General Practice Surgeries Research Articles

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation

BackgroundThere is concern regarding the competency of today’s general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. MethodsNineteen Accreditation Council for Graduate Medical Education–accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. ResultsThere were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18–1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45–4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22–0.45, P < .01). ConclusionThis is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Privacy preserving Generative Adversarial Networks to model Electronic Health Records

Hospitals and General Practitioner (GP) surgeries within National Health Services (NHS), collect patient information on a routine basis to create personal health records such as family medical history, chronic diseases, medications and dosing. The collected information could be used to build and model various machine learning algorithms, to simplify the task of those working within the NHS. However, such Electronic Health Records are not made publicly available due to privacy concerns. In our paper, we propose a privacy-preserving Generative Adversarial Network (pGAN), which can generate synthetic data of high quality, while preserving the privacy and statistical properties of the source data. pGAN is evaluated on two distinct datasets, one posing as a Classification task, and the other as a Regression task. Privacy score of generated data is calculated using the Nearest Neighbour Adversarial Accuracy. Cosine similarity scores of synthetic data from our proposed model indicate that the data generated is similar in nature, but not identical. Additionally, our proposed model was able to preserve privacy while maintaining high utility. Machine learning models trained on both synthetic data and original data have achieved accuracies of 74.3% and 74.5% respectively on the classification dataset; while they have attained an R2-Score of 0.84 and 0.85 on synthetic and original data of the regression task respectively. Our results, therefore, indicate that synthetic data from the proposed model could replace the use of original data for machine learning while preserving privacy.

Reliableness of Telegram between different evaluators in emergency general surgery practice

Background: 'Telegram' is a popularly used social media application in routine clinical practice, often for communication between a resident doctor and a consultant. The purpose of this study is to establish the reliableness of the data transmitted through telegram to validate its use in general surgery practice.Methods: Clinical findings and computerized tomographic (CT) images of 180 patients visiting the trauma center and emergency department were posted in a closed Telegram group involving three consultants (SSC, NBP, and LSB). The CT images were posted in the Telegram group as complete picture (CP) and picture of interest (POI) format and rated on a scale of 1-5. The consultants formulated a temporary diagnosis and initial management plan. The reliableness between different evaluators of these feedbacks was analyzed in our study.Results: Mean CP rating ranged from 3.03±0.61 to 3.73±0.64 [Cronbach alfa (α)-0.494, p=0.006]. Mean POI rating ranged from 3.4±0.56 to 4.13±0.73 (α-0.824, p&lt;0.0001). For diagnosis, the proportion of observed agreement (P0) was 83.3% for SSC and NP, 76.6% for SSC and LB, and 73.3% for NBP and LSB. For management, P0 was 86.6% for NBP and LSB, 86.6% for SSC and NBP, and 80% for SSC and LSB.Conclusions: Telegram messenger serves to transmit good quality pictures of CT scan images. A reasonable diagnosis and management strategy can be formulated using this app with a fair reliableness between different evaluators.

Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial

To our knowledge, there are no trials comparing emollients commonly used for childhood eczema. We aimed to compare the clinical effectiveness and safety of the four main emollient types: lotions, creams, gels, and ointments. We did a pragmatic, individually randomised, parallel group, phase 4 superiority trial in 77 general practice surgeries in England. Children aged between 6 months and 12 years with eczema (Patient Orientated Eczema Measure [POEM] score >2) were randomly assigned (1:1:1:1; stratified by centre and minimised by baseline POEM score and age, using a web-based system) to lotions, creams, gels, or ointments. Clinicians and parents were unmasked. The initial emollient prescription was for 500 g or 500 mL, to be applied twice daily and as required. Subsequent prescriptions were determined by the family. The primary outcome was parent-reported eczema severity over 16 weeks (weekly POEM), with analysis as randomly assigned regardless of adherence, adjusting for baseline and stratification variables. Safety was assessed in all randomly assigned participants. This trial was registered with the ISRCTN registry, ISRCTN84540529. Between Jan 19, 2018, and Oct 31, 2019, 12 417 children were assessed for eligibility, 550 of whom were randomly assigned to a treatment group (137 to lotion, 140 to cream, 135 to gel, and 138 to ointment). The numbers of participants who contributed at least two POEM scores and were included in the primary analysis were 131 in the lotion group, 137 in the cream group, 130 in the gel group, and 126 in the ointment group. Baseline median age was 4 years (IQR 2-8); 255 (46%) participants were girls, 295 (54%) were boys; 473 (86%) participants were White; and the mean POEM score was 9·3 (SD 5·5). There was no difference in eczema severity between emollient types over 16 weeks (global p value=0·77), with adjusted POEM pairwise differences of: cream versus lotion 0·42 (95% CI -0·48 to 1·32), gel versus lotion 0·17 (-0·75 to 1·09), ointment versus lotion -0·01 (-0·93 to 0·91), gel versus cream -0·25 (-1·15 to 0·65), ointment versus cream -0·43 (-1·34 to 0·48), and ointment versus gel -0·18 (-1·11 to 0·75). This result remained unchanged following multiple imputation, sensitivity, and subgroup analyses. The total number of adverse events did not significantly differ between the treatment groups (lotions 49 [36%], creams 54 [39%], gels 54 [40%], and ointments 48 [35%]; p=0·79), although stinging was less common with ointments (12 [9%] of 138 participants) than lotions (28 [20%] of 137), creams (24 [17%] of 140), or gels (25 [19%] of 135). We found no difference in effectiveness between the four main types of emollients for childhood eczema. Users need to be able to choose from a range of emollients to find one that they are more likely to use effectively. National Institute for Health and Care Research.

The Imminent of General Surgery: Progressing to Encounter a Fluctuating Practice

Purpose: As compared to other countries, the practice of General Surgery in Pakistan has gone through a series of important development over the last 30 years, despite major variable training models. There increasing concern is that the current teaching of General Surgery residency does not hold out enough skills that are essential to practice the scope of General Surgery in Pakistan. Procedure: Executed by a National Force on the General Surgery Future, this project directed to advance guidance on the favorable configuration of Training on General Surgery in Multan. A consecutive series of studies based on evidence and a survey was introduced to inform these guidelines. Results: The general results of a procedure in any study show the complexity of the practice in General Surgery. 1 Location matters a lot for a surgeon to practice surgery 2 General surgery accompanies a strong grip for the overall clinical competence as well 3 Today general surgeons experience a subspecialized training too 4 Writing a proper report and guidelines for proper future surgical goals is also a part of training for General surgeons today To be a general surgeon in the 21st century, these are the four recommendations that are necessary to maintain. Conclusion: This project mainly refers to the importance of location for fresh general surgery graduates, emphasizing the impact of variable location in contrast with the implementation of the same objectives of the surgery. The results of this study were sent to the Nishtar College to review the requirements of training and the work on a more precise and comfortable working scheme. Hence, we ensured that the GSRTP General Surgery Residency and Training Programs could work for the wider range of practice all around Pakistan for better training practices.

Comparison of scoring systems regarding the gender as a parameter with the traditional scoring systems for predicting appendicitis.

Although acute appendicitis remains the most common cause of acute abdomen in General Surgery practice, negative appendectomy rates are still high in particularly female patients. Appendicitis scoring systems considering gender can help the clinician to reduce negative appendectomy rates in females. This present study aims to compare the Lintula, Ripasa, Fenyo-Lindberg scoring systems, which use gender as a variable, with the Alvarado, Karaman, scoring systems to evaluate which CSS is more successful in the differential diagnosis of appendicitis in females. We analyzed the records of the patients operated on with a prediagnosis of acute appendicitis in our clinic between 2020 and 2021, retrospectively. Alvarado, adult appendicitis score (AAS), appendicitis inflammatory response score (AIRS), Ripasa, Karaman, Lintula, and Fenyo Lindberg scores were calculated for each patient. The patients were divided into two groups as male and female, according to gender. Receiver operator characteristic (ROC) curve analysis was used to identify the best cut-off value and assess the performance of the test score for appendicitis. Three hundred and sixty-three patients were included in the study. One hundred seventy-two (47.4%) of the patients were male, and 191 (52.6%) were female. Alvarado and AAS were the most valuable score in female (AUC: 0.805, sensitivity: 0.63, specificity: 0.83; and area under curve (AUC): 0.794, Sensitivity 0.71, Specificity: 0.76, respectively), male group (AUC: 0.828, Sensitivity: 0.71, Specificity: 0.83; and AUC: 0.834, Sensitivity 0.74, Specificity: 0.77, respectively), and when patients were not categorized by gender (AUC: 0.818, Sensitivity: 0.67 Specificity: 0.83; and AUC: 0.794, Sensitivity 0.71, Specificity: 0.76, respectively). Although the Alvarado scoring system is the first defined appendicitis scoring system, it seems as superior to the many scoring systems defined after it in predicting appendicitis, even in female patients.

