Primary Care Physicians' Knowledge, Attitude, and Potential Referral Barriers towards Bariatric Surgery: A Northern Saudi Study.

Introduction: Bariatric surgery is the most effective procedure for sustained weight loss and control of obesity-associated comorbidities among morbidly obese patients. Successful bariatric surgery depends on a multidisciplinary approach involving all healthcare workers, including the primary care physicians, from the referral of patients to long-term follow-up. The present study assessed the knowledge, attitude, and potential referral barriers of primary care physicians to bariatric surgery and associated sociodemographic factors. Materials and methods: The present analytical cross-sectional study was conducted among 280 randomly selected primary care physicians using a standard and validated data collection tool. We performed an independent t-test and one-way ANOVA to find the association between sociodemographic characteristics and knowledge, attitude, and referral barrier scores. Furthermore, multilinear regression analysis was executed to determine the association among knowledge, attitude, and barriers. Results: The current study found that 52.9%, 19.3%, and 59.3% had a low score in the knowledge, attitude, and barriers categories. The attitude scores were significantly associated with the education status (p = 0.005) and current position at primary health centers (p = 0.012), and the referral barriers score was significantly associated with the work experience duration (p = 0.004). We found a positive relationship between knowledge and attitude (regression coefficient (ß) [95% CI]:0.389 [0.154 to 0.585], p = 0.001) and a negative relationship between knowledge and referral barriers (ß [95% CI]: -0.291 [-0.127 to -0.058], p = 0.007). Conclusions: Our survey findings suggest that a lack of knowledge regarding bariatric surgery led to several concerns and referral barriers among the physicians. Therefore, the recommendation is to improve the primary care physicians' knowledge through continuing medical education, symposium, and other suitable training methods with a special focus on obesity care in the curriculum. Furthermore, a mixed-method survey involving other provinces of the KSA is warranted to formulate the region-specific training needs.

Efficacy of HFNO during airway management of a COVID pneumonia patient with super morbid obesity undergoing emergency laparotomy.

This case report describes the use of high flow nasal oxygen (HFNO) in a patient with morbid obesity (BMI = 90 kg/m2) who underwent emergency laparotomy under general anesthesia. This 54-year-old female patient with American Society of Anesthesia classification 4 E is known to have COVID pneumonia with Obstuctive Sleep Apnea. She was admitted in the ICU for 3 days and she was on Bilevel Positive Airway Pressure (BiPAP) alternating with HFNO to keep her SpO2 91%-92%, on FiO2 60%, and respiratory rate (RR) 40-45/min. The plan for airway management was rapid sequence intubation with preoxygenation using the HFNO. We here report this case to show the usefulness of HFNO, which adds a new dimension in airway management of similar cases.

Effect of Manual Caudal and Downward Displacement of Lower Cervical Adipose Tissue on Laryngoscopic Grade of Patients with Morbid Obesity.

BACKGROUND: The prevalence of obesity has substantially increased all over the world in the past decades and anesthesiologists more commonly encounter these patients. Excess cervical adipose tissues can result in the narrowing of the pharyngeal opening and affect laryngoscopic grade. OBJECTIVES: To evaluate the effect of manual caudal and cervical displacement of cervical adipose tissue on laryngoscopic view of morbid obese patients. METHODS: A total of 70 patients with a BMI ≥ 35 were enrolled in this study. All patients were placed in the ramp position. Manual caudal and downward displacement of cervical adipose tissue was performed by an anesthesiologist. Laryngoscopy was performed by an anesthesiologist before and after manual displacement. The anesthesiologist was blinded as we had drawn a curtain, therefore, he could not recognize if the maneuver was being performed or not. Thyromental distance, upper lip bite test, hyomental distance, and BMI were recorded for all patients. RESULTS: Age, weight, and BMI didn't have any significant relation with difficult intubation. There was a significant relationship between difficult intubation and thyromental distance, upper lip bite test, Mallampati score, and hyomentaldistance (P: 0.01, 0.04, 0.001, and 0.005, respectively). Cormack-Lehane grade significantly improved after the maneuver (P: 0.001). CONCLUSIONS: Preparation and appropriate management of airway is very important for morbid obese patients. Manual caudal and downward displacement of adipose tissue has a significant effect on the improvement of laryngoscopic view in morbid obese patients. Therefore, ramped position or manual and caudal displacement of chest wall fat tissue can be added to "standard" preoperative airway assessment.

