Surgery was performed for benign disease in 81·5 per cent. Tumour size was significantly greater in malignant disease: 60 (i.q.r. 34-100) versus 40 (24-55) mm (P < 0·001). A minimally invasive approach was employed in 90·2 per cent of operations for benign disease and 48·2 per cent for cancer (P < 0·001). The conversion rate was 3·5-fold higher in malignant disease (17·3 versus 4·7 per cent; P < 0·001). The length of hospital stay was 3 (i.q.r. 2-5) days for benign disease and 5 (3-8) days for malignant disease (P < 0·050). In multivariable analysis, risk factors for morbidity were malignant disease (odds ratio (OR) 1·69, 1·22 to 2·36; P = 0·002), tumour size larger than 60 mm (OR 1·43, 1·04 to 1·98; P = 0·028) and conversion to open surgery (OR 3·48, 2·16 to 5·61; P < 0·001). The in-hospital mortality rate was below 0·5 per cent overall, but significantly higher in the setting of malignant disease (1·2 versus 0·2 per cent; P < 0·001). Malignant disease (OR 4·88, 1·17 to 20·34; P = 0·029) and tumour size (OR 7·47, 1·52 to 39·61; P = 0·014) were independently associated with mortality in multivariable analysis. CONCLUSION: Adrenalectomy is a safe procedure but the higher incidence of open surgery for malignant disease appears to influence postoperative outcomes.


ANTECEDENTES: Este estudio investigó las indicaciones, procedimientos y resultados de la cirugía de la glándula suprarrenal a partir de la base de datos de la UKRETS desde 2005-2017 y comparó los resultados entre enfermedad benigna y maligna. MÉTODOS: Se examinó un registro nacional con datos notificados por cirujanos que incluye 3.994 suprarrenalectomías; 57% mujeres, mediana de edad 53 (8-88 años). Se evaluaron el diagnóstico preoperatorio, la técnica quirúrgica, la duración de la estancia hospitalaria, la morbilidad y la mortalidad hospitalaria. RESULTADOS: En el 82% de los casos la cirugía se realizó por enfermedad benigna. El tamaño del tumor fue significativamente mayor en la enfermedad maligna: 60 mm (34-100 mm) versus 40 mm (24-55 mm), P < 0,001. Se utilizó un abordaje mínimamente invasivo en el 90% de los casos de enfermedad benigna y en el 48% de las operaciones por cáncer (P < 0,001). La tasa de conversión fue 3,5 veces más alta en la enfermedad maligna (17% versus 4,9%, P < 0,001). La duración de la estancia fue 3 días (rango intercuartílico, interquartile range, IQR 2-5) para la enfermedad benigna y 5 (IQR 3-8) días para la enfermedad maligna (P < 0,05). En el análisis multivariable, los factores de riesgo para la morbilidad fueron: enfermedad maligna (razón de oportunidades, odds ratio, OR 1,64, 1,217-2,359; P = 0,002), tamaño del tumor (OR 1,433, 1.040-1,967; P = 0,028) y conversión a cirugía abierta (OR 3,483, 2,160-5,612; P < 0,0001). La mortalidad hospitalaria global fue baja (< 0,5%) pero significativamente mayor en el escenario de la enfermedad maligna (1,2% versus 0,2%, P < 0,001). La enfermedad maligna (OR 4,881, 1,171-20,343; P = 0,029) y el tamaño del tumor (OR 7,474, 1,515-39,610; P = 0,014) se asociaron de forma independiente con la mortalidad en el análisis multivariable. CONCLUSIÓN: La suprarrenalectomía es un procedimiento seguro, pero la mayor incidencia de cirugía abierta para la enfermedad maligna parece tener un impacto sobre los resultados postoperatorios.


