Lessons learned from the metabolic and bariatric surgery accreditation and quality improvement program site surveys: common deficiencies and corrective actions.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a joint program between the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS). On-site surveys of the applicant programs to determine adherence to the MBSAQIP standards are a hallmark of the accreditation process. OBJECTIVES: A retrospective review of 619 site surveys completed over 2 years was performed to include analysis of reviewer decisions, tabulation and cross-reference of identified deficiencies to the MBSAQIP standards and determine final disposition of corrective actions and overall accreditation rates. SETTING: Accredited Hospitals (Community and Academic) within MBSAQIP. METHODS: This is a retrospective review of site surveys by expert panel. RESULTS: ≥1 MBSAQIP Standards deficiencies were present at 149 of the 619 program site surveys (24.07%). The 3 leading Standards in Deficiency were in order: Commitment to Quality Care, Continuous Quality Improvement Process, and Data Collection. Within a year following initial site survey of the149 programs with Standards deficiencies, 59 programs demonstrated compliance, 83 programs were placed on probation (with a specific time-frame to demonstrate compliance) and 7 programs were denied accreditation. Ultimately, 98.9% of programs were able to gain or maintain MBSAQIP accreditation. CONCLUSIONS: The MBSAQIP accreditation through on-site surveys can identify and improve program adherence to MBSAQIP standards.

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program: Bariatric Surgical Risk/Benefit Calculator: 1-year comorbidity remission.

BACKGROUND: Clinical calculators can provide patient-personalized estimates of treatment risks and health outcomes. The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) set out to create a publicly available tool to assess both short-term postoperative risk and long-term benefits for prospective adult patients eligible for 1 of 4 primary bariatric procedures. The calculator is comprised of multiple prediction elements: (1) 30-day postoperative risk, (2) 1-year body mass index projections, and (3) 1-year comorbidity remission. OBJECTIVES: To assess the performance of the 1-year comorbidity remission prediction feature of the calculator. SETTING: Not-for-profit organization clinical data registry. METHODS: MBSAQIP data across 4.5 years from 240,227 total patients indicating at least 1 comorbidity of interest present preoperatively and who had a 1-year follow-up record documenting their comorbidity status were included. Six models were constructed, stratified by the presence of the respective preoperative comorbidity: hypertension, hyperlipidemia, gastroesophageal reflux disease, sleep apnea, non-insulin-dependent diabetes, and insulin-dependent diabetes. A multinomial logistic regression model was used to predict 1-year remission (total, partial, or no remission) of insulin-dependent diabetes. All other outcomes were binary (yes or no at 1 yr), and ordinary logistic regression models were used. RESULTS: All models showed adequate discrimination (C statistics ranging from .58 to .68). Plots of observed versus predicted remission (%) showed excellent calibration across all models. CONCLUSION: All remission models were well calibrated with sufficient discrimination. The MBSAQIP Bariatric Surgical Risk/Benefit Calculator is a publicly available tool intended for integration into clinical practice to enhance patient-clinician discussions and informed consent.

Gastroesophageal junction adenocarcinoma 1-year after sleeve gastrectomy.

Gastroesophageal malignancy after sleeve gastrectomy is rare. A 70-year-old male with a BMI of 46 underwent laparoscopic sleeve gastrectomy with normal endoscopy. By 10 months postop, the patient had reduced BMI to 30.5. Eleven months postop, he presented with emesis and endoscopy showed severe stenosis at the gastroesophageal junction with EUS showing a circumferential mass. Patient had adenocarcinoma of the distal esophagus HER 3+ and MMR proficient, clinical T2N1. He underwent esophageal stent placement followed by FOLFOX switched to carboplatin-Taxol with radiation therapy complicated by a localized perforation requiring antibiotics. After PET scan of esophageal mass indicated response, he underwent an open distal esophagectomy, total gastrectomy with Roux-en-Y esophagojejunostomy, and placement of feeding tube. Pathology revealed poorly differentiated invasive adenocarcinoma with negative margins. In the USA, this represents only the second adenocarcinoma following a sleeve gastrectomy and the first in a non-immune compromised patient.

