Publications by authors named "Sanjay Purkayastha"

148 Publications

The metabolomic effects of tripeptide gut hormone infusion compared to Roux-en-Y gastric bypass and caloric restriction.

J Clin Endocrinol Metab 2021 Aug 30. Epub 2021 Aug 30.

Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, United Kingdom.

Context: The gut-derived peptide hormones glucagon-like peptide-1 (GLP-1), oxyntomodulin (OXM), and peptide YY (PYY) are regulators of energy intake and glucose homeostasis, and are thought to contribute to the glucose-lowering effects of bariatric surgery.

Objective: To establish the metabolomic effects of a combined infusion of GLP-1, OXM and PYY (tripeptide "GOP") in comparison to a placebo infusion, Roux-en-Y gastric bypass (RYGB) surgery, and a very low-calorie diet (VLCD).

Design And Setting: Sub-analysis of a single-blind, randomised, placebo-controlled study of GOP infusion (ClinicalTrials.gov NCT01945840), including VLCD and RYGB comparator groups.

Patients And Interventions: 25 obese patients with type 2 diabetes or prediabetes were randomly allocated to receive a 4-week subcutaneous infusion of GOP (n=14) or 0.9% saline control (SAL; n=11). An additional 22 patients followed a VLCD, and 21 underwent RYGB surgery.

Main Outcome Measures: Plasma and urine samples collected at baseline and 4 weeks into each intervention were subjected to cross-platform metabolomic analysis, followed by unsupervised and supervised modelling approaches to identify similarities and differences between the effects of each intervention.

Results: Aside from glucose, very few metabolites were affected by GOP, contrasting with major metabolomic changes seen with VLCD and RYGB.

Conclusions: Treatment with GOP provides a powerful glucose-lowering effect but does not replicate the broader metabolomic changes seen with VLCD and RYGB. The contribution of these metabolomic changes to the clinical benefits of RYGB remains to be elucidated.
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http://dx.doi.org/10.1210/clinem/dgab608DOI Listing
August 2021

The Ethical Digital Surgeon.

J Med Internet Res 2021 Jul 5;23(7):e25849. Epub 2021 Jul 5.

Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

This viewpoint explores the ethical and regulatory consequences of the digital transformation of the operating room. Surgical robotics is undergoing significant change and future advances will center around the capture and use of data. The consequences of creating this surgical data pipeline must be understood and digital surgical systems must prioritize the safeguarding of patient data. Moreover, data protection laws and frameworks must adapt to the changing nature of surgical data. Finally, digital surgeons must understand changing data legislation and best practice on data governance to act as guardians not only for their own but also for their patients' data.
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http://dx.doi.org/10.2196/25849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8406117PMC
July 2021

Impact of the COVID-19 pandemic On Emergency Adult Surgical Patients and Surgical Services: An International Multi-Center Cohort Study and Department Survey.

Ann Surg 2021 Aug 16. Epub 2021 Aug 16.

Department of Surgery & Cancer, Imperial College London, London, United Kingdom Imperial College Healthcare NHS Trust, London, United Kingdom Centre for Mathematics of Precision Healthcare, Imperial College London, United Kingdom Institute of Global Health Innovation, Imperial College London, London, United Kingdom.

Objectives: The PREDICT study aimed to determine how the COVID-19 pandemic affected surgical services and surgical patients and to identify predictors of outcomes in this cohort.

Background: High mortality rates were reported for surgical patients with COVID-19 in the early stages of the pandemic. However, the indirect impact of the pandemic on this cohort is not understood, and risk predictors are yet to be identified.

Methods: PREDICT is an international longitudinal cohort study comprising surgical patients presenting to hospital between March and August 2020, conducted alongside a survey of staff redeployment and departmental restructuring. A subgroup analysis of 3176 adult emergency patients, recruited by 55 teams across 18 countries is presented.

Results: Among adult emergency surgical patients, all-cause in-hospital mortality (IHM) was 3 6%, compared to 15 5% for those with COVID-19. However, only 14 1% received a COVID-19 test on admission in March, increasing to 76 5% by July.Higher Clinical Frailty Scale scores (CFS >7 aOR 18 87), ASA grade above 2 (aOR 4 29), and COVID-19 infection (aOR 5 12) were independently associated with significantly increased IHM.The peak months of the first wave were independently associated with significantly higher IHM (March aOR 4 34; April aOR 4 25; May aOR 3 97), compared to non-peak months.During the study, UK operating theatre capacity decreased by a mean of 63 6% with a concomitant 27 3% reduction in surgical staffing.

Conclusion: The first wave of the COVID-19 pandemic significantly impacted surgical patients, both directly through co-morbid infection and indirectly as shown by increasing mortality in peak months, irrespective of COVID-19 status.Higher CFS scores and ASA grades strongly predict outcomes in surgical patients and are an important risk assessment tool during the pandemic.
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http://dx.doi.org/10.1097/SLA.0000000000005152DOI Listing
August 2021

The GP-OH (General Practice - Organizational Health) Survey: Development and Validation of a Novel Instrument to Measure Organizational Health in General Practice.

Hosp Top 2021 Jul 30:1-11. Epub 2021 Jul 30.

