Patient and healthcare practitioner evaluation of patient-reported outcomes in bariatric surgery - a modified Delphi study.

BACKGROUND: Patient-reported outcomes are an important emerging metric increasingly utilised in clinical, research and registry settings. These outcomes, while vital, are underutilised and require refinement for the specific patient population of those undergoing bariatric surgery. This study aimed to investigate and compare how pre-surgical patients, post-surgical patients, and healthcare practitioners evaluate patient-reported outcomes of bariatric surgery to identify outcomes that are considered most important. METHODS: A modified Delphi survey was distributed to patients pre- and post-surgery, and to a variety of healthcare practitioners involved in bariatric care. Across two rounds, participants were asked to rate a variety of physical and psychosocial outcomes of bariatric surgery from 0 (Not Important) to 10 (Extremely Important). Outcomes rated 8-10 by at least 70% of participants were considered highly important (prioritised). The highest-rated outcomes were compared between the three groups as well as between medical and allied health practitioner subgroups. RESULTS: 20 pre-surgical patients, 95 post-surgical patients, and 28 healthcare practitioners completed both rounds of the questionnaire. There were 58 outcomes prioritised, with 21 outcomes (out of 90, 23.3%) prioritised by all three groups, 13 (14.4%) by two groups, and 24 (26.7%) prioritised by a single group or subgroup. Unanimously prioritised outcomes included 'Co-morbidities', 'General Physical Health', 'Overall Quality of Life' and 'Overall Mental Health'. Discordant outcomes included 'Fear of Weight Regain', 'Suicidal Thoughts', 'Addictive Behaviours', and 'Experience of Stigma or Discrimination'. CONCLUSION: While there was considerable agreement between stakeholder groups on many outcomes, there remain several outcomes with discordant importance valuations that must be considered. In particular, healthcare practitioners prioritised 20 outcomes that were not prioritised by patients, emphasising the range of priorities across stakeholder groups. Future work will consider these priorities to ensure resulting measures encompass all important outcomes and are beneficial and valid for end users.

Association between frailty, long-term mortality and functional outcomes for older adults undergoing emergency laparotomy.

