The effect of socioeconomic status and training programmes on burnout in postgraduate trainees in the United Kingdom: a cross-sectional analysis.

PURPOSE: Burnout is described as a state of mental exhaustion caused by one's professional life and is characterised by three domains: emotional exhaustion, depersonalisation, and a reduced sense of accomplishment. The prevalence of stress is high amongst doctors and varies by specialty, gender, trainee level, and socioeconomic status. The authors set out to examine the scale of the problem, as well as to determine the influence of both socioeconomic status and chosen training programme on burnout amongst postgraduate trainees. This would identify at-risk groups and aid in future targeted interventions. METHODS: Cross-sectional data were obtained, following approval from the General Medical Council, from The National Training Survey, completed annually by all trainees in the United Kingdom. Data were then anonymised and analysed. Burnout scores were derived from the Copenhagen Burnout Inventory and are positively framed (higher scores equal lower burnout). RESULTS: The questionnaire was completed by 63 122 participants from 2019 to 2020. Mean burnout amongst all trainees was 52.4 (SD = 19.3). Burnout scores from the most deprived quintile was significantly lower compared with those from the least deprived quintile: 51.0 (SD = 20.6) versus 52.9 (SD = 18.9), respectively (P < 0.001). The highest levels of burnout were reported in Internal Medical Training, Emergency Medicine, Obstetrics and Gynaecology, and Core Surgical Training, respectively. CONCLUSION: Postgraduates from lower socioeconomic backgrounds are more likely to encounter burnout during training. At-risk groups who may also benefit from targeted intervention have been identified, requiring further examination through future studies.

Setting up a surgical complex gallstone service in a non-HPB unit.

Objectives: Complex gallstone disease is associated with a higher risk of complication during laparoscopic cholecystectomy than biliary colic and simple cholecystitis. It is traditionally managed in a hepatopancreaticobiliary (HPB) unit where there is expertise for common bile duct exploration and repair. We developed a mentorship scheme for a busy upper gastro-intestinal (UGI) unit, with support from a specialist HPB unit to treat complex gallstone disease, to reduce the burden on the HPB unit and enable local treatment of patients. Material and Methods: Through the creation of a service level agreement, the specialist HPB unit were commissioned to provide mentorship for two surgeons at a large UGI unit with an interest in providing a complex gallstone service to their local population. Eight sessions of mentored operating were supported, with the provision for additional support if complications occurred. Results: There were 14 patients included in the mentorship phase of the programme from November 2015 to May 2017. Cholecystectomies were performed on patients with previously complex histories, which included: previous cholecystostomy; CBD stones and multiple ERCPs; suspected choledochoduodenal fistula; suspected cholecystoduodenal fistula; suspected Mirrizzi's syndrome; previous significant intra-abdominal operation; and significant medical co-morbidities. There was one post-operative complication requiring a return to theatre, and one minor wound infection associated with the complex gallstone lists. Conclusion: We demonstrated a method to reduce the burden on specialist HPB unit for the operative management of complex gallstone disease and safely implement such a service at large UGI unit with an interest in providing a complex gallstone service.

Surgical training in the UK: is cost a barrier to entry?

BACKGROUND: There is good quality evidence linking socioeconomic background and the likelihood of a surgical career. Additionally, training in surgery is more expensive than in other specialties. Our aim was to assess the awareness and perceptions of trainees and medical students of the relative costs of surgical training and to determine whether perceptions of cost deter potential surgical trainees. METHODS: Medical students, foundation doctors and core trainees in England were surveyed over a 2-week period. χ2 tests of independence were used to assess statistically significant associations between measured variables MAIN FINDINGS: A total of 284 responses were received. More than half of respondents (54%) were not previously aware of the high costs of surgical training. More than a quarter of respondents (27%) did not take out a student loan. There was a significant association (p=0.003) between familial income and being less likely to consider a surgical career due to the costs. Respondents who reported receipt of a student loan were also significantly less likely to consider a surgical career due to the costs (p=0.033). CONCLUSION: Our study demonstrates an important relationship between perceived costs of surgical training and future career aspirations. This suggests that access to surgical training may still be difficult for many. This study also highlights a general lack of awareness of high surgical training costs. It is important that surgical training is accessible. Financial status should not be a significant disincentive and widening access to surgical training can only serve to enrich and advance the specialty.

Open tibia/fibula in the elderly: A retrospective cohort study.

