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There are limited opportunities for surgeons to engage in active learning programs once they achieve Fellowship, especially for non-technical skills such as communication. This study aims to address this gap by evaluating a peer-based coaching program in non-technical skill using video-recorded patient consultations from a routine outpatient clinic.Standard outpatient consultations between consultant surgeons and patients were video recorded. The surgeon viewed the videos with a peer-coach (senior surgeon) who helped identify areas of strength and areas for improvement. To test the effect of the coaching session, outpatient consultations were recorded roughly 1 month later. Pre and post-coaching videos were assessed using the Maastricht History-Taking and Advice Scoring - Global Rating List (MAAS), a common tool for evaluating non-technical skills in clinicians.A total of 12 surgeons consented to participate. Coaching significantly improved MAAS scores (mean difference = -0.61; 95% CI (-0.88, -0.33); P 0.0001). Surgeons were generally positive about the experience. All found the method of learning suitable, and most thought the process improved their skills. Most thought that coaching would improve patient outcomes and the majority thought they would participate in ongoing coaching as part of their employment.This supports the concept of surgical coaching as an effective tool to improve communication skills and the quality of surgical consultation. The next step is to expand beyond a voluntary cohort and link surgical coaching to improved patient outcomes.

Superior patient outcomes rely on surgical training being optimized. Accordingly, we conducted an international, prospective, cross-sectional study determining relative impacts of COVID-19, gender, race, specialty and seniority on mental health of surgical trainees.Trainees across Australia, New Zealand and UK enrolled in surgical training accredited by the Royal Australasian College of Surgeons or Royal College of Surgeons were included. Outcomes included the short version of the Perceived Stress Scale, Oxford Happiness Questionnaire short scale, Patient Health Questionnaire-2 and the effect on individual stress levels of training experiences affected by COVID-19. Predictors included trainee characteristics and local COVID-19 prevalence. Multivariable linear regression analyses were conducted to assess association between outcomes and predictors.Two hundred and five surgical trainees were included. Increased stress was associated with number of COVID-19 patients treated (P = 0.0127), female gender (P = 0.0293), minority race (P = 0.0012), less seniority (P = 0.001), and greater COVID-19 prevalence (P = 0.0122). Lower happiness was associated with training country (P = 0.0026), minority race (P = 0.0258) and more seniority (P 0.0001). Greater depression was associated with more seniority (P 0.0001). Greater COVID-19 prevalence was associated with greater reported loss of training opportunities (P = 0.0038), poor working conditions (P = 0.0079), personal protective equipment availability (P = 0.0008), relocation to areas of little experience (P 0.0001), difficulties with career progression (P = 0.0172), loss of supervision (P = 0.0211), difficulties with pay (P = 0.0034), and difficulties with leave (P = 0.0002).This is the first study to specifically describe the relative impacts of COVID-19 community prevalence, gender, race, surgical specialty and level of seniority on stress, happiness and depression of surgical trainees on an international scale.

Patient centred communication ensures patients are well informed and educated, which is vital to providing the best care possible. By asking questions, patients can better understand their disease and make informed decisions regarding their health journey. We aimed to investigate factors that affect question asking behaviours in surgical outpatient consultations and to determine the typical question-asking by doctors, patients, and their companions.This is an observational cross-sectional study, where 182 video recordings of surgical consultations in the surgical outpatient setting at The Queen Elizabeth Hospital, Adelaide, South Australia were reviewed.A total of 3472 questions were asked. Most questions were asked by the surgeon, followed by the patient, and if present, their companion. Pre-surgical consultations resulted in the most questions asked by the patients, compared to post-surgical or follow-up consultations. When companions were present, patients asked more questions in consultants regarding malignant conditions. Interruptions increased the number of questions asked by the patient and their companion. Questions were commonly asked to clarify information given by the surgeon and often regarded the cause of the illness and the timing of the next step in disease management.Patients are generally interested in their health and ask questions during consultations. Companions have a positive effect on patient question asking behaviour and their presence in surgical consultations should be encouraged. Surgeons should develop strategies to encourage question asking and could review their own behaviours via surgical coaching and video review.