BACKGROUND: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored. METHODS: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of ≥5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. RESULTS: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. CONCLUSION: Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Topical Versus Oral Metronidazole After Excisional Hemorrhoidectomy: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Both topical and oral metronidazole have been shown to reduce pain after excisional hemorrhoidectomy. Although recent meta-analyses have demonstrated efficacy against placebo, there has been no comparison between the 2 routes. OBJECTIVE: This study aims to investigate whether topical or oral metronidazole provides the most analgesic properties after excisional hemorrhoidectomy. DESIGN: A prospective, double-blind, randomized controlled trial was performed. SETTING: This trial was conducted at 2 hospitals in New Zealand between March 2019 and February 2020. PATIENTS: Adults undergoing elective excisional hemorrhoidectomy for grade III/IV hemorrhoids were randomized. INTERVENTIONS: Participants were randomized to receive either topical metronidazole ointment and an oral placebo versus oral metronidazole with a placebo ointment for 7 days. MAIN OUTCOME MEASURES: The primary outcome was daily pain scores for 7 days, estimated using a generalized linear mixed model fitted with time and treatment arm and tested for interaction with time and treatment arm. Secondary outcomes included additional analgesia, return to normal activity, recovery scores, and adverse effects. RESULTS: A total of 120 participants were included, with 60 in each group. A unimodal peak of pain was recorded with the maximum at days 3 and 4, but there was no significant difference in resting pain scores, with a mean difference at day 3 of 0.47 (-0.48, 1.42). There were no significant differences for secondary outcomes. Fourteen (11.7%) participants were readmitted, without significant difference between groups. Fifty-nine percent of participants preferred topical analgesic compared with 31% who preferred oral and 9.7% who had no preference. LIMITATIONS: This was a pragmatic study in which we could not have stopped participants seeking other analgesics and with less than perfect complete compliance. CONCLUSION: Postoperative oral and topical metronidazole provide similar analgesia after excisional hemorrhoidectomy. The route should depend on patient preference, with topical administration potentially benefiting from improved antimicrobial stewardship and having less effect on the gut microbiome. See Video Abstract at http:/links.lww.com/DCR/B853 .METRONIDAZOL TÓPICO VERSUS ORAL DESPUÉS DE UNA HEMORROIDECTOMÍA POR ESCISIÓN: UN ENSAYO CONTROLADO ALEATORIO DOBLE CIEGO. ANTECEDENTES: Se ha demostrado que tanto el metronidazol tópico como el oral reducen el dolor después de una hemorroidectomía por escisión. Aunque los metaanálisis más recientes han demostrado eficacia frente al placebo, no ha habido comparación entre las dos vías. OBJETIVO: Este estudio tiene como objetivo investigar si el metronidazol tópico u oral proporciona las propiedades más analgésicas después de una hemorroidectomía por escisión. DISEO: Se realizó un ensayo prospectivo, controlado, aleatorio, a doble ciego. AJUSTE: Este ensayo fue realizado en dos hospitales de Nueva Zelanda entre marzo de 2019 y febrero de 2020. PACIENTES: Se asignaron al azar pacientes adultos sometidos a hemorroidectomía por escisión electiva por hemorroides de grado III / IV. INTERVENCIONES: Los participantes fueron asignados al azar para recibir un ungüento de metronidazol tópico y un placebo oral versus metronidazol oral con un ungüento de placebo durante siete días. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fueron las puntuaciones diarias de dolor durante siete días, estimadas mediante un modelo lineal mixto generalizado ajustado tanto con el tiempo y el brazo de tratamiento y probado para la interacción con el tiempo y el brazo de tratamiento. Los resultados secundarios incluyen analgesia adicional, retorno a la actividad normal, puntuaciones de recuperación y efectos adversos. RESULTADOS: Se incluyó un total de 120 participantes, 60 en cada grupo. Se registró un pico de dolor unimodal con el máximo en los días 3 y 4, pero no hubo diferencias significativas en las puntuaciones de dolor en reposo, con una diferencia media en el día 3 de 0,47 (-0,48, 1,42). No hubo diferencias significativas para los resultados secundarios. Catorce (11,7%) participantes fueron readmitidos, sin diferencias significativas entre los grupos. El cincuenta y nueve por ciento de los participantes prefirió el tópico, en comparación con el 31% por vía oral y el 9,7% sin preferencia. LIMITACIONES: Este fue un estudio pragmático en el que no pudimos haber impedido que los participantes buscaran otros analgésicos, con un cumplimiento completo menos que perfecto. CONCLUSINES: El metronidazol posoperatorio por vía oral o tópica proporciona una analgesia similar después de una hemorroidectomía por escisión. La vía debe depender de la preferencia del paciente, y la administración tópica se beneficia potencialmente por una mejor protección de los antimicrobianos y un menor efecto sobre el microbioma intestinal. Consulte Video Resumen en http://links.lww.com/DCR/B853 . (Traducción-Dr Osvaldo Gauto).

Epidemiology of haemorrhoids and publicly funded excisional haemorrhoidectomies in New Zealand (2007-2016): a population-based cross-sectional study.

AIM: Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand. METHOD: This is a population-based cross-sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non-Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location. RESULTS: A total of 46 095 recorded diagnoses of haemorrhoids were made, with a total of 18 739 haemorrhoidectomies in the 10-year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100 000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100 000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence. CONCLUSION: There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women.

Prospective Validation of the APPEND Clinical Prediction Rule for Appendicitis: A Cohort Study.