Academic Surgical Unit, St Mary's Campus, Imperial College London, London, United Kingdom of Great Britain and Northern Ireland.

Primary care healthcare organizations are complex and multidimensional, and there has been much discussion about the potential dangers of focusing on outcomes as quality indicators in isolation without understanding the processes and system characteristics that drive them. Organizational health, as a concept, shifts the focus of measurement upstream and considers the elements needed for sustainable long-term success. This study has both designed and tested the first survey seeking to measure organizational health specifically within the context of primary care. A stepwise approach was taken to ensure that the validity and reliability of the survey was examined at multiple stages.Supplemental data for this article is available online at https://doi.org/10.1080/00185868.2021.1947164.
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http://dx.doi.org/10.1080/00185868.2021.1947164DOI Listing
July 2021

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m.

Surg Obes Relat Dis 2021 Oct 16;17(10):1732-1738. Epub 2021 Jun 16.

Department of Bariatric Surgery, St George's University Hospitals NHS Foundation Trust, London, United Kingdom.

Background: Bariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.

Objectives: This study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m.

Setting: National Health Service and private hospitals in the United Kingdom.

Methods: This cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.

Results: There were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m for AGB; 75 ± 5 kg/m for SG; 74 ± 5 kg/m for RYGB). The median postoperative follow-up was 13 months for AGB (10-22 mo), 18 for SG (6-28 mo), and 15 for RYGB (6-24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m and 51 ± 11 kg/m, respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.

Conclusion: This study found that primary BMS in patients with a BMI >70kg/m has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG's potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.
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http://dx.doi.org/10.1016/j.soard.2021.06.002DOI Listing
October 2021

Weight Loss by Low-Calorie Diet Versus Gastric Bypass Surgery in People With Diabetes Results in Divergent Brain Activation Patterns: A Functional MRI Study.

Diabetes Care 2021 Aug 22;44(8):1842-1851. Epub 2021 Jun 22.

Department of Digestion, Metabolism and Reproduction, Imperial College London, London, U.K.

Objective: Weight loss achieved with very-low-calorie diets (VLCDs) can produce remission of type 2 diabetes (T2D), but weight regain very often occurs with reintroduction of higher calorie intakes. In contrast, bariatric surgery produces clinically significant and durable weight loss, with diabetes remission that translates into reductions in mortality. We hypothesized that in patients living with obesity and prediabetes/T2D, longitudinal changes in brain activity in response to food cues as measured using functional MRI would explain this difference.

Research Design And Methods: Sixteen participants underwent gastric bypass surgery, and 19 matched participants undertook a VLCD (meal replacement) for 4 weeks. Brain responses to food cues and resting-state functional connectivity were assessed with functional MRI pre- and postintervention and compared across groups.

Results: We show that Roux-en-Y gastric bypass surgery (RYGB) results in three divergent brain responses compared with VLCD-induced weight loss: ) VLCD resulted in increased brain reward center food cue responsiveness, whereas in RYGB, this was reduced; ) VLCD resulted in higher neural activation of cognitive control regions in response to food cues associated with exercising increased cognitive restraint over eating, whereas RYGB did not; and ) a homeostatic appetitive system (centered on the hypothalamus) is better engaged following RYGB-induced weight loss than VLCD.

Conclusions: Taken together, these findings point to divergent brain responses to different methods of weight loss in patients with diabetes, which may explain weight regain after a short-term VLCD in contrast to enduring weight loss after RYGB.
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http://dx.doi.org/10.2337/dc20-2641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8385466PMC
August 2021

The association between obesity and weight loss after bariatric surgery on the vaginal microbiota.

Microbiome 2021 05 28;9(1):124. Epub 2021 May 28.

IRDB, Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Hammersmith Campus, Imperial College London, W12 0NN, London, UK.

Background: Obesity and vaginal microbiome (VMB) dysbiosis are each risk factors for adverse reproductive and oncological health outcomes in women. Here, we investigated the relationship between obesity, vaginal bacterial composition, local inflammation and bariatric surgery.

Methods: Vaginal bacterial composition assessed by high-throughput sequencing of bacterial 16S rRNA genes and local cytokine levels measured using a multiplexed Magnetic Luminex Screening Assay were compared between 67 obese and 42 non-obese women. We further assessed temporal changes in the microbiota and cytokines in a subset of 27 women who underwent bariatric surgery.

Results: The bacterial component of the vaginal microbiota in obese women was characterised by a lower prevalence of a Lactobacillus-dominant VMB and higher prevalence of a high diversity (Lactobacillus spp., and Gardnerella- spp. depleted) VMB, compared with non-obese subjects (p<0.001). Obese women had higher relative abundance of Dialister species (p<0.001), Anaerococcus vaginalis (p=0.021), and Prevotella timonensis (p=0.020) and decreased relative abundance of Lactobacillus crispatus (p=0.014). Local vaginal IL-1β, IL-4, IL-6, IL-8, IFNγ, MIP-1α and TNFα levels were all higher among obese women, however, only IL-1β and IL-8 correlated with VMB species diversity. In a subset of obese women undergoing bariatric surgery, there were no significant overall differences in VMB following surgery; however, 75% of these women remained obese at 6 months. Prior to surgery, there was no relationship between body mass index (BMI) and VMB structure; however, post-surgery women with a Lactobacillus-dominant VMB had a significantly lower BMI than those with a high diversity VMB.