The influences of bariatric surgery on hemoglobin A1c in a sample of obese patients in Saudi Arabia.

BACKGROUND: Although the frequency of surgical weight loss interventions has increased in Saudi Arabia, literature describing the clinical outcomes of bariatric surgery in Saudi Arabia is limited. This study aimed to assess whether weight loss intervention improves hemoglobin A1c (HbA1c) in obese patients and to identify its associated factors. PATIENTS AND METHODS: A retrospective study was carried out on 318 patients with obesity class 1 or higher (body mass index [BMI] ≥ 30 kg/m2) who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass at King Abdulaziz Medical City in Riyadh, Saudi Arabia, between January 1, 2001 and March 31, 2017. Preoperatively and 12 months postoperatively, characteristics of patients were collected. BMI reduction was calculated, based on which patients were divided into three groups (0-9, 10-14, and >14 kg/m2). RESULTS: The postoperative HbA1c was 5.83±0.9, while the baseline level was 6.74±2.1 (P=0.001). Fifty-eight of the 318 patients had diabetes. We observed significantly higher HbA1c in diabetic than in non-diabetic patients preoperatively, whereas an insignificantly different HbA1c was observed postoperatively. Among those who had minimal reduction in BMI (0-9 kg/m2), we observed significantly higher HbA1c in diabetic than in non-diabetic patients, whereas among those who had large reduction in BMI (10-14 kg/m2) and (>14 kg/m2), we observed insignificant differences in HbA1c in diabetic than in non-diabetic patients. CONCLUSION: Being a diabetic patient was related to a significant reduction in HbA1c levels postoperatively. The study suggests that the reduction in HbA1c levels could be modified by BMI, wherein greater reduction in BMI leads to greater reduction in HbA1c levels.

The impact of bariatric surgery on pulmonary function: a meta-analysis.

Morbid obesity may affect several body systems and cause ill effects to the cardiovascular, hepatobiliary, endocrine, and mental health systems. However, the impact on the pulmonary system and pulmonary function has been debated in the literature. A systematic review and meta-analysis for studies that have evaluated the impact of bariatric surgery on pulmonary function were pooled for this analysis. PubMed, Cochrane, and Embase databases were evaluated through September 31, 2016. They were used as the primary search engine for studies evaluating the impact pre- and post-bariatric surgery on pulmonary function. Pooled effect estimates were calculated using random-effects model. Twenty-three studies with 1013 participants were included in the final meta-analysis. Only 8 studies had intervention and control groups with different time points, but 15 studies had matched groups with different time points. Overall, pulmonary function score was significantly improved after bariatric surgery, with a pooled standardized mean difference of .59 (95% confidence interval: .46-.73). Heterogeneity test was performed by using Cochran's Q test (I2 = 46%; P heterogeneity = .10). Subgroup analysis and univariate meta-regression based on study quality, age, presurgery body mass index, postsurgery body mass index, study design, female patients only, study continent, asthmatic patients in the study, and the type of bariatric surgery confirmed no statistically significant difference among these groups (P value>.05 for all). A multivariate meta-regression model, which adjusted simultaneously for these same covariates, did not change the results (P value > .05 overall). Assessment of publication bias was done visually and by Begg's rank correlation test and indicated the absence of publication bias (asymmetric shape was observed and P = .34). This meta-analysis shows that bariatric surgery significantly improved overall pulmonary functions score for morbid obesity.

Orotracheal intubation of morbidly obese patients, comparison of GlideScope(®) video laryngoscope and the LMA CTrach™ with direct laryngoscopy.

