Positioning the Bariatric Amputee: A Case Report.

Traumatic lower limb amputation has been identified as a major risk factor for obesity and metabolic diseases. Surgery in amputees with obesity poses significant complexities with physical and logistical issues of positioning and ergonomics. A 64-year-old gentleman with a history bilateral above knee amputation, obesity, type 2 diabetes mellitus, and obstructive sleep apnea was worked up for bariatric surgery. Due to his amputations, it was unknown whether this would be safe or feasible. In order to ensure this, the patient was brought to the operating room more than a week in advance to trial positioning. The patient was able to be positioned in reverse Trendelenburg with straps across his lower chest and his proximal thighs. Despite obesity being a prevalent and increasing issue facing lower limb amputees, there was relative paucity of literature on the topic. The successful use of this strategy to position a bilateral amputee could be mirrored in future cases.

A highly resolved network reveals the role of terrestrial herbivory in structuring aboveground food webs.

Comparative studies suggest remarkable similarities among food webs across habitats, including systematic changes in their structure with diversity and complexity (scale-dependence). However, historic aboveground terrestrial food webs (ATFWs) have coarsely grouped plants and insects such that these webs are generally small, and herbivory is disproportionately under-represented compared to vertebrate predator-prey interactions. Furthermore, terrestrial herbivory is thought to be structured by unique processes compared to size-structured feeding in other systems. Here, we present the richest ATFW to date, including approximately 580 000 feeding links among approximately 3800 taxonomic species, sourced from approximately 27 000 expert-vetted interaction records annotated as feeding upon one of six different resource types: leaves, flowers, seeds, wood, prey and carrion. By comparison to historical ATFWs and null ecological hypotheses, we show that our temperate forest web displays a potentially unique structure characterized by two properties: (i) a large fraction of carnivory interactions dominated by a small number of hyper-generalist, opportunistic bird and bat predators; and (ii) a smaller fraction of herbivory interactions dominated by a hyper-rich community of insects with variably sized but highly specific diets. We attribute our findings to the large-scale, even resolution of vertebrate, insect and plant guilds in our food web.This article is part of the theme issue 'Connected interactions: enriching food web research by spatial and social interactions'.

Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees.

Importance: The need for trainee sex equality within surgical training has resulted in an appraisal of the training experience in the New Zealand general surgery training program. Objective: To investigate the association between trainee sex and surgical autonomy in the operating room in the New Zealand general surgery training program. Design, Setting, and Participants: Retrospective cohort study conducted from December 10, 2012, to December 10, 2017, examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand. Main Outcomes and Measures: The primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis. Results: This study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI, 76.7-203.2] vs 198.1 [95% CI, 142.3-254.0], P = .02), and minor (456.3 [95% CI, 394.8-517.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures. Conclusions and Relevance: After accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.

Gastroduodenal Artery Aneurysm: A Case Report and Concise Review of Literature.

Gastroduodenal artery (GDA) aneurysm is a rare but potentially fatal vascular disease, with chronic pancreatitis being reported as the commonest aetiological factor. Its main complication is rupture, which is not uncommon and carries high risk of mortality. Clinical suspicion and advanced imaging tools should be employed in a timely fashion to make a diagnosis before this ominous event. We report a case of successfully treated GDA aneurysm who presented with minor bleeding episodes before suffering a major bleed and briefly discuss this pathology in light of the existing literature.

To infiltrate or not? Acute effects of local anaesthetic in breast surgery.

BACKGROUND: There is limited evidence to support use of local anaesthetic (LA) wound infiltration in breast surgery. This study seeks to examine whether wound infiltration of bupivacaine (0.25%) decreases post-operative pain and analgesic use, without increasing post-operative complications. METHODS: A prospective single-blind study was undertaken of 90 patients undergoing breast lump excision, wide local excision and mastectomy with or without axillary surgery. Patients were randomized to receive infiltration with bupivacaine (0.25%) into the surgical wound (Group LA) or no infiltration (Group No LA). Data on post-operative analgesia use was collected. Pain scores were assessed at 1, 24, 48 h and 1 week with a visual analogue scale. Complications associated with wound healing were documented at the first post-operative visit. RESULTS: Forty-five patients received infiltration and 34 patients received none. There were no significant differences in baseline characteristics between patient groups or surgical details. Analysis revealed Group LA used significantly less opioids than Group No LA during the first 48 h post-op (3.42 mg versus 7.33 mg; P = 0.02). Overall, Group LA used half the total average opioid equivalent amount (5.04 mg versus 10.08 mg; P = 0.069). There were no significant differences in post-operative pain scores or complications. Overall pain scores were low, suggesting effective analgesic use by nursing staff. DISCUSSION: LA infiltration during breast surgery has a marked opioid sparing effect, which has significant patient benefits as well as reducing nursing workload and drug costs.