A risk stratification analysis of ASCVD events post-statin discontinuation in patients who underwent sleeve gastrectomy or Roux-en-Y gastric bypass bariatric/metabolic surgeries.

BACKGROUND: Cardiovascular disease remains a leading cause of mortality globally, and its prevalence is notably elevated in individuals with obesity. Bariatric surgery is an effective intervention to reduce obesity-related health risks. However, the implications of discontinuing statin therapy, particularly post-bariatric surgery, among those with a history of atherosclerotic cardiovascular disease have yet to be clarified. We aimed to ascertain the risk of atherosclerotic cardiovascular disease events following statin cessation after bariatric surgery and to delineate the variance in outcomes between primary and secondary prevention cohorts. METHODS: The TriNetX database, encompassing electronic medical records from 69 United States healthcare institutions, spanning 2012 to 2021. Using a retrospective cohort design, patients aged ≥18 years who underwent bariatric surgery and were concurrently on statin therapy were selected. Discontinuation was defined as a 90-day lapse after the last statin prescription. Patients were categorized as "primary" or "secondary" prevention based on their atherosclerotic cardiovascular disease history. The primary outcome was the occurrence of an atherosclerotic cardiovascular disease event post-statin cessation. Multivariable Cox proportional hazards models discerned factors influencing this outcome. RESULTS: Of the 453 statin users who underwent bariatric surgery, 332 (73.1%) were in the primary prevention group and 121 (26.7%) in the secondary prevention group. At 1-year post-surgery, atherosclerotic cardiovascular disease event-free rates were 93% for primary and 68% for secondary prevention groups. Primary prevention patients showed an 82% reduced risk of post-statin cessation atherosclerotic cardiovascular disease events than secondary prevention patients (hazard ratio, 0.181; 95% confidence interval, 0.119-0.274). Additionally, Hispanic/Latino patients had heightened post-statin cessation atherosclerotic cardiovascular disease risks compared to non-Hispanic/Latino peers. CONCLUSION: Post-bariatric surgery statin discontinuation can pose significant risks, especially for those with atherosclerotic cardiovascular disease history and certain demographic groups, such as those over age 40 with diabetes. Ethnic disparities in outcomes necessitate individualized, equitable healthcare strategies. Optimal decisions about statin cessation necessitate comprehensive evaluations of cardiovascular determinants, with future research crucial to refine therapeutic approaches based on these insights.

The Effect of Bariatric Surgery on Menstrual Abnormalities in Saudi Women: A Cross-Sectional Study.

BACKGROUND: Adults in Saudi Arabia are more likely to be obese, which has negative effects on reproductive health, especially for women. While bariatric surgery (BS) provides a sustainable approach, little is known about how it affects menstrual health and requires a study among the Saudi demographic. METHODS: The current investigation is a cross-sectional study conducted in Saudi Arabia. Data were collected using an online questionnaire to assess the impact of BS on menstrual abnormalities in women. Data were cleaned in Excel and analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 24.0, Armonk, NY). RESULTS: This study included 516 Saudi women who underwent various BS procedures, with 37.2% aged 18-30 years and 97.9% residing in Saudi Arabia. Approximately 85.9% underwent sleeve gastrectomy (SG), experiencing a mean weight loss of 54.2 kg. Co-morbidities included polycystic ovary syndrome (PCOS) (12.4%), hypothyroidism or hyperthyroidism (11%), uterine fibroids (4.7%), and hormonal imbalances (2.5%). Post-surgery, 18% encountered BS complications from BS, while 8.3% used antidepressants. Moderate sports participation ranged from 12.2% (five or more days) to 36.2% (one to three days). In particular, no significant associations were found between complications and various parameters, except a marginal association with educational level (p=0.071). The number of menstruations per year did not change statistically significantly, remaining constant at 10.6±4.8 before surgery and 10.6±4.9 after surgery (p = 0.859). However, there was a mild decrease in the amount and duration of menstruation, reported by 23.3% and 27.3% of the participants preoperatively and post-operatively, respectively. CONCLUSION: The study demonstrates the impact of BS on menstrual abnormalities in Saudi women. Despite a significant weight reduction, we found mild improvement in the amount and duration of menstruation with no substantial effect observed on the menstrual cycle frequency. Psychological support after surgery is crucial, considering the increased use of antidepressants.