BACKGROUND: Right iliac fossa (RIF) pain is a common referral to general surgery as acute appendicitis is one of the most common underlying diagnoses. The clinical diagnosis of appendicitis continues to challenge clinicians. Clinical prediction rules (CPRs) are one method used to improve diagnostic accuracy and reduce negative appendicectomy rates. The APPEND score is a novel CPR that was developed at Middlemore Hospital. AIM: To prospectively evaluate the performance of the APPEND CPR within a pathway dedicated to the management of RIF pain. METHODS: A comparative cohort study of the clinical pathway incorporating the APPEND CPR pain was performed from January to July 2016. This was compared to the retrospective cohort used to develop the APPEND CPR. The primary end point was negative appendicectomy rate. RESULTS: The negative appendicectomy rate in the prospective cohort was 9.2% (95% CI: 5.3%, 13.2%) compared to 19.8% (CI 16.2, 23.4%) in the retrospective cohort that did not use the APPEND CPR. After adjusting for multiple variables, the odds ratio of a negative appendicectomy was 2.33 times higher (95% CI; 1.26, 4.3, P value 0.007) in the retrospective cohort compared to the prospective cohort. An APPEND score of ≥5 was 87 % specific for ruling in appendicitis (PPV 94%) and a score of ≥1 was 100% sensitive in ruling out appendicitis (NPV 100%). CONCLUSIONS: In a comparative cohort study of an RIF pain pathway incorporating the APPEND CPR, the rate of negative appendicectomy showed a significant reduction by more than 50%.

Topical analgesia following excisional haemorrhoidectomy: a systematic review and meta-analysis of randomised controlled trials.

PURPOSE: Post-operative pain following excisional haemorrhoidectomy poses a particular challenge for patient recovery, as well as a burden on hospital resources. There appears to be an increasing role for topical agents to improve this pain, but their efficacy and safety have not been fully assessed. This systematic review aims to assess all topical agents used for pain following excisional haemorrhoidectomy. METHODS: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors independently assessed MEDLINE, EMBASE, and CENTRAL databases to 27 June 2019. All randomised controlled trials (RCTs) in English that investigated topical agents following excisional haemorrhoidectomy were included. Meta-analysis was performed using Review Manager, version 5.3. RESULTS: A total of 3639 records were identified. A final 32 RCTs were included in the qualitative analysis. Meta-analysis was performed on 9 RCTs that investigated glyceryl trinitrate (GTN) (5 for diltiazem, 2 for metronidazole and 2 for sucralfate). There were mixed significant changes in pain for GTN compared with placebo. Diltiazem resulted in significant reduction of pain on post-operative days 1, 2, 3 and 7 (p < 0.00001). Metronidazole resulted in significant reduction of pain on days 1 (p = 0.009), 7 (p = 0.002) and 14 (p < 0.00001). Sucralfate resulted in signification reduction of pain on days 7 and 14 (both p < 0.00001). CONCLUSION: Topical diltiazem, metronidazole and sucralfate appear to significantly reduce pain at various timepoints following excisional haemorrhoidectomy. GTN had mixed evidence. Several single trials identified other promising topical analgesics.

The SIARI Score: A Novel Decision Support Tool Outperforms LRINEC Score in Necrotizing Fasciitis.

BACKGROUND: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system was developed to aid the diagnosis of necrotizing fasciitis and guide management [1]. AIM: To validate the LRINEC score and identify clinical predictors to develop a refined diagnostic scoring tool for the diagnosis of necrotizing fasciitis at Middlemore Hospital, New Zealand. METHODS: This was a retrospective case-control study of patients admitted to Middlemore Hospital with necrotizing fasciitis and severe cellulitis between January 2000 and December 2010. The LRINEC scores at admission were evaluated for performance in discriminating between cases of necrotizing fasciitis and severe cellulitis. Cases and controls were randomized into developmental and validation cohorts. Univariate and multivariate logistic regression analysis of demographic, clinical, and laboratory variables for the diagnosis of necrotizing fasciitis was performed. The identified independent predictors were used to develop a new diagnostic scoring tool. RESULTS: The area under the receiver operating characteristic curve (C-statistic) of a LRINEC score ≥6 for the diagnosis of necrotizing fasciitis was 0.679. The newly developed SIARI score [Site other than the lower limb, Immunosuppression, Age < 60 years, Renal impairment (creatinine > 141), and Inflammatory markers (CRP ≥ 150, WCC > 25] demonstrated superior diagnostic ability compared with the LRINEC score in both the developmental (C-statistic: 0.832 vs. 0.691, p < 0.001) and validation cohorts (C-statistic: 0.847 vs. 0.667, p < 0.001). CONCLUSION: The LRINEC score exhibited only modest discriminative performance in this cohort, while the SIARI score is a simplified tool that demonstrates superior diagnostic ability for detecting necrotizing fasciitis. Future external validation studies are required to confirm the trends observed in this study.

