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Objective To develop and evaluate the performance of artificial intelligence (AI) models that can identify safe and dangerous zones of dissection, and anatomical landmarks during laparoscopic cholecystectomy (LC). Summary background data Many adverse events during surgery occur due to errors in visual perception and judgment leading to misinterpretation of anatomy. Deep learning, a subfield of AI, can potentially be used to provide real-time guidance intraoperatively. Methods Deep learning models were developed and trained to identify safe (Go) and dangerous (No-Go) zones of dissection, liver, gallbladder, and hepatocystic triangle during LC. Annotations were performed by four high-volume surgeons. AI predictions were evaluated using 10-fold cross-validation against annotations by expert surgeons. Primary outcomes were intersection-over-union (IOU) and F1 score (validated spatial correlation indices), and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, ± standard deviation. Results AI models were trained on 2627 random frames from 290 LC videos, procured from 37 countries, 136 institutions and 153 surgeons. Mean IOU, F1 score, accuracy, sensitivity, and specificity for the AI to identify Go zones were 0.53 (±0.24), 0.70 (±0.28), 0.94 (±0.05), 0.69 (±0.20) and 0.94 (±0.03) respectively. For No-Go zones, these metrics were 0.71 (±0.29), 0.83 (±0.31), 0.95 (±0.06), 0.80 (±0.21) and 0.98 (±0.05), respectively. Mean IOU for identification of the liver, gallbladder and hepatocystic triangle were: 0.86 (±0.12), 0.72 (±0.19) and 0.65 (±0.22), respectively. Conclusions AI can be used to identify anatomy within the surgical field. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.

Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks.This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods.Twenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061).In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Despite the support for and benefits of data-driven learning, physician engagement is variable. This study explores systemic influences of physician use of data for performance improvement in continuing professional development (CPD) by analyzing and interpreting data sources from organizational and institutional documents.The document analysis is the third phase of a mixed-methods explanatory sequential study examining cultural factors that influence data-informed learning. A gray literature search was conducted for organizations both in Canada and the United States. The analysis contains nonparticipant observations from professional learning bodies and medical specialty organizations with established roles within the CPD community known to lead and influence change in CPD.Sixty-two documents were collected from 20 Canadian and American organizations. The content analysis identified the following: (1) a need to advocate for data-informed self-assessment and team-based learning strategies; (2) privacy and confidentiality concerns intersect at the point of patient data collection and physician-generated outcomes and need to be acknowledged; (3) a nuanced data strategy approach for each medical specialty is needed.This analysis broadens our understanding of system-level factors that influence the extent to which health information custodians and physicians are motivated to engage with data for learning.

Background Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR). Methods In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2–3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points. Results Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p

Older adults living with dementia are at risk for more complex health care transitions than individuals without this condition, non-impaired individuals. Poor quality care transitions have resulted in a growing body of qualitative empirical literature that to date has not been synthesized. We conducted a systematic literature review by applying a meta-ethnography approach to answer the following question: How do older adults with dementia and/or their caregivers experience and perceive healthcare transition: Screening resulted in a total of 18 studies that met inclusion criteria. Our analysis revealed the following three categories associated with the health care transition: (1) Feelings associated with the healthcare transition; (2) processes associated with the healthcare transition; and (3) evaluating the quality of care associated with the health care transition. Each category is represented by several themes that together illustrate an interconnected and layered experience. The health care transition, often triggered by caregivers reaching a “tipping point,” is manifested by a variety of feelings, while simultaneously caregivers report managing abrupt transition plans and maintaining vigilance over care being provided to their family member. Future practice and research opportunities should be more inclusive of persons with dementia and should establish ways of better supporting caregivers through needs assessments, addressing feelings of grief, ongoing communication with the care team, and integrating more personalized knowledge at points of transition.

Telesimulation (TS), the process of using the internet to link educators and trainees at locations remote from one another, harnesses the powers of technology to enable access to high-quality simulation-based education and assessment to learners across the globe. From its first uses in the teaching and assessment of laparoscopic skills to more recent interpretations during the current pandemic, TS has shown promise in helping educators to address pressing dilemmas in medical education.

Summary Postoperative occurrence of pneumonia can increase lengths of stay, risk of morbidity and death and health care costs. At Toronto General Hospital, we identified a high incidence of postoperative pneumonia in patients undergoing hepatectomy and Whipple procedures in 2016. To reduce the incidence of postoperative pneumonia, we implemented an evidence-based bundle approach in 2017. The bundle included the following components: oral care, incentive spirometry, coughing and deep breathing, physical activity, elevation of the head of the bed, and patient and family education. In addition to the bundle components, we provided staff education and created patient education and monitoring tools to ensure competency and compliance with the bundle components. Data collected as part of the National Surgical Quality Improvement Program were reviewed to monitor progress. In this article, we discuss our approach, aimed to reduce the incidence of postoperative pneumonia and associated health care costs in the general surgery population.

The increased use of endoscopy as a minimally invasive therapeutic technique has created a great demand for endoscopic training. The Basic Endoscopic Skills Training (BEST) box provides a low-cost solution by adapting the Fundamentals of Laparoscopic Surgery (FLS) box for flexible endoscopic simulation. The BEST box consists of six endoscopic tasks with a 5-min time limit per task. This study aims to develop a scoring system for objective evaluation of user performance. A total of 165 participants were tested on the BEST box. Participants were divided into two groups: retrospective analysis (n = 100) and prospective analysis (n = 65). From the retrospective group, 55 individuals were also scored on the Global Assessment of Gastrointestinal Endoscopic Skills-Upper Endoscopy (GAGES-UE). Linear regression between user performance on BEST box and GAGES-UE was performed to develop the scoring system. Receiver Operating Characteristic curve was used to determine a threshold score to help users appreciate their endoscopic expertise. Prospective scoring of 65 individuals was then performed using the formula developed (20 experts and 45 trainees). The minimum and maximum possible scores are 30 and 110, respectively. Retrospective analysis showed that the scoring system was able to distinguish between experts and trainees (p

Our qualitative descriptive study compared how older patients and their informal caregivers experienced the care transition from acute care or rehabilitation to home. We recruited patients 65 years of age or older, or their informal caregivers, from in-patient units within acute care hospitals and rehabilitation facilities to participate in semi-structured interviews. We identified emergent themes via thematic analysis. In all, 16 patients and four patient caregivers participated. Across all care settings, caregivers were integral in facilitating the transition as well as experiencing variable discharge preparation, health care providers’ optimizing transitions, and missed care and medication discrepancies at transition points. Orthopedic and rehabilitation patients more commonly voiced prior transition experiences in discharge preparation, including having to unexpectedly coordinate and wait for outpatient services. Differing responses between acute care and orthopedic settings suggest that transitional care practices and policies favor an individualized approach that considers patients’ previous experiences, needs, and care expectations.