Conclusions: Obese women have a significantly different vaginal microbiota composition with increased levels of local inflammation compared to non-obese women. Bariatric surgery does not change the VMB; however, those with the greatest weight loss 6-month post-surgery are most likely to have a Lactobacillus-dominant VMB. Video abstract.
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http://dx.doi.org/10.1186/s40168-021-01011-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164250PMC
May 2021

Long-term cardiovascular outcomes after orlistat therapy in patients with obesity: a nationwide, propensity-score matched cohort study.

Eur Heart J Cardiovasc Pharmacother 2021 May 15. Epub 2021 May 15.

Department of Medicine, Imperial College London, Exhibition Road, London SW7 2AZ, UK.

Aims: The rising prevalence of obesity and its associated comorbidities represent a growing public health issue; in particular, obesity is known to be a major risk factor for cardiovascular disease. Despite the evidence behind the efficacy of orlistat in achieving weight loss in patients with obesity, no study thus far has quantified its long-term effect on cardiovascular outcomes. The purpose of this study is to explore long-term cardiovascular outcomes after orlistat therapy.

Methods And Results: A propensity-score matched cohort study was conducted on the nation-wide electronic primary and integrated secondary healthcare records of the Clinical Practice Research Datalink (CPRD). The 36 876 patients with obesity in the CPRD database who had completed a course of orlistat during follow-up were matched on a 1:1 basis with equal numbers of controls who had not taken orlistat. Patients were followed up for a median of 6 years for the occurrence of the primary composite endpoint of major adverse cardiovascular events (fatal or non-fatal myocardial infarction or ischaemic stroke), and a number of secondary endpoints including primary endpoint components individually, the occurrence of new-onset heart failure, coronary revascularization, new chronic kidney disease stage III+ (CKD3+), and all-cause mortality. During the median study follow-up of 6 years, the occurrence of major adverse cardiovascular events was lower in the orlistat cohort [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.66-0.83, P < 0.001]. Patients who took orlistat experienced lower rates of myocardial infarction (HR 0.77; 95% CI 0.66-0.88, P < 0.001) and ischaemic stroke (HR 0.68; 95% CI 0.56 to -0.84, P < 0.001) as well as new-onset heart failure (HR 0.79; 95% CI 0.67-0.94, P = 0.007). There was no differences in revascularization rates (HR 1.12; 95% CI 0.91-1.38, P = 0.27), but a lower rate of both CKD3+ development (HR 0.78; 95% CI 0.73-0.83, P < 0.001) and mortality (HR 0.39, 95% CI 0.36 to -0.41, P < 0.001) was observed.

Conclusion: In this nation-wide, propensity-score matched study, orlistat was associated with lower rates of overall major adverse cardiovascular events, new-onset heart failure, renal failure, and mortality. This study adds to current evidence on the known improvements in cardiovascular risk factor profiles of orlistat treatment by suggesting a potential role in primary prevention.
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http://dx.doi.org/10.1093/ehjcvp/pvaa133DOI Listing
May 2021

Determinants of burnout and other aspects of psychological well-being in healthcare workers during the Covid-19 pandemic: A multinational cross-sectional study.

PLoS One 2021 16;16(4):e0238666. Epub 2021 Apr 16.

Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

The Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. From 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. Of 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and 'other clinical' (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Significant factors inversely correlated with burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. Our findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238666PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051812PMC
May 2021

Using a Secure, Continually Updating, Web Source Processing Pipeline to Support the Real-Time Data Synthesis and Analysis of Scientific Literature: Development and Validation Study.

J Med Internet Res 2021 05 6;23(5):e25714. Epub 2021 May 6.

PanSurg Collaborative, Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

Background: The scale and quality of the global scientific response to the COVID-19 pandemic have unquestionably saved lives. However, the COVID-19 pandemic has also triggered an unprecedented "infodemic"; the velocity and volume of data production have overwhelmed many key stakeholders such as clinicians and policy makers, as they have been unable to process structured and unstructured data for evidence-based decision making. Solutions that aim to alleviate this data synthesis-related challenge are unable to capture heterogeneous web data in real time for the production of concomitant answers and are not based on the high-quality information in responses to a free-text query.

Objective: The main objective of this project is to build a generic, real-time, continuously updating curation platform that can support the data synthesis and analysis of a scientific literature framework. Our secondary objective is to validate this platform and the curation methodology for COVID-19-related medical literature by expanding the COVID-19 Open Research Dataset via the addition of new, unstructured data.

Methods: To create an infrastructure that addresses our objectives, the PanSurg Collaborative at Imperial College London has developed a unique data pipeline based on a web crawler extraction methodology. This data pipeline uses a novel curation methodology that adopts a human-in-the-loop approach for the characterization of quality, relevance, and key evidence across a range of scientific literature sources.