Medical electives: exploring the determinants of placement and access variables between 2010 and 2016 at the University of Auckland.

BACKGROUND: Medical electives undertaken during sixth year at medical school provide an opportunity for students to work in an overseas or New Zealand health facility to gain exposure to a health system outside their training facility. Previous work suggests that the elective experience can be profound, exposing global health inequities, or influencing future career decisions. This study assessed patterns within elective choice by students' socio demographic and programme entry characteristics. METHODS: A retrospective analysis of student elective records from 2010 to 2016 was undertaken using a Kaupapa Maori research framework, an approach which prioritises positive benefits for Maori (and Pacific) participants and communities. A descriptive analysis of routinely collected de-identified aggregate secondary data included demographic variables (gender, age group, ethnicity, secondary school decile, year and route of entry), and elective site. Route of entry (into medical school) is via general, MAPAS (Maori and Pacific Admissions Scheme) and RRS (Regional and Rural Scheme). Multivariable logistic regression analysis determined the odd ratios for predictors of going overseas for elective and electives taking place in a "High" (HIC) compared to "Low- and middle-income countries" (LMIC). RESULTS: Of the 1101 students who undertook an elective (2010-2016) the majority undertook their elective overseas; the majority spent their elective within a high-income country. Age (younger), route of entry (general) and high school decile (high) were associated with going overseas for an elective. Within the MAPAS cohort, Pacific students were more likely (than Maori) were to go overseas for their elective; Maori students were more likely to spend their elective in a HIC. CONCLUSION: The medical elective holds an important, pivotal opportunity for medical students to expand their clinical, professional and cultural competency. Our results suggest that targeted support may be necessary to ensure equitable access, particularly for MAPAS students the benefit of an overseas elective.

Clinical Prediction Rules for Appendicitis in Adults: Which Is Best?

BACKGROUND: Clinical prediction rules (CPRs) provide an objective method of assessment in the diagnosis of acute appendicitis. There are a number of available CPRs for the diagnosis of appendicitis, but it is unknown which performs best. AIM: The aim of this study was to identify what CPRs are available and how they perform when diagnosing appendicitis in adults. METHOD: A systematic review was performed in accordance with the PRISMA guidelines. Studies that derived or validated a CPR were included. Their performance was assessed on sensitivity, specificity and area under curve (AUC) values. RESULTS: Thirty-four articles were included in this review. Of these 12 derived a CPR and 22 validated these CPRs. A narrative analysis was performed as meta-analysis was precluded due to study heterogeneity and quality of included studies. The results from validation studies showed that the overall best performer in terms of sensitivity (92%), specificity (63%) and AUC values (0.84-0.97) was the AIR score but only a limited number of studies investigated at this score. Although the Alvarado and Modified Alvarado scores were the most commonly validated, results from these studies were variable. The Alvarado score outperformed the modified Alvarado score in terms of sensitivity, specificity and AUC values. CONCLUSION: There are 12 CPRs available for diagnosis of appendicitis in adults. The AIR score appeared to be the best performer and most pragmatic CPR.

Uncomplicated Acute Diverticulitis: Identifying Risk Factors for Severe Outcomes.

BACKGROUND: The management of uncomplicated (Modified Hinchey Classification Ia) acute diverticulitis (AD) has become increasingly conservative, with a focus on symptomatic relief and supportive management. Clear criteria for patient selection are required to implement this safely. This retrospective study aimed to identify risk factors for severe clinical course in patients with uncomplicated AD. MATERIALS AND METHODS: Patients admitted to General Surgery at two New Zealand tertiary centres over a period of 18 months were included. Univariate and multivariate analyses were carried out in order to identify factors associated with a more severe clinical course. This was defined by three endpoints: need for procedural intervention, admission >7 days and 30-day readmission; these were analysed separately and as a combined outcome. RESULTS: Uncomplicated AD was identified in 319 patients. Fifteen patients (5%) required procedural intervention; this was associated with SIRS (OR 3.92). Twenty-two (6.9%) patients were admitted for >7 days; this was associated with patient-reported pain score >8/10 (OR 5.67). Thirty-one patients (9.8%) required readmission within 30 days; this was associated with pain score >8/10 (OR 6.08) and first episode of AD (OR 2.47). Overall, 49 patients had a severe clinical course, and associated factors were regular steroid/immunomodulator use (OR 4.34), pain score >8/10 (OR 5.9) and higher temperature (OR 1.51) and CRP ≥200 (OR 4.1). CONCLUSION: SIRS, high pain score and CRP, first episode and regular steroid/immunomodulator use were identified as predictors of worse outcome in uncomplicated AD. These findings have the potential to inform prospective treatment decisions in this patient group.