Background Obesity and type 2 diabetes can be associated with poor oral health. This can be because of hyposalivation leading to chronic oral inflammation (OI) and periodontal disease. Objective To assess the prevalence of hyposalivation and OI in individuals undergoing Roux-en-Y gastric bypass (RYGB) and determine the relationship with metabolic and anthropometric parameters before and after RYGB. Setting University hospital in Canada. Methods This was a cross-sectional and prospective cohort study of 59 patients undergoing RYGB from September 2015 to December 2019. Anthropometric, biochemical, and oral measurements were taken before surgery and 1 and 6 months post RYGB. Oral parameters included salivary flow rate and neutrophil count as marker of OI. Results Fifty-nine patients were enrolled with 29 completing this study. At baseline, the median age was 47 years and body mass index was 46.5 kg/m2, 52 (88.1%) were female and 14 individuals (23.7%) had type 2 diabetes; 54.2% (n = 32) of patients had hyposalivation and 13.6% (n = 8) had high neutrophil count. Patients with hyposalivation had significantly higher fasting glucose (5.7 mmol/L) compared with those without hyposalivation (5.2 mmol/L) but no difference was found between high versus low neutrophil count. At 6 months post RYGB, all variables except oral neutrophil count significantly improved. Hyposalivation persisted in 7 (24%) individuals. Conclusions In our bariatric patients, more than half the patients had hyposalivation before RYGB and this was associated with higher fasting glucose. Hyposalivation improved post RYGB in parallel with improvements in metabolic parameters but there was no change in OI. Increased salivation may reduce the risk of periodontal disease.

Context.— Laparoscopic sleeve gastrectomy (LSG) has quickly become the bariatric surgical procedure of choice for patients with obesity who have failed medical management. Laparoscopic sleeve gastrectomy results in a gastric remnant that is routinely subject to pathologic examination. Objective.— To perform a histologic and cost-benefit analysis of gastric remnants post-LSG. Design.— All LSG cases performed at University Health Network, Toronto, Ontario, Canada, between 2010 and 2019 were reviewed. Specimens that underwent routine histopathologic assessment and ancillary immunohistochemical analysis were analyzed. Baseline patient characteristics and surgical outcomes were obtained from our internal database. The total cost of specimen gross preparation, examination, sampling, and producing and reporting a hematoxylin-eosin slide was calculated. Results.— A total of 572 patients underwent LSG during the study period and had their specimens examined histologically. A mean of 4.87 blocks generating 4 hematoxylin-eosin slides was produced. The most common histologic findings reported in LSG specimens ranged from no pathologic abnormalities identified together with proton pump inhibitor–related change. A minority of cases demonstrated clinically actionable histologic findings, of which Helicobacter pylori infection was the most common. The total cost for the complete pathologic analysis of these cases amounted to CaD $66 383.10 (US $47 080.21) with a mean of CaD $116.05 (US $82.40) per case. A total of CaD $62 622.75 (US $44 413.30) was spent on full examination of cases that had no further postoperative clinical impact. Conclusions.— There is a broad spectrum of pathologic findings in LSG specimens, ranging from clinically nonactionable to more clinically actionable. The vast majority of histologic findings had no clinical impact, with only a minority of cases being clinically significant. This study therefore recommends that LSG specimens be subject to gross pathologic examination in the vast majority of cases. However, sections should be submitted for microscopic analysis if grossly evident lesions are present and if there is a clinical/known history of clinically actionable findings.

Opioid consumption in North America has risen to alarming levels and represents a potentially modifiable risk factor in perioperative management. Chronic pain and obesity are commonly associated and bariatric surgery remains the most effective intervention for weight loss in morbidly obese patients.To understand how preoperative opioid use impacts surgical outcomes in patients undergoing bariatric surgery.The Ontario Bariatric Registry.Data collected in the Ontario Bariatric Registry between 2010 and 2018 were used for this retrospective study. Preoperative opioid use was retrospectively retrieved from the medication review during preoperative assessment. Primary outcomes were complications and readmissions at 30 and 90 days of surgery. Secondary outcomes included hospital length of stay and complication types at 30 and 90 days. Analyses were risk-adjusted for procedure type and patient-specific risk factors, such as age, sex, race, body mass index, and co-morbid conditions.Overall, 5357 patients were included in the study. Among those, 12% (n = 643) used opioids preoperatively. Risk-adjusted analyses demonstrated that opioid users, compared with opioid-naïve patients, had a longer length of stay (odds ratio: 2.50, 95% confidence interval: 1.05-6.00, P.05) and higher rates of complications at 30 days (odds ratio: 1.40, 95% confidence interval: 1.02-2.18, P.05). Subgroup analyses revealed that within preoperative opioid users, patients who underwent Roux-en-Y gastric bypass had poorer outcomes than those who underwent sleeve gastrectomy.Opioid use is common before bariatric surgery and is independently associated with prolonged length of stay and complication rates at 30 days. Preoperative opioid use represents a potentially modifiable risk factor and a unique target to improving the quality of surgical care.

The role of preoperative screening and treatment of Helicobacter pylori (HP) in asymptomatic patients undergoing laparoscopic sleeve gastrectomy (LSG) remains unclear. This study aims to define the preoperative prevalence and management of HP and their effect on postoperative outcomes at our institution. We reviewed the medical records and surgical specimens of all LSG performed at an academic centre in Toronto, ON between 2010 and 2017. Review of our institutional database identified 222 patients that underwent LSG, of which 200 had preoperative HP screening: 18% tested positive and 15% were treated. Seven surgical specimens were HP-positive (3.2%). No association was found between preoperative HP status, treatment or HP-positive specimen and postoperative complications at 1 year. Although preoperative screening and treatment likely reduce the prevalence of HP in LSG specimens, our findings suggest that they may be of limited clinical value in LSG as they have little influence on surgical morbidity.

Background Improving the quality of care for patients who return home after a hospital stay is an international priority; however, few jurisdictions have engaged broadly with patients and caregivers to understand what most affects their experience transitioning home. We performed Ontario-wide group concept mapping, beginning with a brainstorming phase, to understand patient and caregiver priorities in the transition. Methods We used group concept mapping to engage patients and caregivers who had lived experience transitioning from hospital to home in Ontario in the previous 3 years. We report on the first phase, brainstorming, conducted over 10 weeks beginning Jan. 11, 2018 via an online survey or facilitated group discussion. Participants responded to a single focal prompt: "When leaving the hospital for home, some thing(s) that affected the experience were: ____." The study team identified recurrent concepts and overarching themes. Patients and caregivers informed the study design, recruitment and data interpretation. Results In all, 665 people (263 patients [39.5%], 352 caregivers [52.9%] and 50 people who were both patient and caregiver [7.5%]) participated in brainstorming online, and 71 people participated in 1 of 8 group discussions. Participants identified 6 key areas affecting their experience of transition from hospital to home: home and community care, the discharge process, medical follow-up after discharge, medications, patient and caregiver education, and the kindness and caring of the health care team in hospital. Most notable were challenges with the timeliness, sufficiency, reliability and consistency of publicly funded home care services. Interpretation Patients and caregivers from across Ontario noted a range of issues affecting their experience transitioning from hospital to home, particularly the quality and sufficiency of publicly funded home care. Our findings will be used to inform a provincial quality standard on the transition from hospital to home.