Contemporary Practice of General Surgery in the US: Analysis of American Board of Surgery Diplomate Case Logs.

The demographics and operative experience of general surgeons certified by the American Board of Surgery were last examined a decade ago. This study examines the contemporary workforce and scope of practice of general surgeons. Applications of diplomates seeking American Board of Surgery recertification from 2013 to 2017 were reviewed. Demographic data and case logs from the year before submission were analyzed. Total operative volume was examined, as were total volumes for 13 operative domains and 11 abdominal and alimentary tract subdomains. There were 4,735 general surgeons certified by the American Board of Surgery with a mean ± SD age of 53 ± 8 years and included 19% women and 14% international graduates. Regions of practice were 22% Northeast, 31% Southeast, 20% Midwest, 20% West, and 7% Southwest. Practice settings were 86% urban, 9% large rural, 4% small rural, and 1% isolated. Forty-one percent were 10 years, 35% were 20 years, and 24% were 30 years since initial certification. On average, general surgeons performed 417 ± 338 procedures per year, with abdominal, alimentary tract, and endoscopy being the most common. On multivariable analysis, male sex and being midcareer or late career were positively associated with being a high-volume (top quartile) surgeon, whereas age and practicing in either the Northeast or West demonstrated a negative association. The demographics of general surgeons have remained stable over time, except for an increased proportion of female surgeons. The overall operative experience is similar to years past but is widely variable between surgeons. Periodic analysis of these data is important for education and certification purposes.

Factors predicting amoxicillin prescribing in primary care among children: a cohort study.

BackgroundAntibiotic prescribing during childhood, most commonly for respiratory tract infections (RTIs), contributes to antimicrobial resistance, which is a major public health concern.AimTo identify factors associated with amoxicillin prescribing and RTI consultation attendance in young children in primary care.Design and settingCohort study in Bradford spanning pregnancy to age 24 months, collected 2007–2013, linked to electronic primary care and air pollution data.MethodAmoxicillin prescribing and RTI consultation rates/1000 child–years were calculated. Mixed-effects logistic regression models were fitted with general practice (GP) surgery as the random effect.ResultsThe amoxicillin prescribing rate among 2493 children was 710/1000 child–years during year 1 (95% confidence interval [CI] = 677 to 744) and 780/1000 (95% CI = 745 to 816) during year 2. During year 1, odds of amoxicillin prescribing were higher for boys (adjusted odds ratio [aOR] 1.36, 95% CI = 1.14 to 1.61), infants from socioeconomically deprived households (aOR 1.36, 95% CI = 1.00 to 1.86), and infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.44, 95% CI = 1.06 to 1.94] and outside [aOR 1.42, 95% CI = 1.07 to 1.90]). During year 2, odds of amoxicillin prescribing were higher for infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.46, 95% CI = 1.10 to 1.94] and outside [aOR 1.56, 95% CI = 1.19 to 2.04]) and those born <39 weeks gestation (aOR 1.20, 95% CI = 1.00 to 1.45). Additional risk factors included caesarean delivery, congenital anomalies, overcrowding, birth season, and childcare attendance, with GP surgery explaining 7%–9% of variation.ConclusionSocioeconomic status and ethnic background were associated with amoxicillin prescribing during childhood. Efforts to reduce RTI spread in household and childcare settings may reduce antibiotic prescribing in primary care.