Asunto(s)
Enfermedades de las Glándulas Suprarrenales/cirugía , Adrenalectomía/estadística & datos numéricos , Enfermedades de las Glándulas Suprarrenales/mortalidad , Neoplasias de las Glándulas Suprarrenales/mortalidad , Neoplasias de las Glándulas Suprarrenales/cirugía , Adulto , Anciano , Femenino , Mortalidad Hospitalaria , Humanos , Laparoscopía/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Resultado del Tratamiento , Reino Unido/epidemiología
9.
World J Surg ; 42(11): 3575-3580, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30097705

RESUMEN

AIMS: Post-operative acute kidney injury (AKI) is a common and independent mortality risk factor carrying high clinical and economic cost. This study aimed to establish the incidence of AKI in patients undergoing emergency laparotomy (EL), to determine patients' risk profile and consequent mortality. METHODS: Consecutive 239 patients of median age 68 (IQR 51-76) years, undergoing EL in a UK tertiary hospital, were studied. Primary outcome measure was AKI and in-hospital operative mortality. RESULTS: Ninety-five patients (39.7%) developed AKI, which was associated with in-hospital mortality in 32 patients (33.7%) compared with 7 patients (4.9%) without AKI. AKI occurred in 81.1% of all mortalities, but none occurred when AKI resolved within 48 h of EL. AKI was associated with chronic kidney disease, age, serum lactate, white cell count, pre-EL systolic blood pressure and tachycardia (p < 0.010). Median length of hospital stay in AKI survivors was 15 days compared with 11 days in the absence of AKI (p < 0.001). On multivariable analysis, only AKI at 48 h post-EL was significantly and independently associated with mortality [HR 10.895, 95% CI 3.152-37.659, p < 0.001]. CONCLUSION: Peri-operative AKI after EL was common and associated with a more than sixfold significant greater mortality. Pre-operative risk profile assessment and prompt protocol-driven intervention should minimise AKI and reduce EL mortality.


Asunto(s)
Lesión Renal Aguda/mortalidad , Laparotomía/efectos adversos , Lesión Renal Aguda/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Urgencias Médicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Adulto Joven
10.
World J Surg ; 42(9): 2835-2839, 2018 09.
Artículo en Inglés | MEDLINE | ID: mdl-29497805

RESUMEN

BACKGROUND: Parathyroid hormone (PTH) has a short half-life and is cleared by the liver and kidneys. This study examined whether declining estimated glomerular filtration rate (eGFR) affects application of the Miami criterion for intraoperative PTH (ioPTH) decline during parathyroidectomy for primary hyperparathyroidism (pHPT). METHODS: A retrospective review of consecutive patients undergoes parathyroidectomy for pHPT. Patients with multi-gland disease, without ioPTH, failure-to-cure and those <18 years were excluded. Baseline demographics, pre-operative PTH, ioPTH and 6-month follow-up data were available. Patients were categorised into normal or chronic kidney disease (CKD stage 2-5) based on pre-operative eGFR. Nonparametric data were compared using Mann-Whitney U test/Kruskal-Wallis test. The primary outcome measure was to assess whether CKD-affected ioPTH decline in parathyroidectomy for pHPT. RESULTS: A total of 476 patients were included [75.4% women; median age 63.8 years (18-92)]. CKD was present in 362 (76%) (CKD2:289; CKD3:66; CKD4/5:7). Increasing CKD stage was associated with advancing age [normal 53 years (41-61); CKD2 65 (57-73); CKD3 73.5 (66-78); CKD4/5 74(63-81); p < 0.001] and higher pre-operative PTH [16.6 pmol/L (11.1-22.9); 13.1 (10.4-17.7); 22.6 (13.8-33.7); 33.8(12.4-41.7); p < 0.001]. Baseline and post-excision ioPTH were significantly higher in those with CKD4/5 (p < 0.05). The Miami criterion was met in all patients, but median fall in ioPTH at 10-min varied between groups [normal:0.78 (0.71-0.82); CKD2:0.76 (0.69-0.83); CKD3:0.75 (0.69-0.82); CKD4/5:0.69 (0.61-0.70); p = 0.048)]. It was significantly lower in those with CKD4/5 compared with the remainder of patients [0.69 (0.61-0.70) vs. 0.76 (0.70-0.82); p = 0.008]. CONCLUSIONS: Although the reduction in ioPTH after successful parathyroidectomy is lower in severe CKD, the Miami criterion remains predictive of cure. Differences in absolute levels of PTH and tumour weight suggest that renal HPT may be a confounding factor.


