Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial.

BACKGROUND: Whole brain radiotherapy (WBRT) and dexamethasone are widely used to treat brain metastases from non-small cell lung cancer (NSCLC), although there have been no randomised clinical trials showing that WBRT improves either quality of life or overall survival. Even after treatment with WBRT, the prognosis of this patient group is poor. We aimed to establish whether WBRT could be omitted without a significant effect on survival or quality of life. METHODS: The Quality of Life after Treatment for Brain Metastases (QUARTZ) study is a non-inferiority, phase 3 randomised trial done at 69 UK and three Australian centres. NSCLC patients with brain metastases unsuitable for surgical resection or stereotactic radiotherapy were randomly assigned (1:1) to optimal supportive care (OSC) including dexamethasone plus WBRT (20 Gy in five daily fractions) or OSC alone (including dexamethasone). The dose of dexamethasone was determined by the patients' symptoms and titrated downwards if symptoms improved. Allocation to treatment group was done by a phone call from the hospital to the Medical Research Council Clinical Trials Unit at University College London using a minimisation programme with a random element and stratification by centre, Karnofsky Performance Status (KPS), gender, status of brain metastases, and the status of primary lung cancer. The primary outcome measure was quality-adjusted life-years (QALYs). QALYs were generated from overall survival and patients' weekly completion of the EQ-5D questionnaire. Treatment with OSC alone was considered non-inferior if it was no more than 7 QALY days worse than treatment with WBRT plus OSC, which required 534 patients (80% power, 5% [one-sided] significance level). Analysis was done by intention to treat for all randomly assigned patients. The trial is registered with ISRCTN, number ISRCTN3826061. FINDINGS: Between March 2, 2007, and Aug 29, 2014, 538 patients were recruited from 69 UK and three Australian centres, and were randomly assigned to receive either OSC plus WBRT (269) or OSC alone (269). Baseline characteristics were balanced between groups, and the median age of participants was 66 years (range 38-85). Significantly more episodes of drowsiness, hair loss, nausea, and dry or itchy scalp were reported while patients were receiving WBRT, although there was no evidence of a difference in the rate of serious adverse events between the two groups. There was no evidence of a difference in overall survival (hazard ratio 1·06, 95% CI 0·90-1·26), overall quality of life, or dexamethasone use between the two groups. The difference between the mean QALYs was 4·7 days (46·4 QALY days for the OSC plus WBRT group vs 41·7 QALY days for the OSC group), with two-sided 90% CI of -12·7 to 3·3. INTERPRETATION: Although the primary outcome measure result includes the prespecified non-inferiority margin, the combination of the small difference in QALYs and the absence of a difference in survival and quality of life between the two groups suggests that WBRT provides little additional clinically significant benefit for this patient group. FUNDING: Cancer Research UK, Medical Research Council Clinical Trials Unit at University College London, and the National Health and Medical Research Council in Australia.

Managing, making sense of and finding meaning in advanced illness: a qualitative exploration of the coping and wellbeing experiences of patients with lung cancer.

Coping plays an essential role in maintaining the wellbeing of patients with cancer. A number of different coping responses and strategies have been identified in the literature. The value and relevance of meaning based coping theory has also been emphasised, including Antonovosky's Sense of Coherence (SoC) theory. Ten patients with advanced lung cancer were interviewed up to three times. A total of twenty in depth interviews were carried out, fully transcribed and data were analysed following a methodology of Interpretative Phenomenological Analysis. Three broad domains were identified to categorise the core life concerns of participants; making sense of and managing one's illness; maintaining daily life and relationships and confronting the future. Within these domains multiple coping themes are identified, which to varying degrees help to maintain patient wellbeing and quality of life. This article considers the relevance of SoC theory for understanding the coping experiences of patients with advanced cancer, and identifies resources and factors likely to support patient coping, with implications for health and social care services.

Translating the Interplay of Cognition and Physical Performance in COPD and Interstitial Lung Disease: Meeting Report and Literature Review.