What the public in England know about antibiotic use and resistance in 2020: a face-to-face questionnaire survey

ObjectivesTo describe public attitudes and knowledge around antibiotic activity, resistance and use.DesignFace-to-face household 18 question survey using computer-assisted data collection undertaken by Ipsos Market and Opinion Research International.SettingRandomly selected households...

Views of independent prescribing pharmacists on the community pharmacy pilot independent prescribing service: a qualitative study

Abstract Introduction Independent Prescribing Pharmacists (IPPs) can prescribe autonomously within their scope of practice. Their role is increasing within the community setting (1). The Welsh Pharmaceutical Committee has a vision to have at least one IPP in every community pharmacy by 2030 (1). In 2020, an Independent Prescribers’ Service (IPS) pilot was delivered in 13 pharmacies across six of the seven Health Boards in Wales (2), via Choose Pharmacy (CP), an IT platform that provides access to patients’ General Practitioner (GP) medical record. IPS allowed patients to access advice, and, where relevant, be treated in the community pharmacy setting, rather than the GP surgery. The consultation is recorded on CP and the patient’s GP informed of the outcome. As the IPS is a recent development there is little research on this service. Aim To explore the views of community IPPs delivering the IPS. Methods A qualitative methodology was utilised with semi-structured interviews, via telephone or MS Teams. Only thirteen pharmacies were commissioned to deliver the service. Purposive sampling was used to identify IPPs in these premises, who had completed at least one IPS consultation. Participants were informed of the study and written; informed consent obtained. An interview schedule utilised open questions to explore participants’ experiences of the service. Interviews were recorded, transcribed and analysed via deductive and inductive thematic analysis. Analysis was quality assured through discussion with the research team. All identifiable information in the transcripts were removed to ensure anonymity. Results Nine interviews were conducted, including participants from all Health Boards in the pilot. Interviewees had varied prescribing experience with some only prescribing since the roll out of the pilot. The IPPs’ scope of practice included acute minor ailments, contraception, urinary tract infections and asthma. Four themes were identified: 1.Impact of the IPS: Participants believed the service had impacted on the wider healthcare setting, patients and themselves. Patients had improved convenience and accessibility to a healthcare professional to manage their condition. Patient safety was of a high standard with access to patient notes ensuring informed, appropriate clinical decisions. 2.Relationship with GP: Positive relationships with local GPs was believed to be critical to the pilot’s success. 3.Future delivery: This will rely on support, funding, and ongoing review. A ‘blended approach’ whereby patients are seen with or without an appointment was believed to provide the flexibility that patients want. 4.Remote consultations: Can have an impact on patient safety, making non-verbal communication and language barriers more challenging. After nine interviews, no new information was gathered. Conclusion Participants were supportive of the service which will potentially benefit IPPs, patients and GPs, and improve patient care. Pharmacists, by providing a high quality, accessible service, ensures that forward thinking healthcare is delivered in a manner which makes use of the skills of those working in the community. The study, albeit small scale, explored the thoughts of the majority of IPPs conducting the IPS service at that time. More information is needed to understand the impact of the service and effect on practice, from the practitioner and patient perspective. References (1) Walsh A. All Welsh pharmacies to have independent prescribers. Wales; 2019 [accessed 5 February 2021]. Available from: http://www.pharmacymagazine.co.uk/all-welsh-pharmacies-to-have-independent-prescribers (2) NHS Wales Informatics Service. Choose Pharmacy. Wales; 2021 [accessed 5 Feb 2021]. Available from: http://www.nwis.nhs.wales/systems-and-services/in-the-community/choose-pharmacy/