Investigating major trauma in Maori youth at Te Whatu Ora Counties Manukau.

BACKGROUND: The Ninth Perioperative Mortality Review Committee (POMRC) report found the likelihood of death was over three times higher in Maori youth compared to non-Maori (age: 15-18 years) in the 30-days following major trauma. The aim of our study is to investigate variations in care provided to Maori youth presenting to Te Whatu Ora Counties Manukau (TWO-CM) with major trauma, to inform policies and improve care. METHODS: This was a retrospective, observational study of 15-18-year-olds admitted to Middlemore Hospital from January 2018 to December 2021 following major trauma (Injury Severity Score (ISS) >12 or with (ISS) <12 who died). Data were obtained from the New Zealand Trauma Registry (NZTR). Six key performance indicators were studied against hospital guidelines/international consensus: Deaths, Cause-of-death, trauma call, RedBlanket activations, time-to-computed tomography (CT), and time-to-operating theatre (OT). RESULTS: Of 77 patients, five deaths occurred, four non-Maori, and one Maori (P = 0.645). Five trauma calls were not activated (P = 0.642). There was no statistically significant difference for both median time to CT (P = 0.917) and time to CT for patients with GCS >13 (P = 0.778) between Maori and non-Maori. Five patients did not meet guidelines for time-to-OT (three non-Maori and two Maori) (P = 0.377). CONCLUSION: No statistically significant variations in care were present for Maori youth presenting with major trauma, these findings did not match the national trend.

Gentamicin-collagen implants to reduce surgical site infection: systematic review and meta-analysis of randomized trials.

OBJECTIVE: To determine whether gentamicin-impregnated collagen sponges (gentamicin-collagen implants) decrease the incidence of surgical site infection (SSI). BACKGROUND: SSIs cause substantial morbidity and increase the costs of healthcare. Antibiotic prophylaxis is a cornerstone of SSI reduction. Prophylactic local delivery of antibiotics with novel biodegradable drug carrier systems, such as the gentamicin-collagen implant, is a potential avenue for SSI reduction. Gentamicin-collagen implants have been previously assessed in multiple randomized controlled trials (RCTs) with conflicting results. Therefore, a systematic review and meta-analysis of all relevant RCTs was conducted to determine whether gentamicin-collagen implants reduce SSI. METHODS: Major medical databases and trial registers were searched for published and unpublished RCTs. The endpoint of interest was the incidence of SSI. A random effects model was used and pooled estimates were reported as odds ratios (ORs), with the corresponding 95% confidence interval (CI). A subset analysis by incision type was planned a priori. RESULTS: Fifteen RCTs encompassing a total of 6979 patients were included in the final analysis. The included studies were of moderate to high quality. Gentamicin-collagen implants significantly reduced SSI [OR = 0.51; 95% CI: 0.33-0.77; P = 0.001; number needed to treat (NNT) = 21; I = 75%]. These results were seen in subset analysis of clean (OR = 0.53; 95% CI: 0.33-0.87; P = 0.01; NNT = 30) and clean-contaminated surgery (OR = 0.43; 95% CI: 0.20-0.93; P = 0.03; NNT = 9) specifically. CONCLUSIONS: Gentamicin-collagen implants decrease the rate of SSI.

Effect of preoperative exercise on cardiorespiratory function and recovery after surgery: a systematic review.