Gastroscope-assisted laparoscopic sleeve gastrectomy: A case report with an unexpected old deflated intragastric balloon.

INTRODUCTION AND IMPORTANCE: Obesity has become a global health crisis and is now considered a pandemic. Intragastric balloons (IGB) can aid obese patients achieve a better effect of weight loss than medications while being noninvasive compared to surgical therapy. CASE PRESENTATION: We report a case of a 42-yr-old female with difficulty in losing weight even after three attempts of IGB and several diet programs. At the time of presentation, the patients BMI was 46.2 kg/m2. The patient experienced no gastrointestinal symptoms or stomach complaints and was found to have morbid obesity with hypertension and glucose intolerance. CLINICAL DISCUSSION: Laparoscopic sleeve gastrectomy (LSG) was suggested for the patient. While performing LSG in association with a gastroscope, an unexpected old and deflated gastric balloon was found residing inside the stomach cavity. The rest of the surgery had no difficulty after the old gastric balloon was removed. The patients BMI post-LSG after 18 months was noticed to be 26.6 kg/m2. CONCLUSION: We recommend performing gastroscopy prior to LSG for every patient with a previous gastric balloon insertion, especially if they had it more than once, to avoid potential complications during surgery.

Role of bariatric surgery on psychological and social outcomes of patients: A systematic review.

We aim to systematically review the psychological and social outcomes of patients post-bariatric surgery. The comprehensive search using keywords yielded 1224 records utilizing search engines PubMed and Scopus. After a careful analysis, 90 articles were found to be eligible for complete screening that collectively reported the use of 11 different BS procedures reported among 22 countries. This review is unique in that we collectively presented the result of various psychological and social outcome parameters (depression and anxiety, self-confidence, self-esteem, marital relationship, and personality traits) after BS. Regardless of the BS procedures performed, most studies over months to years presented a positive outcome of the parameters considered, while few presented contrasting unsatisfactory results. Thus, the surgery was not a cessation factor for these results to be permanent and thus suggested psychological interventions and long-term monitoring for assessing the psychological effects after BS. Additionally, the patient's endurance to check weight and eating habits after surgery is ultimately necessary.

Rising incidence of obesity in Saudi residents. A threatening challenge for the surgeons.

OBJECTIVE: Obesity is thought to correlate very strongly with individuals general lifestyles. This study was conducted to determine whether lifestyle patterns were potential risk factors for morbid obesity in Saudi residents. METHODS: This descriptive cross-sectional study was conducted in Unaizah City, Qassim Region, Kingdom of Saudi Arabia, over a 1-year period from March 2013 to March 2014. The study included 646 residents from the general public of Unaizah who were selected by convenient sampling at a mall and a public sector university, regardless of age and gender, and were given questionnaires regarding the details of their lifestyle patterns. The studied variables included demographic details, dietary habits, physical activity, occupation, body mass index, and unhealthy behavioral habits. The data were collected and statistically analyzed using SPSS version 20. RESULTS: The study population had a mean age of 30.13 ± 12.15 years and comprised 202 (31.3%) male and 444 (68.7%) female subjects. The study subjects were students (39.2%), general public included employed (35.3%), unemployed (23.8%), and others (1.7%). Overall, 79.4% comprised Saudi nationals and the majority (48.3%) had a university-level education. A reasonably high proportion of Saudi subjects were found to have sedentary habits and with physical activity levels far below the standard. Obesity was found in 42% of the study population with low physical activity levels and unhealthy dietary habits. Varying proportions of concomitant hypertension, hyperglycemia, and hypercholesterolemia were also observed in these subjects. CONCLUSION: Sedentary habits, low physical activity levels in younger populations, and unhealthy dietary habits are major factors causing obesity in the general public as well as in children and adolescents attending school and university. Serious insight into this problem at the governmental level is needed to improve the overall activity level and avoidance of a sedentary lifestyle by projecting the importance of a healthy lifestyle.

Comparison of the efficacy of standard bariatric surgical procedures on Saudi population using the bariatric analysis and reporting outcome system.