TOPIC IMPORTANCE: Cognitive and physical limitations are common in individuals with chronic lung diseases, but their interactions with physical function and activities of daily living are not well characterized. Understanding these interactions and potential contributors may provide insights on disability and enable more tailored rehabilitation strategies. REVIEW FINDINGS: This review summarizes a 2-day meeting of patient partners, clinicians, researchers, and lung associations to discuss the interplay between cognitive and physical function in people with chronic lung diseases. This report covers four areas: (1) cognitive-physical limitations in patients with chronic lung diseases; (2) cognitive assessments; (3) strategies to optimize cognition and motor control; and (4) future research directions. Cognitive and physical impairments have multiple effects on quality of life and daily function. Meeting participants acknowledged the need for a standardized cognitive assessment to complement physical assessments in patients with chronic lung diseases. Dyspnea, fatigue, and age were recognized as important contributors to cognition that can affect motor control and daily physical function. Pulmonary rehabilitation was highlighted as a multidisciplinary strategy that may improve respiratory and limb motor control through neuroplasticity and has the potential to improve physical function and quality of life. SUMMARY: There was consensus that cognitive function and the cognitive interference of dyspnea in people with chronic lung diseases contribute to motor control impairments that can negatively affect daily function, which may be improved with pulmonary rehabilitation. The meeting generated several key research questions related to cognitive-physical interactions in individuals with chronic lung diseases.

Using appendiceal perforation rates to measure impact of a disaster on healthcare system effectiveness.

OBJECTIVES: To understand baseline inequities in appendiceal perforation rates and the impact of hurricane destruction on the healthcare system with respect to perforation rates and racial disparities. METHODS: We used claims data extracted from Medicaid Analytic Extract files to identify appendicitis diagnoses in children and adolescents based on International Classification of Diseases-9 codes and appendectomy procedures based on Current Procedural Terminology codes in the hurricane-affected states of Mississippi and Louisiana. County-level summary data obtained from 2005 Area Resource Files were used to determine high and low hurricane-affected areas. We estimated logistic regression models, mutually adjusting for race, sex, and age, to examine disparities and mixed logistic regression models to determine whether county-level effects contributed to perforation rates. RESULTS: There were nine counties in the high-impact area and 133 counties in the low-impact area. Living in the high- or low-impact area was not associated with a statistically different rate of perforation before or after Hurricane Katrina; however, living in the high-impact area was associated with a change from a lower risk (odds ratio [OR] 0.62) of perforation prehurricane to a higher risk (OR 1.14) posthurricane compared with those living in the low-impact areas. African Americans had statistically higher perforation rates than whites in the high-impact areas both before (OR 1.46) and after (OR 1.71) Hurricane Katrina. CONCLUSIONS: Health professionals and hospital systems were able to maintain effective levels of care before and after Hurricane Katrina; however, perforation rates in African Americans suggest ongoing racial disparities during disasters.

Ethics in stuttering treatment in the schools: issues and intersections.

When the challenges of providing speech-language pathology services in school settings intersect with the complexities of meeting the unique needs of students who stutter, clinicians may encounter a variety of ethical issues. This article explores some of the ethical challenges of treating stuttering in school settings by discussing three clinical scenarios. Seedhouse's Ethics Grid is provided as a scaffold to support the critical analysis of school-based stuttering treatment issues. Factors examined include creating and respecting autonomy, serving student needs, doing good and minimizing risks, and telling the truth and keeping promises. In addition, clinical outcomes are considered in terms of their impact on students and family members, clinicians, students with communication disorders other than stuttering, and school personnel. Finally, some of the practical concerns when treating stuttering in school settings are discussed, including the law, codes of practice, wishes of others, as well as the effectiveness and efficiency of actions.

Maladaptive Coping as a Mediator of Family Stress.

Family members of women substance users may be at risk for stress-related problems. Family coping responses may affect outcomes for both families and women in treatment. Eighty-two women in treatment for substance use disorders (56 with comorbid psychiatric conditions) and 82 family members were interviewed. Stressors related to women's disorders were significantly related to increased family member burden. Women's behavioral problems predicted greater family member Worry, Displeasure, and Impact. Extent of women's drug or alcohol use predicted greater family member Stigma and Impact. Family member maladaptive coping partially mediated relationships between family member stressors and family member Displeasure and Impact. Family member maladaptive coping also functioned as a moderator between the stressors and Impact.

Secrets of the Hospital Underbelly: Patterns of Abundance of Antimicrobial Resistance Genes in Hospital Wastewater Vary by Specific Antimicrobial and Bacterial Family.