BACKGROUND: This systematic review aims to investigate the extent to which preoperative conditioning (PREHAB) improves physiologic function and whether it correlates with improved recovery after major surgery. METHODS: An electronic database search identified randomized controlled trials (RCTs) investigating the safety and efficacy of PREHAB. The outcomes studied were changes in cardiorespiratory physiologic function, clinical outcomes (including length of hospital stay and rates of postoperative complications), and measures of changes in functional capacity (physical and psychological). RESULTS: Eight low- to medium-quality RCTs were included in the final analysis. The patients were elderly (mean age >60 years), and the exercise programs were significantly varied. Adherence to PREHAB was low. Only one study found that PREHAB led to significant improvement in physiologic function correlating with improved clinical outcomes. CONCLUSION: There are only limited data to suggest that PREHAB confers any measured physiologic improvement with subsequent clinical benefit. Further data are required to investigate the efficacy and safety of PREHAB in younger patients and to identify interventions that may help improve adherence to PREHAB.

General surgical interns contributing to the clerkship learning environment of medical students.

BACKGROUND: Junior doctors are increasingly promoted as clinical teachers but there is limited understanding of how they contribute to medical student clerkship learning. AIM: To describe contributions made by general surgical interns to the student clerkship learning environment. METHODS: The mixed-methods study involved two focus groups attended by volunteer interns and Year 4 students, and a student questionnaire collecting quantitative data. Focus group transcripts were evaluated using a qualitative analysis system. RESULTS: Six interns and five students attended focus groups in June and August 2011. Qualitative analysis found that intern contributions to student learning can be grouped under four distinct roles: physician, supervisor, teacher and person. Data from 85 questionnaires (response rate 57%) revealed that intern-student encounters occurred daily in the surgical wards and emergency department. Interns demonstrated bedside procedures, clerical/administrative tasks and interpretation of laboratory and radiological investigations. Appreciated for approachability, friendliness and ability to relate to students, interns also played a crucial role in integrating students into the surgical team. This significantly correlated to clerkship enjoyment. CONCLUSIONS: Surgical interns improve clerkship learning environments by demonstrating "personal" skills such as friendliness, approachability and relatedness. This has important implications for preparing interns as clinical preceptors.

Development of the national bariatric prioritization tool in Aotearoa New Zealand.

BACKGROUND: Bariatric surgery is a proven effective method of reducing obesity and reversing or preventing obesity-related comorbidities. The aim of this study is to describe the development of a tool to assist with the prioritization of patients with obesity for bariatric surgery. The tool would meet the criteria for being evidence-based, fair, implementable and transparent. METHODS: The development of the tool involved a validated step-by-step process based on the consensus of clinical judgement of the New Zealand Ministry of Health working party. The process involved elicitation of criteria, clinical ranking of vignettes and creation of weightings using the 1000Minds® tool. The concurrent validity was tested by comparing tool rankings of vignettes to clinical judgement rankings. RESULTS: Four major criteria (impact on life, likelihood of achieving maximum benefit with respect to control of diabetes, duration of benefit and surgical risk) are used to characterize the need and potential to benefit. The impact on life criterion has the largest weighting (up to 44.3%). There was good concurrent validity with a correlation coefficient r = 0.67. CONCLUSION: The tool as presented is evidence-based, transparent and internally valid. The next step is to assess the predictive validity of the tool using real patient data to evaluate the effectiveness of the tool and determine what modifications may be required.

The effectiveness of venous thromboembolism prophylaxis interventions in trauma patients: A systematic review and network meta-analysis.