The effects of stocking density on behavior and biological functioning of penned sheep under continuous heat load conditions.

Stocking density may impact sheep welfare during live export voyages that occur under hot and humid conditions. The aim of this study was to assess the welfare implications for sheep housed at three allometric stocking densities (k = 0.030, 0.033, 0.042), while exposed to hot and humid climatic conditions. For 21 d, Merino wethers (n = 216) were housed in 12 pens of 18 wethers, in two climate-controlled rooms where wet-bulb temperature (TWB) mimicked the conditions of a live export voyage with high heat and humidity, and limited diurnal variation. Scan sampling of standing and lying behaviors was conducted on days 2, 5, 8, 11, 15, 18, and 20, at hourly intervals. Agonistic interactions were scored continuously on the same days between 1750 and 1800 h. Liveweights were recorded at the start and end of the study. For a subset of focal wethers (3 per pen), whole blood variables were assessed at the start and end of the experiment, along with fecal glucocorticoid metabolites (FGCM), which were also assessed on days 7 and 14. Rumen temperatures (TRUM) of focal wethers were recorded at 10-min intervals, and their respiration rates (RR) were measured every 2 h on days 1, 3, and from days 7 to 21. Focal wethers were slaughtered for necropsy after the study, and both adrenal glands were excised and weighed. The expression of some lying positions was impaired at high stocking densities, and lying with outstretched legs increased at high TWB. For respiration rates, there was an interaction between stocking density and TWB, such that RR was reduced by the provision of additional space at high TWB. TRUM was relatively unaffected by stocking density but increased at higher TWB, and any effects of stocking density on FGCM concentrations, liveweights (LW), adrenal gland weights or blood variables were minimal. Necropsy examination showed no indication that the wethers had experienced ongoing respiratory distress. These results suggest that the wethers were able to cope with these increases in stocking density under the conditions imposed. However, based on this evidence, the provision of additional space under hot conditions may be beneficial to facilitating the expression of some lying positions. Whilst the experiment was designed to emulate certain conditions relevant during live export voyages, other factors that may induce stress during this mode of transport were not present, and so the conclusions must be interpreted in the context of the experimental conditions.

There is a high demand for Australian sheep to be exported to the Middle East, and for live export voyages which depart during an Australian winter, heat, and humidity increase rapidly as ships cross the equator and approach destination countries. Concern about sheep becoming heat stressed during these voyages has increased, and industry attention has focused on the potential role of stocking density in determining heat stress risk in this context. High stocking densities limit the body surface area available for heat loss and can increase heat exchange between individual sheep. This study aimed to assess the welfare implications of three stocking densities, for sheep exposed to climatic conditions similar to those experienced during a live export voyage to the Middle East. Higher stocking densities restricted the ability of sheep to lie in some positions, but stocking density had limited effects on heat stress indicators or the physiology of the sheep. These results suggested that the sheep were able to cope with these increases in stocking density under the conditions imposed, but the conclusions must be interpreted in the context of the controlled experimental conditions.

Current use of the National Surgical Quality Improvement Program surgical risk calculator in academic surgery: a mixed-methods study.

Background: This study aims to quantitatively assess use of the NSQIP surgical risk calculator (NSRC) in contemporary surgical practice and to identify barriers to use and potential interventions that might increase use. Materials and methods: We performed a cross-sectional study of surgeons at seven institutions. The primary outcomes were self-reported application of the calculator in general clinical practice and specific clinical scenarios as well as reported barriers to use. Results: In our sample of 99 surgeons (49.7% response rate), 73.7% reported use of the NSRC in the past month. Approximately half (51.9%) of respondents reported infrequent NSRC use (<20% of preoperative discussions), while 14.3% used it in ≥40% of preoperative assessments. Reported use was higher in nonelective cases (30.2% vs 11.1%) and in patients who were ≥65 years old (37.1% vs 13.0%), functionally dependent (41.2% vs 6.6%), or with surrogate consent (39.9% vs 20.4%). NSRC use was not associated with training status or years in practice. Respondents identified a lack of influence on the decision to pursue surgery as well as concerns regarding the calculator's accuracy as barriers to use. Surgeons suggested improving integration to workflow and better education as strategies to increase NSRC use. Conclusions: Many surgeons reported use of the NSRC, but few used it frequently. Surgeons reported more frequent use in nonelective cases and frail patients, suggesting the calculator is of greater utility for high-risk patients. Surgeons raised concerns about perceived accuracy and suggested additional education as well as integration of the calculator into the electronic health record.