Asunto(s)
Adenoma/cirugía , Tasa de Filtración Glomerular , Hiperparatiroidismo Primario/cirugía , Monitoreo Intraoperatorio , Hormona Paratiroidea/sangre , Neoplasias de las Paratiroides/cirugía , Insuficiencia Renal Crónica/complicaciones , Adenoma/sangre , Adenoma/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hiperparatiroidismo Primario/etiología , Masculino , Persona de Mediana Edad , Neoplasias de las Paratiroides/sangre , Neoplasias de las Paratiroides/complicaciones , Paratiroidectomía , Insuficiencia Renal , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/cirugía , Estudios Retrospectivos , Carga Tumoral , Adulto Joven
11.
Ann R Coll Surg Engl ; 98(7): 475-8, 2016 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-27269241

RESUMEN

Introduction Pan-speciality consensus guidance advocates mandatory emergency general surgery (EGS) training modules for specialist registrars (StRs). This pilot study evaluated the impact of EGS modules aimed at StRs over 1 year. Methods Eleven StRs were allocated a focused 4-week EGS module, in addition to the standard 1:12 on-call duty rota, in a tertiary surgical centre. Primary outcome measures included the number of indicative emergency operations and validated Procedure Based Assessments (PBAs) performed, both during the EGS module and over the training year. Results StRs performed a median of 11 (range 5-15) laparotomies during the EGS module versus 31 (range 9-49) over the whole training year. StRs attended 43.7% of available laparotomies during the module (range 24.1-63.7%). EGS modules provided more than one-third of the total emergency laparotomy experience, and a quarter of the emergency colectomy, appendicectomy and Hartmann's procedure experience. There were no differences in EGS module-related outcomes between junior and senior StRs. Significantly more PBAs related to laparotomy and segmental colectomy were completed during EGS modules than the on-call duty rota, at 32% versus 14% (p<0.001) and 48% versus 22% (p=0.019), respectively. Performance levels were maintained following module completion. Conclusions These findings provide an important baseline when considering future modular EGS training.


Asunto(s)
Medicina de Emergencia/educación , Cirugía General/educación , Internado y Residencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Humanos , Internado y Residencia/organización & administración , Internado y Residencia/estadística & datos numéricos , Laparotomía/estadística & datos numéricos , Proyectos Piloto
12.
Br J Surg ; 100(13): 1732-8, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-24227357

RESUMEN

BACKGROUND: Moderate wound pain and opiate analgesia requirement is reported following thyroid and parathyroid surgery. A randomized clinical trial was performed to investigate whether intraoperative superficial cervical plexus block (SCPB) would decrease postoperative pain and analgesia use. METHODS: Patients were randomized to incisional local anaesthesia (control) or incisional local anaesthesia plus intraoperative SCPB. The primary outcome measure was pain, assessed by a visual analogue scale (VAS). Secondary outcome measures were analgesia use (strong opiates defined as having potency at least as strong as that of oral morphine), respiratory rate and sedation score. Primary outcome measures were analysed with non-parametric tests, as well as with receiver operating characteristic (ROC) curves calculated as area under the curve (AUC) to discriminate between trial limbs. RESULTS: Twenty-nine patients were randomized to each group. Pain (VAS) scores were lower in patients who received intraoperative SCPB than in controls 30 min after surgery and subsequently (P < 0·020 at all time points), with a median pain score of zero on the day of operation in the SCPB group. Corresponding analysis of ROC curves showed differences between groups at 30 min (AUC = 0·722, P = 0·012), 90 min (AUC = 0·747, P = 0·005), 150 min (AUC = 0·803, P < 0·001) and 210 min (AUC = 0·849, P < 0·001) after surgery, and at 07.00 hours on postoperative day 1 (AUC = 0·710, P = 0·017). Fewer patients in the SCPB group required strong opiates (5 of 29 versus 16 of 29 in the control group; P = 0·003) and rescue opiates (6 of 29 versus 20 of 29; P < 0·001). CONCLUSION: Intraoperative SCPB reduces pain scores following thyroid and parathyroid surgery, and reduces the requirement for strong and rescue opiates. REGISTRATION NUMBER: 2009-012671-98 (https://www.clinicaltrialsregister.eu).