Background In a fiscally constrained health care environment, the need to reduce unnecessary spending is paramount. Postoperative complications contribute to hospital costs and utilization of health care resources. Objective The purpose of this observational study was to identify the cost associated with complications of common general surgery procedures performed at a major academic hospital in Toronto, Ontario. Methods The institutional National Surgical Quality Improvement Program database was used to identify complications in patients who underwent general surgical procedures at our institution from April 2015 to February 2018. A mix of elective and emergent cases was included: bariatric surgery, laparoscopic appendectomy, laparoscopic cholecystectomy, thyroidectomy, right hemicolectomy and ventral incisional hernia repair. The total cost for each visit was calculated by adding all the aggregate costs of inpatient care. Median total costs and the breakdown of cost components were compared in cases with and without complications. Results A total of 2713 patients were included. Nearly 6% of patients experienced at least one complication, with an incidence ranging from 1.1% after bariatric surgery to 23.8% after right hemicolectomy. The most common type of complication varied by procedure. Median total costs were significantly higher in cases with complications, with a net increase ranging from $2989 CAD (35% increase) after bariatric surgery to $10 459 CAD (161% increase) after ventral incisional hernia repair. Conclusion Postoperative complications after both elective and emergent general surgery procedures add substantially to hospital costs. Quality improvement initiatives targeted at decreasing postoperative complications could significantly reduce costs in addition to improving patient outcomes.

Background Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are at high-risk of readmission after hospital discharge. There is conflicting evidence however on whether timely follow-up with a primary care provider reduces that risk. The objective of this study is to understand the perspectives of patients with COPD and CHF, and their caregivers, on the role of primary care provider follow-up after hospital discharge. Methods A qualitative study design with semi-structured interviews was conducted among patients or their family caregivers admitted with COPD or CHF who were enrolled in a randomized controlled study at three acute care hospitals in Ontario, Canada. Participants were interviewed between December 2017 to January 2019, the majority discharged from hospital at least 30 days prior to their interview. Interviews were analyzed independently by three authors using a deductive directed content analysis, with the fourth author cross-comparing themes. Results Interviews with 16 participants (eight patients and eight caregivers) revealed four main themes. First, participants valued visiting their primary care provider after discharge to build upon their longitudinal relationship. Second, primary care providers played a key role in coordinating care. Third, there were mixed views on the ideal time for follow-up, with many participants expressing a desire to delay follow-up to stabilize following their acute hospitalization. Fourth, the link between the post-discharge visit and preventing hospital readmissions was unclear to participants, who often self-triaged based on their symptoms when deciding on the need for emergency care. Conclusions Patients and caregivers valued in-person follow-up with their primary care provider following discharge from hospital because of the trust established through pre-existing longitudinal relationships. Our results suggest policy makers should focus on improving rates of primary care provider attachment and systems supporting informational continuity.

Introduction Accelerating rates of dementia worldwide coupled with older adults living longer in the community calls for greater focus on quality home care support services. Few frameworks for quality dementia home care exist though prior findings have found elements considered to be important for “good” home care for people living with dementia. This study aimed to identify core components of a quality home care experience for people with dementia and their caregivers. Methods As part of a larger research study, in-depth interviews were conducted with persons living with dementia and caregivers (n = 25) to explore hospital-to-home care transitions. The design used for this study was a qualitative description. We used deductive-inductive thematic analysis, which was informed by previous work in this area. Open codes were mapped to pre-determined themes, and for codes not accommodated by an a piori framework, new themes were developed. Findings Our findings resulted in 4 overarching themes. Two themes were identified deductively (Availability and Acceptability of Home Care Services) and two inductively (Adaptability and Affordability of Home Care Services). Findings highlight the roles of family—care provider partnerships and responsive support in receiving quality home care, and the cost associated with unmet needs. Interpretation With an aging population, an increase in home care client acuity, and post-COVID-19 concerns over long-term care, more attention is needed to improve the quality of home care. The demand for these services will continue to increase particularly for those living with dementia and their families. The findings of availability, acceptability, adaptability, and affordability as core to quality care can help lay the groundwork for a home care framework for persons living with dementia and their caregivers. Future research could benefit from comparative analyses to evaluate the applicability of the findings to non-dementia home care service users and caregivers.

Laparoscopic sleeve gastrectomy (LSG) represents one of the most commonly performed bariatric procedures and, in contrast to the Roux-en-Y gastric bypass, produces a specimen for pathologic examination. This study aims to describe unexpected histopathological findings in order to better define preoperative management of patients undergoing LSG. All LSG cases performed at an academic center in Toronto, Ontario between 2010 and 2017 were reviewed. All specimens underwent histopathological assessment, while those with findings suspicious for neoplasia or the presence of Helicobacter pylori underwent additional immunohistochemical stainings. Baseline patient characteristics and surgical outcomes were obtained from our internal database. A total of 222 patients underwent LSG during the study period and had their specimens examined histologically. Among them, 22.5% underwent preoperative endoscopy. The most common histopathological diagnosis was no abnormal findings (50.9%) followed by gastritis (25.7%). Abnormal findings warranting a change in postoperative management or follow-up were discovered in 8.6% of specimens and included H. pylori infection, intestinal metaplasia, malignancy, and atrophic gastritis. Only 4.7% of all patients had not undergone preoperative endoscopy and had truly unexpected findings. No significant association was found between abnormal findings and age, sex, or baseline body mass index (BMI). Although a majority of patients had a gastric specimen within normal limits, 8.6% had findings requiring a change in postoperative management. This rate dropped to 4.7% when patients whose diagnoses were known preoperatively were excluded. Our findings suggest that further research is needed to better define the role of preoperative endoscopy to potentially reduce the number of unexpected findings following LSG.