OBJECTIVES: To  compare the efficacy of various standard bariatric surgical procedures using the Bariatric Analysis and Reporting Outcome System (BAROS). Methods: This is a prospective, descriptive analytical study conducted in 2 medical institutions in Saudi Arabia. A total of 270 patients who had different bariatric surgery during the period between March 2010 and December 2012 were included. The data was analyzed and scored against 3 outcomes, excess weight loss, cure or improvement of comorbidities, and quality of life changes. Results: All patients who had different bariatric procedures were included in our study. Seventy-nine (29.3%) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP), 159 (58.9%) had laparoscopic sleeve gastrectomy (LSG), and 32 (11.9%) had laparoscopic adjustable gastric banding (LAGB). Complete remission of at least one comorbidity was reported in 36% of LRYGBP, 51% in LSG, and 42% in LAGB. While all other patients have improved comorbidities. The BAROS score was good or higher in 78.5% of LRYGBP, 83.6% for the LSG, and 84.4% of LAGB patients. The average excess weight loss was 67.9% in LRYGBP, 75.8% in LSG, and 81.7% LAGB patients. Conclusion: Bariatric surgery provides a substantial reduction in excess weight, improvement and cure of comorbidities, and improvement in quality of life. Standard bariatric procedures have different degrees of outcomes that can be beneficial in selecting appropriate procedure for appropriate indications and patients.

Umbilical pilonidal sinus.

Pilonidal sinuses are commonly encountered, but their occurrence in the umbilical area is rare. The author presents one such case of an umbilical pilonidal sinus in an obese male patient that presented with recurrent episodes of umbilical discharge. The condition was treated with sinus excision and umbilical reconstruction. There was no recurrence of the disease until one year of follow up.

Umbilical hernia repair with proceed ventral patch.

Umbilical hernia is one the commonest surgical lesions and there is a variety of methods available for its repair. Proceed Ventral Patch is a recent and novel innovation in hernia management and we present a successful management of umbilical hernia in a 45 years old obese patient with this technique.

Hand Hygiene Practices in Medical Students: A Follow-Up Study.

Objective. The study was conducted to study the impact of various measures instituted to improve hand hygiene practices of the medical students after having documented poor hand hygiene awareness and compliance in a study conducted in 2012. Methods. A self-designed questionnaire based on World Health Organization's concept of "Five Moments for Hand Hygiene" was used to evaluate the awareness of the indications of hand hygiene. Compliance was observed during Objective Structured Clinical Examination (OSCE) sessions. Fifty-one students participated voluntarily in the study. Results. The awareness and compliance of hand hygiene among the medical students in 2014 had shown statistically significant improvement (P < 0.005) as compared to figures of the study conducted in 2012. Conclusion. Dedicated multifaceted intervention can improve the hand hygiene practices in medical students.

Using simulation to improve the cognitive and psychomotor skills of novice students in advanced laparoscopic surgery: a meta-analysis.

Advances in simulation technologies have enhanced the ability to introduce the teaching and learning of laparoscopic surgical skills to novice students. In this meta-analysis, a total of 18 randomized controlled studies were identified that specifically looked at training novices in comparison with a control group as it pertains to knowledge retention, time to completion and suturing and knotting skills. The combined random-effect sizes (ESs) showed that novice students who trained on laparoscopic simulators have considerably developed better laparoscopic suturing and knot tying skills (d = 1.96, p < 0.01), conducted fewer errors (d = 2.13, p < 0.01), retained more knowledge (d = 1.57, p < 0.01) than their respective control groups, and were significantly faster on time to completion (d = 1.98, p < 0.01). As illustrated in corresponding Forest plots, the majority of the primary study outcomes included in this meta-analysis show statistically significant support (p < 0.05) for the use of laparoscopic simulators for novice student training on both knowledge and advanced surgical skill development (28 of 35 outcomes, 80%). The findings of this meta-analysis support strongly the use of simulators for teaching laparoscopic surgery skills to novice students in surgical residency programs.

Hand Hygiene Practices among Medical Students.