Patient perceptions of clinical pharmacists in general practice

Abstract Introduction As a result of changes in the demands and pressures on the NHS, the role of the pharmacist has advanced from purely dispensing and compounding medicines to a more clinical and patient-centred approach to care (1). Since 2015, NHS England set a target of recruiting practice-based pharmacists into 20% of practices by 2020-2021 as a way of reducing these pressures (2). Conducting evaluations of clinical pharmacists in individual practices is essential for role integration and evolution. Aim To explore patient perceptions of clinical pharmacists across three general practices. Methods A paper-based questionnaire consisting of open and closed questions was used to gather patient perceptions on the role of a clinical pharmacist and their consultation experiences. Participants included patients over the age of 18 who had attended a face-to-face appointment with a clinical pharmacist from one of three general practice surgeries in England between November and December 2019. The clinical pharmacists were used as a gateway to recruit participants; post-consultation, the pharmacist asked patients if they would complete a questionnaire. Patients were provided with an information sheet and consent form prior to completion of the questionnaire. The questionnaire was anonymous. Data were analysed using descriptive statistics and content analysis. Results A total of 39 participants completed the questionnaire. Most participants were elderly (28%) and female (64%). The primary reason for the consultations was due to an acute illness (79%), and the most common outcome was the supply of a prescription (83%). Patients were predominantly unfamiliar with the role of a clinical pharmacist (56%) and 31% of patients reportedly thought their appointment had been with a doctor. All patients were positive about their experience and reported they would “be more than happy to see a pharmacist in the future” and that the role was “a very necessary addition to the practice”. All patients reported that their consultation was the same (51%) or better than they have had with a doctor (49%). Patients commented on the pharmacists’ consultation skills, making statements such as [they] “listened to me”, “asked me questions”, “were really good at explaining” and “spoke in a way I understood”. Clinical pharmacists were reported as being “very professional” and knowledgeable as “[they] knew more about my medication [than the doctor] and prescribed me something to help”. Patients reported that they would recommend the clinical pharmacist to their family and friends when seeking an appointment. Conclusion This research highlights patient acceptance towards consultations with a clinical pharmacist and reinforces the competence of pharmacists to undertake this role. A key finding related to the effective consultation skills of the pharmacists and involving the patients in their care. The number of patients who participated limits the generalisability of the findings, and the patient responses may have been a reaction to the individual clinical pharmacists rather than their thoughts on the role overall. Increased publicity and patient education of the role of a clinical pharmacist may promote a greater integration into the multidisciplinary team. References (1) Robertson R, Wenzel L, Thompson J, Charles A. Understanding NHS financial pressures. How are they affecting patient care. 2017. The Kings Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Understanding%20NHS%20financial%20pressures%20-%20full%20report.pdf (2) NHS England 2016. General Practice Forward View. https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

Is there strength in numbers? Current trends in U.S. general surgery practice consolidation

DR. ROBIN ALLEY (Peoria, Illinois): This is actually a very timely paper for me as my private group of 12 surgeons just recently merged with a larger multi-specialty private group of 450 physicians. Looking at future trends of decreasing reimbursement rates, hospital system politics and increasing costs, it was very clear to us that within the next five to ten years, we would have had to have become hospital employees if we didn't make a change sooner than that. Merging with the larger group provides us with better financial stability and better reimbursement rates while allowing us to keep our autonomy.

Experience of depression in older adults with and without a physical long-term condition: findings from a qualitative interview study

ObjectiveTo understand how the lived experience of depression differs among patients with a long-term condition (LTC) compared with those without an LTC, and how the experience differs across different types...

The neglected surgery - Hernioscopy - Maybe the best choice for strangulated groin hernias in the COVID-19 pandemic.

Abstract Objective: Although due to the Covid-19 Pandemic, elective surgeries have been postponed worldwide, emergency operations cannot be delayed and are being performed. In general surgery practice, incarcerated / strangulated inguinal hernias have a prominent place among emergency surgeries. In 1% of these patients, the hernia content reduces spontaneously into the abdomen until the hernia sac is opened. It is imperative that these bowel segments be evaluated for possible intestinal necrosis. Methods: Patients who underwent emergency surgery and hernioscopy in the Sakarya Training and Research Hospital General Surgery Service due to incarcerated or strangled inguinal hernia during the period from March 2020 to October 2020 were included in the study. Hernioscopy procedure was performed using single-port and glove-port methods. For each patient, age, duration of complaints, comorbidities, hernia repair method, operation time, incarcerated organ, whether ischemia improved after reduction or whether resection was required, postoperative complications were recorded. Results: Hernioscopy was performed on ten patients due to strangled inguinal hernia during the eight months. While femoral hernia was detected in 2 patients, eight patients had an inguinal hernia. In 1 patient, bowel resection and anastomosis were performed with the transabdominal approach because the small intestine necrosis was detected during the hernioscopy procedure. Conclusion: The hernioscopy method, which is performed under spinal anesthesia, prevents unnecessary laparotomies and should be preferred more during the COVID-19 pandemic process in patients who are urgently operated for strangled inguinal hernia. Key words: Hernioscopy; Strangulated Hernia; COVID-19 Pandemic

