1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

: In two patients, a man aged 67 and a woman aged 80, an abdominal compartment syndrome was diagnosed. The man had been treated surgically for an abdominal aortic aneurysm; he recovered after re-operation. The woman had been treated by sigmoidectomy because of ileus. A Bogota bag and a vacuum-assisted wound-closure system were applied to the abdominal wound. Her condition deteriorated, an intestinal perforation became apparent, of which she did not recover and died. An abdominal compartment syndrome should always be kept in mind when a patient at risk presents with increased intra-abdominal pressure and at least one of the following symptoms: oliguria, decreased cardiac output, increased pulmonary-artery pressure, hypotension and acidosis. Measurement of the bladder pressure remains the method of choice to establish the abdominal pressure level. However, there is a lack of correlation between the measured pressure and the clinical condition of the patient. Therefore, the combination of clinical findings and the observed trend in serial measurements of the bladder pressure is preferred to a single pressure measurement.

The abdominal compartment syndrome

Conventional cardiovascular monitoring may not detect tissue hypoxia, and conventional cardiovascular support aiming at global hemodynamics may not restore tissue oxygenation. NIRS offers non-invasive online monitoring of tissue oxygenation in a wide range of clinical scenarios. NIRS monitoring is commonly used to measure cerebral oxygenation (rSO(2)), e.g. during cardiac surgery. In this review, we will show that tissue hypoxia occurs frequently in the perioperative setting, particularly in cardiac surgery. Therefore, measuring and obtaining adequate tissue oxygenation may prevent (postoperative) complications and may thus be cost-effective. NIRS monitoring may also be used to detect tissue hypoxia in (prehospital) emergency settings, where it has prognostic significance and enables monitoring of therapeutic interventions, particularly in patients with trauma. However, optimal therapeutic agents and strategies for augmenting tissue oxygenation have yet to be determined.

/pdf/monitoring-tissue-oxygenation-by-near-infrared-spectroscopy-459xr3dyy9.pdf

Monitoring tissue oxygenation by near infrared spectroscopy (NIRS): background and current applications

Context Referral to high-volume hospitals has been recommended for operations with a demonstrated volume-outcome relationship. The characteristics of patients who receive care at low-volume hospitals may be different from those of patients who receive care at high-volume hospitals. These differences may limit their ability to access or receive care at a high-volume hospital. Objective To identify patient characteristics associated with the use of high-volume hospitals, using California's Office of Statewide Health Planning and Development patient discharge database. Design, Setting, and Participants Retrospective study of Californians receiving the following inpatient operations from 2000 through 2004: elective abdominal aortic aneurysm repair, coronary artery bypass grafting, carotid endarterectomy, esophageal cancer resection, hip fracture repair, lung cancer resection, cardiac valve replacement, coronary angioplasty, pancreatic cancer resection, and total knee replacement. Main Outcome Measures Patient race/ethnicity and insurance status in high-volume (highest 20% of patients by mean annual volume) and in low-volume (lowest 20%) hospitals. Results A total of 719608 patients received 1 of the 10 operations. Overall, non-whites, Medicaid patients, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals when controlling for other patient-level characteristics. Blacks were significantly (P<.05) less likely than whites to receive care at high-volume hospitals for 6 of the 10 operations (relative risk [RR] range, 0.40-0.72), while Asians and Hispanics were significantly less likely to receive care at high-volume hospitals for 5 (RR range, 0.60-0.91) and 9 (RR range, 0.46-0.88), respectively. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations (RR range, 0.22-0.66), while uninsured patients were less likely to be treated at high-volume hospitals for 9 (RR range, 0.20-0.81). Conclusions There are substantial disparities in the characteristics of patients receiving care at high-volume hospitals. The interest in selective referral to high-volume hospitals should include explicit efforts to identify the patient and system factors required to reduce current inequities regarding their use.