Background: Hospital wastewater is a major source of antimicrobial resistance (AMR) outflow into the environment. This study uses metagenomics to study how hospital clinical activity impacts antimicrobial resistance genes (ARGs) abundances in hospital wastewater. Methods: Sewage was collected over a 24-h period from multiple wastewater collection points (CPs) representing different specialties within a tertiary hospital site and simultaneously from community sewage works. High throughput shotgun sequencing was performed using Illumina HiSeq4000. ARG abundances were correlated to hospital antimicrobial usage (AMU), data on clinical activity and resistance prevalence in clinical isolates. Results: Microbiota and ARG composition varied between CPs and overall ARG abundance was higher in hospital wastewater than in community influent. ARG and microbiota compositions were correlated (Procrustes analysis, p=0.014). Total antimicrobial usage was not associated with higher ARG abundance in wastewater. However, there was a small positive association between resistance genes and antimicrobial usage matched to ARG phenotype (IRR 1.11, CI 1.06-1.16, p<0.001). Furthermore, analyzing carbapenem and vancomycin resistance separately indicated that counts of ARGs to these antimicrobials were positively associated with their increased usage [carbapenem rate ratio (RR) 1.91, 95% CI 1.01-3.72, p=0.07, and vancomycin RR 10.25, CI 2.32-49.10, p<0.01]. Overall, ARG abundance within hospital wastewater did not reflect resistance patterns in clinical isolates from concurrent hospital inpatients. However, for clinical isolates of the family Enterococcaceae and Staphylococcaceae, there was a positive relationship with wastewater ARG abundance [odds ratio (OR) 1.62, CI 1.33-2.00, p<0.001, and OR 1.65, CI 1.21-2.30, p=0.006 respectively]. Conclusion: We found that the relationship between hospital wastewater ARGs and antimicrobial usage or clinical isolate resistance varies by specific antimicrobial and bacterial family studied. One explanation, we consider is that relationships observed from multiple departments within a single hospital site will be detectable only for ARGs against parenteral antimicrobials uniquely used in the hospital setting. Our work highlights that using metagenomics to identify the full range of ARGs in hospital wastewater is a useful surveillance tool to monitor hospital ARG carriage and outflow and guide environmental policy on AMR.

'All hands-on deck', working together to develop UK standards for public involvement in research.

BACKGROUND: Public involvement in research is an established part of the research process in the UK, however there remain questions about what good public involvement in research looks and feels like. Until now public involvement practitioners, researchers and members of the public have looked for answers in examples shared across networks, published case studies, guidance and research articles. Pulling these strands together, the UK Standards for Public Involvement provides six statements (standards) about public involvement in research. They were produced by a partnership of organisations from Scotland, Northern Ireland, Wales and England with contributions from involvement practitioners, public partners, researchers and research funders. MAIN BODY: Each standard has reflective questions, which are designed to encourage standard users to use approaches and behaviours that improve involvement, over time. The standards are designed to be used as a practical tool, and reflect the agreed hallmarks of good public involvement in research for example, flexibility in approaches used, shared learning, and mutual respect.The standards development process is described from the initial idea and scoping, via the appraisal of existing standard sets and integration of values and principles in public involvement in research. The collaborative writing process of and consultation on the draft standard set is described, together with what changed as a result of feedback. The initiation of a year-long testing programme with forty participating research organisations, the experiential feedback and the resulting changes to the standards is summarised. CONCLUSION: This commentary paper describes, in some detail, a process to develop a set of six standards for public involvement in research in the UK. Producing a complex, national public involvement initiative is not without its challenges, and in supplementary material partnership members reflect on and share their experiences of standards development. The next phase of integration and implementation is explored with concluding comments from those that tested and helped improve the standards.

Disparities in influenza treatment among disabled Medicaid patients in Georgia.

OBJECTIVES: We explored possible disparities in seasonal influenza treatment in Georgia's disabled Medicaid population. We sought to determine whether racial/ethnic, geographic, or gender disparities existed in antiviral drugs usage in the treatment of influenza. METHODS: Medicaid claims were analyzed from 69 556 clients with disabilities enrolled in a Georgia Medicaid disease management program. RESULTS: There were 519 patients who met inclusion criteria (i.e., adults aged 18-64 years with an influenza diagnosis on a 2006 or 2007 Medicaid claim). Roughly one third (36.2%) of patients were classified as African American, 44.5% as White, and 19.3% as "other." Most patients had 2 or more comorbid chronic diseases. Antivirals were used in only 14.5% of patients diagnosed with influenza. Treatment rates were nearly 3 times higher for White patients (19.5%) than for African American patients (6.9%). CONCLUSIONS: Our analysis suggests limited use of antiviral treatment of influenza overall, as well as significant racial disparities in treatment. Additional studies are needed to further explore this finding and its implications for care of racial/ethnic minority populations during seasonal influenza and for effective pandemic influenza planning for racial/ethnic minority populations.