Improving Post-procedure Outcomes With Clinical Care Pathway for Enteral Access.

Our health system introduced an enteral access clinical pathway (EACP) hoping to increase nutritionist consults and decrease presentation to the Emergency Department, readmission to the hospital, and overall hospital length of stay. We followed patients with short-term access (STA), longterm access (LTA), and short-long-term conversions (SLT) seen in the six months prior to the EACP launch (baseline group) and the six months after (performance group). The baseline cohort consisted of 2,553 patients and the performance cohort of 2,419 patients. Those in the performance group were more likely to receive a nutrition consult (52.4% vs 48.0%, P < .01), less likely to re-present to the ED (31.9% vs 42.6%, P < .001), and less likely to be readmitted to the hospital (31.0% vs 41.6%, P < .001. These findings suggest that the EACP may increase the likelihood of both expert-driven nutritional support and effective discharge planning for hospitalized patients.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Bariatric Surgical Risk/Benefit Calculator: 1-year weight.

BACKGROUND: Data-driven tools can be designed to provide patient-personalized estimates of health outcomes. Clinical calculators are commonly built to assess risk, but potential benefits of treatment should be equally considered. The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) sought to create a risk and benefit calculator for adult patients considering primary metabolic and bariatric surgery with multiple prediction features: (1) 30-day risk, (2) 1-year body mass index (BMI) projections, and (3) 1-year co-morbidity remission. OBJECTIVE: To assess the performance of the 1-year BMI projections feature of this tool. SETTING: Not-for-profit organization, clinical data registry. METHODS: MBSAQIP data from 596,024 cases across 4.5 years from 882 centers with ∼2.5 million records through 18 months postoperatively were included. A generalized estimating equation model was used to estimate BMI over time for 4 primary procedures: laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. RESULTS: The mean absolute error (MAE) in BMI predictions through postoperative month 12 was 1.68 units; overall correlation of actual and predicted BMI was .94. MAE of postoperative BMI estimates (1-12 mo) was lowest for laparoscopic sleeve gastrectomy (1.64) and highest for biliopancreatic diversion with duodenal switch (1.99). BMI predictions at 12 months showed MAE = 2.99 units. CONCLUSIONS: Predicted BMI closely aligned with actual BMI values across the 12-month postoperative period. The MBSAQIP Bariatric Surgical Risk/Benefit Calculator is publicly available with the intent to facilitate patient-clinician communication and guide surgical decision making. This tool can aid in evaluating postoperative risk as well as benefits and long-term expectations.

Corrigendum: Stocking density, restricted trough space, and implications for sheep behaviour and biological functioning.

[This corrects the article DOI: 10.3389/fvets.2022.965635.].

Clinical features, outcomes, and long-term survival times of cats and dogs with central nervous system cryptococcosis in Australia: 50 cases (2000-2020).