In Canada, bariatric surgery continues to remain the most effective treatment for severe obesity and its comorbidities. As the number of bariatric surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. In colorectal surgery, enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this review is to develop evidence-based ERAS guidelines for bariatric surgery. A literature search of the MEDLINE database was performed using ERAS-specific search terms. Recently published articles with a focus on randomized controlled trials, systematic reviews, and meta-analyses were included. Quality of evidence and recommendations were evaluated using the GRADE assessment system. Canadian bariatric surgeons from six provinces and ten bariatric centers performed a review of the evidence surrounding ERAS in bariatric surgery and created consensus guidelines for 14 essential ERAS elements. Our main recommendations were (1) to encourage participation in a presurgical weight loss program; (2) to abstain from tobacco and excessive alcohol; (3) low-calorie liquid diet for at least 2 weeks prior to surgery; (4) to avoid preanesthetic anxiolytics and long-acting opioids; (5) unfractionated or low-molecular-weight heparin prior to surgery; (6) antibiotic prophylaxis with cefazolin ± metronidazole; (7) reduced opioids during surgery; (8) surgeon preference regarding intraoperative leak testing; (9) nasogastric intubation needed only for Veress access; (10) to avoid abdominal drains and urinary catheters; (11) to prevent ileus by discontinuing intravenous fluids early; (12) postoperative analgesia with acetaminophen, short-term NSAIDS, and minimal opioids; (13) to resume full fluid diet on first postoperative day; (14) early telephone follow-up with full clinic follow-up at 3–4 weeks. The purpose of addressing these ERAS elements is to develop guidelines that can be implemented and practiced clinically. ERAS is an excellent model that improves surgical efficiency and acts as a common perioperative pathway. In the interim, this multimodal bariatric perioperative guideline serves as a common consensus point for Canadian bariatric surgeons.

The fundamentals of laparoscopic surgery (FLS) program is a simulation-based training program designed to teach and assess the basic skills necessary for laparoscopic surgery. Preliminary work has demonstrated the feasibility of using Skype™ as a telesimulation modality in reliably scoring the exam for remote centers. Google Glass (GG) (Mountain View, California) is referred to as a wearable computer containing a heads-up display and front-facing camera allowing point-of-view video transmission. The objective of this study was to evaluate the feasibility of GG in scoring the technical skills component of the FLS exam. Twenty-eight participants were asked to complete the peg transfer and intracorporeal knot tasks of FLS using both GG and Skype™ setups. GG employed a third-party HIPAA-compliant video software (Pristine; Austin, TX) for video transmission. Participants were alternated between setups and evaluated by onsite and remote proctors. Times and errors were recorded by both proctors. Interrater reliability of their FLS scores was compared using Intraclass Correlation Coefficients (ICCs). GG experience was evaluated based on participant survey responses using a 5-point Likert scale. Interrater reliability for GG demonstrated a statistically significant correlation between onsite (OP) and remote (RP) proctors with ICCs of 0.985 (95% Confidence Interval [CI], 0.969–0.993) and 0.997 (95% CI 0.993–0.998), respectively, for peg and suture tasks. Skype™ demonstrated ICCs of 1.0 (95% CI 1.0–1.0). Average Likert scale responses found GG to be distracting (2.71), obstructive of the view (2.79), and a limitation to task execution (2.75). Overall, there was no statistical difference in scores between GG and Skype™ setups for either the peg (t = 1.446, p = 0.154) or suture task (t = − 0.710, p = 0.480), only 1 participant found the use of GG superior to Skype™. Our findings suggest that although GG are feasible in remote assessment of FLS with strong interrater reliability (ICC > 0.95), Skype™ was the preferred modality.

The use of a flexible optical bronchoscopic (FOB) for intubation is an essential airway management skill.Our primary objective was to compare the effects of simulator training (ORSIM high-fidelity simulator) with no simulation training on the performance of FOB intubation in anaesthetised patients.Randomised controlled trial.Single-centre tertiary hospital; trial conducted between April 2015 to May 2016.Medical students, anaesthesia assistants and anaesthesia residents with experience of less than five FOB intubations from whom informed consent was obtained.Students, anaesthesia assistants and anaesthesia residents viewed a didactic presentation before performing an initial FOB intubation in an anaesthetised patient. Intubations were recorded and evaluated using the Global Rating Scale (GRS) and checklist scores. Subsequently, participants were randomised to control group (Group CON) and had no simulation training, or to a simulation group (Group SIM) and underwent 60 min of simulation practice. Within a week, participants performed a second FOB intubation and were similarly evaluated.Pretraining and posttraining intubation time, GRS and checklist scores.Baseline characteristics were similar between groups. In Group SIM, there was significant improvement between pre and posttraining GRS [22.9 ± 8.1 vs. 28.2 ± 7.3, mean difference (95% CI) 5.3 (0.3 to 10.3), P = 0.04], and intubation time [177.6 ± 77.6 vs. 119.3 ± 52.2 s, mean difference (95% CI) -58.4 (-100.3 to -16.5) s, P = 0.01]. There was no difference in Group CON, between pre and posttraining intubation time, GRS or checklist.We conclude, posttraining performance of FOB intubation, as measured by intubation time and GRS, improved in Group SIM, while it was unchanged in the Group CON. The ORSIM simulator may be a useful adjunct in acquiring FOB intubation skills.ClinicalTrials.gov ID: NCT02699242.

Background Obesity affects individuals worldwide and is currently the 5 th leading cause of death according to the WHO. Bariatric surgery is an effective strategy that produces durable long-term weight loss. There is a bidirectional interplay between mental health and obesity; with higher depression and anxiety in the obese population as well as significant effects on weight loss for people with mental health disorders. Objective Our cross-sectional study aimed to examine psychosocial predictors of cognition for the pre-operative bariatric surgery population and its effect on work productivity. Methods Demographic data, perceived cognitive deficits (PDQ-5), depression scale (PHQ-9), anxiety (GAD-7), Quality of life (SF36) and work impairment (LEAPS) was collected from 302 pre-operative bariatric surgery candidates at their initial assessment. Multiple regression was conducted with perceived cognitive deficits as the dependent variable. A secondary analysis was done controlling for anxiety and depression. Results Variables that were significantly associated with perceived cognition were anxiety, depression, work productivity and overall mental health quality of life. Perceived cognition was also significantly associated with work impairment independent of mood symptoms. Discussion Anxiety and depression are prevalent in the pre-operative bariatric surgery population, significantly affecting cognition, and should be routinely screened. Work performance was also affected by cognition in our population but the link between obesity and cognition needs to be further explored. Conclusions We identified a significant association between perceived cognition and psychosocial factors in pre-operative bariatric surgery candidates. Further studies will be needed to better explore obesity and its impact on cognition.