Results: REDASA (Realtime Data Synthesis and Analysis) is now one of the world's largest and most up-to-date sources of COVID-19-related evidence; it consists of 104,000 documents. By capturing curators' critical appraisal methodologies through the discrete labeling and rating of information, REDASA rapidly developed a foundational, pooled, data science data set of over 1400 articles in under 2 weeks. These articles provide COVID-19-related information and represent around 10% of all papers about COVID-19.

Conclusions: This data set can act as ground truth for the future implementation of a live, automated systematic review. The three benefits of REDASA's design are as follows: (1) it adopts a user-friendly, human-in-the-loop methodology by embedding an efficient, user-friendly curation platform into a natural language processing search engine; (2) it provides a curated data set in the JavaScript Object Notation format for experienced academic reviewers' critical appraisal choices and decision-making methodologies; and (3) due to the wide scope and depth of its web crawling method, REDASA has already captured one of the world's largest COVID-19-related data corpora for searches and curation.
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http://dx.doi.org/10.2196/25714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8104004PMC
May 2021

Imperforate hymen mimicking acute appendicitis in an adolescent woman: a rare presentation.

BMJ Case Rep 2021 Mar 9;14(3). Epub 2021 Mar 9.

Department of General Surgery, Imperial College NHS London, London, UK.

Imperforate hymen is a rare congenital malformation of the female genital tract. The condition poses several diagnostic challenges owing to its low incidence and often atypical presentation. Classical symptoms include amenorrhoea and cyclical abdominal pain. Delayed diagnosis leads to potentially irreversible and lifechanging sequelae including infertility, endometriosis and renal failure. A premenarchal 13-year-old girl with a background of chronic constipation presented with symptoms mimicking acute appendicitis. The underlying cause was imperforate hymen and retrograde menstruation. The diagnosis was made during diagnostic laparoscopy. As with this patient, pre-existing symptoms are often troublesome long before the true diagnosis is made. This case report highlights the importance of recognising imperforate hymen as a potential cause of acute abdominal pain in premenarchal adolescent girls. The clinical picture may present as right or left iliac fossa pain. Early identification reduces the risk of adverse complications and avoids unnecessary and potentially harmful interventions.
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http://dx.doi.org/10.1136/bcr-2020-238547DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944990PMC
March 2021

Long-term cerebrovascular outcomes after bariatric surgery: A nationwide cohort study.

Clin Neurol Neurosurg 2021 Apr 14;203:106560. Epub 2021 Feb 14.

Department of Surgery and Cancer, Imperial College, Praed Street, London, W2 1NY, United Kingdom.

Background: The proinflammatory state and metabolic changes associated with obesity contribute to cerebrovascular disease. Bariatric surgery can achieve a reliable reduction in body weight and improved metabolic profile in obese patients. However, its impact on cerebrovascular morbidity remains unexplored. This study investigates the effect of bariatric surgery on long-term risk of major cerebrovascular events.

Methods: A retrospective cohort study was designed. Data was extracted from the Clinical Practice Research Datalink. 4212 bariatric surgery patients were compared to 4212 age, sex, and BMI-matched controls. The primary composite endpoint was occurrence of any major adverse cerebrovascular event. Secondary endpoints included composite endpoints of ischaemic events, haemorrhagic events, individual components of the primary endpoint alone and all-cause mortality. An adjusted Cox proportional hazards model was implemented to analyse time to event data.

Results: Mean follow-up length was 11.4 years. The primary endpoint occurred in 73 patients. The bariatric surgery group had significantly lower adjusted major cerebrovascular event rates (HR 0.352, 95 %CI 0.195-0.637). Bariatric surgery was associated with lower rates of ischaemic events (HR 0.315, 95 %CI 0.156-0.635), particularly from transient ischaemic attacks (HR 0.364, 95 %CI 0.171-0.775). There was no difference in the rate of haemorrhagic events (HR 0.442, 95 %CI 0.147-1.330) or acute ischaemic stroke (HR 0.221, 95 %CI 0.046-1.054). In total 229 patients died during follow-up. Overall, all-cause mortality was significantly lower in the bariatric surgery group (HR 0.352, 95 %CI 0.195-0.637).

Conclusions: This study identifies an association between bariatric surgery and lower long-term risk of major adverse cerebrovascular events in patients with obesity.
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http://dx.doi.org/10.1016/j.clineuro.2021.106560DOI Listing
April 2021

Investigating the Ethical and Data Governance Issues of Artificial Intelligence in Surgery: Protocol for a Delphi Study.

JMIR Res Protoc 2021 Feb 22;10(2):e26552. Epub 2021 Feb 22.

Imperial College London, London, United Kingdom.

Background: The rapid uptake of digital technology into the operating room has the potential to improve patient outcomes, increase efficiency of the use of operating rooms, and allow surgeons to progress quickly up learning curves. These technologies are, however, dependent on huge amounts of data, and the consequences of their mismanagement are significant. While the field of artificial intelligence ethics is able to provide a broad framework for those designing and implementing these technologies into the operating room, there is a need to determine and address the ethical and data governance challenges of using digital technology in this unique environment.

Objective: The objectives of this study are to define the term digital surgery and gain expert consensus on the key ethical and data governance issues, barriers, and future research goals of the use of artificial intelligence in surgery.