OBJECTIVE: To describe the clinical findings and outcomes of Australian cats and dogs with CNS cryptococcosis. ANIMALS: 19 cats and 31 dogs with CNS cryptococcosis diagnosed between 2000 and 2020. PROCEDURES: A case series and cohort study were performed using the same 50 animals. Both studies were multi-institutional and both retrospective and prospective. Disease features were compared between cats and dogs, and associations between putative risk factors and survival time (ST) were assessed. RESULTS: Dogs were younger at initial presentation than cats and had lower latex cryptococcal antigen agglutination titers. Extraneurologic signs were common and frequently involved sinonasal and contiguous tissues. Neuroanatomic localization was predominantly forebrain, central vestibular (including cerebellum), multifocal, or diffuse. CSF analysis predominantly showed pleocytosis, with eosinophilic inflammation common in dogs. Seventy-eight percent (39/50) of patients received antifungal treatment. Median STs (from presentation) in treated patients were 1,678 days for cats and 679 days for dogs. Abnormal mentation at presentation (in dogs) and CSF collection (in cats) were associated with shorter STs. In treated dogs, those that received glucocorticoids prior to diagnosis, or single rather than multiple antifungal agents, had shorter STs. CLINICAL RELEVANCE: The prognosis for feline and canine CNS cryptococcosis is guarded, yet long STs are possible with appropriate treatment. Presence of subtle upper respiratory tract signs may suggest cryptococcosis in patients with neurologic signs, while the absence of neurologic signs does not preclude CNS involvement.

Stocking density, restricted trough space, and implications for sheep behaviour and biological functioning.

Stocking density and trough space allowance can potentially impact sheep welfare during live export voyages. The aim of this study was to assess the welfare implications for sheep housed at five allometric stocking densities, with either unrestricted or restricted trough space allowance. Merino wethers (n = 720) were housed in 40 pens of 18 heads for 18 days. Two 5-min continuous focal animal observations (n = 3/pen) were conducted on days 3, 5, 11, and 17. Scan sampling of standing and lying behaviours were conducted on the same days at hourly intervals. Live weights and immune cell counts were quantified at the start and end of the experiment, as well as faecal glucocorticoid metabolites (FGCMs), which were also assessed on days 6 and 12. Focal animals housed at higher stocking densities spent less time lying during one of the continuous observation periods, but no important effects on the overall number of animals lying or on the synchronicity of lying were evident. The scan sampling results indicated that the expression of some preferred lying positions was impaired at high stocking densities, and that high stocking densities also resulted in increased agonistic social interactions and displacement events at the start of the trial. There was a slight reduction in day 18 live weights for animals housed at higher stocking densities, but FGCM concentrations and immune cell counts were essentially unaffected. Trough space had no important effects on day 18 live weight, FGCM concentrations, or immune cell counts, and had limited effects on sheep behaviour. The lack of important impacts on biological fitness traits suggests that the behavioural responses observed were sufficient in allowing sheep to cope with their environment. However, we provide evidence that the provision of additional space is beneficial in reducing the time it takes for animals to adapt to their environment and to facilitate the expression of some preferred lying positions. While designed to emulate certain conditions relevant during live export voyages, some factors that may induce stress during this mode of transport were not present such as heat and ocean swell, so the conclusions must be interpreted in the context of the experimental conditions.

Adoption Can Be a Risky Business: Risk Factors Predictive of Dogs Adopted from RSPCA Queensland Being Returned.