Laparoscopic adjustable gastric banding (LAGB) has declined in popularity due to poor weight loss and high revision rates. The study aim was to evaluate complication rates following LAGB removals, including conversions to other bariatric procedures.This was a retrospective cohort study of patients who underwent LAGB removal, identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from the Toronto Western Hospital site. Patients were filtered using principal procedure and concurrent procedural terminology (CPT) codes. Patients converted to other bariatric procedures were also included. Outcomes were evaluated for 30-day morbidity, mortality, readmissions, and costs.From 2012 to 2018, 93 patients met inclusion. 96.77% had elective surgery, and 3.23% were emergent. Thirty-day postoperative complication rate was 11.83%, with 4.30% readmissions and no deaths. Surgical site infections accounted for 81.82% of complications (54.55% superficial, 27.27% deep). Thirty-day complication rate for LAGB removal alone was 17.50% and 33.33% following emergent explantation. 56.99% LAGBs were converted to other bariatric procedures: 48.39% laparoscopic Roux-en-Y gastric bypass (LRYGB) and 8.6% sleeve gastrectomy (LSG). Conversion to LSG had a significantly higher 30-day complication rate (all Clavien-Dindo class I-II) compared to conversion to LRYGB (37.50% versus 2.22%, p 0.009). Direct costs of LAGB explantation to the healthcare system were $665,443, amounting to $7,155 per patient.Thirty-day complication rates for LAGB explantation and conversion to other bariatric procedures are significant and may be higher than previously reported for LAGB removal alone. Conversion to LSG may have the highest complication rate, amounting to significant costs.

Reducing inappropriate blood tests has been highlighted by Choosing Wisely as a key area of focus. Computer physician order entry is one modifiable contributor, but little is known about how computer ordering compares to paper methods when it comes to low-value laboratory testing.To determine which method of order entry is associated with a greater amount of appropriate lab testing. Furthermore, to identify ordering patterns for more targeted interventions in future.We conducted a retrospective observational cohort study of inpatients discharged at two hospitals (one site uses paper order sets, while the other uses electronic order sets).General internal medicine wards at two Canadian teaching hospitals.At site 1 (electronic orders), all general internal medicine discharges from May 2015 and February 2016. At site 2 (paper orders), all general internal medicine discharges from April 15, 2015 to May 26, 2015.Main outcome was the percentage of inpatient discharges at each site with orders for daily laboratory tests for three days on admission. Secondary measures include proportion of tests with appropriate indications and rates of discontinuation of daily laboratory tests.We reviewed 395 discharges with a mean patient age of 69.5 ± 18.9 years and mean length of stay of 12.1 days. Daily laboratory tests were more common with paper orders (site 2) compared to electronic order sets (site 1) for complete blood count (CBC) (90.8% vs. 68.5%, p 0.001), electrolytes (93.8% vs 71.5%, p 0.001), and creatinine (93.8% vs 70.0%, p 0.001) testing. However, paper orders for daily laboratory tests were more often appropriate, both in CBC (76.3% vs. 38.9%, p 0.001) and electrolyte/creatinine (80.3% vs 44.2%, p 0.001) testing. Discontinuation of daily labs occurred more often with paper orders (35.4% vs. 6.7%, p 0.001).Compared to written orders, daily laboratory testing using electronic ordering was associated with higher rates of inappropriate indications and lower rates of discontinuation. Our results support interventions aimed at ensuring electronic order sets incorporate appropriate indications and a mechanism for discontinuation of daily lab orders. Further studies aimed at understanding how the process of completing paper or electronic orders influence appropriateness of daily laboratory orders are needed to further minimize inappropriate testing.

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.

The reported incidence of surgical site infection (SSI) following bariatric surgery ranges from 1.4 to 30%. The use of skin staples and tissue adhesive was shown to be superior to sutures in reducing SSI in a variety of surgical disciplines; however, this area is under-investigated in elective bariatric surgery. The aim of this study was to examine the effect of tissue adhesive for skin closure on SSI in patients undergoing bariatric surgery.A retrospective analysis was performed to determine the incidence of SSI in patients who underwent elective laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Tissue adhesive was selectively used for skin closure during the study period. Patient characteristics, operative data, and 30-day postoperative outcomes were collected from patient charts and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.A total of 1,579 patients were included in the study. Tissue adhesive was used in 31.2% of all operations (n = 494). The rate of incisional SSI in our study was 2.2% (n = 35). The use of tissue adhesive was more common in patients who developed incisional SSI compared with those without incisional SSI (54.3 vs. 30.8%, p = 0.003). On multivariate analysis, the use of tissue adhesive remained an independent predictor for the development of incisional SSI (OR 2.77, p = 0.007).The use of tissue adhesive was an independent predictor for incisional SSI following elective bariatric surgery. This is the first study to report the effects of tissue adhesive in this patient population.

Despite growing international interest, the caregiving body of literature lacks a recent understanding of young carers’ experiences and their contact with the health care system. We conducted a systematic review of qualitative studies to (1) synthesize more recent qualitative evidence on young carers’ experience, and (2) to identify how these young carers interact with the health care system in their caregiving role. Using a meta-ethnographic synthesis, a total of 28 empirical studies met inclusion. Key findings helped inform an overarching framework of the experience of young carers as illustrated by a journey map. The journey map is a visual depiction of the stages these young carers go through when in a caregiving role framed by three themes: (1) encountering caregiving; (2) being a young caregiver, and (3) moving beyond caregiving. The caregiving experience is perceived by young people as challenging and complex, which could be improved with more informational navigation and emotional support. Understanding these experiences provides insight into gaps in health services and potential solutions that align with the stages outlined in the journey map.

Background Medication changes during transitions of care is a recognized challenge that has been linked to adverse events. The delivery of medication instructions during transition from hospital to home is a priority area for improvement. Objective The goals of this work were to 1) understand the current experiences of patients and families; and 2) co-design tools to improve medication information transfer during transitions of care together with patients, families, and providers. Methods A participatory action approach, using mixed methods within a design thinking framework was used. Participants were chosen from patient groups at higher risk of adverse events, guided by extreme user design, which posits that needs of extreme users can also fit the majority. Providers, patients and family (users) were interviewed to understand current experiences with medication information transfer during transitions of care and to solicit input on potential elements to inform tool design. Users were engaged in iterative creation of prototypes. Results A total of 116 patients, family caregivers, and providers were engaged throughout this project. Findings highlighted challenges currently experienced, strengthening the case for tools that engage the patient and family in medication information transfer. Important information included why medications were prescribed, how to take them, side effects, and an explanation of the role of community pharmacists. Displaying information in a grid format was preferred. Two tools were prototyped: (1) A Medication Whiteboard for engaging patients and families in creating their medication routine, and (2) A Patient Oriented Medication List for providing medication instructions and as a reference once patients are home. Conclusions Through the use of mixed methods within a design thinking framework, the team was able to understand the challenges and design prototypes of tools that both engage patients and families in developing their medication routine and improve medication information transfer during transitions of care.

Background Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process. Methods Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations. Results Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant. Conclusions This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation.

Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks.The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action.We conducted a narrative review of the existing literature surrounding the risks of viral transmission during laparoscopic surgery and balance these risks against the benefits of minimally invasive approaches. We also propose mitigation measures to address these risks that we have adopted in our institution.While it is currently assumed that open surgery minimizes operating room staff exposure to the virus, our findings reveal that this may not be the case. A well-informed, evidence-based opinion is critical when making decisions regarding which operative approach to pursue, for the safety and well-being of the patient, the operating room staff, and the healthcare system at large. Minimally invasive surgical approaches offer significant advantages with respect to both patient care, and the mitigation of the risk of viral transmission during surgery, provided the appropriate equipment and expertise are present.

Background Perioperative patient education and engagement are critical components of care in patients undergoing bariatric surgery, given the short length of stay and the requirements to adhere to various instructions. The use of patient engagement mobile technology may promote adherence to perioperative protocols and improve care by potentially identifying complications earlier and reducing associated health care costs. Materials and methods We introduced a mobile app that provides bariatric patients with access to educational materials and the ability to report on their symptoms. Using the data from the app and linking the data to patient outcomes collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we examined the effects of the app on readmission, length of stay, visits to the emergency department (ED), and patient satisfaction. Results A total of 505 patients were enrolled in the app between July 2017 and March 2019. Among them, 396 patients who met the inclusion criteria for the study were compared with 458 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who were not enrolled in the app for the same study period. While the use of the app was not associated with the rates of prolonged length of stay, ED visits, and readmission, patients who completed a survey at 30 d after discharge reported that the app helped them avoid phone calls to the hospital (48.5%) and ED visits (13.0%). Furthermore, 94.8% of these patients reported that they would recommend the app to other patients undergoing the same surgery. Conclusions Additional features, such as the ability for patients to directly communicate with the health care providers within the app, may be effective in decreasing unnecessary health care utilization.

Diabetic foot wounds account for up to one-third of diabetes-related health care expenditure and are the greatest cause of extremity amputation in Canada. Physicians encounter patients with such wounds in all specialties, particularly as generalists in medical wards and emergency departments. However, there is a dearth of literature on the optimal way to teach and to assess the management of these patients. Given the importance of assessment for learning in the shift toward competency-based medical education, we aimed to develop an assessment tool and to build validity evidence for its use in this context.A consensus process involving nine Canadian experts in diabetic wound management was used to develop the Diabetic Wound Assessment Learning Tool (DiWALT) items and two 10-minute simulation-based testing scenarios. The simulators used were modified from commercially available models to serve the testing scenarios. Validity evidence for the DiWALT was subsequently evaluated by assessing 24 physician participants' performance during the two scenarios. All participants were novices (50 cases managed). Two assessors independently rated participants using the DiWALT. Evidence was organized using Kane's validity framework and included Cronbach α for interitem consistency as well as test-retest and inter-rater reliability using the intra-class correlation coefficient (ICC).Cronbach α was 0.92, implying high internal consistency. Test-retest reliability was also excellent with ICC of 0.89 (confidence interval [CI], 0.76-0.95) for single measures and ICC of 0.94 (CI, 0.86-0.98) for average measures. Inter-rater reliability was fair for single measures with ICC of 0.68 (CI, 0.65-0.71) and good for average measures with ICC of 0.81 (CI, 0.79-0.83).These results demonstrate that the DiWALT consistently and reliably evaluates competence in diabetic wound management during simulated cases using a small, homogeneous sample of physicians. Further work is necessary to quantify sources of error in the assessment scores, to establish validity evidence when it is used to assess larger and more heterogeneous participants, and to identify how well the DiWALT differentiates between different experience levels.

Morbid obesity is associated with multiple comorbidities including obstructive sleep apnea (OSA) and non-alcoholic fatty liver disease (NAFLD). It has been suggested that OSA may contribute to NAFLD pathogenesis due to intermittent nocturnal hypoxia. The objective of this study was to assess the apnea-hypopnea index (AHI) and lower minimum oxygen saturation, markers of OSA, in patients undergoing bariatric surgery (BSx) with perioperative liver biopsy to detect NAFLD. This was a single center cross-sectional study of 61 patients undergoing BSx who consented to have a perioperative wedged liver biopsy. Biochemical, clinical, anthropometric variables, and a sleep study test were performed prior to BSx. NAFLD was diagnosed in 49 (80.3%) patients; 12 had normal liver (NL). Those with NAFLD had significantly higher (p

Marginal ulcer formation is a known complication following RYGB. While most respond to medical therapy, many patients have recurrent or chronic MU. Although non-steroidal anti-inflammatory drug (NSAID) use, smoking and Helicobacter pylori infection are known risk factors of MU, little is known about what increases the likelihood of developing recalcitrant ulcers. The objective of this study is to identify risk factors for marginal ulcer (MU) formation, including recalcitrant ulcers requiring surgical revision, and to define the incidence and outcomes of revisional surgery.All patients who underwent RYGB between 2011 and 2017 at a high-volume academic center were included. Patients with a postoperative diagnosis of MU were identified from the institution's bariatric database. Patient characteristics, operative data and surgical outcomes were analyzed using data collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and the Ontario Bariatric Registry.A total of 2830 RYGB were performed during the study period. The incidence of MU was 6.9% with 1% of patients requiring revisional surgery for a recalcitrant ulcer. Patients with a history of smoking (HR 5.03), immunosuppression (HR 4.60) and preoperative NSAID use (HR 3.11) were significantly more likely to develop a MU requiring surgical revision. Patients undergoing revision reported resolution of their symptoms in only 36% of cases with 57% developing a recurrent ulcer.Patients with a history of smoking and use of immunosuppressive medication were at significantly higher risk of developing MU that failed medical therapy. Additional evidence is needed to inform perioperative management of bariatric patients.

BackgroundBariatric surgical procedures are employed when there is a failure of lifestyle modification in arresting obesity. Laparoscopic sleeve gastrectomy (LSG) is quickly becoming the bariatric surgical procedure of choice. LSG results in a gastric remnant that is subject to pathological examination. The objective of this paper is to review the literature in regard to histological findings identified in gastric remnants post-LSG and identify the most pertinent histological findings.Materials and methodsA literature search was performed to identify relevant case series. Data gathered from relevant case series then underwent statistical analysis.ResultsThe most common histological findings in an LSG specimen were clinically indolent findings such as no pathological abnormalities identified followed by non-specific gastritis. A minority of cases demonstrated clinically actionable findings for which Helicobacter pylori represented the majority of these findings.ConclusionThere is a broad spectrum of pathological findings in LSG specimens, ranging from clinically indolent to clinically actionable. The most common histological findings are clinically indolent and only a small portion are of clinical significance and, hence, actionable.