Asunto(s)
Anestesia Local/métodos , Bloqueo Nervioso/métodos , Dolor Postoperatorio/prevención & control , Enfermedades de las Paratiroides/cirugía , Enfermedades de la Tiroides/cirugía , Tiroidectomía/métodos , Anciano , Analgésicos/uso terapéutico , Anestésicos Locales/administración & dosificación , Área Bajo la Curva , Bupivacaína/administración & dosificación , Plexo Cervical , Femenino , Hematoma/etiología , Humanos , Cuidados Intraoperatorios/métodos , Masculino , Persona de Mediana Edad , Cuello , Bloqueo Nervioso/efectos adversos , Curva ROC , Resultado del Tratamiento
13.
Obes Surg ; 22(4): 641-5, 2012 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-22252746

RESUMEN

BACKGROUND: Shared medical appointments (SMAs) are group clinics where practitioners see several patients, with common health needs, at once. There is a great financial strain on the National Health Service (NHS) to provide bariatric surgery. The aim of this study was to review patient satisfaction with the SMA that is the default means of following up patients after bariatric surgery at one particular NHS trust. METHODS: A patient-validated questionnaire was designed and handed out at the end of the SMAs. Patients who attended an SMA earlier in 2011 were also retrospectively sent questionnaires via post. RESULTS: A total of 47 patients completed the questionnaire from seven different SMAs covering the period from January to July 2011. All patients underwent laparoscopic adjustable gastric banding. After attending an SMA, patients gave an overall mean satisfaction rating of 4.13 ± 0.163 (on a scale of 1 to 5, 1 = very poor and 5 = excellent) which represented an increase (p < 0.01) compared to preconceptions before the clinic (3.59 ± 0.175). A cost analysis estimated a yearly saving of £4,617 or 65.1% made by the SMAs compared to 1:1 appointments. CONCLUSIONS: The bariatric surgery SMA demonstrates high levels of patient satisfaction and is cost-effective.


Asunto(s)
Cuidados Posteriores/economía , Cuidados Posteriores/organización & administración , Citas y Horarios , Cirugía Bariátrica , Continuidad de la Atención al Paciente , Satisfacción del Paciente , Encuestas y Cuestionarios , Cirugía Bariátrica/economía , Análisis Costo-Beneficio , Femenino , Estudios de Seguimiento , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Encuestas y Cuestionarios/normas , Reino Unido
15.
Urol Clin North Am ; 23(1): 43-54, 1996 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-8677536

RESUMEN

Aging is associated with a decreased physiological functioning, reflecting the body's progressive inability to maintain homeostasis as age increases. The physiologic dysfunctions experienced in response to the aging process increase the individual's susceptibility to infection. Many elderly subjects are hospitalized for the care and treatment of functional disabilities; thus, an increased exposure to possible uropathogens (many with antimicrobial resistance) often results in infection. Additionally, indwelling catheters and other attending procedures may provide a microenvironment conducive to infection. In catheterized patients, the drainage bag often is infected with polymicrobes, which enhances the transference of antimicrobial genetic information. Postmenopause reflects a decrease in circulating estrogen, and a relational decrease in lactobacilli colonization with a lower vaginal pH. Consequently, vaginal colonization with possible uropathogenic and gastrointestinal bacteria increases, which partially may account for the generally higher incidence of bacteriuria in elderly women as opposed to elderly men. Urinary infections in the elderly more commonly are asymptomatic. Treatment for asymptomatic bacteriuria is not justified and will often present opportunities for the infecting organism to acquire antimicrobial resistance. Only symptomatic bacteriuria presenting adverse conditions in the host should be treated. Antimicrobial selection for the treatment of complicating symptomatic urinary infections in elderly subjects is complicated by the many physiological and environmental conditions associated with older age patients. Unfortunately, data confirming the efficacy and safety of antimicrobial agents for the treatment of symptomatic infections in the elderly presently are insufficient.


Asunto(s)
Bacteriuria , Anciano , Bacteriuria/diagnóstico , Bacteriuria/terapia , Femenino , Humanos , Masculino , Infecciones Urinarias
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