Barriers to accessing cancer services for adults with physical disabilities in England and Wales: an interview-based study.

OBJECTIVES: The aim of this study was to explore the barriers to accessing cancer services faced by adults with pre-existing physical disabilities. DESIGN: Cross-sectional, exploratory qualitative study. Data were collected by semistructured interviews and analysed thematically. SETTING: Participants were recruited through statutory and third sector organisations in England and Wales between October 2017 and October 2018. PARTICIPANTS: 18 people with a diagnosis of cancer and a pre-existing physical disability. RESULTS: The findings illustrate that people with physical disabilities in England and Wales face a variety of barriers to accessing cancer services. The overall theme that emerged was that participants experienced a lack of attitudinal and institutional preparation both from healthcare professionals and healthcare facilities. This overall theme is illustrated through three subthemes: lack of acknowledgment of disability, unseeing disability and physical inaccessibility. CONCLUSIONS: As the population ages and increasing numbers of people live with cancer and disability, it is important to develop knowledge to respond to the needs of this population. The mere existence of services does not guarantee their usability. Services need to be relevant, flexible, and accessible and offered in a respectful manner. It is important that healthcare professionals work towards inclusive healthcare provision, enabling the utilisation of services by all. Necessary steps to be taken include better communication between the various professionals and across the different teams involved in patients' care, raising awareness of how physical disability can affect or interact with cancer-related treatment and creating more accessible physical environments.

Procedural memory and emotional attachment in Alzheimer disease: implications for meaningful and engaging activities.

With an increasing number of older adults being diagnosed with Alzheimer disease, the need to find meaningful and enjoyable activities in which they can successfully engage is important for providing good quality of life while preventing behavioral difficulties that often accompany this diagnosis. Dementia-related neuropsychological impairments hinder engagement in a variety of enjoyable activities. For many older adults with Alzheimer disease who have been involved in a religious tradition, well-rehearsed rituals and emotionally salient behaviors can be employed well into the later stages of this disease. An approach called procedural and emotional religious activity therapy, or PERAT, can provide enjoyable and meaningful activities that may reduce agitation and increase quality of life for patients as well as for caregivers. Knowledge about the neuropsychology of procedural and emotional memory is needed to understand how PERAT works.

Cognitive remediation therapies for older adults: implications for nursing practice and research.

Among older adults, 20%-56% report having cognitive problems, and such cognitive complaints frequently correspond to actual neuropsychological impairment. The loss of cognitive abilities can be frustrating and frightening and can have a negative impact on instrumental activities of daily living and quality of life. Cognitive remediation interventions have been shown to be successful in improving mental function in older adults in many situations and may increase the number of everyday activities they are able to carry out. Nurses, given their direct contact with older adult patients, are able to inquire about or observe cognitive loss, make appropriate referrals, and emphasize steps such as cognitive remediation and other interventions that promote successful cognitive aging.

Sponsorship transformation at Ascension Health.

Two Catholic health systems, the Daughters of Charity National Health System and the Sisters of St. Joseph Health System, came together to create St. Louis-based Ascension Health in 1999. A third organization, Carondelet Health System, then merged with Ascension Health in December 2002. Ascension Health is sponsored by four provinces of the Daughters of Charity, the Sisters of St. Joseph of Nazareth, and the Sisters of St. Joseph of Carondelet. Ascension Health operates according to a concept it calls "sponsorship of the whole," which has been defined as follows: "The sponsors of Ascension Health exercise canonical responsibility to ensure that the health ministry sustains and strengthens Catholic identity while expressing the charisms of the present and future sponsors. The sponsors act as stewards of Ascension Health's mission and resources, and commit, in partnership with others, to educate, influence, nurture, and develop the combined health ministry to further the healing ministry of Jesus." After several years of serving together on the Sponsors Council-and following much prayer, theological reflection, and in-depth discussion-the sponsors decided to accept the "Sponsorship of the Whole" document. The document challenges sponsors to open their hearts and arms to embrace all of Ascension Health's local health ministries. When Ascension Health was formed in November 1999, it was with the intention of adding laypeople to the Sponsors Council. In late 2005, the system created a work group to explore key areas pertinent to the appointment of lay members to the council. The Sponsors Council then engaged in a rigorous identification and selection process, after which, on July 1, 2006, it welcomed two lay members. Ascension Health will continue to develop its own preferred culture and identity. As the system's metamorphosis unfolds, personal conversion, a new way of relating to others, and changes in both attitudes and values will be necessary.

