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Publikacije (15)

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J. Kevric, Katherine J L Suter, R. Hodgson, G. Chew

The number of female trainees is on the rise, and so too are the issues surrounding fertility and barriers to family planning. Over the past decade, studies of surgical residents across the United States have demonstrated a strong prevalence of fertility challenges. Strenuous training requirements have American female surgical trainees delaying pregnancy, having fewer children, and reporting increased rates of pregnancy complications, infertility, and use of assistive reproductive technology. Similarly, a survey of British surgical trainees showed over a quarter of trainees felt unsupported by their department during pregnancy, while almost a quarter of both of male and female trainees experienced difficulty in arranging parental leave. Our recent article investigated how our long training programmes are affecting Australasian surgical trainees’ ability to start families, particularly when compared with other specialities. While we acknowledge there are limitations to online surveys, the results of this survey of 1099 doctors demonstrated that surgeons, when compared with physicians and GPs, are experiencing greater challenges in balancing work and family, across multiple areas of fertility and child-caring. Surgical training occurs in the prime reproductive years and as a consequence, when many trainees finally complete their training, they are living the real-world consequences of reduced fertility because of their age. This highlights the critical need for a cultural change that’s becoming increasingly important as the surgical workforce demographic changes. Training bodies are in a prime position to provide solutions to the many obstacles surgical trainees face in family planning. There are several ways the colleges and hospitals can support a more equitable future for its members who want to pursue parenthood.

J. Kevric, Katherine J L Suter, R. Hodgson, Grace Chew

Objective To describe the incidence of infertility, pregnancy complications, and breastfeeding practices among Australian and New Zealand doctors and identify factors associated with increased pregnancy complication rates. Methods A survey of ANZ doctors using an online questionnaire during November 2021. Results One thousand ninety-nine completed responses were received. The median age of female doctors at the time of their first child was 32.4. Fertility testing was undertaken by 37%, with 27% having in vitro fertilization. More than 60% of respondents delayed family planning due to work. Pregnancy loss occurred in 36% of respondents, and 50% suffered a pregnancy complication. There were significant differences between specialists, with surgeons working longer hours before and after pregnancy, but having greater access to maternity leave than general practitioners. Conclusion Female doctors delay starting and completing their family due to work-related demands and structural biases in career progression, which may result in higher infertility and pregnancy complication rates.

Thomas Payne, J. Kevric, W. Stelmach, Henry To

Background Electronic consultations (eConsults) are an increasingly used form of telemedicine that allows a nonspecialist clinician to seek specialist advice remotely without direct patient-specialist communication. Surgical clinics may see benefits from such forms of communication but face challenges with the need for intervention planning. Objective We aimed to use the Quadruple Aim Framework to integrate published knowledge of surgical outpatient eConsults with regard to efficacy, safety, limitations, and evolving use in the era of COVID-19. Methods We systematically searched for relevant studies across four databases (Ovid MEDLINE, Embase, Scopus, and Web of Science) on November 4, 2021, with the following inclusion criteria: English language, published in the past 10 years, and data on the outcomes of outpatient surgical eConsults. Results A total of 363 studies were screened for eligibility, of which 33 (9.1%) were included. Most of the included studies were from the United States (23/33, 70%) and Canada (7/33, 21%), with a predominant multidisciplinary focus (9/33, 27%). Most were retrospective audits (16/33, 48%), with 15% (5/33) of the studies having a prospective component. Conclusions The surgical eConsult studies indicated a possible benefit for population health, promising safety results, enhanced patient and clinician experience, and cost savings compared with the traditional face-to-face surgical referral pathway. Their use appeared to be more favorable in some surgical subspecialties, and the overall efficacy was similar to that of medical subspecialties. Limited data on their long-term safety and use during the COVID-19 pandemic were identified, and this should be the focus of future research.