The incidence of open tibia/fibula fractures in the elderly is increasing, but current national guidelines focus on the aggressive treatment of high-energy injuries in younger patients. There is conflicting evidence regarding whether older age affects treatment provision and outcomes in open fractures. The aim of this study was to determine if elderly patients are sustaining a different injury to younger patients and how their treatment and outcomes differ. This may have implications for future guidelines and verify their application in the elderly. In this retrospective single centre cohort study (December 2015-July 2018), we compared the injury characteristics, operative management and outcomes of elderly (≥65 years) and younger (18-65 years) patients with open tibia/fibula fractures. An extended cohort examined free flap reconstruction. In total, 157 patients were included. High-energy injuries were commoner in younger patients (88% vs 37%; p<0.001). Most were Gustilo-Anderson IIIb in both age groups. Elderly patients waited longer until debridement (21:19 vs 19:00 h) and had longer inpatient stays (23 vs 15 days). There was no difference in time to antibiotics, operative approach or post-operative complications. Despite the low-energy nature of elderly patients' injuries, the severity of soft tissue insult was equivalent to younger patients with high-energy injuries. Our data suggest that age and co-morbidities should not prohibit lower limb reconstruction. The current application of generic guidelines appears suitable in the elderly, particularly in the acute management. We suggest current management pathways and targets be reviewed to reflect the greater need for peri-operative optimisation and rehabilitation in elderly patients.

30-day morbidity and mortality of sleeve gastrectomy, Roux-en-Y gastric bypass and one anastomosis gastric bypass: a propensity score-matched analysis of the GENEVA data.

BACKGROUND: There is a paucity of data comparing 30-day morbidity and mortality of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB). This study aimed to compare the 30-day safety of SG, RYGB, and OAGB in propensity score-matched cohorts. MATERIALS AND METHODS: This analysis utilised data collected from the GENEVA study which was a multicentre observational cohort study of bariatric and metabolic surgery (BMS) in 185 centres across 42 countries between 01/05/2022 and 31/10/2020 during the Coronavirus Disease-2019 (COVID-19) pandemic. 30-day complications were categorised according to the Clavien-Dindo classification. Patients receiving SG, RYGB, or OAGB were propensity-matched according to baseline characteristics and 30-day complications were compared between groups. RESULTS: In total, 6770 patients (SG 3983; OAGB 702; RYGB 2085) were included in this analysis. Prior to matching, RYGB was associated with highest 30-day complication rate (SG 5.8%; OAGB 7.5%; RYGB 8.0% (p = 0.006)). On multivariate regression modelling, Insulin-dependent type 2 diabetes mellitus and hypercholesterolaemia were associated with increased 30-day complications. Being a non-smoker was associated with reduced complication rates. When compared to SG as a reference category, RYGB, but not OAGB, was associated with an increased rate of 30-day complications. A total of 702 pairs of SG and OAGB were propensity score-matched. The complication rate in the SG group was 7.3% (n = 51) as compared to 7.5% (n = 53) in the OAGB group (p = 0.68). Similarly, 2085 pairs of SG and RYGB were propensity score-matched. The complication rate in the SG group was 6.1% (n = 127) as compared to 7.9% (n = 166) in the RYGB group (p = 0.09). And, 702 pairs of OAGB and RYGB were matched. The complication rate in both groups was the same at 7.5 % (n = 53; p = 0.07). CONCLUSIONS: This global study found no significant difference in the 30-day morbidity and mortality of SG, RYGB, and OAGB in propensity score-matched cohorts.

Current concepts in the management of bisphosphonate associated atypical femoral fractures.

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Exploiting Iminoquinones as Electrophilic at Nitrogen "N+" Synthons for C-N Bond Construction.

New methods for C-N bond construction exploiting the N-centered electrophilic character of iminoquinones are reported. Iminoquinones, generated in situ via the condensation of o-vinylanilines with benzoquinones, undergo acid-catalyzed cyclization to afford N-arylindoles in excellent yields. Under similar reaction conditions, homoallylic amines react analogously to afford N-arylpyrroles. Additionally, organometallic nucleophiles are shown to add to the nitrogen atom of N-alkyliminoquinones to provide amine products. Finally, iminoquinones are shown to be competent electrophiles for copper-catalyzed hydroamination.