Background. Hand hygiene is a cost-effective method in preventing infection transmission. Hand hygiene practices have been found to be faulty in most healthcare settings. We conducted a study to evaluate the awareness, and compliance of hand hygiene among undergraduate medical students during their clinical phase in Qassim College of Medicine, Saudi Arabia. Methods. A questionnaire based on World Health Organization's concept of "Five Moments for Hand Hygiene" was used to evaluate the awareness of the indications for hand hygiene and compliance was observed during Objective Structured Clinical Examination (OSCE) sessions. Sixty students including thirty-six males (60%) and twenty-four females (40%) participated voluntarily in the study. Results. The average awareness regarding the positive indications of hand hygiene was 56%. Rest of the 44% of students were either not sure or unaware of the indications of hygiene. Only 29% of students were able to identify all the five indications for hand hygiene in the questionnaire. Compliance as assessed during OSCE sessions was only 17% with no significant difference between the genders. Conclusion. It was concluded that serious efforts are needed to improve the hand hygiene practices among medical students.

The effect of simulation in improving students' performance in laparoscopic surgery: a meta-analysis.

BACKGROUND: There is increasing interest in using simulators for laparoscopic surgery training, and simulators have rapidly become an integral part of surgical education. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, and Google Scholar for randomized controlled studies that compared the use of different types of simulators. The inclusion criteria were peer-reviewed published randomized clinical trials that compared simulators versus standard apprenticeship surgical training of surgical trainees with little or no prior laparoscopic experience. Of the 551 relevant studies found, 17 trials fulfilled all inclusion criteria. The effect sizes (ES) with 95 % confidence intervals [CI] were calculated for multiple psychometric skill outcome measures. RESULTS: Data were combined by means of both fixed- and random-effects models. Meta-analytic combined effect size estimates showed that novice students who trained on simulators were superior in their performance and skill scores (d = 1.98, 95 % CI: 1.20-2.77; P < 0.01), were more careful in handling various body tissue (d = 1.08, 95 % CI: 0.36-1.80; P < 0.01), and had a higher accuracy score in conducting laparoscopic tasks (d = 1.38, 95 % CI: 0.30-2.47; P < 0.05). CONCLUSION: Simulators have been shown to provide better laparoscopic surgery skills training for trainees than the traditional standard apprenticeship approach to skill development. Surgical residency programs are highly encouraged to adopt the use of simulators in teaching laparoscopic surgery skills to novice students.

Anal cancer - a review.

Anal cancer accounts for only 1.5% of gastrointestinal malignancies but this disease has shown a steady increase in incidence particularly in HIV positive males. The understanding of pathophysiology and treatment of anal cancer has changed radically over last thirty years. Risk factors have been identified and organ preservation by chemoradiotherapy has become a standard. This article aims to review the clinical presentation, diagnostic evaluation, and treatment options for anal cancer in the light of current literature.

Endoscopic treatment of Zenker diverticulum: results of a 7-year experience.

BACKGROUND: Zenker diverticulum (ZD) is a rare disease usually seen in elderly patients who present with symptoms of worsening dysphagia and regurgitation. Although open surgical approach is still the standard management for symptomatic patients, the endoscopic technique has evolved as an alternative approach, especially for highly morbid patients. We are reporting our experience for treating ZD using endoscopic needle-knife papillotome. STUDY DESIGN: A total of 18 patients with a mean age of 80 years (range 68 to 91 years) were included in our prospective cohort study. All patients underwent endoscopic cricopharyngeal myotomy for symptomatic ZD using needle-knife papillotome at Brandon Regional Health Centre during a 7-year period. Mean follow-up was 27.5 months. A dysphagia score system from 0 (no dysphagia) to 4 (severe dysphagia) was used. All patients' baseline characteristics, pre- and postoperative symptoms, operative time, time to oral intake, length of hospital stay, recurrence of symptoms, and complications were analyzed. RESULTS: Dysphagia score and regurgitation symptoms improved substantially after treatment. Mean operative time was 28.4 minutes. Oral intake was resumed within 24 hours in all but 1 patient. Hospital stay for the majority was 24 to 48 hours. Only 1 patient had a microperforation treated conservatively and 2 patients had re-do procedures for persistence of dysphagia. CONCLUSIONS: Endoscopic cricopharyngeal myotomy using needle-knife papillotome is an effective approach to manage ZD for highly morbid patients. It is minimally invasive, decreases anesthetic time, shortens hospital stay, and has a low complication rate.

Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation.