Not all dog adoptions are successful. This two-year retrospective study used survival (i.e., time-to-event) analyses to investigate readmissions for dogs adopted from RSPCA Queensland shelters between 1 January 2019 and 31 December 2020. A better understanding of temporal patterns and risk factors associated with readmission may help RSPCA Queensland shelters better target and tailor resources to improve retention by adopters. The failure function (the cumulative percentage of adoptions that were readmitted by day of the adoption period) increased rapidly during the first 14 days of the adoption period. Approximately two-thirds of all returns occurred in this period. This readmission rate may have been influenced by the RSPCA Queensland adoption-fee refund policy. The cumulative percentage of adoptions that were readmitted plateaued at just under 15%. Dog size, age, coat colour, breed, and spending time in foster before adoption were factors associated with the risk of readmission. Failure functions for a low and a high-risk adoption example demonstrated the large degree of difference in hazard of readmission between covariate patterns, with estimated percentages of adoptions being returned by 90 days for those examples being 2% and 17%, respectively. Spending time in foster care before adoption appears to be protective against readmission, presumably because it supports a successful transition to the new home environment. Behaviour support and training provided for dogs during foster care may contribute to improve their outcomes. These findings highlight the profile of the higher-risk dogs potentially providing shelters with an opportunity to examine where and how resources could be allocated to maximize outcomes for the overall cohort. Population attributable 90-day failure estimates were calculated for each of bodyweight and age at adoption, coat colour, spending time in foster care before adoption, and breed. This calculation shows the expected reduction in the cumulative percentage of dogs readmitted by day 90 if the hazards of readmission for higher risk categories were reduced to those of a lower risk category. Expected reductions for individual factors ranged from 1.8% to 3.6% with one additional estimate of 6.8%. Risk of readmission could be reduced through increased development of foster capacity and capability, targeted interventions, improved adopter-dog matching processes, and more effective targeting of support for higher risk dogs, such as older or larger dogs. Population impact analyses provide a macro view that could assist shelters in strategically assessing the return on investment for various strategies aiming to improve adoption outcomes and potentially reduce readmissions.

First report from the American Society of Metabolic and Bariatric Surgery closed-claims registry: prevalence, causes, and lessons learned from bariatric surgery medical malpractice claims.

BACKGROUND: Bariatric surgery has demonstrated sustained improvements in quality. Malpractice closed claims have been offered as a means of assessing quality. Few studies have investigated malpractice closed claims and opportunities for improvement in bariatric surgery. OBJECTIVES: To examine the prevalence and causes of malpractice claims with examination of prospects for quality improvement. SETTING: University hospital, United States; private practice. METHODS: Four national malpractice insurers participated in the closed-claims registry. Data regarding patients, staff, procedures, and hospital status were gathered from closed-claims files. Following data collection, a clinical summary of each closed claim was collected and later assessed by an expert panel on the basis of the following: contributing diagnosis and treatment events; whether complications were potentially preventable by the surgeon; the role of language, fatigue, distraction, workload, or teaching hospital/trainee supervision; communication concerns; and final care determination. RESULTS: A total of 175 closed claims were collected from index bariatric surgeries within the period from 2006-2014. Of these, 75.9% of surgeons were board certified and 43.3% of the hospitals were accredited for bariatric surgery. Most clinical complications after bariatric surgery that led to malpractice lawsuits were mortality (35.1%) and leaks (17.5%). While they were not the common cause for malpractice suits, bleeding (5.3%), retained foreign body (5.3%), and vascular injury (4.4%) occurred at higher rates than national averages. CONCLUSION: Prevalence of malpractice claims regarding bariatric surgery is low. Failure to diagnose, delay in treatment, postoperative care, and communication domain responses indicate future opportunities for improvement.

Beyond 5 years: a matched cohort of sleeve gastrectomy versus gastric bypass.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has demonstrated excellent short-term outcomes. However, existing studies suffer from loss to follow-up, and most long-term data focus on laparoscopic Roux-en-Y gastric bypass (LRYGB). This study compares weight loss in patients ≥5 years from LSG with that in matched patients who underwent LRYGB. OBJECTIVES: The purpose of this study was to compare long-term weight loss in patients undergoing LRYGB and LSG. SETTING: University hospital, United States. METHODS: We retrospectively evaluated patients who underwent LSG before August 2012 with follow-up data ≥5 years. LSG patients were matched 1:1 with LRYGB patients by sex, age at surgery, and preoperative body mass index. Univariate and multivariate analyses were performed with weight loss at the longest duration the primary outcome. RESULTS: One-hundred and sixty-five patients underwent LSG during the study period. Long-term follow-up data (≥5 years) were available for 85 patients (52%). There were no preoperative differences between those with and without follow-up data. Six LSG patients (7%) were excluded because they underwent reoperation that altered intestinal anatomy. Of the 79 patients remaining, 75 were matched with post-LRYGB patients. The average follow-up period was 6.4 years for LSG patients and 6.5 years for LRYGB patients (P = .08, not significant). Change in body mass index was 6.81 kg/m2 for LSG patients and 13.11 kg/m2 for LRYGB patients. Percentage of total body weight loss was 15.25% for LSG patients and 28.73% for LRYGB patients. Percentage of excess body weight loss was 37% for LSG patients and 67% for LRYGB patients (P < .0001). Weight loss for LSG patient follow-up in clinic versus outside the clinic was 46% versus 34% (P = .18, not significant). CONCLUSIONS: LSG is now the most common bariatric surgery in the United States. Long-term data are needed to confirm that observed short-term favorable outcomes are maintained. Recent studies have produced divergent results. We observed significantly less weight loss at ≥5 years in LSG patients compared with matched LRYGB patients.