"Hitting the spot": Developing individuals with lived-experience of health and social care as facilitators to deliver a course to enhance public involvement in research - a Welsh perspective.

PLAIN ENGLISH SUMMARY: Public involvement in research has become an important and integral part of the research process in health and social care, from the early stages of research prioritisation and development to the later stages of research conduct and dissemination. Learning and development opportunities, including training, can assist the public and researchers in working together in the research process, and a training schedule exists in Wales for this purpose. One of the key components of this training schedule in Wales is the course Involving the Public in the Design and Conduct of Research: Building Research Partnerships. Building on the existing successes of this UK-wide course, first developed by Macmillan Cancer Support, a project was established between Health and Care Research Wales and Macmillan Cancer Support to develop three members of the Involving People Network into trained facilitators. Once trained, the aim was for the three facilitators to deliver the course in Wales. Macmillan Cancer Support and Health and Care Research Wales selected, through a competitive process, three members of the Involving People Network to use their lived experience of Involvement in research projects, as well as any lived experience of a physical or mental health condition or illness, to become facilitators of the course in the unique context of public involvement in research in Wales. Through this process many benefits were realised, including developing the course content and its delivery in Wales, as well as building the skills and confidence of the individuals themselves as facilitators. This has contributed to a continuing commitment to the sustainable delivery of the Involving the Public in the Design and Conduct of Research: Building Research Partnerships course in Wales and a combined approach to addressing any challenges and obstacles which presented. ABSTRACT: Health and Care Research Wales has a strategic aim to Ensure public involvement and engagement is central to what we do and visible in all elements of it. As part of the ongoing development of the Health and Care Research Wales Training Programme a project was initiated to develop members of the public as facilitators to deliver a public involvement in research course. The project was undertaken in collaboration with Macmillan Cancer Support and was advertised via the Involving People Network in Wales. Three trainee facilitators were recruited, from 14 people that applied, to deliver a public involvement in research training course, the Building Research Partnerships course, as it was known then, originally developed for and by Macmillan Cancer Support. As members of the Involving People Network, the trainees were given training, mentorship, financial and administrative support to develop their role as facilitators over a two year period. This has been reciprocated with incredible commitment, ongoing course delivery in Wales, excellent course evaluations, course review and involvement in future planning. Through this project several benefits were realised, including developing the course content and its delivery and building the skills and confidence of the individual facilitators themselves. Additionally, and importantly, the project team found that patients and members of the public who are given appropriate training and support can greatly enhance a research training programme and act as highly effective ambassadors to further the cause of public involvement in research.

"I didn't really understand it, I just thought it'd help": exploring the motivations, understandings and experiences of patients with advanced lung cancer participating in a non-placebo clinical IMP trial.

BACKGROUND: Few studies have explored in depth the experiences of patients with advanced cancer who are participating in clinical investigational medicinal product trials. However, integrated qualitative studies in such trials are needed to enable a broader evaluation of patient experiences in the trial, with important ethical and practical implications for the design and conduct of similar trials and treatment regimes in the future. METHODS: Ten participants were recruited from the control and intervention arms of FRAGMATIC: a non-placebo trial for patients with advanced lung cancer. Participants were interviewed at up to three time points during their time in the trial. Interviews were analysed using Interpretive Phenomenological Analysis. RESULTS: Patients were motivated to join the trial out of hope of medical benefit and altruism. Understanding of randomisation was mixed and in some cases poor, as was appreciation of trial purpose and equipoise. The trial was acceptable to and evaluated positively by most participants; participants receiving the intervention focused on the potential treatment benefits they hoped they would receive, whilst participants in the control arm found alternative reasons, such as altruism, personal fulfilment and positive attention, to commit to and perceive benefits from the trial. However, whilst experiences were generally very positive, poor understanding, limited engagement with trial information and focus on treatment benefits amongst some participants give cause for concern. CONCLUSIONS: By exploring longitudinally the psychological, emotional and cognitive domains of trial participation, we consider potential harms and benefits of participation in non-placebo trials amongst patients with advanced lung cancer and identify several implications for future research with and care for patients with advanced cancer. TRIAL REGISTRATION: ISRCTN80812769 . Registered on 8 July 2005.