X. Ling, J. Kevric, Alexandra DuGuesclin, Julie A. Teague, M. Perera, E. Penington

Metastatic involvement of the gallbladder is uncommon. We report a case of an 84-year-old male who presented with acute cholecystitis secondary to metastatic urothelial carcinoma (UC). An 84-year-old man presented with right upper quadrant pain and a positive Murphy's sign on the background of known metastatic UC. He was diagnosed with acute cholecystitis and underwent laparoscopic cholecystectomy. His postoperative period was complicated by a cardiac event, and he died 2 days later. Histology of the gallbladder revealed extensive infiltration by nested malignant epithelioid proliferation, consistent with UC. This case demonstrates that although uncommon, UC may metastasize to unusual sites, including the gallbladder. This serves as a reminder for surgeons to consider metastatic disease as a cause for acute cholecystitis.

J. Kevric, M. Ashour, Anamitra Sarkar

De Garengeot hernia is defined as a femoral hernia containing the appendix, which can be normal or inflamed. It is a rare condition, comprising of about 1% of all diagnosed hernias. Patients typically present with symptoms of incarceration. There is no consensus on the management of patients with De Garengeot hernia and concurrent appendicitis. To date, less than 100 reports have been published in literature and only a few discussed the use of mesh in an infected femoral field. An 81-year-old female presented to our emergency department with a 3-day history of lower abdominal pain associated with mild nausea. Abdominal examination revealed tenderness in the right femoral region and an incarcerated femoral hernia was suspected. She proceeded to an abdominal computed tomography (CT), which confirmed the suspected diagnosis of a femoral hernia containing appendix without radiological signs of bowel obstruction (Fig. 1). Within an hour, the patient was transferred to the operating theatre and intraoperative inspection revealed a femoral canal containing a sac which had a vermiform appendix as its content, demonstrating a De Garengeot hernia. The fixation involved a high approach with a longitudinal incision extending downwards overlying the hernia sac. The sac was 2 × 3 cm in size with surrounding tissue oedema. The opened sac identified inflamed tip of appendix. Subsequently, the retroperitoneal plane was dissected and peritoneum opened to deliver the appendix under vision. Exploration revealed a healthy base of appendix and an incarcerated tip of appendix herniating through femoral defect of about 0.5 cm in diameter (Fig. 2). There was no perforation. Standard appendicectomy was performed with ligation of base end mesoappendix using absorbable sutures. The extended incision allowed the suture ligation of the sac and a mesh plug was inserted into the femoral ring. The patient made an uneventful recovery and was discharged 2 days later with oral antibiotics for 5 days. There have been no postoperative complications at 8-week follow-up. The first case of appendicitis within a femoral hernia was reported by Rene Jacques Croissant De Garengeot, an 18th century Parisian surgeon who performed the appendicectomy and primary hernia repair in 1731. This hernia is extremely rare ranging from 0.5 to 3.3%, while only 0.13% contain an acutely inflamed appendix. Other rare hernia containing the appendix is the Amyand’s hernia seen in the inguinal region reported in 1% of cases. De Garengeot hernia is often misdiagnosed as incarcerated femoral hernia and the diagnosis of appendicitis is often only made intraoperatively. It is postulated that the signs of appendicitis are not evident clinically because of the local response related to the inflammation within the confined femoral space. A CT scan in our case had demonstrated the appendix within the hernia sac, but only three published cases of CT diagnosed De Garengeot hernia are documented in literature. This further demonstrates the dilemma surrounding this diagnosis, as the surgical treatment for this condition may be more challenging than anticipated based on the patient’s clinical presentation.

J. Kevric, N. Papa, Sumeet H Toshniwal, M. Perera

Groin hernia repairs (GHRs) are among the commonest general surgical procedures in the Western population. The introduction of minimally invasive surgery has prompted the development of laparoscopic totally extraperitoneal and trans‐abdominal preperitoneal hernia repairs. We aimed to determine the hernia treatment trends in Australia over the last 15 years.