30-Day morbidity and mortality of bariatric metabolic surgery in adolescence during the COVID-19 pandemic - The GENEVA study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. OBJECTIVES: This study examined the safety of MBS in adolescents during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This was a global, multicentre and observational cohort study of MBS performed between May 01, 2020, and October 10,2020, in 68 centres from 24 countries. Data collection included in-hospital and 30-day COVID-19 and surgery-specific morbidity/mortality. RESULTS: One hundred and seventy adolescent patients (mean age: 17.75 ± 1.30 years), mostly females (n = 122, 71.8%), underwent MBS during the study period. The mean pre-operative weight and body mass index were 122.16 ± 15.92 kg and 43.7 ± 7.11 kg/m2 , respectively. Although majority of patients had pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (n = 146; 85.9%), only 42.4% (n = 72) of the patients were asked to self-isolate pre-operatively. Two patients developed symptomatic SARS-CoV-2 infection post-operatively (1.2%). The overall complication rate was 5.3% (n = 9). There was no mortality in this cohort. CONCLUSIONS: MBS in adolescents with obesity is safe during the COVID-19 pandemic when performed within the context of local precautionary procedures (such as pre-operative testing). The 30-day morbidity rates were similar to those reported pre-pandemic. These data will help facilitate the safe re-introduction of MBS services for this group of patients.

Safety and feasibility of revisional bariatric surgery following Laparoscopic Adjustable Gastric Band - Outcomes from a large UK private practice.

BACKGROUND: Revisional bariatric surgery is unavoidable in a proportion of patients. Despite its need, the development of this speciality has been hampered by its complexity and preferred delivery in institutional set ups. Although primary bariatric surgery can be delivered in the private sector; safety and feasibility of revisional bariatric surgery remains unexplored in this setting. MATERIALS AND METHODS: Patients undergoing revisional bariatric surgery following previous Laparoscopic Adjustable Gastric Band (LAGB) between 2008 and 2019 at a single private bariatric unit with a minimum follow up of at least 6 months were included. The primary aim was safety outcomes and 30-day morbidity. RESULTS: 178 patients with BMI of 45.6 ± 8.2 kg/m2 underwent revisional bariatric surgery. One stage conversion was performed for 86.5% of the cases. At 9.5 ± 5.3 months follow up, BMI and percentage excess BMI loss were 31.8 ± 6.2 kg/m2 and 62.6 ± 40% respectively. There was no mortality, and the major complication rate was 2.8%. There was no statistically significant difference in the incidence of complications based on one-stage vs. two-stage conversion (p = 0.52). There were no differences in weight loss outcomes post-revisional surgery according to the indication for revision (p = 0.446) or weight loss following primary surgery (p = 0.12). CONCLUSION: Revisional bariatric surgery can be delivered safely in the private sector with good outcomes. One-stage conversions are feasible and do not detrimentally affect the morbidity of the procedure or the weight loss outcomes. More importantly, success following revisional surgery is independent of the indication for revision and weight loss outcomes following primary surgery.

Effect of COVID-19 pandemic on global Bariatric surgery PRActiceS - The COBRAS study.

INTRODUCTION: There is a paucity of data in scientific literature on the impact of Coronavirus Disease 2019 (COVID-19) pandemic on bariatric surgery. The aim of this study was to evaluate the impact of COVID-19 pandemic on Bariatric Surgery globally. METHODS: We conducted a global online survey of bariatric surgeons between 16/04/20 - 15/05/20. The survey was endorsed by five national bariatric surgery societies and circulated amongst their memberships. Authors also shared the link through their personal networks, email groups, and social media. RESULTS: 703 respondents from 77 countries completed the survey. Respondents reported a drop in elective bariatric activity from a median (IQR) of 130 (60-250) procedures in 2019 to a median of 0 (0-2) between16/03/2020 and 15/04/2020 during the pandemic. The corresponding figures for emergency activity were 5 (2-10) and 0 (0-1) respectively. 441 (63%) respondents did not perform any bariatric procedures during this time period. Surgeons reported outcomes of 61 elective bariatric surgical procedures during the pandemic with 13 (21%) needing ventilation and 2 (3.3%) deaths. Of the 13 emergency bariatric procedures reported, 5 (38%) needed ventilation and 4 (31%) died. 90 (13%) surgeons reported having had to perform a bariatric surgical or endoscopic procedure without adequate Personal Protective Equipment. CONCLUSIONS: COVID-19 pandemic led to a remarkable decline in global elective and emergency bariatric surgery activity at its beginning. Both elective and emergency procedures performed at this stage of the pandemic had considerable morbidity and mortality.

A qualitative study of seven simulation models for tendon repairs.