Oral antihistamine-decongestant-analgesic combinations for the common cold.

Oral antihistamine-decongestant-analgesic combinations for the common cold.

P357 Monitoring of Thiopurines and Methotrexate in Inflammatory Bowel Disease: Are we Monitoring Too Frequently? A Cross Sectional Study

Abstract Background The use of immunosuppressive medications such as thiopurines and methotrexate (MET) are commonly employed in inflammatory bowel disease (IBD) to control symptoms and maintain remission. The British Society of Gastroenterology recommends three monthly full blood count (FBC) and liver function tests (LFT) to monitor for myelotoxicity and hepatotoxicity after being established on therapy. However, the quality of evidence for this is low. Due to the high burden of blood tests and patients becoming increasingly apprehensive to attend hospital or their general practice surgery in the midst of a pandemic, we aimed to investigate (1) the feasibility to adhere to these recommendations and (2) the frequency of abnormal blood test when recommendations are adhered. Methods We performed a, 12-month cross sectional study from July, 2017 to July, 2018 of patients established on azathioprine (AZA), 6-mercaptopurine (6-MP), or MET. The timeline was split into four windows of three months each. A patient was removed from the study if they reached any one of these six end points: no FBC or LFT checked within a window, new abnormal LFT, white cell count (WCC) less than, 3.5, change in medication, change in dosage, and medication stopped. Results As of, 2019, 4327 patients were under the care of our specialist IBD team with, 1081 on active therapy. We identified, 205 patients who were established on these agents (AZA = 156, 6-MP = 41, MET = 8) within the determined study period. A total number of, 96 patients reached an end point during this period. For our first objective, a patient was deemed to have been monitored if FBC and LFT was checked at least once during a window., 26% (54/212) of patients were removed from the study as they did not fulfil this criteria. Of the remaining, 41 patients who reached an end point, 14 were due to a new abnormal LFT result (AZA = 8, 6-MP = 6, MET = 0) and, 5 due to a WCC less than, 3.5 (AZA = 4, 6-MP = 1, MET =0). Excluding non-adherent patients, our study revealed only, 12% (19/158) of patients had to discontinue therapy due to an abnormal blood test. Conclusion Achieving an adherence of, 74% was possible with a team of dedicated IBD specialist nurses and doctors in a tertiary centre. Whilst there is still much room for improvement, this may be difficult to replicate in smaller centres with more limited resources. Despite the small sample size, our finding of only, 12% of abnormal blood test is consistent with similar studies done by Fournier et.al in, 2010 and Chaparro et.al in, 2013. This would certainly pose the question if we can consider monitoring less frequently.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs

Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years. Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents. ACGME accredited general surgery residency programs. Not applicable. General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend. The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Morbimortality assessment in abdominal surgery: are we predicting or overreacting?

BackgroundHigh-risk surgical procedures represent a fundamental part of general surgery practice due to its significant rates of morbidity and mortality. Different predictive tools have been created in order to quantify perioperative morbidity and mortality risk. POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) is one of the most widely validated predictive scores considering physiological and operative variables to precisely define morbimortality risk. Nevertheless, seeking greater accuracy in predictions P-POSSUM was proposed. We aimed to compare POSSUM and P-POSSUM for patients undergoing abdominal surgery.MethodsA retrospective observational study with a prospective database was conducted. Patients over 18 years old who complied with inclusion criteria between 2015 and 2016 were included. Variables included in the POSSUM and P-POSSUM Scores were analyzed. Descriptive statistics of all study parameters were provided. The analysis included socio-demographic data, laboratory values ​​, and imaging. Bivariate analysis was performed.Results350 Patients were included in the analysis, 55.1% were female. The mean age was 55.9 ± 20.4 years old. POSSUM revealed a moderated index score in 61.7% of the patients, mean score of 12.85 points ± 5.61. 89.1% of patients had no neoplastic diagnosis associated. Overall morbidity and mortality rate was 14.2% and 7.1%. P-POSSUM could predict more precisely mortality (p < 0.00).ConclusionsThe POSSUM score is likely to overestimate the risk of morbidity and mortality in patients with high/moderate risk, while the P-POSSUM score seems to be a more accurate predictor of mortality risk. Further studies are needed to confirm our results.