BACKGROUND: Ultrasound guidance during central line insertion has significantly reduced complications associated with this procedure and has led to it being incorporated as standard of care in many institutions. However, inadvertent arterial penetration and dilation remains a problem despite ultrasound guidance and can result in significant morbidity and even mortality. Dynamic ultrasound confirmation of guidewire position within the vein prior to dilation may help to prevent and even eliminate this feared complication. METHODS: A prospectively collected database of central line insertions for one author utilizing this novel technique was retrospectively reviewed for all incidents of arterial dilation over a period from September 2008 to January 2010. RESULTS: During the study period 53 central lines were inserted with no incidents of arterial dilation. CONCLUSIONS: Ultrasound confirmation of guidewire position has the potential to reduce or eliminate the morbidity and mortality of arterial dilation during central line placement.

Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma.

BACKGROUND: Traumatic injury is a leading cause of morbidity and mortality in developed countries worldwide. Recent studies suggest that many deaths are preventable if injuries are recognized and treated in an expeditious manner - the so called 'golden hour' of trauma. Ultrasound revolutionized the care of the trauma patient with the introduction of the FAST (Focused Assessment with Sonography for Trauma) examination; a rapid assessment of the hemodynamically unstable patient to identify the presence of peritoneal and/or pericardial fluid. Since that time the use of ultrasound has expanded to include a rapid assessment of almost every facet of the trauma patient. As a result, ultrasound is not only viewed as a diagnostic test, but actually as an extension of the physical exam. METHODS: A review of the medical literature was performed and articles pertaining to ultrasound-assisted assessment of the trauma patient were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION: In this review we explore the benefits and pitfalls of applying resuscitative ultrasound to every aspect of the initial assessment of the critically injured trauma patient.

User's perceptions of remote trauma telesonography.

We established a pilot tele-ultrasound system between a rural referring hospital and a tertiary care trauma centre to facilitate telementoring during acute trauma resuscitations. Over a 12-month period, 23 tele-ultrasound examinations were completed. The clinical protocol examined both the Focused Assessment with Sonography for Trauma (FAST) and the Extended FAST (EFAST) for pneumothoraxes. Twenty of the examinations were conducted during acute trauma resuscitations and three during live patient simulations. FAST examinations were completed in all 23 cases and EFAST examinations in 17 cases. There were 18 clinical users, of whom 14 completed a survey (76% response rate). Overall, 93% of respondents were either satisfied or very satisfied with the telemedicine interaction and agreed or strongly agreed that the technology could potentially benefit injured patients in the far north of Canada. In addition, 93% of the respondents felt that the project had improved collegiality between the two institutions involved. The majority of respondents (71%) agreed or strongly agreed that the project had improved their ultrasound skills. We believe that as further experience is obtained, tele-ultrasound will prove to be an important aid to the care of remotely injured and ill patients.

Resuscitative Long-Bone Sonography for the Clinician: Usefulness and Pitfalls of Focused Clinical Ultrasound to Detect Long-Bone Fractures During Trauma Resuscitation.

Bone has one of the highest acoustic densities (AD) in the human body. Traditionally, bone has been considered to be a hindrance to the use of ultrasound (US), as US waves are reflected by the dense matrix and obscure underlying structures. The intense wave reflection, however, can clearly illustrate the cortical bony anatomy of long bones, making cortical disruption obvious. Ultrasound can be used at the bedside concurrently with the overall trauma resuscitation, and may potentially limit the patient's and treating team's exposure to ionizing radiation, corroborate clinical findings, and augment procedural success. The extended focused assessment with sonography for trauma (EFAST) is an essential tool in the resuscitation of severe torso trauma, frequently demonstrating intra- pericardial and intra-peritoneal fluid, inferring hemo/pneumothoraces, and demonstrating cardiac function. Although it is typically considered as a diagnosis of exclusion, multiple long-bone fractures may be a source of shock and can be quickly confirmed at the bedside with EFAST. Further, the early detection of long-bone fractures can also aid in the early stabilization of severely injured patients. Sonographic evaluation for long-bone fractures may be particularly useful in austere environments where other imaging modalities are limited, such as in the battlefield, developing world, and space. While prospective study has been limited, selected series have demonstrated high accuracy among both physician and para-medical clinicians in detecting long-bone fractures. Pitfalls in this technique include reduced accuracy with the small bones of the hands and feet, as well as great reliance on user experience.