Methods: Experts from the fields of surgery, ethics and law, policy, artificial intelligence, and industry will be invited to participate in a 4-round consensus Delphi exercise. In the first round, participants will supply free-text responses across 4 key domains: ethics, data governance, barriers, and future research goals. They will also be asked to provide their understanding of the term digital surgery. In subsequent rounds, statements will be grouped, and participants will be asked to rate the importance of each issue on a 9-point Likert scale ranging from 1 (not at all important) to 9 (critically important). Consensus is defined a priori as a score of 7 to 9 by 70% of respondents and 1 to 3 by less than 30% of respondents. A final online meeting round will be held to discuss inclusion of statements and draft a consensus document.

Results: Full ethical approval has been obtained for the study by the local research ethics committee at Imperial College, London (20IC6136). We anticipate round 1 to commence in January 2021.

Conclusions: The results of this study will define the term digital surgery, identify the key issues and barriers, and shape future research in this area.

International Registered Report Identifier (irrid): PRR1-10.2196/26552.
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http://dx.doi.org/10.2196/26552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939941PMC
February 2021

Who will benefit from bariatric surgery for diabetes? A protocol for an observational cohort study.

BMJ Open 2021 02 10;11(2):e042355. Epub 2021 Feb 10.

Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK

Introduction: Type 2 diabetes mellitus (T2DM) and obesity are pandemic diseases that lead to a great deal of morbidity and mortality. The most effective treatment for obesity and T2DM is bariatric or metabolic surgery; it can lead to long-term diabetes remission with 4 in 10 of those undergoing surgery having normal blood glucose on no medication 1 year postoperatively. However, surgery carries risks and, additionally, due to resource limitations, there is a restricted number of patients who can access this treatment. Moreover, not all those who undertake surgery respond equally well metabolically. The objective of the current research is to prospectively investigate predictors of T2DM response following metabolic surgery, including those directly involved in its aetiopathogenesis such as fat distribution and genetic variants. This will inform development of a clinically applicable model to help prioritise this therapy to those predicted to have remission.

Methods And Analysis: A prospective multicentre observational cohort study of adult patients with T2DM and obesity undergoing Roux-en-Y gastric bypass surgery. Patients will be comprehensively assessed before surgery to determine their clinical, metabolic, psychological, genetic and fat distribution profiles. A multivariate logistic regression model will be used to assess the value of the factors derived from the preoperative assessment in terms of prediction of diabetes remission.

Ethics And Dissemination: Formal ethics review was undertaken with a favourable opinion (UK HRA RES reference number 18/LO/0931). The dissemination plan is to present the results at conferences, in peer-reviewed journals as well as to lay media and to patient organisations.

Trial Registration Details: ClinicalTrials.gov, Identifier: NCT03842475.
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http://dx.doi.org/10.1136/bmjopen-2020-042355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878155PMC
February 2021

The Complex Association Between Bariatric Surgery and Depression: a National Nested-Control Study.

Obes Surg 2021 May 3;31(5):1994-2001. Epub 2021 Feb 3.

Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, W2 1NY, UK.

Background: Although bariatric surgery has been shown to reduce weight loss and obesity-related conditions, an improvement in depression remains unclear. The aim of this study was to determine whether bariatric surgery is associated with a resolution of depression, and the prevention of its onset.

Method: Patients with a BMI ≥ 30 kg/m who had undergone bariatric surgery were identified from the Clinical Practice Research Datalink (CPRD), matched 5:1 to controls. Cox regression analysis was used to determine the risk of developing de novo depression. Kaplan-Meier analysis compared the proportion of patients with no further consultations related to depression between the two groups.

Results: In total, 3534 patients who underwent surgery, of which 2018 (57%) had pre-existing depression, were matched to 15,480 controls. Cox proportional hazard modelling demonstrated surgery was associated with a HR of 1.50 (95% CI 1.32-1.71, p < 0.005) for developing de novo depression. For those with pre-existing depression, by 5 years, just over 20% of post-surgical patients had no further depression episodes compared with 17% of controls.

Conclusion: In individuals with a history of depression, bariatric surgery is associated with an improvement in mental health. On the contrary, the finding of increased de novo diagnoses of depression following surgery indicates the need for further study of the mechanisms by which bariatric surgery is associated with depression in this subset of patients.
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http://dx.doi.org/10.1007/s11695-020-05201-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041688PMC
May 2021

SARS-CoV-2 and Obesity: "CoVesity"-a Pandemic Within a Pandemic.

Obes Surg 2021 04 22;31(4):1745-1754. Epub 2021 Jan 22.

Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, Academic Surgical Unit, 10th Floor QEQM, South Wharf Road, London, W2 1NY, UK.