Bariatric surgery is an effective weight loss tool that results in sustained weight loss, improvement in obesity-related comorbidities, and positive psychosocial outcomes. However, bariatric procedures also present with risks, as surgical complications are not uncommon.This study aims to better understand the effect of postoperative complications from bariatric surgeries on patients' psychosocial well-being.Surgical data on postoperative complications were matched with results from self-administered psychosocial questionnaires. Depression, anxiety, and quality of life (QOL) were assessed preoperatively, and at 1-year postoperatively.A total of 365 patients were included. Overall, the complication rate was 15.3% (n = 56), with 31 (8.5%) patients experiencing complications within 30 days of surgery, and 25 (6.8%) experiencing late complications. All patients achieved significant weight loss at 1-year postoperatively. Patients with uncomplicated recoveries showed significant improvement in depression (P0.001), anxiety (P0.001), mental QOL (P0.001), and physical QOL (P0.001) at 1-year postsurgery. Patients who experienced postoperative complications showed significant improvement in depression (P0.001), anxiety (P = 0.04) and physical QOL (P0.001), but not in mental QOL (P = 0.210). Despite improved psychosocial outcomes from baseline, patients experiencing complications showed higher postoperative depression scores (P0.01) and lower physical QOL (P0.01) than patients without complication. Comparison between those with early and late complications did not show significant difference in outcomes.Complications following bariatric surgery can hinder improvements in patient's psychological well-being and QOL. Bariatric centers should provide more support for patients who have experienced complications.

In obese individuals undergoing Roux-en-Y gastric bypass (RYGB), nonalcoholic fatty liver disease (NAFLD) is seen in 75% to 100% of cases. This improves postsurgery, but some patients continue to have persistent NAFLD.The purpose of this study was to determine the factors associated with persistent NAFLD at 12 months post-RYGB.University Hospital, Canada, bariatric clinic.This is a prospective cohort study of 42 patients who underwent RYGB. Liver biopsy, biochemical and clinical parameters were collected pre- and 12 months post-RYGB. Based on histology at 12 months, patients were separated in 2 groups, normal liver (NL) and persistent NAFLD.At baseline, NAFLD was diagnosed in 85.7% of patients and at 12 months post-RYGB, NAFLD was present in 19.1% of patients. Patients who had an NL at baseline remained with NL. RYGB resulted in significant decreases in body mass index, waist circumference, blood pressure, aspartate aminotransferase, alanine aminotransferase, fasting glucose and insulin, glycated hemoglobin, and triglycerides and significant increases in high-density lipoprotein cholesterol. Changes were similar in both groups except for waist circumference, which showed lower changes in those with persistent NAFLD. These patients also had significantly higher (P.05) fasting glucose and insulin with a higher proportion of patients having insulin resistance compared with those with NL.RYGB resulted in significant improvements in liver histology, biochemical, and clinical parameters. However, despite similar weight loss, persistent NAFLD was associated with less improvement in waist circumference and worse glycemic control.

Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients' health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7-39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5-39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.

Laparoscopic adjustable gastric band (LAGB) placement remains a common bariatric procedure. While LAGB procedure is performed within private clinics in most Canadian provinces, public health care is often utilized for LAGB-related reoperations. We identified 642 gastric band removal procedures performed in Ontario from 2011 to 2014 using population-level administrative data. The number of procedures performed increased annually from 101 in 2011 to 220 in 2014. Notably, 54.7% of the patients required laparotomy, and 17.6% of patients underwent a subsequent bariatric surgery. Our findings demonstrated that LAGB placement in private clinics resulted in a large number of band removal procedures performed within the public system. This represents a significant public health concern that may result in significant health care utilization and patient morbidity.

The purpose of this study was to evaluate the relationship between patient, clinical and laboratory characteristics, and bleeding after bariatric surgery. A retrospective chart review was performed for all patients, who underwent a laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy at our institution between March 2012 and May 2014. In total, 788 patients were included in this study. Seventeen patients had postoperative bleeding. The demographics, comorbidities, and preoperative medications were similar between the groups. Mean postoperative hemoglobin in the bleeding group was significantly lower (94 vs. 126; P

Continuing professional development (CPD) can support delivery of high-quality care, but may not be optimized until we can understand cultural barriers and facilitators, especially as innovations emerge. Lifelong learning (LLL), linked with quality improvement, competence, and professionalism, is a core competency in medical education. The purpose of this study is to examine cultural factors (individual, organizational, and systemic) that influence CPD and specifically the use of clinical data to inform LLL and CPD activities. This mixed-method study will examine the perceptions of two learner groups (psychiatrists and general surgeons) in three phases: (1) a survey to understand the relationship between data-informed learning and orientation to LLL; (2) semistructured interviews using purposive and maximum variation sampling techniques to identify individual-, organizational-, and system-level barriers and facilitators to engaging in data-informed LLL to support practice change; and (3) a document analysis of legislation, policies, and procedures related to the access and the use of clinical data for performance improvement in CPD. We obtained research ethics approval from the University Health Network in Toronto, Ontario, Canada. By exploring two distinct learner groups, we will identify contextual features that may inform what educators should consider when conceptualizing and designing CPD activities and what initial actions need to be taken before CPD activities can be optimized. This study will lead to the development of a framework reflective of barriers and facilitators that can be implemented when planning to use data in CPD activities to support data adoption for LLL.

BackgroundWith greater transparency in health system reporting and increased reliance on patient-centred outcomes, patient satisfaction has become a priority in delivering quality care. We sought to explore the relationship between patient satisfaction and short-term outcomes in patients undergoing general surgical procedures.MethodsSatisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. Short-term clinical outcomes were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients rated their level of satisfaction on a 5-point Likert scale, and ordered logistic regression model was used to determine predictors of high patient satisfaction.Results757 patient satisfaction surveys were completed. The mean age of patients surveyed was 52.2 years; 60.0% of patients were female. The majority of patients underwent a laparoscopic procedure (85.9%) and were admitted as inpatients following surgery (72%). 91.5% of patients rated satisfaction of 4–5, and 95.0% said they would recommend the service. The odds of overall satisfaction were lower in patients who had complications (OR: 0.52, 95% CI 0.31 to 0.87) and 30-day readmission (OR: 0.35, 95% CI 0.17 to 0.70). Having elective surgery was associated with higher odds of satisfaction (OR: 1.62, 95% CI 1.07 to 2.47).ConclusionsWe found a significant association between patient satisfaction and both 30-day readmission and the occurrence of postoperative surgical complications. Given this association, further study is warranted to evaluate patient satisfaction as a healthcare quality indicator.