Background Variation in cut-off values for what is considered a high volume (HV) hospital has made assessments of volume-outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta-analysis comparing in-hospital mortality after PD in hospitals above and below HV thresholds of various cut-off values. Method PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in-hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random-effects model was used for meta-analysis, including meta-regressions. Registration: PROSPERO, CRD42021224432. Results From 1855 records, 17 observational studies of moderate quality were included. Median HV cut-off was 25 PDs/year (IQR: 20-32). Overall relative risk of in-hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in-hospital survival benefit in performing PDs at HV hospitals. Meta-regressions from included studies found no statistically significant associations between relative risk of in-hospital mortality and region (USA vs. non-USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut-off values. Significant inverse relationships were found between PD hospital volume and other outcomes. Conclusion In-hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut-off value or region. Future research is required to investigate regions where low-volume centres have specialized PD infrastructure and the potential impact on mortality.

Background Surgical outpatient consultations are demanding for the surgeon and patients without a definite formula for success. Various factors have been identified regarding factors that influence patient satisfaction and engagement. We aimed to examine the modern-day surgical outpatient consultation and report on these factors. Methods An observational cross-sectional study was performed by reviewing video recordings of 182 surgical consultations by 12 surgeons at The Queen Elizabeth Hospital, South Australia, Australia. Results The mean consultation time was 12.3 min, with pre-surgical consultations being the longest. There were 107 consultations for benign conditions (58%). Proportionally, the consultant spoke most (51.9% of total consultation time), followed by the patient (19.5%) and then companion (8.2%). Forty-eight (26.4%) patients brought a companion to the clinic but monopolisation of the consultation by the companion was rare. When a companion was present, there was more mutual eye gaze between the consultant and the patient. Interruptions were present in 23.6% of consultations and were associated with a significant increase of the length of the consultation. Table positioning did not seem to affect the dynamics of the outpatient consultation. Conclusion Companions are highly valuable for promoting patient engagement and their presence should be encouraged in surgical outpatients. Interruptions should be kept to a minimum to avoid unnecessary delays. Further studies should be conducted to investigate the effect of companions, interruptions and table positioning during a consultation on patient outcomes.

Background Diverting ileostomy (DI) is utilised in rectal cancer surgery to mitigate the effects of anastomotic leak. The aim of this study was to assess the clinical risk factors associated with post-operative complications of DI reversal. Methods A single-centre retrospective analysis of patients who underwent surgical resection for rectal cancer and subsequent DI reversal between January 2012 and December 2020 was undertaken. Medical records were reviewed to extract clinical, operative and pathologic details and post-operative complications according to the Clavien-Dindo classification. Univariate and multivariable analyses were undertaken to assess risk factors associated with post-operative complications of DI reversal. Results One hundred and twenty-six adult patients who underwent DI reversal were included of which 49 had a post-operative complication (39%). The most common complication was prolonged post-operative ileus, which occurred in 24 patients (19%). On multivariable analysis smoking was significantly associated with overall complications (odds ratio [OR] = 5.60, 95% confidence interval [CI] 1.90-16.52, p = 0.0018), and high Clavien-Dindo (2-5) category complications (OR = 4.60, 95% CI 1.81-11.68, p = 0.0013). In addition, patients who received adjuvant chemotherapy were less likely to have a reversal of DI complication (OR = 0.43, 95% CI 0.19-0.94, p = 0.0342) and less likely to have a high Clavien-Dindo (2-5) category complication (OR = 0.44, 95% CI 0.20-0.93, p = 0.0311). Conclusion Smokers who have undergone surgical resection of rectal cancer have a significantly increased risk of post-operative complications after DI reversal. In these patients, the importance of smoking cessation must be emphasised. The decreased complication rate observed in patients who received adjuvant chemotherapy was an unexpected finding.

Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesia care unit. The primary hypothesis was that a clinical trial of advanced recovery room care was feasible. The secondary hypothesis was that this model may have a sustained impact on postoperative in-hospital and post-discharge events. This was a multicentre, prospective, feasibility before-and-after trial of moderate-risk patients (predicted 30-day mortality of 1-4%) undergoing non-cardiac surgery and who were scheduled for postoperative ward care. Patients were managed using defined assessment checklists and goals of care in an advanced recovery room care setting in the immediate postoperative period. This utilised existing post-anaesthesia care unit infrastructure and staffing, but extended care until the morning of the first postoperative day. The advanced recovery room care trial was deemed feasible, as defined by the recruitment and per protocol management of > 120 patients. However, in a specialised cancer centre, recruitment was slow due to low rates of eligibility according to narrow inclusion criteria. At a rural site, advanced recovery room care could not be commenced due to logistical issues in establishing a new model of care. A definitive randomised controlled trial of advanced recovery room care appears feasible and, based on the indicative data on outcomes, we believe this is warranted.

Background Hepatectomy has been the gold standard procedure for curative treatment of benign and malignant hepatobiliary lesions for over a century. The aim of this study is to report on the 16-year experience of a single institution. Methods All patients admitted to The Queen Elizabeth Hospital, South Australia, for a hepatectomy between 2001 and 2016 were included in this audit. Data regarding demographics, tumour type and operative outcomes were prospectively collected. To identify trends, patients were divided into four periods, each spanning 4 years (Period 1 = 2001-2004, Period 2 = 2005-2008, Period 3 = 2009-2012 and Period 4 = 2012-2016). Results Between 2001 and 2016, 388 consecutive patients (230 men; 158 women; mean age ± SD = 63.7 ± 13.0 years) underwent hepatectomy. From Periods 2 to 4, complex cases increased from 14.4% to 18.9%, and there was an increase in mean duration of operation time from 187.0 ± 60.6 to 217.3 ± 78.7 min. Length of hospitalization decreased from Periods 1 to 4 (12.2 ± 9.2 to 8.1 ± 5.6 days). Intraoperative and 90-day mortalities were 0.5% and 2.3%, respectively. Length of stay, morbidity and 90-day mortality were significantly affected by mass of resection. Conclusion Hepatectomy can be safely performed in a specialized Western centre with low mortality. Advances in health care have facilitated in shorter duration of hospitalization despite more frequent complex resections, operating on older patients and patients with worse American Society of Anesthesiologists scores, without increasing rates of mortality.

BACKGROUND AND AIM Adenoma detection rate (ADR) is an important quality metric in colonoscopy. However, there is conflicting evidence around factors that influence ADR. This study aims to investigate the effect of time of day and endoscopist background on ADR and sessile serrated adenoma/polyp detection rate (SSA/P-DR) for screening colonoscopies. METHODS Consecutive patients undergoing colonoscopy in 2016 were retrospectively evaluated. Primary outcome was the effect of time of day and endoscopist specialty on screening ADR. Secondary outcomes included evaluation of the same factors on SSA/P-DR and other metrics and collinearity of ADR and SSA/P-DR. Linear regression models were used for association between ADR, time of day, and endoscopist background. Bowel preparation, endoscopist, session, patient age, and gender were adjusted for. Linear regression model was also used for comparing ADR and SSA/P-DR. Chi-square was used for difference of proportions. RESULTS Two thousand six hundred fifty-seven colonoscopies, of which 558 were screening colonoscopies, were performed. The adjusted mean ADR (screening) was 36.8% in the morning compared with 30.5% in the afternoon (P