BACKGROUND: Morbidly obese patients are at increased risk of difficult mask ventilation and intubation as well as increased risk of hypoxemia during tracheal intubation. Recently, new video-assisted intubation devices have been developed. The GlideScope(®) videolaryngoscope and LMA CTrach™ (CT) allows continuous video-endoscopy of the tracheal intubation procedure. OBJECTIVE: this study is to determine whether the GlideScope(®) videolaryngoscope (GVL) and the LMA CTrach™ (CT) provide the best airway management, measured primarily in intubation difficulty scale (IDS) scores, time and numbers of intubation attempts, and improvement in the intubation success rate of morbidly obese patients when compared with the direct Macintosh laryngoscope (DL). MATERIALS AND METHODS: After Ethics' Committee approval, 90 morbidly obese patients (BMI > 35 kg/m(2)) scheduled for general, gynecological, and bariatric surgery were included in this prospective study. Patients were randomly assigned in three groups: tracheal intubation using direct laryngoscopy (DL), GlideScope(®) videolaryngoscope (GVL) or the LMA CTrach™ (CT). Characteristics and consequences of airway management were evaluated. The primary outcome was the intubation difficulty scale score (IDS), Secondary outcomes were theintubation time, overall success rate, number of attempts, Cormack-Lehane grade, subjective difficulty of intubation, desaturation and upper airway morbidity. RESULTS: Difficulty in facemask ventilation was similar in the three groups. IDS scores were significantly lower with GVL and CT than with DL. The mean TTI was 14 s faster in patients intubated with the GVL (86 s, IQR: 68-115) compared with DL (100 s, IQR; 80-150), and was 34 s faster when compared with CT (120 s, IQR; 95-180). The success rate of tracheal intubation was lower with the DL (80%) compared with the GVL (100%) or the CT (100%). Six cases of failed intubation occurred in group DL, four patients from the six patients were intubated successfully with GVL, and two patients were intubated with the CT. Both the GVL and the CTimproved the Cormack and Lehane view obtained at laryngoscopy, compared with the DL. Significantly high percent of patients in DL (43%) and CT (27%) required optimization maneuvers (external laryngeal pressure) compared with GVL (0%). In the CT group, 30% of the patients required laryngeal mask manipulation (for view optimization) compared with (0%) in GVL and CT groups. CONCLUSION: The GlideScope(®) videolaryngoscope and the LMA CTrach™ reduced the difficulty, improved laryngoscopic views and overall success rate of tracheal Intubationto a similar extent compared with the Macintosh laryngoscope in morbidly obese patients. The GVL improved intubation time for tracheal intubation compared with the CT and DL but no patient became hypoxic with CT because of prolonged intubation time.

Use of intubating laryngeal mask airway in a morbidly obese patient with chest trauma in an emergency setting.

A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting.

Compulsão alimentar em pacientes no pré-operatório de cirurgia bariátrica / Binge-eating in pre-operative patients after bariatric surgery

Com o objetivo de verificar a prevalência de compulsão alimentar em obesos mórbidos durante o período pré-operatório de cirurgia bariátrica, aplicou-se o questionário de escala de compulsão alimentar periódica, em 30 pacientes atendidos no ambulatório de cirurgia bariátrica da santa casa de misericórdia da PUCPR, no período de abril e maio de 2005. Do total de pacientes, 26 eram do sexo feminino e 4 do sexo masculino. Verificou-se que 53,2 porcento dos entrevistados apresentaram compulsão alimentar moderada ou grave, sendo que 25 porcento dos pacientes com obesidade mórbida apresentaram compulsão alimentar grave. O IMC médio dos pacientes foi de 51,26 kg/m, sendo de 38,4 e de 50,44 kg/m, para pacientes com obesidade moderada e grave, respectivamente. Quando aplicado o teste qui-quadrado, não foi encontrada correlação significativa entre IMC e grau de compulsão alimentar (p>0,05). Com este estudo, conclui-se que os pacientes obesos mórbidos apresentam maiores índices de compulsão alimentar do que pacientes obesos, mas nada teve a ver o grau de compulsão com o IMC. O acompanhamento psicológico é de suma importância para a boa evolução do paciente, bem como o acompanhamento nutricional. Estudos futuros serão necessários para melhor compreensão, do quadro do paciente, sendo objetivo, para um próximo trabalho, a re-avaliação deles quando estes estiverem com 6 meses ou mais de pós-operatório para verificar a evolução do quadro