BACKGROUND: Venous thromboembolism (VTE) is a major complication of trauma. Currently, there are few studies summarising the evidence for prophylaxis in trauma settings. This review provides evidence for the use of VTE prophylactic interventions in trauma patients to produce evidence-based guidelines. METHODS: A PRISMA-compliant review was conducted from Sep 2021 to June 2023, using Embase, Medline and Google Scholar. The inclusion criteria were: randomized-controlled trials (RCTs) in English published after 2000 of adult trauma patients comparing VTE prophylaxis interventions, with a sample size higher than 20. The network analysis was conducted using RStudio. The results of the pairwise comparisons were presented in the form of a league table. The quality of evidence and heterogeneity sensitivity were assessed. The primary outcome focused on venous thromboembolism (VTE), and examined deep vein thrombosis (DVT) and pulmonary embolism (PE) as separate entities. The secondary outcomes included assessments of bleeding and mortality. PROSPERO registration: CRD42021266393. RESULTS: Of the 7,948 search results, 23 studies with a total of 21,312 participants fulfilled screening criteria, which included orthopaedic, spine, solid organ, brain, spinal cord, and multi-region trauma. Of the eight papers comparing chemical prophylaxis medications in patients with hip or lower limb injuries, fondaparinux and enoxaparin were found to be significantly superior to placebo in respect of prevention of DVT, with no increased risk of bleeding. Regarding mechanical prophylaxis, meta-analysis of two studies of inferior vena cava filters failed to provide significant benefits to major trauma patients. CONCLUSION: Enoxaparin and fondaparinux are safe and effective options for VTE prevention in trauma patients, with fondaparinux being a cheaper and easier administration option between the two. Inconclusive results were found in mechanical prophylaxis, requiring more larger-scale RCTs.

Does the National Bariatric Prioritization Tool predict health outcomes?

BACKGROUND: The National Bariatric Prioritization Tool (NBPT), developed in Aotearoa New Zealand (AoNZ), has not been validated using real patient data. The aim was to determine the predictive validity of the NBPT on health outcomes. METHODS: An observational study was undertaken of consecutive patients undergoing elective bariatric surgery at Middlemore Hospital using the NBPT from December 2014 to December 2016. The primary outcome was the correlation between prioritization score and percentage total weight loss (%TWL) at 18 months follow-up, with secondary outcomes being correlation with change in HbA1c, lipids, resolution of OSA, resolution of hypertension, and reduction in arthritis medications. Equity of access was measured by the relationship to age group, gender and ethnicity. RESULTS: There were 294 patients included. There was no correlation between %TWL and prioritization score (correlation -0.09, P = 0.14). The benefit score correlated with %TWL (correlation 0.25, P < 0.0001). There were correlations between prioritization score and HbA1c reduction (correlation 0.28, P < 0.0001), resolution of OSA (correlation 0.20, P < 0.001) and resolution of hypertension (correlation 0.20, P < 0.001). There was a significant difference in prioritization score based on ethnicity, with Maori and Pasifika scoring higher than New Zealand European (P = 0.0023). CONCLUSIONS: While the NBPT does not correlate with %TWL, it may have predictive validity through correlations with improvement of comorbidities such as diabetes, OSA and hypertension. Given higher rates of obesity and comorbidities in Maori and Pasifika, the higher scores may suggest the tool may be used to achieve equity of access. Further modifications should be considered to optimize outcomes.

Bariatric Surgery Efficiency, Safety and Health Outcomes in Government Versus Privately Funded Hospitals.

PURPOSE: This study aims to determine if the hospital efficiency, safety and health outcomes are equal in patients who receive bariatric surgery in government-funded hospitals (GFH) versus privately funded hospitals (PFH). MATERIALS AND METHODS: This is a retrospective observational study of prospectively maintained data from the Australia and New Zealand Bariatric Surgery Registry of 14,862 procedures (2134 GFH and 12,728 PFH) from 33 hospitals (8 GFH and 25 PFH) performed in Victoria, Australia, between January 1st, 2015, and December 31st, 2020. Outcome measures included the difference in efficacy (weight loss, diabetes remission), safety (defined adverse event and complications) and efficiency (hospital length of stay) between the two health systems. RESULTS: GFH treated a higher risk patient group who were older by a mean (SD) 2.4 years (0.27), P < 0.001; had a mean 9.0 kg (0.6) greater weight at time of surgery, P < 0.001; and a higher prevalence of diabetes at day of surgery OR = 2.57 (CI95%2.29-2.89), P < 0.001. Despite these baseline differences, both GFH and PFH yielded near identical remission of diabetes which was stable up to 4 years post-operatively (57%). There was no statistically significant difference in defined adverse events between the GFH and PFH (OR = 1.24 (CI95% 0.93-1.67), P = 0.14). Both healthcare settings demonstrated that similar covariates affect length of stay (LOS) (diabetes, conversion bariatric procedures and defined adverse event); however, these covariates had a greater effect on LOS in GFH compared to PFH. CONCLUSIONS: Bariatric surgery performed in GFH and PFH yields comparable health outcomes (metabolic and weight loss) and safety. There was a small but statistically significant increased LOS following bariatric surgery in GFH.