Use of Remote Camera Traps to Evaluate Animal-Based Welfare Indicators in Individual Free-Roaming Wild Horses.

We previously developed a Ten-Stage Protocol for scientifically assessing the welfare of individual free-roaming wild animals using the Five Domains Model. The protocol includes developing methods for measuring or observing welfare indices. In this study, we assessed the use of remote camera traps to evaluate an extensive range of welfare indicators in individual free-roaming wild horses. Still images and videos were collected and analysed to assess whether horses could be detected and identified individually, which welfare indicators could be reliably evaluated, and whether behaviour could be quantitatively assessed. Remote camera trapping was successful in detecting and identifying horses (75% on still images and 72% on video observation events), across a range of habitats including woodlands where horses could not be directly observed. Twelve indicators of welfare across the Five Domains were assessed with equal frequency on both still images and video, with those most frequently assessable being body condition score (73% and 79% of observation events, respectively), body posture (76% for both), coat condition (42% and 52%, respectively), and whether or not the horse was sweating excessively (42% and 45%, respectively). An additional five indicators could only be assessed on video; those most frequently observable being presence or absence of weakness (66%), qualitative behavioural assessment (60%), presence or absence of shivering (51%), and gait at walk (50%). Specific behaviours were identified in 93% of still images and 84% of video events, and proportions of time different behaviours were captured could be calculated. Most social behaviours were rarely observed, but close spatial proximity to other horses, as an indicator of social bonds, was recorded in 36% of still images, and 29% of video observation events. This is the first study that describes detailed methodology for these purposes. The results of this study can also form the basis of application to other species, which could contribute significantly to advancing the field of wild animal welfare.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program bariatric surgical risk/benefit calculator: 30-day risk.

BACKGROUND: There is increasing demand for data-driven tools that provide accurate and clearly communicated patient-specific information. These can aid discussions between practitioners and patients, promote shared decision-making, and enhance informed consent. The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) sought to create a risk calculator for adult patients considering primary metabolic and bariatric surgery, with multiple prediction features: (1) 30-day risk; (2) 1-year body mass index projections; and (3) 1-year co-morbidity remission. OBJECTIVES: To evaluate the 30-day risk estimation feature of this tool. SETTING: Not-for-profit organization, international bariatric surgery clinical data registry. METHODS: MBSAQIP data across 5.5 years, 925 hospitals, and 775,291 cases were used to develop the 30-day risk feature. Logistic regression models were employed to estimate postoperative risks for 9 outcomes across 4 procedures: laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, laparoscopic adjustable gastric band, and biliopancreatic diversion with duodenal switch. RESULTS: The tool showed good discrimination for mortality and surgical site infection models (c-statistics, .80 and .70, respectively), and was slightly less accurate for the 7 other complications (.62-.69). Graphical representations showed excellent calibration for all 9 outcomes. CONCLUSIONS: Overall, the 30-day risk models were accurate and well calibrated, with acceptable discrimination. The MBSAQIP bariatric surgical risk/benefit calculator is publicly available, with the intent to be integrated into healthcare practice to guide bariatric surgical decision-making and care planning, and to enhance communication between patients and their surgical care team.