Randomized Phase III Trial of Standard Therapy Plus Low Molecular Weight Heparin in Patients With Lung Cancer: FRAGMATIC Trial.

PURPOSE: Venous thromboembolism (VTE) is common in cancer patients. Evidence has suggested that low molecular weight heparin (LMWH) might improve survival in patients with cancer by preventing both VTE and the progression of metastases. No trial in a single cancer type has been powered to demonstrate a clinically significant survival difference. The aim of this trial was to investigate this question in patients with lung cancer. PATIENTS AND METHODS: We conducted a multicenter, open-label, randomized trial to evaluate the addition of a primary prophylactic dose of LMWH for 24 weeks to standard treatment in patients with newly diagnosed lung cancer of any stage and histology. The primary outcome was 1-year survival. Secondary outcomes included metastasis-free survival, VTE-free survival, toxicity, and quality of life. RESULTS: For this trial, 2,202 patients were randomly assigned to the two treatment arms over 4 years. The trial did not reach its intended number of events for the primary analysis (2,047 deaths), and data were analyzed after 2,013 deaths after discussion with the independent data monitoring committee. There was no evidence of a difference in overall or metastasis-free survival between the two arms (hazard ratio [HR], 1.01; 95% CI, 0.93 to 1.10; P = .814; and HR, 0.99; 95% CI, 0.91 to 1.08; P = .864, respectively). There was a reduction in the risk of VTE from 9.7% to 5.5% (HR, 0.57; 95% CI, 0.42 to 0.79; P = .001) in the LMWH arm and no difference in major bleeding events but evidence of an increase in the composite of major and clinically relevant nonmajor bleeding in the LMWH arm. CONCLUSION: LMWH did not improve overall survival in the patients with lung cancer in this trial. A significant reduction in VTE is associated with an increase in clinically relevant nonmajor bleeding. Strategies to target those at greatest risk of VTE are warranted.

Lumbo-sacral radiculopathy referral decision-making and primary care management. A case report.

Low back pain guideline recommendations can inform a decision in primary care to refer for surgical assessment. The purpose of this report is to present a patient with clinical signs and symptoms of lumbo-sacral radiculopathy who experienced pain of high intensity, severe paresis and depression. The guideline informed decision-making process resulted in a decision not to refer. This case report aims to increase awareness of referral guidelines and to demonstrate radicular pain and weakness, disability and depression outcomes subsequent to primary care management.

Supersized America: help your patients regain control of their weight.

With 64-ounce sodas and "supersized" fast food on nearly every street corner, America has become the land of the obese. Despite disheartening statistics regarding the success of weight-loss plans, patients are more likely to take steps to lose weight if encouraged to do so by their primary care physician.

Severe obesity: the neglected epidemic.

Severe obesity (SO) is increasing faster than obesity in adults and in children. Because it is associated with numerous comorbidities, SO accounts for more health care expenditures than any other medical condition. Furthermore, it is associated with poor pregnancy outcomes for mother, fetus, and infant and a high risk of offspring obesity carried into adulthood. Bariatric surgery is the treatment of choice for SO because nonoperative methods fail to provide medically significant durable weight loss and because it is both preventive and therapeutic. The number of operations has sharply increased globally, yet only a small fraction of eligible patients are referred for surgical treatment demonstrating the need for improved access, especially for those disproportionately affected by SO. The risks of surgery mandate careful postoperative long-term multidisciplinary follow-up care. Education is critical for truly informed consent and must continue postoperatively, especially for women with reproductive potential. Even so, surgical treatment of SO remains cost-effective compared to conventional nonoperative treatment, which also requires long-term care. Just as obesity affects all medical disciplines (from allergology and immunology to oncology, urology and women's health), so does postoperative management of bariatric surgery patients. We offer wide-ranging recommendations for policymakers and others to consider in addressing SO.