Non-alcoholic fatty liver disease (NAFLD) affects 75 to 100% of the patients undergoing bariatric surgery (BSx), with non-alcoholic steatohepatitis (NASH) being present in 24 to 98% of the patients. We do not know whether these rates were before or after a very low calorie diet (VLCD) often prescribed before laparoscopic BSx and what is the prevalence of NAFLD post-VLCD. The purpose of this study is to determine the prevalence of simple steatosis (SS) and NASH in obese individuals undergoing BSx post-VLCD and assess biochemical markers pre- and post-VLCD in a subgroup of patients. One hundred and thirty-nine patients undergoing BSx at a single Canadian bariatric program had biochemical and clinical variables collected pre-VLCD. In 21 patients, biochemical measurements were repeated post-VLCD. During BSx, a wedged liver biopsy was performed in all patients and histology was reported as normal liver (NL), SS, or NASH. NAFLD was diagnosed in 76.3% of the BSx patients with 61.9% having SS and 14.4% having NASH; 23.7% had NL. Those with NASH had significantly higher (p < 0.05) pre-VLCD ALT, AST, insulin resistance, and proportion of individuals with diabetes compared to those with NL. Overall, VLCD resulted in significant decreases in BMI, ALP, fasting glucose and insulin, HbA1c, total cholesterol, HDL and LDL cholesterol, and significant increases in AST and ALT. Changes were similar between groups. Post-VLCD, the prevalence of NAFLD and NASH was lower compared to published reports, with almost 25% of the patients having a NL. With VLCD, metabolic and clinical changes were similar between the three groups suggesting that pre-VLCD factors may affect liver histology.

The Fundamentals of Laparoscopic Surgery® (FLS) certification exam assesses both cognitive and manual skills, and has been administered for over a decade. The purpose of this study is to report results over the past 9 years of testing in order to identify trends over time and evaluate the need to update scoring practices. This is a quality initiative of the SAGES FLS committee. A representative sample of FLS exam data from 2008 to 2016 was analyzed. The de-identified data included demographics and scores for the cognitive and manual tests. Standard descriptive statistics were used to compare trends over the years, training levels, and to assess the pass/fail rate. A total of 7232 FLS tests were analyzed [64% male, 6.4% junior (postgraduate year—PGY1–2), 84% senior (PGY3–5), 2.8% fellows (PGY6), and 6.7% attending surgeons (PGY7)]. Specialties included 93% general surgery (GS), 6.2% gynecology, and 0.9% urology. The Pearson correlation between cognitive and manual scores was 0.09. For the cognitive exam, there was an increase in scores over the years, and the most junior residents scored the lowest. For the manual skills, there were marginal differences in scores over the years, and junior residents scored the highest. The odds ratio of PGY3+ passing was 1.8 (CI 1.2–2.8) times higher than that of a PGY1–2. The internal consistency between tasks on the manual skills exam was 0.73. If any one of the tasks was removed, the Cronbach’s alpha dropped to between 0.65 and 0.71, depending on the task being removed. The cognitive and manual components of FLS test different aspects of laparoscopy and demonstrate evidence for reliability and validity. More experienced trainees have a higher likelihood of passing the exam and tend to perform better on the cognitive skills. Each component of the manual skills contributes to the exam and should continue to be part of the test.

Enhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery. All patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis. A total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01–1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14–1.58, p

The objective of the study was to determine whether compliance with Enhanced Recovery after Surgery (ERAS) urinary catheter recommendations is associated with decreased urinary tract infections (UTI) and length of stay (LOS). Patients having colorectal surgery at 15 academic hospitals were included. Patient and outcome data were collected prospectively. The guideline recommends that urinary catheters following colonic and rectal procedures should be removed at or before 24 and 72 h, respectively. Two thousand nine hundred and twenty-seven patients (1397 females and 1522 males; mean age 60.3 years) were enrolled. Small bowel or colonic procedures were performed in 1897 (64.9%) and rectal procedures in 1030 (35.2%) patients. Overall, 53.2% of patients had their catheter removed in compliance with the guidelines (44.3% after colonic resections and 69.5% after rectal resections). Following colonic operations, 0.8% of patients who were guideline compliant had a UTI compared to 4.1% non-compliant patients (RR 0.20, 95% CI 0.07–0.58; p = 0.003). Following rectal operations, 3.5% of patients who were guideline compliant had a UTI compared to 9.6% of patients who were non-compliant (RR 0.37, 95% CI 0.20–0.68; p = 0.001). Median LOS was decreased in compliant patients: 4 vs 5 days following colonic procedures (RR 0.73, 95% CI 0.66–0.82; p

BACKGROUND: The relative educational benefits of virtual reality (VR) and physical simulation models for endoscopic third ventriculostomy (ETV) have not been evaluated "head to head."OBJECTIVE: To compare and identify the relative utility of a physical and VR ETV simulation model for use in neurosurgical training.METHODS: Twenty-three neurosurgical residents and 3 fellows performed an ETV on both a physical and VR simulation model. Trainees rated the models using 5-point Likert scales evaluating the domains of anatomy, instrument handling, procedural content, and the overall fidelity of the simulation. Paired t tests were performed for each domain's mean overall score and individual items.RESULTS: The VR model has relative benefits compared with the physical model with respect to realistic representation of intraventricular anatomy at the foramen of Monro (4.5, standard deviation [SD] = 0.7 vs 4.1, SD = 0.6; P = .04) and the third ventricle floor (4.4, SD = 0.6 vs 4.0, SD = 0.9; P = .03), although the overall anatomy score was similar (4.2, SD = 0.6 vs 4.0, SD = 0.6; P = .11). For overall instrument handling and procedural content, the physical simulator outperformed the VR model (3.7, SD = 0.8 vs 4.5; SD = 0.5, P CONCLUSION: Simulation model selection should be based on educational objectives. Training focused on learning anatomy or decision-making for anatomic cues may be aided with the VR simulation model. A focus on developing manual dexterity and technical skills using endoscopic equipment in the operating room may be better learned on the physical simulation model.

Background Patient-centered discharge tools provide an opportunity to engage patients, enhance patient understanding, and improve capacity for self-care and postdischarge outcomes. Purpose To review studies that engaged patients in the design or delivery of discharge instruction tools and that tested their effect among hospitalized patients. Data sources We conducted a search of 12 databases and journals from January 1994 through May 2014, and references of retrieved studies. Study selection English-language studies that tested discharge tools meant to engage patients were selected. Studies that measured outcomes after 3 months or without a control group or period were excluded. Data extraction Two independent reviewers assessed the full-text papers and extracted data on features of patient engagement. Data synthesis Thirty articles met inclusion criteria, 28 of which examined educational tools. Of these, 13 articles involved patients in content creation or tool delivery, with only 6 studies involving patients in both. While many of these studies (10 studies) demonstrated an improvement in patient comprehension, few studies found improvement in patient adherence despite their engagement. A few studies demonstrated an improvement in self-efficacy (2 studies) and a reduction in unplanned visits (3 studies). Conclusions Improving patient engagement through the use of media, visual aids, or by involving patients when creating or delivering a discharge tool improves comprehension. However, further studies are needed to clarify the effect on patient experience, adherence, and healthcare utilization postdischarge. Better characterization of the level of patient engagement when designing discharge tools is needed given the heterogeneity found in current studies. Journal of Hospital Medicine 2017;12:110-117.