Impaired glucose tolerance (IGT) in cystic fibrosis (CF) manifests as postprandial hyperglycaemia. Pancreatic enzyme supplementation reduces the latter; restoring incretin secretion and slowing gastric emptying. We aimed to determine the acute effect of exenatide on postprandial glycaemia in young people with CF and IGT. Six participants with CF and IGT were studied on 2 days, in a double-blind randomized crossover trial. After overnight fasting, they received exenatide 2.5 mcg or placebo (0.9% saline) subcutaneously 15 minutes before a pancake meal labelled with 13 C octanoate and pancreatic enzyme replacement. The primary outcomes, area under the curve over 240 minutes (AUC 240 ) for blood glucose (P < 0.0001) and peak blood glucose (7.65 mM ± 0.34 [mean ± SE] vs 9.53 mM ± 0.63, P < 0.0001), were markedly lower after exenatide than placebo. AUC240 for insulin, C-peptide, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) was also lower after exenatide. Gastric emptying was markedly slower after exenatide, as assessed by time for 10% gastric emptying and peak 13 CO2 excretion. We report for the first time that exenatide corrects postprandial hyperglycaemia in young people with CF and IGT. GLP-1 agonists are a candidate treatment in CF-related diabetes.

Objective To provide a current review of the clinical characteristics, predictors and outcomes in critically ill patients presenting to the ED with acute pancreatitis and subsequently admitted to an intensive care unit (ICU) of a tertiary referral centre in Australia. Methods A retrospective single-centre study of adult patients admitted with pancreatitis. Severe acute pancreatitis defined by Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥2. Results Eighty-seven patients fulfilled criteria for inclusion during the study period, representing 0.9% of all ICU admissions. The median age of patients was 54. Survival was independent of patients’ age, sex, aetiology and comorbidities. Mortality was 30.8% for both inpatient referrals to the ICU and for direct referrals via the ED. Higher mortality was identified among patients requiring mechanical ventilation (74.2 vs 24.6% in survivors; P

Objectives: The efficacy of lamotrigine as maintenance treatment for bipolar disorder (BD), particularly for delaying depressive episodes, is well established, but its efficacy in the acute treatment of bipolar depression is less clear. This paper reports the results of five randomized, double-blind, placebo-controlled trials of lamotrigine monotherapy for the acute treatment of bipolar depression. Methods: Adult subjects with bipolar I or II disorder experiencing a depressive episode were randomized to placebo or lamotrigine monotherapy (after titration, at a fixed dose of 50 mg or 200 mg daily in Study 1; a flexible dose of 100–400 mg daily in Study 2; or a fixed dose of 200 mg daily in Studies 3, 4 and 5) for 7–10 weeks. Results: Lamotrigine did not differ significantly from placebo on primary efficacy endpoints [17-item Hamilton Depression Rating Scale in Studies 1 and 2; Montgomery–Asberg Depression Rating Scale (MADRS) in Studies 3, 4 and 5]. In Study 1, lamotrigine significantly separated from placebo on some secondary measures of efficacy, including the MADRS, the Clinical Global Impressions-Severity (CGI-S) and the CGI-Improvement (CGI-I), but seldom differed on secondary efficacy endpoints for the other studies. Conclusions: Lamotrigine monotherapy did not demonstrate efficacy in the acute treatment of bipolar depression in four out of five placebo-controlled clinical studies. Lamotrigine was well tolerated in the acute treatment of bipolar depression.

Questionnaires were sent to 900 secondary school teachers throughout England and Wales; 373 (41%) were returned. Teachers agreed on many issues but opinion was divided on the abolition of the remaining grammar schools and the question of mixed‐ability teaching. Underlying dimensions of traditionalism, belief in equality of the sexes and feminism were identified in teachers’ attitudes. Older teachers were more traditional than younger ones, and science and craft teachers were more traditional than arts teachers. Women were more emphatic about sex equality than men and London teachers were more feminist than others. Teachers in schools which had been involved in the Girls Into Science and Technology (GIST) project were slightly less traditional and more in favour of equality of the sexes than other teachers.