Knowledge and Perception of Bariatric Surgery Among Primary Care Physicians: a Survey of Family Doctors in Ontario.

PURPOSE: The primary objective of this study was to identify Ontario family physicians' knowledge and perceptions of bariatric surgery. METHODS: The study population included all physicians practicing family medicine in Ontario who were listed in the Canadian Medical Directory. A self-administered questionnaire consisting of 28 questions was developed and validated using a focus group of seven primary care physicians. The questionnaire was distributed to 1328 physicians. RESULTS: One hundred sixty-five surveys were completed. 8.8 % of physicians did not have any bariatric surgical patients, and 71.3 % had no more than five in their practice. 70.2 % referred no more than 5 % of their morbidly obese patients for surgery. Only 32.1 % had the appropriate equipment and resources to manage obese patients. 92.5 % of physicians would like to receive more education about bariatric surgery. Physicians with no history of referral (n = 21) were earlier into their practices and had less morbidly obese patients than physicians with previous referrals (n = 141). They were also less likely to discuss bariatric surgery with their patients (30 vs. 79.3 %; p < 0.001) and less likely to feel comfortable explaining procedure options (5.6 vs. 33.9 %; p = 0.013) and providing postoperative care (26.7 vs. 64.2 %; p = 0.005). 55.6 % would refer a family member for surgery, compared to 85.4 % of physicians with previous referrals; p = 0.002. CONCLUSION: There appears to be a knowledge gap in understanding the role of bariatric surgery in the treatment of obesity. There is an opportunity to improve education and available resources for primary care physicians surrounding patient selection and follow-up care. This may improve access to treatment.

Understanding Quality Issues in Your Surgical Department: Comparing the ACS NSQIP With Traditional Morbidity and Mortality Conferences in a Canadian Academic Hospital.

INTRODUCTION: Review of surgical complications in traditional morbidity and mortality (M&M) rounds remains an important mechanism to identify and discuss quality-of-care issues. This process relies on case selection by providers; therefore, complications identified for review may differ from those captured in comprehensive quality programs such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Additionally, although the ACS NSQIP captures robust data on complications in surgical wards, without strategies to disseminate this information to staff and improve practice, minimal change may result. The objective of this study was to compare complications identified by the ACS NSQIP with those captured in M&M conferences at a large Canadian academic hospital. METHODS: Retrospective medical record reviews of all patients admitted to the general surgery unit from March 2012 to March 2013 were reviewed. Number and types of complications were recorded for cases that were both submitted and reviewed in M&M rounds and those cases that were submitted but not reviewed. These complications were compared with those extracted from our local ACS NSQIP database. RESULTS: A total of 1348 general surgical procedures were performed. The ACS NSQIP captured complications in 143 patients compared with 58 patients identified for review in M&M rounds. Both the methods identified similar proportions of major and minor complications (ACS NSQIP 52% major, 48% minor; M&M 58% major, 42% minor). More postoperative deaths were entered into the ACS NSQIP (12) than in M&M conferences (8 reviewed and 2 submitted). The ACS NSQIP identified higher proportions of surgical site infections and readmissions. However, M&M conferences captured additional complications in patients who did not undergo surgery and identified potential quality issues in patients who did not ultimately experience an adverse outcome. CONCLUSIONS: M&M rounds and the ACS NSQIP provide important and potentially complementary data on surgical quality. Incorporating the ACS NSQIP outcomes data into traditional M&M conferences may help to optimize quality improvement efforts.

The TAg-RB murine retinoblastoma cell of origin has immunohistochemical features of differentiated Muller glia with progenitor properties.

PURPOSE: Human retinoblastoma arises from an undefined developing retinal cell after inactivation of RB1. This is emulated in a murine retinoblastoma model by inactivation of pRB by retinal-specific expression of simian virus 40 large T-antigen (TAg-RB). Some mutational events after RB1 loss in humans are recapitulated at the expression level in TAg-RB, supporting preclinical evidence that this model is useful for comparative studies between mouse and human. Here, the characteristics of the TAg-RB cell of origin are defined. METHODS: TAg-RB mice were killed at ages from embryonic day (E)18 to postnatal day (P)35. Tumors were analyzed by immunostaining, DNA copy number PCR, or real-time quantitative RT-PCR for TAg protein, retinal cell type markers, and retinoblastoma-relevant genes. RESULTS: TAg expression began at P8 in a row of inner nuclear layer cells that increased in number through P21 to P28, when clusters reminiscent of small tumors emerged from cells that escaped a wave of apoptosis. Early TAg-expressing cells coexpressed the developmental marker Chx10 and glial markers CRALBP, clusterin, and carbonic anhydrase II (Car2), but not TuJ1, an early neuronal marker. Emerging tumors retained expression of only Chx10 and carbonic anhydrase II. As with human retinoblastoma, TAg-RB tumors showed decreased Cdh11 DNA copy number and gain of Kif14 and Mycn. It was confirmed that TAg-RB tumors lose expression of tumor suppressor cadherin-11 and overexpress oncogenes Kif14, Dek, and E2f3. CONCLUSIONS: TAg-RB tumors displayed molecular similarity to human retinoblastoma and origin in a cell with features of differentiated Müller glia with progenitor properties.