Seven models for tendon repair simulation (urinary catheter, liquorice, fishing lure, dental rolls, drinking straw, silicone sealant and the authors' modification of silicone sealant with Micropore™ tape) were assessed for their performance in a number of domains. The silicone sealant and surgical tape model scored highest overall and for each individual domain. This was significantly higher than all other models with the exception of the silicone sealant alone. The lowest scoring model was the drinking straw model.

Waiting lists for symptomatic joint arthritis are not benign: prioritizing patients for surgery in the setting of COVID-19.

AIM: Restarting elective services presents a challenge to restore and improve many of the planned patient care pathways which have been suspended during the response to the COVID-19 pandemic. A significant backlog of planned elective work has built up representing a considerable volume of patient need. We aimed to investigate the health status, quality of life, and the impact of delay for patients whose referrals and treatment for symptomatic joint arthritis had been delayed as a result of the response to COVID-19. METHODS: We interviewed 111 patients referred to our elective outpatient service and whose first appointments had been cancelled as a result of the response to the COVID-19 pandemic. RESULTS: Patients reported significant impacts on their health status and quality of life. Overall, 79 (71.2%) patients reported a further deterioration in their condition while waiting, with seven (6.3%) evaluating their health status as 'worse than death'. CONCLUSIONS: Waiting lists are clearly not benign and how to prioritize patients, their level of need, and access to assessment and treatment must be more sophisticated than simply relying on the length of time a patient has been waiting. This paper supports the contention that patients awaiting elective joint arthroplasty report significant impacts on their quality of life and health status. This should be given appropriate weight when patients are prioritized for surgery as part of the recovery of services following the COVID-19 pandemic. Elective surgery should not be seen as optional surgery-patients do not see it in this way.

Triaging of respiratory protective equipment on the assumed risk of SARS-CoV-2 aerosol exposure in patient-facing healthcare workers delivering secondary care: a rapid review.

OBJECTIVES: In patient-facing healthcare workers delivering secondary care, what is the evidence behind UK Government personal protective equipment (PPE) guidance on surgical masks versus respirators for SARS-CoV-2 protection? DESIGN: Two independent reviewers performed a rapid review. Appraisal was performed using Critical Appraisal Skills Programme checklists and Grading of Recommendations, Assessment, Development and Evaluations methodology. Results were synthesised by comparison of findings and appraisals. DATA SOURCES: MEDLINE, Google Scholar, UK Government COVID-19 website and grey literature. ELIGIBILITY CRITERIA: Studies published on any date containing primary data comparing surgical facemasks and respirators specific to SARS-CoV-2, and studies underpinning UK Government PPE guidance, were included. RESULTS: Of 30 identified, only 3 laboratory studies of 14 different respirators and 12 surgical facemasks were found. In all three, respirators were significantly more effective than facemasks when comparing protection factors, reduction factors, filter penetrations, total inspiratory leakages at differing particle sizes, mean inspiratory flows and breathing rates. Tests included live viruses and inert particles on dummies and humans. In the six clinical studies (6502 participants) included the only statistically significant result found continuous use of respirators more effective in clinical respiratory illness compared with targeted use or surgical facemasks. There was no consistent definition of 'exposure' to determine the efficacy of respiratory protective equipment (RPE). It is difficult to define 'safe'. CONCLUSIONS: There is a paucity of evidence on the comparison of facemasks and respirators specific to SARS-CoV-2, and poor-quality evidence in other contexts. The use of surrogates results in extrapolation of non-SARS-CoV-2 specific data to guide UK Government PPE guidance. The appropriateness of this is unknown given the uncertainty over the transmission of SARS-CoV-2.This means that the evidence base for UK Government PPE guidelines is not based on SARS-CoV-2 and requires generalisation from low-quality evidence of other pathogens/particles. There is a paucity of high-quality evidence regarding the efficacy of RPE specific to SARS-CoV-2. UK Government PPE guidelines are underpinned by the assumption of droplet transmission of SARS-CoV-2.These factors suggest that the triaging of filtering face piece class 3 respirators might increase the risk of COVID-19 faced by some.

Joystick reduction and percutaneous Kirschner wire stabilisation for dislocation of the pisiform.

We report the case of a sportsman who fell injuring his left non-dominant wrist. He suffered an unusual injury, a fracture dislocation of the pisotriquetral joint which left him with a painful restriction of wrist movement. We describe his presentation and treatment with a novel 'joystick' technique following failed manipulation.