Disparities in the utilization of high-volume hospitals for complex surgery. Commentary

Cerebral and tissue oximetry

Importance Coping with the COIVD-19 global-pandemic major changes in healthcare and educational operational policies, mandates the implementation of alternative surgical curriculum objects (components) to replace some of the traditional face-to-face activities. Objective The objective of the study is to review and discuss various alternative curriculum objects (components) that can be used to restructure conventional surgical training curricula during the Declared Healthcare Emergency surgery rotations. The goal is to identify and recommend effective alternative educational activities that are compliant with the new social physical distancing regulations. Evidence review Various curricular components and objects were examined. The educational value of the curriculum objects is studied and analyzed in terms of feasibility, knowledge gain/learning effectiveness, the need for facilitation or feedback, and the evaluation. Several curriculum objects were proposed with description of their value and applications. Findings The selected and proposed activities include scenario-based MCQ writing exercises, video-based surgical skills interactive training, online learning modules, virtual rounding, reflection assignments, surgical skills simulation training, research education, and medical education learning. Their educational value is described and scaled. Conclusion There is urgent and challenging need for surgical training using additional alternative curriculum objects (components). Working with the available resources and experiences is crucial to maximize the learning outcomes. Distance (online) education and educational technology tools and concepts provide a spectrum of valuable educational activities. Further work and studies are needed to optimize their utility.

Alternatives surgical training approaches during COVID-19 pandemic

Laparoscopic Surgical Box-Trainer devices have been used by surgery residents to learn specific skills not traditionally taught to surgeons. Assessment of performance, however, is crude, frequently focusing on speed alone or subjective observations. For a better, objective assessment, the residents' efficiency should be recorded and have the process be tracked and have a system in place to provide consistent automated assessment and analysis. In this paper, we propose a novel framework for the detection and recognition of multi-class laparoscopic instruments for our Intelligent Box-Trainer System. This framework is based upon the Faster R-CNN architecture and RESNet-50 for an open-source module with our custom dataset (AR-Set). Despite a relatively limited number of training examples, experimental results have proved that our approach is effective for locating regions of interest and detecting multi-class instruments. This research is a cooperation between the Department of Electrical and Computer Engineering and the Department of Surgery of the Homer Stryker M.D. School of Medicine, at WMU.

Multi-Class Detection of Laparoscopic Instruments for the Intelligent Box-Trainer System Using Faster R-CNN Architecture

Background The optimal timing for performing appendectomy in adults remains controversial. Method A one-year retrospective review of adult patients with acute appendicitis who underwent appendectomy. The cohort was divided by time-to-intervention into two groups: patients who underwent appendectomy within 8 h (group 1), and those who had surgery after 8 h (group 2). Outcome measures including perioperative morbidity and mortality, post-operative length of stay, and the 30-day readmission rate were compared between the two groups. Results A total of 116 patients who underwent appendectomy met the inclusion criteria: 75 patients (65%) in group 1, and 41 (35%) in group 2. There were no differences between group 1 & 2 in perioperative complications (6.7% vs. 9.8%, P = 0.483), postoperative length of stay (median [IQR]; 19.5 [11.5–40.5] vs. 20.0 [11.25–58.5] hours, P = 0.632), or 30-day readmission rate (2.7% vs. 4.9%, P = 0.543). There were no deaths in either group. Conclusion Delayed appendectomy performed more than 8 h was not associated with increased perioperative complications, postoperative length of stay, 30-day readmission rate, or mortality.

Early versus delayed appendectomy: A comparison of outcomes.

Background Resident operative autonomy (ROA) is critical and a shared responsibility of both faculty and residents during training. We hypothesize that there is a perception of gender bias in residents’ performance as evaluated by faculty and residents. Method Over a period of five academic years, between July 2014 and June 2019, ROA was evaluated using the Zwisch score. Reciprocal evaluations were completed by faculty and residents. Results 39 surgeons (30 males, 9 females) and 42 residents (25 males, 15 females) completed 2360 evaluations (1180 by faculty, and a matched number by residents). PGY level was significantly associated with granting a higher level of autonomy. Gender of residents didn’t affect the level of granted autonomy as evaluated by faculty. However, on self-evaluations, female residents rated their degree of autonomy lower than that of their male counterparts. Conclusion Gender did not influence the perception of autonomy granted as evaluated by faculty. However, on self-evaluations, female residents reported a lower degree of autonomy received.

Saad Shebrain

Papers

Alternatives surgical training approaches during COVID-19 pandemic

Multi-Class Detection of Laparoscopic Instruments for the Intelligent Box-Trainer System Using Faster R-CNN Architecture

Early versus delayed appendectomy: A comparison of outcomes.

Gender perception bias of operative autonomy evaluations among residents and faculty in general surgery training.

Virtual Surgery Oral Board Examinations in the Era of COVID-19 Pandemic. How I Do It!