Individuals who are overweight or suffering from obesity are in a chronic state of low-grade inflammation, making them particularly susceptible to developing severe forms of respiratory failure. Studies conducted in past pandemics link obesity with worse health outcomes. This population is thus of particular concern within the context of the COVID-19 pandemic, considering the cessation of obesity management services. This systematic review highlights [1] the reciprocal link between the obesity and COVID-19 pandemics, [2] obesity as a risk factor for more severe disease in past pandemics, [3] potential mechanisms that make individual's suffering from obesity more susceptible to severe disease and higher viral load, and [4] the need to safely resume bariatric services as recommended by expert guidelines, in order to mitigate the health outcomes of an already vulnerable population.
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http://dx.doi.org/10.1007/s11695-020-04919-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819768PMC
April 2021

Long-term incidence and outcomes of obesity-related peripheral vascular disease after bariatric surgery.

Langenbecks Arch Surg 2021 Jun 12;406(4):1029-1036. Epub 2021 Jan 12.

Department of Surgery and Cancer, Imperial College London, Praed Street, London, W2 1NY, UK.

Background And Aims: Patients with obesity are at high risk of suffering from arterial and venous peripheral vascular disease (PVD). Bariatric surgery is an effective strategy to achieve weight reduction for patients with obesity. The long-term impact of bariatric surgery on obesity-related morbidity is subject to increasing research interest. This study aimed to ascertain the impact of bariatric surgery on the long-term occurrence of PVD in patients with obesity.

Methods: The study population was extracted from the Clinical Practice Research Datalink, a nation-wide database containing primary and secondary care records of consenting patients. The intervention cohort was 2959 patients who had undergone bariatric surgery during follow-up; their controls were 2959 propensity-score-matched counterparts. The primary endpoint was development of any PVD: arterial or venous. Secondary endpoints were incident peripheral arterial disease alone, incident peripheral venous disease alone.

Results: Three hundred forty-six patients suffered a primary endpoint during follow-up. Bariatric surgery did not improve peripheral vascular disease rates as a whole, but it was associated with significantly lower event rates of arterial disease (HR = 0.560, 95%CI 0.327-0.959, p = 0.035) but higher event rates of venous disease (HR = 1.685, 95%CI 1.256-2.262, p < 0.001).

Conclusions: Bariatric surgery was associated with significantly reduced long-term occurrence of arterial disease but increased occurrence of venous disease in patients with obesity.
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http://dx.doi.org/10.1007/s00423-020-02066-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8208905PMC
June 2021

Atherosclerotic disease burden after bariatric surgery in patients with obesity and type 2 diabetes.

J Diabetes 2021 Aug 19;13(8):640-647. Epub 2021 Jan 19.

Department of Medicine, Imperial College London, London, UK.

Background: The rising rates of obesity, along with its associated morbidities, represent an important global health threat. Atherosclerotic cardiovascular disease (ASCVD) is among the most common and hazardous obesity-related morbidity, and it is especially prevalent among those who suffer from type 2 diabetes (T2DM). Bariatric surgery (BS) is known to help with effective weight management and reduce the burden of cardiovascular risk factors, especially T2DM.

Methods: A nested propensity-matched cohort study was carried out using the Clinical Practice Research Datalink. The cohort included 1186 patients with no past history of ASCVD, 593 of whom underwent BS and 593 propensity-score matched controls, followed up for a mean of 42.7 months. The primary end point was the incidence of new ASCVD; defined as new coronary artery disease (CAD), cerebrovascular disease (CeVD), peripheral arterial disease (PAD), or miscellaneous atherosclerotic disease; secondary end points included primary end point components alone and all-cause mortality.

Results: Patients who underwent BS had significantly lower rates of new ASCVD (hazard ratio [HR] 0.53, confidence interval [CI] 0.30-0.95, P = 0.032. There were no significant differences in rates of CAD, CeVD, and PAD individually across cohorts, but a lower rate of all-cause mortality was observed in the BS cohort (HR 0.36, CI 0.19-0.71, P = 0.003).

Conclusions: BS was associated with improved ASCVD outcomes and lower mortality in patients with obesity and T2DM. This study provides evidence for increased awareness of potential benefits of BS in the management of obesity by highlighting a potential role in primary prevention for ASCVD.
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http://dx.doi.org/10.1111/1753-0407.13151DOI Listing
August 2021

Roux-en-Y Gastric Bypass Increases Glycemic Variability and Time in Hypoglycemia in Patients With Obesity and Prediabetes or Type 2 Diabetes: A Prospective Cohort Study.

Diabetes Care 2021 02 17;44(2):614-617. Epub 2020 Dec 17.

Department of Metabolism, Digestion and Reproduction, Imperial College London, London, U.K.

Objective: Roux-en-Y gastric bypass (RYGB) is an established treatment for type 2 diabetes and obesity. The study objective was to establish RYGB's effects on glycemic variability (GV) and hypoglycemia.

Research Design And Methods: This was a prospective observational study of 10 participants with obesity and prediabetes or type 2 diabetes who underwent RYGB. Patients were studied before RYGB (Pre) and 1 month, 1 year, and 2 years postsurgery with continuous glucose measurement (CGM). A mixed-meal test (MMT) was conducted at Pre, 1 month, and 1 year.

Results: After RYGB, mean CGM decreased (at 1 month, 1 year, and 2 years), and GV increased (at 1 year and 2 years). Five of the 10 participants had a percent time in range (%TIR) <3.0 mmol/L (54 mg/dL) greater than the international consensus target of 1% at 1 or 2 years. Peak glucagon-like peptide-1 (GLP-1) and glucagon area under the curve during MMT were positively and negatively associated, respectively, with contemporaneous %TIR <3.0 mmol/L.