Consensus-defined sarcopenia predicts adverse outcomes after elective abdominal surgery: meta-analysis.

BACKGROUND: Sarcopenia refers to the progressive age- or pathology-associated loss of skeletal muscle. When measured radiologically as reduced muscle mass, sarcopenia has been shown to independently predict morbidity and mortality after elective abdominal surgery. However, the European Working Group on Sarcopenia in Older People (EWGSOP) recently updated their sarcopenia definition, emphasizing both low muscle 'strength' and 'mass'. The aim of this systematic review and meta-analysis was to determine the prognostic impact of this updated consensus definition of sarcopenia after elective abdominal surgery. METHODS: MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for studies comparing prognostic outcomes between sarcopenic versus non-sarcopenic adults after elective abdominal surgery from inception to 15 June 2022. The primary outcomes were postoperative morbidity and mortality. Sensitivity analyses adjusting for confounding patient factors were also performed. Methodological quality assessment of studies was performed independently by two authors using the QUality in Prognosis Studies (QUIPS) tool. RESULTS: Twenty articles with 5421 patients (1059 sarcopenic and 4362 non-sarcopenic) were included. Sarcopenic patients were at significantly greater risk of incurring postoperative complications, despite adjusted multivariate analysis (adjusted OR 1.56, 95 per cent c.i. 1.39 to 1.76). Sarcopenic patients also had significantly higher rates of in-hospital (OR 7.62, 95 per cent c.i. 2.86 to 20.34), 30-day (OR 3.84, 95 per cent c.i. 1.27 to 11.64), and 90-day (OR 3.73, 95 per cent c.i. 1.19 to 11.70) mortality. Sarcopenia was an independent risk factor for poorer overall survival in multivariate Cox regression analysis (adjusted HR 1.28, 95 per cent c.i. 1.13 to 1.44). CONCLUSION: Consensus-defined sarcopenia provides important prognostic information after elective abdominal surgery and can be appropriately measured in the preoperative setting. Development of targeted exercise-based interventions that minimize sarcopenia may improve outcomes for patients who are undergoing elective abdominal surgery.

The length of hospital stay following bariatric surgery in Australia: the impact of patient, procedure, system and surgeon.

BACKGROUND: The length of a patient's stay (LOS) in a hospital is one metric used to compare the quality of care, as a longer LOS may flag higher complication rates or less efficient processes. A meaningful comparison of LOS can only occur if the expected average length of stay (ALOS) is defined first. This study aimed to define the expected ALOS of primary and conversion bariatric surgery in Australia and to quantify the effect of patient, procedure, system, and surgeon factors on ALOS. METHODS: This was a retrospective observational study of prospectively maintained data from the Bariatric Surgery Registry of 63 604 bariatric procedures performed in Australia. The primary outcome measure was the expected ALOS for primary and conversion bariatric procedures. The secondary outcome measures quantified the change in ALOS for bariatric surgery resulting from patient, procedure, hospital, and surgeon factors. RESULTS: Uncomplicated primary bariatric surgery had an ALOS (SD) of 2.30 (1.31) days, whereas conversion procedures had an ALOS (SD) of 2.71 (2.75) days yielding a mean difference (SEM) in ALOS of 0.41 (0.05) days, P < 0.001. The occurrence of any defined adverse event extended the ALOS of primary and conversion procedures by 1.14 days (CI 95% 1.04-1.25), P < 0.001 and 2.33 days (CI 95% 1.54-3.11), P < 0.001, respectively. Older age, diabetes, rural home address, surgeon operating volume and hospital case volume increased the ALOS following bariatric surgery. CONCLUSIONS: Our findings have defined Australia's expected ALOS following bariatric surgery. Increased patient age, diabetes, rural living, procedural complications and surgeon and hospital case volume exerted a small but significant increase in ALOS. STUDY TYPE: Retrospective observational study of prospectively collected data.