Pamela Andreatta, Pinho Gomes, Daniel Yeomans, J. Kevric, Nathan Papa, Marlon Perera, Prem Rashid

Journal Surgical Education SE001 DEVELOPING AND MAINTAINING MASTERY AS A SURGEON

J. Kevric, V. Aguirre, K. Martin, D. Varma, M. Fitzgerald, C. Pilgrim

Introduction. Management of haemodynamically stable patients with penetrating abdominal injuries varies from nonoperative to operative management. The aim was to investigate whether peritoneal breach when used as an indication for exploratory laparotomy appropriately identified patients with intra-abdominal visceral injury. Methods. We conducted retrospective cohort study of all patients presenting with PAI at a major trauma centre from January 2007 to December 2011. We measured the incidence of peritoneal breach and correlated this with intra-abdominal visceral injury diagnosed at surgery. Results. 252 patients were identified with PAI. Of the included patients, 71 were managed nonoperatively and 118 operatively. The operative diagnoses included nonperitoneal-breaching injuries, intraperitoneal penetration without organ damage, or intraperitoneal injury with organ damage. The presenting trauma CT scan was reported as normal in 63%, 34%, and 2% of these groups, respectively. The total negative laparotomy/laparoscopy rate for all patients presented with PAI was 21%, almost half of whom had a normal CT scan. Conclusion. We found that peritoneal breach on its own does not necessarily always equate to intra-abdominal visceral injury. Observation with sequential examination for PAI patients with a normal CT scan may be more important than exclusion of peritoneal breach via laparoscopy.

Male breast cancer (MBC) is a rare condition whose incidence is on the rise. To date there are limited support services available to men with breast cancer and no Australian studies looking at the social determinants of MBC and its impact on the prognosis of this disease. Lack of MBC awareness and specific information continues to be an issue for the men. A literature search was undertaken using PubMed to identify articles published on the topic of MBC. Breast cancer is not a gender exclusive disorder and the current lack of open discussion and research into the MBC and its psychosexual consequence has shown to be associated with harmful effects on mental and sexual health of men. More research is necessary to study its biological nature as well as its association with psychosocial and sexual effects.

J. Kevric, Sanil Nair, D. Ernest

We report a case of a 29-year-old primigravida at 36 weeks of gestation following an emergency caesarean section, complicated by respiratory distress and multiorgan failure secondary to superior vena cava (SVC) obstruction, requiring intubation and prolonged ventilatory support. The presented case highlights the consequences of delayed recognition of SVC obstruction due to a reluctance to undertake appropriate radiological imaging during pregnancy.

J. Kevric, G. Jelinek, J. Knott, T. Weiland

Objectives To determine (a) the inter-rater reliability of pairs of emergency doctors' and/or nurses' ratings of the Glasgow Coma Scale (GCS) and the Full Outline of Unresponsiveness (FOUR) Scale in emergency department (ED) patients, (b) the concurrent validity of the FOUR Scale using the GCS as the reference scale and (c) doctors' and nurses' knowledge and attitudes towards the GCS and FOUR Scale. Methods A prospective observational study was conducted using staff participants' ratings for a convenience sample of ED patients requiring quantification of conscious state. Participating doctors and nurses attended a formal training session on the correct use of the GCS and FOUR Scale. Pairs of clinicians then independently completed the GCS and FOUR Scale on patients within 5 min of each other. Results 140 clinicians were recruited and trained in the use of the GCS and FOUR Scale. A total of 217 observations were performed on 203 patients presenting to the ED with various conditions. The inter-rater reliability for the FOUR Scale was greater than that of the GCS (FOUR: к=0.76, p<0.01; GCS: к=0.59, p<0.01). The reliability for both the GCS and the FOUR Scale was poorest within doctor–nurse pairs. Conclusion The FOUR Scale showed greater reliability than the GCS in ED patients using ED clinicians as raters. A larger study of ED patients is warranted to determine the predictive validity of the FOUR Scale and to further examine the reliability of the scale in various patient populations.

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