Conclusions: Patients undergoing RYGB are at risk for development of postbariatric hypoglycemia due to a combination of reduced mean glucose, increased GV, and increased GLP-1 response.
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http://dx.doi.org/10.2337/dc20-1609DOI Listing
February 2021

Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic.

J Am Med Dir Assoc 2020 12 5;21(12):1751-1758.e5. Epub 2020 Oct 5.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Emergency Medicine Department, National University Hospital, Singapore.

Objectives: The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs.

Design: Cross-sectional survey study.

Setting And Participants: Doctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic.

Methods: Study questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs.

Results: Among 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite.

Conclusions And Implications: Every level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.
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http://dx.doi.org/10.1016/j.jamda.2020.09.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534835PMC
December 2020

The Effect of Standard Versus Longer Intestinal Bypass on GLP-1 Regulation and Glucose Metabolism in Patients With Type 2 Diabetes Undergoing Roux-en-Y Gastric Bypass: The Long-Limb Study.

Diabetes Care 2021 05 6;44(5):1082-1090. Epub 2020 Nov 6.

Department of Surgery, King's College London, London, U.K.

Objective: Roux-en-Y gastric bypass (RYGB) characteristically enhances postprandial levels of glucagon-like peptide 1 (GLP-1), a mechanism that contributes to its profound glucose-lowering effects. This enhancement is thought to be triggered by bypass of food to the distal small intestine with higher densities of neuroendocrine L-cells. We hypothesized that if this is the predominant mechanism behind the enhanced secretion of GLP-1, a longer intestinal bypass would potentiate the postprandial peak in GLP-1, translating into higher insulin secretion and, thus, additional improvements in glucose tolerance. To investigate this, we conducted a mechanistic study comparing two variants of RYGB that differ in the length of intestinal bypass.

Research Design And Methods: A total of 53 patients with type 2 diabetes (T2D) and obesity were randomized to either standard limb RYGB (50-cm biliopancreatic limb) or long limb RYGB (150-cm biliopancreatic limb). They underwent measurements of GLP-1 and insulin secretion following a mixed meal and insulin sensitivity using euglycemic hyperinsulinemic clamps at baseline and 2 weeks and at 20% weight loss after surgery.

Results: Both groups exhibited enhancement in postprandial GLP-1 secretion and improvements in glycemia compared with baseline. There were no significant differences in postprandial peak concentrations of GLP-1, time to peak, insulin secretion, and insulin sensitivity.

Conclusions: The findings of this study demonstrate that lengthening of the intestinal bypass in RYGB does not affect GLP-1 secretion. Thus, the characteristic enhancement of GLP-1 response after RYGB might not depend on delivery of nutrients to more distal intestinal segments.
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http://dx.doi.org/10.2337/dc20-0762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132320PMC
May 2021

Impact of COVID-19 on Obesity Management Services in the United Kingdom (The COMS-UK study).

Obes Surg 2021 02 13;31(2):904-908. Epub 2020 Oct 13.

Division of Surgery and Cancer, Imperial College London, London, W2 1NY, UK.

Coronavirus Disease-2019 (COVID-19) has had a severe impact on all aspects of global healthcare delivery. This study aimed to investigate the nationwide impact of the pandemic on obesity management services in the UK in a questionnaire-based survey conducted of professionals involved in the delivery. A total of 168 clinicians took the survey; the majority of which maintained their usual clinical roles and were not redeployed except physicians and nurse specialists. Nearly all (97.8%) elective bariatric surgery was cancelled, 67.3% of units cancelled all multidisciplinary meeting activity, and the majority reduced clinics (69.6%). Most respondents anticipated that the services would recommence within 1-3 months. This study found that the COVID-19 pandemic has had a severe impact on the services involved in the management of patients suffering from severe, complex obesity in the UK.
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http://dx.doi.org/10.1007/s11695-020-05005-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552587PMC
February 2021

What Has Been the Impact of Covid-19 on Safety Culture? A Case Study from a Large Metropolitan Healthcare Trust.

Int J Environ Res Public Health 2020 09 25;17(19). Epub 2020 Sep 25.

Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK.

Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and, in turn, with patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK healthcare trust during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. SAQ scores of doctors and "other clinical staff", were relatively higher than the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40-49 years, non-White ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13), non-disclosed ethnicity (-0.11), nursing role (-0.15), and support (0.29) persisted to a level of significance. A significant decrease ( < 0.003) was seen in error reporting after the onset of the Covid-19 pandemic. This is the first study to investigate SAQ during Covid-19. Differences in SAQ scores were observed during Covid-19 between professional groups when compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics.
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http://dx.doi.org/10.3390/ijerph17197034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579589PMC
September 2020

Imperial Satiety Protocol: A new non-surgical weight-loss programme, delivered in a health care setting, produces improved clinical outcomes for people with obesity.

Diabetes Obes Metab 2021 01 15;23(1):270-275. Epub 2020 Oct 15.

Imperial Weight Centre, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.