НЕЗАВИСИМЫЕ ПРЕДИКТОРЫ ГЕМОДИНАМИИЧЕСКИ ОСЛОЖНЕННОГО ТЕЧЕНИЯ РАННЕГО ПОСЛЕОПЕРАЦИОННОГО ПЕРИОДА У ПАЦИЕНТОВ С ИБС: РОЛЬ СОВРЕМЕННЫХ БИОМАРКЕРОВ

Cardiac biomarkers are recommended to stratify the risk of surgery in general surgical practice, but their adoption in cardiac surgery patients is limited. The aim of our study is assessing the prognostic possibility and predictive significance of modern cardiac-specific biomarkers (NT-proBNP, sST-2, hsTn-I, Galectin-3, hsCRP and IL-6) in the determining of patient-oriented treatment strategies. In the open prospective cohort study 352 patients with moderate or severe functional IMR were included. The inclusion criteria in the study were the reduced myocardial contractility (LV EF &lt; 40 %) in chronic CAD patients. CABG combined with mitral valve repair was performed in 239 patients (67.9 %), mitral valve replacement in 35 patients (9.9 %), and isolated in 78 patients (22.2 %). The primary end-point of the study was defined as a complicated postoperative period with worsening of heart failure. Complicated postoperative period has been registered in 80 patients (22.7% of cases). The complicated early postoperative period did not relate to surgical strategies (χ2 = 0.398, p = 0.528). We didn’t find any difference in the degree of LV remodeling between patients with complicated or not postoperative course (mean LV EDD - 68.2 mm, LV ESD - 56.3 mm, iEDV - 118.9 ml/m2 and iESV - 81.2 ml/m2, p &gt; 0.05). By contrast, all of the used pre-operative biomarker tests differed in the examined groups of patients (p &lt; 0,001). The complicated postoperative course was observed in 24.6 % of cases with isolated elevation of NT-proBNP &gt; 136 pg/ml, in 44.4 % of cases with isolated elevation of sST2 &gt; 35.8 ng/ml, and 59.3 % of cases in combined increase in thresholds and sST2 and NT-proBNP (χ2 = 71.67, p = 0.001). The highest quality of the model and the estimate forecast of the postoperative low-output syndrome was measured for sST2 and NT-proBNP biomarkers (AUC = 0,792, 95 % CI 0,709–0,846). The inclusion of both thresholds of sST2 and NT-proBNP retained their reliable influence on the forecast, with the model showed a high level of consent (79.7 % of correctly recognized cases).

Current trends in U.S. general surgery practice consolidation

BackgroundConsolidation of physician practices is well-documented in recent years, yet minimal data exist regarding consolidation in general surgery. This study evaluates current trends in general surgery practice consolidation. MethodsData were obtained through the CMS Physician Compare database. Surgeons and practices were categorized by size, and trends were analyzed using the Cochran-Armitage test. Data were stratified by US region. ResultsFrom 2012 to 2020, practicing general surgeons increased from 20,044 to 20,637 (+3%). Unique general surgery practices declined from 8178 to 6489 (−21%). The percentage of surgeons in practices of 1 or 2 declined from 19% to 12%, while surgeons in groups of 500 or more grew from 20% to 31%. Tests for trends towards consolidation at both the individual surgeon and unique practice levels were significant (p < .001). The Midwest region demonstrated the highest degree of consolidation. ConclusionConsistent with trends in medicine overall, general surgery is experiencing substantial practice consolidation.