Verifying the prevalence of binge eating in morbid obeses during the bariatric surgery pre-operative period, aquestionnaire was applied in the Periodic Binge Eating Scale, in thirty patients in the bariatric surgery ward at SantaCasa de Misericórdia/PUCPR, from April to May, 2005. From all the patients, 26 was female and 4 male. It wasverified that 53,2% of the patients presented binge eating moderate or severe. The average BMI of the patients was51,26 kg/m_, being 38,4 and 50,44 kg/m_, for patients with moderate and severe obesity, respectively. When theQui-quadrado Test was applied, a meaningful correlation was not found between the BMI and level of binge eating(p>0,05). Using this work It was concluded that the morbid obese patients presented higher indexes of binge eatingthan the obese patients. Nothing else is related to the binge eating level with the BMI. The psychological assistanceis fundamental to follow better patient ́s behavior, as well as, the nutritional assistance. Further researches will benecessary for a better understanding about the patient ́s situation, aiming for the next work, a re-evaluation of thepatients in post-operative sixth months or more, to verify its evolution

A experiência vivida por pessoas com tumor cerebral e por seus familiares / The experience of brain tumor patients and their family members

O presente artigo constitui o relato de uma pesquisa cujo objetivo foi investigar a experiência vivida por pessoas com tumor cerebral e por seus familiares. Para tanto, partiu-se da assistência psicossocial oferecida em grupos de sala de espera no ambulatório de neurocirurgia oncológica do hospital das clínicas da faculdade de medicina de Ribeirão Preto - USP. Sete sessões de grupo foram gravadas, transcritas e analisadas. Na compreensão dos relatos analisados, duas questões ganharam evidência. Primeiramente, a de que a experiência do adoecimento para os pacientes é marcada pelo sentido de que a vida presente é muito diferente da de outrora. Há como que um choque entre o eu-corpo atual e o eu-corpo passado. Em segundo lugar, é notável a restrição pessoal que marca esta experiência do enfermo. Tal restrição revela-se nas perturbações da motricidade, nos temores e angústias que o assaltam, nas relações estabelecidas em família, marcadas por uma superproteção que cerceia e pela dependência em relação aos cuidados do outro, e nas experiências com o meio social extrafamiliar que despertam vergonha e o ímpeto de se isolar. Quanto aos familiares, vivenciam uma intensa carga de preocupações e temores que os levam a uma atitude, por vezes, superprotetora.

Verifying the prevalence of binge eating in morbid obeses during the bariatric surgery pre-operative period, aquestionnaire was applied in the Periodic Binge Eating Scale, in thirty patients in the bariatric surgery ward at SantaCasa de Misericórdia/PUCPR, from April to May, 2005. From all the patients, 26 was female and 4 male. It wasverified that 53,2% of the patients presented binge eating moderate or severe. The average BMI of the patients was51,26 kg/m_, being 38,4 and 50,44 kg/m_, for patients with moderate and severe obesity, respectively. When theQui-quadrado Test was applied, a meaningful correlation was not found between the BMI and level of binge eating(p>0,05). Using this work It was concluded that the morbid obese patients presented higher indexes of binge eatingthan the obese patients. Nothing else is related to the binge eating level with the BMI. The psychological assistanceis fundamental to follow better patient ́s behavior, as well as, the nutritional assistance. Further researches will benecessary for a better understanding about the patient ́s situation, aiming for the next work, a re-evaluation of thepatients in post-operative sixth months or more, to verify its evolution