'Imperial Satiety Protocol' (I-SatPro) is a new multifaceted approach to weight loss for people with obesity (PwO), encompassing dietary advice, time-restricted eating, physical activity and coaching to support behaviour change. Participants (n = 84) attended fortnightly I-SatPro group sessions for 30 weeks, with 70% of participants completing. On completion at 30 weeks, the mean weight loss was 15.2 ± 1.1 kg (13.2 ± 0.8% from baseline, P < .0001), which was maintained to 52 weeks (16.6 ± 1.5 kg, 14.1 ± 1.2%, P < .0001). Weight loss was not associated with reduced energy expenditure. In participants with type 2 diabetes and pre-diabetes (n = 16), glycated haemoglobin fell from 50 to 43 mmol/mol (P < .01). Systolic blood pressure fell by 12 mmHg (P < .0001). Triglycerides fell by 0.37 mmol/L (P < .01) and high-density lipoprotein rose by 0.08 mmol/L (P < .01). Short Form-36 (SF-36) functioning and wellbeing scores increased in all domains post I-SatPro intervention. For selected PwO, I-SatPro delivers clinically meaningful weight loss, and the potential for long-term health and wellbeing improvements.
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http://dx.doi.org/10.1111/dom.14207DOI Listing
January 2021

Uptake and accessibility of surgical robotics in England.

Int J Med Robot 2021 Feb 7;17(1):1-7. Epub 2020 Oct 7.

Department of Surgery and Cancer, Imperial College London, London, UK.

Background: The distribution, utilisation and accessibility of surgical robotics in England is unknown.

Methods: A nationwide Freedom of Information (FOI) request was sent to all acute National Health Service (NHS) trusts. Accessibility was assessed for 32 843 Lower Super Output Areas in England.

Results: All 149 acute NHS trusts responded to the FOI request. Sixty-one robots are distributed between 48 trusts. The number of robots and robotic procedures has increased annually. Urological procedures comprise 84.2% of robotic procedures. Procedure volume varies between robotic centres ranging from 1 to 683 in 2018. Over 2.4 million people have a travel time of over 1 hour to their nearest robotic centre.

Discussion: National accessibility to robotic services and case volumes are variable and does not represent good value for the NHS. A national robotic surgery registry could improve the quality of robotic surgery and is needed to dynamically assess national provision of this technology.
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http://dx.doi.org/10.1002/rcs.2174DOI Listing
February 2021

Comparison of surgeon gaze behaviour against objective skill assessment in laparoscopic cholecystectomy-a prospective cohort study.

Int J Surg 2020 Oct 23;82:149-155. Epub 2020 Aug 23.

Department of Surgery and Cancer, Imperial College London, London, UK. Electronic address:

Background: Eye tracking technology may provide the basis of a novel, objective technical skill assessment in surgery. Past research has showed differences in the gaze patterns between expert and novice surgeons. The aim of this study was to investigate the relationship between gaze behaviors and technical skill during laparoscopic cholecystectomy as determined by objective assessment scores.

Methods: Gaze behaviors of surgeons performing laparoscopic cholecystectomies were mapped using wearable eye tracking apparatus. Two impartial surgeons retrospectively analyzed video footage of the procedure to perform Objective Structured Assessment of Technical Skill (OSATS) assessments. Primary endpoints were correlation between gaze behaviours (dwell time (%) and fixation frequency (count/s)) and OSATS scores. Dwell time was defined as the percentage of time spent fixating on particular visual areas of interest (AOI). Pearson's correlation coefficient was used to estimate the relationship between primary endpoints and AOIs. Statistical significance was set at p < 0.05.

Results: 13 procedures were analyzed. Throughout all operative segments, a negative correlation was present between operating theatre dwell time and OSATS scores (p < 0.05). During dissection of Calot's triangle, there was a strong positive correlation between laparoscopic screen dwell time and OSATS scoring [r = 0.655, p < 0.05]. Scrub nurse dwell time during dissection of Calot's triangle showed a strong negative correlation with OSATS scoring [r = -0.619, p < 0.05]. During dissection of gallbladder fossa, operating theatre fixation frequency negatively correlated against OSATS scores [r = -0.566, p < 0.05].

Conclusion: The results suggest a greater focus on significant visual stimuli alongside a lack of attention to non-essential stimuli during critical stages of the operative period is associated with greater technical skill. This aids the validation of eye tracking as an adjunct high-stakes technical skill assessment.
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http://dx.doi.org/10.1016/j.ijsu.2020.08.006DOI Listing
October 2020

Observational study of UK mobile health apps for COVID-19.

Lancet Digit Health 2020 08 24;2(8):e388-e390. Epub 2020 Jun 24.

Department of Surgery and Cancer, Imperial College London, London, W2 1NY, UK. Electronic address:

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http://dx.doi.org/10.1016/S2589-7500(20)30144-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314454PMC
August 2020

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times.

Obes Surg 2021 01 1;31(1):451-456. Epub 2020 Aug 1.

CHI Memorial Hospital, Chattanooga, TN, USA.

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.
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http://dx.doi.org/10.1007/s11695-020-04883-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395568PMC
January 2021
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